benchmarking inpatient antibiotics: new challenges · benchmarking inpatient antibiotics: new...

Confidential—For Internal Use Only

Kalvin Yu, M.D.

Medical Director

BD Digital Health

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Benchmarking Inpatient Antibiotics: New Challenges and Opportunities for Data Use


• The clinical ramifications of antibiotic misuse

• What is the ‘optimal’ Antimicrobial Stewardship Program?

• Clinically intuitive ways to benchmark antibiotic use

– ASP workflow

– Clinically relevant data integration

– Current benchmarking techniques

– Future?

Outline

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What is Antibiotic “Overuse”?

• 50% of all antimicrobial use is inappropriate*

• 30-50% of hospitalized pts receive antibiotics

• Antibiotics account for ~30% of hospital pharmacy costs

• USA one of world’s top spenders on antibiotics

page 3

* 2015 White House National Plan for Fighting Antimicrobial Resistance. https://www.cdc.gov/drugresistance/pdf/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf

What is Antimicrobial Stewardship?

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“Good antimicrobial stewardship is the o pti selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment of infection with minimal toxicity to the patient and minimal impact on subsequent resistance.”

The USA Likes Antibiotics and Pays the Price

Albrich WC, et al. Emerg Infect Dis 2004;10:514-7

If that isn’t enough…

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Required by law in California

SB 739

TJC, CMS/PSLS surveys

Penalty for failure to comply

Senate Bill No. 739

CHAPTER 526

(4) Require that general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which shall be monitored jointly by appropriate representatives and committees involved in quality improvement activities.

A Growing Trend

An example: CALIF state law ASP requirementsper CDPH ASP subcommittee, Sacramento, 2015

• Usage patterns of broad-spectrum antibiotics• Usage measured by either Defined Daily Dosing (DDD) or Days of Therapy (DOT)

is collected for antibiotics; results are examined for appropriate use. The institution monitors antibiotics determined to be of importance to the resistance ecology of that facility

• Multi-Drug Resistant Organisms (MDRO) rates and trends• SCIP measures (performance)• Medical Use Evaluations (MUEs) for total and class-specific antibiotics used• A risk assessment for each facility is performed and includes the above

parameters as well as a definition of the scope of practice of a facility• An antibiogram is developed consistent with guidelines issued by the Clinical

and Laboratory Standards Institute; there is documentation to indicate that it is distributed to the Medical Staff and is being used for education

Yearly Clostridium difficile–related Mortality by Listing on Death Certificates, United States, 1999–2004

Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419.

De

ath

s p

er

millio

n p

op

ula

tio

n

• HAIs 2%-10% inpatients=1.6 million patients= 90,000 deaths/year nationwide

• Cost: $28- $35 billion/year• Most Common Reportable HAIs :

• Bloodstream infections (CLBSI)• Surgical Site infections (SSI)• CAUTIs– Catheter Associated Urinary Tract Infections• Ventilator Assoc. Events: including Ventilator Associated Pneumonia• C.difficile

• *Many severe HAIs and C.difficile are caused by antibiotic misuseand improper sterile/hygiene technique Multi-drug Resistant Organisms (MDOs) and C.diff cultivation HAIs

*https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf (2009)


• Clostridium difficile is a gram-positive spore-forming anaerobic bacteria

– spores can be viable for weeks in the environment; EVS bleach; HH; UV?

• Cdiff is present in 3–7% of the healthy/ asymptomatic adult population

– This goes up with people who have been in-patients in hospitals: 4-15%

– And up to 50% for those living in long term care facilities

• Clostridium difficile infections (CDIs) are the leading cause of diarrhea in healthcare settings and are becoming a common cause of diarrhea in the community*

Microbiology and Pathophysiology

Measures to Control and Prevent Clostridium difficile Infection Dale N. Gerding Carlene A. Muto Robert C. Owens, Jr.Clinical Infectious Diseases, Volume 46, Issue Supplement_1, 15 January 2008, Pages S43–S49, https://doi.org/10.1086/521861


• Cdiff can opportunistically dominate the gut flora via ingestion of spores and After exposure to antibiotics

• The clinical symptoms range from:

– mild watery diarrhea

– fulminant pseudomembranous colitis

– toxic megacolon/ intestinal perforation

– septic shock

Clinical Syndromes


High and Low Risk for C. diff: the link to ASP

A Comprehensive Assessment Across the Healthcare Continuum: Risk of Hospital-Associated Clostridium difficile Infection Due to Outpatient and Inpatient Antibiotic ExposureSara Y. Tartof , Kalvin Yu, et.al., ICHE, https://doi.org/10.1017/ice.2015.220

LAB (antibiograms)Infection Control Comm

Quality and/orMed Exec Committee

The Journey from ASP pilot to ASP Benchmarking

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Evaluation of dedicated infectious diseases pharmacists on antimicrobial stewardship teams. Yu, et al., Am J Health Syst Pharm June 15, 2014, 71:1019-1028

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Yu, et al., Am J Health Syst Pharm June 15, 2014,71:1019-1028

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Anderson, et al. Antimicrob Agents Chemother, 2006 May; 50 (5) 1715-20Song, et al. infection control and Hosptial Epidemiology 2003

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*Sarma, JB, et al.,Effects of fluoroquinolone restriction (from 2007 to 2012) on resistance in Enterobacteriaceae: interrupted time-series analysis. J of Hospital Infection, May 15, 2015**Sarma, JB et al., Effects of fluoroquinolone restriction (from 2007 to 2012) on Clostridium difficile infections: interruptedtime-series analysis,” J of Hospital Infection, May 8, 2015***Cook,et al. “Long Term Effects of an Antimicrobial Stewardship Program at a tertiary-care teaching hosptial”, Internationa Journal of Antimicrobial Agents, 45,2015

North CarolinaDecrease in

Pseudomonas cipro R over 12 years***

UK (2007-2012)• Decreased FQ use:

• Decreased c.diff**• Decreased Ecoli R*

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Ranking By Consumption: Pros & Cons

•

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Assessment: What is a “Better” ASP?MDs: is this data risk-adjusted for ‘___’?

What is the “better” ASP hospital practice?

0

200

400

600

800

1000

1200

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Total DOT per 1K days by protected status

Protected DOT per 1K Days Unprotected DOT per 1K Days

Protected = antipseudomonals/carbapenems/anti-MRSA

• Pros– Attempts to risk adjust antibiotic use

(“expected”) by tertiary +/-, hospital size

and unit type

– Observed/Expected Ratio of abx use

– SAAR > 1.0 = likely overuse

– SAAR 1.0 observed = expected

– SAAR < 1.0 “better” use (OR under use)

• Cons– No encounter level data

– No risk adjustment based on patient

population

• Transplant, oncology

• ESRD, surgical procedures

Benchmarking: a new frontierCDC/NHSN SAAR metric

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Risk-Adjusting Antimicrobial Use: The Next Phase?

*Account for different severity patient populations• risk-adjust for different demographics• Procedures • “I have sicker patients”-- Dr. X• Comorbid conditions• 2 step process:

• Recursive Partitioning (DRGs)• Compared 3 Regression models:

• 1. ALL factors model (“Gold Standard’)

• 2. 5 highest weighted: ASP Ratio• 3. SAAR-like model

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Polk, Ibrahim, “Antimicrobial Use Metrics and Benchmarking to Improve Stewardship Outcomes : Methodology, Opportunities, and Challenges,” infectious Disease Clinics of America, vol 28, (2), june 2014

Facility level Encounter level

Encounter Clinical/Prior utilization

Percent ICU

Hospital bed size

Case Mix Index

Number of admissions per month

Percent overall capacity

Percent ICU capacity

Percent Medicare patients

Percent surgical

Percent transplant patients

(history of transplant)

Patient

demographics

Infection

present on

admission

ICU encounter

Risk score (e.g.,

DxCG,

Charlson, HCC)

DRGs in some

format of

increasing abx

use?

ICD codes

Comorbid burden and

conditions

Prior clinic, ED, and

inpatient encounters

Presenting lab values

(e.g., WBC, other

laboratory markers of

infection)

Vital signs

Clinical risk scores

(e.g., APACHE,

SOFA)

Fluid I/O

CDC/NHSN AU Module Adjusters

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Bucketing DRGs to correlate with antimicrobial use

DRG – Diagnosis related groups contain for a hosptilization: 1. Primary diagnosis and

2ndry diagnoses (5)2. Age, sex3. Procedures rendered4. Comorbid factors

Incorporate DRGs into the regression model for analysis


• X axis: Gold Standard (all risk variables:

Complex ASP Ratio)

• Y axis top: SAAR-like metric

• Y axis bottom 2 rows: Simplified ASP Ratio

• Simplified ASP (5 most influential risk

factors ) high correlation

• SAAR-like (facility risk-adjustment) lower

correlation

What were those 5 risk factors?

Results:

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What were those 5 risk factors?

1. DRG groupings

2. ICD codes w infection on admit

3. Unit type

4. Patient class (ICU,med/surge, obs)

5. History of MRSA/VRE (anti-MRSA)

Results:

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Did we explain discordance b/w

SAAR and Simplified ASP Ratio?

Ex: within this ICU:

1. 32% vs. avg 20% of ICU days are

patients with DRG w infection dx

2. 15% vs. avg 7% of ICU days w pts

with hx/of MRSA/VRE in past 12 mo

SAAR-like: 1.8 (high “overuse” MRSA)

Simplified ASP: 1.04 (observed= expect)

Results:validate

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• Blue= rank based on pure total abx use

• Circle=rank using Simplified ASP ratio

• Triangle=rank based on SAAR-like ratio

Ranking is different for each

Would this affect benchmarking of hospitals?

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*Observed/Expected Ratios:

-Heat map: prioritize ASP teams with limited

resources (what are the low hanging fruit?)

- Situational awareness of antibiotic use at the

unit level

- pharmacist/ID low FTE-> optimize time

- Retrospective audits: where can we improve

- Baseline for new ASP initiatives

Real World?

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ASP is more than “restricting” or policing antibiotics

Pakyz et al. “An evaluation of the association of an antimicrobial stewardship score and antimicrobial useage”, J antimicrob Chemother, Jan 21,2015;“Evaluation of dedicated infectious diseases pharmacists on antimicrobial stewardship teams.” Yu, et al., Am J Health Syst Pharm June 15, 2014, 71:1019-1028

Avoid ADRBroaden abxIncrease doseCulture change

Appropriate for that patient

ASP: multi-layered

AMS

Isolation +

Cleaning

Hand hygiene

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Appropriate Abx use

? Influence C.diff and HAI rates

Decrease in morbidity and mortality

Increase patient safety

Admin: ALL IN

- $8 million, avoidance

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• Why do we need ASP?• MDROs• C.Diff• Preserve anti-infectives• Cost effective/mortality

• How should we look at ASP?• Self-assessment (vs.

“rank”)• Quality enhancement• Inform data use • Sepsis campaign

Equalizer


Questions

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THANK YOU!

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