Getting Serious About Antimicrobial Stewardship
It’s been over a half-century since the medical community first heard a cautionary reminder from Sir Alexander Fleming (who discovered penicillin) about avoiding overuse of antibiotics.
In the last decade, the clarion call for judicious antibiotic use swelled to world-wide attention with the emergence and rapid rise of resistant infections and the simultaneous drought in pharmaceutical research and development to find new therapies. The World Health Organization WHO), the Centers for Disease Prevention and Control (CDC) and a growing number of professional societies have mounted impressive campaigns to raise awareness, educate medical practitioners, stimulate commercial investment in new drug development and pose solutions to improve stewardship of our last antibiotic arsenal.
Despite this clear consensus about what we “should” do, it’s evident that the concept is not yet firmly rooted in practice. Not every hospital sustains a dedicated antibiotic stewardship program and most long-term care facilities lack the expertise to do so. Diagnostic testing to confirm the need for an antibiotic (or inform which antibiotic is best) is neither universally available nor used. One can visit any pediatrician’s office, parent blog site, local emergency room or primary care doctor’s office and hear varying recommendations for appropriate use of antibiotics.
The Vital Signs report from CDC called on local hospitals, clinics, long-term care facilities and public health departments to improve collaboration on infection surveillance, infection control and antibiotic stewardship. This is an important step forward and puts all actors in a community’s system of care on notice that they are responsible (and mutually at risk) for effective stewardship.
We need to see correlating investment in stimulating and replicating rapid transformation within these communities. With millions invested in comparative effectiveness work by PCORI, it’s hard to understand why an equally large funding pool is not available for this immediate threat to our health. Major hospitals, government agencies, foundations, pharmaceutical companies and corporate healthcare entities should emulate the collaboration they seek on the front line. The financial investment from these sectors to establish a central resource of leadership, expert technical assistance, best practice and research would be a legacy to future generations and proof that we didn’t waste the last moments of opportunity in endless dialogue.
Changing the culture of care to deemphasize the “prescribe first” and “just in case” approach to medicine will take time. It will challenge both provider autonomy and a patient’s sense of what is in their best interest. It’s vital that all stakeholders look beyond immediate self-interest and join together to change attitudes and behavior, demand professional accountability, and become stewards of a precious resource before it’s too late.
Every other day I read an article about “trends in healthcare.” Newt Gingrich said recently that anyone claiming to know the direction of healthcare in the future should be thrown out on his or her ear. Well, I agree no one can predict the future with full accuracy, but here are some policy, research investment and practice change trends to embrace and promote!
- Prevention as a primary focus in health care
- Free health apps for patients and providers to share and monitor key metrics of health
- Patients involved in care planning, self-management, records review and research
- Providers and payers embracing fully integrated care
- Community health workers involved in care transitions and coordination
- Healthy behavior promotion
- Better stewardship — of drugs, diagnostics and treatments
- Patient-Family-provider Dialogue about end of life care
We’re All In This Together
I spent time recently with a roomful of behavioral health providers – non-profit and for-profit – whose highest priority is serving some of the sickest in their communities. These noble individuals and organizations have endured several years of evolving system change that affects both payment for and design of services they deliver. At the same time, they’ve been adapting to new world realities and future directions that emphasize data-driven decisions, and focus on outcomes and wellness as a basis for reimbursement and determination of “value.”
In many cases, these providers are novice adopters of electronic health records and are constrained by payment systems that continue to emphasis volume of services, rather than the clinical and social outcomes produced by all their hard work. I was struck by how valiantly these organizations are striving to do the best for the clients and families they serve, while they struggle to stay fiscally viable in a highly competitive health care market.
The policy structure at the federal and most especially at the state level needs to do more to support the true laboratories of reform. We should be grateful that these dedicated individuals go to work every day passionate about doing more and better with the tools they have. Not all of these providers will survive the turbulent transformation period we are facing, but policymakers can do more to help boost the success rate. Here are a few ideas:
Make Data Accessible – HIPAA is important, but we’re hiding from true progress by using this law as an excuse to slow down or avoid true data integration and interoperability. Facilitate sharing within community networks and with the state, force vendors to collaborate and harmonize, and help all organizations better understand their population and the opportunities to serve.
Set the Bar; Don’t Dictate the Model – The trend seems to be “finding” the best practice, model or tool, rather than articulating the goals we want to see. Does it really matter what approach is used if we are seeing a change in health behaviors, clinical outcomes and service mix? This is the promise of case rates/bundled reimbursement versus continuing our dependence on fee-for-service. But truly embracing the latter requires that we stop dictating how providers must achieve that outcome for every patient. If we embrace that each patient is unique, then the approach to his or her wellness must, by definition, also be unique.
Foster (Don’t Try to Control) Relationships – Policy entities need to prioritize inclusive stakeholder engagement and foster solutions born of dialogue and local innovation. Bring people to the table and get out of the way.
Give Policy Changes Time to Germinate…and Blossom – Perhaps no other trend is more troubling than the attention deficit that our policy and financing governance has for change. If it is well understood that culture and practice takes time to evolve, then we must extend the timetable for examining change and its impact on health. We continue to ignore that transformation may cost more in the short-term even as it delivers unexpected change that delivers good for individuals and for the system overall. Allow time for policies to really embed and use early data – whatever it shows – to drive process improvement dialogues and allow performance to create system competition organically (as opposed to penalizing organizations, for example).
Focus on outcomes that matter – Budget neutrality for Medicaid/Medicare (while important) should not be a paramount driver of patient-level care decisions. Are more patients being served able to get (and keep) a job? Are their chronic illnesses better managed (e.g. their glucose levels more constant? is their BMI improving?) These outcomes are vital indicators of improved health – maybe more than avoidance of ED use, lower readmission rates, or reduced prescription drug costs.
It’s an exciting, and yet unsettling, time in healthcare. While we spend energy and scarce resources to support patients as they engage in their healthcare, our policy establishment needs to also support those that deliver care in the community.
It’s not a call to guarantee their existence or enable continued dependence on outdated approaches. Rather, it’s an appeal to invest in and cultivate the passion and the creative possibilities of the real front line in healthcare.
Change the Incentive; Change the System of Care
What if healthcare really focused on outcomes that matter to patients? What if payment for services was based on whether someone’s cholesterol level went down, diabetes was under control, they quit smoking, lost ten pounds, returned to work without complications from surgery? What if effectiveness for mental health services were shown by number of individuals able to hold a job (or get a job) or maintain a living situation of their choice. What if cancer care effectiveness was measured by whether a patient could maintain normal routines for family and work and whether their emotional well-being was valued on equal basis with the “stage” of their tumor?
What if we stop measuring events that shouldn’t happen and start really aiming for the outcomes we want in healthcare? What if we truly focus on prevention – the version that is focused on promoting an individual’s best health opportunity rather than wasting hours and dollars chasing after non-hand washers, vaccine shirkers, “non-adherent” patients, fraudulent billers and innovators out to make a quick buck with no commitment to improving health.
That’s why a focus on value and payment based on care “episodes” is intriguing. Pay for care that accelerates an individual toward the good health outcome they want and deserve. The burden is on everyone involved – patient, family, provider – to think about methods and interventions to achieve their goals, instead of focusing on units of service and time, or ticking a box for monthly contact. It’s certainly no guarantee that the outcome will be achieved. That’s another discussion about our need to accept the realities of illness and mortality. But it’s a best shot at a system that focuses on health and care for the individual first.
First Things First
Someone asked me today why I thought Europe seemed to be showing stronger gains in healthcare on several fronts — patient centeredness, infection prevention, antimicrobial stewardship, better surgical protocols. Perhaps it is the more centralized payment and regulatory structures in Europe that allow a focus on quality and patient outcomes? Less obsession with the need for multi-million dollar innovation? A desire to use what they have better versus constant innovation for something new? It’s something to ponder. In the U.S. we seem doomed to repeat missed opportunities for truly transformative health care. Just two examples recently come to mind, but they are significant.
First, a JAMA article by esteemed bioethicists posits that a modern mental health system ought to employ 19th century approaches. I’m sure I’m not the only one shocked at the proposition. Perhaps they were, as one notable advocate pointed out, merely trying to provoke long-overdue dialogue about what needs to be fixed in the mental health “care” system. Asylum or Warehouse? « Linda’s Corner Office. Perhaps. Or maybe the article was a reflection of the greater tendency to want to avoid the difficult cases — chronic debilitating illness, mental health and substance abuse, dementia, autism… We are challenged at this moment to authentically address and solve some of the problems that cause such a drain on our health care system. Doing so with panacea solutions and last-century thinking is the wrong jumping off point. Such discussion requires a deep reservoir of compassion, of caring for the individual experiences of people dealing with such conditions, and the capacity to focus on dignity and the possibility for independence and recovery first and foremost.
Second, was the announcement of President Obama’s proposed budget in which a disproportionately high $650 million is proposed for NIH and BARDA research for development of drugs and diagnostics to combat antibiotic-resistant organisms. In contrast, a fraction ($280 million) is bestowed on the CDC, dedicated to the consistent and vigilant surveillance of resistance and stewardship of the antibiotics we have available. It’s not that health care providers and patients won’t benefit from a new arsenal of drugs or diagnostic tools to combat real and here-today pathogens for which there is no treatment. It’s that once again, we are missing the opportunity to prioritize a higher level of resources on improving our methods of preventing the spread of resistance and optimizing the use of already available tools. Without significant investment in the latter, we will release a set of new and powerful tools into an inconsistent delivery and management system. Here’s hoping the ultimate budget strikes a better balance.
In both instances, better policy requires clearer thinking about what will benefit patients most. For mental health, it’s access to care that supports their life in the community. For individuals with antibiotic resistant infections (or in settings where such infections are prevalent), its how best to prevent the spread of such infections in the first place. With all due respect to the efforts of researchers, drug and device makers and hospitals everywhere, let’s spend time and money on those efforts first. The dividend could be truly transformative.