infectious diseases strategies to limit hospitalization,reduce risk and add value
DESCRIPTION
INFECTIOUS DISEASES STRATEGIES TO LIMIT HOSPITALIZATION,REDUCE RISK AND ADD VALUE. Ronald G Nahass, MD, MHCM, FIDSA President – ID CARE Clinical Professor of Medicine-Rutgers University Robert Wood Johnson Medical School. Disclosures. Clinical Trial Support - PowerPoint PPT PresentationTRANSCRIPT
INFECTIOUS DISEASES STRATEGIES TO LIMIT HOSPITALIZATION,REDUCE RISK
AND ADD VALUE
Ronald G Nahass, MD, MHCM, FIDSAPresident – ID CARE
Clinical Professor of Medicine-Rutgers University Robert Wood Johnson Medical School
Disclosures
Clinical Trial SupportGilead, Merck, Abbvie, BMS, Roche
Advisory Board Janssen, Gilead
Speaker SupportGilead, Merck, Vertex, Janssen
Infection Prevention ContractsSomerset Medical Center, East Mountain Hospital, Bridgeway Care Center, University
Radiology
Objectives
• Review the role of infection-related problems that lead to unnecessary admissions, readmissions, and avoidable complications
• Discuss the cost from the fiscal and patient outcomes perspective
• Illustrate the importance of the Infectious Diseases Physician – Hospital Partnership
• Propose for consideration “The Infectious Diseases Service Line”
Case Study: 72 Year Old Diabetic Woman
Day 0 Day 1 Day 2 Day 3 Day 4 Day 11 Day 12 Day 13 Day 14
ID Calle
d
• Antibiotic treatment stopped as gout was diagnosed.
• Clostridium difficile test ordered and treatment for this started.
• Patient was isolated. • C difficile diagnosed. • ICU with dilated colon –
operating room for colon resection.
Emergency Dept. Hospital Nursing
Home
Presents with fever and
painful, red footTreated with
broad-spectrum antibiotics
Fever not better, Abx changed
Develops diarrhea
After 12 days in hospital, patient discharged to
Nursing Home
Case Analysis
Day 0 Day 1 Day 2 Day 3 Day 4 Day 11 Day 12 Day 13 Day 14
ID Calle
d
• Antibiotic treatment stopped as gout was diagnosed.
• Clostridium difficile test ordered and treatment for this started.
• Patient was isolated. • C difficile diagnosed. • ICU with dilated colon –
operating room for colon resection.
Emergency Dept. Hospital Nursing
Home
Presents with fever and
painful, red footTreated with
broad-spectrum antibiotics
Fever not better, Abx changed
Develops diarrhea
After 12 days in hospital, patient discharged to
Nursing Home
Potentially avoidable complication of antimicrobial therapy leading to lengthy stay
Numerous antibiotics – most of which not needed
Wrong initial diagnosis
Prolonged recovery including sub-acute stay
Late consultation with infectious disease
Key Take-Aways
• Inappropriate diagnosis and treatment for infectious diseases is costly to the patient and system
• Late consultation with ID specialist is costly
Some Basic Statistics
Keep 3 things in mind:1. Infections can happen
anywhere
2. Infections can be costly
3. Antibiotic resistance is a problem so Stewardship and Infection Control are critical
Aggregate Costs Of Infectious Diseases
• Clostridium difficile – nearly $9 Billion in annual costs
Ref: Torio CM (AHRQ), Andrews RM (AHRQ). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. HCUP Statistical Brief #160. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf.
Infection Related Health Care Admissions
• Primary Diagnosis Ranking*– Pneumonia 1– Septicemia 4– Complications of implant 7– Skin and subcutaneous tissue infection 9
• What this could mean to you:– 10% of your admissions may have an infectious disease diagnosis– The number of admissions for ID related problems are almost 2x that of cardiovascular disease diagnoses
* Ranking excludes pregnancy and psychiatry related diagnosesRef: Pfuntner, A (Truven Health Analytics), Wier, LM (Truven Health Analytics), Stocks, C (AHRQ). Most Frequent Conditions in U.S. Hospitals, 2010. HCUP Statistical Brief #148. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148.pdf.
Infection Related Health Care Re-Admissions
• Primary Diagnosis Ranking*– Pneumonia 1– Septicemia 4– Complications of implant 8– Skin and subcutaneous tissue infection 9– Urinary tract infections 12
• What this could mean to you:– 21% of your septic patients are likely to be readmitted within 30 days– 20% of your patients with an implantable device or graft are likely to be
readmitted within 30 days
* Ranking excludes pregnancy and psychiatry related diagnosesRef: All-cause 30-day readmissions ranked by the most frequently treated conditions* in U.S. hospitals, 2010 - Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf.
Special Pathogens – Clostridium difficile
• Clostridium difficile – Healthcare associated diarrhea infection related to antibiotic use– Adds an estimated $26,000 marginal cost per case to
each hospitalized patient – Admissions nearly doubled from 2001-2010 - from 4.5 to
8.2 cases / 1000 admissions.– In 2009, C. diff accounted for a total of 336,000
admissions or 1% of all admissions– Estimated to have excess attributable costs of $1.3 billion
Lucado, J. (Social & Scientific Systems), Gould, C. (CDC), and Elixhauser, A. (AHRQ). Clostridium difficile Infections (CDI) in Hospital Stays, 2009. HCUP Statistical Brief #124. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf
Lucado, J. (Social & Scientific Systems), Gould, C. (CDC), and Elixhauser, A. (AHRQ). Clostridium difficile Infections (CDI) in Hospital Stays, 2009. HCUP Statistical Brief #124. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf
W Ant mo to and
ATANATIONAL SUMMARY
Estimated minimum number of illnesses anddeaths caused by antibiotic resistance*:
2,049,442At least illnesses,
23,000*bacteria and fungus included in this report
deaths
Estimated minimum number of illnesses anddeath due to Clostridium difficile (C. difficile), a unique bacterial infection that, althoughnot significantly resistant to the drugs used to treat it, is directly related to antibiotic use and resistance:
250,000 14,000
At least illnesses,
deaths
WHERE DO INFECTIONS HAPPEN?Antibiotic-resistant infections can happen anywhere. Data show thatmost happen in the general community; however, most deaths related to antibiotic resistance happen in healthcare settings, such as hospitals and nursing homes.
The Infectious Diseases Service Line Is A Solution
• Antimicrobial Stewardship• Clinical Care• Infection Prevention• Microbiology Laboratory• Employee Health• Resource Management
Antibiotic Overuse Is Dangerous and Costly
• Studies indicate that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate.
1. Ref: http://www.cdc.gov/getsmart/healthcare/2. Anderson DJ, Moehring RW, Sloane R, Schmader KE, Weber DJ, et al. (2014) Bloodstream Infections in Community Hospitals in the 21st Century: A Multicenter Cohort Study. PLoS ONE 9(3): e91713. doi:10.1371/journal.pone.0091713
Antibiotic Stewardship Is Needed
And the ID Specialist will be your championRef: Combes J.R. and Arespacochaga E., Appropriate Use of
Medical Resources. American Hospital Association’s Physician Leadership Forum, Chicago, IL. November 2013
Stewardship Creates Value
ID Specialists Improve Outcomes and Reduce Cost – Clinical Care
Early ID Clinician Engagement for clinical care is critical to achieve
the best outcomes
Ref: Schmitt et al. “ Infectious Diseases Specialty Intervention is Associated with Decreased Mortality and Costs.” Clin Infect Dis. (2014) 58 (1): 22-28. doi: 10.1093/cid/cit610 First published online: September 25, 2013
Improving Outcomes and Reducing Costs
• Infection Prevention Intervention
Clostridium difficile at Rhode Island Hospital
Metric 2006 2012Incidence/1000 discharges
12.2 3.6
Mortality (N) 52 19
Results of a 5 step program focused on reducing the incidence of Clostridium difficile• C difficile infection control plan• Monitor morbidity and mortality of C. difficile• Improve test sensitivity• Enhance environmental cleaning• Standardize the treatment plan• Other interventions as necessary
Mermel, LA et al, Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach. The Joint Com J 2013;39:298.
ID Clinicians Offer A Unique System and Population Orientation
• Long-term focus of risk reduction and safety through system-wide infection prevention and control efforts
• One of the few specialties that focuses on efficient resource management, across various sites-of-service
• Effective managers of patient care transitions
– Employing Outpatient Parenteral Antimicrobial Therapy (OPAT)
– Extensivist activity in LTC
• Strong competency towards promoting team communication across all specialties and within the continuum of care
The Infectious Diseases Service Line Is the Solution
Clinical Care
ID Specialist-
led Intervention
s
Efficient Resource Utilization
Early ID consults
Rescue ID
Infection Control & Prevention
Antimicrobial Stewardship
Judicious use of radiology services, micro/lab servicesHazardous
waste (“red bag”)
management
Case Study – ID Rescue• 64 year old man has a total knee replacement.
– Hospital has established TKR bundled payment agreement with payer
• 2 weeks later the patient has fever and drainage from the knee incision. A diagnosis of infected joint is made.
• Multiple treatment decision points, each with different cost implications
Hospital PayerBundled Payment
Total Knee Replacement
Option 1 – prolonged IV treatment and hope for the best $$
Option 2 – short course IV then long course oral treatment $$$
Option 3 – remove joint, IV treatment, replace joint $$$$$
There is a Better Way to Mitigate Risk
Hospital PayerBundled Payment
Total Knee Replacement
ID ServicesCo-Management Agreement or
Gain-sharing agreement with your ID Clinicians
Link payment to Quality:• Metrics for acute care
– Antibiotic utilization– Resistant organism prevalence– C. difficile rates– CLASBI, CAUTI, SSI
• Metrics for population management– Readmissions– Vaccination rates
Clinical Care
ID Specialist-
led Interventio
ns
Efficient Resource Utilization
Early ID consults
Rescue ID
Infection Control & Prevention
Antimicrobial Stewardship
Judicious use of Imaging/
Labs
Hazardous waste
management
Strategies to Limit Hospitalization and Cost Without Sacrificing Outcomes
• Acute infection diagnosis– Acute infection medical service
• Out patient – Alternate site care• Early ID Consultation• Rescue care
• Readmission– Focused programs on septicemia, pneumonia, UTIand surgical wound disruptions at LTC
Case Study – Alternate Site Care
• 54 yo man with fever for 2 weeks had blood cultures performed by his doctor.
• He was seen by ID doctor because of long duration of fever. – Blood cultures positive for Streptococcus bacteremia. IV antibiotic treatment started as out-
patient. – Workup and treatment for endocarditis complicated as outpatient
• Total savings = $10,000 (Based on Millman and hospital per diem)• Patient Satisfaction = High• Risks = marked reduction for HAI
ED/Hosp
PCP
Option 2 – OPAT and care $$management under ID
Option 1 – Send patient to ED $$$$$
Outpatient ID
The Infectious Diseases Service Line
• Is a solution for– Quality– Cost– Outcomes
VALUE
Final Key Messages
Aligning incentives through gain sharing and co-management for the ID Service line provides a mechanism to
achieve greater value
Final Key Messages
• If you are not engaged with your ID consultants you are missing opportunities to reduce risk and add value
• If your ID consultants are not engaged with you then you have the wrong consultants
THANK YOU!
QUESTIONS or COMMENTS?