Discussion

We have reported physician and pharmacist stewards’ views on the development and implementation of ASPs at their institutions. Generally, individual characteristics do not affect the majority of those views. Although we thought that gender bias in medicine may affect female stewards’ self-efficacy and perception of their authority, this was not the case. Stewards reported high interest in antibiotic stewardship; they often volunteered for the role and stated that the ASP was advantageous to both the institution and patient care. Physician and pharmacist stewards were engaged in their programs, felt strongly that there was buy-in from clinical staff, and felt that the clinical leadership provided stewards with the authority to enforce the ASP policies.

The commitment of hospital leadership to ASPs is a core element identified by the CDC and encompasses financial, human, and technological resources. ¹² In our study, stewards, regardless of individual characteristics, did not think that hospital leadership provided sufficient support in the form of protected time and resources to do the job. This finding is consistent with a qualitative study of pharmacists’ perspectives that found pharmacist champions and stewards in one healthcare system identified inadequate time for stewardship activities as a barrier to successful ASP implementation. ^{Reference Appaneal, Luther, Timbrook, LaPlante and Dosa1} In another study, a survey of ASP physicians and pharmacists from 21 academic medical centers revealed that in addition to a lack of dedicated time for stewardship, insufficient personnel, such as the absence of a full-time ID physician, resulted in delayed uptake of pharmacists ASP recommendations. ^{Reference Pakyz, Moczygemba, VanderWielen, Edmond, Stevens and Kuzel5}

Providing support to time-strapped ASP staff can be achieved in several ways. Access to computerized decision-support tools reduces the amount of time stewards need to do their job. ^{Reference Appaneal, Luther, Timbrook, LaPlante and Dosa1} In institutions with financial and human resource constraints, hospital leadership can provide access to external software if they are unavailable locally and/or if IT personnel are shared across institutions to support technological efforts in the ASP. ^{Reference Appaneal, Luther, Timbrook, LaPlante and Dosa1} If there is an absence of on-site ID expertise, leadership can also employ a telehealth approach in which ID consultations and stewardship support can be provided remotely. ^{Reference Appaneal, Luther, Timbrook, LaPlante and Dosa1} Although the stewards in our study believed that dedicated financial support and protected time for their ASP were insufficient, this belief did not affect their views regarding their ability to do their job. Stewards reported high self-efficacy, stating that not only did they have the skills to do the job but also the authority to enforce ASP guidelines. Moreover, this level of self-efficacy was consistently reported across stewards regardless of sex, leadership role, specialized training, or whether the steward was a pharmacist or a physician. Our findings add to the growing literature supporting the expanding leadership role of pharmacists within ASPs and their strength in this role. For example, in France, where stewardship programs are led by ID physicians, a multicenter study of 88 hospitals reported that sites with pharmacist stewards, referred to as antibiotic advisors, had less antibiotic consumption than those with nonpharmacist advisors. ^{Reference Ourghanlian, Lapidus, Antignac, Fernandez, Dumartin and Hindlet13} This finding is consistent with those of Doernberg et al ^{Reference Doernberg, Abbo and Burdette8} in 2018, which showed that increasing pharmacist FTE was associated with significant improvement in ASP effectiveness, whereas increasing physician FTE did not result in significant improvement.

Although research on ASPs often focuses on the importance of physical and financial resources, ^{Reference Cunha3} other components are crucial to success. In our study, stewards exhibited personal ownership of the program through their high level of volunteerism and specialized training in antibiotic education or infectious diseases. In addition, volunteers and those with specialized training were less likely to think that the ASP was mandated. This finding suggests that the stewards in our survey had a high interest in stewardship and would have been champions for ASP activities regardless of directives. The importance of personal investment has been highlighted in other healthcare settings. In a study conducted across three accountable care organizations, motivation for behavior change went beyond financial incentives; instead, factors related to a provider’s personal motivation, such as mastery of skill and a feeling of social purpose, were much more important. ^{Reference Phipps-Taylor and Shortell14} Additionally, our previous qualitative work with stewards in this project details similar motivations. Stewards not only welcomed learning new skills but also enjoyed their roles and felt that their job was important in improving clinical care. ^{Reference Barlam, Childs and Zieminski10}

This study had several limitations. Although we recruited participants from 154 hospitals, they represented only 2 health systems; thus, our findings may not be generalizable to other healthcare institutions. Additionally, we combined responses across systems and this may have obscured differences between the VA and IHC sites. However, given that there was often general agreement, this is unlikely. Stewards may have self-selected to respond to the survey, and those with less interest in the ASP may not have responded; therefore, the results may not reflect the views of all stewards; however, the high survey response rate (81.8%) makes this less likely. Even with these limitations, our findings highlight the fact that that interpersonal factors are important in the development and sustainability of ASPs.

In conclusion, stewards generally had positive views toward the ASPs in their institutions. Those who volunteered for their role or had specialized training more often viewed the ASP in a positive light. Our findings suggest that, though insufficient financial support and limited staff can be barriers to a successful ASP, the personal investment of stewards is critical to success. These findings are timely and indicate that in a new climate in which ASPs are required, hospitals might see the full benefits of their programs if they recruit and provide training to individuals with a true interest in stewardship.