Demonstrating the Value of Antimicrobial Stewardship

SUPPLEMENT ARTICLE

Demonstrating the Value of Antimicrobial Stewardship Programs to Hospital Administrators Jerod L. Nagel,1 James G. Stevenson,1 Edward H. Eiland III,2,a and Keith S. Kaye3 1

University of Michigan Hospitals and Health System, Ann Arbor; 2Department of Pharmacy, Huntsville Hospital, Alabama; and 3Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan

Keywords. antimicrobial stewardship; hospital administrator.

Due to significant cost and quality pressures on the US healthcare system, the model for reimbursement has been undergoing reform [1–3]. There is a movement away from fee-for-service models to those that emphasize reimbursement based on the quality of care provided. The methods used can be either payment incentives for achieving or exceeding quality benchmarks or financial penalties for failing to achieve a certain threshold or for negative clinical outcomes. Additionally, many of these measures may be publicly reported as evidence of an organization’s quality or safety. The goal of these models is to improve process measures and clinical outcomes while reducing costs. Various organizations, including the Centers for Medicare and Medicaid Services (CMS), the Agency for Healthcare Research and Quality, the National Quality Forum, The Joint Commission, and the Leapfrog Group, have established quality metrics and in some cases these have direct ties to reimbursement or financial penalties (Table 1).

a

Present affiliation: Vital Care, Inc, Meridian, Mississippi. Correspondence: Keith S. Kaye, MD, MPH, Division of Infectious Diseases, Wayne State University School of Medicine, 4201 Saint Antoine, Ste 2B, Box 331, Detroit, MI 48201 ([email protected]). Clinical Infectious Diseases 2014;59(S3):S146–53 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. DOI: 10.1093/cid/ciu566

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Antimicrobial stewardship programs (ASPs), in conjunction with good infection control and prevention practices, have been shown to be effective in managing the use of antimicrobial agents, slowing or reversing the development of antimicrobial resistance [4–6], decreasing Clostridium difficile infections [7, 8], and reducing costs [9–15]. Traditionally, these programs have been justified through measures of antimicrobial utilization with an associated reduction in the cost of antimicrobial therapy and changes in resistance rates and susceptibility patterns [14, 15]. With the increased emphasis in the emerging healthcare system on quality, safety, and outcomes data as key components of reimbursement and the public reporting of specific measures, there is an opportunity and need to refocus the value of the ASP on these important parameters. Some publicly reported metrics are process measures that presumably will produce better clinical outcomes and reduce resistance. One example is the Surgical Care Improvement Program (SCIP) measures related to selection of the most appropriate preoperative antibiotic as well as appropriate timing of administration and discontinuation, with the presumption that such actions lead to decreased surgical site infections (SSIs). Through the work of ASPs, organizations have demonstrated improved compliance with SCIP measures linked to value-based purchasing, and may

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The movement away from fee-for-service models to those that emphasize quality of care and patient outcomes affords a unique opportunity for antimicrobial stewardship programs to expand their value for hospital administration. Antimicrobial stewardship participants must collaborate with administrators and key stakeholders to position themselves to improve economic, process, and outcomes measures. This will allow the establishment of antimicrobial stewardship programs as essential components of the present and future healthcare quality journey.

Table 1. Infectious Disease Metrics Currently Measured by Various Regulatory or Quality Improvement Organizations Measure

Organization

High risk for pneumococcal disease—pneumococcal vaccination

ActiveHealth Management

Bacterial pneumonia admission rate (PQI 11) Death rate in low-mortality Diagnosis-Related Groups (PSI 2)

AHRQ AHRQ

Pneumonia mortality rate (IQI 20)

AHRQ

Urinary tract infection admission rate (PQI 12) CAUTI

AHRQ AHRQ

CLABSI

AHRQ

MRSA SSTIs Risk-adjusted urinary tract infection outcome measure after surgery

AHRQ American College of Surgeons

Acute otitis externa: systemic antimicrobial therapy—avoidance of inappropriate use

AMA-PCPI

Acute otitis externa: topical therapy Emergency medicine: CAP—empiric antibiotic

AMA-PCPI AMA-PCPI

Hepatitis C: HCV RNA testing at no later than week 12 of treatment

AMA-PCPI

Hepatitis C: testing for chronic hepatitis C—confirmation of hepatitis C viremia Influenza immunization

AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI AMA-PCPI

Paired measure: hepatitis C: hepatitis A vaccination (paired with 0400)

AMA-PCPI

Perioperative care: discontinuation of prophylactic parenteral antibiotics (non-cardiac procedures) Perioperative care: timing of prophylactic parenteral antibiotics—ordering physician

AMA-PCPI AMA-PCPI

Timing of prophylactic antibiotics—administering physician

AMA-PCPI

Prophylactic intravenous antibiotic timing Bloodstream infection in hemodialysis outpatients

ASC Quality Collaboration CDC

Hepatitis B vaccine coverage among all live newborn infants prior to hospital or birthing facility discharge Influenza vaccination coverage among healthcare personnel

CDC

Late HIV diagnosis

CDC

NHSN CLABSI outcome measure NHSN facility-wide inpatient hospital-onset Clostridium difficile infection outcome measure

CDC CDC


Otitis media with effusion: systemic antimicrobials—avoidance of inappropriate use Paired measure: HCV genotype testing prior to treatment (paired with 0395) Paired measure: hepatitis C RNA testing before initiating treatment (paired with 0396)

CDC

NHSN facility-wide inpatient hospital-onset MRSA bacteremia outcome measure

CDC

NHSN CAUTI outcome measure Antibiotic selection for CAP in immunocompetent patient (PN-6)

CDC CMS

Prophylactic antibiotic selection for surgical patients (SCIP-Inf-2)

CMS

Prophylactic antibiotics discontinued within 24 h after surgery end time (SCIP-Inf-3) Influenza immunization (IMM-2)

CMS CMS

Pneumonia 30-day mortality rate (MORT-30-PN)

CMS

Central venous catheter–related bloodstream infection rate (AHRQ PSI-90) Postoperative sepsis rate (AHRQ PSI-90)

CMS CMS

Healthcare-associated infections: CLABSI rates

CMS

Healthcare-associated infections: CAUTI rates Healthcare-associated infections: SSI rates—colon

CMS CMS

Healthcare-associated infections: SSI rates—abdominal hysterectomy

CMS

CMS hospital-acquired conditions reduction program: central venous catheter–related bloodstream infection rate CMS hospital-acquired conditions reduction program: postoperative sepsis rate

CMS

CMS readmissions reduction program: pneumonia 30-day readmission rate

CMS

Hospital 30-day, all-cause, RSRR following pneumonia hospitalization Hospital 30-day, all-cause, RSMR following pneumonia hospitalization

CMS CMS

Influenza immunization

CMS

Initial antibiotic selection for CAP in immunocompetent patients

CMS

CMS

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Table 1 continued. Measure

Organization

Percentage of residents assessed and appropriately given the seasonal influenza vaccine (longstay)

CMS

Percentage of residents or patients who were assessed and appropriately given the seasonal influenza vaccine (short-stay)

CMS

Percentage of residents with a urinary tract infection (long-stay)

CMS

PN3a—blood cultures performed within 24 h prior to or 24 h after hospital arrival for patients who were transferred or admitted to the ICU within 24 h of hospital arrival

CMS

Pneumococcal immunization

CMS

Pneumococcal polysaccharide vaccine ever received (Home Health) Prophylactic antibiotic received within 1 h prior to surgical incision

CMS CMS

Prophylactic antibiotic selection for surgical patients

CMS

Prophylactic antibiotics discontinued within 24 h after surgery end time HIV medical visit frequency

CMS HRSA—HIV/AIDS Bureau

HIV RNA suppression

HRSA—HIV/AIDS Bureau

Prescription of HIV antiretroviral therapy Gap in HIV medical visits

HRSA—HIV/AIDS Bureau HRSA—HIV/AIDS Bureau Kidney Care Quality Alliance

Intrapartum antibiotic prophylaxis for group B Streptococcus Appropriate prophylactic antibiotic received within 1 h prior to surgical incision—cesarean delivery

Massachusetts General Hospital Massachusetts General Hospital/Partners Health Care System

Avoidance of antibiotic treatment in adults with acute bronchitis Chlamydia screening and follow-up

National Committee for Quality Assurance National Committee for Quality Assurance

Flu vaccinations for adults aged 18 and older

National Committee for Quality Assurance

HIV/AIDS: CD4 cell count or percentage performed HIV/AIDS: Pneumocystis jiroveci pneumonia prophylaxis


HIV/AIDS: sexually transmitted diseases—screening for chlamydia, gonorrhea, and syphilis


HIV/AIDS: tuberculosis screening Human papillomavirus vaccine for female adolescents


Immunizations for adolescents


Pneumococcal vaccination status for older adults Health care–associated bloodstream infections in newborns

National Committee for Quality Assurance The Joint Commission

CLABSI in ICU

The Leapfrog Group

CAUTI in ICU PNA count

The Leapfrog Group The Leapfrog Group

PNA LOS

The Leapfrog Group

Duration of antibiotic prophylaxis for cardiac surgery patients Risk-adjusted deep sternal wound infection rate

The Society of Thoracic Surgeons The Society of Thoracic Surgeons

Selection of antibiotic prophylaxis for cardiac surgery patients

The Society of Thoracic Surgeons

Abbreviations: AHRQ, Agency for Healthcare Research and Quality; AMA, American Medical Association; ASC, ambulatory surgery center; CAP, communityacquired pneumonia; CAUTI, catheter-associated urinary tract infection; CDC, Centers for Disease Control and Prevention; CLABSI, central line–associated bloodstream infection; CMS, Centers for Medicare and Medicaid Services; ESRD, end-stage renal disease; HCV, hepatitis C virus; HIV, human immunodeficiency virus; HRSA, Health Resources and Services Administration; ICU, intensive care unit; LOS, length of stay; MRSA, methicillin-resistant Staphylococcus aureus; NHSN, National Healthcare Safety Network; PCPI, Physician Consortium for Performance Improvement; PNA, pneumonia; RSRR, riskstandardized readmission rate; SCIP,Surgical Care Improvement Program; SSI, surgical site infection; SSTI, skin and soft tissue infection.

represent an additional opportunity for cost justification of ASPs [16–21]. Clinical outcome measures are potentially more impactful than process measures as a means of assessing the effectiveness and impact of the ASP. However, with the likelihood of an

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expansion of future metrics linked to clinical outcomes and performance (as illustrated in Table 1), there is an opportunity to associate improvements in infectious disease–related measures with a specific financial impact to the organization and to recognize the efforts of ASPs. In this environment, strategies that


Influenza immunization in the ESRD population (facility level)

will decrease the overall cost per patient case and prevent readmissions must be identified. There is growing recognition that ASPs play an important role (usually in conjunction with “bundles” of infection control and other strategies) in producing better patient outcomes, reduced overall (not just antimicrobial) costs of care, and reduced readmission rates [16, 17]. Stewardship program members should ensure that they are familiar with the current quality, safety, and cost incentives by which health systems are being measured, and develop actions that will positively impact these important metrics. Hospital administrators continually assess the economic success and quality of patient care within the institution, and allocate resources to improve these measures. Therefore, hospital administration plays a significant role in determining the value of an ASP to the institution. The goal of this article is to describe the potential role of ASPs and the ability to demonstrate value to hospital administrators.

The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance [14]. Implementation of a successful ASP is a significant undertaking, and identifying appropriate resources to successfully achieve goals is of utmost importance. ASP personnel are encouraged to meet with hospital administrators to establish goals and expected outcome measures, and to obtain adequate authority and resources needed to successfully track and achieve goals. ASPs must understand current outcome measures that hospitals are evaluated against, and periodically reevaluate the needs of the institution and modify goals accordingly. Hospital administrators and key physician and nursing leaders should provide support given that the ASP goals are aligned with The Joint Commission standards, CMS performance measures, and quality metrics proposed by the National Quality Forum, Agency for Healthcare Research and Quality, Leapfrog Group, and others. Stakeholders including healthcare professionals, payers, patients, and the public at large should be informed of new ASP initiatives and associated outcomes. ASPs that position themselves to demonstrate improvements in clinical outcomes (especially decreasing inpatient length of hospitalization, or early transition to outpatient care), and improved compliance with outcome measures linked to value-based purchasing may show significant overall savings that dwarf antimicrobial cost savings alone. Based on the mantra of “measure not, improve not,” the ASP should continually engage in data analysis and synthesis correlating with specific outcome measures. Given the increasing focus on performance measures, in addition to traditional

Perspectives of the Healthcare Administrator

The hospital administrators’ primary goal is providing optimal patient care and ensuring economic vitality of the institution, which play a significant role in determining the value of an ASP. The availability of accurate and timely data is essential for administrators to effectively make decisions, allocate resources, and achieve goals. As the focus on patient outcomes and quality of care continues to increase, ASPs have the opportunity to play a key role in improving outcomes and providing key metrics to hospital administrators. From the hospital administrator’s perspective, healthcare metrics can be divided into 4 distinct categories: clinical outcome


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POSITIONING ANTIMICROBIAL STEWARDSHIP PROGRAMS TO DEMONSTRATE VALUE

stewardship-specific activities, obtaining information can be challenging. Information technology support is essential in obtaining timely and accurate data. Clinical decision support software can help efficiently find patients who require stewardship team review, prioritize daily stewardship activities, track and organize interventions, and facilitate implementation of specific stewardship initiatives. ASPs are encouraged to seek data mining resources in the form of hospital informatics service or other individuals capable of extracting data from large databases to assist with demonstrating the impact of the ASP on patient outcomes. Process improvement methods such as the PlanDo-Check-Act model are key to analyzing the designated metrics that allow for continued advancement of the program. Although no standardized metrics for stewardship programs exist, there are core recommendations that apply to all stewardship programs [14, 17] (Table 2). In addition, each hospital has unique problems and challenges that require antimicrobial stewardship intervention and reporting of associated metrics. Concise reports showing the impact and challenges of an ASP should be routinely presented to hospital administration, the Infection Control Committee, the Pharmacy and Therapeutics Committee, the Medication Safety Committee, and the Clinical Quality Improvement Committee, which can aid in physician compliance with initiatives, help to identify future areas of emphasis, and share the benefits of the stewardship program. Additionally, the aforementioned committees can also help facilitate ASP efforts and can provide unique multidisciplinary insights when developing or analyzing initiatives. Monthly or quarterly updates to a stewardship dashboard are effective methods for communicating outcome measures and can be posted on a hospital intranet or e-mailed to stakeholders. In summary, communication with various committees inside and outside the hospital helps foster support for stewardship initiatives and attain appropriate resources. ASPs and hospital administrators should determine the appropriate resources needed to accomplish goals, including appropriate personnel, technology, data, and authority, in addition to systematically aligning daily tasks with stated goals and reporting associated outcomes.

Table 2. Guidance Statements for Establishing and Evaluating Antimicrobial Stewardship Metrics that Demonstrate Value to Administrators

measures, process measures, workload measures, and economic measures. Optimizing clinical outcomes through appropriate antimicrobial prescribing and disease-state management should be the primary focus of ASPs [14]. From a stewardship perspective, clinical outcome measures could include improving traditional metrics (eg, mortality, length of hospitalization, hospital readmission), but also decreasing reinfection rates, minimizing infectionrelated complications, curtailing the risk of secondary infections (such as C. difficile infection), preventing toxicity, and attenuating development of antimicrobial resistance. Process measures are the result of actions taken to optimize clinical outcomes. CMS recognizes the importance of process and clinical outcome measures and links these with the Hospital Value-Based Purchasing (VBP) program. Workload measures describe the effort to optimize clinical, process, and economic outcomes. Workload measures are beneficial when requesting resources, but may carry little weight in daily decisions of hospital administrators. Economic measures are also essential, and ASPs are encouraged to evaluate the impact of initiatives on total hospital costs, not just antimicrobial expenditure. Clinical Outcome Measures

Stewardship programs have the opportunity to position themselves to implement process improvements that improve clinical outcomes. A growing number of studies consistently suggest that ASP review and intervention following real-time alerts for patients with bacteremia (with and without rapid diagnostic testing) can decrease mortality, decrease length of hospitalization, and reduce hospital costs [22–24]. Additionally, optimizing dosing through extended-infusion β-lactams appears to

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decrease mortality and length of hospitalization for some high-risk patients [25]. Similarly, ASPs can impact outcome measures linked to disease-based guidelines. Stewardship teams have demonstrated improvements in the management of specific disease states (eg, acute respiratory tract infections, community-acquired pneumonia [CAP], and candidemia) [26–28]. Additionally, ASPs have demonstrated improvements in medication and non-medication-related performance measures, such as improved rates of ophthalmologic consultation for patients with candidemia [27]. Thus, establishing a systematic approach to evaluate compliance with performance measures linked to treatment guidelines allows another avenue for ASPs to demonstrate value and improve outcomes. Ultimately, providing measures and trends regarding the length of stay, total cost of care, mortality, and readmissions for patients being treated with antimicrobials for certain infectious syndromes (such as CAP and cellulitis) to stewardship personnel would help them to design and focus interventions and measure the impact of such interventions. Benchmarks for these types of metrics and comparing these metrics among hospitals would be extremely useful in driving improved antimicrobial processes and patient care. Process Measures

The Centers for Disease Control and Prevention’s Antimicrobial Use and Resistance project aims to implement a standardized reporting and benchmarking system for antimicrobial utilization in hospitals based on risk-adjusted antimicrobial days of therapy per 1000 patient-days [29]. The ability to use such a system to link utilization to resistance trends or define


• Members of the stewardship program should negotiate with hospital leadership to define expected goals and obtain adequate authority and resources to achieve outcome measures for the program. Measures should extend beyond traditional antimicrobial utilization to include impact on overall resource utilization, improved patient outcomes, and performance on publicly reported measures associated with financial incentives or penalties. • Members of the antimicrobial stewardship program should keep current with outcome measures being evaluated by various quality improvement organizations, and collaborate with appropriate hospital groups to improve any deficiencies related to the management of antimicrobials or specific infectious diseases. • Process measures are essential to understand the contribution of antimicrobial stewardship interventions and the association between intervention and clinical outcomes. Particular attention should be focused on process measures that are associated with financial incentives or penalties, or those that are publicly reported. • Successes and challenges in meeting predefined goals and improving outcome measures should be routinely reported to hospital leadership, Pharmacy & Therapeutics Committee, Infection Control Committee, Medication Safety Committee, Clinical Quality Improvement Committee, and other stakeholders. • Multidisciplinary development of evidence-based treatment guidelines and recommended criteria for specific antimicrobials is encouraged with routine tracking of adherence and related outcome measures and frequent feedback to prescribers. An active process of evaluating appropriate adherence to treatment guidelines and antimicrobial criteria is essential in optimizing outcomes. • Even if a stewardship intervention is not expected to improve clinical outcomes (such as length of stay, readmission, and mortality), measuring these endpoints as balancing measures to confirm the absence of harm may be worthwhile. • Cost-effectiveness evaluation of stewardship initiatives are needed that incorporate overall healthcare-associated costs or savings, other than those related to antimicrobial acquisition, as well as costs required to resource the stewardship intervention. • Appropriate outcome metrics to confirm the impact of antimicrobial stewardship activities on antimicrobial resistance rates are needed. • Stewardship initiatives are more likely to garner additional or continued support from hospital administrators if they clearly describe institutional deficiencies relating to outcome measures, provide a clear process for improving outcomes, and estimate and measure return on investment.

Economic Measures

Because metrics for stewardship are not standardized, many hospitals use antimicrobial acquisition cost as a surrogate for stewardship activity. Primary focus on antimicrobial budget without consideration of other related areas of care (such as length of stay and readmission) perpetuates the “silo” mentality of healthcare finance [30], where different components of clinical care are separated from one another and not considered in conjunction with one another. Using this silo mentality can lead to flawed and inaccurate interpretations regarding the effectiveness and quality of a stewardship team, and can lead to poor strategic decisions that may ultimately harm patient care. A first step away from the silo mentality is to embrace metrics for total cost of care rather than antimicrobial acquisition cost. Evaluating trends in antimicrobial expenditure may help identify areas where stewardship attention is warranted, but the success of a program should not be linked to continual year-over-year reductions in antimicrobial costs. Accreditation and Quality Indicators

Measuring processes of care and outcomes, such as the ones discussed above, is complex and not currently or readily available at many hospitals. A more practical and immediate way to improve the recognition for antimicrobial stewardship and to select metrics by which stewardship is judged is to focus on processes and outcomes that are both routinely measured and

important to healthcare administrators. In general, healthcare administrators view hospital quality based on accreditation and national quality indicators. From a regulatory perspective, attaining and maintaining The Joint Commission accreditation is of critical importance. Several stewardship metrics are either direct or indirect components of accreditation [31]. The Joint Commission Core Measures that are related to antimicrobial stewardship include those related to management of CAP (PN-3a, PN-3b, PN-6a, PN-6b); perioperative antimicrobial prophylaxis (SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3); and immunization (IMM-1, IMM-2). In addition, National Patient Safety Goal NPSG.07.03.01 specifically targets prevention of healthcare-associated infections due to multidrug-resistant organisms. By helping to optimize their hospital’s compliance with The Joint Commission Core Measures and National Patient Safety Goals, the antimicrobial stewardship team can demonstrate value to healthcare administrators. Other national quality indicators, including those supported by CMS, also have associations with antimicrobial stewardship. The VBP program is a CMS initiative that rewards hospitals with incentive payments based on the quality of care provided to Medicare patients [32]. Several processes of care measures incorporated in VBP scores relate to antimicrobial stewardship, including The Joint Commission Core Measures for pneumonia (PN-3b, PN-6) and surgical prophylaxis (SCIP-Inf-1 and SCIPInf-4). Infection-related outcome measures incorporated into VBP include central line–associated bloodstream infection and pneumonia 30-day mortality rate (MORT-30-PN). Readmissions within 30 days following discharge for patients with pneumonia can also impact CMS payment to hospitals, as can 30-day readmissions following a variety of other conditions. All of these metrics represent opportunities for antimicrobial stewardship teams to impact patient care, a hospital’s quality scores, and CMS payment; and for the ASP to increase recognition from healthcare administrators. Public reporting of infection rates and inclusion of infection rates on hospital “scorecards” or “dashboards” has also increased the visibility of antimicrobial stewardship in the corporate suite. For example, CMS now requires hospitals to report hospital-acquired C. difficile infection and hospital-acquired methicillin-resistant Staphylococcus aureus bloodstream infection, and these infections are also required to be publicly reported in many states. Many states require hospitals to report rates of SSI following a variety of different types of surgeries, and CMS requires hospitals to report SSIs following colon surgery and abdominal hysterectomy. Due to the increased visibility of these types of infections and their potential fiscal impact on hospitals as well as their impact on public perception, they are often placed on hospital dashboards, which are routinely scrutinized by hospital administrators. The increased recognition of these infections as important and preventable increases


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antibiotic-associated risk factors for hospital-acquired infections could move administrators (as well as stewardship personnel) away from dollars and toward drug utilization metrics that are more meaningful from a quality perspective and would allow for improved benchmarking with other hospitals. The defined daily dose per 1000 patient-days is also an effective process measure and provides greater sensitivity for identifying changes in dosing strategies. Measuring the amount of antimicrobial utilization touches only a small component of antimicrobial stewardship activities. Metrics regarding antimicrobial process, such as time to effective therapy for bloodstream infection, and appropriate antimicrobial selection and duration of therapy for certain infection types including CAP or for surgical prophylaxis are reflections of the quality of infectious disease management. Workload measures can help characterize the effort in achieving predefined goals. Describing the number of patients on restricted antibiotics, or number of patients linked to a specific disease-based stewardship intervention (such as C. difficile infection), is an essential first step in characterizing any deficiencies and developing a process to improve outcomes and economic measures. Characterizing the number of interventions and time per intervention may be helpful in obtaining additional resources if linked to improvements in economic or outcome measures.

the value of ASPs to hospital administration with regard to prevention and optimal management of these types of infections. Allocation of Resources

CONCLUSIONS ASPs must expand beyond traditional measures linked to cost and utilization, and position themselves to improve process

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Notes Acknowledgments. Editorial support was provided by ApotheCom ScopeMedical (Yardley, Pennsylvania) and funded by Cubist Pharmaceuticals. Supplement sponsorship. This article appears as part of a supplement titled “Antimicrobial Stewardship: Patients Over Process,” sponsored by Cubist Pharmaceuticals. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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When demonstrating importance of ASPs to healthcare administrators, it is important to note that stewardship has impact across almost all services within a hospital. Issues pertaining to invasive infections, such as C. difficile and antimicrobial resistance, are common to various services and departments within a healthcare system, and it is important for healthcare administrators to be aware of the critical role that stewardship plays in effectively managing these issues. It is also important to note that antimicrobial stewardship personnel play an important role in the education of providers across a wide range of practices with regard to effective and appropriate antimicrobial use and are a valuable component of physician and licensed independent provider trainee programs. Administrators receive frequent requests for resources, and identifying where to best allocate the resources can be challenging. ASPs are ideally positioned to influence specific process or outcome measures that impact areas across the entire healthcare system (such as C. difficile infection, compliance with vaccination recommendations, or rates of 30-day readmission following pneumonia diagnosis). ASPs should clearly identify institutional deficiencies in providing optimal care or improving process measures, with special focus on those that are publicly reported or linked to pay for performance. Describing the role of ASP in improving deficiencies and estimating the associated return on investment (the impact of improvements in clinical and economic outcomes) will enhance the value of the ASP, and optimize the probability of obtaining or continuing to receive support from hospital administration. The landscape of healthcare delivery is rapidly changing. Decisions regarding where and how to most cost-effectively manage infected patients are becoming increasingly complex due to changes in reimbursement, new technology, and availability of new antimicrobial agents. Antimicrobial stewardship teams will increasingly be called upon to assist in decision making regarding optimal methods and alternative locations to the inpatient setting for delivery of antimicrobial therapeutics (eg, infusion centers or emergency room), and will be critical in the development and implementation of newer approaches to treatment of infections. These types of decisions and analyses are going to continue to grow in frequency and complexity, and it is imperative that healthcare administration include the antimicrobial stewardship personnel in strategic planning and decisions.

and clinical outcome metrics. The process to improve outcomes is often complex and multifactoral, and requires collaboration between ASPs, hospital leaders, and stakeholders to achieve common goals. Establishing predefined goals and aligning daily stewardship activities and respective tracking of outcomes metrics are key in establishing the value of a stewardship program. The increasing focus on pay for performance and quality of care presents a unique opportunity for ASPs to establish themselves as essential components of the healthcare quality journey.

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