Benchmarking Inpatient Antimicrobial Use: A Comparison of Risk-Adjusted Observed-to-Expected Ratios
Benchmarking Inpatient Antimicrobial Use: A Comparison of Risk-Adjusted Observed-to-Expected Ratios
复制标题
DOI：
10.1093/cid/ciy354
复制
发表时间：
2018-12-01
影响因子：
11.8
通讯作者：
Jones, Jason
中科院分区：
文献类型：
--
作者：
Yu, Kalvin C.;Moisan, Elizabeth;Jones, Jason
背景。不断增加的抗生素耐药性使得住院患者适当使用抗生素成为全球优先事项，得到了专家协会和监管机构的支持；然而，公平的设施间比较的标准风险调整一直难以实现。我们描述了风险调整后的抗生素暴露比，这可能有助于促进抗菌药物使用的评估。方法。这是一项对 270 万名入院患者进行的回顾性队列研究，采用递归划分和泊松回归的两步法，评估了一系列与预期抗生素消耗量相关的潜在解释变量。计算了风险调整后抗生素使用的观察与预期比率。比较了不同复杂性的三种模型：（1）由分层模型中所有可用抗生素使用风险因素组成的复杂比率； (2) 使用通用设施和单水平模型中的遭遇因素简化抗菌药物管理计划 (ASP) 比率； (3) 仅使用广泛的医院特征的设施比率。结果。诊断相关群体、入院时出现的感染、患者类别和病房类型是预期抗生素使用的主要预测因素。除了过去 12 个月内抗甲氧西林金黄色葡萄球菌药物的革兰氏阳性耐药史之外，额外的临床和共病史信息并没有改善模型。简化的 ASP 比率与复杂比率（R-2 = 0.97-0.99）相比，与设施比率（R-2 = 0.57-0.85）具有更高的 Pearson 相关性，并在不一致时提供临床解释。结论。简化的 ASP 比率源自简约模型，该模型通过患者层面的风险调整纳入疾病负担，并更好地为管理评估提供信息。这可以改善医疗机构之间抗生素使用的比较。
Background. Increasing antibiotic resistance has made benchmarking appropriate inpatient antibiotic use a worldwide priority supported by expert societies and regulatory bodies; however, standard risk adjustment for fair interfacility comparison has been elusive. We describe a risk-adjusted antibiotic exposure ratio that may help facilitate assessment of antimicrobial use.Methods. This was a retrospective cohort study of 2.7 million admissions evaluating a wide array of potential explanatory variables for correlation with expected antibiotic consumption in a 2-step approach using recursive partitioning and Poisson regression. Observed-to-expected ratios of risk-adjusted antibiotic use were calculated. Three models of varying complexity were compared: (1) a complex ratio consisting of all available antibiotic use risk factors in a hierarchical model; (2) a simplified antimicrobial stewardship program (ASP) ratio using common facility and encounter factors in a single-level model; and (3) a facility ratio using only broad hospital characteristics.Results. Diagnosis-related groups, infection present on admission, patient class, and unit type were the major predictors of expected antibiotic use. Aside from a history of gram-positive resistance in the prior 12 months for anti-methicillin-resistant Staphylococcus aureus drugs, additional clinical and comorbid history information did not improve the model. The simplified ASP ratio demonstrated higher Pearson correlation (R-2 = 0.97-0.99) to the complex ratio than the facility ratio (R-2 = 0.57-0.85) and provided clinical explanations when discordant.Conclusions. The simplified ASP ratio is derived from a parsimonious model that incorporates disease burden through patient-level risk adjustment and better informs stewardship assessment. This may allow for improved comparison of antibiotic use between healthcare facilities.