Patient Roles in Antibiotic Management at the Hospital-to-Home Transition

Abstract

Objective: Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients’ role in managing antibiotics at the hospital-to-home transition.

Methods: We performed a qualitative study including semi-structured interviews with healthcare workers and contextual inquiry with patients discharged home on oral antibiotics. The setting was one academic medical center and one community hospital. Participants included 37 healthcare workers and 16 patients. We coded interview transcripts and notes from contextual inquiry and developed themes

Results: We identified six themes involving barriers or strategies for antibiotic MM. We identified dissonance between participant descriptions of the ease of antibiotic MM at the hospital- to-home transition and their experience of barriers. Similarly, patients did not always recognize when they were experiencing side effects. Lack of access to follow-up care led to unnecessarily long antibiotic courses. Instructions about completing antibiotics were not routinely provided. However, patients typically did not question the need for the prescribed antibiotic.

Conclusion: There are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition. Mismatches between patient perceptions and patient experiences around antibiotic MM at the hospital-to-home transition provide opportunities for health system improvement.

Keywords: Antibiotic stewardship; care transitions; antibiotic decision-making; healthcare delivery; medication management.

Introduction

The goal of antibiotic stewardship (AS) is for patients to receive the right antibiotic at the right time at the right dose for the right duration.¹ For clinicians preparing to discharge a patient from the hospital to the home on an antibiotic, responsibility for the final attainment of these goals² falls to the patient and caregiver who must perform medication management (MM) tasks to actually take the antibiotic. MM refers to the ability to obtain, administer, and take medications according to a prescribed regimen³ and is particularly important during the hospital-to-home transition, a high-risk period for medication errors.³ Understanding the intersection of AS and antibiotic MM is essential in understanding how patients may play a role in achieving AS. Little research has specifically explored home antibiotic MM in the setting of the need to meet AS requirements.

MM during the hospital-to-home transition involves stakeholders in different work systems. Working in multiple work systems, which may include the hospital, the home, the pharmacy, and the ambulatory clinic, increases the likelihood of error.⁴ Meanwhile, changes to medication regimens, especially new medications or short-term medications (such as antibiotics) can increase confusion and complicate patient and caregiver MM tasks.⁵ Medication safety interventions often focus on services offered by healthcare workers (HCWs), such as needs assessment, medication reconciliation, patient education, arranging timely follow-up appointments, and telephone follow-up,^6–8 but have not addressed the role of patients in MM, particularly in short-term medications or medications that require rapid titration.⁴ Understanding the perspectives of patients and informal caregivers in MM is essential, especially when medications need to be initiated and completed quickly.

While many reports have focused on patient performance of MM tasks after hospital discharge, most of these reports have focused on chronic medications.^3,4,9–11 Chronic MM may differ from the management of medications taken on a short-term basis (such as antibiotics, steroids, opioids, anxiolytics, corticosteroids, or certain anticoagulants). For example, patient-led antibiotic MM may differ from other MM tasks as patients must start taking these antibiotics immediately on discharge, and stop taking these medications on course completion.^3,12–16 An understanding of patient-managed oral antibiotic MM at the hospital-to-home transition is necessary to reduce the likelihood of adverse drug events, improve AS, and provide insights to management of other short-term medications. We performed semi-structured interviews of HCWs and direct observations of and semi-structured interviews with patients to characterize tasks required for, barriers to, and strategies for patient-led oral antibiotic MM at the hospital-to-home transition.^3,4,9

Methods

HCWs and patients were recruited from a tertiary care hospital in Baltimore, MD and a community hospital in suburban Bethesda, MD. At the tertiary care hospital, many patients are provided with medications from the on-site pharmacy prior to discharge. At the community hospital, there is no on-site pharmacy, but informational cards targeted to the individual patient’s medications are provided to patients on discharge. We used two approaches to evaluate antibiotic MM at the hospital-to-home transition: in-person semi-structured interviews with HCWs and contextual inquiries followed by semi-structured interviews of patients performing antibiotic MM tasks after discharge. Contextual inquiry involves observing individuals-–in this case, patients--in their work system (managing antibiotics), and asking clarifying questions.^17–19

Our semi-structured interview guide was based on the Four Moments of Antibiotic Decision-Making -- a framework that emphasizes healthcare teams pausing to reflect on antibiotic indication, choice, and duration2--and the Transition Model of MM, which describes processes required for MM at the hospital-to-home transition (Appendix).3 Interviews were recorded and transcribed.

HCW semi-structured interviews were conducted by two investigators individually (SLS and SCK) January 2019-August 2019. HCW interviews lasted 20–40 minutes and focused on antibiotic-decision making, antibiotic MM, and challenges in antibiotic prescribing.² Eligible HCW participants included inpatient physicians, pharmacists, nurses, discharge coordinators, nurse practitioners, and physician assistants, as well as clinicians from a hospital follow-up clinic. HCWs were recruited through e-mail outreach to relevant clinical groups. HCWs were excluded if they were not involved in discharging patients on antibiotics or following patients after discharge. We performed purposive sampling to ensure capture of experiences from different HCW roles.²⁰

Patients eligible for contextual inquiries were on antibiotic courses for at least two days after hospital discharge to home, and were contacted just prior to or within a day of discharge. Patients were excluded if they did not speak or read English, were <18 years of age, enrolled in hospice services, or unable to provide consent. Patients who lived within an hour of either of the two hospitals were prioritized. Contextual inquiries occurred between July 2019-February 2020 while the patient was still receiving the antibiotic and were followed by recorded interviews. One or two investigators (SLS, SCK) visited patients’ homes to ask about the transition home, antibiotic MM, and follow-up. Notes were taken on the home environment.

All interviews were audio-recorded and transcribed. Two investigators (SCK and SLS) created a preliminary coding template after independently reviewing and comparing the same three randomly selected transcripts. A third investigator (AIA) independently reviewed eight transcripts to further refine the coding template. AIA, SCK, and SLS discussed and revised the coding template, with changes applied retroactively. Two investigators (SCK and SS) reviewed all transcripts to ensure that consensus was reached.

Directed content analysis of the transcripts was performed, focusing on barriers to, strategies for, and processes and outcomes of antibiotic MM at the hospital-to-home transition. Interviews were conducted and coded until thematic saturation was reached.²¹ Triangulation between HCW and patients as well as across individual patients with antibiotic indication, contextual inquiry notes, and interview was applied to further contextualize the data.22 Analysis was facilitated with NVivo 12 Pro (QSR International, Australia). Themes presented included recurrent unifying concepts or statements.²³ To aid in development of themes, we considered frequency, novelty, and relevance. The Johns Hopkins University School of Medicine Institutional Review Board approved this study.

Results

A total of 37 semi-structured interviews were conducted with HCWs, and 16 contextual inquiries were conducted with patients (Table 1). Descriptions of the tasks required for patient-led antibiotic MM at the hospital-to-home transition are presented in the Appendix and barriers to and strategies for tasks in patient-led antibiotic MM as presented by patients and HCWs are described in Table 2. Themes arose (Figure 1) in the synthesis of the data. We highlight tasks associated with patient-led antibiotic MM and barriers to and strategies for these tasks...

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Dr. Nicholas Ladikos, PharmD, FASCP, BCPS, BCGP, BCIDP, is a Clinical Pharmacist and Drug Regimen Error expert. He started and operationalized system-level programs at the Johns Hopkins Hospital and the National Institutes of Health (NIH), and is also the founder of MedOp Advisors, a concierge medication, nutrition, and health & wellness advisory company. Dr. Ladikos is a subject matter expert in several pharmacy-related areas and serves as an expert witness on a number of Pharmaceutical litigation matters. Numerous hospitals have used his skillset and expertise in medical chart reviews to identify errors in medication preparation and prescribing, drug side effect management, standard of care compliance, continuing education delivery, and personnel assessments.

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