Antibiotic stewardship programs are good for patients' health and good for the business health of hospitals that operate them.
Here are some of the practical lessons I've learned from my experience that may help hospitals overcome common barriers to establishing effective antibiotic stewardship programs.
Clinical and Financial Benefits of Antibiotic Review
The first barrier for a hospital is recognizing the fact that it needs an antibiotic stewardship program for both clinical and financial reasons. Historically, the role of hospital pharmacy was filling antibiotic prescriptions ordered by physicians for patients being treated at the hospital. Now, the hospital pharmacy is taking an active role in how those antibiotics are used by becoming an integral part of the clinical care team. That means pharmacists rounding with physicians as they see patients or reviewing patient cases to provide recommendations on antibiotic use and effect.
The shift to playing an active role is being driven by the rise of antibiotic-resistant bacteria strains as a global public health threat. The World Health Organization described antibiotic resistance as the “…single greatest challenge in infectious diseases today.” (2015, April 29)
Hospitals must do their part on a local level as part of the care delivery system to appropriately use antibiotics and reduce the threat. In practice, that means prescribing antibiotics appropriately for complex patient cases, understanding the proper use of niche antibiotics, choosing narrow-spectrum antibiotics to treat specific infections and knowing when not to prescribe antibiotics.
Doing all those things right – or doing them wrong – can have significant financial consequences for hospitals, particularly with the growth of value-based reimbursement systems and reimbursement systems that penalize hospitals for higher-than-expected infection rates. If you undershoot, patients can get sicker, stay in the hospital longer and increase their use of costly services. If you overshoot, you're driving up utilization and costs without any additional clinical benefit to patients and contributing to the antibiotic-resistant bacteria problem.
One hospital I've worked with, Cheyenne (Wyo.) Regional Medical Center reduced its spending on antibiotics by more than $400,000 in the first year of its antibiotic stewardship program, which represented 3.6 percent of total annual drug spending at the hospital (See chart).
Analyzing Data on Antibiotic Prescribing
The second barrier is developing the antibiotic-prescribing expertise that results in optimum clinical outcomes for the patients at the lowest possible cost to the hospital. One effective way to obtain that expertise is through data analysis. These range from reviewing purchase history and antimicrobial resistance to advanced technology solutions available to help hospital pharmacists match patients to the appropriate antibiotics. For example, by identifying patients who are on broad-spectrum antibiotic therapies but for whom there may be other more beneficial medication options. This requires the solutions to be integrated into a hospital's EHR and pharmacy management systems and available to doctors and pharmacists through patients' EMRs and through the hospital's computerized physician-order entry systems. Even less advanced or integrated systems can provide valuable insight by identifying patterns and trends.
Advocating for Appropriate Use of Antibiotics
Technology alone, though, doesn't make an effective antibiotic stewardship program. It's the people using the technology. The third barrier is identifying and appointing an in-house leader or champion on the appropriate use of antibiotics. Most commonly, this person is a physician infectious-disease specialist working in concert with the hospital pharmacy department.
However, as recently reported in StatNews, the industry may be on the front end of a coming shortage in infectious disease specialists as more than one third of infectious disease medical residency slots recently went unfilled. For some hospitals, that means the person in charge of antimicrobial stewardship will be a hospital pharmacist. If that's the case, then ideally the pharmacist will go through an infectious disease residency program or receive specialized training and education to obtain the competencies required to run and champion an antibiotic stewardship program.
Gaining Prescriber Buy-in
The fourth barrier is achieving adoption or alignment from all of the hospital's prescribers. This is where education and physician practice pattern data are essential. The antibiotic stewardship program should educate clinician prescribers on the goals of the program and appropriate use of antibiotics for hospitalized patients. In addition, involving clinicians in the development of the program's goals and prescribing guidelines is essential. And it must collect, analyze and report back prescriber compliance with the evidence-based prescribing protocols established by the program. It's been my experience that physicians will adjust their practice patterns and prescribing habits favorably in response to education supported by the data.
Antibiotic Education for Patients
The fifth and final barrier is educating patients on the proper use of antibiotics. The programs must educate patients on the proper use of antibiotics prescribed to them after discharge—what to take, why to take it, how to take it, possible side effects and what to do if they have a problem. This is why it's also important for the programs to connect with their outpatient and local retail pharmacies, which can be great allies on patients' medication adherence. They can notify hospitals and prescribing physicians if prescriptions haven't been filled and follow up with patients after they've started taking their antibiotics and troubleshoot any problems.
Whether you are creating or improving and existing antibiotic stewardship program, keep these five key areas of focus in mind to improve clinical outcomes and control costs.
Related White Paper: Improving Patient Health and Your Bottom Line with Antibiotic Stewardship Programs