Published in the June 2012 issue of Today’s Hospitalist
IN AN ERA OF RAZOR-THIN PROFIT MARGINS and growing antibiotic resistance, you’d think that a stewardship program that slashed costs without jeopardizing outcomes would be a sure thing. But in a cautionary tale out of Baltimore’s University of Maryland Medical Center, an antimicrobial monitoring program that had been a resounding success was dismantled in favor of providing automatic infectious disease consults instead.
When the stewardship program was shut down, the results were swift and unsettling. While the program had cut the hospital’s antibiotic costs by 45%, those costs jumped 32% within two years after the program was discontinued. (A cost analysis appeared in the April 2012 issue of Infection Control and Hospital Epidemiology.)
Harold Standiford, MD, led the design of the original program when he was the center’s medical director for infection control and now helps staff a modified initiative that the center has again put in place. For him, those cost swings are an object lesson in the need for central oversight.
“You need someone guiding a program to make specific policies that everybody concerned can develop and buy into,” Dr. Standiford says. “You also need someone or some team providing a daily overview to pick up aberrances. It has to be real, day-to-day monitoring and education.”
Preauthorizations and education
The medical center launched its stewardship program in 2001 to curb both growing resistance and rising costs.
The monitoring team consisted of an infectious disease physician who first devoted 25%, then 50%, of his clinical time to the program, as well as an infectious disease-trained pharmacist who worked on the program almost full time. The program conducted a real-time (and computer-assisted) review of all orders made throughout the medical center, with an emphasis on orders for restricted antimicrobials. Those included expensive medications, therapies with developing resistance, and broad-spectrum or potentially toxic drugs.
Doctors who wanted to order restricted antimicrobials had to first page an infectious disease fellow. That fellow worked with the stewardship team to decide whether to give preauthorization to the ordering physician. Part of the program’s value, according to Dr. Standiford, was to intervene on unnecessary or duplicative orders, and to educate clinicians about more appropriate or cost-effective therapies.
When the program was initiated, team members set a three-year goal of saving between 10% and 20% in antimicrobial costs. That would translate to between $600,000 and $1,200,000.
But when the program tallied its savings for its first three years, the total came to $3 million, with no increase in the center’s length of stay or mortality or readmission rates.
Where savings came from
The biggest area of initial savings, Dr. Standiford points out, was in antifungals, particularly those used in the cancer center. In three years, the monitoring team cut antifungal spending by 61%, a $2.25 million reduction.
At the time, they were using a drug that was very expensive: an amphotericin B derivative,” Dr. Standiford explains. “By developing a policy, we were able to switch them to a much more reasonable derivative.”
The program also snagged what he calls “low-hanging fruit.” Team members made sure that patients were switched from IV to PO medications as soon as they could safely do so (for a one-year savings of $170,000), and they eliminated unnecessary double coverage. One of the most common errors in that category had to do with piperacillin tazobactam.
“Many physicians didn’t realize it had anaerobic activity, so they would use another anaerobic drug on top of it,” Dr. Standiford notes. “Metronidazole happened to be a favorite.”
Doctors also tended to double up on gram-positive coverage. The stewardship team also cut costs by ensuring that antimicrobial therapy was stopped after five days, Dr. Standiford says, “when there weren’t positive cultures showing you needed it.”
The program maintained its level of savings for seven years. But in 2008, the medical center and its staff opted to dismantle the program and end the preauthorization policy for restricted antimicrobials. Instead, doctors ordering those drugs had to have an associated, automatic infectious disease consult, usually by the following day.
Why fix what wasn’t broken? According to Dr. Standiford, “People don’t necessarily like preauthorization. They didn’t like calling up to get approval for restricted drugs.”
But a big factor in the program’s demise was “the philosophy that infectious disease physicians are the experts, and that having them see all patients on restricted drugs would be a stewardship program in itself.” An additional team, the thinking went, would be superfluous.
That rationale, Dr. Standiford admits, proved almost immediately wrong, as costs rose $2 million over the next two years. While antifungal savings held steady, spending on antibacterials shot up. Within two years, spending on daptomycin had more than tripled, while costs related to vancomycin had more than doubled.
“Throwing money away”
What went wrong? For one, says Dr. Standiford, a dedicated team monitoring all antimicrobial orders had a big-picture view that individual physicians providing specialty care in different parts of the medical center may not have.
And it became apparent that “infectious disease physicians are not necessarily trained well in stewardship,” he notes. “They’re not trained to look at cost-effectiveness or the effect of using specific drugs on a hospital unit.” Clinical pharmacists, he adds, are often much better trained in that regard.
Ending the stewardship program also meant the demise of more uniform, standardized prescribing throughout the medical center.
“You don’t need a Cadillac for all the various indications,” Dr. Standiford says, pointing to the rise in unnecessary orders for expensive antibiotics such as daptomycin. And while “linezolid is a superb antibiotic against staphylococcus and is very good in ventilator-associated pneumonia due to MRSA, most patients don’t have MRSA pneumonia. It tends to be used many times when it’s not necessary, so you’re just throwing money away.”
Bringing the program back
The fix was bringing the stewardship program back in modified form. Since last September, a part-time infectious disease specialist and an infectious disease-trained pharmacist are again helping set prescribing guidelines. They’re also reviewing all antimicrobial orders, particularly for restricted therapies. And any order for a restricted antimicrobial now triggers an infectious disease consult “a process that Dr. Standiford calls “the best of both worlds.”
He acknowledges that he has access to resources “for the monitoring team and computer decision-support “that many hospitals do not have. At the same time, he’s sure that a community hospitalist with an interest in antimicrobials and a hospital willing to bankroll some clinical time for stewardship would make a big difference, particularly when combined with an interested part-time clinical pharmacist.
“The hospital would get that investment back,” Dr. Standiford points out. The primary reason for such a program is not to save money, he notes, but to “prevent adverse reactions, resistance and C. difficile infections.”
But savings are an added benefit. “In times when hospitals have to make decisions on where to put their money,” he notes, “antimicrobial stewardship with a monitoring team would be a good one.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.