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?