Global Forum on Bacterial Infections, New Delhi

Dr Gary Kantor

October, 2011

Using Payer Data to Assess Antibiotic

Utilization and Support Improvement

Agenda

• Context

• Purpose

• Methodology

• Examples

• Conclusions

Agenda

• Context

• Purpose

• Methodology

• Examples

• Conclusions

•Adverse events in ≥10% of hospital patients

•50% preventable, 7.5% fatalWhy ?

• Hospitals, clinical leadership, funders, stateWho ?

• Measurement, improvement

• Accelerating pace of change, collaborationCommitment

• Prevent CLABSI, CAUTI, SSI, VAP

• Antibiotic stewardshipInterventions

• “Improvement science”

• Bundles, change packages, teams, etcMethods

Best Care Always…! Campaign

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 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)

n = 161 Hospitals

US $ 1 ~ ZAR 7

22.7% average ABx cost increase!

35.9% ICU increase!!

Hospital Antibiotic Utilization

Agent 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%

Top 10 Hospital Antibiotics: Cost

“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”.

Hospital Group A

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 120 129 0.54% 0.57% 6.6%

9 - SKIN, SUBCUTANEOUS TISSUE

AND BREAST 75 129 1.56% 2.58% 64.8%

Grand Total 1081 1,363 0.77% 0.95% 24.1%

Hospital Data / Analysis Funder Data / Analysis

Period Hospital admission only In hospital

Out of hospital

Unit of analysis Single / multiple hospitals

Hospital, ward, patient

Single / ALL hospitals

Hospital, unit, patient, etc

% of coverage All patients in a facility % depending on market share

Case-mix analysis + +++

DDDs 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

Hospital vs Funder

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.

30%

reduction in

antibiotic

overuse

Optimal

antibiotic

use in 80%

of patients

receiving AB

AIMS 10 DRIVERS CHANGE

CONCEPTS

CAUTI bundle

SSI bundle

CLABSI bundle

VAP bundle

Antibiotic form

Clinical

pharmacist

review

Path lab hotline

Periodic review for

cessation, route,

reason for treatment

Prescriber access to

knowledge and data

Cost reports

Prompt initiation, for

defined reasons

Stable /

decreased

antibiotic

resistance

Resistance

reports

Prevention of

hospital-acquired

infection

*Prevent SSI,

CLABSI, VAP and

CAUTI

INTERVENTION

Day 3 and Day

7 review

Separate AB

prescribing

from other Rx

Info on how to Rx

Info on what it costs

↑ availability of

first dose

Antibiotic ward

stock

AB Bundles

*Interventions already associated with the BCA

campaign

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. Treatment not prophylaxis

2. State antibiotic indication or stop

3. Culture(s) ordered or done

4. 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:1. Treatment not prophylaxis

2. State antibiotic indication or stop

3. Culture(s) ordered or done

4. Reassess drug choice

% overall compliance with

Day 7 Bundle for the first

antibiotic prescribed during

hospital course

% 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

Agenda

• Context

• Purpose

• Methodology

• Examples

• Conclusions

Prolonged Therapy 2009 2010

Therapy > 7 days (7 DDDs)

Therapy >14 days (14 DDDs)

6.1%

1.6%

6.2%

1.5%

BCA Antibiotic Utilization Measures

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

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

http://www.whocc.no/atcddd/

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

Agent 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%

Total 1,039,000 100%

Top 10 Antibiotics: DDD

Top 10 highest cost

antibiotics

Concurrent Agents 2009 2010

≥4 concurrent agents 0.8% 1.2%

≥ 2 gram negative agents

≥ 2 gram positive agents

≥ 2 antifungals

0.65%

0.07%

0.12%

0.71%

0.10%

0.14%

BCA Antibiotic Utilization Measures

n = 161 Hospitals

BCA Antibiotic Utilization Measures

Microbiology specimens: 2009 2010

All antibiotic events

- Before initiation of antibiotic

- After initiation of antibiotic

No specimen

30.4%

23.2%

7.1%

69.6%

31.4%

24.0%

7.4%

68.6%

n = 161 Hospitals

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

= prophylaxis?

*Cefepime, imipenem, meropenem, ertapenem, linezolid,

teicoplanin, vancomycin, voriconazole, caspofungin

BCA Antibiotic Utilization Measures

2009 2010

Inappropriate surgical prophylaxis* 1.7% 1.7%

n = 161 Hospitals

??

Burden of Health Care Infection

Estimating Hospital-Acquired Infection

2

2

2

2

2

= HAI

Day 0

Day 0

Day 0

Day 0

Day 0

= HAI

2Day 0

Estimating HAI Rates

Suspected HAI

(across all admissions)

Incidence 2009

Incidence 2010

All admissions

“Clean” surgical procedures

ICU admissions

1.4%

1.5%

7.9%

1.5%

1.7%

7.9%

n = 161 Hospitals

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

0

20

40

60

80

100

120

140

160

5805988 - Garden City Clinic

5808502 -Linksfield Park

Clinic

5808138 - Unitas Hospital

5808510 -Olivedale Clinic

5808588 - Linmed Hospital

5805090 - Milpark Hospital

5808111 -Krugersdorp

Private Hospital

5808227 -Sunward Park

Hospital

5808855 - Pretoria East Private

Hospital

5808413 -Sunninghill

Nursing Home

Inci

de

nce

Ev

en

t co

un

t

By Hospital

Event count 2009

Event count 2010

Incidence 2009

Incidence 2010

Comparing Hospitals

DDD >= 14 by hospital

“Clean” Procedures

• CABG

• Caesarean section

• Craniotomy

• Colorectal procedures

• Head and neck procedures

• Hysterectomy

• Knee and hip procedures

• Vascular procedures

• Ventricular shunts

2009 2010 Change

Events 5,255 4,979 -5.3%

Incidence 35.2% 33.3% -5.4%

Clean procedures with > 2DDDs

n = 60 Hospitals

Kidney & Urinary tract

2009 2010 Change

Paid / event R814 R947 16.4%

DDD / event 4.49 4.77 6.4%

Digestive system

2009 2010 Change

Paid / event R 924 R 1,077 16.5%

DDD / event 4.93 5.21 5.5%

Ear, nose and throat

2009 2010 Change

R253 R274 8.0%

3.40 3.40 0.2%

Musculoskeletal system

2009 2010 Change

R601 R654 8.7%

2.91 3.02 3.7%

Respiratory System

2009 2010 Change

Paid / event R 1,558 R 1,958 25.6%

DDD / event 8.71 9.43 8.3%

Cost / DDD’s by MDC

SEP increase = 7.4%

Case-Mix Adjustment

2009 2010 Change

CMA

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%

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 – 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.

Case-Mix: Diagnosis Related Groups

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

All group antibiotic incidence for tonsil and adenoid procedures

= 25.8%

Hospital Events with

antibiotics

Events Incidence Incidence case mix adjusted

(all DRGs)

Hospital A 3,071 6,046 50.8% 50.9%

Hospital B 86 923 9.3% 12.4%

Hospital Events with

antibiotics

Events Incidence

Dr R at Hospital A 20 52 38.5%

Dr R at Hospital B 2 41 4.9%

Hospital A: acute hospital

Hospital B: day clinic

In Hospital A:

12 admissions “prophylaxis”: 5 ceftriaxone, 7 amoxicillin

12 admissions “treatment”: amoxicillin

Agenda

• Context

• Purpose

• Methodology

• Examples

• Conclusions

Conclusions

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 Hospital-

acquired 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

& Next Steps