Table 1.

Challenges with utilization of the AXR metric and tactics to optimize impact

Challenges	Tactics
Creating metric meaning for clinicians • A non-dichotomous metric that includes patients who “sometimes” should receive antibiotics • Need to clearly communicate that metric is benchmarked by service line	• Report and monitor AXR at an organization and service line-level, but report more concrete metrics to clinicians (for example: URI, AAB, CWP) • Report clinician AXR performance over time
Identifying optimal targets • Not yet clear what the “ideal” rate is and may vary across different systems, service lines, and geographies • Unclear how to benchmark across systems with variable patient acuity and heterogeneity • Tracking over time will be limited as population case mix varies	• Set initial target at median, with subsequent stepwise decrease over time • Benchmark to similar regional healthcare systems
Limitations of the metric • Does not distinguish narrow- vs broad-spectrum antimicrobial use • Does not capture if antibiotic was prescribed at appropriate dose or duration • Does not include antibiotic use in non-respiratory conditions	• Report days of therapy per diagnosis as an additional rate measure • Co-report rates of broad-spectrum antibiotic use or high-risk antimicrobial use
Incorporating AXR into the HEDIS® metric landscape • AXR is the 4th antimicrobial stewardship-focused HEDIS® measure • Institutional bandwidth to target all four may be limited	• Target the HEDIS® metric or other clinically impactful, associated stewardship metric with the largest room for improvement, as this will also impact AXR performance
Assessing Equitable Care • AXR does not provide granular insight into why antibiotic prescription rates vary between patient groups	• Assess differential trends in AXR performance between groups following stewardship interventions • Engage stakeholders to understand reasons for disparities

Legend: AXR = percentage of episodes for patients 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event, URI = avoidance of antibiotic prescribing for upper respiratory infection, AAB = avoidance of antibiotic prescribing for acute bronchitis/bronchiolitis, CWP = appropriate testing for group A streptococcus prior to antibiotic dispensing for pharyngitis, HEDIS^® = Healthcare Effectiveness Data and Information Set