Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Tamar F Barlam; Ellen Childs; Sarah A Zieminski; Tsega M Meshesha; Kathryn E Jones; Jorie M Butler; Laura J Damschroder; Matthew Bidwell Goetz; Karl Madaras-Kelly; Caitlin M Reardon; Matthew H Samore; Jincheng Shen; Edward Stenehjem; Yue Zhang; Mari-Lynn Drainoni

doi:10.1093/ofid/ofaa229

Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Open Forum Infect Dis. 2020 Jun 15;7(7):ofaa229. doi: 10.1093/ofid/ofaa229. eCollection 2020 Jul.

Authors

Tamar F Barlam¹, Ellen Childs², Sarah A Zieminski¹, Tsega M Meshesha², Kathryn E Jones³, Jorie M Butler⁴, Laura J Damschroder⁵, Matthew Bidwell Goetz⁶, Karl Madaras-Kelly⁷, Caitlin M Reardon⁵, Matthew H Samore^{8

9}, Jincheng Shen¹⁰, Edward Stenehjem¹¹, Yue Zhang⁹, Mari-Lynn Drainoni^{1

2

12

13}

Affiliations

¹ Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.
² Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.
³ Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.
⁴ Department of Internal Medicine, Division of Geriatrics, University of Utah; Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.
⁵ VA Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan, USA.
⁶ Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine, UCLA, Los Angeles, California, USA.
⁷ Boise Veterans Affairs Medical Center; College of Pharmacy, Idaho State University, Meridian, Idaho, USA.
⁸ IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.
⁹ Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA.
¹⁰ Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA.
¹¹ Office of Patient Experience, Intermountain Healthcare, Salt Lake City, Utah, USA.
¹² Evans Center for Implementation and Improvement Sciences, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.
¹³ Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Boston, Massachusetts, USA.

Abstract

Background: Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.

Methods: Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.

Results: We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.

Conclusions: The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.

Keywords: antibiotic resistance; antibiotic stewardship; infection prevention; infectious diseases.