Improving antimicrobial use at hospitals that lack infectious disease specialists

此应用程序的主要目标是促进丹尼尔利沃西博士的发展， 一个独立的VHA调查员，致力于改善抗菌药物处方在整个 医疗保健的连续性。此应用程序特别关注优化 资源有限环境下的抗菌药物管理计划（ASP）。 ASP是以医院为基础的计划，确保患者在 正确的剂量和持续时间这些计划已证明有好处，例如 提高患者安全性和减少抗菌素耐药性。ASP现在被授权在 每个VHA设施，并将很快要求在非VHA医院以及。广泛 实施强有力的ASP对于解决抗生素耐药性危机至关重要。 虽然有必要，但广泛实施ASP将是一个挑战。许多ASP 缺乏获得传染病（ID）专家-包括23%的VHA-ASP-它是 不清楚ASP如何在资源有限的环境中发挥作用。此应用程序将开始 通过一个雄心勃勃但可实现的研究计划来解决这个问题。 项目1将分析来自VHA的抗菌药物使用数据。多变量分析 将用于确定与最佳设施级ASP相关的结构和过程因素 性能，通过机构抗菌药物使用（主要结局）和7个次要结局测量 指标.目标是确定即使在没有ID的情况下也能为ASP工作的流程 药剂师和身份识别医生。设施也将在风险调整后的主要 结果;将确定高绩效和低绩效。项目2将使用定性研究 方法来确定提供者的态度和组织因素，阻碍或促进 8家VHA医院的抗菌药物管理，ASP缺乏ID支持。本工程 小组将在4个低性能和4个高性能设施进行研究， 根据主要结局的表现。项目3将综合项目1的结果 2.为缺乏ID支持的低绩效ASP制定试点改进策略。的 医生指导实施模型将指导这种干预， 设计将用于评估2家干预医院的干预效果 与2家对照医院相比。 除了上述研究计划，本申请还提出了综合职业生涯 开发活动建立在Livorsi博士在领先ASP方面的专业知识和他之前的 具有定性评估和二级数据分析的经验。这些职业 发展活动有以下目标：1）获得流畅的分析， 国家VHA数据库和多层次回归模型的使用; 2） 实施科学，重点是定性评估; 3）提高熟练程度 多中心干预的实施和分析。 这些研究和职业发展计划将为Livorsi博士提交 一项由研究者发起的研究提案，重点是改进现有的管理指标。在 此外，这项工作将为未来的评估和实施调查奠定基础。 其他医疗保健环境中的管理流程，包括门诊、急诊 房间和社区生活中心。

The primary goal of this application is to foster the development of Dr. Daniel Livorsi as an independent VHA investigator devoted to improving antimicrobial-prescribing across the continuum of healthcare. This application specifically focuses on optimizing the performance of antimicrobial stewardship programs (ASPs) in resource-limited settings. ASPs are hospital-based programs that ensure patients receive the right antimicrobial at the right dose and for the right duration. These programs have proven benefits, such as improving patient safety and reducing antimicrobial resistance. ASPs are now mandated in every VHA facility and will soon be required in non-VHA hospitals as well. The widespread implementation of robust ASPs is essential for addressing the crisis of antimicrobial resistance. Though necessary, widespread ASP implementation will be challenging. Many ASPs lack access to Infectious Disease (ID) specialists—including 23% of VHA-ASPs—and it is unclear how ASPs can be effective in such resource-limited settings. This application will begin to address this problem through an ambitious but achievable Research Plan. Project 1 will analyze antimicrobial use data from across the VHA. Multivariable analysis will be used to identify structural and process factors associated with optimal facility-level ASP performance, as measured by facility antimicrobial usage (primary outcome) and 7 secondary metrics. The goal is to identify processes that work for ASPs even in the absence of ID pharmacists and ID physicians. Facilities will also be ranked on the risk-adjusted primary outcome; high and low performers will be identified. Project 2 will use qualitative research methods to determine provider attitudes and organizational factors that impede or foster antimicrobial stewardship at 8 VHA hospitals with ASPs lacking ID support. For this project, the team will conduct research at 4 low-performing and 4 high-performing facilities, as determined by performance on the primary outcome. Project 3 will synthesize the findings from Projects 1 and 2 to develop pilot improvement strategies for low-performing ASPs that lack ID support. The model of Physician Mentored Implementation will guide this intervention, and a pretest-posttest design will be used to assess the effect of the intervention at the 2 intervention hospitals compared to 2 control hospitals. In addition to the above Research Plan, this application proposes integrated Career Development activities that build on Dr. Livorsi’s expertise in leading ASPs and his prior experience with qualitative assessments and secondary data analysis. These career development activities have the following objectives: 1) gaining fluency in the analysis of national VHA databases and the use of multilevel regression models; 2) building expertise in implementation science with a focus on qualitative assessments; and 3) developing proficiency in the conduct and analysis of multicenter interventions. These Research and Career Development plans will prepare Dr. Livorsi for submitting an Investigator-Initiated Research proposal focused on refining existing stewardship metrics. In addition, this work will set the stage for future investigations into evaluating and implementing stewardship processes in other healthcare settings, including ambulatory clinics, emergency rooms, and Community Living Centers.