[BLOG]: Providers and payers share responsibility in making antimicrobial stewardship programs a priority

The number of antibiotic-resistant strains continues to rise rapidly. Statistics from the Centers for Disease Control and Prevention (CDC) and the Infectious Diseases Society of America (IDSA) point to alarming trends that are exacerbated by fewer new antibiotics coming into the market and high costs.

BLOG: Optimize antibiotic stewardship

According to a 2013 CDC report, at least 2 million individuals become infected with bacteria that are resistant to antibiotics each year, and at least 23,000 die as a result.¹ Costs associated with this epidemic are staggering-$21 billion to $34 billion each year to the US healthcare system alone, according to the IDSA, an organization that promotes excellence in infectious diseases research, education, prevention, and patient care.²

Combating antimicrobial resistance is a global concern that is most effectively addressed through antimicrobial stewardship programs (ASPs). ASPs have been proven to lower antimicrobial resistance, reduce adverse events, improve clinical outcomes, and lower costs. Although the focus on combating antimicrobial resistance has historically been on providers, industry best practices suggest that a more collaborative approach is needed that brings together all stakeholders-providers, payers, and patients-to share responsibility in combating this growing challenge.

Antimicrobial stewardship teams help save lives

All healthcare entities are under the microscope in today’s evolving accountable care landscape. In terms of improving overuse of antibiotics, the National Committee for Quality Assurance’s 2013 report on health care quality found that no progress has been made.³ Health plan performance for antibiotic avoidance over a 5-year period across health maintenance organizations or preferred provider organizations either declined or remained stagnant.

Going forward, payers in particular have a vested interest in making certain that hospitals and health systems invest in ASPs as a best practice priority. Healthcare organizations that have deployed an ASP are reaping the benefits of improved patient care and lower costs-driving better performance outcomes for payers. Fully leveraging this opportunity and embracing the responsibility to combat antibiotic resistance will require that payers take a stance to hold hospitals accountable for having these programs in place.

Best practices ASP implementation

Like any major health system initiative that requires collaboration and cooperation toward a common goal, success with an ASP must start with top-down commitment. Gaining buy-in from the C-Suite to take a purposeful and hard-nosed approach to combating antibiotic resistance is paramount.

A top-down approach extends to ensuring proper resource allocation for an ASP committee, one that brings together physicians, pharmacy, laboratory personnel, quality control, and infection preventionists to prioritize focus areas for the greatest impact, return on investment, and patient outcomes. Pharmacy departments should take a lead role in the development of the ASP, and the committee should include a physician champion to help spearhead the effort. Once in place, the committee is charged with establishing formalized policies and procedures and implementing effective governance and accountability measures.

The goal of any ASP should be optimization of antimicrobial use-finding the balance between appropriate use and overuse. Processes must address the management of proper antibiotic selection, duration, dose, and route of administration. To successfully achieve these aims, an ASP should include methods for tracking and reducing antimicrobial resistance, encouraging appropriate treatment patterns, collaboration between key departments, and ongoing education of staff and providers.

Critical to getting a successful initiative off the ground is to start with “low-hanging fruit” clinical initiatives. For instance, focus areas such as intravenous-to-oral conversions, formulary restrictions, therapeutic substitutions/interchanges, and renal dose optimizations are effective starting points that will produce clear outcomes improvements in most healthcare organizations.

Guidelines from IDSA point to formulary restriction and preauthorization as 1 of 2 core methodologies for ASP development-the other being prospective audit with intervention. Formulary restriction and preauthorization has proven most effective for managing use and decreasing costs, in that it limits use via a direct control and approval process. By requiring physicians to obtain approval for targeted antimicrobial agents at the time of an order, denials can be triggered when requests are made outside of formulary guidelines.

Antibiotics prescribed unnecessarily in kids, more antimicrobial stewardship needed

Common methods of implementing formulary restriction are preauthorization and the establishment of preapproved appropriate use criteria. In the case of preauthorization, antibiotics may be restricted to an infectious disease physician. The establishment of appropriate use criteria can be an alternative to labeling an antibiotic as “restricted,” in that it provides specific patient population and/or antibiotic parameters for use.  

To fully leverage a formulary restriction strategy that is built on appropriate use criteria, hospitals must engage a strong formulary review process. Appropriate use criteria should be developed by the pharmacy with the assistance of an antimicrobial stewardship committee (with oversight by an infectious disease physician) or with input from a pharmacy and therapeutics committee. The criteria developed should be evidenced based and in compliance with FDA-approved indications for use.

Technology for the bigger picture of antimicrobial stewardship

Real-time surveillance and tracking is a critical element in combating antimicrobial resistance, as early identification and intervention is key to prevention. Manual processes often place healthcare organizations in a reactive mode, and the ability to thwart bad outcomes is minimized.

Surveillance technology that provides for real-time aggregation of patient data has advanced in the market and can substantially aid hospitals in their efforts to proactively track use and reduce antimicrobial resistance. When automated through a foundation of advanced technology, healthcare professionals can access intelligently filtered information built on customized rules to identify problematic areas and make necessary adjustments.

Clinical decision support solutions can also prompt professionals that the potential for antimicrobial resistance exists. Although programs differ in complexity, some can provide such real-time notification as restricted antimicrobials that have been ordered, antimicrobial regimen comparisons, renal function surveillance for patients on antimicrobial therapies, surveillance of patient allergy or drug-drug interaction risks, and possible hospital-acquired infections.

Conclusion

Antimicrobial stewardship is a shared responsibility between providers, payers, and patients. Going forward, payers will need to take a more active role in requiring best practices such as ASPs to hold hospitals and health systems accountable.

It’s a win-win proposition for all involved, as ASPs have not only been shown to improve patient outcomes but also to lower costs. 

Conclusion

Antimicrobial stewardship is a shared responsibility between providers, payers, and patients. Going forward, payers will need to take a more active role in requiring best practices such as ASPs to hold hospitals and health systems accountable.

It’s a win-win proposition for all involved, as ASPs have not only been shown to improve patient outcomes but also to lower costs.

References

1. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/. Accessed October 15, 2014.

2. Infectious Diseases Society of America. Facts about antibiotic resistance. http://www.idsociety.org/AR_Facts/. Accessed October 15, 2014.

3. National Committee for Quality Assurance. Improving quality and patient experience. The State of Health Care Quality 2013. October 2013. http://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf.  Accessed October 15, 2014.

Dr Clark is pharmacy clinical program manager for Pharmacy OneSource, Wolters Kluwer Health.