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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
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• 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
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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.”
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The USA Likes Antibiotics and Pays the Price
Albrich WC, et al. Emerg Infect Dis 2004;10:514-7
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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
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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
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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
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• 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)
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• 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
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• 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
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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
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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 ‘___’?
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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
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• 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
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• 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
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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
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- $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
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Questions
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THANK YOU!