Discussion

Our national survey of VA CLCs provides a valuable assessment of the current state of stewardship in this unique care setting. We observed high uptake of cornerstone antibiotic stewardship strategies, including preauthorization, prospective audit and feedback, and local treatment guidelines. However, opportunities remain to develop and standardize quality measures used for internal tracking and benchmarking. In addition, there are opportunities to improve the frequency of giving feedback to prescribers. The survey also identified perceived barriers preventing programs from strengthening antibiotic stewardship practices. Notably, 4 out of every 10 CLCs reported the lack of dedicated FTEs to support stewardship personnel, which indicates adequate funding for stewardship was absent at a large proportion of responding sites.

Prior studies into stewardship in the postacute care setting have largely focused on community nursing homes. These studies showed comparatively lower levels of involvement by trained antibiotic stewards and less utilization of key strategies such as preauthorization or prospective audit and feedback. ^{Reference Fu, Mantell, Stone and Agarwal2,Reference Stone, Herzig, Agarwal, Pogorzelska-Maziarz and Dick3} In contrast, VA CLCs may benefit from a national directive mandating pharmacy and physician support for stewardship efforts. The synergistic relationship between VAMCs and their CLCs could serve as a model for partnership between large health systems and community nursing homes. Prior work within the VA has demonstrated the efficacy of telehealth-supported stewardship activities in the postacute care setting; this could serve as a model for private sector nursing homes. ^{Reference Livorsi, Sherlock and Cunningham Goedken6}

Our survey additionally sheds light on some limitations affecting antibiotic stewardship in CLCs. The most consistent theme reported by respondents was a lack of support for information technology and data analytic needs. A lack of informatics support could limit the implementation of interventions that leverage the electronic medical record or data monitoring specific to a new stewardship strategy. The VA national office has created an interactive dashboard to access antibiotic use data in CLCs, and further research will be needed to clarify if stewards are unaware of these resources or find them to be inadequate. In the private sector, acute care hospitals are being encouraged to submit antibiotic use data to the National Healthcare Safety Network allowing for generation of reports on antibiotic use and interfacility benchmarking. Encouraging data submission by long-term care facilities or otherwise centralizing data analytics through university and private partnerships may be a path to further improvement. At the current time, however, there are no validated quality measures on antibiotic use for stewardship programs in long-term care facilities to track.

Our study has limitations. VA CLCs operate within the largest integrated healthcare system in the US and differ from other nursing homes. Additionally, our survey was voluntary and completed by staff from variable disciplines, potentially introducing significant variability into the responses. Finally, our survey was not a previously validated tool and may be an imperfect measure of day-to-day stewardship activities in VA CLCs. Despite these limitations, we feel our survey adds value in describing the current landscape and guiding potential future projects for VA.

The CDC estimates that over 1.3 million people in the United States live in nursing homes with this population expected to grow rapidly as the population ages. ⁷ Over time, improving antibiotic stewardship practices in long-term care settings will only increase in importance. Our survey emphasizes the benefits of nursing home partnership with acute care facilities. It further highlights the need for centralized informatics support to facilitate standardized metrics, benchmark evaluation, and change. Antibiotic stewardship has always been a team sport, and this collaborative spirit is also essential in the long-term care setting.