Speaker 1: You're listening to Intermountain Healthcare's podcast channel.

Shannon: This is Shannon Phillips. I have the privilege today of hosting a podcast with our guests from Pew Charitable Trust and some of our Intermountain leaders to talk about a really important topic today, antibiotic stewardship. And I think we'll start by having our guests introduce themselves. 

David: Great. Well, thank you for having us. We're excited to be speaking with all of you today. So my name is David Hyun. I'm a Senior Officer with the Antibiotic Resistance Project at the Pew Charitable Trust. And I primarily work in antibiotic stewardship in human healthcare settings.

Rachel: Yeah, and I'm Rachel Zetts. I'm an officer on the project with David and I focus primarily on our outpatient stewardship efforts at Pew.

Shannon: Okay. And let's have our Intermountain experts introduce themselves.

Eddie: Great. Eddie Stenehjem. I am the Medical Director of antibiotic stewardship for Intermountain Healthcare. So I oversee antibiotic prescribing across the continuum of care, so inpatient, outpatient, and transitions and care, and am one of the co-leaders of the urgent care stewardship projects.

Adam: And I'm Adam Hersh. Great to be here today. I'm a faculty member at the University of Utah in pediatric infectious diseases and a collaborator with Eddie on antibiotic stewardship interventions.

Shannon: And we happen to get clinical care in the same hospital, Primary Children's right?

Adam: Primary Children's Hospital. 

Shannon: Go team. Let's maybe start, I'm not sure that our audience knows Pew, so maybe if you'll tell us a little bit about the organization, its interest in antibiotic stewardship, and then have we a history together, Intermountain and Pew?

David: Sure. Yeah. So the Pew Charitable Trusts, we are a global, nonpartisan and nonprofit public policy organization. A lot of our work is focused on performing research that generates data to inform the process of improving public policy. And we have several different portfolios and projects in the environmental area, state and consumer initiatives. And then there's several projects underneath the health policy projects and that's where Antibiotic Resistance project falls under, which is where Rachel and I are part of the larger project team. So when Pew makes a decision to work in certain areas, they are looking for opportunities to make a significant impact and achieve measurable outcomes to improve the public life. And so when there was a recognition by the organization, combating antibiotic resistance, was something that we could make significant impact on by taking it into several different approaches.

David: There's work around improving antibiotic use in animal agriculture. There's work around improving drug innovation and making sure the pipeline doesn't run dry. And then there's the work that Rachel and I are part of, which is antibiotic stewardship in human healthcare settings. And that's really born out of the recognition that antibiotic stewardship is a essential component of combating antibiotic resistance. Because even with it, even if the pipeline improves, if the shelf life of these drugs, even the newer drugs and the existing antibiotics are not conserved, then we won't be making any progress in terms of combating antibiotic resistance.

Shannon: So we are, at Intermountain, particularly focused I think on making sure patients get the right care at the right time in a place or circumstance that's convenient to them. And the project that I think we're most excited about right now is in urgent care. How do you think that right time, right place, right care delivery feel in the work that you at Pew are championing?

Rachel: Yeah, so in the outpatient space, the last few years we've really been focused on understanding how antibiotics are being prescribed across the spectrum of outpatient care. And so we've worked with CDC and experts like Adam to understand where and how antibiotics are being prescribed and where there's room for improvement and found that in outpatient settings like physician offices and emergency departments and hospital clinics, about one out of every three antibiotic was prescribed unnecessarily, but that did not include settings that are playing an increasingly important role such as urgent care and retail clinics and telemedicine.

Rachel: And so we then did follow up research that evaluated outpatient prescribing in that care and showed, or in that setting, and showed that there's significant room for improved prescribing there as well. So looking at claims data, we found that among visits that were for diagnoses where antibiotics aren't appropriate, about 46% of the time they were receiving antibiotics in urgent care settings, which is significantly higher than what we were seeing in other outpatient settings like physician offices and even retail clinics where about 14% of the visits were receiving antibiotics. And so we have taken the approach that stewardship really needs to be implemented in all settings and that there is room for improved prescribing practices for all physicians.

Shannon: And so this work maybe that Intermountain's got underway allows us to understand both the barriers and the things that might work. Have you seen other examples around the country where people are in this space and we might learn ahead of or additively to the work we're doing here?

Rachel: So I think Intermountain has really been a leader in this space, particularly in urgent care. I think there has been increasing recognition recently that urgent care and other outpatient settings are important aspects of antibiotic stewardship and outpatient settings, but I think Intermountain has probably gone the furthest in terms of implementing abroad program in that setting.

David: And I would say historically, including the hospital antibiotic stewardship program, the work that Intermountain and other health system and other stewardship leaders have been very helpful from a public policy standpoint because it really informs our policy recommendations because we're always looking for demonstration of not just a science of stewardship interventions and whether you're effective in reducing inappropriate antibiotic use at the provider level, but we're also at our policy level, we're always looking for evidence or demonstration of feasibility and scalability. And when a health system like Intermountain, a large health system like Intermountain, that also happens to have so many different hospitals of different shapes and sizes implements a system wide stewardship program, there is a lot of data points that come from that process and it tells us what kind of resources are going to be needed based on the size of the hospital and the existing resources on the ground level. And as I mentioned, it tells us about the feasibility of the specific types of policies that we're considering leveraging with the goal of trying to spur and motivate other hospitals to join in.

Shannon: So I think it's one of the things that feels very relevant to me is Intermountain is sort of a microcosm of a lot of different delivery questions. So reframe what you said, from rural to urban and different modalities of delivering care. I guess I'll ask my Intermountain colleagues, telemedicine, urgent care, primary care, hospital stewardship. We're leaning in on a space, I think right now that is uncomfortable and uncharted territory nationally. Are we able to lean in on some of the other work we're doing? And you might comment on any of that. And how's that helping accelerate maybe, or not, get us to some answers and feasibility, scalability for urgent care?

Eddie: Yeah, I think from an Intermountain side of things, like David mentioned, we're fortunate because we have this variability in where patients seek care, whether it be rural or urban, the size of the, and then all of these different outpatient areas where they can see care, whether it be through telemedicine, urgent care, any of our community based care clinics. How we see care today is so different than it was even 10, 15, 20 years ago. And what Intermountain has been able to do is kind of leverage some of that uniqueness to be able to describe how to do stewardship in some of these uncomfortable settings. And so our first kind of approach to this was in small hospitals, how do we do stewardship? Nobody's focusing on stewardship in small hospitals and we were able to do a research study to turn that into operational care in terms of telemedicine and now be able to provide inpatient antibiotic stewardship support for all of our hospitals in a very system-ness manner.

Eddie: And that was our first kind of approach to like, we really got to explore this. We have to move just from the large hospitals where we know how to do stewardship and into some of these areas that need stewardship but don't have it. And so we did that, we've operationalized that and now we're pivoting, like you said, into urgent care. And urgent care we learned from Pew, and our CDC colleagues, that urgent care was this burgeoning healthcare delivery option for patients. It's convenient, it's cheaper, and at Intermountain it was growing too. And so we're now up to 600,000 encounters per year in urgent care. And that's going up steadily each year. And with their research, we found out that antibiotic prescribing appropriateness wasn't as good as in emergency departments and family practice and internal medicine clinics. So it was using that research then to look inward and say, what's our opportunity to help with stewardship in this arena? And that's really why we launched into the urgent care field and now are learning such incredible insights in terms of antibiotic prescribing in our 39 urgent care clinics.

Shannon: So what I hear you talking about is I think something that's a tenant of healthcare at Intermountain, which is we want you to get your care, the right care, as close to home as possible, that that's both great for you as a person and your family and your network, and it's also the opportunity to, if you will, make sure that things that yesterday we didn't think were possible to do, for example in rural care, and deliver that as though you were at any other place in the system with the same support. And I think the power of that model, whether stewardship or other things, I think is incredibly important. So do either of you want to share, we're on a journey in urgent care, do you want to give a little background to that? And maybe some previews, a peek at some early learns from that, both in maybe the pre-work and then where we are live, if you will, and trying to study some implementation.

Adam: Couple of thoughts on that, just reiterating what was kind of touched on before. The kinds of secular trends that are occurring nationwide in terms of where patients are seeking care in these non traditional settings, whether it's small community hospitals because of rural location, telemedicine, urgent cares, retail clinics, those same secular trends that are occurring nationwide are occurring in this large integrated care delivery system, Intermountain healthcare. So part of the background that really pushed us towards focusing on this arena is the fact that, number one, we learned that more than half of antibiotics that are prescribed in the outpatient setting in the Intermountain healthcare system originate in urgent care. That's probably as it should be, but it also reflects the disproportionate number of encounters that are related to infectious diseases and respiratory tract infections in general. So this is kind of where the money is in terms of antibiotic stewardship.

Adam: So that was something that we learned. We learned that not only is this the origin of the predominant number of antibiotic prescriptions, but there are secular trends such that the number of visits are increasing rapidly. We're opening new urgent cares rapidly to meet patients, kind of like you said, where they are access convenient and efficient and high value. But there are features, and this is another area where we're actively learning, there are features of urgent care that are different and distinct from other more traditional sites of care. So for instance there are pressures on the healthcare providers in that setting to achieve rapid turnaround. Patients may have a different set of expectations when they arrive at an urgent care. They may be at a time of day that's more convenient for them, but they may have expectations of rapid turnaround and getting in and out really quickly.

Adam: Another really important feature of urgent care that's more like emergency medicine is that most of the time the patients and the clinicians have no prior relationship and that's very different than a more traditional medical home. And learning and understanding kind of what that brings to the encounter is a really important part of designing and implementing an effective antibiotic stewardship program in that setting. So early on we learned that large quantities of antibiotics are prescribed and in fact disproportionately in urgent care, as it should be though because that's where we're encouraging patients with uncomplicated respiratory tract infections for example, to seek care. We also learned early on and have learned early on that sometimes clinicians understanding or beliefs about what patients expect from the encounter. So for instance, the idea that most clinicians feel that patients that are seeking care for respiratory tract infections expect to get an antibiotic at the end of the visit.

Adam: That didn't match with what patients told us when we did a number of patient interviews. Patients were seeking care, they want a plan, they want to feel cared for, and they want to have a plan, and oftentimes a contingency plan. They didn't necessarily want to have an antibiotic prescribed. And in fact, in many cases actually preferred not to have an antibiotic prescribed. So that mismatch of expectations became really important.

Shannon: I think you're myth busting.

Adam: To some extent, yeah. And talking to patients is kind of where the rubber meets the road. And then as you said, finally, I'm learning that in many cases clinicians didn't feel like they had the tools at their disposal to both meet patients where they needed to be, but at the same time provide the appropriate care was really important to kind of building a stewardship program focused on that setting. So we developed a number of different interventions and tools designed both with the input of clinicians and patients in mind and these included tools in the electronic health record, these included educational tools, these included updating and developing new guidelines and care process models for our clinicians. Collectively putting this all together and developing a system for tracking patterns of care. Early on, the early returns of with our interventions have been really quite favorable. And as the conversation goes on, we can talk about some of the early returns in terms of how antibiotics are being prescribed really just over the last couple of months since we turned on our stewardship program.

Shannon: So I think I heard you say, listen to those who are giving care, understand the barriers and the opportunities and bring the voice of the patient to that work as we figure out what are the right levers to pull. And it sounds like given there's an education thread and some tools and so forth that any one, cause you might say, oh well the science of it would say just do one thing at a time. I think we understand it's complex and that it's going to take multiple threads to get where we need to go. Are we keeping it simple?

Eddie: We're trying. You know this is a complex problem that we've been, and by we the infectious disease stewardship community, that have been trying to tackle for decades. Antibiotic prescribing and outpatients has been looked at for decades without a single solution. So we knew that going into this, we're not going to have one single solution that's going to change antibiotic prescribing and be the most favorable it can be.

Eddie: And so we knew we needed a multi-modal intervention. And I think to your point, we kept the urgent care clinician and the urgent care patient at the forefront. And Adam and I are infectious disease physicians, we don't work in urgent care. We don't do this. And so we knew from the get go that we needed urgent care clinicians on our team. We needed to be in their clinics and understand their complexities and their challenges, and we needed to talk to patients and listen to patients in terms of what they wanted, and then we modified our interventions to meet their needs. And so we're trying to keep it as simple as possible. And what we do is we keep the needs of the patient in mind. That's our...

Shannon: Can't go to wrong with that, right?

Eddie: We can't go too wrong with that.

Shannon: And yeah, so interestingly people might say, hopefully we don't need to convince anyone anymore that antibiotic stewardship and antibiotic resistance are a public health threat, hopefully not. We won't do that here. A lot of times we talk about policy and Pew has a stake in the ground in making sure we have effective policy to deliver on health. Sometimes we jump to regulating, right? So we say, oh well if CMS would only put a regulation in place that everyone has to have X, Y, or Z, that's going to fix it. Interested in your thoughts in this space that we're talking about now, is regulation the answer to the problem?

David: I think it's going to depend on what area of healthcare we're trying to apply antibiotic stewardship. But taking a step back, I would probably say in general the regulatory approach of creating mandates and requirements can be a valuable tool, but we have to be cautious in not applying the regulatory approach across the board for antibiotic stewardship across all these different healthcare settings. I think when you look at where we are right now for hospital antibiotic stewardship, there's more regulatory action coming online. The joint commission standards for antibiotic stewardship programs in the acute care hospitals went into effect in January, 2017. CMS had proposed in 2016 of adding the antibiotic stewardship program as one of the conditions of participation for Medicare and Medicaid requirements. And I think for those kind of regulatory requirements for hospitals stewardship it made sense and it was time because there a lot of evidence built around it leading up to it.

David: A lot of publications and experiences from health systems and hospitals like Intermountain that supported the value of antibiotic stewardship. And there was a certain level of consensus built in that stewardship program was really needed in these hospital settings. So to really help kind of take that to the next level, those types of regulatory requirements made sense. But I think whenever we're talking about these regulatory mandates, we also have to make sure that these requirements and mandates do not outpace the resource availability, and therefore the feasibility and the success of those policies. And I think that's what you were sort of alluding to is that sometimes if a policy is put in place prematurely without the full understanding of the resources needed and in a situation like this, that we're talking about for hospital stewardship program, I think a good example is the question of whether small hospitals and critical access hospitals truly have the resources to implement the stewardship programs that are being asked of.

Shannon: It's interesting because a lot of times the smallest hospitals will get carved out and they'll say, oh, not rural or critical access. And at the same time, could you support community hospitals with a tele strategy, which is actually leaning on a system rather than what you can do in your bricks and mortar. And so there's that tension, which I think is a good one, and I think your description of using regulation as a lever to make sure people are putting this in their agenda is a very strong argument. And what we haven't seen enough of, I think in regulation, is flexibility to say, it's not that I have to have a literally a stewardship pharmacist or somebody boots on the ground, but that I have to demonstrate that I can deliver this in any number of ways and that those should be okay. And I think that opportunity we want to see more and more of as we leverage telemedicine and other ways to approach this.

David: Yeah, and we completely agree with what you just said in terms of trying to be flexible, trying to have some ability to tailor these requirements or mandates or regulatory policies around the specific types of hospitals or specific types of healthcare settings. I think one very good example we kind of touched, Eddie touched on it a little bit earlier, is with CMS and joint commission starting to put these standards up for antibiotic stewardship program implementation, we quickly recognize, and CDC as well, that the pace of implementation rate was lagging. There was a lot more lag for the smaller hospitals and the critical access hospitals.

David: So we actually partnered with CDC and AHA a couple of years ago, Eddie was there as one of the experts when we pulled these panel together to really dive into and talk about how stewardship can be accomplished, how the CDC core elements can be achieved within the resource availability of the small critical access hospitals. And that was put together in a publication that CDC eventually published. And it was very helpful because it demonstrates the idea that the one size, that we should not be taking these stewardship regulation or policies, with the idea that one size fits all. But rather that we keep sort of these requirement criteria and definition at a higher level and set these principles in place but try not to be [crosstalk 00:24:45] and try not to be as prescriptive.

Shannon: Which I think that's the history. If you go back 20 years it was pretty much line by line and I just see this as a very positive as much as you can shutter it, this concept of positive and regulatory. Maybe in the same sentence, the fact that we can think about flexibility. Like you said, here are the guiding principles, here's what we're trying to get done for the patient. There are probably a lot of ways to do this. Show us that you can, being mindful of curbing unnecessary extra cost. So I think that's a powerful space and actually stewardship is a really positive example for a lot of other areas in healthcare and hospital quality, safety that need work.

Eddie: I think we have the obligation to as a healthcare system to provide these services to our small community hospitals. They're part of the Intermountain system. Their job is so much harder in these small community hospitals because they're it, they're isolated. And I think it's our opportunity and our obligation as a system to be able to provide them those resources, whether it's a 24 hours a day, seven days a week phone number that they call and reach an infectious disease doctor, or whether they can get a cardiology consult, or whatever it might be. We'd like to keep them in their communities and I think as a system we have that ability to do it and I think it's on these large systems like Intermountain, I think it's on us to be able to provide those services and I think we've done a nice job in the stewardship space to lead in and lead out on that front.

Shannon: And to just think, there's a lot of other pieces of healthcare that could look at this model and do some innovative things and to your point, keep people closer to home, unless in coronary circumstances unless that's really indicated for the condition of the patient. You all must have an incredible view at Pew of practices, innovations, payers that are leading out in antibiotic stewardship and resistance work. Couple of things you might share with our audience that stand out to you in terms of being extraordinary or having that potential to really take us to a new place.

Rachel: Yeah, so in the outpatient space it is relatively new and sort of the role we've long recognized that it's going to really require action from a full array of healthcare stakeholders in order to both provide the resources that primary care physicians and other outpatient physicians are going to need to implement stewardship in their practices, as well as to help incentivize them to take action in this space, knowing that primary care physicians and outpatient physicians deal with a whole range of healthcare issues within their populations. So in the outpatient space, while relatively new, there have been some interesting approaches. So there is what Intermountain is doing in terms of helping to provide data to physicians and feedback and leverage sort of those shared resources across the system to give providers what they need to take action at the encounter level. Payers have also begun sort of exploring this space using their claims data that they have with their physicians within their network.

Rachel: So Aetna has implemented a project over the past few years where they have identified physicians that are high prescribers for unnecessary prescriptions and sent individualized letter to those physicians informing them of the fact that they are high prescribers and provided them with guidelines and resources in terms of how they could better improve their prescribing within their patient population. They also, in comparison, also sent congratulatory letters to those physicians who were really doing things that all well. [crosstalk 00:28:44].

Shannon: Dear Dr. Doe, you're doing good. I love the dear Dr. Doe, you're great.

Rachel: Exactly. Yeah, so they've taken it from both aspects and we think that that's an important role that payers can play moving forward. Additionally, and this is an area that has been less explored, but we do think that there's a role for payers and providing the incentives, whether it be financial or otherwise, to providers to focus on stewardship within their practice and to really spend some time thinking on how they can improve their prescribing practices.

Rachel: We conducted a survey recently among primary care physicians in the U.S. We presented the results at a recent conference and we're hoping to publish the full array soon, but that found that while there is this sort of national recognition that you would think of antibiotic resistance being a problem in the U.S and inappropriate prescribing being a problem in the U.S, physicians within our survey were less likely to recognize them as problems within their practice and to prioritize this as an issue. And so we do think that an outside poll is going to be needed to really ensure that there is nationwide implementation of stewardship across the board.

Shannon: So I think there's a couple of levers there. One is care process models defining what great looks like. There's a payer influence in, can you one, give visibility to people to incentivize them to practice differently, and then there's the interesting piece of, on the provider side, would they, payers and providers, pick this as something they would align because many providers have a quality component to reimbursement or their incentive structure that says, hey this year focus on these things. And so you have a couple levers, do the right thing because you want to and you want to be a great doctor, the payer side and the provider side to potentially incentivize, as you say, push along what we know is the right thing to do. Are we playing in that space?

Eddie: Yeah, we are playing in that space and working with our urgent care service line for example, is a great example and we wouldn't have been able to do this work unless we had a leader who said, yes, this is a priority. And that has been a lever that we have to have and it's been absolutely critical, and Tony Wallin has been outstanding in terms of getting behind this, and he's recognized that urgent care clinics are essentially mini infectious disease clinics. You know, 40% of the encounters in urgent care may require an antibiotic. That's a huge number and when we approached Tony with this initially, he's like, what else would we do? Of course this is going to be a quality measure for us because this is the bulk of prescribing and so it makes sense in urgent care and having that leadership support is absolutely critical.

Shannon: So we are getting a chance to pull a lever that hopefully the country can learn from in terms of the space. We talked about regulation, Intermountain I think through what we've talked about here has had a really great opportunity to impact sort of national thinking in stewardship. I also see that there are some states, Missouri, California, others who have mandated stewardship programs and is that the right approach? Should Intermountain work with our Utah legislature, for example, on this or is that the right lever to be pulling in stewardship?

David: Yeah, so California and Missouri are the two states that have so far implemented, legislatively, implemented requirements for antibiotic stewardship programs in the hospitals in their states. It's one of those things again that we kind of had to take it by a state by state approach. The legislative approach requirements and mandates I think that you kind of have to look back at that states on their historical track record of whether there is a history of success in achieving these public health goals through legislation. And I think for states like California, it made sense because even if you go back and look at how their healthcare acquired infection reporting requirements and quality improvement around those things evolved, there was a clear precedents set that if you set legislation, take the legislative route in California, they could make a significant impact in increasing the number of hospitals with stewardship programs.

David: And it has, when you look at the year to year increase in numbers in California, it has worked. For a state like Utah, well first of all, we should say that Utah has always had a much higher than the national average percentage of implementation rates for stewardship programs. And for the first couple of years, and the CDC is tracking this, Utah actually was at a much higher number than California, who was still a few years out from their legislative requirement. And right now, I believe Utah sits around 80% roughly 80-81% of hospitals reporting to CDC of having stewardship programs that meet all the core elements that the CDC has defined. So when you look at it from that sense, is it really worth all the effort to get the last 20%, I think maybe perhaps that's not the best way to spend the resources and the political capital of all the stakeholders to achieve that goal.

David: But maybe taking this back at a broader sense, maybe there are opportunities to explore statewide policies. And when we talk about statewide policies, legislation is one of the levers. But you know, whether it's health department agency rulemaking or even policies owned by non governmental entities, such as the state hospital associations, those are areas that we tend to consistently explore to see if there's ways to help spur the, not the number of stewardship programs in the state, but really about focusing on the quality of those stewardship programs and whether we can try to help support the implementation of meaningful stewardship programs.

David: So one example area that we're exploring right now is trying to see if antibiotic use reporting, for instance, is something that certain, depending on the state, whether there's an opportunity to try to let state level policies encourage and increase the number of hospitals reporting antibiotic use, for instance, into CDC's national healthcare safety network. This is another example where potentially a state policies could help, but we really do look at this from a state to state basis of what makes the most sense.

Adam: Possibly necessary definitely not sufficient. [crosstalk 00:36:06]

Shannon: But I'm like pretty psyched that it's 80%, so we are in a good position. So the 20% I think you got a couple nice ideas about how we might close even that gap successfully.

Eddie: I think partnerships is related to legislation. I think partnerships is where there's room for growth and development and future collaborations. Partnerships between healthcare delivery organizations. Partnerships between delivery organizations and academia. Partnerships between delivery operations and organizations and state and local health departments. And I think that's an area where we can really continue to move the needle in this arena of antimicrobial stewardship.

Shannon: Okay, got one more question for Pew, and then if you have something back at us, we should take that. How do we work with Pew going forward in this space to collaborate to get there faster and better? It feels like there's a lot of alignment and if you were talking to another large health system like us, is our focus right? Where should we be pointed? Is there something we're not doing today that we should be?

David: Yeah. As you just said, the missions around antibiotic stewardship and the goals are very much aligned. As I mentioned earlier, we look towards health systems like Intermountain who are leaders in this space of antibiotic stewardship to help us guide our policy decisions and informed feasibility, and as we mentioned, the scalability of this. And I think especially with the continued work that you all are doing that are very novel, that are on the leading edge of antibiotic stewardship, I think that relationship is something that we would like to continue to cultivate and find ways to partner on because the urgent care work that y'all are doing, it's something that everybody's desperately looking for data points and demonstration of the success and then we can take that and disseminate it and share it with the larger public health stakeholders to show here is a great example of how this can work.

David: Let's see if we can use that as a starting point for discussion in terms of, let's see how we can make this work. Maybe not in a carbon copy sense, but let's see if we can take the key principles of what Intermountain did and see if we can adapt it to your organization or your state. And that's an area that we feel that we would tremendously value moving forward in terms of where we could work together. I would probably, kind of flipping the question back to you [crosstalk 00:39:11], you asked what could Intermountain be doing moving forward and we would be very interested in hearing where do you go from urgent care stewardship? What are your plans moving forward? Because urgent care is just one, as we talked about, is one key sector of the outpatient stewardship, for outpatient care and outpatient antibiotic use. Are there plans to expand the urgent care work into the broader, into other sectors of outpatient...

Shannon: I'm feeling a little pressure, good pressure, for my friends, what's next? This isn't everything. And outpatient prescribing is where the vast majority of prescribing is.

Eddie: Right. Great question, David. We can't address population health from an antimicrobial resistance standpoint by just focusing on urgent care, especially if our patients go from urgent care into their family practice clinic or internal medicine clinic or pediatric clinic. So I think where we'd like to take this is to ensure that yes, we solidify and we integrate stewardship practices into urgent care, but we also get them integrated into our other community based care partners within Intermountain and also those affiliated providers that take care of select health patients, inpatients at large. And it's disseminating and adapting those interventions to those clinics to make sure that it fits right. You know, the prioritization is different. Internal medicine does not see the number of infectious disease patients that urgent care does. Neither does family practice or pediatrics.

Eddie: Pediatrics sees a lot more. And so how do we smartly implement in those areas that are within Intermountain and also our affiliated providers. Antibiotic stewardship is public health. So Intermountain has to take the long view in this and how do we make sure that the messages are getting across to all of the patients, all of our communities in Utah. And how do we really push that out into other service lines in a consistent manner and measure them consistently.

Shannon: So I think antibiotic stewardship is a great example of empowering our communities to live their healthiest lives and our caregivers to be present for people in a way that meets what they need where they are consistently, and paying attention to this is the right thing to do. And David and Rachel, thank you for visiting with us today and Adam and Eddie, thank you for the work. I would be the first person anxious to see the next few months of how the implementation is going. So I'm grateful for that work, grateful to Pew for interest and pushing us to be at our best. And thanks for joining.