Tackling the U.S. Healthcare System’s Infectious Disease Management Problem

Tackling the U.S. Healthcare System’s Infectious Disease Management Problem

February 23, 2016

Dr. Susan E. Sharp, Ph.D., DABMM, FAAM• Regional Director of Microbiology and the Molecular Infectious Disease Laboratories in the

Department of Pathology for Kaiser Permanente• President-Elect of the American Society for Microbiology• Diplomat of the American Board of Medical Microbiology, Fellow in the American Academy of

Microbiology, and 2012 bioMerieux Sonnenwirth laureate

Dr. Margret Oethinger, MD. PhD.• Medical Director of Microbiology at Providence Health & Services• Ph.D. in Endocrinology• Board Certified in Clinical Pathology and Molecular Microbiology by both the American Board for

Pathology and the American Board for Medical Microbiology

Dr. Eleanor Herriman, MD, MBA – Host• Chief Medical Informatics Officer at Viewics• Former Senior Fellow with Professor Michael Porter at HBS Institute for Strategy and

Competitiveness

Panelists

Agenda

Infectious Disease and Value-based Healthcare

Antibiotic Resistance

Rapid Pathogen Identification

Advancements in Infectious Disease Diagnostics

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Infectious Disease and Value-based Healthcare

Infectious Disorders Comprised 32% of Avoidable Costs in a Study using the Prometheus Bundling System

Non-infectious complication categories 48%

Other -miscellaneous

20%

Infectious disorders 32%

Percent of Avoidable Cost Dollars

Source: Study conducted for College of American Pathologists by G2 Intelligence Eleanor Herriman in 2013, data on file. 5

Value Case Metric No. of Hospital Beds

Annual Cost Savings

Sepsis Sepsis costs 350-500 beds $6.9MMeningitis Avoided viral admissions 500 beds $230K

Pneumonia readmissions Avoided pneumonia readmits

500 beds $700K

Glycemic control – surgical site infections (SSIs)

SSIs avoided 350-500 beds $645K

Hyponatremia Savings from dec LOS 400 beds $2M

Acute kidney injury / ARF Preventing late stage AKI 350-500 beds $4.3M

Glycemic control – ICU patients Avoiding severe hypo > shorter LOS

350-500 beds $765K

Blood product utilization Transfusion costs Large teaching hospitals

$450-560K

TOTAL ~$16M

$8.5M

“New pathology and lab services could reduce all PAC costs and by 30%, thus helping drive the generation of 30% of new value.”

Infectious PACs Dollars were Over Half of the Lab Intervention Opportunity Savings

Antibiotic Resistance

The Problem of Antibiotic Resistance

U.S. infections with antibiotic-resistant organisms > 2M annually

23,000 annual deaths in U.S. from antibiotic resistant infections

0

10

20

30

40

Cost Burden, U.S.

Antibiotic Resistance Infections Cost Burden, U.S. $B

Health Care Lost Productivity

Source: Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: CDC, and Curr Opin Pulm Med 2015, 21:293–303.8

Top Threats by Organism – CDC 2015

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• Clostridium difficile (C.difficile)• Carbapenem-resistant Enterobacteriaceae (CRE)• Drug-resistant Neisseria gonorrhoeae (cephalosporin resistance)

Top Threats by Organism – CDC 2015

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• MRSA accounts for 10-40% of all hospital acquired pneumonias (HAP)• Pseudomonas pneumonia cases: ~20-35% showed reduced susceptibility to beta lactams

• Streptococcus pneumoniae is the most commonly isolated pathogen in community-acquired bacterial pneumonia (CABP) – Macrolide resistance varies geographically from 45% to 88%– Over the past decade, the percentage of macrolide-resistant Strep. pneumoniae has doubled in the United States

CDC’s Antibiotic Resistance Solutions Initiative, 2016

Stop Spread;; Protect PeopleAction in every state• Establish State AR Prevention Programs (“Protect Programs”), groups of healthcare

facilities in communities around the country that work together to better track outbreaks, improve prescribing, and prevent infections

• Detect and respond rapidly to reduce spread of multidrug-resistant gonorrhea (GC) and better treatment of GC

• Identify critical new interventions against multidrug-resistant tuberculosis (TB) and expand pre-migration TB screening beyond immigrants and refugees

• Support development of next generation rapid susceptibility tests for drug-resistant pathogens

• Identify new ways to prevent human infections caused by resistant bacteria (such as Salmonella) from food animals using the National Antimicrobial Resistance Monitoring System (NARMS)

11Source: http://www.cdc.gov/drugresistance/solutions-initiative/the_action.html


Track Superbugs;; Measure ImpactAccelerate outbreak detection and prevention innovation• New Detect Network of AR Regional Labs to improve response to outbreaks of urgent,

serious, or concerning threats;; know faster which antibiotics work;; and use cutting edge methods to track and get ahead of spread

• New AR Isolate Bank to provide a complete collection of current resistant threats;; help keep pace with mutations;; and provide information for FDA-approval of products and for companies/researchers’ new tests and antibiotics

• Measure impact of antibiotics on human microbiome to learn if a healthy microbiomeprotects people and to learn if antibiotics given to infants and elderly lead to health problems or higher risk of drug-resistant infection

• Double number of CDC’s Emerging Infections Program (EIP) sites to expand tracking to urgent and serious threats;; track evolving AR threats better;; and improve understanding of who is at risk

• Enhance global partnerships for prevention and detection to combat AR internationally



Track and Improve PrescribingImprove antibiotic use and reduce antibiotic resistance• Provide real-time data about antibiotic use and trends in healthcare in specific

facilities and across regions using the National Healthcare Safety Network (NHSN);; set the standard for how facilities, communities, states, and the nation can improve antibiotic use and reduce resistance

• Improve antibiotic prescribing practices in healthcare (antibiotic stewardship) by ensuring all hospitals have effective stewardship programs and evaluating state-to-state variations in antibiotic use to improve prescribing outside of hospitals

• Provide real-time data about antibiotic use and trends for outpatient care to better understand prescribing practices and set national goals for improving antibiotic use

• Measure the impact of antibiotic use on human and animal health and greatly scale up rapid detection of AR infections commonly transmitted through food to humans by collaborating with FDA and USDA to expand the National Antimicrobial Resistance Monitoring System (NARMS)


Antibiotic Resistance Panel Discussion

• Comment on antibiotic resistance problem/challenges• Discuss the role that the lab plays in controlling resistance rates• Discuss the role of lab analytics in addressing challenging antibiotic resistance problems

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Rapid Pathogen Identification

Rapid Pathogen Identification (RPI)

• Rapid pathogen identification of emergency and inpatient infections involves using a variety of interventions to minimize the time to reporting the identity and drug susceptibility of a patient’s pathogen.

• Interventions employed may include: – Advanced diagnostic assays– Lab testing and reporting workflow optimization– Lab information technology tools

Clinical Impact of RPI

• Why RPI is important:

– In many cases patients are not started on the appropriate antibiotic – e.g., ~33% of sepsis patients were started on inappropriate antibiotics.

– Inappropriately treated infections increase the length of stay, rates of complications, and mortality.

– Rapid pathogen identification shortens the time to appropriate antibiotics, enabling the clinician to switch from empirically chosen to pathogen-directed therapy.

17Source: Shorr, et al. Critical Care Medicine, 2011.

Clinical Impact of RPI

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• RPI in sepsis:

– Every hour of delay in reporting pathogen identification/getting the right drug to clinician translates to increased mortality rates and hospital costs.

– Study showed that each 1-hour delay in appropriate antibiotic treatment increases mortality by 7 – 10%.

– A >48-hour delay in instituting effective therapy for enterococcal bacteremia carried a 5-fold increased risk in 14-day mortality.

– A >12-hour delay in effective therapy for candidemia carried a 2-fold increase in hospital mortality.

Estimated Savings Using RPI Testing and Stewardship

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Analysis for non-federal, acute care hospitals with 350-500 beds Source

Average number of discharges 18,089 AHD Directory

Septicemia cases for 350-500 beds 416 National Hospital Discharge Survey, CDC, 2010

Average cost for blood stream infection 46,000 Perez, et al. Arch Path Lab Med, 2012

Apply 36% cost reduction from rapid pathogen ID services $16,560Perez, et al. Arch Path Lab Med, 2012 and KA Bauer, et al. Clin Infect Dis. 2010 Nov 1;;51(9): 1074-80

Total cost reduction per year ~$7M

Rapid Pathogen Identification Panel Discussion

• Discuss rapid pathogen identification and resistance diagnostics (molecular and mass spec)– Current usage of rapid micro assays – molecular and mass spec– Importance of role of antibiotic stewardship (AS) teams– How labs work with AS teams

• Discuss role of lab analytics in rapid pathogen identification solutions – Tools for optimizing RPI through TAT continuous improvement– Analytics for identifying TAT outliers

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About G2 Intelligence – CAP Prometheus ValueStudy

This study employed Health Care Incentives Improvement Institute (HCI3)’s Prometheus Payment bundled payment

methodology and extensive literature reviews to assess the contributions pathology and lab services could make in reducing

costs related to gaps in care. Reducing these care gap costs, which Prometheus terms “Potentially Avoidable Complications or

Costs (PACs),” can be considered equivalent to generating a common payer definition of value, since quality is improved by

avoiding or reducing gaps in care and related costs are reduced. Using a Prometheus database for a commercially insured

population of 4.7M adults, we analyzed PACs from 21 episodes of care across chronic and acute conditions, as well as

inpatient and outpatient procedures to identify opportunities for new pathology and lab services to prevent or reduce these

care gap costs. Based on evidence from peer-reviewed publications supporting the efficacy of pathology and lab interventions,

we calculated the percent cost reduction that might be achieved from implementing these services for various PAC categories.

The results indicated that new pathology and lab services could reduce the PAC costs from these episodes by 30%, and thus

help drive the generation of 30% of new value in this area.

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