Preauthorization and prospective audit and feedback have long been recommended as evidence-based interventions to improve antimicrobial use.
The Infectious Diseases Society of America strongly recommends their adoption in their 2016 Guidelines on Implementing an Antibiotic Stewardship Program. In the 2023 update to the Joint Commission Medication Management standards MM.09.01.01, element of performance 17 requires ASP to implement one or both of the following:
- Preauthorization for specific antibiotics that includes an internal review and approval process prior to use
- Prospective review and feedback regarding antibiotic prescribing practices, including the treatment of positive blood cultures, by a member of the antibiotic stewardship program
Preauthorization requires the clinician to obtain approval from antimicrobial stewards before prescribing selected antimicrobials. Typically, these selected antimicrobials may include:
- Broad-spectrum agents
- Drugs subject to misuse
- Antibiotics with a high incidence of adverse reactions and/or severe adverse reactions regardless of incidence
- High-cost agents
Prospective audit and feedback refer to reviewing and discussing a patient’s antimicrobial therapy with the ordering clinician after the antimicrobial was prescribed. The audit and feedback may or may not result in a change in therapy. Based on the Joint Commission requirements mentioned above, AMS leaders should also review the treatment of positive blood cultures.
For hospitals that have not implemented either of these interventions, we will discuss the recommended steps to launch these interventions.
Considerations in implementing preauthorization
Engage with key stakeholders
Preauthorizations are often associated with the administrative burdens imposed on outpatient prescriptions by insurance companies. Therefore, the word preauthorization can be emotionally charged with prescribing clinicians. Antimicrobial stewards should craft their message to distinguish the purpose of this intervention from the cost-saving aim imposed by insurance payers. The goal is to improve the use of antimicrobials and reduce the pace of resistance development to broad-spectrum and/or newly approved antimicrobials. We encourage stewards to take the time to listen to the prescriber and incorporate their concerns into designing processes to ensure that therapies are not delayed if prescribed appropriately.
Secure resources from leadership
Implementation of preauthorization requires significant financial, human, and technological resources. Leadership must commit to providing the resources to support a preauthorization program. Stewards must determine who and how antimicrobials will be approved 24/7. Hospitals with infectious diseases physicians on staff will typically rely on their expertise and on-call coverage to provide this service. The hospitals will need to establish reimbursement for the provision of this service. This may be in the form of a flat fee or a per-call fee. Pharmacists unfamiliar with physician reimbursement may wish to discuss the process with their medical staff office to determine how to provide this reimbursement to their physicians.
In hospitals without access to infectious diseases physicians, the approver may be an infectious diseases-trained pharmacist or a clinical pharmacy manager. Depending on the volume of authorization requests, pharmacy leadership should ensure adequate coverage and plan to offset any tasks required of the approving pharmacists.
Select antimicrobials requiring preauthorization
As discussed earlier, AMS leaders may often select drugs that are broad-spectrum, likely to be misused, or with severe and/or high incidence of adverse reactions to include in the program. You may also wish to review your past antibiograms to determine if there are any potential resistance trends or leverage benchmarks such as Standardized Antimicrobial Administration Ratios (SAAR) to identify drugs for inclusion in this program.