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.