Reducing Invasive Fungal Infections and Reducing Cost

Presenter: Lee Hamley

Hospital: THE ALFRED – Vic

Key problem

• In 2007-08 haematologists noted increasing invasive fungal infections (IFI) in acute leukaemia and stem cell transplant patients

• This is a difficult problem to measure due to definitional issues related to IFI

• At the same time, Pharmacy recorded LARGE increases in the use of anti-fungal agents, which can be extremely expensive

• Alfred Health realised we had a problem!

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Proven Probable Possible

Overall IFI = proven + probable

Clinical IFI = proven + probable + possible

Ascioglu et al CID 2002;34 p7-13Pauw et al 2008 CID 2008: 46 p1813

Host factors&

Clinical/radiology(eg HRCT – dense lesions +/- halo)

&Micro criteria

(eg fungi from sputum/BAL)

Host factors&

Clinical/radiology(eg HRCT – dense lesions +/- halo)

(ie no micro results)

Fungi in histology, micro from a sterile site

or BC

(ie need biopsy)

Audit definitions of IFI

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Aim of this Innovation

• To decrease invasive fungal infections in patients with acute leukaemia or stem cell transplantation from a baseline level of around 15% (proven & probable IFI) to best practice levels reported in the literature.

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Haem & SCT use >80% of The Alfred’s Ambisome

Allografts = 20 Allografts = 23

Baseline Ambisome costs at The Alfred

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Key changes implemented

• Changes to clinical practice – see next slide• Changes to the environment and related systems – see

next slide• Collaborative project for the introduction of in house

drug levels – These were not available in Victoria– Levels either not done or sent interstate– Very slow turn around time for results

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2007 2008 2009 2010 2011

Allo-SCT Itra→posa posa→VoriVori

Vori Vori/Posa

AMLItra→posa posa→Vori

Vori Vori Posa

ALLItra→posa posa→Vori

Azole/Amb Azole/Amb Azole/Amb

Environmental

HEPA filter Ward cleaning

Policies

Renovation 7EAST

Audit Audit & feedback

Patient selection Modified allo-SCT selection criteria

Increased number of patients treated on OP clinical trials for AML

Key changes to clinical practice

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Invasive fungal disease (proven + probable IFD)

2007n = 73

2008n = 89

2009n = 69

2010n = 92

2011n =75

Allograft 26% 0% 5% 4% 5%

AML 6% 15% 5% 5% 5%

ALL 17% 4% 0% 0% 0%

OVERALL RATE

15.1% 8% 4% 4% 4%

Clinical invasive fungal disease(proven + probable + possible IFD)

2007n = 73

2008n = 89

2009n=69

2010n =92

2011n = 75

52% 7% 8% 10% 7%

41% 33% 20% 21% 18%

34% 30% 20% 0% 33%

42% 25% 16% 14% 13%

Overall Rates IFI all groups 2007-2011

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Outcomes

• Significant reduction in IFI in the target groups to levels reported in the literature

• Large cost savings in high cost antifungal drugs, estimated to be approximately $1million per annum

• On site drug monitoring now available

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2007n = 23

2008n = 27

2009n = 39

2010n = 48

2011n = 43

Ambisome 15 (65%) 7 (30%) 7 (18%) 2 (4%) 2 (5%)

Voriconazole IV 10 (48%) 6 (22%) 9 (23%) 1 (2%)

Voriconazole oral 12 (52%) 5 (18%) 10 (25%) 1 (2%) 1 (2%)

Caspofungin 8 (35%) 1 (3.7%) 1 (2.5%) 0

Posaconazole 1 (2%)

Overall on treatment dose antifungals

19 (83%) 8 (30%) 12 (31%) 5 (10%) 3 (7%)

Allo-SCT – treatment dose antifungals

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0

2

4

6

8

10

12

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Nu

mb

er o

f pat

ien

ts/c

ases

patients in ward fungal infections

2007 2008 2009 2010 2011

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Figure 2: cost of treatment dose antifungals for high risk patients

$2,173,305

$1,064,302

$801,668

$195,056

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

2007 2008 2009 2010

An

tifu

ng

al c

os

ts

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$-

$500,000

$1,000,000

$1,500,000

$2,000,000

Ambisome Voriconazole IV Voriconazole oral caspofungin

Figure 3: total (treatment and prophylaxis) costs of antifungals for high risk patients

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Lessons learned

• Fungal infections have significant consequences, both clinical and economic

• Measurement is critical – if you don’t measure you don’t know!

• For complex problems, solutions often cross Departments e.g. Haematology, Pharmacy, Ward, Engineering, Pathology etc

• Executive support is essential to facilitate this.

• Big gains can be made where you may least expect them, both in terms of patient safety and financial

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