Research On The Effect Of Medical Staffing On Hospital Antimicrobial Stewardship Performance

Objectives: The overuse and inappropriate use of antimicrobials account for antimicrobial resistance(AMR).To deal with this problem,antimicrobial stewardship has been widely implemented in the hospitals of different countries to ensure the prudent use of antimicrobials.Medical staffing is essential to the performance of hospital antimicrobial stewardship,however,few empirical studies have investigated the quantitative relationship between them.The study aimed to(1)systematically review the prior empirical studies on the relationship between medical staffing and hospital antimicrobial stewardship performance,integrate their empirical results,seek the potential factors influencing the empirical results,and summarize the research gaps;and(2)model the relationship between medical staffing and hospital antimicrobial stewardship performance based on the domestic dataset to fill the research gaps,provide policy makers and hospital managers empirical evidence on the allocation,utilization,and management of healthcare human resources for antimicrobial stewardship.Methods: Literature research,systematic review,and statistical modeling were used.Firstly,literature research was conducted to design the search strategy and collect related empirical studies.The strategy contained five modules,the first four modules were designed based on the four key words of the study theme,namely,“hospital”,“antimicrobial”,“stewardship” and “staff”.To avoid “Simpson's paradox” and improve the retrieval efficiency,the last module aimed to select the studies based on multivariate regression analyses.With the search strategy,we searched in three international databases,namely,Web of Science,PubMed and EMBASE,and picked out the studies on the effect of medical staffing on hospital antimicrobial stewardship performance.Literature data were collected.Secondly,the study introduced Meta regression analysis,a method of systematic review.The regression coefficients of the medical staffing to the stewardship performance were chosen as the effect sizes.Funnel graph and funnel-asymmetry test detected the publication bias.Then Meta regressions were modeled to integrate the empirical results,and seek the potential factors influencing the empirical results from the aspects of variables,methodologies,and literatures.Thirdly,based on the research gaps,the study employed statistical methods to conduct an empirical analysis with a provincial panel dataset in China,2009-2016.The data came from China's Statistical Yearbooks of Health and Family Planning 2010-2017,and CHINET Surveillance Reports of Bacterial Resistance 2009-2016.The production function served as the conceptual framework.The numbers of different kinds of medical professionals served as the labor inputs,whereas the methicillin resistance rates of S.aureus and coagulasenegative staphylococci(CoNS)as the outputs.Fixed-effect model and dynamic panel data model were used for statistical modeling.Results:(1)Meta Regression Analysis of the Effect of Medical Staffing on HospitalAntimicrobial Stewardship PerformanceTotally 2,081 studies were searched out.14 ones conformed to our criteria.Pharmacists served as the medical staffing in 6 studies,infectious diseases physicians in 4 studies,and nurses in 1 study.There were 4 studies referred to two or more kinds of medical staffing: infectious diseases physicians and/or pharmacists in 2 studies,infectious diseases physicians and clinical microbiologists in 1 study,and infectious diseases physicians,pharmacists and clinical microbiologists in 1 study.The evaluation indicators of the stewardship performance could be divided into two categories:(1)antimicrobial use-related indicators(e.g.inappropriate antibiotic use,de-escalation use of antibiotics,and antimicrobial use in accordance with national or local guidelines,etc.);(2)patients' outcome-related indicators(e.g.length of stay < 28 d,death,and incidence of nephrotoxicity from vancomycin,etc.).34 comparable records from 10 studies of the above 14 ones were collected to conduct Meta regression analysis.The funnel graph provided a rough approximation to the expected inverted funnel shape.Nevertheless,more points seemed to concentrated on the right side of the vertical axis.The funnel-asymmetry test found no significant publication bias(Coef.= 0.617, = 0.412).Each Meta regression model indicated a significantly positive effect of medical staffing on antimicrobial stewardship performance(Coef.= 0.124,0.249,0.125,0.204,and 0.375; = 0.018,0.001,0.023,0.021,and 0.021)after the integration of the enrolled studies.However,infectious diseases physicians and the combination of infectious diseases physicians and clinical microbiologists showed weaker positive effects than pharmacists(Coef.=-2.733 and-2.211; = 0.037 and 0.096).Besides,the positive effect of medical staffing on stewardship performance in developed countries or regions was weaker than that in developing countries(Coef.=-3.307, = 0.001).Using different evaluation indicators is also a significant influencing factor(Coef.= 1.512 and 1.751; = 0.061 and 0.032).(2)Evaluating the Effect of Medical Staffing on Hospital AntimicrobialStewardship Performance Based on Provincial Panel Dataset in ChinaResearch gaps were summarized from the prior studies:(1)Almost all prior studies were conducted from micro perspectives.To our best knowledge,there is no macro study.(2)Most studies were carried out in developed countries and regions,while few in developing countries such as China.(3)Most studies employed binomial variables to indicate whether there was input of medical staffing,which merely contained little statistical information.Only few studies measured medical staffing by quantitative variables with more information.In order to fill the above gaps,the study based on the domestic panel dataset was carried out.In this part of study,the number of clinical microbiologists in hospitals per 100,000 population displayed significantly negative effects on the methicillin resistance of CoNS(Coef.=-0.191 and-0.351; = 0.070 and 0.004).It indicated that a larger number of clinical microbiologists was associated with a better hospital antimicrobial stewardship performance.On the contrary,the number of nurses in hospitals per 100,000 population showed a significant but positive effect on the resistance of S.aureus(Coef.= 0.648, = 0.044),indicating a worse stewardship performance.Apart from clinical microbiologists and nurses,the numbers of infectious diseases physicians and pharmacists showed no significant effects.Conclusions:(1)By integrating the given empirical studies,it was found that medical staffing is crucial to hospital antimicrobial stewardship.Compared with infectious diseases physicians and clinical microbiologists,pharmacists even play a more important role.(2)The role of medical staffing in the antimicrobial stewardship in developed countries and regions seems less important than that in developing countries.It may be attributable to the more labor-intensive medical sectors in developing countries,which rely more on medical staffing.(3)Clinical microbiologists are vital to the hospital antimicrobial stewardship in China.The government should attach more importance to the adequate supply of clinical microbiologists and talent development in the related fields.(4)The reverse effect of nurses on the stewardship performance in China may be related to the output indictors chosen in the study.Besides,nurses' lack of the knowledge about antimicrobial stewardship and the role awareness also account for such result.Measures should be taken to provide nurses more trainings on antimicrobial stewardship,and raise their role awareness.(5)Pharmacists and infectious diseases physicians show insignificant associations with the stewardship performance in China.It is explained by the fact that most of our pharmacists lack capabilities to guide appropriate use of medicines,and our infectious diseases physicians focus mainly on notifiable communicable diseases rather than bacterial and fungal infections.The government should improve the clinical training of pharmacists,and divert infectious diseases physicians' focus.