Transcript Reducing Invasive Fungal Infections and

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 antifungal agents, which can be extremely expensive
• Alfred Health realised we had a problem!
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Audit definitions of IFI
Proven
Fungi in histology,
micro from a sterile site
or BC
(ie need biopsy)
Probable
Possible
Host factors
&
Clinical/radiology
Host factors
&
Clinical/radiology
(eg HRCT – dense lesions +/- halo)
(eg HRCT – dense lesions +/- halo)
&
Micro criteria
(ie no micro results)
(eg fungi from sputum/BAL)
Overall IFI = proven + probable
Clinical IFI = proven + probable + possible
Ascioglu et al CID 2002;34 p7-13
Pauw et al 2008 CID 2008: 46 p1813
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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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Baseline Ambisome costs at The Alfred
Haem & SCT use >80% of The Alfred’s Ambisome
Allografts = 20
Allografts = 23
5
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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Key changes to clinical practice
Allo-SCT
AML
ALL
Environmental
2007
2008
Itra→posa
posa→Vori
Itra→posa
posa→Vori
Itra→posa
posa→Vori
HEPA filter
Ward cleaning
Policies
2009
2010
2011
Vori
Vori/Posa
Vori
Vori
Posa
Azole/Amb
Azole/Amb
Azole/Amb
Vori
Renovation
7EAST
Audit
Audit & feedback
Patient selection
Modified allo-SCT selection criteria
Increased number of patients treated on OP clinical trials for AML
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Overall Rates IFI all groups 2007-2011
Invasive fungal disease
(proven + probable IFD)
Clinical invasive fungal disease
(proven + probable + possible IFD)
2007
n = 73
2008
n = 89
2009
n = 69
2010
n = 92
2011
n =75
2007
n = 73
2008
n = 89
2009
n=69
2010
n =92
2011
n = 75
Allograft
26%
0%
5%
4%
5%
52%
7%
8%
10%
7%
AML
6%
15%
5%
5%
5%
41%
33%
20%
21%
18%
ALL
17%
4%
0%
0%
0%
34%
30%
20%
0%
33%
OVERALL
RATE
15.1%
8%
4%
4%
4%
42%
25%
16%
14%
13%
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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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Allo-SCT – treatment dose antifungals
2007
n = 23
2008
n = 27
2009
n = 39
2010
n = 48
2011
n = 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%)
Caspofungin
8 (35%)
1 (3.7%)
1 (2.5%)
0
Posaconazole
Overall on
treatment dose
antifungals
1 (2%)
1 (2%)
19 (83%)
8 (30%)
12 (31%)
5 (10%)
3 (7%)
10
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Number of patients/cases
12
10
8
6
4
2
0
2007
2008
2009
patients in ward
2010
fungal infections
2011
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Figure 2: cost of treatment dose antifungals for high risk patients
$2,500,000
$2,173,305
Antifungal costs
$2,000,000
$1,500,000
$1,064,302
$1,000,000
$801,668
$500,000
$195,056
$2007
2008
2009
2010
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Figure 3: total (treatment and prophylaxis)
costs of antifungals for high risk patients
$2,000,000
$1,500,000
$1,000,000
$500,000
$Ambisome
Voriconazole IV
Voriconazole oral
caspofungin
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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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