Background
Over 7 million older Americans are homebound.Reference Reckrey, Yang and Kinosian1 Homebound persons have complex chronic conditions comparable to nursing home residents and are at high risk of hospitalization. Approximately 11% of homebound older Americans receive home-based primary care (HBPC).Reference Reckrey, Yang and Kinosian1 HBPC provides longitudinal primary care in the home. The Department of Veterans Affairs (VA) HBPC program operates in 140 medical centers and cares for nearly 60,000 patients each year.Reference Datta, Fried and O’Leary2,Reference Karuza, Gillespie and Olsan3 The most common HBPC model features a nurse practitioner as the primary care clinician, with teams supported by a median of 9 disciplines, designated physicians at 80% of sites, and variable access to specialists.Reference Karuza, Gillespie and Olsan3 We observed a high prevalence of antibiotic prescription dispensing and antibiotic resistance in this program.Reference Datta, Fried and O’Leary2,Reference Datta, Pirruccio and Fried4 There are also unique challenges to the diagnosis and treatment of infection in HBPC.Reference Datta, Kiwak and Fried5 Yet, to date, HBPC has fallen outside the scope of traditional antibiotic stewardship efforts.6,Reference Barlam, Cosgrove and Abbo7 To inform the development of antibiotic stewardship interventions in HBPC, we aimed to identify strategies that clinicians in HBPC have employed to help ensure they are making appropriate antibiotic prescribing decisions.
Methods
Methods and results are reported in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ).Reference Tong, Sainsbury and Craig8 The study protocol was approved by the institutional review boards at the Veterans Affairs Connecticut Healthcare System and Yale University.
We recruited physicians and advanced practice providers who practiced in the VA HBPC Program and prescribed antibiotics using a national listserv of HBPC Medical Directors. There were no exclusion criteria. We conducted interviews until data saturation was achieved, and further interviews provided no new insights. This occurred after 22 interviews had been performed.Reference Guest, Bunce and Johnson9 Participation was voluntary, uncompensated, and subsequent to verbal informed consent.
In-depth, one-on-one interviews were performed by a trained clinical research nurse between June 2022 and September 2022 using a discussion guide developed by the research team. The discussion guide contained open-ended questions about management of suspected infections, how antibiotics are prescribed, and how prescribing can be improved (Appendix). It was pilot-tested with 3 HBPC physicians and modified based on feedback. All interviews were video-recorded and transcribed in Microsoft Teams and independently verified for accuracy.
Transcripts were de-identified, analyzed using grounded theory, and coded through the constant comparative method. Two investigators independently reviewed and coded transcripts, resolving disagreements through discussion. This process was iteratively applied to five initial transcripts, and no major differences were identified. New transcripts were compared to previously coded ones. Once a coding structure was established, the remaining transcripts were coded. The research team then examined the relationship among codes and identified themes. Analyses used ATLAS.ti 7.1 (Berlin, Germany).
Results
We interviewed 22 clinicians from 19 HBPC programs across 18 states (Table 1). Mean age of participants was 48.5 years (standard deviation, 9.3 yr).
Table 1. Characteristics of study participants (n = 22)
Interviews revealed 3 themes related to facilitators of appropriate antibiotic decision-making in HBPC: (1) Infectious disease specialists enhance the management of infection; (2) Clinical pharmacists aid the selection of antibiotics; and (3) Local initiatives within programs support antibiotic prescribing decisions.
Theme 1. Infectious disease specialists enhance the management of infection
Participants reported that infectious disease specialists assisted clinicians in HBPC by offering clinical guidance through remote consultations in the electronic health record, coordinating intravenous antibiotic therapy at home, and providing recommendations regarding the management of multidrug-resistant organisms (Table 2). Contributions from infectious diseases specialists also included formal education tailored to clinicians in HBPC. According to one participant, “[infectious disease conducts] grand rounds on a regular basis, probably quarterly, [that] deal with multiple multidrug-resistant infections at our medical center and associated programs…they’re constantly updating us.”
Table 2. Factors that assist clinicians with challenges related to antibiotic decision-making
Theme 2. Clinical pharmacists aid the selection of antibiotics
Participants acknowledged that clinical pharmacists were helpful resources when selecting the class or dose of antibiotics. Most often, clinical pharmacists provided insight regarding drug–drug interactions and the potential for adverse drug events with antibiotics. Clinical pharmacists also provided comprehensive medication reviews (Table 2). Not all participants had clinical pharmacists on their interdisciplinary teams, and those without access to them expressed difficulty with antibiotic selection.
Theme 3: Local initiatives within programs support antibiotic prescribing decisions
Several initiatives within HBPC programs supported antibiotic prescribing decisions. Participants described a range of interventions in the electronic health record that informed the selection of antibiotics. Some of these interventions were generated specifically by members of the HBPC program, such as order sets related to the treatment of infectious diseases, whereas others were available through participation in national initiatives. Participants also described local antibiotic stewardship champions. According to one participant, “[I]in one of our outlying programs, the provider got the whole team involved and gave a little antibiotic stewardship mini education. [S]he expressed…the process of how she wanted to proceed in kind of establishing that culture of stewardship and then maintaining it through constant re-education. I think that’s a major thing.” Other initiatives included peer review and feedback between physicians and advanced practice providers (Table 2).
Discussion
Antibiotic stewardship interventions have largely focused on institutional and office-based settings with limited focus on HBPC.Reference Barlam, Cosgrove and Abbo7 In the absence of interventions specific to HBPC, we sought to explore what clinicians in HBPC deemed helpful in making appropriate antibiotic prescribing decisions. We found that infectious disease physicians and clinical pharmacists facilitate the management of infection and selection of antibiotics, respectively, and that local initiatives within programs support antibiotic prescribing decisions.
The Core Elements of Outpatient Antibiotic Stewardship include commitment, action for policy and practice, tracking and reporting, and education and expertise.Reference Sanchez, Fleming-Dutra, Roberts and Hicks10 Our work suggests that these elements may be generalizable to HBPC. Through remote consultations with infectious disease specialists, access to expertise can be expanded to HBPC programs when needed. Active participation of pharmacists on interdisciplinary HBPC teams can improve how antibiotics are prescribed. This may be impactful among the 10% of HBPC programs that reported a lack of assistance from clinical pharmacists with medication management.Reference Karuza, Gillespie and Olsan3 Approaches that are tailored to the distinct needs and resources of programs, such as interventions in the electronic health record, peer review and discussion, and education, may further promote antibiotic stewardship in HBPC.
There are unique challenges to antibiotic prescribing in HBPC. Prior work has highlighted limited access to diagnostic testing and the challenges of collecting and transporting microbiological specimens in the field.Reference Datta, Kiwak and Fried5 Notably, facilitators that may address these challenges were not discussed by study participants. Future studies should consider developing and testing clinical decision support systems or enhanced diagnostic tools, such as point-of-care ultrasounds, which are specifically tailored to improve the management of commonly encountered infections in HBPC such as urinary tract infections, pneumonia, and skin and soft tissue infections.Reference Datta, Fried and O’Leary2
Because our study focused on the VA HBPC program, the results may have limited generalizability outside the VA and to patients who are homebound but not receiving HBPC. Findings also reflect the attitudes and experiences of clinicians. We did not observe HBPC clinicians in practice. Additionally, clinicians were recruited, so study participants may have specific views of antibiotic stewardship. Notwithstanding these limitations, we show that infectious disease specialists, clinical pharmacists, and local initiatives within programs are key facilitators of antibiotic decision-making in HBPC. Future research should develop stewardship interventions that facilitate specialist engagement, support tailored approaches to antibiotic prescribing, and incorporate health outcomes to quantify the impact of antibiotic stewardship in HBPC.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ice.2024.241
Acknowledgments
This work was supported with resources from and the use of facilities at the Hospital Epidemiology and Infection Prevention Program at the Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
Financial support
Dr. Datta was supported by a career development award from the National Institute of Aging (NIA) of the National Institutes of Health (NIH) under Award Number U54AG063546, which funds the NIA Imbedded Pragmatic Alzheimer’s Disease and AD-Related Dementias Clinical Trials Collaboratory (NIA IMPACT Collaboratory). This publication was made possible by CTSA Grant Award UL1 TR001863 from the National Center for Advancing Translational Science (NCATS), a component of the NIH, the Operations Core of the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342), the Yale Physician-Scientist Development Award, and the Society for Healthcare Epidemiology of America Epidemiology Competition Award. Dr. Krein receives funding support from a VA Health Services Research & Development Service Research Career Scientist Award (11-222). Dr. Cohen was supported in part by NIA grant K76AG059987.
Competing interests
All authors report no conflicts of interest relevant to this article.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs.
Role of the funding source
The funders had no role in the study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
