Kil Huh, Senior Vice President, The Pew Charitable Trusts
Antibiotics revolutionized medical treatment and are a cornerstone of modern health care. However, the global rise of antibiotic-resistant bacteria is making infections costlier and deadlier. After a 2008 report commissioned by The Pew Charitable Trusts highlighted these concerns, the organization invested in multiple projects to set limits on the use of antibiotics and to spur the development of new drugs.
This work evolved significantly over the years, reflecting the targeted, flexible, rigorous, and nonpartisan approach that Pew uses to help solve urgent problems and achieve tangible results. For 16 years, Pew’s antibiotics team listened to feedback from policymakers, partners, and key stakeholders it worked with every day, and it also conducted formal, independent evaluations. This experience illustrates how Pew builds on the knowledge it acquires and then uses the research, when possible, to inform its peers.
Lessons from Working on Antibiotics
One of the earliest lessons the Pew antibiotics team learned was the importance of working on a diversified set of issues. At the outset, the work focused on federal legislation to regulate the use of antibiotics in animals raised for human consumption. Despite strong leadership from sponsors of the bill and many dedicated advocates working for its passage, Congress did not pass the legislation. In response, Pew and its partners pursued a broader set of policies to curb antibiotic overuse; for example, in 2013, the U.S. Food and Drug Administration (FDA) issued guidance advising pharmaceutical companies, veterinarians, and food-animal producers to use the drugs only to treat sick animals, and, in 2015, the U.S. Department of Agriculture (USDA) launched a school lunch and labeling program to highlight products that used antibiotics responsibly.
The team also learned that it needed to continue expanding its group of partners, including finding common ground with potential opponents, such as some pharmaceutical and livestock companies. At the beginning, the project worked with victims of drug-resistant infections, scientists, doctors, and other stakeholders in a coalition that secured some policy wins. But to go further and build support for responsible antibiotic use on farms, Pew convened major food, agriculture, and pharmaceutical stakeholders in 2018 to develop a Framework for Antibiotic Stewardship in Food Animal Production. Doing so offered food and drug companies clear guidance for reducing the use of these medically important drugs in food animals, which in turn has helped prevent the evolution of new drug-resistant bacteria. Partially in response to the FDA and USDA policies, consumer concerns about antibiotic overuse in food production, and the industry framework, sales of agricultural antibiotics dropped 37 percent from 2015 to 2023.
As the work on reducing antibiotics in food animals progressed, the Pew team recognized that antibiotics were also being overprescribed to people, and it needed a strategy to reduce their use in human medicine. Applying lessons from its agricultural work, Pew engaged a broad coalition of infectious disease doctors, hospital administrators, pharmacists, government officials, and insurance industry executives, among others, to pursue a variety of policy shifts. The breadth of this coalition enabled the project to synthesize diverse perspectives and interests into a set of evidence-based policies while expanding support for enacting and implementing those policies.
Pew also came to recognize the power of other ways to increase leverage. For example, the organization worked with the Centers for Medicare & Medicaid Services (CMS) and individual state Medicaid agencies to shift their policy so that hospitals could only be eligible for full Medicare and Medicaid reimbursements if they implemented programs systems to improve antibiotic use and measured and reported their progress.
In addition, the antibiotics team recognized that voluntary accreditation programs could also influence practices that improve health outcomes. So Pew conducted research that helped inform the national accreditation requirements of the Joint Commission—a leading nonprofit health care certification organization—which about 70 percent of U.S. hospitals meet; as of 2017, participating hospitals are required to implement programs that ensure responsible antibiotic use and most providers are similarly required to report antibiotic prescribing data to public health agencies. And today, as a result, all accredited U.S. hospitals, and most hospitals overall, do both.
As the project neared the end of its term, Pew commissioned an independent evaluation to review its achievements and contributions to combatting antibiotic resistance. This review affirmed the team’s decision to address multiple antibiotic-related issues and settings under a unified strategy, stating that Pew’s achievements related to antibiotic resistance were “unequivocally attributed” to its multifaceted and coordinated approach. The review also highlighted Pew’s commitment to a wide range of partnerships and collaboration as key to the project’s success. The evaluation validated previous strategic decisions, and many of the project’s lessons have wide-ranging applicability to Pew’s other health policy initiatives.
Applying Lessons Across Pew’s Health Portfolio
Now, a different Pew project, one on public health data improvement, is benefiting from what Pew learned in its antibiotics work about improving the quality of data that public health agencies need to detect, prevent, and control the spread of disease. For example, the project is using federal certification requirements similar to the Joint Commission’s accreditation program—this time, requirements from the U.S. Department of Health and Human Services’ Office of Assistant Secretary for Technology Policy—to ensure that electronic health records software meets criteria that make it easier for doctors to report timelier and more complete and accurate disease data to state public health departments. The project is also working with CMS to develop and implement data quality measures that encourage providers to share immunization and lab data with public health agencies.
Pew’s substance use prevention and treatment initiative, meanwhile, is working with federal and state stakeholders to enable more people with substance use disorder to receive care, including by engaging CMS on the expansion of access to medications for treating opioid use disorder. And the organization’s suicide risk reduction project is leveraging its existing relationship with the Joint Commission to help expand the use of screening tools that identify people at risk of suicide and connect them to lifesaving care. Pew’s projects are also improving state policy by drawing on experiences from programs outside of health, including its safety and justice programs, which have secured bipartisan criminal justice reform laws in dozens of states whose leaders span the political spectrum.
These are just a few examples of how the lessons Pew learned from its antibiotic resistance project continue to shape the organization’s work on public and behavioral health. By learning from experience and adapting strategies as the context evolves, Pew can continue to drive meaningful change and improve health outcomes.
Kil Huh is a senior vice president at The Pew Charitable Trusts, leading the organization’s work on state fiscal and economic policy, consumer finance, safety and justice, and public health.