Antimicrobial stewardship, readmissions

Summaries from ACP Hospitalist Weekly.

Specific components of antimicrobial stewardship programs associated with improvements

Favorable changes in antimicrobial utilization were attributed to specific components of antimicrobial stewardship programs in a recent study of the Veterans Affairs (VA) system.

Researchers surveyed all 130 VA facilities with acute care services in 2012 to identify and compare 34 components of antimicrobial stewardship programs against four utilization measures: aggregate antimicrobial use, antimicrobial use in patients with noninfectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral therapy, and double anaerobic coverage.

Results were published in the May 2017 Journal of Hospital Medicine.

Photo by Thinkstock
Photo by Thinkstock.

The variables associated with at least three positive changes in utilization were the presence of postgraduate physician/pharmacy training programs, number of order sets specific to antimicrobials, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases attendings on acute care ward teams, and formal infectious diseases training of the lead pharmacist of the stewardship program.

Based on these findings, the highest-yield initiatives may include order sets in the electronic health record and systematic efforts to de-escalate broad-spectrum therapy, the authors said. They noted limitations of the study, such as how the survey was not specifically designed to analyze antimicrobial utilization measures and how the VA population does not reflect the general U.S. population.

An accompanying editorial offered several suggestions for how hospitalists can put this research into practice and be good antimicrobial stewards when treating the three conditions that drive about two-thirds of all inpatient antibiotic use: pneumonia, urinary traction infection (UTI), and skin and soft-tissue infection.

Suggestions included shorter courses of antibiotics for uncomplicated pneumonia, order sets to guide appropriate urine culture ordering in UTI, and improved diagnostic workups and antibiotic treatment of skin and soft-tissue infections, according to the editorialists.

“As leaders in patient safety and quality, and as the most important antibiotic prescribers in hospitals, hospitalists must play a central role in stewardship if we are to make meaningful progress,” they wrote.

Another study, published online May 1 by JAMA Internal Medicine, found that a behavioral approach to stewardship that preserved prescriber autonomy resulted in increased appropriate use of antimicrobials that lasted at least 12 months.

From Oct. 1, 2011, through Dec. 31, 2015, researchers offered prescribers at two hospitals in the Netherlands a free choice of how to improve their antimicrobial prescribing (while stimulating them to choose an intervention set that was likely to be effective in their department based on root-cause analysis). At baseline, they assessed the appropriateness of antimicrobial prescriptions for 1,121 patient cases with 700 antimicrobial prescriptions and compared it with 882 cases and 531 prescriptions during the intervention period.

Although no decrease was found in antimicrobial use, the mean appropriateness of antimicrobial prescriptions increased from 64.1% at the start of the intervention to 77.4% at 12 months (relative risk, 1.17; 95% CI, 1.04 to 1.27). “The effectiveness of our approach is explained by the advantages of using methods from behavioral science,” the study authors wrote. “We hypothesize that participating department members felt relatively nonthreatened by our approach because of their freedom in choosing a personal solution, which is an important theme in antimicrobial stewardship.”

They noted limitations to their study, such as the potential for the Hawthorne effect, the nonrandomized stepped-wedge enrollment order, and limited generalizability to health care systems outside the Netherlands.

CMS metric for 30-day readmissions may not be linked with improved care quality, outcomes after MI

Excess readmission ratio (ERR), the performance measure used by CMS as part of its Hospital Readmissions Reduction Program, is not associated with improved care quality or long-term clinical outcomes after acute myocardial infarction (MI), a recent study suggested.

To examine the association between MI-ERR and inpatient care quality, researchers used data from consecutive patients admitted with MI (n=229,252) to 519 hospitals from July 1, 2008, to June 30, 2011 (the time period used to calculate readmission penalties for the first cycle of the CMS program). Process-of-care outcomes included adherence to MI performance measures (acute and discharge), as well as a composite defect-free care metric.

To examine readmissions and mortality, researchers performed a one-year outcome analysis in 51,453 patients from 377 sites who were discharged alive from the index hospitalization and had follow-up data available. Clinical outcomes included days from discharge to the composite of all-cause mortality and all-cause readmission within one year of discharge.

Results were published online on April 26 by JAMA Cardiology.

Researchers grouped hospitals into four categories based on their ERR for MI for fiscal year 2013 (one group with MI-ERR ≤1 and three groups with MI-ERR >1). There were minimal differences in age and proportion of women across groups, but the proportion of black patients was significantly higher among groups with MI-ERR greater than 1 than the group with MI-ERR of 1 or less (7.6% vs. 4.5%; P=0.01).

Overall adherence to MI process-of-care measures was high, and researchers found no significant differences between groups in the unadjusted adherence to acute MI measures. Centers with higher MI-ERR showed a significantly yet modestly lower rate of use of aspirin and beta-blockers at discharge (P=0.03 and P=0.04, respectively) than those with lower MI-ERR. Defect-free care was not significantly associated with continuous measures of MI-ERR in unadjusted or adjusted analyses.

For long-term outcomes, the overall adjusted analysis (1 to 365 days after discharge) showed that the risk for the composite outcome of mortality or all-cause readmission within one year was higher with increasing MI-ERR (9% higher risk per 0.1-unit increase in MI-ERR up to 1; 6% higher risk per 0.1-unit increase thereafter). However, in the adjusted landmark analysis (31 to 365 days after discharge), MI-ERR was not significantly associated with long-term risk for composite outcomes.

The study authors noted limitations to their work, such as how hospitals were National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines centers that participated in the first cycle of the Readmissions Reduction Program, so results may not be generalizable to all hospitals. They added that they did not consider ED visits or observation status admissions during follow-up and that the results may not be applicable to the time period after the study (2012 and later).

They emphasized that the number of black patients and those with higher clinical severity (e.g., more prevalent heart failure symptoms, lower ejection fraction, more bleeding events) were significantly higher at centers with higher MI-ERR. They added that the CMS measure adjusts for many hospital-level differences in patient characteristics (e.g., age, comorbidities, patient case-mix) but does not account for race/ethnicity or any measures of symptoms or ejection fraction.

“Because MI-ERR does not associate with indices of quality of care or 1-year mortality or readmissions between 31 and 365 days, our findings raise questions of whether CMS readmissions penalties are equitably and justly applied for hospitals with a high prevalence of socially and/or medically complex patients,” they wrote.