1348. Indirect Standardization to Improve Comparison of Children’s Hospitals’ Antimicrobial Use

Abstract Background Antimicrobial use (AU) measured by days of therapy per 1000 patient-days (DOT/1000pd), the most established metric, varies widely between children’s hospitals despite robust adoption of antimicrobial stewardship. Differences in diagnoses and procedures (case mix) between hospitals are a source of AU variation not included in adjustment methods such as the Standardized Antimicrobial Administration Ratio. In this study, we evaluated an indirect standardization method to adjust children’s hospital AU for case mix. Methods This multicenter retrospective cohort study included 51 children’s hospitals participating in the Pediatric Health Information System database from 2016-2018. All inpatient, observation, and neonatal admissions were included, with a total of 2,558,948 discharges. Hospitalizations were grouped into 83 strata defined based on All Patients Refined Diagnosis Related Groups (APR-DRGs). Observed to expected (O:E) ratios were calculated by indirect standardization of mean antibiotic DOT per case, with expected values from 2016-2018 and observed values from 2018, and compared to DOT/1000pd. Outlier hospitals were defined by O:E z-scores corresponding to below 10th percentile (low outlier) and above 90th percentile (high outlier). Results Antibacterial DOT/1000pd ranged from 345 to 776 (2.2-fold variation from lowest to highest), whereas O:E ratios ranged from 0.8 to 1.14 (1.4-fold variation from lowest to highest) (Figure 1). O:E ratios were moderately correlated with DOT/1000pd (correlation estimate 0.45; 95% CI 0.19-0.64; p=0.0008). Three high outlier hospitals and 6 low outlier hospitals were identified. Examining hospitals with comparably high DOT/1000pd but discordant O:E ratios, differences could be explained by variation in both case mix and condition-specific AU within strata defined by APR-DRGs. Figure 1. Individual hospitals labeled on the X-axis, ordered by level of antibacterial DOT/1000pd (left axis), represented by bars. Diamonds represent O:E ratios derived by indirect standardization (right axis). Outlier hospitals (low and high) are highlighted in yellow. Dashed horizontal lines represent 10th percentile (lower) and 90th percentile (upper) limits of the O:E ratio distribution. Conclusion The observed variation in DOT/1000pd between hospitals is reduced when indirect standardization is applied to account for case mix differences. This approach can be adapted for more specific uses including clinical conditions, patient populations, or antimicrobial agents. Indirect standardization may enhance stewardship efforts by providing adjusted comparisons that incorporate case mix differences between hospitals. Disclosures All Authors: No reported disclosures

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Indirect Standardization as a Case Mix Adjustment Method to Improve Comparison of Children’s Hospitals’ Antimicrobial Use

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1854 ◽

2020 ◽

Author(s):

Rachel L Wattier ◽

Cary W Thurm ◽

Sarah K Parker ◽

Ritu Banerjee ◽

Adam L Hersh ◽

...

Keyword(s):

Health Information System ◽

Case Mix ◽

Antimicrobial Use ◽

Children's Hospitals ◽

Children’S Hospitals ◽

Days Of Therapy ◽

Z Scores ◽

Case Mix Adjustment ◽

Indirect Standardization ◽

Correlation Estimate

Abstract Antimicrobial use (AU) in days of therapy per 1000 patient-days (DOT/1000pd) varies widely among children’s hospitals. We evaluated indirect standardization to adjust AU for case mix, a source of variation inadequately addressed by current measurements. Hospitalizations from the Pediatric Health Information System were grouped into 85 clinical strata. Observed to expected (O:E) ratios were calculated by indirect standardization and compared to DOT/1000pd. Outliers were defined by O:E z-scores. Antibacterial DOT/1000pd ranged from 345 to 776 (2.2-fold variation; interquartile range [IQR] 552-679), whereas O:E ratios ranged from 0.8 to 1.14 (1.4-fold variation; IQR 0.93-1.05). O:E ratios were moderately correlated with DOT/1000pd (correlation estimate 0.44; 95% CI 0.19-0.64; p=0.0009). Using indirect standardization to adjust for case mix reduces apparent AU variation and may enhance stewardship efforts by providing adjusted comparisons to inform interventions.

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Identifying Targets for Antimicrobial Stewardship in Children's Hospitals

Infection Control and Hospital Epidemiology ◽

10.1086/673982 ◽

2013 ◽

Vol 34 (12) ◽

pp. 1252-1258 ◽

Cited By ~ 58

Author(s):

Jeffrey S. Gerber ◽

Matthew P. Kronman ◽

Rachael K. Ross ◽

Adam L. Hersh ◽

Jason G. Newland ◽

...

Keyword(s):

Antibiotic Therapy ◽

Antimicrobial Stewardship ◽

Severity Of Illness ◽

Antibiotic Use ◽

The United States ◽

High Impact ◽

Antimicrobial Use ◽

Children's Hospitals ◽

Children’S Hospitals ◽

Days Of Therapy

Objective.Antimicrobial stewardship programs (ASPs) are recommended to optimize antimicrobial use for hospitalized patients. Although mechanisms for the implementation of ASPs have been described, data-driven approaches to prioritize specific conditions and antimicrobials for intervention have not been established. We aimed to develop a strategy for identifying high-impact targets for antimicrobial stewardship efforts.Design.Retrospective cross-sectional study.Setting and Patients.Children admitted to 32 freestanding children's hospitals in the United States in 2010.Methods.We identified the conditions with the largest proportional contribution to the total days of antibiotic therapy prescribed to all hospitalized children. For the 4 highest-using conditions, we examined variability between hospitals in antibiotic selection patterns for use of either first- or second-line therapies depending on the condition. Antibiotic use was determined using standardized probability of exposure to selected agents and standardized days of therapy per 1,000 patient-days, adjusting for patient demographics and severity of illness.Results.In 2010, 524,364 children received 2,082,929 days of antibiotic therapy. Surgical patients received 43% of all antibiotics. The 4 highest-using conditions—pneumonia, appendicitis, cystic fibrosis, and skin and soft-tissue infection—represent 1% of all conditions yet accounted for more than 10% of all antibiotic use. Wide variability in antibiotic use occurred for 3 of these 4 conditions.Conclusions.Antibiotic use in children's hospitals varied broadly across institutions when examining diagnoses individually and adjusting for severity of illness. Identifying conditions with both frequent and variable antimicrobial use informs the prioritization of high-impact targets for future antimicrobial stewardship interventions.

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Quantifying Empiric Antibiotic Use in US Children’s Hospitals

Hospital Pediatrics ◽

10.1542/hpeds.2021-005950 ◽

2021 ◽

Author(s):

Kathleen Chiotos ◽

Lauren D’Arinzo ◽

Eimear Kitt ◽

Rachael Ross ◽

Jeffrey S. Gerber

Keyword(s):

Broad Spectrum ◽

Antibiotic Use ◽

Level Variation ◽

Hospital Level ◽

Broad Spectrum Antibiotic ◽

Children's Hospitals ◽

Broad Spectrum Antibiotics ◽

Children’S Hospitals ◽

Days Of Therapy ◽

Rule Out

OBJECTIVES Empirical broad-spectrum antibiotics are routinely administered for short durations to children with suspected bacteremia while awaiting blood culture results. Our aim for this study was to estimate the proportion of broad-spectrum antibiotic use accounted for by these “rule-outs.” METHODS The Pediatric Health Information System was used to identify children aged 3 months to 20 years hospitalized between July 2016 and June 2017 who received broad-spectrum antibiotics for suspected bacteremia. Using an electronic definition for a rule-out, we estimated the proportion of all broad-spectrum antibiotic days of therapy accounted for by this indication. Clinical and demographic characteristics, as well as antibiotic choice, are reported descriptively. RESULTS A total of 67 032 episodes of suspected bacteremia across 42 hospitals were identified. From these, 34 909 (52%) patients were classified as having received an antibiotic treatment course, and 32 123 patients (48%) underwent an antibiotic rule-out without a subsequent treatment course. Antibiotics prescribed for rule-outs accounted for 12% of all broad-spectrum antibiotic days of therapy. Third-generation cephalosporins and vancomycin were the most commonly prescribed antibiotics, and substantial hospital-level variation in vancomycin use was identified (range: 16%–58% of suspected bacteremia episodes). CONCLUSIONS Broad-spectrum intravenous antibiotic use for rule-out infections appears common across children’s hospitals, with substantial hospital-level variation in the use of vancomycin in particular. Antibiotic stewardship programs focused on intervening on antibiotics prescribed for longer durations may consider this novel opportunity to further standardize antibiotic regimens and reduce antibiotic exposure.

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Profile of Antimicrobial Use in the Pediatric Population of a University Hospital Centre, 2015/16 to 2018/19

The Canadian Journal of Hospital Pharmacy ◽

10.4212/cjhp.v74i1.3037 ◽

2021 ◽

Vol 74 (1) ◽

Author(s):

Lydia R Rahem ◽

Bénédicte Franck ◽

Hélène Roy ◽

Denis Lebel ◽

Philippe Ovetchkine ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Antimicrobial Agents ◽

Pediatric Population ◽

University Hospital ◽

Antimicrobial Use ◽

Defined Daily Dose ◽

Centre Hospitalier ◽

Stewardship Program ◽

Centre Hospitalier Universitaire ◽

Days Of Therapy

Background: Antimicrobial stewardship is a standard practice in health facilities to reduce both the misuse of antimicrobials and the risk of resistance. Objective: To determine the profile of antimicrobial use in the pediatric population of a university hospital centre from 2015/16 to 2018/19. Methods: In this retrospective, descriptive, cross-sectional study, the pharmacy information system was used to determine the number of days of therapy (DOTs) and the defined daily dose (DDD) per 1000 patient-days (PDs) for each antimicrobial and for specified care units in each year of the study period. For each measure, the ratio of 2018/19 to 2015/16 values was also calculated (and expressed as a proportion); where the value of this proportion was ≤ 0.8 or ≥ 1.2 (indicating a substantial change over the study period), an explanatory rating was assigned by consensus. Results: Over the study period, 94 antimicrobial agents were available at the study hospital: 70 antibiotics (including antiparasitics and antituberculosis drugs), 14 antivirals, and 10 antifungals. The total number of DOTs per 1000 PDs declined from 904 in 2015/16 to 867 in 2018/19. The 5 most commonly used antimicrobials over the years, expressed as minimum/maximum DOTs per 1000 PDs, were piperacillin-tazobactam (78/105), trimethoprim-sulfamethoxazole (74/84), ampicillin (51/69), vancomycin (53/68), and cefotaxime (55/58). In the same period, the care units with the most antimicrobial use (expressed as minimum/ maximum DOTs per 1000 PDs) were hematology-oncology (2529/2723), pediatrics (1006/1408), and pediatric intensive care (1328/1717). Conclusions: This study showed generally stable consumption of antimicrobials from 2015/16 to 2018/19 in a Canadian mother-and-child university hospital centre. Although consumption was also stable within drug groups (antibiotics, antivirals, and antifungals), there were important changes over time for some individual drugs. Several factors may explain these variations, including disruptions in supply, changes in practice, and changes in the prevalence of infections. Surveillance of antimicrobial use is an essential component of an antimicrobial stewardship program. RÉSUMÉ Contexte : La gestion des antimicrobiens est une pratique courante dans les centres hospitaliers afin de réduire l’utilisation inappropriée des antimicrobiens et le risque de résistance. Objectif : Décrire l’évolution de l’utilisation des antimicrobiens dans un centre hospitalier universitaire de 2015-16 à 2018-19. Méthodes : Dans cette étude rétrospective, descriptive et transversale, les dossiers pharmacologiques ont servi à déterminer le nombre de jours de traitement (NJT) et la dose définie journalière (DDD) par 1000 jours-présence (JP) pour chaque antimicrobien et pour chaque unité de soins par année de l’étude. Pour chaque mesure, on a également comparé le ratio de 2018-19 à celui de 2015-16, qui est exprimé en proportion; lorsque la valeur de cette proportion était ≤ 0,8 ou ≥ 1,2, ce qui indiquait un changement important durant la période de l’étude, une note explicative a été attribuée par consensus. Résultats : Durant la période à l’étude, 94 antimicrobiens ont été disponibles dans notre centre : 70 antibiotiques (dont les antiparasitaires et les antituberculeux), 14 antiviraux et 10 antifongiques. Le nombre total de NJT par 1000 JP a diminué de 904 en 2015-16 à 867 en 2018-19. Les cinq antimicrobiens utilisés le plus fréquemment et présentés en minimum / maximum de NJT par 1000 JP étaient les suivants : piperacilline-tazobactam (78/105), trimethoprim-sulfamethoxazole (74/84), ampicilline (51/69), vancomycine (53/68) et cefotaxime (55/58). Pendant la même période, les unités de soins qui faisaient la plus grande utilisation d’antimirobiens (exprimée en minimum / maximum de NJT par 1000 JP) étaient hématologie-oncologie (2529/2723), pédiatrie (1006/1408) et soins intensifs pédiatriques (1328/1717). Conclusions : Cette étude démontre une consommation stable d’antimicrobiens entre 2015-16 et 2018-19 dans un centre hospitalier universitaire mère-enfant canadien. Malgré le fait que la consommation entre les groupes d’antimicrobiens (antibiotiques, antiviraux, antifongiques) était stable, on a constaté d’importantes variations concernant certains médicaments individuels. Plusieurs facteurs peuvent expliquer cette variation, notamment des ruptures d’approvisionnement, des changements de pratique et des changements dans la prévalence d’infections. La surveillance de la consommation des antimicrobiens est une partie essentielle de tout programme d’antibiogouvernance.

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1019. Defining electronic patient phenotypes to inform risk-adjustment strategies in hospital antimicrobial use comparisons

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.883 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S359-S359

Author(s):

Rebekah W Moehring ◽

Matthew Phelan ◽

Eric Lofgren ◽

Alicia Nelson ◽

Melinda M Neuhauser ◽

...

Keyword(s):

Risk Adjustment ◽

Diagnosis Related Groups ◽

Patient Characteristics ◽

Antibiotic Use ◽

Low Risk ◽

Antimicrobial Use ◽

Cell Transplant ◽

Lengths Of Stay ◽

Days Of Therapy ◽

Adjustment Factors

Abstract Background Comparison of antimicrobial use (AU) rates among hospitals can identify areas to intervene for antimicrobial stewardship. Hospital AU interpretation is difficult without risk-adjustment for patient mix. Identifying high- or low-risk patient characteristics, or “electronic phenotypes,” for receipt of antimicrobials using data from electronic health records (EHR) could help define risk-adjustment factors AU comparisons. Methods We performed a retrospective study of EHR-derived data from adult and pediatric inpatients within the Duke University Health System from October 2015 to September 2017. Encounters were included if the patient spent time in an inpatient location. The analysis aimed to identify subpopulations that were high- or low-risk for antimicrobial exposure based on EHR data summarized on the encounter level. Antimicrobial days of therapy (DOT) and days present, representing the length of stay (LOS), were defined as in the 2018 NHSN AU Option. Location exposures were defined in binary variables if patients were housed at least 1 day on a hospital unit type. We compared antimicrobial-exposed to unexposed patients as well as DOT among various factors including demographics, location, nonantimicrobial medications, labs, ICD-10 codes, and diagnosis-related groups (DRG). Results The EHR-derived dataset included 170,294 encounters and 204 variables in one academic and two community hospitals; 80,192 (47%) received at least one antimicrobial. Distributions of both LOS and DOT were zero-inflated and skewed by long outliers (figure). Encounters with >=7 DOT made up 63% of total DOT, but only 9% of inpatient encounters. Electronic phenotypes with highest DOT included those with long lengths of stay, older age, exposures to stem cell transplant, pulmonary, and critical care units, and DRG that included transplant, respiratory, or infectious diagnoses. Zero DOT phenotypes included those with short lengths of stay, exposure to labor and delivery wards, medical wards, and DRG that included birth and pregnancy. Conclusion Future work in defining risk-adjustment factors for hospital AU data comparisons should determine if factors associated with low- or high-risk electronic phenotypes assist in prediction of antibiotic use. Disclosures All authors: No reported disclosures.

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Establishing Benchmarks for Antimicrobial Use in Canadian Children’s Hospitals

The Pediatric Infectious Disease Journal ◽

10.1097/inf.0000000000003170 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Julie Blackburn ◽

Nicholas Barrowman ◽

Jennifer Bowes ◽

Anne Tsampalieros ◽

Nicole Le Saux

Keyword(s):

Antimicrobial Use ◽

Children's Hospitals ◽

Children’S Hospitals

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Variability in Antifungal and Antiviral Use in Hospitalized Children

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.40 ◽

2017 ◽

Vol 38 (06) ◽

pp. 743-746 ◽

Cited By ~ 6

Author(s):

Jennifer L. Goldman ◽

Rachael K. Ross ◽

Brian R. Lee ◽

Jason G. Newland ◽

Adam L. Hersh ◽

...

Keyword(s):

High Risk ◽

Antimicrobial Stewardship ◽

Infect Control Hosp ◽

Hospitalized Children ◽

Children's Hospitals ◽

Children’S Hospitals ◽

Days Of Therapy ◽

High Risk Children

We analyzed antifungal and antiviral prescribing among high-risk children across freestanding children’s hospitals. Antifungal and antiviral days of therapy varied across hospitals. Benchmarking antifungal and antiviral use and developing antimicrobial stewardship strategies to optimize use of these high cost agents is needed. Infect Control Hosp Epidemiol 2017;38:743–746

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Methods of estimating vancomycin use in an inpatient setting: days of therapy versus therapeutic drug monitoring–based exposure days

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2018.364 ◽

2019 ◽

Vol 40 (3) ◽

pp. 375-379

Author(s):

Shutaro Murakami ◽

Junko Hiroi ◽

Yasuharu Tokuda ◽

Ed Casabar ◽

Hitoshi Honda

Keyword(s):

Therapeutic Drug Monitoring ◽

Drug Monitoring ◽

Antimicrobial Agents ◽

Therapeutic Drug ◽

Inpatient Setting ◽

Antimicrobial Use ◽

Days Of Therapy ◽

The Difference

AbstractUnderestimating antimicrobial use based on days of therapy (DOT) is recognized for certain antimicrobial agents. We investigated the difference between DOT and therapeutic drug monitoring (TDM)–based exposure days in estimating vancomycin use and demonstrated that DOT may underestimate vancomycin exposure by ∼10%.

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