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.
Design the preauthorization program
Even though it appears obvious to many, AMS leaders may wish to diagram the medication use process and determine how to implement the preauthorization process best. Some items to consider include:
- How do you indicate restricted antimicrobials in CPOE so prescribers will know they require preauthorization?
- How does a prescriber request authorization?
- Who would approve or deny the request?
- What criteria are used to assess the appropriateness of each antimicrobial? In programs where pharmacists review the requests, we recommend that AMS leaders work with medical staff to establish such criteria using as much objective clinical data as possible.
- How would the approval and denial be communicated to the prescriber and pharmacy?
- What alternative treatment would you recommend to the prescriber if the requested antimicrobial is not approved?
Communicate the process with medical staff, nurses, and pharmacists
As you diagram the medication use process, the AMS leader should share the logistics with relevant stakeholders before the program's rollout. The stakeholders have different interests, and their concerns must be addressed to ensure a successful rollout. For instance, prescribers may view this program as infringing on their autonomy. In contrast, nurses may be under pressure from their managers and quality departments to administer antibiotics as soon as possible due to regulatory pressure from the SEP-1 bundle.
Adjudication/appeal process
In conjunction with the medical staff and compliance with applicable policies and by-laws, the AMS leaders should spell out the process to appeal a decision. During the appeal process, it would help to consider how to provide a suitable antimicrobial, including the requested drug. Many hospitals will have the ultimate appeal decision rest with the chair of the medical staff. In addition, AMS leaders should spell out the service-level expectations for the authorizations. For example, a call back within 30 minutes, or the pharmacy may dispense a dose to minimize any delay that could jeopardize the patient’s outcome as the request works through the process.
Metric collection
As with any performance improvement process, AMS leaders shall collect information such as the number of requisitions, % approvals, reasons for denials, turnaround times, and antimicrobial utilization such as Days of Therapy to measure program performance.
Considerations for implementing prospective feedback
Engage with key stakeholders
Prospective feedback is often provided by the AMS team or a pharmacist to the prescriber. Before the program's rollout, AMS leaders should communicate the program's intent and address any concerns.
Secure resources from leadership
Implementation of prospective feedback requires dedicated time by the feedback providers to review antimicrobial orders. The reviewer should not be tasked with other activities, such as order verifications or dispensing medications. Pharmacy leadership should also provide coverage for weekends and vacations to ensure the continuity of the program. Technology resources may also be needed to generate a list of patients due for review and provide a workflow to document reviews and pharmacist intervention. While some electronic health records can generate a list of patients with antimicrobial orders of interest, many programs prefer to keep notes related to these reviews off individual patients’ charts. These reviews are sometimes classified as quality or performance improvement initiatives, and review documentation is not considered part of the individual patient’s medical record. AMS leaders should consider how to keep track of these reviews. Cloud-based clinical surveillance tools, like Sentri7, may help record performance improvement activity documentation.
