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Original Investigation
May 1, 2017

Behavioral Approach to Appropriate Antimicrobial Prescribing in HospitalsThe Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study

Author Affiliations
  • 1Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
  • 2EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands
  • 3Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, the Netherlands
  • 4Department of Internal Medicine, OLVG Amsterdam, Amsterdam, the Netherlands
  • 5Department of Pediatrics, VU University Medical Center, Amsterdam, the Netherlands
  • 6Department of Medical Microbiology and Infection Prevention, VU University Medical Center, Amsterdam, the Netherlands
  • 7Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
JAMA Intern Med. Published online May 1, 2017. doi:10.1001/jamainternmed.2017.0946
Key Points

Question  How effective is an antimicrobial stewardship approach grounded in behavioral theory and focused on preserving prescriber autonomy and participation in improving appropriateness of antimicrobial prescribing in hospitals?

Findings  In this multicenter intervention study examining 1121 patient cases with 700 antimicrobial prescriptions during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period, appropriateness of antimicrobial prescribing significantly increased by 13.3% during a follow-up period of 12 months after intervention start.

Meaning  Future antimicrobial stewardship efforts in hospitals should use behavioral theory to improve intervention effectiveness in various clinical settings.

Abstract

Importance  Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.

Objective  To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals.

Design, Setting, and Participants  The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study.

Interventions  We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.

Main Outcomes and Measures  Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.

Results  A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.

Conclusions and Relevance  Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

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