The VHA ASP model

Formal affiliations between VAMCs and academic hospitals were established in 1946, with the goals of supporting the medical care of the veteran population, expanding the national healthcare workforce, and improving medical practice through education and research. ^{Reference Lypson and Roberts5} Currently, VHA is the second largest funding source for graduate medical education, its facilities provide clinical sites for thousands of trainees from university programs, and many faculty have dual appointments with VHA and affiliate academic medical centers. ^{Reference Petrakis and Kozal6,Reference Sells and McQuaid7}

In 2010, the VHA began the Antimicrobial Stewardship Initiative to provide national guidance and resources for the development of VAMC ASPs. ^{Reference Kelly, Jones and Echevarria8,Reference Ramakrishnan and Patel9} The initiative is implemented through the Antimicrobial Stewardship Task Force (ASTF), a multidisciplinary team that develops educational tools, sample policies, antimicrobial utilization dashboards, and other national resources. ^{Reference Kelly, Jones and Echevarria8,Reference Ramakrishnan and Patel9} The ASTF facilitated the creation of regional stewardship collaboratives organized within the 21 Veterans Integrated Service Networks. ^{Reference Ramakrishnan and Patel9} While it provides tools and resources nationally, the VHA has not mandated specific stewardship initiatives locally. Local ASP policies and initiatives informed by nationally developed tools and resources have effectively reduced inpatient and total antibiotic use by 12% and 2.1%, respectively, in VHA studies. ^{Reference Kelly, Jones and Echevarria8,Reference Graber, Jones and Goetz10}

Opportunities for harmonization

There are several ways ASPs across affiliated sites could harmonize their programs (Table 1). Development of treatment guidance by ASPs remains a priority intervention within the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship, and collaborative guideline development ensures that nuances such as formulary differences and local resistance patterns are addressed. ^{11–Reference Young, Shihadeh and Skinner13} A recent example is the Colorado Hospital Association’s antimicrobial stewardship collaborative, which implemented evidence-based guidelines for urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs) at 26 hospitals, though this did not include a VAMC (personal correspondence). ^{Reference Jenkins, Hulett and Knepper12} Over an 18-month period, there were significant reductions in the use of fluoroquinolones for UTIs, broad-spectrum antibiotics for SSTIs, and total duration of antimicrobial therapy at the participating hospitals. ^{Reference Jenkins, Hulett and Knepper12} Treatment guidelines can be made available via mobile-based medical applications to facilitate access and increase adherence. ^{Reference Young, Shihadeh and Skinner13–Reference Hand, Clancy and Allen15}

Table 1. Opportunities for harmony between ASPs within University Health Systems, Veterans Affairs Medical Centers, and Other Affiliates

Note. ASP, antimicrobial stewardship program.

Another opportunity for harmonization is the development of regional antibiograms to provide useful epidemiologic information on antimicrobial resistance, especially for smaller facilities that may have insufficient isolates to produce a validated local antibiogram. ^{Reference Hostler, Moehring and Dodds Ashley16,Reference Bailey, Antosz and Daniels17} The information can be specifically helpful for academic networks that frequently share patients.

Perhaps the greatest opportunity for harmonization is the production of educational resources for the affiliated academic network. These include teaching sessions for trainees and staff, which take considerable time to produce and are often duplicated across sites. Sharing these resources can reduce the burden for a smaller ASP, offer additional opportunities for professional development, and allow for shared trainees to receive a more cohesive curriculum across clinical sites. Antimicrobial stewardship programs can also develop joint educational conferences, including case discussions, lectures, and/or journal clubs. These can provide further opportunities to discuss current literature and ways to implement evidence-based practices locally. Collaborative efforts can be formalized in periodic strategic planning sessions between affiliated ASPs to develop common goals and initiatives. Mentorship and sponsorship from more experienced ASPs can facilitate the growth and development of staff at resource-limited or newer programs. An emphasis on a shared mission is critical to foster growth and promote sharing of existing resources.

Overall, there is a paucity of literature regarding stewardship integration across academic or looser affiliated networks. Most of the published literature focuses on partnerships between ASPs and specific institutional service lines or large, more formalized networks such as centralized, health-system ASPs, consultative stewardship services, and hospitals with shared EMRs. ^{Reference Dodds Ashley and Spires18–Reference Watson, Trautner and Russo23} This provides a significant opportunity to further the literature on collaborative stewardship interventions in affiliated networks.

Present challenges

While there are opportunities for ASP harmonization within affiliated systems, many challenges remain. Antimicrobial stewardship programs may have insufficient resources, expertise, and support to carry out their activities effectively. ²⁴ There may be drastic differences in programmatic structure, antimicrobial restriction policies, pharmacy formularies, as well as the overall culture between facilities. The benefits of harmonization are typically downstream, while the start-up cost, and time commitments, can be high, especially for programs already stretched to complete their core tasks. Collaborative guideline development introduces additional complexities to production, approval, and revision as compared to single-facility guidance. Collaboratively developed guidelines take longer to produce and require facility-level approval for the initial document and any revisions. This creates obstacles to keeping the guidance documents updated but can be managed by ensuring appropriate stakeholders are involved in initial development and periodic review. Antimicrobial stewardship programs can also make supplemental guidance while remaining a party to the collaborative products.

Partnerships between VAMCs and academic affiliates can be uniquely challenging due to additional federal privacy protections on patient-level data and the VA EMR, which create logistical hurdles for research, especially clinical decision support interventions. Veterans Affairs medical centers also have a unique patient population that is generally older and predominantly male, which differs from those at the affiliates. ^{Reference Wong, Wang and Liu25} Collectively, these barriers, along with the existing VA stewardship infrastructure, make it easier for VAMCs to collaborate within the VA network rather than with their academic affiliates, creating parallel rather than integrated networks.