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强风险因素 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） 对抗抗菌素耐药性的重要工具。 VHA 内部和外部均强制要求 ASP。 意义： 没有一个普遍接受的指标来评估 ASP 的成功。医院级别的指标， 被称为标准化抗菌药物管理比率（SAAR），正在美国广泛实施 医院，包括 VHA 医院。然而，SAAR 尚未得到验证，并且存在一些缺陷， 包括缺乏患者层面的风险调整以及没有考虑抗菌活性谱。 创新和影响：该提案将通过开发、完善和验证来解决关键的研究空白 解决 SAAR 局限性的新颖指标。这些新颖的指标包括：1）风险标准化 治疗天数 (DOT) 比率 (RSDTR)，与 SAAR 的不同之处在于它针对患者差异进行了调整 案例组合； 2) 抗菌谱覆盖天数 (DASC) 评分，其与 SAAR 的不同之处在于 捕获抗菌药物的使用和活性谱，以及 3) 风险标准化 DASC。通过我们的目标， 我们将评估 SAAR 和 3 个新颖指标的 3 种有效性（结构、内容和预测）。 具体目标： A1：确定导致 VHA 抗菌药物使用适当变化的不可改变因素 通过评估潜在的患者层面、医院层面和环境影响来对急症护理医院进行评估。 H1：不可修改的因素可以通过建立共识的练习和数学技术来识别。 A2：评估医院是否实施了更健全的管理流程（以 强制性 VHA 调查，在 SAAR 和三个新颖指标上表现更好。 H2：管理稳健性与医院指标绩效之间的关联为 风险标准化 DASC 评分最强。 A3：使用定性方法，评估 SAAR 的内容有效性以及关键的三个新指标 十家医院的利益相关者，包括高绩效和低绩效医院。 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 会对不涉及患者层面风险调整的指标的有效性感到担忧。 A4：评估医院在四个指标上的绩效与医院绩效之间的纵向关系 医疗保健相关抗菌药物耐药性的出现。 H4：与 SAAR 相比，新指标与未来抗菌药物耐药性的关联性更强。 方法论：我们的建议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，将整合数据驱动和人类驱动的选择策略， 确定不可修改的风险因素，这些因素应用于对 DASC 和 DOT 进行风险标准化（例如 RSDTR 指标）。在目标 2 中，我们将使用医院对强制性调查的答复来衡量关联性 管理活动的强度和指标绩效（结构有效性）之间的关系。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，以评估内容的有效性 四个指标。在目标 4 中，我们将利用 17 年的 VHA 数据来确定医院的绩效是否 每个指标都与抗菌素耐药性的未来发展相关（预测有效性）。 后续步骤/实施：我们验证的任何指标都将为卫生政策提供信息，并可以纳入 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审核和反馈 利用仪表板和经过验证的指标来改善住院患者抗菌药物使用的试验。