/dr_gareth_kantor-2

Using Payer Data to Assess Antibiotic

Utilization and Support Improvement Global Forum on Bacterial Infections, New Delhi Dr Gary Kantor October, 2011

Agenda

• Context

• Purpose • Methodology

• Examples • Conclusions

Agenda

• Context • Purpose • Methodology

• Examples • Conclusions

Best Care Always…! Campaign Why ?

•Adverse events in ≥10% of hospital patients •50% preventable, 7.5% fatal

Who ?

• Hospitals, clinical leadership, funders, state

Commitment

• Measurement, improvement • Accelerating pace of change, collaboration

Interventions

• Prevent CLABSI, CAUTI, SSI, VAP • Antibiotic stewardship

Methods

• “Improvement science” • Bundles, change packages, teams, etc

Since August 2009, 202 public and private hospitals signed up for at least 1 intervention

www.bestcare.org.za

Discovery Health • South Africa’s largest private health insurer • 2.5 million members in South Africa • + UK, US, China divisions • Co-founder and sponsor of BCA • Large store of claims and clinical data

• Tools, analysts

Hospital Antibiotic Utilization Hospital Admissions

2009

2010

Hospital admissions with antibiotics

51.0%

53.0%

Average antibiotic cost

R853 ($120)

R1,047 ($150)

Average ICU antibiotic cost

R5,862 ($840)

R7,971 ($1,140)

22.7% average ABx cost increase!

35.9% ICU increase!! n = 161 Hospitals US $ 1 ~ ZAR 7

Top 10 Hospital Antibiotics: Cost Millions (R)

%

Teicoplanin

35.6

17%

Meropenem

29.8

14%

Piperacillin / tazobactam

14.6

7%

Cefepime

13.6

6%

Levofloxacin

13.3

6%

Ertapenem

12.4

6%

Ceftriaxone

11.3

5%

Linezolid

10.0

5%

Ciprofloxacin

8.4

4%

Imipenem

6.9

3%

Other

56.6

27%

Total

212.5

100%

Agent

Hospital Group A “A 34.4% increase in antibiotic expenditure is driven primarily by the increased utilisation of high cost antibiotics. teicoplanin (10%), meropenem (7.3%) voriconazole (2.7%) - antibiotics which carry costs per event of over R8,000 – are responsible for most of the aggregate 34.4% increase in expenditure�. n = 60

Hospital Group: Teicoplanin

MDC

Event count 2009

Event count 2010

Utilisation 2009

Utilisation 2010

% change

5 - CIRCULATORY SYSTEM

226

264

2.19%

2.48%

13.3%

4 - RESPIRATORY SYSTEM

162

219

1.39%

1.84%

32.3%

8 - MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 128

141

0.88%

0.97%

10.7%

6 - DIGESTIVE SYSTEM

129

0.54%

0.57%

6.6%

9 - SKIN, SUBCUTANEOUS TISSUE AND BREAST 75

129

1.56%

2.58%

64.8%

Grand Total

1,363

0.77%

0.95%

24.1%

120

1081

Hospital vs Funder Hospital Data / Analysis Period

Funder Data / Analysis

Hospital admission only

In hospital Out of hospital

Single / multiple hospitals Hospital, ward, patient

Single / ALL hospitals Hospital, unit, patient, etc

All patients in a facility

% depending on market share

+

+++

Not in use?

Yes

ABx admin data

Yes but hard to analyze

No

ABx billing data

Yes

Yes

Detailed clinical data

+++ Theoretically

+

PURPOSE

Research mindset Billing

Identify inefficiency Focus on outliers

Unit of analysis % of coverage Case-mix analysis DDDs

PURPOSE‌.Why Measure?

Research

Judgment (comparison)

Improvement

Agenda

• Context

• Purpose • Methodology

• Examples • Conclusions

Measurement for Best Care…Always!

Inappropriate prophylaxis • Excessive duration (>24 hrs) • “High level antibiotics” in theatre Excessive duration of therapy • >7 days Inappropriate combinations • Double Gram +ve cover • Double Gram –ve cover • Double antifungals • 4 or more antimicrobials simultaneously Microbiology workup (culture)

Stewardship Pilot Site: Aims 1. Optimised antibiotic use in 80% of patients through implementation of Antibiotic Stewardship Inception and Maintenance Bundles – within 10 months, in 2 hospitals, at unit level.

2. A 30% reduction in the overuse of antibiotics – within 10 months, in 2 hospitals, at unit level.

3. Stable or decreasing antibiotic resistance.

AIMS

Optimal antibiotic use in 80% of patients receiving AB

30% reduction in antibiotic overuse

10 DRIVERS

CHANGE CONCEPTS ↑ availability of first dose

Prompt initiation, for defined reasons Periodic review for cessation, route, reason for treatment Prescriber access to knowledge and data

Separate AB prescribing from other Rx

Day 3 and Day 7 review Info on how to Rx

INTERVENTION Antibiotic ward stock Antibiotic form AB Bundles Clinical pharmacist review Path lab hotline Resistance reports

Info on what it costs Cost reports

Stable / decreased antibiotic resistance

SSI bundle

Prevention of hospital-acquired infection

*Prevent SSI, CLABSI, VAP and CAUTI

*Interventions already associated with the BCA campaign

CAUTI bundle CLABSI bundle VAP bundle

Stewardship Pilot Site: Measures OUTCOME MEASURE

20 PROCESS MEASURES

% with compliance to all bundles (“optimal use”)

% compliance with each Inception bundle element: 1. <2 hrs from order → admin (treatment) 2. Prophylaxis within 1 hr of incision

% compliance with each Day 3 Maintenance bundle element: 1.

2.

3.

4.

Treatment not prophylaxis State antibiotic indication or stop Culture(s) ordered or done Reassess drug choice

% compliance with each Day 7 Maintenance bundle element: 1. AB Stopped or re-ordered 2. Conversion from IV to oral or N/A

Stewardship Pilot Site: Measures OUTCOME MEASURE

10 PROCESS MEASURES

20 PROCESS MEASURES

% with compliance to all bundles (“optimal use”)

% receiving timely antibiotics for prevention or treatment – first antibiotic prescribed during hospital course

% compliance with each Inception bundle element: 1. <2 hrs from order → admin (treatment) 2. Prophylaxis within 1 hr of incision

% overall compliance with Day 3 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Day 3 Maintenance bundle element:

% overall compliance with Day 7 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Day 7 Maintenance bundle element:

1.

2.

3.

4.

Treatment not prophylaxis State antibiotic indication or stop Culture(s) ordered or done Reassess drug choice

1. AB Stopped or re-ordered 2. Conversion from IV to oral or N/A

Agenda

• Context

• Purpose

• Methodology

• Examples • Conclusions

BCA Antibiotic Utilization Measures

Prolonged Therapy

2009

2010

Therapy > 7 days (7 DDDs)

6.1%

6.2%

Therapy >14 days (14 DDDs)

1.6%

1.5%

n = 161 Hospitals

Days of Treatment – From billing data?

Defined daily dose….. total grams of an antimicrobial agent used divided by grams in an average adult daily dose of the agent http://www.whocc.no/atcddd/

Vancomycin DDD = 2 grams • If a patient receives 2 grams/day for 5 days, then the total use (10 g) ÷ DDD (2 g) = 5 days of therapy • When the actual prescribed daily dose = DDD, then DDD = Days of Therapy “The use of defined daily doses is recommended so that hospitals may compare their antimicrobial use with that of other similar hospitals, recognizing the challenges of inter-hospital comparisons and the potential need for “risk adjustment.”

IDSA/SHEA Antimicrobial Stewardship Guidelines

Discovery Health mapped 1,700 systemic antimicrobials from local codes (NAPPI) to DDDs….. and shared this with the industry http://www.bestcare.org.za

DDD Limitations Date dispensed = date administered?

Dispensed dose = administered dose?

DDD = days of treatment (DOT)?

DDD and DOT are close for some drugs, not for others

DDD/100 bed-days [Ireland: 80.6 DDD/100 bed-days]

84.7

Top 10 Antibiotics: DDD Agent

Top 10 highest cost antibiotics

Total DDDs

%

Amoxicillin/clav

275,400

27%

Cefuroxime

197,300

19%

Ceftriaxone

102,700

10%

Cefazolin

54,200

5%

Clarithromycin

40,200

4%

Levofloxacin

33,300

3%

Cefepime

32,600

3%

Meropenem

29,000

3%

Ciprofloxacin

27,100

3%

Ertapenem

26,000

3%

1,039,000

100%

Total

BCA Antibiotic Utilization Measures Concurrent Agents

2009

2010

≥4 concurrent agents

0.8%

1.2%

≥ 2 gram negative agents

0.65%

0.71%

≥ 2 gram positive agents

0.07%

0.10%

≥ 2 antifungals

0.12%

0.14%

n = 161 Hospitals

BCA Antibiotic Utilization Measures Microbiology specimens:

2009

2010

All antibiotic events

30.4%

31.4%

23.2% 7.1%

24.0% 7.4%

69.6%

68.6%

- Before initiation of antibiotic - After initiation of antibiotic

No specimen

~ 53% of patients who get antibiotics receive <1DDD = prophylaxis?

n = 161 Hospitals

BCA Antibiotic Utilization Measures

Inappropriate surgical prophylaxis*

2009

2010

1.7%

1.7%

*Cefepime, imipenem, meropenem, ertapenem, linezolid, teicoplanin, vancomycin, voriconazole, caspofungin

n = 161 Hospitals

Burden of Health Care Infection

??

Estimating Hospital-Acquired Infection = HAI Day

0

2



Day

0

2

Day

0

2



 Day

0

2

 Day

Day

0

0

2

2

= HAI

Estimating HAI Rates Suspected HAI (across all admissions)

Incidence Incidence 2009 2010

All admissions

1.4%

1.5%

â&#x20AC;&#x153;Cleanâ&#x20AC;? surgical procedures

1.5%

1.7%

ICU admissions

7.9%

7.9%

n = 161 Hospitals

Comparing Hospitals

By Hospital 160

3.0%

140 2.5% 120 2.0%

80

1.5%

Incidence

Event count

100

Event count 2009 Event count 2010

Incidence 2009 60 1.0%

Incidence 2010

40

0.5% 20

0

0.0% 5805988 - Garden 5808502 - 5808138 - Unitas 5808510 - 5808588 - Linmed5805090 - Milpark 5808111 City Clinic Linksfield Park Hospital Olivedale Clinic Hospital Hospital Krugersdorp Clinic Private Hospital

5808227 - 5808855 - Pretoria 5808413 Sunward Park East Private Sunninghill Hospital Hospital Nursing Home

DDD >= 14 by hospital

“Clean” Procedures • CABG

Clean procedures with > 2DDDs

• Caesarean section • Craniotomy • Colorectal procedures • Head and neck procedures

Events Incidence

2009 2010 5,255 4,979 35.2% 33.3%

Change -5.3% -5.4%

• Hysterectomy • Knee and hip procedures • Vascular procedures • Ventricular shunts

n = 60 Hospitals

Cost / DDDâ&#x20AC;&#x2122;s by MDC Kidney & Urinary tract

Ear, nose and throat

2009

2010

Change

2009

2010

Change

Paid / event

R814

R947

16.4%

R253

R274

8.0%

DDD / event

4.49

4.77

6.4%

3.40

3.40

0.2%

Digestive system

Musculoskeletal system

2009

2010

Change

2009

2010

Change

Paid / event

R 924

R 1,077

16.5%

R601

R654

8.7%

DDD / event

4.93

5.21

5.5%

2.91

3.02

3.7%

Respiratory System

Paid / event DDD / event

2009

2010

Change

R 1,558 8.71

R 1,958 9.43

25.6% 8.3%

SEP increase = 7.4%

Case-Mix Adjustment

2009

2010

CMA Change 2009

CMA 2010

Change

Incidence

49.1%

49.4%

0.7%

50.0%

50.2%

0.4%

DDD / event

4.82

5.22

8.2%

4.89

5.08

3.7%

Cost / event

R857

R1,119

30.6%

R869

R1,029

18.4%

Case-Mix: Diagnosis Related Groups

DRGs are used to categorise hospital admissions into clinically and statistically homogeneous groupings DRG Case Mix can be used to risk adjust trends in hospital experience â&#x20AC;&#x201C; removing the impact of a change in the mix and severity of admissions Unique case mix indices are constructed to risk adjust hospital cost, antibiotic cost, antibiotic utilisation and DDD per event.

Risk Adjustment: Other Approach

Risk-adjustment model: • number of hospital beds • days in the ICU per 1,000 patient-days • surgeries per 1,000 discharges • cases of pneumonia, bacteremia, and UTI per 1,000 discharges Model R2 = 31%

Hospital: Doctor: Procedure Dr R (ENT) – tonsil & adenoid procedures Hospital Dr R at Hospital A Dr R at Hospital B

Events with antibiotics 20 2

Events

Incidence

52 41

38.5% 4.9%

In Hospital A: 12 admissions “prophylaxis”: 5 ceftriaxone, 7 amoxicillin 12 admissions “treatment”: amoxicillin Hospital

Hospital A Hospital B

Events with antibiotics

Events

3,071 86

6,046 923

Incidence

Incidence case mix adjusted (all DRGs)

50.8% 9.3%

50.9% 12.4%

All group antibiotic incidence for tonsil and adenoid procedures = 25.8% Hospital A: acute hospital Hospital B: day clinic

Agenda

• Context

• Purpose • Methodology

• Examples

• Conclusions

Conclusions & Next Steps 1. In partnership with hospitals we can use claims data, tools and analysis to improve understanding of antibiotic use • Overuse and misuse of antibiotics can be assessed and monitored • DDDs are useful to go beyond cost • Can drill down to hospital and even doctor level • Can adjust for case-mix and analyse clinical treatment groups 2. HAI rates and costs can be estimated 3. We have not yet demonstrated improvement in antibiotic use or Hospitalacquired infection 4. Improvement requires intentional “system change” to effect change in prescribing behavior

Jointly refine the methodology: Produce quarterly “run charts” that can demonstrate change / IMPROVEMENT!!

Process re-engineering