Reducing Infectious Diseases Readmissions - How It Is Done

Infectious Disease readmissions are a major problem for healthcare systems.   With the increased scrutiny for readmissions anything a healthsystem can do to reduce readmissions for infection problems is of great interest.  Of particular note pneumonia is the number 1 cause of readmission to hospitals.  Septicemia is the 5th most common but represents the most costly cause of readmission.

There has been a lot of emphasis on cardiovascular diseases as a cause for readmission with a lot of successful efforts to limit those through outreach to the venues of care after hospitalization whether in the home or the skilled nursing facility to implement processes that address reasons for readmission - medication management and timely follow up among the most important.  

There is less standardization for action designed to reduce readmission for infection.  In part this is related to the absence of an accountability formula for a physician  responsible for evaluation of risks and predispositions to infection.   It is also related to the absence of a coordinated process of care for early identification and management of infection related illness to prevent re-admission and keep people safe. Furthermore, infections after a recent hospitalization can be very random making prediction hard.  Since infections are not organ specific these issues can only be addressed and lead by an infectious disease clinician skilled in these concepts.   In the absence of this leadership any program put in place to address this concern runs the risks of over-utilization of tests and antimicrobial medications with the attendant costs and complications this brings.  Most notable are the concerns for multi-drug resistant organism infections and Clostridium difficile infection.  

A well coordinated plan to address infectious diseases diagnosis as a cause for readmission can be readily implemented in a skilled nursing facility by an infectious diseases physician led team at the facility which develops a global process to address this concern.   The process starts with a risk stratification to identify those individuals with the highest risk for the most common infectious diseases readmission causes.   For example, people with recent strokes or other central nervous system disorders that run the risk for pneumonia.   Individuals with multiple comorbidities who received prior antibiotic therapy and now have risk for Clostridium difficile.  Patients admitted from a hospital where they had a prolonged time with a foley catheter putting them at risk for a urinary tract infection, and possibly even septicemia because of urine retention.   Patients with a prolonged hospital stay with multiple indwelling intravenous lines maybe a greater risk for bacteremia.   Patients with newly placed devices such as pacemakers, defibrillators, prosthetic joints and other devices are at risk for surgical site infections.  

Staff education for early signs and symptoms of infection with prompt engagement of the infection treatment team to provide proper guidance is the next important key point.    Proper culture, proper testing and proper use of early interventions to treat the most likely problems will limit the chance of deterioration to a the point of needing admission and reduce complications from over testing or over treating.  Use of point of care testing to properly assess risk can be an important part of this management.

With these steps SNF can reduce their readmissions to their partner hospitals.  

Antibiotics Can Be Dangerous and Costly

Today the CDC released a report on their web site on the overuse of antibiotics and the dangers that poses.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0304a1.htm?s_cid=mm63e0304a1_w.  The infectious disease community has been aware of this problem for decades but has been unable to mobilize systemic action to address it because of the perception that generally antibiotic therapy is safe, relatively inexpensive, easy to prescribe, and critically important to save lives to be administered early.  With the CDC's announcement, the ongoing focus on patient safety and cost of healthcare,  and the additional funding by the federal government to address the concern also announced today, we the infectious diseases community are poised to deal with this issue. Lets briefly review the misperceptions

First antibiotics are generally safe.   Although broadly speaking and at first blush this appears to be true. The report by the CDC points out that one particularly bad complication of antibiotic therapy, Clostridium difficile, is epidemic in our country with over 250,000 cases developing in US hospitals, associated with up to 14,000 deaths and nearly $9 billion in excess costs.   Since most cases of Clostridium difficile are antibiotic associated they are not so safe for those people getting them.

Second although many antibiotics now in use in hospitals are generic and so the direct cost of antibiotic therapy has dropped, it is the indirect costs or downstream cost of the complications that we are concerned about.  Clostridium difficile is one striking example of the downstream cost of antibiotic therapy incorrectly used.   Another highlighted by the CDC is the impact of antimicrobial therapy on the development of "superbugs" bacteria resistant to all antibiotics.    This problem is part of the natural selection process that occurs in hospitals where antibiotics are overused.   When these superbugs cause infection patients are isolated costing more to provide care, they have limited or no options for treatment costing lives, and act as a vector for transmission to others costing even more.   These are not inexpensive therapies but indeed rather costly treatments when these downstream costs are included.

Unlike cancer chemotherapy, antibiotics are prescribed by clinicians with all types of training.  Indeed you can get antibiotics over the counter in many countries outside the US without a prescription.  Here in the US some antibiotics have been available at no cost in some of the large national pharmacies.  So indeed antibiotics have been easy to prescribe.  However it is not the prescribing we should be worried about.  It is the diagnosing we need to understand and here is the rub.   Many patients are given antibiotics for conditions that do not require antibiotic therapy.  The report highlights that more than 50% of hospitalized patients receive an antibiotic during their stay.  More than 1/3 receive them unnecessarily.   How many people get antibiotics for colds or flu, the majority of which are viral infections that do not require antibiotic therapy.   In the hospital the challenges are the use of antibiotics for too long a time period, for infections that do not require antibiotics, for conditions that are not infections, and the use of "broad spectrum" antibiotics when a more focused treatment would be appropriate.  These examples are more about making and understanding the right diagnosis to provide the right care which is not easy.

My last point, antibiotic treatment early in the setting of serious infection is important to saving lives underlies a lot of the concern of clinicians in over prescribing.   This critical and very true point again emphasizes the problem of the right diagnosis or circumstance to using antibiotics.  Many patients are continued on antibiotic therapy for no good reason simply because a patient appears improved, a major problem outlined in the report.  This pattern is borne from the uncertainty of a diagnosis, the uncertainty of risk to patient from infection and lack of recognition of risk from this approach - collectively all as a result of the unclear diagnosis.  A clinician skilled in diagnosis and consequences of serious infection will know what to start, how long to treat, and when to stop antibiotics treatment safely.

What are we to do?  The CDC has outlined a number of steps toward improving antibiotic use in hospitals, an Antibiotic Stewardship checklist.   It provides a roadmap toward improving use of antimicrobial therapy.   http://www.cdc.gov/getsmart/healthcare/implementation/checklist.html.  The top line items incorporated include senior leadership, clinical leadership, pharmacy leadership and appropriate team members.   All are critically important to the success but of absolute certainty is the role of the infectious disease clinician as the clinical leader on this team for the reasons I mentioned.  Now is the time for the leadership of the ID clinicians   We are the ones best able to create clarity from the uncertainties mentioned above. 

Infectious Disease Doctors Bring Value to Health Systems

How can the infectious diseases physician participate in the healthcare delivery and payment reform changes that are occurring?  I will be speaking on this topic as it relates to healthsystems and the ID Clinician at the Beckers 5th Annual Hospital Conference in Chicago on May 17.    I will be emphasizing the "product line" we bring to health systems and how using your ID Clinicians to effectively manage and lead that product line will add real value to a health system.  

The products the ID Service line include clinical care, antimicrobial stewardship, infection prevention, microbiology laboratory oversight, employee health and resource management.   Effectively managing and leading the services will provide solutions for systems in important areas of care including quality, cost, outcomes, readmission and rescue.

The ID Clinician has been undervalued in our healthcare system because typically the greatest value was given to those who admitted and brought cases to a hospital or health system.  Those clinicians who limited hospitalization, reduced cost, and reduced risk were not seen as providing value in a service driven business model.  As the model changes toward value, we the ID Clinicians, need to lead this change.