Federally Qualified Health Centers Lead AMR Stewardship
With approximately 60% of total antibiotic use in the U.S. associated with outpatient settings, and millions of antibiotic prescriptions written annually, it has become crucial to address the issue of overuse and misuse of antimicrobials both within and outside the walls of health systems. In fact, of the over 200 million antimicrobial prescriptions written each year in the U.S., almost 30% are considered unnecessary, and 50% are considered inappropriate (i.e., the dosage, duration or selection of the pharmaceutical is considered unfitting).
As outpatient settings are responsible for a substantial portion of antimicrobial usage, health centers are turning their sights to stewardship programs to promote responsible prescribing practices, enhance medication safety and, ultimately, mitigate the impending concern of antimicrobial resistance (AMR). While the adoption of such programming has been slow across various health systems, Federally Qualified Health Centers (FQHCs), which serve historically marginalized populations, are well-positioned to contribute to equitable care while leading stewardship efforts.
Guiding Framework for Antimicrobial Stewardship Programs
Of the over 200 million antimicrobial prescriptions written each year in the U.S., 30% are considered unnecessary and 50% are considered inappropriate.
Source: Flickr. To tackle health-care related AMR challenges, the Centers for Disease Control and Prevention (CDC) released the report, Core Elements of Outpatient Antibiotic Stewardship, in 2016. These core elements provide a framework for outpatient practices to focus on 4 key pillars:
1. Commitment.
2. Action for policy and practice.
3. Tracking and reporting.
4. Education and expertise.
The target audiences for these core elements include primary care clinics, retail health clinics, urgent care facilities, emergency departments and dental offices.
Even with the CDC's framework, the adoption of outpatient stewardship programs has been slow. To address this, The Joint Commission introduced new standards for ambulatory health care in 2019 to encourage accredited organizations to establish outpatient stewardship programs. These standards emphasize the importance of identifying stewardship leaders, implementing evidence-based practice guidelines, providing necessary resources and collecting data related to stewardship goals.
Acknowledging the longstanding inequities that impact patient populations affected by AMR (with overlap between patients served by FQHCs and those who are disproportionally impacted by AMR), health care professionals and advocates of stewardship programming are turning their focus to FQHCs, which aim to provide affordable care to historically underserved patient populations.
How FQHCs Can Support Multidisciplinary Stewardship Teams
FQHCs serve over 30 million patients annually, with nearly 1,400 centers across the U.S. These centers play a pivotal role in reducing health disparities. “FQHCs are uniquely positioned to provide equitable care to underserved patients, with the aim of promoting health equity,” said Kierra Wilson, Pharm.D., BCPS, AAHIVP, pharmacy clinical coordinator at Chase Brexton Health Care, a 501(c)(3) nonprofit medical center based in Maryland.
However, implementing stewardship programs in FQHCs comes with several challenges, including funding constraints, staffing shortages, limited access to diagnostic tools and high patient volume. Despite these limitations, Wilson noted several emerging strengths for these health centers. The overall medical landscape of FQHCs has changed over the past decade, with expanded onsite services (e.g., pharmacy, dental, behavioral health, case management) and an increasing emphasis on comprehensive care. Wilson emphasized that, with these robust clinical offerings, it is essential for stewardship teams to be multidisciplinary.
“Stewardship programs warrant multidisciplinary collaboration in order to be successful, and we need that in terms of allowing us to be able to optimize the resources that we provide, allowing for more people at the table and more diverse perspectives, and to allow for interprofessional communication,” Wilson explained. “Multidisciplinary teams have been shown to [improve] management and outcomes for patients with many chronic diseases. And that involves medical providers—not just physicians, but also your advanced practice providers, pharmacy and nursing staff. Each of us has a unique perspective.”
When it comes to antimicrobial stewardship involvement, Wilson said there are 2 groups, in particular, that should be included: pharmacy staff and nursing staff. Between 2016 and 2020, FQHC pharmacy staff increased from 21.8% to 25.2%. The number of advanced practice providers, like nurse practitioners and physician assistants, has also grown in recent years, with health experts noting their heightened importance as physician and nursing shortages loom. Both pharmacy staff and advanced practice providers are often responsible for a significant portion of antimicrobial prescribing, so why aren’t they always included in antimicrobial stewardship efforts? Wilson offers 1 possible answer: a lack of AMR-related education and training.
Implementing Stewardship Education
Educational initiatives for FQHC staff members that are not one-off occurrences, but rather sustained year-round, are critical for stewardship programs, Wilson said. This training should include staff from a variety of clinical and nonclinical teams, emphasizing the desired multidisciplinary approach. Wilson offered several recommendations for educational programming during a scientific session at ASM Microbe 2023:
- Focus on the health system’s commitment to antimicrobial stewardship, emphasizing why this work is important to public health. "[You can] disseminate that information throughout your organization to show that you are a champion of stewardship," Wilson said.
- Collaborate with marketing teams to develop educational materials and posters for providers and patients.
- Explain antimicrobial selection and appropriateness, with an emphasis on infection control and patient monitoring.
- Outline roles and responsibilities in antimicrobial management for a variety of positions within the health system.
- Discuss health inequities and social determinants of health, and how this relates to antimicrobial stewardship and public health outcomes.
- When applicable, collaborate with information technology (IT) teams to provide guidance on electronic health record (EHR) use when making prescription decisions.
Assistance From Electronic Health Records
IT emerges as a “hidden hero” in antimicrobial stewardship programs, according to Anna Zhou, Pharm.D., BCIDP, co-director of the adult antimicrobial stewardship program at Loma Linda University Medical Center and an assistant professor of pharmacy practice at Loma Linda University. Zhou highlighted IT’s role in supporting activities, like prospective audit and feedback, antibiotic timeout (i.e., reviewing a patient’s response to an antimicrobial a few days after starting treatment) and clinical decision support. In particular, she noted how clinical decision support systems (i.e., software that assists health care workers in making decisions by matching patient data with clinical recommendations) can enhance guideline adherence and reduce antimicrobial consumption.
"As human beings, we simply cannot remember every guideline and every pivotal study that's out there," Zhou explained. "Research shows that 30-60% of decisions would actually be different if we had new information at the time of decision-making. And that's where clinical decision support comes into play."
Clinical decision support systems can include a vast set of evidence-based recommendations categorized by the infectious disease indication in the form of an empiric antibiotic order set. This takes into account the local antibiogram data (e.g., empiric antimicrobial susceptibility) and patient-specific factors, like an allergy to penicillin or the patient’s renal function.
What does this look like in practice? Let’s say a patient comes in with community-acquired pneumonia. For medication considerations, all the clinician has to do is click under “pneumonia” in the EHR and establish several factors that may impact the patient’s treatment, like if the patient has a penicillin allergy or not. Then, the software will populate antimicrobial orders for review and placement.
How Gender Bias Influences Antimicrobial Stewardship
Even with steadfast programming in place, unconscious biases can shape a patient’s experience and health outcomes, and possibly counteract stewardship efforts at FQHCs (or any health center, for that matter). Sara Alosaimy, a postdoctoral scholar at Wayne State University, examined gender bias in her research, in particular, noting that gender bias against both patients and providers can impact antimicrobial stewardship.
Gender bias is a socially constructed set of norms and rules, varying across societies and cultures. This type of bias is driven by prejudice and stereotypes, affecting the health and well-being of individuals, particularly historically underrepresented gender identities. Alosaimy explained that this can lead to “bikini medicine,” where marginalized gender identities are treated based on their sex assigned at birth, with much of the focus being on reproductive and sexual health, while “everything else is forgotten.”
"Typically, when we talk about antimicrobial resistance, we acknowledge terms that are very surrogate, like data and aggregate surveillance and health outcomes, but we forget to explore the correlation between sex, gender and antimicrobial resistance," Alosaimy said. "Antimicrobial stewardship programs can be biased. Think about all the reports selected, all the instruments designed—the [diversity of] people [that are chosen] to lead those programs and [who serve] on multidisciplinary teams is sometimes forgotten."
Several studies highlight gender disparities in antimicrobial prescribing. For example, patients who are assigned female at birth are often prescribed antimicrobials at a higher rate. Recommendations for treatment are also less likely to be accepted from health care professionals who are not cis-men. With these data in mind, the World Health Organization (WHO) released a report in 2018 explicitly outlining the need to address gender bias and inequities when combating AMR.
Alosaimy stressed the need to investigate and address gender bias in antimicrobial stewardship programs systematically. This includes calling for gender-conscious decision-making in health care and the inclusion of gender bias training in education and reporting. Furthermore, Alosaimy advocates for achieving gender equality in health care teams to create a more inclusive and effective antimicrobial stewardship environment.
"[Many] health care systems with antimicrobial stewardship programs reflect and reinforce gender biases, which compromises the safety of [patients and providers]. Gender bias primarily affects women and marginalized genders, causing a high burden of illness among these groups," she said. "Investigating gender bias in [antimicrobial stewardship programs] is an unmet clinical need. We need more descriptive variables and categories for gender, and we need to be able to assess this [with the context of] gender norms and behavior in order to protect the patient's well-being, and therefore impact the ability to prescribe in a very effective way that prevents the overuse of medication."
The Future of Health Center Stewardship
Looking ahead, ensuring the sustainability of equitable antimicrobial stewardship programs will be key. FQHCs could start embedding stewardship into job descriptions, ensuring protected time for program leaders, as well as provide ongoing education, training and collaboration with experts from various disciplines. The creation of an outpatient and inpatient stewardship program also necessitates strong leadership support. Collaborative efforts between stewards and leaders should align with several common goals, including improving clinical outcomes, addressing health inequities, reducing hospitalizations and lowering health care costs.
As efforts expand, future projects may aim to strengthen partnerships with laboratories for rapid diagnostics, local health departments for surveillance, health care payers for reimbursement opportunities and other health centers for idea-sharing and research.
Research in this article was presented at ASM Microbe, the annual meeting of the American Society for Microbiology, held June 15-19, 2023, in Houston.
Read About Clinical Education in the Stewardship Movement
Author: Leah Potter, M.S.
In This Issue:
- Lessons From a Decade of Antimicrobial Resistance Policy
- Growing Resistance: How Plant Agriculture Contributes to AMR
- Understanding the Risks of Antifungal Resistance
- Experts in East Africa Propose Equitable AMR Interventions
- Wastewater As a Key Driver of AMR
- Exploring a One Health Approach to AMR in Pakistan
- Federally Qualified Health Centers Lead AMR Stewardship
- Updating Breakpoints in Antimicrobial Susceptibility Testing
- Hunting for Antibiotics in Unusual and Unculturable Microbes
- What's Hot in the Microbial Sciences