Attitudes of Housestaff towards a Prior Authorization Based Antimicrobial Stewardship Program

Background: Antimicrobial stewardship programs (ASP) are advocated as a strategy to ensure appropriate use of antimicrobials and minimize the development of antimicrobial resistance. One well accepted strategy involves restricting antimicrobials and requiring prescribers to obtain prior authorization (PA) before use.

Objective: To assess housestaff opinions of the utility, functionality and educational value of a well established PA based ASP.  

Methods: A 26 item, Likert scale based questionnaire composed of statements about a prior authorization based antimicrobial stewardship program was distributed to all housestaff at a 496 bed academic tertiary care hospital. Proportion of respondents in agreement with each statement and 95% confidence intervals were calculated. Comparisons between proportions were made using the 2 sided-Fisher Exact Test. 

Results: 116 of 285 housestaff (41%) completed the survey of which 28% were interns and 39% were from surgical programs. A majority (61%, 95%CI 52-70%) believed that antibiotic resistance is a serious problem, that the primary purpose of the ASP is to prevent the development of resistance (73%, 95%CI 65-81%), and that overall having the ASP was a good idea (60%, 95%CI 51-68%). Housestaff that believed antibiotic resistance was a serious problem were significantly more likely to believe having the ASP was a good idea (84% vs. 43%, p=.028). Despite a majority believing that they received consistent recommendations (61%, 95%CI 52-70) and a timely response when paging for approval (76%, 95%CI 68-83), a majority found being required to call for approval frustrating (50%, 95%CI 41-59) and believed that it resulted in significant delays in patients receiving their antibiotics (56%, 95%CI 47-65). Residents compared to interns (63.9% v 28.6% p=.010) were significantly more likely to believe that the program limited their autonomy. One in 10 residents (10%, 95%CI 4-15%) admitted that they would make up clinical information in order to get the antibiotic they wanted if they believed approval was unlikely. Subjects who did not think having an ASP was a good idea were significantly more likely to admit to making up clinical information to undermine the approval process (6% vs. 29%, p=.015). Only one-third (33%, 95%CI 22-41%) found the process educational.

Conclusions: A PA based ASP was generally well accepted as a means to ensure appropriate antibiotic use and decrease resistance; however there was significant frustration with the time requirement and limitation of autonomy resulting from such a program. A significant percentage of housestaff that did not “buy-in” to the rationale of the ASP admitted to attempting to bypass ASP procedures. Interventions that improve understanding of the rationale behind ASPs and address these perceived negatives may improve user satisfaction and compliance with prior authorization programs and warrant further investigation.