The Use of Telehealth-Supported Stewardship Activities in Acute-Care and Long-Term Care Settings: an Implementation Effectiveness Trial

Background:We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). Design:Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). Setting:The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. Participants:The study included inpatient providers at participating sites who prescribe antibiotics. Intervention:During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. Methods:The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. Results:The telehealth program reviewed 502 unique patients and made 681 recommendations to 24 providers; 77% of recommendations were accepted. After program initiation, antibiotic DOT immediately decreased in the LTC units (-30%; P < .01) without a significant immediate change in the acute-care units (+16%; P = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. Conclusions:The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.