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Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4084 — Effects of Policy and Resources on Antimicrobial Stewardship Interventions in the VA using a Transaction Cost Economics Framework

Lead/Presenter: Ann Chou, COIN - Los Angeles
All Authors: Chou AF (VA Greater Los Angeles Healthcare System) Zhang Y (VA Salt Lake City Healthcare System) Jones M (VA Salt Lake City Healthcare System) Graber CJ (VA GLA Healthcare System) Goetz MB (VA GLA Healthcare System) Madaras-Kelly K (VAMC Boise) Kelly A (National Infectious Diseases Service, VA Central Office) Samore M (VA Salt Lake Healthcare System) Glassman PA (VA GLA Healthcare System)

Inappropriate antimicrobial use poses a serious threat to patient safety. Various antimicrobial stewardship interventions (ASI) have been proposed to optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. This study aims to examine associations between organizational policy and resources and ASI implementation in VA inpatient facilities.

Implementing new practices can often be difficult as it requires changes in organizational structure and culture; clinicians and staff encounter issues that had not been a part of their professional repertoire. As ASIs require coordination among staff and activities, the transaction cost economics (TCE) perspective is used to examine ASI uptake, with dimensions describing: (1) uncertainty; (2) frequency with which transactions recur; and (3) asset specificity. This study employs a cross sectional design, surveying 140 VA facilities in 2015. Outcomes examined were: (1) facility tracking more than three ASIs; and (2) barriers to optimal antimicrobial use. Independent variables include those describing site specificity, physical assets, personnel, and various AS policies as proxies for uncertainty. Multivariable logistic regression analysis with the Least Absolute Shrinkage and Selection Operator (LASSO) approach was used to identify the subset of variables and generate odds ratios across the TCE dimensions that are informative for predicting ASIs.

Infectious Disease attendings assigned to medical wards, clinical pharmacists assigned to teams, required documentation of indication in medical record/order entry, policies on intravenous to oral conversion, using electronic tools to facilitate AS activities were all associated with greater ASI uptake. Similar variables also decreased the likelihood of facilities experiencing certain barriers to optimal antibiotic use.

Overall, we found that site specificity, human resources, physical assets, and policies affected ASI uptake and ameliorated barriers to optimal antimicrobial use. These variables represent mechanisms that improved efficiencies of coordination and provided resources to achieve intended stewardship goals.

ASI implementation in VA facilities represents a complex change, requiring a system-wide response. The TCE framework is useful to inform facilities in their strategies to adopt new ways of organizing in order to manage emerging demands that include changing clinician work, coordinating across units and departments, and developing new tools for optimizing antimicrobial use.