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

背景：抗生素耐药性是一个紧迫的公共卫生问题，也是对患者安全的威胁。 抗菌药物的使用是出现抗菌素耐药性的最大风险因素，因为它减少了 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 在对抗抗菌素耐药性的战斗中的重要工具。无论是在VHA内部还是外部，ASP都是强制要求的。 意义：目前还没有一个普遍接受的衡量标准来评估ASP的成功。一项医院级别的指标， 被称为标准化抗菌素管理比率(SAAR)，正在美国各地广泛实施 医院，包括在VHA。然而，SAAR尚未得到验证，存在几个弱点， 包括缺乏患者层面的风险调整，以及没有考虑抗菌谱的活性。 创新和影响：该提案将通过开发、改进和验证来针对一个关键的研究差距 解决SAAR局限性的新颖指标。这些新的衡量标准包括：1)风险标准化 治疗天数(DOT)比率(RSDTR)，这与SAAR的不同之处在于其对患者差异的调整 病例组合；2)天数抗菌谱覆盖(DASC)评分，与SAAR在以下方面有所不同 获取抗菌剂的使用和活性光谱，以及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种类型的效度(结构、内容和预测性)。 具体目标： 答案1：确定导致VHA中抗菌药物使用适当差异的不可修改因素 通过评估潜在的患者水平、医院水平和环境影响，对急诊医院进行评估。 H1：不可修改的因素可以通过建立共识的练习和数学技巧来确定。 A2：评估实施了更强健的管理流程的医院是否通过 强制性VHA调查，在SAAR和三个新指标上表现更好。 H2：管理的稳健性和医院的指标绩效之间的关联将是 风险标准化DASC得分最高。 A3：采用定性方法，评估SAAR的内容有效性和关键因素中的三个新指标 十家医院的利益相关者，包括高绩效和低绩效网站。 H3：所有站点的关键利益相关者将确认RSDTR和风险标准化DASC的有效性，并 将对不涉及患者层面风险调整的指标的有效性表示担忧。 答4：评估一家医院在四个指标上的表现与 出现与医疗保健相关的抗菌素耐药性。 H4：与SAAR相比，新的指标将与未来的抗菌素耐药性有更强的关联。 方法：我们的提案将利用定量和定性两种方法。在目标1中，我们将使用 改进的两阶段德尔菲法，将数据驱动和人驱动的选择策略结合在一起，以 确定应用于对DASC和DOT进行风险标准化的不可更改的风险因素(例如 RSDTR度量)。在目标2中，我们将使用医院对强制性调查的反应来衡量这种联系 管理活动的强度与度量绩效之间的关系(结构效度)。在《目标3》中，我们将 与主要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 每项指标都与抗菌素耐药性的未来发展(预测效度)有关。 后续步骤/实施：我们验证的任何指标都将告知健康策略，并可合并到 我们团队现有的管理仪表盘。我们的发现可以用于多中心的审计和反馈 利用仪表板和有效指标(S)改善住院患者抗菌药物使用的试验。

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.