Pharmacy Benefits Management Services Antimicrobial Stewardship: Role of IT Solutions Melinda Neuhauser, PharmD, MPH Richard Pham, PharmD STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 1 Objectives 1) Describe the importance of antimicrobial stewardship in this era of multi-drug resistant pathogens. 2) Identify key data elements for building tools and reports for antimicrobial stewardship programs. 3) Demonstrate a query approach for creating an antimicrobial usage metric report. What is ABX Stewardship? Definition: Optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance A multi-faceted approach to influence antimicrobial prescribing, institution-wide to improve outcomes, prevent resistance and minimize excessive costs IDSA Guidelines. Clin Infect Dis 2007;44:159 Resistance Active Agents Why do I care? # Antibiotics Approved The antibiotic pipeline is nearly dry 18 16 14 12 10 8 6 4 2 0 Adapted from Clin Infect Dis. 2011;52:S397-S428 Why do I care? http://www.idsociety.org/10x20.htm Bad Bugs, No Drugs: No ESKAPE! Enterococcus faecium Staphylococcus aureus Klebsiella pneumoniae Acinetobacter baumanii Pseudomonas aeruginosa Enterobacter species L. Rice, JID 2008;197:1079–1081 How did we get here? • 50% of use in hospitals is inappropriate • Antibiotic misuse adversely impacts patients – Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD). – Getting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism. http://www.cdc.gov/getsmart/healthcare/ Improving antibiotic use is a public health imperative • • • Using antibiotics properly is analogous to developing and maintaining good roads Bringing new antibiotics into our current environment is akin to buying a new car because you hit a pot hole, but doing nothing to fix the road. Fixing the “antibiotic use road” is part of the mission of public health. SNAPSHOT OF VA ABX Stewardship Programs • Many of the facilities have active stewardship programs • Most do not have an electronic tool to aid them in stewardship activities • Field requests…. – Reports for positive microbiology results – Drug-bug mismatch – Antimicrobial usage measurements VA National Antimicrobial Stewardship Taskforce Purpose: • Optimize the care of Veterans by developing, deploying and monitoring a national-level strategic plan for improvements in antimicrobial therapy management • Co-Chairs: – Infectious Diseases Program Office and PBM • Members: – Broad multi-disciplinary representation Committee Objectives • Most important for this audience…. – Develop a coordinated plan to leverage clinical information tools that support patient care and performance measurement IT Specialist Microbiologist ABX Stewardship Team: Core Members ID MD and Pharmacist Epidemiologist Hospital Admin IDSA Guidelines. Clin Infect Dis 2007;44:159 Draft Subcommittees • Survey • Antimicrobial Tools and Resources – Creation of SharePoint for Best Practices • Metrics • Implementation Stewardship Activities • Formulary restriction and preauthorization • Prospective audit with intervention and feedback • Supplemental activities – – – – – Guidelines and clinical pathways Streamlining or de-escalation of therapy Dose optimization Conversion from parenteral to oral therapy Education IDSA Guidelines. Clin Infect Dis 2007;44:159 Tools for Interventions Identification of Inpatients on Antimicrobials Microbiology Duration of Therapy Positive cultures w/sterile body fluids (blood, etc) Extended Therapy Bug-drug mismatches Switch IV to oral Positive micro results Dosing/Levels Appropriate dosing/serum levels Tools for Interventions Identification of Inpatients on Antimicrobials and Indication as part of provider order Empiric vs Definitive Drop-down of infection types Tools for Managing Program Measurements Antimicrobial Use Benchmarking Ratio of IV to oral therapy Antimicrobial Resistance Other Benchmarking Duration of antibiotic-specific therapy linked with/indication Switch IV to oral Compliance of empiric therapy w/guidelines Outcomes of C. difficle & interventions Proposed Antibiotic Use Metrics • The first metrics proposed by Antibiotic Stewardship are in the lines of information gathering – Antibiotic Use (AU) – Antibiotic Resistance (AR) Problem – We Have Little Idea of What Data Are Available • We do not know what our usage is! • We have no minimum dataset • Our data is a mess • I’m going to show you WHAT kind a mess this is… STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 20 Questions That We Always Need To Know To Make A Metric • What are we measuring? • Why are we measuring it? What outcome are we trying to prevent? • What group are we interested in measuring? • What characteristic in the group are we measuring? • How is this evaluated? Healthcare Research Patient Personnel Safety Safety Biovigilance and Development CDC Benchmarking Tools Antimicrobial Use & Resistance (AUR) Option Antimicrobial Use Option Antimicrobial Resistance Option Antimicrobial Use Option Objective Measure antimicrobial usage to provide riskadjusted inter- and intra-facility comparisons Antimicrobial Metric Antimicrobial days / Days present by month, patient location Data Source eMAR / BCMA Implementation Partner with commercial infection surveillance systems and electronic health record vendors to electronically capture numerator and denominator for importation into NHSN Antimicrobial Usage Measurement Antimicrobial Days Days Present = Metric Example Data Elements in Report Time Period August 2011 Location Adult Medical Intensive Care Unit Denominator X Days Present Numerators X Amikacin Days X Amoxicillin Days X Amoxicillin/clavulanate X Amphotericin B etc Example: Risk-adjusted (MICU) Benchmarking Output Antimicrobial Classes Aminoglycosides Facility-MICU AU Rate: 220 Pooled Mean 180 Percentile Anti-MRSA Agents 480 300 93% Carbapenems 450 320 85% Fluoroquinolones 380 290 89% 60% AU Metric: Antimicrobial days/1000 days present Data for Example Only Preliminary Numbers for Region I (VISN 1922) – FY 2011 (Rounded to Nearest 1000) VISN Numerator Denominator 19 5,000 62,000 20 11,000 126,000 21 18,000 103,000 22 21,000 162,000 Defining A Population • We need the number of hospital days a facility has for exposure • We get this from the Patient Treatment File (45) • Why do we need exposure days? – Sample representation – Different types of unit exposure • What is an exposure unit? – This is hard to tell Talking About PTF STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 30 Talking About Inpatient Pharmacy • Dispense Files – Unit Dose (UD) – Intravenous (IV) • Administration File – BCMA STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 31 Lesson Learned – Do Not Use Dispense Files! • Incomplete – Automation – PRN dosing (UD) – IMO • Not necessarily administered STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 32 Ward Location STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 33 BCMA BCMA STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 34 BCMA - IV STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 35 BCMA – Dispensed Drug STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 36 Defining A Group • What constitutes an antibiotic day? – Any exposure to antibiotics during that time period • This is hard to calculate – Needs to be taken from BCMA – Not IV – Not UD – Not Billed Antimicrobial Days Definition: Sum of the calendar days on which each antimicrobial was administered Medical Ward Monday December 28 Meropenem 1gm IV every 8 hours Given: 2300 Amikacin 1gm IV every 24 hours Given: 2300 Tuesday December 29 Given: 0700 Given: 1500 Given: 2300 Wednesday December 30 Given: 0700 Given: 2300 Schwartz D et al. SHEA Abstract #2466, Atlanta 2010. Preliminary Numbers for Regions I and II (VISN 19-22) – FY 2011 (Rounded to Nearest 1000) VISN Numerator Denominator 19 5,000 62,000 20 11,000 126,000 21 18,000 103,000 22 21,000 162,000 Problems That We Need Help • Untangling BCMA – Unable to Scan – Variance • Untangling Location – Census of locations • Working with local formularies STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 40 Problems With The Calculation • Hospital Location – No clear identifier what is an inpatient bed by NHSN criteria • Bed hopping – Patient Movement is nearly impossible to figure out a straight answer to where people are • Meaningfulness – Even if I know these numbers for antimicrobial use, what do I do about them? Days Present Definition: Aggregate number of patients housed to a patient care location anytime throughout a day during a calendar month Modification of “Patient Days” denominator utilized in other NHSN Modules Micro – The Next Domain STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 43 Application of Benchmarking Data • Does not assess appropriateness of use • Tool for stewardship program – Quality improvement efforts – Aggregate reports of patient care locations and facility usage Role of IT Solutions • Short-term goals include locally created – Fileman Reports – Electronic Templates for CPRS • Potential long-term solutions may include – National Reports available via CDW – Infection Control Surveillance Vendors – Validation critical before national roll-out! Conclusions • IT solutions are essential for antimicrobial stewardship programs to promote the appropriate and safe use of antimicrobials • Please contact me directly for – Volunteering in subcommittee – Sharing data tools or ideas! [email protected] Questions? The views expressed in this presentation reflect those of the author, and not necessarily those of the Department of Veterans Affairs or Centers for Disease STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION 47 Control and Prevention.