One Size Doesn't Fit All-Stewardship Interventions Need To Be Tailored in Large Healthcare Systems

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial

BACKGROUND

Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.

METHODS

This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.

DISCUSSION

Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06106204 on 10/30/23.

Data-driven approach for tailoring facilitation strategies to overcome implementation barriers in community pharmacy

Background

Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques.

Methods

Six change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy.

Results

During the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a ‘lack of ability to plan for change’, ‘lack of internal supporters for the change’, ‘lack of knowledge and experience’, ‘lack of monitoring and feedback’, ‘lack of individual alignment with the change’, ‘undefined change objectives’, ‘lack of objective feedback’ and ‘lack of time’. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was ‘to empower stakeholders to develop objectives and solve problems’.

Conclusions

Results from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01138-8.

Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities

BACKGROUND

Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted.

AIM

To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities.

METHODS

This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities.

FINDINGS

The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37.

CONCLUSION

Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.

Stewardship program on carbapenem prescriptions in a tertiary hospital for adults and children in France: a cohort study

Antimicrobial stewardship programs aim at reducing the overuse of broad-spectrum antibiotics such as carbapenems, but their impact remains unclear. We compared the use of carbapenems between paediatric and adult subjects admitted to a French tertiary hospital and described the intervention of an antibiotic stewardship team (AST). As part of AST routine activity, all adult and paediatric patients receiving carbapenems are identified in real time using a computer-generated alert system and reviewed by the AST. Data associated with carbapenem prescriptions were extracted for 2 years (2014-2015) and were compared between paediatric and adult wards. Prescription appropriateness (i.e. no clinically suitable narrower spectrum alternative to carbapenem for de-escalation) and AST intervention were analysed. In total, 775 carbapenem prescriptions for 291 children and 262 adults were included. Most patients (95%) had a comordity and 52% had known recent carriage of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE). Most carbapenem prescriptions came from intensive care units (n = 269, 35%) and were initiated for urinary tract (n = 200, 27%), sepsis (n = 181, 25%), and lung (n = 153, 21%) infections. Carbapenems were initiated empirically in 537 (70%) cases, and an organism was isolated in 523 (67%) cases. Among the isolated organisms, 47% (n = 246) were ESBLE and 90% (n = 468) were susceptible to carbapenems, but an alternative existed in 61% (n = 320) of cases according to antibiotic susceptibility testing. Among prescriptions reviewed by the AST, 39% (n = 255) were considered non-appropriate and led to either antibiotic discontinuation (n = 47, 7%) or de-escalation (n = 208, 32%). Non-appropriate prescriptions were more frequent in paediatric wards (p = 0.01) and in microbiologically documented infections (p = 0.013), and less observed in immunocompromised patients (p = 0.009) or with a known ESBLE carriage (p < 0.001). Tailored stewardship programs are essential to better control carbapenem use and subsequent antimicrobial resistance.

How Far We've Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration

PURPOSE OF REVIEW

This review highlights several of the successes in antimicrobial stewardship seen in the largest integrated healthcare system in the USA, the Veterans Health Administration.

RECENT FINDINGS

Since deploying antimicrobial stewardship programs on a national scale in the Veterans Health Administration, decreases in overall antimicrobial use and Clostridioides difficile infections have been observed. Concurrent infection prevention initiatives have also contributed to these improvements in the Veterans Health Administration.

SUMMARY

By embracing multidisciplinary stewardship teams, focusing on education and research in the field of antimicrobial stewardship, and leveraging the vast data available within the national system, the Veterans Health Administration has made substantial advances in antimicrobial stewardship.

Alcohol screening and brief intervention among military service members and veterans: rural-urban disparities

BACKGROUND

Access to screening, brief intervention and referral to treatment programmes for alcohol use have been shown to be effective; however, little is known about access to these services among service members and veterans. We examined the association of service member or veteran rural-dwelling area and the following outcomes: recent general health check-up, alcohol screening and alcohol brief intervention.

METHODS

Data on 5080 military service members and veterans were obtained from the 2017 Behavioural Risk Factor Surveillance System of the USA. We estimated rural-urban disparities in the receipt of a recent voluntary general health check-up, as well as the receipt of alcohol screening and brief intervention, using a mixed logit model.

RESULTS

Of the 5080 participants in the study, a total of 4666 (90.49%, 95% CI 89.39% to 91.48%) reported a general health check-up in the last 2 years. Results showed 7.48% of the sample (95% CI 6.64% to 8.41%) exhibited heavy alcohol consumption patterns. Of the 414 participants who did not undergo a general health check-up, 13.80% (95% CI 9.63% to 19.41%) exhibited a pattern of heavy alcohol consumption. Rural individuals were less likely to report a recent health check-up (adjusted OR=0.82, 95% CI 0.79 to 0.87). Rurality was also independently associated with decreased likelihood of receiving an alcohol screening and brief intervention.

CONCLUSION

Greater access to telehealth or other geographically flexible screening and brief intervention programmes is needed in rural areas for service members and veterans.