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Meghan E. Griebel et al
Table 1. Clinical Outcomes in Patients Who Received at Least 1 Dose of an Inpatient Antimicrobial Before and During the Period of Prospective-Audit-and-Feedback at the Iowa City VA Medical Center, January 1, 2013 to December 31, 2017
Clinical Outcome
Length-of-stay, median (IQR) Inpatient mortality, %
Clostridium difficile infections within 30 days of hospital discharge, % Readmission within 30 days of hospital discharge, %
Pre-PAF (n=4,974) 4.0 (3–7) 2.1 0.7
15.2
Note. PAF, prospective audit and feedback; SD, standard deviation. aThe Wilcoxon rank-sum test was used to compare median length of stay between periods. A χ2 test was used for all categorical variables.
PAF (n=4,159) 4.0 (3–7) 2.3 0.6
13.5
P Valuea .71 .59 .60 .02
Table 2. Antimicrobial Prescribing Outcomes for 4 Clinical Conditions Before and During the Period of Prospective-Audit-and-Feedback: Antimicrobial Appro- priateness on Day 3 of Therapy and Total Duration of Therapy
Antimicrobial Appropriateness
Cohort (Sample Size for Pre-PAF, Sample Size for PAF) Pre-PAF, No. (%) PAF, No. (%)
CAP (42, 40)
COPD-E (48, 40) Cellulitis (40, 25) Cystitis (40, 36)
33 (78.6) 24 (50.0) 19 (47.5) 15 (37.5)
27 (67.5) 25 (62.5) 20 (80.0) 26 (72.2)
Duration of Therapy, Days
P Value Pre-PAF, Mean (SD) PAF, Mean (SD) .26 .24
<.01 <.01
9.0 (3.0) 7.1 (2.5) 13.2 (4.5) 11.4 (4.4)
7.0 (2.3) 5.3 (1.2) 12.1 (3.9) 8.4 (2.8)
P Value <.01 <.01 .48
<.01 Note. CAP, community-acquired pneumonia; COPD-E, acute exacerbations for chronic obstructive pulmonary disease; PAF, prospective audit and feedback; SD, standard deviation.
antimicrobial, including inpatient mortality (2.1% vs 2.3%; P=.59), length-of-stay (median, 4.0 vs 4.0 days; P=.71), and Clostridium difficile infections as defined by a positive enzyme immunoassay for toxins A and B (0.7% vs 0.6%; P=.60) (Table 1). However, hospital readmissions within 30 days of discharge significantly declined during the PAF period (15.2% vs 13.5%; P=.02). During the PAF period, the same proportion of patients were discharged on oral antimicrobials (38.6% vs 36.9%; P=.08) but the mean duration of antimicrobials on discharge decreased (5.2 days vs 4.5 days; P=.01). There was no change in the pla- cement of peripherally inserted central catheters for outpatient parental antimicrobial therapy (2.8% vs 2.9%; P=.58).
Antimicrobial-prescribing outcomes
In total, 1,145 patient admissions from the entire cohort were eligible for chart review. Overall, 1,003 charts were reviewed to assess antimicrobial-appropriateness and duration of therapy (Supplemental Fig. 2), and 311 (31.0%) met inclusion criteria. PAF implementation was associated with increased antimicrobial appropriateness in cellulitis (47.5% vs 80.0%; P<.01) and cystitis (37.5% vs 72.2%; P<.01) but no change in appropriate pre- scribing for CAP (78.6% vs 67.5%; P=.26) and COPD-E (50.0% vs 62.5%; P=.24) (Table 2). Reasons for inappropriate anti- microbial prescribing can be found in Supplemental Table 3. PAF implementation was also associated with a decreased mean duration of therapy in CAP (9.0 vs 7.0 days; P<.01), COPD-E (7.1 vs 5.3; P<.01), and cystitis (11.4 vs 8.4; P<.01), but not cellulitis (13.2 vs 12.1; P=.48) (Table 2).
Discussion
In this single-center study, the SAAR for total antimicrobial use significantly and immediately decreased in response to PAF imple- mentation, a finding described in at least 1 other study.6 Before PAF, thebaselineSAARat
the facility was <1, which indicates that
antimicrobial use was already lower than the predicted utilization for a comparable hospital. Nevertheless, the SAAR decreased even fur- ther upon implementation of PAF, while antimicrobial-prescribing outcomes and patient safety outcomes remained stable or improved. Although the optimal SAAR for a hospital has not been defined, our findings suggest that values substantially <1.0 can be safely achieved. After the initial decrease in the SAAR, it started to minimally
but significantly rise over time despite the continuation of PAF. There are several potential explanations for this finding. First, the initial reduction in the SAAR may have been too extreme, and the changes seen through the remainder of the PAF period may reflect a recalibration. Second, the ASP team was increasingly encouraged to give clinical team pharmacists opportunities to make their own stewardship recommendations. This is reflected by a decrease over time in the number of PAF recommendations. Our study has several limitations. First, without a control group,
we were unable to prove that changes in any metrics were due to PAF and not an alternate process. For example, patient case-mix changed after PAF implementation, which may have contributed to changes in the SAAR. Second, although our regression model eval- uated monthly SAARs, quarterlySAARs maybe more meaningful, especially at small facilities like ours. Third, these study results may not be generalizable to hospitals with fewer ASP resources. Finally, we excluded many patients from chart review to identify a cohort for which established guidelines would apply.
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