predictors of asp recommendation disagreement 811
table 2. Multivariate Logistic Regression Model of Predictors for PAFR Nonadherence24
Value
Recommendation group Stop
Clarify
Optimize dose or frequency IV to PO Other
Duration modification Change agent
Infectious problem grouping Bacteremia Other UTI
Prophylaxis
Respiratory infection Sepsis
Gastrointestinal/IAI Febrile neutropenia
Skin and soft-tissue infection Days to audit category 0–30
31–90 91+
Medical service group Intensive care Surgical
Neonatology Medical
Cardiovascular intensive care Years post training
Odds Ratio (95% CI)
Reference
0.15 (0.05–0.43) 0.20 (0.09–0.47) 0.47 (0.19–1.17) 0.94 (0.49–1.81) 1.15 (0.59–2.26) 1.24 (0.76–2.01)
Reference
0.78 (0.15–4.17) 1.18 (0.32–4.38) 1.62 (0.61–4.34) 1.71 (0.71–4.11) 2.26 (0.97–5.24) 5.5 (1.99–15.21) 6.14 (2.08–18.12) 6.16 (1.92–19.77)
Reference
2.08 (1.36–3.18) 1.06 (0.56–2.00)
Reference
0.32 (0.03–2.92) 0.37 (0.22–0.63)
Heme-onc/stem-cell transplant 0.50 (0.22–1.16) 0.70 (0.31–1.60) 1.17 (0.73–1.88) 1.02 (1.01–1.04)
P Value <.001
…
<.001 <.001 .097 .84 .67 .38
<.001 …
.77 .80 .33 .22
.053
<.001 <.001 .002 .003 …
<.001 .86
<.001 …
.30
<.001 .10 .39 .50 .01
NOTE. Heme-onc, hematology-oncology; IAI, intra-abdominal infection; IV, intravenous; LOS, length of stay; PAFR, prospective audit and feedback recommendation; PO, enteral; UTI, urinary tract infection.
and skin and soft-tissue infections as predictors of provider disagreement with PAFR. Given the existence of evidence- based consensus guidelines for the management of these infections, the degree of disagreement between the patient care team and ASPs is particularly interesting.11,12 Our institution implemented a clinical practice guideline for the treatment of febrile neutropenia in June 2015, before the PAF program was initiated in the hematology-oncology unit. Although this guideline served as the foundation of ASP PAFR for patients with febrile neutropenia, we found significant provider disagreement with ASP recommendations. Thus, establishing institutional guidelines for an infectious problem, in isolation, may not resolve potential disagreement between the care team and the ASP. Additional opportunities to improve antimicrobial utilization may exist, and prospective monitor- ing of adherence to institutional guidelines may be essential to their success as stewardship interventions. The involvement of
the ASP team in the formulation of institutional treatment guidelines is also essential if there is to be consensus on the approach to antimicrobial therapy. We examined the relationship between several character-
istics of a patient’s hospitalization and provider disagreement with PAFR. In our study, providers were twice as likely to disagree with recommendations for patients who had been hospitalized 31–90 days at the time of PAF compared to patientswho had been hospitalized for ≤30 days. One potential explanation for this finding may be that patients with prolonged hospitalizations face unique infectious issues. This finding should be examined in future PAF research, as it may represent an important opportunity for ASPs to optimize appropriate antimicrobial prescribing in patients with extended hospital stays or who are receiving prolonged course of antibiotics (eg, endocarditis, osteomyelitis, menin- gitis) as inpatients. Given this finding, it may be helpful for ASPs to recommend formal ID consultations for patients with longer lengths of stay or prolonged antimicrobial courses. Because our program implemented PAF to the indi- vidual units on a rolling basis, we evaluated the time between PAF program implementation on a given unit to the time of a given audit. We were reassured to find that this was not a statistically significant predictor of PAFR disagreement, suggesting that the responsiveness of care teams to PAFR did not wane over time. The only programmatic predictor of PAFR disagreement
identified by our study was the recommendation type; provi- ders were significantly less likely to agree with recommenda- tions to stop antimicrobials than to clarify the indication or optimize the dosing. Similarly, prior studies have shown a willingness of providers to modify dosing of antimicrobials as recommended by the ASP.7 Given that our program’s most
common recommendation was to stop the antimicrobial, the finding that providers are less likely to follow this recom- mendation is concerning and merits further examination. Qualitative research that explores the decision process provi- ders use to decide whether to accept or disagree with PAFR may clarify this finding. Our study is the first to identify an association between the
years of attending experience and PAFR disagreement. This finding may reflect the relatively recent national prioritization
of antimicrobial stewardship and associated implementation of formal programs in hospitals in the last decade.4 As a result, many medical education and doctor-in-training programs have evolved to include principles of antimicrobial steward- ship. Clinicians who have trained at hospitals with formal ASP programs may respond more favorably to interventions supporting the judicious use of antimicrobials. On the other hand, physicians who trained prior to the antimicrobial stewardship era may be less inclined to follow PAFR. This finding underscores the need for incorporating antimicrobial stewardship into continuing education strategies for all physicians.13,14 Our study results indicated that PAFR for audits performed on patients in the PICU were less likely to be followed
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
