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Szymczak JE, Petty LA, Gandhi TN, Neetz RA, Hersh A, Presson AP, Lindenauer PK, Bernstein SJ, Muller BM, White AT, Horowitz JK, Flanders SA, Smith JD, Vaughn VM. Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial. Implement Sci 2024; 19:23. [PMID: 38439076 PMCID: PMC10910678 DOI: 10.1186/s13012-024-01348-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
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.
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Affiliation(s)
- Julia E Szymczak
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert A Neetz
- MyMichigan Medical Center Midland, MyMichigan Health, Midland, MI, USA
| | - Adam Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Peter K Lindenauer
- Baystate Medical Center Department of Healthcare Delivery and Population Science, Center for Quality of Care Research, Springfield, MA, USA
| | - Steven J Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Brandi M Muller
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Andrea T White
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott A Flanders
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Justin D Smith
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA
| | - Valerie M Vaughn
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA.
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Vaughn VM, Krein SL, Hersh A, Buckel WR, White AT, Horowitz J, Patel PK, Gandhi TN, Petty LA, Spivak ES, Bernstein SJ, Malani AM, Johnson LB, Neetz RA, Flanders SA, Galyean P, Kimball E, Bloomquist K, Zickmund T, Zickmund SL, Szymczak JE. Excellence in Antibiotic Stewardship: A mixed methods study comparing High, Medium, and Low Performing Hospitals. Clin Infect Dis 2023:ciad743. [PMID: 38059532 DOI: 10.1093/cid/ciad743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. METHODS We conducted an explanatory, sequential mixed methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. RESULTS Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (p=0.001), considered valuable team members (p=0.001), comfortable recommending antibiotic changes (p=0.02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had four distinguishing characteristics: a) robust knowledge of and access to antibiotic stewardship guidance, b) high quality clinical pharmacist-physician relationships, c) tools and infrastructure to support stewardship, and d) highly engaged Infectious Diseases physicians who advocated stewardship principles. CONCLUSION This mixed-method study demonstrates the importance of organizational context for high performance in stewardship and suggests improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah L Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adam Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Whitney R Buckel
- Intermountain Healthcare Pharmacy Services, Taylorsville, UT, USA
| | - Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jennifer Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Division of Infectious Diseases, Department of Medicine, Intermountain Health, Salt Lake City, Utah, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anurag M Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health Michigan, Ann Arbor, Michigan, USA
| | - Leonard B Johnson
- Division of Infectious Diseases, Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Robert A Neetz
- Department of Pharmacy, MyMichigan Health, Midland, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Patrick Galyean
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elisabeth Kimball
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Susan L Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Informatics, Decision-Enhancement & Analytic Sciences Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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