Discussion

In our in-depth evaluation of 21 CAH ASPs that did not meet all 7 CDC Core Elements, the greatest deficiencies were in accountability and education. In contrast to our findings, the CDC 2021 NHSN survey found that 95% of ASPs self-reported adherence to all core elements, including 71 (85.5%) of 83 of Nebraska ASPs and 107 (96.4%) of 111 of Iowa ASPs. ⁷ In these surveys, 100% of Iowa ASPs and 98% of Nebraska ASPs reported that they met the accountability core element, compared to 19% in this evaluation. ⁷ Although our evaluation was not a systematic survey, 16 Iowa CAH ASPs and 5 Nebraska CAH ASPs did not meet all 7 core elements, including nearly 25% that were deficient in multiple core elements. Several factors may explain these differences. Our population was enriched with deficient facilities due to our sampling method, but not all facilities are represented in the NHSN data, either. Concern about penalties when responding to official surveys may prompt overly generous self-assessments. Our evaluation methods may have been stricter than the CDC methodology, but even when given credit for partial adherence, 71% of these ASPs did not meet all 7 core elements. Several programs had no regular ASP meetings, physician leader, educational activities, or specific antimicrobial stewardship–related training for their physician or pharmacist leaders. Thus, NHSN surveys may overestimate adherence to the core elements and underrepresent CAHs, especially those with less well-developed ASPs. The 2021 NHSN annual survey response rates were only 54 (86%) of 63 Nebraska CAHs and 69 (84%) of 82 of Iowa CAHs. ⁷ We identified significant leadership deficits, with most physicians and pharmacists lacking training in ID or antimicrobial stewardship, which The Joint Commission and the CMS now require. ^3,8 This finding is not unexpected in these rural locations where experts are unavailable. At the same time, CAH ASPs are looking for opportunities to improve and are actively seeking expert guidance. The COVID-19 pandemic likely contributed to disruption in some of these ASPs. The limitations of this study include small sample size, qualitative assessment methodologies, and selection bias. Thus, these results should be extrapolated cautiously.

Our findings suggest a need for greater emphasis on developing ASPs in CAH settings, given unique barriers to establishing and maintaining successful ASPs. A 2017 Kansas survey identified several barriers more prevalent in CAHs than acute-care hospitals: fewer full-time pharmacists, less leadership support, a lack of clinical decision support, no antibiograms, and no defined formulary. ^{Reference Poteete and Scaletta9} In 6 Vermont CAH ASPs, similar barriers were recognized: lack of protected time for ASP leaders, EMR data-acquisition difficulties, financial limitations with high physician and pharmacist turnover (including temporary clinicians), and slow turnaround time from outside microbiology laboratories. ^{Reference Smith and Ahern10} Despite these barriers, CAHs have several advantages over larger, urban hospitals: less institutional bureaucracy to navigate and smaller, more familiar clinical staff. ^{Reference Smith and Ahern10}

Identified barriers included a lack of physician leadership, a lack of ID and antimicrobial stewardship training and expertise, and a lack of financial and/or personnel resources. Most physician leaders had family or internal medicine training with residency programs that traditionally lack stewardship training. A lack of customizable EMRs and clinical decision-support tools, which preclude NHSN reporting or make data tracking and reporting difficult, were an additional barrier, even in CAHs belonging to larger hospital networks. Potential strategies to improve CAH ASPs include the use of telestewardship to increase the access of ID physicians to rural areas and the creation of collaborative CAH ASP networks to educate, train, and coach non-ID physicians and pharmacists in leading ASPs. CAH ASPs warrant further study to improve antibiotic use in rural communities.