Development, Validation and Real-World Application of Comprehensive Metrics to Improve Hospitals' Antibiotic Prescribing

改善医院抗生素处方的综合指标的开发、验证和实际应用

• 批准号: 10636459
• 负责人: Michihiko Goto
• 金额: --
• 依托单位: IOWA CITY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-01 至 2027-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10636459
• 关键词: Address; Advisory Committees; Antibiotics; Antimicrobial Resistance; Bacteria; Beds; Case Mixes; Consensus; Data; Development; Disease; Educational process of instructing; Effectiveness; Exercise; Feedback; Focus Groups; Future; Goals; Health Policy; Healthcare; Hospital Administration; Hospitalization; Hospitals; Human; Inpatients; Interview; Knowledge; Length of Stay; Location; Mathematics; Measures; Methodology; Methods; Patients; Performance; Process; Public Health; Qualitative Methods; Quality of Care; Recommendation; Reporting; Research; Risk; Risk Adjustment; Risk Factors; Role; Safety; Site; Standardization; Structure; Surveys; Techniques; Validation; Variant; Veterans; Veterans Health Administration; Work; acute care; antimicrobial; dashboard; data integration; emerging antimicrobial resistance; hospital care; hospital performance; improved; innovation; novel; patient safety; programs; real world application; response; success; tool

Background: Antimicrobial resistance is an urgent public health problem and a threat to patient safety. Antimicrobial use is the strongest risk factor for the emergence of antimicrobial resistance By reducing unnecessary antimicrobial use and improving necessary use, antimicrobial stewardship programs (ASPs) are an important tool in the battle against antimicrobial resistance. ASPs are mandated both in and outside VHA. Significance: There is not a universally accepted metric to assess ASP success. A hospital-level metric, known as the Standardized Antimicrobial Administration Ratio (SAAR), is being widely implemented across US hospitals, including in VHA. However, the SAAR has not been validated and has several weaknesses, including lack of patient-level risk adjustment and no consideration for antimicrobial spectrum of activity. Innovation & Impact: This proposal will target a critical research gap by developing, refining and validating novel metrics that address the limitations of the SAAR. These novel metrics include: 1) a risk-standardized days of therapy (DOT) ratio (RSDTR), which differs from the SAAR in its adjustment for differences in patient case-mix; 2) a Days of Antimicrobial Spectrum Coverage (DASC) score, which differs from the SAAR in its capture of both antimicrobial use and spectrum of activity, and 3) a risk-standardized DASC. Through our aims, we will assess 3 types of validity (construct, content and predictive) for the SAAR and the 3 novel metrics. Specific Aims: A1: Identify non-modifiable factors that contribute to appropriate variation in antimicrobial use across VHA acute-care hospitals by evaluating potential patient-level, hospital-level, and environmental effects. H1: Non-modifiable factors can be identified by consensus-building exercises and mathematical techniques. A2: Evaluate whether hospitals that have implemented more robust stewardship processes, as measured by a mandatory VHA survey, perform better on the SAAR and the three novel metrics. H2: The association between the robustness of stewardship and a hospital's metric performance will be strongest for the risk-standardized DASC score. A3: Using qualitative methods, assess the content validity of the SAAR and the three novel metrics among key stakeholders across ten hospitals, including high and low-performing sites. H3: Key stakeholders across all sites will confirm the validity of the RSDTR and risk-standardized DASC and will have concerns about the validity of metrics that do not involve patient-level risk-adjustment. A4: Evaluate the longitudinal relationship between a hospital's performance on the four metrics and the emergence of healthcare-associated antimicrobial resistance. H4: The novel metrics will have a stronger association with future antimicrobial resistance than the SAAR. Methodology: Our proposal will leverage both quantitative and qualitative methods. In Aim 1, we will use a modified two-stage Delphi method, which will integrate data-driven and human-driven selection strategies, to identify non-modifiable risk factors that should be used to risk-standardize DASC and also DOT (e.g. the RSDTR metric). In Aim 2, we will use hospitals' responses to a mandatory survey to measure the association between the intensity of stewardship activities and metric performance (construct validity). In Aim 3, we will perform semi-structured interviews and focus groups with key stakeholders to assess the content validity of the four metrics. In Aim 4, we will leverage 17 years of VHA data to determine whether a hospital's performance on each metric is associated with the future development of antimicrobial resistance (predictive validity). Next Steps/Implementation: Any metric we validate would inform health policy and could be incorporated into our team's existing stewardship dashboard. Our findings could be used in a multicenter, audit-and-feedback trial that leverages the dashboard and the validated metric(s) to improve inpatient antimicrobial use.

背景：抗生素耐药性是一个紧迫的公共卫生问题，对患者安全构成威胁。 抗菌药物的使用是出现抗菌药物耐药性的最大风险因素 不必要的抗菌药物使用和改善必要的使用，抗菌药物管理计划（ASP）是 是对抗抗菌素耐药性的重要工具。ASP在VHA内外都有授权。 重要性：没有一个普遍接受的指标来评估ASP的成功。一个医院级别的指标， 被称为标准化抗菌药物管理比率（SAAR），正在美国各地广泛实施 医院，包括VHA。然而，SAAR尚未得到验证，并且有几个弱点， 包括缺乏患者水平的风险调整和没有考虑抗菌活性谱。 创新和影响：该提案将通过开发、完善和验证来瞄准关键的研究差距。 解决SAAR局限性的新指标。这些新的指标包括：1）风险标准化 治疗天数（DOT）比率（RSDTR），其与SAAR的不同之处在于其对患者差异的调整 病例组合; 2）抗菌谱覆盖天数（DASC）评分，与SAAR的不同之处在于 捕获抗菌药物的使用和活性谱，和3）风险标准化的DASC。通过我们的目标， 我们将评估SAAR和3个新指标的3种有效性（结构、内容和预测）。 具体目标： A1：确定导致VHA中抗菌药物使用适当变化的不可修改因素 通过评估潜在的患者水平、医院水平和环境影响来评估急性护理医院。 H1：不可修改的因素可以通过建立共识的练习和数学技术来确定。 A2：评估实施了更稳健的管理流程的医院， 强制性VHA调查，在SAAR和三个新指标上表现更好。 H2：管理的稳健性与医院指标绩效之间的关联将是 风险标准化DASC评分最强。 A3：使用定性方法，评估SAAR的内容效度和关键指标中的三个新指标 10家医院的利益相关者，包括高绩效和低绩效站点。 H3：所有地点的主要利益相关者将确认RSDTR和风险标准化DASC的有效性， 将关注不涉及患者水平风险调整的指标的有效性。 A4：评估医院在四个指标上的表现与 医疗保健相关的抗菌素耐药性的出现。 H4：与SAAR相比，新指标与未来抗菌素耐药性的关联更强。 方法：我们的提案将利用定量和定性方法。在目标1中，我们将使用 改进的两阶段德尔菲法，它将整合数据驱动和人为驱动的选择策略， 确定应用于DASC和DOT风险标准化的不可修改的风险因素（例如， RSDTR度量）。在目标2中，我们将使用医院对强制性调查的回应来衡量这种关联 管理活动的强度和度量性能之间的关系（结构效度）。在目标3中，我们 与关键利益相关者进行半结构化访谈和焦点小组，以评估 四个指标。在目标4中，我们将利用17年的VHA数据来确定医院在以下方面的表现： 每个度量与抗菌剂耐药性的未来发展相关（预测有效性）。 下一步/实施：我们验证的任何指标都将为卫生政策提供信息，并可纳入 我们团队现有的管理仪表板。我们的研究结果可用于多中心， 利用仪表板和经验证的指标改善住院患者抗菌药物使用的试验。