Antibiotic Awareness Week 2023

Advancing Health Equity in Antimicrobial Stewardship

After rounding with the hospitalist team one day, I shut down my computer to return to campus. 

The discharge nurse approached me and said, "Hold on, you can't leave yet to return to campus. Are you teaching this afternoon?..... I really need your help with this one patient; the doctor changed their mind and wants to send him home today on fidaxomicin. When I called his pharmacy, they said they didn't have it. Please help me. Remember, this is the patient that had diarrhea for several months, and he says this is the first time that he has had a normal bowel movement after taking the antibiotic for four days."

I stayed on the floor for several hours, calling several pharmacies, finding the manufacturer’s coupon, and educating the patient on what to expect when picking up his prescription and completing the therapy. I know many pharmacists who can identify with this story; therefore, as antimicrobial stewards, we have to strive to embed health equity into our daily practice.

What is Pharmacoequity and Health Equity?

Pharmacoequity is a health equity goal that ensures that “individuals, regardless of race, ethnicity, and socioeconomic status, have access to the highest-quality medications required to manage their health needs”¹ 

The Centers for Disease Control and Prevention (CDC) defines health equity as "the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities"²  

Why is health equity needed in Antimicrobial Stewardship (AS)?

The primary goal of antimicrobial stewardship is to promote appropriate use of antimicrobials to improve patient outcomes and slow microbial resistance. AS is truly about ensuring quality improvement. A valuable quote shared by Dr. Grace Lee at IDWeek 2023 states, "There is no quality without equity, and there is no equity without quality."³ Inequities in overprescribing or undertreatment of infections will lead to poor outcomes; therefore, identifying non-medical factors like social determinants of health (SDoH) that affect health outcomes is imperative. Kim and colleagues developed a framework of factors contributing to health inequities in antimicrobial prescribing.⁴  The framework shows individual-, healthcare-, community-, and national-level factors potentially related to antibiotic prescribing inequities. Exploring the characteristics of the population experiencing antimicrobial-related inequities, also considered markers for health equity in AS, and the factors that cause or perpetuate the inequity also considered drivers for health equity in AS, is vital to further understanding the need for health equity in AS.

Who are the stakeholders to partner with to help address advancing health equity in AS?

The stakeholders range from the patient to the C-suite and everyone in between. Within the C-suite, support is needed to ensure funding to carry out the work and identify markers and drivers of health inequity. The new directive from the Joint Commission to reduce healthcare disparities will help provide this support. Partnering with the assigned C-suite leader to track this data on the antimicrobial stewardship report would be helpful. For example, teasing out the percentage and demographics of patients with difficulty paying for antimicrobial prescriptions on discharge. Using the data-driven evidence may support justification for increased resources by pairing the social work and pharmacy departments to institute a policy on best practices for obtaining expensive discharge antibiotics.

Additionally, the new Joint Commission directive will increase access to documenting patient's self-identified race, ethnicity, age, and sex. This directive will allow institutions to review antimicrobial usage by demographics to help identify or assess drivers of health inequities. In this instance, working closely with hospital informatics, who may be in charge of data collection, would be helpful to mine the data. Empowering all providers to be aware of health inequities in AS is vital, including continuing education or annual certifications on health equity topics such as implicit bias, microaggressions, disability awareness, etc. Nurses can play a huge role in advancing health equity in AS; educating and empowering them is essential. The microbiology department has always been a core team player in AS, and including them in health equity education in AS is imperative. Lastly, we empower patients to understand their diagnosis and any discharge plans. With this in mind, we must ensure we educate them using their preferred language with additional family members present to help with recall later. In conclusion, advancing pharmacoequity and identifying the markers and drivers of health equity in AS is imperative to improving patient outcomes and potentially slowing antimicrobial resistance.