Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veterans Affairs Medical Center from 1987 to 1989

PURPOSE: Controlling inappropriate antibiotic usage is a major focus for hospital quality assurance and cost-containment programs. We assessed the impact of strengthening a parenteral antibiotic control policy and instituting continuous infectious disease service (IDS) reviews of the appropriateness of antimicrobial therapy on cost and patient outcomes. PATIENTS AND METHODS: All patients receiving intravenous antibiotics during a 3.5-year period from 1986 to 1989 were included in either the pre- or post-policy study group. Antibiotic costs 16 months before were compared with antibiotic costs 26 months after implementation of a new policy to restrict inappropriate usage of (1) broad-spectrum antibiotics when not necessary, (2) expensive agents when a less costly agent could be used, and (3) an excessive dosage or interval. Patient subgroups treated 4 months before and 4 months after policy implementation were compared further within diagnosis-related group (DRG) assignments using patient demographic, cost, and outcome measures. RESULTS: The average monthly antibiotic costs during the 26-month post-policy period were $7,600 less than during the 16-month pre-policy period (p less than 0.0001), resulting in an average yearly drug cost reduction of $91,200. The IDS team altered therapy in 611 (34.5%) of 1,769 reviews of antibiotic usage during the 26-month period. The comparisons among similar patient groups by DRG classification revealed the average number of antibiotic doses per study patient admission was decreased 24% (p = 0.005) and drug costs were reduced 32% (p = 0.004) after policy implementation. In two DRG categories (i.e., respiratory infections plus pneumonia), patients in the post-policy group had a 33% decrease in average number of doses (p = 0.05) and 45% decrease in antibiotic costs (p = 0.04) compared with the pre-policy group. Similar trends were observed in most DRG categories. There was an average $70 per admission decrease in drug cost and a reduction of eight antibiotic doses per admission after policy initiation. The overall prevalence of deaths (p = 0.22) and average length of antibiotic therapy (p = 0.29) were less in the post-policy period despite group similarities in patient characteristics and lengths of hospital stay. CONCLUSION: Antibiotic control policies can be developed to ensure quality care and can be designed to select for cost-effective agents. Prospective and continuous monitoring of antibiotic usage by the IDS resulted in a significant and sustained reduction in antibiotic costs without detrimental effect on the length of therapy or deaths.     

Results of a Local Antibiotic Management Program on Antibiotic Use in a Tertiary Intensive Care Unit in Hungary

Background  Massive antibiotic use in intensive care units (ICU) is associated with increased microbial resistance. Therefore avoiding unneccesary antibiotic usage is essential. To achieve a more considered antibiotic prescribing practice, a new antibiotic policy was implemented at our ICU. In this paper, we evaluated the impact of this intervention, and described the aetiology and incidence of blood stream infections and selected antibiotic-resistant pathogens. Materials and Methods  In November 2002, a local antibiotic management program (LAMP) was implemented. This included a new infectious diseases specialist consultation service and restricted authorisation to prescribe antibiotics. The effect on ward-level antibiotic use was examined by segmented regression analysis. Patient, ICU and microbiology data were also recorded and compared before and after policy implementation. Results  The patient populations and the subsequent mortality rate were comparable before and after the implementation of the policy. Total antibiotic consumption was markedly reduced from 162.9 to 101.3 defined daily dose (DDD) per 100 patients, and per day (DDD per 100 patient-days). This was mainly accounted for a reduction in the use of quinolones, aminoglycosides, glycopeptides, metronidazol, carbepenems and third generation cephalosporins. Conclusion  This study has confirmed that establishing a targeted LAMP, based on close co-operation between intensive care physicians and infectious disease specialists together with a restricted prescribing authority, can reduce the use of antibiotics.     

Incidence and clinical significance of reactive thrombocytosis in children aged 1 to 24 months, hospitalized for community-acquired infections

The aims of this study were to identify demographic, clinical and laboratory characteristics associated with reactive thrombocytosis useful for clinical management and to evaluate potential complications of this condition in a cohort of children selected for they young age as at high risk of reactive thrombocytosis. Retrospective analysis of medical records of 239 children among 902 aged 1-24 months, hospitalized during a 12-month period, and discharged with a diagnosis of infectious disease was performed. One hundred and nineteen children out of 239 (49.8%) presented thrombocytosis (>500 platelets x 10(9)/L; normal range 150-499 x 10(9)/L), 81/119 (68%) on admission. The incidences of thrombocytosis or extreme thrombocytosis (>1,000 x 10(9)/L) were 13.2% (119/902) and 0.8% (7/902). Thrombocytotic children had higher counts of white blood cells and had been treated more frequently with steroids (36/82, 43.9% vs. 5/53, 9.4%; p = 5 x 10(-5); relative risk 7.51, 95% confidence intervals 2.71-20.82). No significant difference was found in relation to sex, age, fever, C reactive protein level, diagnoses and antibiotic therapy. Two out of 239 (0.8%) enrolled children, both thrombocytotic and with other acquired risk factors, developed thrombosis. In conclusion, reactive thrombocytosis in children aged 1 up to 24 months is frequent and unrelated to markers of disease activity or degree of inflammation.     

Antibiotic use in patients admitted with acute exacerbations of chronic obstructive pulmonary disease.

The objective of this report was to document the pattern of initial antibiotic prescribing in acute exacerbations of chronic obstructive pulmonary disease (COPD) in a hospital setting. All episodes of acute exacerbation of COPD, as diagnosed by the admitting doctor, in one hospital in the period January to May 1996, were identified. Case notes were reviewed retrospectively. Cases of radiographic pneumonia, bronchiectasis and incorrectly coded admissions were excluded. Symptoms, microbial cultures and initial antibiotic therapies were recorded. One hundred and fifty-nine patient episodes were identified; 40 were excluded yielding a sample of 119. Nineteen case notes were unavailable leaving a sample of 100 (84%) episodes. Eighty were treated with antibiotics on admission; amoxycillin was the most frequently prescribed, in 46 (58%) episodes. Of the antibiotic treated group, 42 (53%) patients were given dual therapy, most commonly a macrolide antibiotic with either amoxycillin or a cephalosporin. Intravenous treatment was used in 22 (28%) cases. The duration of intravenous treatment was >48 h in 12 (15%) cases. A total of 76 sputum samples were analysed from 55 patient episodes: 34 (45%) were culture positive. In 15 (27%) patient episodes, antibiotic therapy was changed or instituted on the basis of culture results. These data suggest that antibiotic treatment is not optimal, with overuse of antibiotics, especially intravenous and dual therapy.     

Immediate outcomes of medical therapy in patients with caseous pneumonia

The immediate outcomes of treatment were studied in 119 patients with caseous pneumonia whose age was 20 to 64 years. In most cases, caseous pneumonia was found to preserve its classic traits by characterizing by acute onset (85.8%), prompt progression, high proportion of fatal outcomes in the early postoperative period (54.1% within 3 early postoperative months). There is an increase in cases of more "benign" course of this form of tuberculosis (subacute onset and prolonged slow progression) at the same time. The use of current methods for combined intensive antibiotic and pathogenetic therapies substantially improves the outcomes in this most severe group of patients, reduces the initiation of a phase of relative stabilization of a specific process and of cessation of bacterial isolation.     

Determinants of Physician Ordering of Preoperative Autologous Donations

Preoperative autologous donation (PAD) is frequently utilized to reduce infectious disease transmission risks, but it is an expensive form of hemotherapy that is not always closely matched with the needs of the patients. We compared the use of PAD in an academic medical center with patient needs and then investigated the efficacy of a simple intervention to promote targeting of PAD toward patients most likely to benefit from having PADs available. Over a 3-month period, surgeons whose patients received allogeneic components were asked to complete a questionnaire designed to identify reasons for not ordering PAD. PAD units were used in 14 (11%) of 124 cases, accounting for 6% of perioperative red cell use. The responses (46, 42% of the surveys sent) stated that PAD had not been ordered because of time constraints (39%), medical problems (26%), anemia (15%), and lack of expectation of blood use (24%). Chart review documented the presence of cited conditions in 88% of cases. Logistic and cost concerns were not evident. However, only 8% of the 176 PAD units collected in that period were transfused. Following dissemination of PAD ordering guidelines, this proportion rose to 52% without a reduction in the proportion of elective surgical cases utilizing autologous transfusion. This improvement in ordering practice was maintained over at least in 5-month period. Thus we were able to improve the efficiency of PAD application (reducing over-ordering) through a simple feedback to surgeons that assisted them in targeting PAD toward patients most likely to need transfusion.     

Cost Reduction after Introduction of a Multidisciplinary Infectious Disease Service at a German University Hospital

Summary Background: In 1997 an infectious disease service (IDS) similar to those in the US was established at a university hospital in Munich, Germany. Patients and Methods: We assessed the economic impact of the new policy by performing a cost comparison analysis. Inpatients with pneumonia, skin infections/cellulitis, urinary tract infections (UTI) and bacteremia/sepsis were assigned to two groups: patients from a 6-month period after the establishment of the IDS (post-IDS group) were compared with similar patients before the implementation of the ID-servide (pre-IDS group). Costs of microbiological investigation (MB), antibiotic treatment (AB), clinical imaging (CI), total costs and length of antibiotic therapy were analyzed. Results: Patients with UTIs in the post IDS-group had 39% fewer MBs (p < 0.05) than patients in the pre-IDS group, resulting in a 33% decrease in average MB costs (p < 0.05). In the total group, in which subgroups with pneumonia, skin infection and UTI were summarized, the post-IDS group had 37% fewer MBs (p < 0.05) resulting in MB cost reductions of 34% (p < 0.05). There were no significant differences in expenditures for AB and CI and in the average length of antibiotic therapy. Conclusion: This study shows that continuous consultation by an IDS does not increase diagnostic and treatment costs, but results in significant cost reductions. Received: March 13, 2000 · Revision accepted: July 28, 2000     

The nature of an infectious disease practice in a community hospital

Populations of patients in community and university-affiliated teaching hospitals differ, and therefore, problems encountered by infectious disease specialists in these two types of hospitals also differ. However, most infectious disease specialists are trained only in university hospitals. In order to characterize the nature of an infectious disease practice in a community hospital, the authors report data for the patients seen during a period of three years (July 1978-June 1981). Most of the 1,238 cases were referred by other physicians. General practitioners referred 35% of the cases, whereas internists, orthopedists, and surgeons referred 20%, 16%, and 10% respectively. Skin and wound infections accounted for the largest percentage of referrals (16%). Fever accounted for 9%, abdominal problems for 6%, and respiratory infections for 6%. Other problems referred to the infectious disease service included infections of the central nervous system, urinary tract infections, osteomyelitis, and arthritis.     

Teaching global public health in the undergraduate liberal arts: a survey of 50 colleges

All diseases diagnosed in a primary healthcare clinic situated in Leogane, Haiti, were recorded prospectively during a 7-month period. Among the patients in this cohort, 2,821 of 6,631 (42.6%) presented with an infectious disease. The three most common syndromes among the patients presenting with infections were respiratory tract infections (33.5%), suspected sexually transmitted diseases--mostly among females with recurrent disease (18.1%)--and skin and soft tissue infections, including multiple cases of tinea capitis (12.8%). Of the 255 patients presenting with undifferentiated fever, 76 (29.8%) were diagnosed with falciparum malaria. Other vector-borne diseases included 13 cases of filariasis and 6 cases of dengue fever. Human immunodeficiency virus infection was diagnosed in 19 patients. Four cases of mumps were detected among unimmunized children. A large proportion of these infections are preventable. Concerted efforts should be made to create large-scale preventive medicine programs for various infectious diseases.     

Occurrence of infectious symptoms in children in day care homes

Transmission of enteric pathogens is facilitated in child day care centers, including family day care homes, by frequent and intimate exposure among susceptible hosts, with diaper changing as the highest-risk procedure for such transmission. The objective of this study was to evaluate the effectiveness of an intervention program in decreasing the incidence of infectious disease symptoms in children attending family day care homes during a 12-month period. Each of 24 family day care homes was randomly assigned to an intervention or control group. The intervention included four components: (1) a handwashing educational program and (2) use of vinyl gloves, (3) use of disposable diaper changing pads, and (4) use of an alcohol-based hand rinse by the day care provider. Symptoms of enteric disease (diarrhea and vomiting) were significantly reduced in intervention family day care homes (p less than or equal to 0.05), whereas respiratory symptoms were not significantly different between intervention and control family day care homes (p = 0.35). Diarrhea was reported in 1 of every 100 child care days, representing one diarrhea episode per month in a typical family day care home.     

A retrospective observational study of people with Type 1 diabetes with self‐reported severe hypoglycaemia reveals high level of ambulance attendance but low levels of therapy change and specialist intervention

Aim

To evaluate the impact of severe hypoglycaemia on NHS resources and overall glycaemic control in adults with Type 1 diabetes.

Methods

An observational, retrospective study of adults (aged ≥ 18 years) with Type 1 diabetes reporting one or more episodes of severe hypoglycaemia during the preceding 24 months in 10 NHS hospital diabetes centres in England and Wales. The primary outcome was healthcare resource utilization associated with severe hypoglycaemia. Secondary outcomes included demographic and clinical characteristics, diabetes control and pathway of care.

Results

Some 140 episodes of severe hypoglycaemia were reported by 85 people during the 2‐year observation period. Ambulances were called in 99 of 140 (71%) episodes and Accident and Emergency attendance occurred in 26 of 140 (19%) episodes, whereas 29 of 140 (21%) episode required no immediate help from healthcare providers. Participants attended a median of 5 (range 0–58) diabetes clinic consultations during the observation period; 13% (70 of 552) of all consultations were severe hypoglycaemia‐related. Of the HbA_1c measurements recorded closest prior to severe hypoglycaemia (n = 119), only 7 of 119 measurements were < 48 mmol/mol (< 6.5%) and mean HbA_1c was 70 (sd 19) mmol/mol (8.5%, sd 1.7%). Some 119 changes to diabetes treatment were recorded during the observation period (median/person 0;, range 0–11), of which 52 of 119 changes (44%) followed severe hypoglycaemic events.

Conclusions

We observed a high level of ambulance service intervention but surprisingly low levels of hypoglycaemia follow‐up, therapy change and specialist intervention in people self‐reporting severe hypoglycaemia. These results suggest there may be important gaps in care pathways for people with Type 1 diabetes self‐reporting severe hypoglycaemia.     

Using e-mail in the management of tuberculosis patients, north-west Russia.

SETTING: Ten health care institutions in north-west Russia. OBJECTIVE: To improve the management of tuberculosis patients using e-mail. DESIGN: Over an 18-month period, all outgoing and incoming e-mails at the Arkhangelsk Regional Tuberculosis Centre were saved and categorised. All e-mails relating to distance learning were logged, and a consensus panel discussed and answered questionnaires regarding 47 e-mail-based second opinions. RESULTS: e-mail was found to speed up communication and increase the availability of specialist advice. Distance learning was positively received, but was used in moderation. For six of 47 consultations (13%), the consensus panel deemed that fast access to a second opinion saved lives. In 30 consultations (64%), the patient was saved a round trip to a specialist centre. In 24 consultations (51%), the panel considered that the patients had started correct treatment between 1 week and 1 month earlier than without e-mail access. In 11 of these consultations, 23% of the total, the patient was found to be infectious. The learning effects of second opinions were recognised. CONCLUSION: General e-mail use and the second opinion service in particular were found to be useful. Further studies are needed to investigate the advantages and disadvantages of using e-mail as a tool in the management of TB.     

Evaluating the Diabetes–Cardiology interface: a glimpse into the diabetes management of cardiology inpatients in western Sydney’s ‘diabetes hotspot’ and the establishment of a novel model of care

Background

Approximately two-thirds of individuals presenting to emergency departments in Western Sydney have glucose dysregulation, accelerating their risk of cardiovascular disease (CVD). We evaluated the prevalence and management of type 2 diabetes (T2D) in cardiology inpatients in Western Sydney. A novel model of care between diabetes and cardiology specialist hospital teams (joint specialist case conferencing, JSCC) is described herein and aimed at aligning clinical services and upskilling both teams in the management of the cardiology inpatient with comorbid T2D.

Methods

Cardiology inpatients at Blacktown-Mount Druitt Hospital were audited during a 1-month period.

Results

233 patients were included, mean age 64?±?16 years, 60% were male, 27% overweight and 35% obese. Known T2D comprised 36% (n?=?84), whereas 6% (n?=?15) had a new diagnosis of T2D, of which none of the latter were referred for inpatient/outpatient diabetes review. Approximately, 27% (n?=?23) and 7% (n?=?6) of known diabetes patients suffered hyper- and hypoglycaemia, respectively, and 51% (n?=?43) had sub-optimally controlled T2D (i.e. HbA1c?>?7.0%); over half (51%, n?=?51) had coronary artery disease. Only two patients were treated with an SGLT2 inhibitor and no patients were on glucagon like peptide-1 receptor analogues. The majority were managed with metformin (62%) and therapies with high hypoglycaemic potential (e.g., sulfonylureas (29%)) and in those patients treated with insulin, premixed insulin was used in the majority of cases (47%).

Conclusions

Undiagnosed T2D is prevalent and neglected in cardiology inpatients. Few patients with comorbid T2D and CVD were managed with therapies of proven cardiac and mortality benefit. Novel models of care may be beneficial in this high-risk group of patients and discussed herein is the establishment of the diabetes-cardiology JSCC service delivery model which has been established at our institution.

     

Effectiveness of an educational program to reduce ventilator-associated pneumonia in a tertiary care center in Thailand: a 4-year study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection-related death and morbidity in intensive care units (ICUs). We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU (MICU). METHODS: A 4-year controlled, prospective, quasi-experimental study was conducted in an MICU, surgical ICU (SICU), and coronary care unit (CCU) for 1 year before the intervention (period 1), 1 year after the intervention (period 2), and 2 follow-up years (period 3). The SICU and CCU served as control ICUs. The educational program involved respiratory therapists and nurses and included a self-study module with preintervention and postintervention assessments, lectures, fact sheets, and posters. RESULTS: Before the intervention, there were 45 episodes of VAP (20.6 cases per 1000 ventilator-days) in the MICU, 11 (5.4 cases per 1000 ventilator-days) in the SICU, and 9 (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days; P=.001) and remained stable in the SICU (5.6 cases per 1000 ventilator-days; P=.22) and CCU (4.8 cases per 1000 ventilator-days; P=.48). The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days; P=.07), and rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 (P<.001) and by 8.9 days in period 3 (P<.001). The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50% (P<.001) and 37%-45% (P<.001), respectively. CONCLUSIONS: A focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.     

Role of the infectious disease specialist in containing costs of antibiotics in the hospital

Antimicrobial agents account for a significant proportion of drug expenditures and are used inappropriately approximately half the time in hospital practice. This has led to substantial increases in medical costs for hospitalized patients. Methods have been proposed to reduce inappropriate use of antibiotics, particularly in hospitalized patients. Two of these methods, education and control, were employed effectively by infectious disease specialists at a university teaching hospital to reduce inappropriate use of second-generation cephalosporins. These efforts resulted in significant savings of approximately $130,00 per year. The infectious disease specialist may also make major contributions to cost containment of antibiotics in other equally important areas, including other classes of antibiotics, inappropriate daily frequency, excessive duration of administration, and prevention of adverse drug reactions. The infectious disease specialist is better trained in appropriate antimicrobial use and clinically more knowledgeable in treating infections than other medical specialists and is the best-equipped member of the medical staff to educate the medical community on antibiotic use and to control antibiotic costs.