Research Article: A whole-health–economy approach to antimicrobial stewardship: Analysis of current models and future direction

Date Published: March 29, 2019

Publisher: Public Library of Science

Author(s): Monsey McLeod, Raheelah Ahmad, Nada Atef Shebl, Christianne Micallef, Fiona Sim, Alison Holmes

Abstract: In a Policy Forum, Alison Holmes and colleagues discuss coordinated approaches to antimicrobial stewardship.

Partial Text: It is estimated that around 700,000 people die annually from drug-resistant infections, with experts predicting an alarming possible increase to 10 million deaths each year by 2050 and major future challenges to the way we practice medicine and surgery [1,2]. It was welcome news that tackling antimicrobial resistance (AMR) and infectious diseases along with health system strengthening were featured at the G20 summit (November, 2018), under the wider aim of improving sustainability, and progress towards more coordinated international efforts will be reviewed at the 73rd session of the UN General Assembly (September 2018) [3]; but how are health professionals, managers, and policymakers assuring coordinated efforts within human healthcare? Globally, there has been much emphasis on a ‘One Health’ approach that involves connecting the health of humans, animals, and the environment to tackle AMR [2]. This is driving much-needed antimicrobial stewardship (AMS) activities in animal production sectors [4]. However, we have yet to achieve and establish joined-up approaches within human health. This paper, therefore, focuses on an analysis of multisectoral AMS in human health. AMS remains a cornerstone for addressing AMR with numerous initiatives implemented with varying degrees of success [5,6]. A critical gap we have identified is that approaches have largely focused efforts separately in primary care or secondary care, and have also heavily targeted medical prescribers. In this paper, we propose that policymakers, clinical leaders, and healthcare managers assess and consolidate AMS activities across the whole health economy, and we use a novel, to our knowledge, approach to demonstrate how such an assessment can be made. We present the extent to which existing AMS initiatives are multisectoral or integrated across a whole health economy within individual countries and their impact on antimicrobial-related outcomes. We then highlight some challenges and key considerations for developing and harnessing potential benefits of integrated AMS approaches.

Health systems are required to deliver best outcomes efficiently, facing the challenges of macroeconomic constraints, technology costs, and increasing public need and demand. Consolidating the sometimes disparate programs and initiatives within the health sector is necessary, and integrated models of care across primary, secondary, tertiary, and long-term care can help with coordinated implementation of AMS [7]. Assessment of the degree of integration of AMS across the whole health economy is essential if we are to understand how a ‘One Health’ approach to addressing AMR may be achieved. Much AMS activity has been concentrated in hospital settings, creating a practical but somewhat artificial boundary that neglects bidirectional influences between hospital and community care services. Antimicrobial use in the community is associated with the development of AMR in and outside hospitals [8]. Furthermore, use of accident and emergency departments by ambulatory patients contributes to fragmented care and overuse of antimicrobials [9]. The way people access healthcare has evolved: the availability of blended care and complex patient-care pathways in some countries allows for patient-centred approaches as well as more rational use of services. The availability of antimicrobials without a prescription in some countries and increasing availability of online pharmacies provides an additional challenge for AMS. Fundamentally, AMS is lagging behind the advances made in health service delivery and patient behaviours by remaining sector-based.

The One Health perspective on integration involves multiple sectors communicating and working together to design and implement programs, policies, legislation, and research to achieve better public health outcomes [2]. In practice, in England, new integrated care models are being developed through 50 selected collaborative organisations that will inform potential redesign of the whole health system, and 25 integrated care pioneer sites to test new and different ways of joining up health and social care services [10]. Elsewhere in Europe, the Dutch Ministry of Health, Welfare, and Sport established nine pioneer sites to integrate clinical and community services with the aim of achieving ‘better healthcare at lower cost’ [11]. In the United States, accountable care organisations—which typically involve multiple physician practices and at least one hospital—have been established to improve the quality of care while lowering costs [12]. However, AMS is not explicit in any of these wider health-system–integration models.

Integration mapping of the 16 initiatives based on Table 1 suggests that a range of approaches have been used to achieve multisectoral AMS (Fig 1). Full integration in Planning was often considered a key factor for establishing many initiatives coupled with an integrated Stewardship and Governance approach. Integration in these two facets was mainly achieved through expansion of the AMS program, by which the primary governance responsibilities remained with the host institution [19,20,30,32,33], rather than through establishment of new structures [25]. AMS initiatives that had a shared governance structure across healthcare organisations (i.e., partially integrated) were either national programs [27] or state-wide programs [26,31]. While these provide examples of an integrated AMS governance approach, effective governance is likely to require much more than a multistakeholder approach to plan and deliver services; a mixed regulatory and persuasive strategy including effective public engagement is needed [38]. In our analysis, nine initiatives were partially integrated for Demand Generation, showing a potential missed opportunity for this critical facet that includes raising awareness and increasing engagement with the public, practitioners, health service managers, and policymakers. Monitoring and Evaluation relate to the functions around data collection, analysis, reporting, and performance-management systems. Full integration was identified in one initiative in which the health system oversaw these functions regionally or was responsible for these functions directly [33]. More often, data collection and analyses were managed by the wider health system; however, performance management roles were not [19,20,22,25,26,32]. Financing relates to the pooling of funds/funding source, cross-program use of funds, and provider payment methods involved in the AMS initiative. The majority of initiatives did not report on how they were or should be financed or how the funds were or should be used [19,20,22,23,26,30,32]. While fund pooling was partially integrated in three initiatives [25,32,33], decisions for provider payment methods were not. Overall, 11 studies evaluated the AMS initiative using mainly quasiexperimental study designs [19–23,25,27,30,31,39] (S2 Table). These reported on a range of positive impacts including reductions in antibiotic prescribing, reductions in the proportion of broad-spectrum antibiotic prescribed, reduction in C. difficile infection rates, and perceived improvement in citizens’ knowledge and attitudes about self-management of minor infections. However, potential for bias should be borne in mind because of study limitations associated with uncontrolled research designs, insufficient data time points, and risk of self-selection by participants who are interested in AMS.

Especially when planning new initiatives, a health system function framework as employed here can be critical to minimise duplication of effort and achieve efficiencies from the viewpoint of healthcare professionals and service users. Our assessment has highlighted strengths of initiatives associated with beneficial outcomes, and we present these as three interconnected practical recommendations for policymakers to consider.



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