1. INFECTIOUS DISEASES STRATEGIES TO LIMIT HOSPITALIZATION,REDUCE RISK AND ADD VALUE Ronald G Nahass, MD, MHCM, FIDSA President – ID CARE Clinical Professor of Medicine-Rutgers University Robert Wood Johnson Medical School

2. Disclosures Clinical Trial Support Gilead, Merck, Abbvie, BMS, Roche Advisory Board Janssen, Gilead Speaker Support Gilead, Merck, Vertex, Janssen Infection Prevention Contracts Somerset Medical Center, East Mountain Hospital, Bridgeway Care Center, University Radiology

3. Objectives Review the role of infection-related problems that lead to unnecessary admissions, readmissions, and avoidable complications Discuss the cost from the fiscal and patient outcomes perspective Illustrate the importance of the Infectious Diseases Physician – Hospital Partnership Propose for consideration “The Infectious Diseases Service Line”

4. Case Study: 72 Year Old Diabetic Woman Day 0Day 1Day 2Day 3Day 4Day 11Day 12Day 13 Day 14 ID Called Antibiotic treatment stopped as gout was diagnosed. Clostridium difficile test ordered and treatment for this started. Patient was isolated. C difficile diagnosed. ICU with dilated colon – operating room for colon resection. Emergency Dept. Hospital Nursing Home Presents with fever and painful, red foot Treated with broad-spectrum antibiotics Fever not better, Abx changed Develops diarrhea After 12 days in hospital, patient discharged to Nursing Home

5. Case Analysis Day 0Day 1Day 2Day 3Day 4Day 11Day 12Day 13 Day 14 ID Called Antibiotic treatment stopped as gout was diagnosed. Clostridium difficile test ordered and treatment for this started. Patient was isolated. C difficile diagnosed. ICU with dilated colon – operating room for colon resection. Emergency Dept. Hospital Nursing Home Presents with fever and painful, red foot Treated with broad-spectrum antibiotics Fever not better, Abx changed Develops diarrhea After 12 days in hospital, patient discharged to Nursing Home Potentially avoidable complication of antimicrobial therapy leading to lengthy stay Numerous antibiotics – most of which not needed Wrong initial diagnosis Prolonged recovery including sub-acute stay Late consultation with infectious disease

6. Key Take-Aways Inappropriate diagnosis and treatment for infectious diseases is costly to the patient and system Late consultation with ID specialist is costly

7. Some Basic Statistics Keep 3 things in mind: 1.Infections can happen anywhere 2.Infections can be costly 3.Antibiotic resistance is a problem so Stewardship and Infection Control are critical

8. Aggregate Costs Of Infectious Diseases Clostridium difficile – nearly $9 Billion in annual costs Ref: Torio CM (AHRQ), Andrews RM (AHRQ). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. HCUP Statistical Brief #160. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup- us.ahrq.gov/reports/statbriefs/sb160.pdf.

9. Infection Related Health Care Admissions Primary Diagnosis Ranking* –Pneumonia 1 –Septicemia 4 –Complications of implant 7 –Skin and subcutaneous tissue infection 9 What this could mean to you: –10% of your admissions may have an infectious disease diagnosis –The number of admissions for ID related problems are almost 2x that of cardiovascular disease diagnoses * Ranking excludes pregnancy and psychiatry related diagnoses Ref: Pfuntner, A (Truven Health Analytics), Wier, LM (Truven Health Analytics), Stocks, C (AHRQ). Most Frequent Conditions in U.S. Hospitals, 2010. HCUP Statistical Brief #148. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148.pdf.

10. Infection Related Health Care Re-Admissions Primary Diagnosis Ranking* –Pneumonia 1 –Septicemia 4 –Complications of implant 8 –Skin and subcutaneous tissue infection 9 –Urinary tract infections12 What this could mean to you: –21% of your septic patients are likely to be readmitted within 30 days –20% of your patients with an implantable device or graft are likely to be readmitted within 30 days * Ranking excludes pregnancy and psychiatry related diagnoses Ref: All-cause 30-day readmissions ranked by the most frequently treated conditions* in U.S. hospitals, 2010 - Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf.

11. Special Pathogens – Clostridium difficile Clostridium difficile – Healthcare associated diarrhea infection related to antibiotic use –Adds an estimated $26,000 marginal cost per case to each hospitalized patient –Admissions nearly doubled from 2001-2010 - from 4.5 to 8.2 cases / 1000 admissions. –In 2009, C. diff accounted for a total of 336,000 admissions or 1% of all admissions –Estimated to have excess attributable costs of $1.3 billion Lucado, J. (Social & Scientific Systems), Gould, C. (CDC), and Elixhauser, A. (AHRQ). Clostridium difficile Infections (CDI) in Hospital Stays, 2009. HCUP Statistical Brief #124. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf

13. W Ant mo to and ATA NATIONAL SUMMARY Estimated minimum number of illnesses and deaths caused by antibiotic resistance*: 2,049,442 At least illnesses, 23,000 *bacteria and fungus included in this report deaths Estimated minimum number of illnesses and death due to Clostridium difficile (C. difficile), a unique bacterial infection that, although not significantly resistant to the drugs used to treat it, is directly related to antibiotic use and resistance: 250,000 14,000 At least illnesses, deaths WHERE DO INFECTIONS HAPPEN? Antibiotic-resistant infections can happen anywhere. Data show that most happen in the general community; however, most deaths related to antibiotic resistance happen in healthcare settings, such as hospitals and nursing homes.

14. The Infectious Diseases Service Line Is A Solution Antimicrobial Stewardship Clinical Care Infection Prevention Microbiology Laboratory Employee Health Resource Management

15. Antibiotic Overuse Is Dangerous and Costly Studies indicate that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate. 1. Ref: http://www.cdc.gov/getsmart/healthcare/http://www.cdc.gov/getsmart/healthcare/ 2. Anderson DJ, Moehring RW, Sloane R, Schmader KE, Weber DJ, et al. (2014) Bloodstream Infections in Community Hospitals in the 21 st Century: A Multicenter Cohort Study. PLoS ONE 9(3): e91713. doi:10.1371/journal.pone.0091713

16. Antibiotic Stewardship Is Needed And the ID Specialist will be your champion Ref: Combes J.R. and Arespacochaga E., Appropriate Use of Medical Resources. American Hospital Association’s Physician Leadership Forum, Chicago, IL. November 2013

17. Stewardship Creates Value

18. ID Specialists Improve Outcomes and Reduce Cost – Clinical Care Early ID Clinician Engagement for clinical care is critical to achieve the best outcomes

19. Ref: Schmitt et al. “ Infectious Diseases Specialty Intervention is Associated with Decreased Mortality and Costs.” Clin Infect Dis. (2014) 58 (1): 22-28. doi: 10.1093/cid/cit610 First published online: September 25, 2013

20. Improving Outcomes and Reducing Costs Infection Prevention Intervention

21. Clostridium difficile at Rhode Island Hospital Metric20062012 Incidence/1000 discharges 12.23.6 Mortality (N)5219 Results of a 5 step program focused on reducing the incidence of Clostridium difficile C difficile infection control plan Monitor morbidity and mortality of C. difficile Improve test sensitivity Enhance environmental cleaning Standardize the treatment plan Other interventions as necessary Mermel, LA et al, Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach. The Joint Com J 2013;39:298.

22. ID Clinicians Offer A Unique System and Population Orientation Long-term focus of risk reduction and safety through system- wide infection prevention and control efforts One of the few specialties that focuses on efficient resource management, across various sites-of-service Effective managers of patient care transitions –Employing Outpatient Parenteral Antimicrobial Therapy (OPAT) –Extensivist activity in LTC Strong competency towards promoting team communication across all specialties and within the continuum of care

23. The Infectious Diseases Service Line Is the Solution Clinical Care ID Specialist-led Interventions Efficient Resource Utilization Early ID consults Rescue ID Infection Control & Prevention Antimicrobial Stewardship Judicious use of radiology services, micro/lab services Hazardous waste (“red bag”) management

24. Case Study – ID Rescue 64 year old man has a total knee replacement. –Hospital has established TKR bundled payment agreement with payer 2 weeks later the patient has fever and drainage from the knee incision. A diagnosis of infected joint is made. Multiple treatment decision points, each with different cost implications HospitalPayer Bundled Payment Total Knee Replacement Option 1 – prolonged IV treatment and hope for the best$$ Option 2 – short course IV then long course oral treatment$$$ Option 3 – remove joint, IV treatment, replace joint$$$$$

25. There is a Better Way to Mitigate Risk HospitalPayer Bundled Payment Total Knee Replacement ID Services Co-Management Agreement or Gain-sharing agreement with your ID Clinicians Link payment to Quality: Metrics for acute care –Antibiotic utilization –Resistant organism prevalence –C. difficile rates –CLASBI, CAUTI, SSI Metrics for population management –Readmissions –Vaccination rates Clinical Care ID Specialist-led Interventions Efficient Resource Utilization Early ID consults Rescue ID Infection Control & Prevention Antimicrobial Stewardship Judicious use of Imaging/ Labs Hazardous waste management

26. Strategies to Limit Hospitalization and Cost Without Sacrificing Outcomes Acute infection diagnosis –Acute infection medical service Out patient – Alternate site care Early ID Consultation Rescue care Readmission –Focused programs on septicemia, pneumonia, UTI and surgical wound disruptions at LTC

27. Case Study – Alternate Site Care 54 yo man with fever for 2 weeks had blood cultures performed by his doctor. He was seen by ID doctor because of long duration of fever. –Blood cultures positive for Streptococcus bacteremia. IV antibiotic treatment started as out- patient. –Workup and treatment for endocarditis complicated as outpatient Total savings = $10,000 (Based on Millman and hospital per diem) Patient Satisfaction = High Risks = marked reduction for HAI ED/Hosp PCP Option 2 – OPAT and care $$ management under ID Option 1 – Send patient to ED$$$$$ Outpatient ID

28. The Infectious Diseases Service Line Is a solution for –Quality –Cost –Outcomes VALUE

29. Final Key Messages Aligning incentives through gain sharing and co-management for the ID Service line provides a mechanism to achieve greater value

30. Final Key Messages If you are not engaged with your ID consultants you are missing opportunities to reduce risk and add value If your ID consultants are not engaged with you then you have the wrong consultants

31. THANK YOU! QUESTIONS or COMMENTS?