title: Effect of Financially Punished Audit and Feedback in a Pediatric Setting in China, within an Antimicrobial Stewardship Program, and as Part of an International Accreditation Process.
abstract: BACKGROUND
  Prior authorization, audit and feedback, and pay for performance are the three core "active" strategies of antimicrobial stewardship program (ASP), yet little is known about the individual or combined benefits of such programs, particularly in a pediatric setting.
  
  
  OBJECTIVE
  The aim of this study was to compare these core ASP strategies and determine the incremental effect of financially punished audit and feedback.
  
  
  METHODS
  During the journey to the Joint Commission International accreditation, a tertiary pediatric medical center performed two different hospital-wide stewardship interventions in succession. The first stage without formalized ASPs served as pre-intervention period, January 2011 to April 2011. The ASP used prior authorization alone during the first-intervention period, May 2011 to September 2011. In October 2011, financially punished audit and feedback was introduced, marking the start of the second-intervention period, October 2011 to November 2012. We compared the differences of the change in monthly average use of antibiotics and expenditure on antibiotics before and after the ASP changes by using interrupted time series via dynamic regression. The main end points included the proportions of antibiotic prescriptions and expenditure on antibacterial relative to all medications.
  
  
  RESULTS
  Before the second-intervention period, neither the proportion of antibiotic prescriptions nor the proportion of expenditure on antibiotics declined significantly in both ambulatory and inpatient settings. However, after the introduction of financially punished audit and feedback, the proportion of both antibiotic prescriptions (β = -6.269, P < 0.001, and reduction = 59.4% for outpatients; β = -1.235, P < 0.001, and reduction = 19.8% for inpatients) and expenditure on antibiotics (β = -7.777, P < 0.001, and reduction = 46.7% for outpatients; β = -4.933, P = 0.001, and reduction = 16.3% for inpatients) dropped immediately.
  
  
  CONCLUSIONS
  The combination of more than one core strategies (prior authorization, audit and feedback, and pay for performance) will be more effective than one strategy alone.
authors.affiliation: Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Sitang
authors.initials: S
authors.lastname: Gong
authors.affiliation: Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Xiu
authors.initials: X
authors.lastname: Qiu
authors.affiliation: Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Yanyan
authors.initials: Y
authors.lastname: Song
authors.affiliation: Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Xin
authors.initials: X
authors.lastname: Sun
authors.affiliation: Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Yanling
authors.initials: Y
authors.lastname: He
authors.affiliation: Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Yilu
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Minqing
authors.initials: M
authors.lastname: Li
authors.affiliation: Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Rui
authors.initials: R
authors.lastname: Luo
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Liya
authors.initials: L
authors.lastname: He
authors.affiliation: Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Qing
authors.initials: Q
authors.lastname: Wei
authors.affiliation: Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Songying
authors.initials: S
authors.lastname: Shen
authors.affiliation: Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Yu
authors.initials: Y
authors.lastname: Liu
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Lian
authors.initials: L
authors.lastname: Zhang
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Wei
authors.initials: W
authors.lastname: Zhou
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Ping
authors.initials: P
authors.lastname: Huang
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Jianning
authors.initials: J
authors.lastname: Mai
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Li
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Yi
authors.initials: Y
authors.lastname: Xu
authors.affiliation: Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University , Guangzhou , China.
authors.forename: Huiying
authors.initials: H
authors.lastname: Liang
authors.affiliation: Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China.
authors.forename: Huimin
authors.initials: H
authors.lastname: Xia
keywords: antimicrobial prescription; antimicrobial stewardship; audit and feedback; observational study; pay for performance; prior authorization