Infection Control & Hospital Epidemiology (2018), 39, 1476–1479 doi:10.1017/ice.2018.248
Concise Communication
Understanding changes in the standardized antimicrobial administration ratio for total antimicrobial use after implementation of prospective audit and feedback
Meghan E. Griebel PharmD1, Brett Heintz PharmD, BCPS AQ-ID, AAHIVE1, Bruce Alexander PharmD1,
Jason Egge PharmD, BCPS, MS1, Michihiko Goto MD, MS1,2 and Daniel J. Livorsi MD, MSc1,2 1Iowa City Veterans Affairs Health Care System, Iowa City, Iowa and 2Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
Abstract
In this single-center study, the standardized antimicrobial administration ratio (SAAR) for total antimicrobial use decreased in response to a stewardship intervention. Antimicrobial prescribing and clinical outcomes were stable or improved during the period of lower SAARs. Our findings suggest that SAAR values of ~0.8 can be safely achieved.
(Received 27 June 2018; accepted 30 August 2018; electronically published October 10, 2018)
Measuring and evaluating antimicrobial use at the facility level is an important component of antimicrobial stewardship.1 In 2014, the Centers for Disease Control and Prevention introduced a novel metric, the standardized antimicrobial administration ratio (SAAR), which has since been endorsed by the National Quality Forum. The SAAR compares observed antimicrobial use at a given hospital to predicted use, while adjusting for hospital size, unit type, and academic affiliation.2 A study of 75 hospitals found that 41% had a SAAR for total antimicrobial use that was sta- tistically >1.3 While the purpose of the SAAR is to facilitate benchmarking
across hospitals, it is unclear whether changes in the SAAR cor- respond to changes in antimicrobial appropriateness or in clinical outcomes.4,5 The goal SAAR also remains undefined. Our objective was to evaluate whether declines in the SAAR at
our facility were associated with changes in antimicrobial pre- scribing and associated outcomes.
Methods Study design
This retrospective cohort study was conducted at the Iowa City Veterans Affairs (VA) Medical Center, which includes a 58-bed medical-surgical unit and a 10-bed intensive care unit. In October 2015, the hospital’s antimicrobial stewardship program (ASP) began performing prospective audit and feedback
Author for correspondence: Daniel Livorsi, MD, MSc, Division of Infectious Dis-
eases, University of Iowa Carver College of Medicine, Iowa VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246. E-mail:
daniel-livorsi@uiowa.edu
Cite this article: Griebel M, et al. (2018). Understanding changes in the standardized
antimicrobial administration ratio for total antimicrobial use after implementation of prospective audit and feedback. Infection Control & Hospital Epidemiology 2018, 39, 1476–1479. doi: 10.1017/ice.2018.248
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
(PAF) during weekdays on all inpatients receiving antimicrobials. For this report, we describe a pre-PAF period (January 1, 2013, through June 30, 2015), a washout period (July 1, 2015, through September 30, 2015), and a PAF period (October 1, 2015, through December 31, 2017). During the pre-PAF period, an infectious disease–trained pharmacist was responsible for inpatient clinical pharmacy services. Antimicrobial utilization data was submitted to the anti-
microbial use option of the National Healthcare Safety Network (NHSN). Monthly reports of the SAAR for all antimicrobial agents were downloaded from the NHSN website. To assess baseline characteristics and outcomes among
patients who received antimicrobials, a cohort was developed that included all hospitalized patients who had received at least 1 dose of an inpatient antimicrobial during study dates.2 All relevant data were extracted from the VA Informatics and Computing Infrastructure (VINCI) data warehouse. To assess antimicrobial prescribing, manual chart reviews were performed on a subset of inpatients with eligible diagnostic codes from January 1, 2013, through June 30, 2015, and from October 1, 2015, through June 30, 2017. There were 4 diagnostic cohorts for this chart review: community-acquired pneumonia (CAP), acute exacerbations of chronic obstructive pulmonary disease (COPD-E), cellulitis, and cystitis (supplemental protocol).
Statistical analysis
To assess changes in the SAAR, we constructed a Poisson regression model with a generalized estimated equation using a harmonic seasonality adjustment. Observed days of therapy (DOTs) was the outcome variable, and predicted DOTs was the denominator (offset) variable. Slopes of trends and changes in intercepts were calculated as incidence rate ratios (IRRs). Model diagnostics, including autocorrelation functions and residual
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