Transcript [Poster title] - Health Systems Renovators, LLC

ASSESSING THE FEASIBILITY OF ANTIBIOTIC MANAGEMENT
SERVICES THROUGH PROSPECTIVE EVALUATION
Kevin D. Mills, Pharm D1; Corstiaan Brass, MD2; Marisa Rahn, Pharm D, BCPS3; James Fenner, B. Sc., Pharm D, BCPS4; Salvi Parpia, B. Sc., Pharm D, MRCF5
1Clinical
Pharmacy Coordinator, Kaleida Health/DeGraff Memorial Hospital; 2Clinical Associate Professor, SUNY at Buffalo School of Medicine; 3Assistant Professor of Pharmacy Practice, Albany College of Pharmacy;
4Clinical
Pharmacy Coordinator, Kaleida Health/Millard Fillmore Suburban Hospital; 5Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia
METHODS
ABSTRACT
PURPOSE: The inappropriate and unnecessary use of antibiotics is
an important problem in the hospital setting. The goal of this
assessment was to prospectively evaluate the extent of antibiotic
misuse at a community hospital, and to realistically quantify the
potential reduction of direct and indirect hospital costs if an antibiotic
management service were employed.
METHODS: A 3-week prospective evaluation was performed at a 100
bed private hospital facility. During the evaluation period, all antibiotic
use at the facility was captured by a residency-trained antibiotic
streamlining pharmacist. Appropriateness of antibiotic therapy was
assessed based on infection diagnosis and supporting evidence for
the presence of active infection. The extent of inappropriate antibiotic
use, as well as the potential direct and indirect hospital cost of nonfocused antibiotic utilization, was estimated using a customized
database.
RESULTS: Of a total of 149 patients who received antibiotic therapy
during the evaluation period, 116 were evaluated and actively
followed by the streamliner. A total of 137 potential interventions were
identified. Seventy-four of the potential interventions involved
antibiotic change or discontinuation, while 44 involved change from IV
to oral therapy. An estimated $8,354 in potential drug cost savings
was identified ($144,807 annually). If an antibiotic management
program were employed, the initial acceptance rate of
recommendations would likely be around 85 percent. Thus, a
realistically achievable estimate of drug cost savings from antibiotic
management is $7,100 over three weeks, or $123,000 annually. A
minimum cumulative reduction of 23 patient days could have been
achieved by earlier conversion to oral therapy, accounting for an
additional $5,750 in potential cost savings to the facility ($99,750
annually).
DISCUSSION: The annual cost savings for the facility that could be
achieved through focusing of antibiotic therapy is approximately
$223,000. Based on the results of this observational evaluation, there
is sufficient inappropriate and non-focused antibiotic use to justify the
presence of an antibiotic management service at MSM. We intend to
initiate an antibiotic management program at this facility beginning in
2005. Once this program has been established, we will be able to
evaluate the accuracy of our methods for determining the potential
cost savings of antibiotic management services.
 Antimicrobial stewardship initiatives have consistently been
associated with significant reductions in antibiotic use,
improved bacterial susceptibility patterns, and reduced
inpatient LOS of infected patients
 Many facilities continue to operate without such programs
- One likely reason is the perceived lack of financial
resources needed for the development and implementation
of these programs
 The relationship between sub-optimal antibiotic use and
potential cost savings to a facility has not been clearly
established
 A valid means of prospectively evaluating the potential
impact of antibiotic management initiatives would be useful
 The goal of this assessment was to prospectively
evaluate the extent of antibiotic misuse at this facility, and
to realistically quantify the potential for reduction of direct
and indirect hospital costs if an antibiotic management
service were employed
RESULTS
The Facility
Evaluation dates: May 3rd through May 24th, 2004
 Mount St Mary’s Hospital (MSM) is a 100 bed secondary care facility
• A member of the Ascension Catholic hospital network
• 11 bed intensive care unit
• Non-teaching facility
• At the time of this evaluation, no significant measures to improve
cost-effectiveness of antibiotic therapy were employed

Total No. of patients who received antibiotic
therapy during study period: 149
Patient Demographics
Characteristic
68.6 +/17.6 years
68, 45.6%
Age (mean +/- SD)
Data collection and Analysis
Male sex (No, %)
 A prospective, observational evaluation was conducted at MSM over
a three week period
• All antibiotic use at the facility was captured along with patient
demographic data, details of infection and concomitant diagnosis,
and relevant laboratory and culture data
• Data collection and antibiotic regimen assessment were
performed by a residency trained clinical pharmacist (KM)
 Antibiotic selection, dosing, and duration of therapy were evaluated
based on evidence-based practice standards and guidelines
 The definitions used when determining the appropriateness,
redundancy, and focus of prescribed antibiotic regimens are stated
below
 A physician specialist in infectious diseases (CB) was consulted for
further insight into the appropriateness and/or focus of a given regimen
when necessary
 Each IV antibiotic regimen was assessed daily for potential
conversion to oral therapy based on the stated criteria
Term
Inappropriate
Redundant
Focused
INTRODUCTION
RESULTS
Appropriate for
IV to oral
conversion
Definition
No objective evidence of active infection
Cultured organism(s) not susceptible to prescribed antibiotic
Excessive duration of therapy based on evidence-based guidelines
Use of broad spectrum antibiotic with coverage of nosocomial
organisms in patients with no prior hospital exposure
Two antimicrobial agents with overlapping spectra of activity used
simultaneously (ex. ampicillin/sulbactam plus metronidazole:
redundant coverage of anaerobic organisms)
Most cost-effective and narrow-spectrum antibiotic therapy
- No underlying gastrointestinal pathology existed that would
preclude reliable enteral ingestion/absorption
- Patient tolerating at least one other enteral medication
- Patient received at least 48 hours of IV antibiotic therapy
Inpatient LOS (patients discharged
during study period only)(mean +/- SD)
 Estimating potential impact on antibiotic cost
• When an antibiotic regimen was deemed inappropriate or nonfocused, a potential intervention was recorded and a focused regimen
was formulated
• Patient’s actual antibiotic regimen and the focused regimen were
tracked until patient discharge or discontinuation of therapy
• Estimated drug cost savings = Cost of prescribed regimen(s) - Cost
of focused regimen(s)
 Estimating impact on inpatient length of stay (LOS)
• If a patient (as a result of IV to oral conversion) would subsequently
be off all IV medications and had no other unresolved medical issues,
a potential LOS decrease of 1 (one) day was recorded.
• Mean cost per day of inpatient stay was obtained from the facility
 All data were collected and analyzed using a customized Access®
database.
 Cost of antibiotic therapy was determined using purchasing data
obtained from the facility’s Department of Pharmacy
Result
Prescribed
regimens
Focused
regimens
Total antibiotic days
1538
1288
Excess
antibiotic daysa
250
IV antibiotic days
1130
792
338
Oral antibiotic days
408
496
Ratio IV:oral antibiotic days
2.77
1.60
Mean days to oral therapy
(or therapy discontinuation)
4.5
3.33
a. Total antibiotic days for prescribed regimens - focused regimens
Infection syndrome
Intra-abdominal
Pulmonary
Upper respiratory tract
Skin or soft tissue
Urinary
Bacteremia
Prophylaxis
No reason
Fever
Leucocytosis
Meningitis or CNS
Bone/ joint
(Patient not seen and evaluated)
29
21
18
10
9
7
7
5
4
3
2
1
33
Potential Therapy Interventions
Result
No. of patients evaluated and
followed during study period
No. of antibiotic regimens evaluated
during study period
No. of instances of inappropriate
antibiotic therapy
No. of instances of redundant
antibiotic therapy
Potential Antibiotic Streamlining
Interventions
44 (32.1%)
Potential Impact of an Antibiotic Management Program on Antibiotic Spending
Study period
(3 weeks)
Result
Annualized
Total cost of actual (prescribed) antibiotic therapy $26,183.51
$453,847.51
Total cost of optimized antibiotic therapy
$17,829.22
$309,039.81
Estimated potential drug cost savings
$8,354.29
$144,807.69
 If an antibiotic management program were employed, the initial acceptance
rate of recommendations would likely be around 85%
- Thus, a realistically achievable estimate of drug cost savings from
antibiotic management is $7,100 over three weeks, or $123,000 annually
Estimated (minimum) LOS Impact of IV to Oral Conversions
No.
Study period
(3 weeks)
Result
116
Estimated days saved through IV to oral
conversions (see criteria in methods section)
240
51
Expected cost savings to the facility per day
of reduced LOS
Estimated cost savings due to decrease in
LOS
23
137
Annualized
23 days
399 days
$250.00
$250.00
$5,750.00
$99,750.00
60 (43.8%)
D/C Antibiotic
Change Antibiotic
Dose Change
IV to PO Change
9
- White blood cell count < 15 x 10 /L
- Afebrile (Temp < 100.0oF) > 24 hours
- Equivalent oral antibiotic available
- Antibiotic NOT used for one of the following indications:
meningitis, endocarditis, febrile neutropenia, prosthetic device
infection, staph. aureus bacteremia
7.7 +/- 4.8
days
Antibiotic Regimen Details Over 3-week Study Period
(prescribed vs. focused)
DISCUSSION
 The minimum expected annual cost savings for the facility from drug cost
savings and decreased inpatient LOS is approx. $223,000
19 (13.9%) 14 (10.2%)
Potential Therapy Interventions (Cont.)
Rationale for antibiotic therapy change or
discontinuation
Use of antibiotic therapy in patients with
insufficient evidence of active infection
n
23
Use of multiple antibiotics with similar/ overlapping
18
antimicrobial spectra
 The potential decrease in LOS of 23 days over 3 weeks was meant to be
a conservative estimate
- In the literature, the impact of early IV to PO conversion on inpatient
LOS has been suggested to be much greater (from 1 to 2.5 days per
conversion)
Limitations
Adjustment of antibiotic therapy based on culture
data or other diagnostic test result
8
• Short observation period
• Method for evaluating the prescribed antibiotic regimens was superficial
(info. obtained from patient records, no direct patient assessment)
Excessive duration of antibiotic therapy for active
infection
7
Conclusion
Use of broad spectrum antibiotic with coverage of
nosocomial organisms in patients with no prior
hospital exposure
5
the presence of an antibiotic management service at MSM
Excessive duration of prophylactic antibiotic
5
Inappropriate antibiotic selection based on
evidence-based medicine and standard of care
 Our intent is to establish an antibiotic management program at this facility
beginning in 2005
5
Use of multiple antibiotics when single agent
would provide adequate antimicrobial coverage
3
 There is sufficient inappropriate and non-focused antibiotic use to justify
 Once this program has been established, we will be able to draw
conclusions as to the accuracy of our methods for determining the potential
cost savings of antibiotic management services