The Daily Briefing's Aly Seidel sat down with Sarah O'Hara, a senior consultant with the Medical Group Strategy Council, to discuss how resource-strapped providers can implement a successful antimicrobial stewardship program.
Question: CDC estimates that up to 50 percent of antimicrobial use in the United States is inappropriate or unnecessary. What kind of real-world effects does that have on the health care system?
Sarah O'Hara: It's well accepted in the health care community that overuse of antimicrobials leads to antibacterial resistance—which, in turn, kills patients and raises costs.
Antibiotic-resistant bacteria infect two million people annually, killing an estimated 23,000 patients per year, and costing the health care system as much as $20 billion.
The more we use these antibiotics, the less useful they are. I agree with a recent JAMA commentary: Antibiotics are basically a social good, and we need to protect them like a social good and begin to educate providers around that idea.
Q: So, where do hospitals start?
O'Hara: Hospitals can start by cutting inappropriate and unnecessary use through antibiotic stewardship programs (ASPs), which focus on making sure the hospital uses antibiotics appropriately.
It's worth nothing that stewardship is not about giving up antibiotics. It's about making sure you're using them the right way.
For example, sepsis can progress very quickly. A patient could go from just being diagnosed but relatively healthy to dead in a very short period of time. If doctors don't know what's causing the infection, the guidance states that they should start with broad-spectrum antibiotics that can kill off a lot of bacteria. Most hospitals do that.
But once the cultures come back from the lab and clinicians know what they're dealing with, they should downshift to a narrower drug if they can—and do so as soon as possible. That doesn't always happen.
The more that we use these big-gun, broad-spectrum drugs, the more we're going to run into problems. We want to make sure we're conserving them.
So it's not about saying, "Don't use these broad-spectrum antibiotics." It's about saying, "We're using these antibiotics for now, and the minute we get those cultures back, let's look and reassess what antibiotic the patient should be on."
Q: CMS has mentioned some potential regulations that would require hospitals to have an ASP. Can you talk about that?
O'Hara: Potential is the key word here. CMS has said it's going to propose that all hospitals be required to have an ASP by 2017 in order to participate in Medicare. But it has not come out with a formal proposal—so we don't know what the requirements of that program would be, or if it's even still on CMS's agenda.
And when you look at what our members are doing, many of them already have these antibiotic stewardship programs. Eighty-one percent have created an antibiotic stewardship program already. Of course, some are more robust than others, but most providers are doing something.
Q: Without these regulatory guidelines, what can providers do to bolster their ASPs?
O'Hara: In our research, we found a few elements a basic ASP should have that should be fairly easy to implement, regardless of your resources.
First, if you're going to do anything, have a process to review new antibiotics to make sure it is appropriate to add them to the formulary.
Second, you should absolutely have an ASP leadership team. It should include a pharmacy leader to oversee the day to day aspects of stewardship and at least one physician champion to support that person. While ideally, the champions would be infectious disease doctors, they don't have to be. In our research, we spoke to members who have used hospitalists, intensivists—we've heard people say that any physician who cares about this could be a champion, even a cardiologist who is passionate about infectious diseases!
All of this is about basic de-escalation of antibiotic use. Figure out where you have clear opportunities for intervention. Look at your own data and develop your policy in conjunction with your physicians.
Q: What are hospitals seeing after they gather that information?
O'Hara: After looking at the data, you're likely to find pockets of just plain overuse that can't be explained for clinical reasons and represent opportunities to intervene.
For instance, you might see that everyone on your surgery staff happens to use a particular antibiotic that might be unnecessary. Ask yourself: Is the usage consistent with clinical literature, or are providers just set in their ways? Look for those opportunities to figure out where you might have unnecessary utilization.
Physician education is another big piece of this. Sometimes, it's just that doctors have been practicing a certain way, that's how they do it, and you need to get them thinking about different practice protocols..
Q: That's a good point: Sometimes entrenched practices aren't the best practices. How can you start to engage physicians in practice change?
O'Hara: Some of that is through individual interventions. We've talked to a lot of programs that have a pharmacy team that reviews the prescription of a certain number of antibiotics each day to see how they're being used. They'll actually go and talk to the physician if they think something else would be more appropriate. That level of intervention—generally educating physicians about why you're suggesting a change and why it's important— is not terribly difficult for people to implement.
As part of that, you need to be respectful in how you are talking to physicians. You want to involve physicians in making that change, and that's part of why you need a physician champion: You need to ensure you have somebody at the table who can engage physicians in the question, "Is there a better way for us to be doing this?"
This really doesn't require many resources: You don't necessary need to have a huge tech force or a huge number of physicians who can support this. It does take some staff and physician time, but these are largely things that you can be doing with the resources you already have.
Q: You mention that these interventions aren't too costly. Why, then, are some hospitals not implementing them?
O'Hara: Part of the problem is simply that getting serious about stewardship requires changes in "business as usual." Making those changes will require commitment and support from senior leadership to seize the opportunity. Senior leadership needs to be okay with the idea that the organization is going to be dedicating some pharmacy time and talking to physicians about combating antibiotic resistance.
In other cases, hospitals may fear they don’t have adequate resources for stewardship. A lot of the guidance on how to start an ASP, from places like the CDC, is intended for programs at larger hospitals.
For example, CDC recommends that an ASP program, ideally, have a doctor with training in infectious diseases as its leader. But a lot of smaller hospitals may not have any infectious disease doctors on staff, or have just one or two—and those guys are busy!
Smaller hospitals are also more likely to have less access to IT. They may not have adequate resources to collect data and invest in technologies that, for instance, automatically flag opportunities to deescalate antibiotic use.
As we’ve talked about already, in actuality, we see hospitals engage other types of physicians to champion the ASP, and they can accomplish a lot even without advanced technology. But hospitals may initially not realize that stewardship can be started without a lot of resources.
Q: What do you think the future holds? Can stewardship help stave off antibiotic resistance?
O'Hara: In the past, there hasn't been as much urgency around stewardship, and I think CMS and the White House are trying to change that. Everyone knows it's a problem, but it's one of those things that you don't necessarily see right in front of you on a day-to-day basis.
But now, providers are paying attention and realizing they are the ones who need to deal with it—and stewardship programs are one of those first steps.