scholarly journals Inpatient antibiotic utilization in the Veterans’ Health Administration during the coronavirus disease 2019 (COVID-19) pandemic

2020 ◽  
pp. 1-3 ◽  
Author(s):  
Thomas D. Dieringer ◽  
Daisuke Furukawa ◽  
Christopher J. Graber ◽  
Vanessa W. Stevens ◽  
Makoto M. Jones ◽  
...  
Keyword(s):  
Antibiotic Use ◽  
Veterans Health Administration ◽  
Antibiotic Prescribing ◽  
Veterans Health ◽  
Health Administration ◽  
Prescribing Practices ◽  
Antibiotic Utilization ◽  
Days Of Therapy

Abstract Antibiotic prescribing practices across the Veterans’ Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

2020 ◽  
pp. 1-8
Author(s):  
James L. Lowery ◽  
Bruce Alexander ◽  
Rajeshwari Nair ◽  
Brett H. Heintz ◽  
Daniel J. Livorsi
Keyword(s):  
Emergency Departments ◽  
Respiratory Infections ◽  
Antibiotic Use ◽  
Veterans Health Administration ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Veterans Health ◽  
Health Administration ◽  
Urgent Care Centers ◽  
Exacerbation Of Copd

Abstract Objective: Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). Design: This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. Results: There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). Conclusions: Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

scholarly journals Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship within Veterans Health Administration Emergency Department and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes

2020 ◽  
Author(s):  
Karl Madaras-Kelly ◽  
Christopher Hostler ◽  
Mary Townsend ◽  
Emily M Potter ◽  
Emily S Spivak ◽  
...  
Keyword(s):  
Respiratory Tract ◽  
Antibiotic Stewardship ◽  
Odds Ratio ◽  
Veterans Health Administration ◽  
Antibiotic Prescribing ◽  
Veterans Health ◽  
Health Administration ◽  
Difference In Differences ◽  
The Core ◽  
Core Elements

Abstract Background The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but evidence supporting safety are limited. We report the impact of Core Elements implementation within Veterans Health Administration sites. Methods A quasi-experimental controlled study assessed the effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARI). Outcomes included per-visit antibiotic prescribing, treatment appropriateness, potential benefits and complications of reduced antibiotic treatment, and change in ARI diagnoses over a 3-year pre-implementation and 1-year post implementation period. Logistic regression adjusted for covariates [OR (95% CI)] and a difference-in-differences analysis compared outcomes between intervention and control sites. Results From 2014-2019, there were 16,712 and 51,275 patient-visits in 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre-post implementation in intervention sites were 59.7% and 41.5%, respectively; in control sites they were 73.5% and 67.2%, respectively [difference-in-differences p&lt;0.001]. The intervention site pre-post implementation odds ratio to receive appropriate therapy increased [1.67 (1.31, 2.14)] which remained unchanged within control sites [1.04 (0.91, 1.19)]. There was no difference in ARI-related return visits post-implementation [(-1.3% vs. -2.0%; difference-in-differences p=0.76] but all-cause hospitalization was lower within intervention sites [(-0.5% vs. -0.2%); difference-in-differences p=0.02]. The odds ratio to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention [1.27(1.21,1.34)] but not control [0.97(0.94,1.01)] sites. Conclusions Implementation of the Core Elements was associated with reduced antibiotic prescribing for uncomplicated ARIs and a reduction in hospitalizations. ARI diagnostic coding changes were observed.

scholarly journals 12. Development of Provider-Specific Antibiotic Prescribing Feedback for Inpatient Antibiotic Stewardship Programs in Veterans Affairs (VA) Facilities (ASP)

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S8-S9
Author(s):  
Matthew B Goetz ◽  
Matthew B Goetz ◽  
Michelle Fang ◽  
Feliza Calub ◽  
Pamela Belperio ◽  
...  
Keyword(s):  
Acute Care ◽  
Broad Spectrum ◽  
Medical Records ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Days Of Therapy ◽  
Control And Prevention ◽  
Medical Wards ◽  
Future Work

Abstract Background Provision of provider-specific outpatient antibiotic prescribing data has resulted in significant decreases in antibiotic use. We describe the development of reports of inpatient antibiotic prescribing by hospitalists attending on acute medical wards in VA medical facilities. Methods We created algorithms for determining the attending physician responsible for patient days present (DP), by considering changes of service (e.g., prior to admission from the emergency department) and transfers between services or physicians. Each antibiotic dose was assigned to a single attending, ward location, and service according to denominator assignment. Antibiotic use was grouped into Centers for Disease Control and Prevention drug categories and expressed as antibiotic days of therapy (DOT) per 1000 DP. Data were obtained from the VA Corporate Data Warehouse. Algorithms were iteratively refined based on reviews of medical records from three VA medical centers and applied to acute care patients at a single site for 2018-2020. Results In 2018-2020, 294 attendings oversaw acute inpatient care for &gt;= 14 DP. 129 attendings with &gt;= 300 DP oversaw 88.0% of all patient care and prescribed 87.6% of all antibiotics (480 DOT/1000 DP, IQR 375-559), 90.1% of broad-spectrum therapy for hospital-onset infections (55 DOT/1000 DP, IQR 31-72) and 88.3% of resistant Gram-positive therapy (70 DOT/1000 DP, IQR 39-89) in inpatient wards. The distribution of antibiotic use for acute care ward patients amongst these 129 staff is shown in the following figure. Conclusion We developed algorithms to attribute antibiotic therapy to inpatient attendings that can be broadly applied in facilities with electronic medical records. As with outpatient prescribing, we found large variation across inpatient attendings in overall antibiotic use and broad-spectrum antibiotic use. In future work, we will obtain provider feedback of report usability and interpretability and assess whether distribution of these reports allows antibiotic stewards to favorably influence provider prescribing practices. Disclosures Matthew B. Goetz, MD, Nothing to disclose Arjun Srinivasan, MD, Nothing to disclose

Assessing the impact of prescribing directives on opioid prescribing practices among Veterans Health Administration providers

2016 ◽  
Vol 26 (1) ◽  
pp. 40-46 ◽  
Author(s):  
Catherine Barber ◽  
David Gagnon ◽  
Jennifer Fonda ◽  
Kelly Cho ◽  
John Hermos ◽  
...  
Keyword(s):  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
The Impact

scholarly journals Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone Prescribing at Hospital Discharge: A Retrospective Analysis Among 122 Veterans Health Administration Hospitals

2019 ◽  
Vol 71 (5) ◽  
pp. 1232-1239 ◽  
Author(s):  
Hiroyuki Suzuki ◽  
Eli N Perencevich ◽  
Bruce Alexander ◽  
Brice F Beck ◽  
Michihiko Goto ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Retrospective Cohort ◽  
Veterans Health Administration ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Patient Admissions ◽  
Days Of Therapy ◽  
Strategy Types ◽  
Prospective Audit And Feedback

Abstract Background Despite increasing awareness of harms, fluoroquinolones are still frequently prescribed to inpatients and at hospital discharge. Our goal was to describe fluoroquinolone prescribing at hospital discharge across the Veterans Health Administration (VHA) and to contrast the volume and appropriateness of fluoroquinolone prescribing across 3 antimicrobial stewardship strategy types. Methods We analyzed a retrospective cohort of patients hospitalized at 122 VHA acute-care hospitals during 2014–2016. Data from a mandatory VHA survey were used to identify 9 hospitals that self-reported 1 of 3 strategies for optimizing fluoroquinolone prescribing: prospective audit and feedback (PAF), restrictive policies (RP), and no strategy. Manual chart reviews to assess fluoroquinolone appropriateness at hospital discharge (ie, postdischarge) were performed across the 9 hospitals (3 hospitals and 125 cases per strategy type). Results There were 1.7 million patient admissions. Overall, there were 1 727 478 fluoroquinolone days of therapy (DOTs), with 674 918 (39.1%) DOTs prescribed for inpatients and 1 052 560 (60.9%) DOTs prescribed postdischarge. Among the 9 reviewed hospitals, postdischarge fluoroquinolone exposure was lower at hospitals using RP, compared to no strategy (3.8% vs 9.3%, respectively; P = .012). Postdischarge fluoroquinolones were deemed inappropriate in 154 of 375 (41.1%) patients. Fluoroquinolones were more likely to be inappropriate at hospitals without a strategy (52.8%) versus those using either RP or PAF (35.2%; P = .001). Conclusions In this retrospective cohort, the majority of fluoroquinolone DOTs occurred after hospital discharge. A large proportion of postdischarge fluoroquinolone prescriptions were inappropriate, especially in hospitals without a strategy to manage fluoroquinolone prescribing. Our findings suggest that stewardship efforts to minimize and improve fluoroquinolone prescribing should also focus on antimicrobial prescribing at hospital discharge.

scholarly journals A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative

2017 ◽  
Vol 38 (5) ◽  
pp. 513-520 ◽  
Author(s):  
Allison A. Kelly ◽  
Makoto M. Jones ◽  
Kelly L. Echevarria ◽  
Stephen M. Kralovic ◽  
Matthew H. Samore ◽  
...  
Keyword(s):  
Healthcare System ◽  
Antimicrobial Stewardship ◽  
Antibiotic Use ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Antimicrobial Utilization ◽  
Before And After ◽  
Gram Negative Organisms ◽  
Proportional Distribution

OBJECTIVETo detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program.DESIGNObservational analysis.SETTINGThe VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities.METHODSUtilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities.RESULTSNationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection.CONCLUSIONSThe VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs.Infect Control Hosp Epidemiol 2017;38:513–520

scholarly journals 211. A Comprehensive Assessment of Carbapenem Use across 90 Veterans Health Administration Hospitals with Defined Stewardship Strategies for Carbapenems

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S108-S109
Author(s):  
Hiroyuki Suzuki ◽  
Eli N Perencevich ◽  
Michihiko Goto ◽  
Bruce Alexander ◽  
Rajeshwari Nair ◽  
...  
Keyword(s):  
Veterans Health Administration ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Prospective Audit ◽  
Assessment Scores ◽  
Important Target ◽  
Days Of Therapy ◽  
Prospective Audit And Feedback ◽  
Research Grant

Abstract Background Carbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use. Methods We analyzed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute-care hospitals during 2016 and mandatory survey data that characterized each hospital’s carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit-and feedback (PAF), or restrictive policies (RP). Sites that could not be classified were excluded. Inpatient carbapenem use was compared across strategies using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two Infectious Disease (ID) physicians independently performed manual chart reviews in 425 randomly-selected carbapenem-treated cases (100 for PAF/NS and 225 for RP). Auditors assessed for the presence of ID consultation and carbapenem appropriateness on day 4 of therapy. Assessments were categorized as follows: appropriate (1), acceptable (2), suboptimal (3), unnecessary (4) and inappropriate (5). Assessment scores across strategies were compared with the Kruskal-Wallis test. Results There were 429,602 admissions in 90 sites (8 PAF, 24 NS, 58 RP). Median carbapenem use across sites was 17.4 (IQR 8.6–28.4) days of therapy/1,000 days-present. Inpatient carbapenem use was lower at PAF than NS sites [RR 0.67 (95% CI, 0.46–0.98); p=0.04] but similar between RP and NS sites [RR 0.86 (95% CI, 0.61–1.22); p=0.41]. Carbapenem use was considered appropriate or acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were higher (i.e. worse) at NS than RP sites (mean 2.7 vs 2.3; p&lt; 0.01) but did not differ significantly between NS and PAF sites (mean 2.7 vs 2.5; p=0.14). ID consultations were more common at PAF/RP than NS sites (51% vs 29%; p&lt; 0.01). ID consultations were associated with lower (i.e. better) assessment scores (2.3 vs. 2.6; p&lt; 0.01). Conclusion In this VHA cohort, AS strategies and ID consultations were associated with either less or more appropriate carbapenem-prescribing. The use of AS and ID consultations may be complementary, and hospitals could leverage both to optimize carbapenem use. Disclosures Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support)

scholarly journals Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists

2020 ◽  
Author(s):  
Daniel J Livorsi ◽  
Rajeshwari Nair ◽  
Brian C Lund ◽  
Bruce Alexander ◽  
Brice F Beck ◽  
...  
Keyword(s):  
Infectious Disease ◽  
Antibiotic Stewardship ◽  
Negative Binomial ◽  
Negative Binomial Regression ◽  
Antibiotic Use ◽  
Negative Binomial Regression Model ◽  
Veterans Health ◽  
Health Administration ◽  
Patient Admissions ◽  
Days Of Therapy

Abstract Background Many US hospitals lack infectious disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist. Methods This retrospective VHA cohort included all acute-care patient admissions during 2016. A mandatory survey was used to identify hospitals’ antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy per days present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient admissions. Results Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525 451 (95.8%) admissions at ID hospitals and 23 007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use (odds ratio, 0.92; 95% confidence interval, .85–.99). Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials (0.61; .54–.70) and higher narrow-spectrum β-lactam use (1.43; 1.22–1.67). Total antibacterial exposure (inpatient plus postdischarge) was lower among patients at ID versus non-ID sites (0.92; .86–.99). Conclusions Patients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship.

scholarly journals 102. Evaluation of the Association between the Antibiotic Spectrum Index and Antibiotic Days of Therapy: A Retrospective Study across 124 Acute-care Hospitals

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S165-S166
Author(s):  
Satoshi Kakiuchi ◽  
Michihiko Goto ◽  
Fernando Casado-Castillo ◽  
Eli N Perencevich ◽  
Daniel J Livorsi
Keyword(s):  
Acute Care ◽  
Rank Order ◽  
Antibiotic Use ◽  
Antibiotic Consumption ◽  
Hospital Performance ◽  
Veterans Health ◽  
Health Administration ◽  
Hospital Level ◽  
Average Spectrum ◽  
Days Of Therapy

Abstract Background Antibiotic stewardship programs often measure antibiotic days of therapy (DOT), but this metric does not reflect the antibiotic spectrum. In this study, we used the previously published Antibiotic Spectrum Index (ASI), which attaches a score (1-13) to the spectrum of each antibiotic, to evaluate the content of antibiotic use across all Veterans Health Administration (VHA) hospitals. We also assessed how benchmarking hospital performance changed when ASI was used instead of DOT. Methods We conducted a retrospective cohort study of patients admitted to 124 acute-care VHA hospitals during 2018. We obtained data on administered antibiotics, the days of antibiotic use (DOT), and days-present (DP) from the VHA Corporate Data Warehouse and then aggregated data to the hospital-level using the National Healthcare Safety Network’s methodology. We modified the original ASI by changing 3.8% of the bug-drug scores to ensure consistency across all scores and adding 27 new antibiotics agents. For each hospital, we calculated ASI/DOT, ASI/1,000 DP, and DOT/1,000 DP and ranked hospitals on their performance. We performed a Spearman’s rank-order correlation to compare hospitals on these metrics and their associated rankings. Results At the hospital-level, the median ASI/DOT, ASI/1,000 DP and DOT/1,000 DP were 5.4 (interquartile range: 5.2-5.8), 2,332.7 (1,941.8-2,796.2) and 443.5 (362.5-512.2), respectively. There was a strong correlation between the ASI/1,000 DP and DOT/1,000 DP metrics [Spearman’s correlation test: r=0.97 (p&lt; 0.01)] but only a weak and insignificant correlation between ASI/DOT and DOT/1,000 DP [r=0.17 (p=0.06), Figure 1]. Twenty (16.1%) hospitals showed a difference of 10% or more in their ranking for ASI/1,000 DP compared to their ranking for DOT/1,000 DP. The range of ranking difference was from -17.7% to 21.0% (Figure 2a and b). Figure 1. Distribution of the Antibiotic Spectrum Index / Day of Therapy by Days of Therapy / 1000 Days Present for 124 Acute-Care VHA Hospitals during 2018. Black line: Median values of DOT/1,000 DP and ASI/DOT, respectively. Figure 2. (a) Distribution of the rankings in DOT/1,000 DP and ASI/1,000 DP. Blue line: the position of same ranking between ASI/1,000 DP and DOT/1,000 DP. (b) Distribution of the differences in each hospital’s ranking for DOT/1,000 DP and ASI/1,000 DP Conclusion Our findings suggest that hospitals using fewer days of antibiotic therapy did not necessarily use narrower-spectrum antibiotics. ASI/1,000 DP, as a combined measure of antibiotic consumption quantity and average spectrum, provided a different view of hospital performance than DOT/1,000 DP alone. Future work is needed to define how this new metric relates to the quality of antibiotic use. Disclosures All Authors: No reported disclosures

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