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Plan to require ASPs in ambulatory settings raises questions
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Beginning on Jan. 1, 2020, all ambulatory health care organizations accredited by the Joint Commission that regularly prescribe antimicrobial agents will be required to abide by newly established antimicrobial stewardship requirements.
The requirements are a continuation of regulations established by the commission in 2016 for hospitals, critical access hospitals and nursing care center programs. They will apply to organizations such as surgery centers, office-based surgery programs, imaging centers, sleep centers, urgent care centers and ambulatory clinics.
According to the CDC, at least 30% of antibiotics prescribed in outpatient settings are not necessary, and as much as 50% of all outpatient antibiotic use may be inappropriate, which includes improper use as well as inappropriate selection, dosing and duration.
Source: Division of Infectious Diseases, Penn Medicine
The framework from the Joint Commission establishes five elements of performance (EPs) that address antimicrobial stewardship in these types of settings: 1) identifying an antimicrobial stewardship leader; 2) establishing an annual antimicrobial stewardship goal; 3) implementing evidence-based practice guidelines related to the antimicrobial stewardship goal; 4) providing clinical staff with educational resources related to the antimicrobial stewardship goal; and 5) collecting, analyzing and reporting data related to the antimicrobial stewardship goal.
“Multidisciplinary stewardship programs in the inpatient setting are a well-established part of health care quality and safety operations,” Priya Nori, MD, medical director of the antimicrobial stewardship program and associate program director of the infectious disease fellowship program at Montefiore Health System in New York, said in an interview. “We’ve known about the harms of antibiotic overprescribing for decades. CDC guidelines, Joint Commission and CMS mandates came more recently. The reason that stewardship has become a mandate in the inpatient setting — and now in the outpatient setting — is because stewardship programs have been very successful at reducing antibiotic overuse, combating drug-resistance and improving patient outcomes.”
However, questions remain about how the Joint Commission’s requirements will be implemented. Infectious Disease News spoke with experts about the potential barriers to staffing, data collection and compensation, among other concerns.
“The statement from the Joint Commission is so new,” Sara C. Keller, MD, MPH, MSPH, assistant professor of medicine in the division of infectious diseases at Johns Hopkins University School of Medicine, told Infectious Disease News. “There was a long period for comment before this, but the actual, finalized statements are so new that it’s going to be interesting to see how it is carried out.”
Michael J. Durkin, MD, MPH, assistant professor of medicine in the division of infectious diseases at Washington University School of Medicine, voiced a similar sentiment.
“In the hospital, we think of the Joint Commission as a regulatory body,” he said. “Almost all hospitals participate in the Joint Commission or a separate program to receive accreditation. However, in outpatient clinic settings, participating in the Joint Commission is largely voluntary. As such, fewer clinics participate in the outpatient Joint Commission program. I’m not sure about the impact it’s going to have in primary care settings or other clinics, but it’s still an important next step.”
Identifying a leader
Most experts cited the need to identify an antimicrobial stewardship leader as the most critical EP addressed in the Joint Commission requirements. It requires organizations to select an individual who will be “responsible for developing, implementing and monitoring activities to promote appropriate antimicrobial medication prescribing.”
“If you don’t have a champion for the program, it’s not going to work,” Ebbing Lautenbach, MD, MPH, MSCE, chief of the division of infectious diseases and professor of medicine at the University of Pennsylvania Perelman School of Medicine, said in an interview. “Having that central person who can really drive the program, be the face of the program and be the person that prescribers can go to with questions is really important. I think everything else that follows thereafter in the guidelines comes through from this first step.”
The statement issued by the Joint Commission also demonstrates the importance of this first EP. According to the statement, naming a person or people who will be responsible for the organization’s antimicrobial stewardship program (ASP) makes the chances of success greater, because it establishes “clear lines of accountability.” Appointing that person or people will demonstrate the organization’s dedication to improving the use of antimicrobials, according to the statement.
The person identified as the leader will vary depending on several factors, including the size of the staff, the practice location and the resources available in the organization and the surrounding community, experts said. These factors highlight several of the barriers that may impact the successful implementation of these programs.
“This is not work that can be done in 15 minutes per week,” Lautenbach said. “The leader needs to be someone who has the time allocated to take that on. Depending on the resources of the practice, that could be pretty challenging. It will fall on the institution and on the practice to identify the resources that come into play to help support someone in that role.”
Asking a clinician to do this work “solely out of the goodness of their hearts” is difficult, according to Durkin.
“Those programs tend to run better if someone’s getting paid for it and they’re being evaluated for the work that they’re doing,” he said.
Keller outlined several potential ways in which the leader of an ASP in the outpatient setting may be compensated.
“How is this person going to have the dedicated time to put such a program into place? In really lean, busy clinics, having one person in charge is essential, but we also need to think about how it’s going to be worth that one person’s time,” she said. “If they’re an employee, for example, are they going to have a reduction in their relative value unit targets or a specific time where they are not scheduled to see patients? Do they get extra money? Do they get extra time? We think that it’s better to have a clinician or a doctor in this role because, in our experience, it has been hard to get clinicians, doctors especially, to listen to administration. But what does this person get?”
Barriers to implementation
There also are concerns about how data will be collected and how resources might be strained at smaller practices. Data collection is addressed by the Joint Commission in the fifth EP. This part of the guidelines requires the “collecting, analyzing and reporting [of] data” related to the organization’s antimicrobial stewardship goal.
Data collection and analytics are among the big challenges for ASPs, according to Nori, and this requirement from the Joint Commission may be the most challenging one to implement.
“To tap into the prescription data and present it in a way that is valuable and meaningful to stakeholders, you really need expertise,” she said. “You need IT support. You need to have someone in your organization who has access to these data and has some programming or analytic expertise.”
How feasible data collection is will likely depend on the size of the organization and is something that will vary from practice to practice.
“Some clinics, especially smaller clinics, may not know how to get their data,” Keller said. “Smaller practices may not have easily accessible resources with their electronic medical records vendors to access this data. Trying to figure out how these smaller clinics get at that data is an upfront barrier to implementing these requirements.”
Outpatient practices associated with large academic centers may have “a leg up” when it comes to data, according to Lautenbach.
“These practices likely have clinicians working in stewardship already who have some experience. In addition, they have more infrastructure regarding data collection and distribution,” he said. “This is part of why you have a person leading the program. That person can look at the challenges and opportunities in the practice and, from there, figure out what kind of data you have access to and what sorts of interventions you might be able to do. It’s going to be very different for a rural, smaller, internal medicine practice than it is for a faculty practice in downtown Philadelphia to implement these requirements.”
One strategy that may help smaller practices, or those in rural settings or critical access areas, abide by the EPs outlined by the Joint Commission involves using a local expert or members of a local ASP affiliated with an academic medical center to consult with the practice, according to Nori. This could be achieved by means of telemedicine if necessary.
“The strategy that seems to work best for critical access hospitals or long-term care facilities is to consult with an expert from a local stewardship program to perform a needs assessment of your facility,” she said. “This involves understanding what stewardship tools are already in place and then figuring out, based on size, number of providers, available resources and EMR system, what can be done at each individual site.
“It cannot be a one-size-fits-all approach — what works for a university-affiliated network of clinics in Brooklyn may not work for a rural hospital or ambulatory care network somewhere in the Midwest. The most impactful stewardship interventions in the outpatient setting are likely those that are simplest, most engaging and easiest to implement and sustain — those that are low risk and high reward.”
The success of ASPs in the inpatient setting, which have been very effective, is reliant on resources, according to Durkin. This includes access to pharmacists in addition to other factors like the size of the practice and the availability of certain technology. Implementing these programs in the outpatient setting is going to be a bigger challenge.
“In a hospital, they have more resources, such as pharmacists who analyze antibiotic utilization, and they have complex rules,” he said. “Pharmacists look at certain combinations of antibiotics that don’t make sense and call the doctor to inquire about why that combination was chosen. In outpatient settings, we don’t have pharmacists with these rule-based systems that evaluate patients as closely. Clinics are more resource limited; the real-time effect that pharmacists can have on antibiotic prescribing isn’t there. It’s a lot more challenging to change provider behavior.”
Changing behaviors, expectations
Changing provider behavior — as well as patient expectations — may be a critical, albeit difficult to achieve, part of the success of antimicrobial stewardship programs in the outpatient setting.
The fourth EP outlined by the Joint Commitment states that organizations should provide all clinical staff, including independent practitioners, with educational materials related to the program’s antimicrobial stewardship goals and strategies. This EP will help ensure that “patients receive clear, consistent recommendations when antimicrobials are not indicated,” according to the report.
This tactic is “really about behavior change,” Lauri A. Hicks, DO, director of the CDC’s Office of Antibiotic Stewardship, told Infectious Disease News.
“In most situations, clinicians know what they’re supposed to do,” Hicks said. “This is really about the psychosocial factors that influence prescribing — trying to please the patient and wanting to make sure the patient walks out with their expectations met. This strategy, which I think is really important, involves teaching clinicians how to communicate effectively with patients so that, when antibiotics aren’t needed, the patient walks out with a sense of knowing what they’re supposed to do, what to expect in terms of illness duration and having some alternatives for management of their symptoms.”
If a provider believes a patient wants an antibiotic, “they’re much more likely to prescribe one,” she continued. As a result, arming providers with strategies “to manage those expectations is really an important step in the outpatient setting.”
Keller echoed the notion that providers often “know what to do” regarding prescribing antimicrobials.
“Clinicians often know that somebody with an upper respiratory infection has a virus and doesn’t need an antibiotic,” she said. “However, they may still prescribe the antibiotic for other reasons. This gets at doctor-patient communication and the reasons why a doctor would prescribe an antibiotic even if they don’t think the patient needs it. The patient may expect it; the clinician might be worried that they’ll get poor reviews on a patient satisfaction survey or even on a platform like Yelp if they don’t oblige.”
In addition to patient expectations, time management is a factor.
“Providers may just not have the extra time, especially at the end of a busy clinic day, or the extra energy or patience at the end of a busy clinic day, to have that conversation with a patient about why they don’t need an antibiotic,” Keller continued. “It’s often easier just to prescribe the antibiotic. Focusing on improving communication skills and improving patient education is a lot more difficult.”
The Joint Commission suggests that educational materials should specifically address patient expectations about receiving an antibiotic and the potential adverse effects of these agents.
Lautenbach agreed that helping patients understand why they may not need an antibiotic is certainly more time-consuming for providers than simply prescribing one and moving on with the next appointment. However, researchers have demonstrated that, when clinicians take time to explain to patients why an antibiotic is not warranted for certain illnesses, patients understand and leave the appointment just as satisfied as they would with a prescription.
“Clinicians in a busy outpatient practice don’t always have the time to explain, ‘I think you have a viral infection. Antibiotics only work against bacteria; they don’t work against viruses, so that’s not going to make you better. There’s a big problem with antibiotic resistance, and I don’t want you to get an antibiotic-resistant infection,’” he said. “That takes a long time to explain. But studies have shown that when you explain it at that level, patients get it. I think there’s enough knowledge about antibiotic resistance and superbugs, now even in the lay press, that talking about antibiotic resistance generally doesn’t come as a surprise to patients.”
Reasonable expectations
The experts who spoke with Infectious Disease News agreed that the Joint Commission’s guidelines are flexible, which could be an asset when it comes to implementation.
“These suggestions are open to interpretation. They’re not oppressive,” Nori said. “For example, a suggestion from the Joint Commission is to put into place an intervention that would reduce overprescribing for viral upper respiratory infections. For a well-resourced facility with access to IT expertise and clinical decision support tools, treatment algorithms can be developed, and best practice alerts set up within the EMR that can be activated when a provider tries to prescribe an antibiotic for a viral upper respiratory infection. For a facility without such resources there are other simpler interventions like commitment posters that say ‘I, Dr. Priya Nori, promise to only prescribe an antibiotic for you or your loved one when you absolutely need it to avoid X, Y and Z complications.’”
In fact, the Joint Commission may have accounted for the different capabilities of practices and been more general on purpose, according to Lautenbach.
“The data collection and the complexity of the program may be very different from place to place. That’s OK, as long as the Joint Commission sees that you’re working to identify what the issues are and that you’re developing a plan to address them,” he said. “Based on my understanding of the statement, there’s nothing that says you have to be doing this a certain way. You need to have someone who’s leading the program, you need to have a plan, you need to have a way of monitoring what you’re doing — and those are all reasonable expectations. But the output may be very different from place to place.” – by Julia Ernst, MS
- References:
- Joint Commission. Ambulatory health care. Available at: www.jointcommission.org/accreditation/ambulatory_healthcare.aspx. Accessed July 10, 2019.
- Joint Commission. R3 report: Requirement, rationale, reference. Available at: www.jointcommission.org/assets/1/18/R3_23_Antimicrobial_Stewardship_AMB_6_14_19_FINAL.pdf. Accessed July 9, 2019.
- For more information:
- Michael J. Durkin, MD, MPH, can be reached at mdurkin@wustl.edu.
- Lauri A. Hicks, DO, can be reached at antibioticuse@cdc.gov.
- Sara C. Keller, MD, MPH, MSPH, can be reached at skeller9@jhmi.edu.
- Ebbing Lautenbach, MD, MPH, MSCE, can be reached at ebbing@pennmedicine.upenn.edu.
- Priya Nori, MD, can be reached at pnori@montefiore.org.
Disclosures: Durkin, Hicks, Keller, Lautenbach and Nori report no relevant financial disclosures.