Urgent Care Antibiotic Stewardship Summit July 15 th -16 th, 2018 u Atlanta, GA Background and Discussion Guide Antibiotic resistance is a major public health threat. In the United States alone, the Centers for Disease Control and Prevention (CDC) estimates that at least 2,000,000 illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria each year 1. Antibiotic use is a key driver of antibiotic resistance. Appropriate uses of antibiotics can be life-saving; however, overuse and misuse of antibiotics drives the emergence and spread of resistance and can cause side effects that range from allergic reactions to severe Clostridium difficile infections. Most U.S. antibiotic prescriptions are given in the outpatient setting. As a growing outpatient sector that focuses on providing care to walk-in patients with acute, non-emergent conditions, including many with infectious disease-associated presentations. Given the most commonly encountered diagnoses in this care setting, urgent care antibiotic stewardship has a unique opportunity to significantly improve outpatient antibiotic prescribing, enhance patient care quality, and combat antibiotic resistance. Yet, a number of factors hinder the initiation, continual improvement, and evaluation of antibiotic stewardship activities by urgent care centers (UCCs). The Antibiotic Resistance Action Center (ARAC) at the George Washington Milken Institute School of Public Health, together with the Center for Disease Control and Prevention (CDC), and the Urgent Care Association (UCA) are hosting this summit of urgent care, urgent care stakeholders, and healthcare experts to discuss and further develope the urgent care industry s commitment and action plan on antibiotic stewardship. Funding for the Urgent Care Antibiotic Stewardship Summit was provided by the George Washington Milken Institute School of Public Health through the Antibiotic Resistance Action Center. Summit Goals Attendees will be asked to share their perspectives, expertise, and experience, with the goal of developing: A. Joint Commitment Statement on Antibiotic Stewardship in Urgent Care (Sunday, July 15 th ) B. Industry Action Plan on Antibiotic Stewardship in Urgent Care (Monday, July 16 th ) v Discuss challenges and solutions in urgent care antibiotic stewardship v Share success stories in urgent care antibiotic stewardship v Characterize the guidance and resources needed for the initiation, continual improvement, and evaluation of stewardship in urgent care v Discuss how urgent care stakeholders can support antibiotic stewardship in urgent care National Goals for Healthcare Antibiotic Stewardship The National Strategy for Combating Antibiotic-Resistant Bacteria was developed by the White House in 2014 as a guidance for the National Action Plan for Combating Antibiotic-Resistant Bacteria (2015). In addition to setting national goals for healthcare antibiotic stewardship (Table 1), the National Strategy set additional goals for agricultural antibiotic stewardship, one-health surveillance, development of rapid diagnostics, international collaboration, and the development of antibiotics, vaccines, and antibiotic alternatives. Page 1 of 7
Table 1. Healthcare antibiotic stewardship goals to be achieved through cooperation of federal agencies, private sector and other stakeholders by 2020. Inappropriate outpatient antibiotic use for monitored conditions/agents will be reduced by 50% from 2010 levels à Most applicable to Urgent Care At least 95% of eligible hospitals will report antibiotic use data to the National Healthcare Safety Network (NHSN). Inappropriate inpatient antibiotic use for monitored conditions/agents will be reduced by 20% from 2014 levels. All States, the District of Columbia, and Puerto Rico will have: 1. Implemented antibiotic stewardship activities in human healthcare delivery settings. 2. Established or enhanced regional efforts to reduce transmission of antibiotic resistant pathogens and improve appropriate antibiotic use in healthcare facilities across the continuum of care (e.g., acute care, long term care, and outpatient care). HHS, DOD, and VA will review existing regulations and propose new regulations and other actions, as appropriate, which require hospitals and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs that adhere to best practices, such as those defined by the CDC s Core Elements of Hospital Antibiotic Stewardship Programs. To achieve the 2020 outpatient reduction goal, The National Action Plan includes milestones for the CDC, CMS, AHRQ, and other agencies to develop stewardship program interpretative guidance and best practices, expand quality measures (e.g., PQRS, MIPS), and conduct studies to benchmark prescribing and develop interventions to reduce misuse of antibiotics 1. Urgent Care in the United States Urgent care centers (UCCs) are physician-based ambulatory facilities that offer walk-in care for non-emergent conditions. It is estimated that approximately 7,500 UCCs are operating in the U.S today, with an average of 12,000 annual visits per center. While there is yet to be a unified definition of urgent care, in order to be certified as a traditional or comprehensive UCC by the Urgent Care Association (UCA) certification, the urgent care facility must meet the following criteria 2 : a) be capable of evaluating walk-in patients of all ages for a broad spectrum of illnesses, b) have a licensed physician as the Medical Director, c) meet a minimum criteria for hours of operation (seven days a week and a minimum of 4 hours/day and 3,000 hours/year), d) have a minimum of two exam rooms, and e) during all posted hours of operation, have the equipment and licensed provider to perform and read EKG, X-ray, administer medications/fluids, and perform minor procedures, and the trained staff to use automated defibrillator, airway and oxygen support, and drug cart. There is also a wide range of urgent care ownerships, including clinician-owned and/or - operated, corporate-owned (e.g., managed healthcare company, private equity, or other types of shareholders), healthcare system-owned, or other types of joint ventures with healthcare systems. Size of urgent care also vary widely and range from a single center to upwards of 200+ UCCs. The diversity in ownerships and operational structures in urgent care contribute significantly to the variability in how different UCCs achieve institutional buy-in and identify leadership for antibiotic stewardship, as well as in the types of guidance/resources needed and organizational resources (e.g., funds, time, manpower) available for antibiotic stewardship. Page 2 of 7
Unique Role of Urgent Care in Outpatient Antibiotic Stewardship As walk-in clinics, urgent care sees a disproportionate proportion of patients with infectious disease-associated symptoms, as compared to primary care or internal medicine clinics. Approximately one in two urgent care visits has a respiratory-related diagnosis, with chief complaints ranging from cough (13.0%), sore throat (10.8%), sinus congestion (6.6%), ear pain (4.3%), to fever (2.8%). Antibiotics is the most-prescribed medication during urgent care visits (Unpublished data). Urgent care is estimated to account for 80-100 million U.S. outpatient visits each year. Based on CDC estimates of antibiotic prescribing rates in urgent care visits (~40%) 3, urgent care could account for 32-40 million antibiotic prescriptions each year. While the rate of inappropriate prescribing is not fully known for urgent care, given the types of illnesses most commonly seen in urgent care, it has unique opportunities to significantly improve outpatient antibiotic prescribing, enhance patient care quality, and combat antibiotic resistance through antibiotic stewardship. High-Priority Conditions for Antibiotic Stewardship in Urgent Care The ultimate goal of antibiotic stewardship is to give patients the right antibiotics at the right dosage and duration and at the right time. In other words, reducing inappropriate prescribing encompasses reducing overprescribing, mis-prescribing, and under-prescribing of antibiotics. Examples of the high-priority conditions for antibiotic stewardship in urgent care are listed in Table 2. Given the scope of urgent care visits, there are major opportunities to tackle overprescribing ( unnecessary prescribing ) in respiratory conditions through stewardship. Urgent care also has major opportunities to address overuse and misuse of antibiotics in other respiratory and genitourinary conditions. Table 2. Examples of the High-Priority Conditions for Antibiotic Stewardship in Urgent Care 4 A. Unnecessary Prescribing 1. Conditions for which antibiotics are overprescribed, such as conditions for which antibiotics are not indicated. Examples: Acute bronchitis, nonspecific upper respiratory infection, or viral pharyngitis. B. Other Inappropriate Prescribing 1. Conditions for which antibiotics might be appropriate but are over-diagnosed, such as a condition that is diagnosed without fulfilling the diagnostic criteria. Examples: Acute uncomplicated sinusitis, acute otitis media, or streptococcal pharyngitis 2. Conditions for which antibiotics might be indicated but for which the wrong agent, dose, or duration often is selected. Examples: uncomplicated UTIs, bacterial community-acquired pneumonia, and sexually transmitted infections such as gonorrhea, chlamydia, and syphilis. 3. Conditions for which watchful waiting or delayed prescribing is appropriate but underused. Examples: Acute otitis media or acute uncomplicated sinusitis. CDC Efforts on Outpatient Antibiotic Stewardship The CDC conducts a major education campaign on antibiotic resistance and antibiotic use through its Be Antibiotics Aware campaign (formerly the Get Smart About Antibiotics) 5. The campaign targets the general public (i.e., patients, consumers), as well as healthcare professionals and policy-makers. In addition to providing promotional and educational materials targeting broad audiences, the Be Antibiotics Aware campaign also organize and collaborate with diverse stakeholders such as state health departments, non-profit, Page 3 of 7
corporations to provide education and guidance. A major annual event is U.S. Antibiotic Awareness Week, which is in November to coincide with the onset of flu season. For healthcare providers, the CDC provides guidance for outpatient antibiotic stewardship, including urgent care centers, in the 2016 Core Elements of Outpatient Antibiotic Stewardship. These Core Elements, which are Commitment, Action for policy and practice, Tracking & Reporting, and Expertise & Education, provide a framework for implementing stewardship in outpatient settings and contain specific evidence-based interventions to improve antibiotic use in the outpatient setting 4. The MITIGATE Toolkit, released in June 2018, is a toolkit developed for emergency departments and urgent cares and is an evidence-based guide for implementing the Core Elements of Outpatient Antibiotic Stewardship in acute care settings treating outpatients with common acute respiratory infections. In July 2018, CDC will be releasing an interactive web-based training program on antibiotic stewardship 6. This CE-eligible program will include a section on provider training to improve communicate with parents of pediatric patients with respiratory infections 7 and fulfills Improvement Activities Patient Safety and Practice Assessment under CMS Merit-based Incentive Payment System (MIPS). Tracking and Reporting Antibiotic Prescribing in Urgent Care Stewardship Tracking and reporting antibiotic prescribing is among the most critical stewardship activities for UCCs, but it is also among the most time- and labor-intensive. Tracking antibiotic use is essential for benchmarking, developing internal stewardship goals, and evaluating the effectiveness of antibiotic stewardship. Internal reporting of antibiotic use at the provider-level can be highly-effective report cards to improve prescribing and can also be used to identify providers who need academic detailing and/or other stewardship-related training. There are several barriers to effective tracking and reporting in urgent care. In addition to the resource limitation issues, other factors include the limited options for automatic EHR-based reporting and a need for well-defined algorithms and exclusion criteria (e.g., delayed prescribing, patients with other complaints and co-morbidities requiring antibiotics) for extracting meaningful prescribing metrics. One of the most commonly used prescribing metrics are the Healthcare Effectiveness Data and Information Set (HEDIS) measures for pediatric URI 8, acute bronchitis in adults 9, and diagnosis of streptococcal pharyngitis in children 10. Internal rapid (i.e., monthly) tracking and reporting are ideal for urgent care stewardship. However, for UCCs who do not yet track and report internally, feedback from payers, such as prescribing-related HEDIS measures, while delayed and typically infrequent, is a highly valuable assistance. Specifically, payers provider-level feedback has enabled UCC medical officers to identify providers who need additional training and support. Urgent Care Accreditation and Certification Industry standards, representing industry practice goals including those surrounding quality improvement areas such as antibiotic stewardship are typically developed and evaluated by accrediting bodies through the accreditation process. While accreditation is not required for ambulatory care, including urgent care, several payers from specific states now require new UCCs to be accredited to stay in-network or before contracting. There are four national accrediting bodies in the U.S.: UCA, Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), and National Urgent Care Center Accreditation (NUCCA). UCA and Joint Commission accredit the most number of UCCs. Page 4 of 7
The exact number of accredited UCCs in the U.S. is difficult to determine, but the majority of UCCs in the U.S. are not yet accredited. Of the 7,500 UCCs operating, it is estimated that ~750, ~400, and ~200 UCCs are accredited by UCA, NUCCA, and the Joint Commission, respectively 11-12. Several factors may explain the relatively low rate of accreditation, such as the time and efforts needed to meet the accreditation standards and the cost of accreditation. Certification is another pathway to evaluate and recognize industry standards; it tends to focus on a specific area of practice and at lower costs. Some payers now require certification as part of their contracting process with UCCs. Currently, UCA is the only entity offering urgent carespecific certification, which focuses on scope of practice. Specifically, UCA certifies the following types of UCCs: a) Traditional/Comprehensive, b) Pediatric, c) Seasonal, d) Occupational Medicine/Health, e) Rural, f) Pediatrics After Hours, and g) Orthopedic. The costs of certification are substantially lower than accreditation on a per-center basis, at $649-779 per center 13. Thus, certification represents an affordable and less effort-intensive option for some UCCs; however, it can become costly for larger operators. Both Joint Commission and UCA are currently determining how to incorporate antibiotic stewardship into their respective urgent care accreditation standards. There are currently no certification alternatives that can assess and recognize antibiotic stewardship or other qualityimprovement programs in non-accredited UCCs. Urgent Care Reimbursements by Public and Private Payers The payer mix of U.S. UCCs are estimated at ~55% private payer and ~17% Medicare, with the remaining being a combination of self-pay, Medicaid, Workers Comp, Tricare, etc. Urgent care reimbursements are typically through fee-for-service or global rate contracts (S9083), with some UCCs electing to bill as primary care. However, some payers are now foregoing global contracts and require fee-for-service billing in order to collect more utilization data. Patient co-pays for urgent care visits typically fall between primary care and emergency department visits. On average, new and established visits to UCCs are reimbursed at $135 and $116, respectively 14. Value-based performance payments related to prescribing are available to UCCs through CMS Merit-based Incentive Payment System (MIPS) tied to Medicare Part B under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and infrequently, through private payers. UCCs can report on five MIPS measures related to antibiotic prescribing, including the three HEDIS measures and two sinusitis-related measures. While MIPS can potentially be a source of tracking/reporting data from EHR and financially incentivize improved prescribing practices, the MIPS reporting rates by UCCs are unknown due to the payer mix of UCCs and the efforts needed for MIPS reporting. The metrics from UCCs value-based performance arrangements with private payers are primarily regarding reduced emergency department (ED) utilization and follow-up visits, reflecting the fact that the key value propositions of UCCs to payers are primarily cost-savings from averted ED visits and at times, for providing primary care services. If private payers were to develop financial incentives for urgent care antibiotic stewardship, it may be important to consider the heterogeneity in UCCs in goal setting. For example, incentives based on a combination of reduction goals (for UCCs needing improvement) and maintenance goals (for UCCs achieving top benchmark) may be used to encourage sharing of expertise and support equity. Barriers to Antibiotic Stewardship in Urgent Care Various barriers to antibiotic stewardship are presented in a high-level summary in Table 3. Page 5 of 7
Table 3. Barriers to Antibiotic Stewardship in Urgent Care Barrier Cause(s) Stakeholders Consumer-like Lack of existing patient-provider Patients attitudes and relationship Providers expectations in Convenience is a key value proposition urgent care patients to patients Pressure to maintain patient satisfaction Pressure to achieve rapid turnaround time for visits UCC resources needed for antibiotic stewardship Limited urgent carespecific resources for stewardship evaluation Difficulty with tracking and reporting prescribing data Concerns regarding effectiveness and financial impact of urgent care antibiotic stewardship Antibiotics (e.g, lack of prescription, conflicting diagnoses from other clinics etc.) is a common source of patient complaints at UCCs. Importance of positive reviews and returning patients to UCCs. Provider performance reviews frequently involve patient satisfaction scores (but not stewardship) Patient volume can vary highly from day to day Turnaround time impacts patient satisfaction Patient education is perceived to be time-consuming UCCs frequently have limited time, money, and manpower for stewardship and other quality improvement programs Few resources provided in operationalizable format Resources often list potential activities ( what ); however, more how-to guidance, including performance assessment is needed Accreditation standards may not be feasible or available to non-accredited UCCs EHR data extraction, analysis, and reporting are time-consuming Few standard EHR based reporting on prescribing More clear reporting metrics and algorithms needed, including clear exclusion criteria Few antibiotic stewardship success stories available to UCCs Research needed on urgent care antibiotic stewardship effectiveness and impact on patient satisfaction and financial performance Other sectors, such as primary care, retail, etc. Patients Providers Social media Patients Providers Accrediting bodies Electronic health record vendors Accrediting bodies Payers Electronic health record vendors Accrediting bodies Page 6 of 7
References Payers 1. National Action Plan for Combating Antibiotic-Resistant Bacteria. https://obamawhitehouse.archives.gov/sites/default/files/docs/national_action_plan_for_combati ng_antibotic-resistant_bacteria.pdf. Accessed June 30th, 2018. 2. Urgent Care Association. Types of Certification Offered https://cdn.ymaws.com/www.ucaoa.org/resource/resmgr/certification/2018_types of_certificat ion.pdf. Accessed June 30th, 2018. 3. Palms D, Hicks L, Hersh AL, et al. Variation in Antibiotic Prescribing among Emergency Departments, Urgent Care Centers, and Retail Health Clinics in the United States, 2014. Open Forum Infectious Diseases. 2017;4(Suppl 1):S507. doi:10.1093/ofid/ofx163.1314. 4. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep. 2016 Nov 11;65(6):1-12. doi: 10.15585/mmwr.rr6506a1. PubMed PMID: 27832047. 5. Center for Disease Control and Prevention. Be Antibiotics Aware. https://www.cdc.gov/antibiotic-use/. Accessed on July 2 nd, 2018. 6. CDC Training on Antibiotic Stewardship. https://www.train.org/cdctrain/course/1075730/compilation. Accessed on July 9th, 2018. 7. Magione-Smith, Rita. DART Learning Modules. http://www.seattlechildrens.org/research/child-health-behavior-and-development/mangionesmith-lab/dart-learning-modules/. Accessed on July 9th, 2018. 8. National Committee for Quality Assurance. Appropriate Treatment for Children with Upper Respiratory Infection. https://www.ncqa.org/report-cards/health-plans/state-of-health-carequality/2017-table-of-contents/uri. Accessed on July 2 nd, 2018. 9. National Committee for Quality Assurance. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. http://www.ncqa.org/report-cards/health-plans/state-of-health-carequality/2017-table-of-contents/apc. Accessed on July 2 nd, 2018. 10. National Committee for Quality Assurance. Appropriate Testing for Children with Pharyngitis. http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2017- table-of-contents/pharyngitis. Accessed on July 2 nd, 2018. 11. Merchant Medicine. Urgent Care Accreditation: Joint Commission or UCAOA? https://www.merchantmedicine.com/marketreport/2018/3/14/urgent-care-accreditation-jointcommission-or-ucaoa. Accessed June 30th, 2018. 12. Personal Communications. 13. Urgent Care Association. Certified Urgent Care (CUC) Program. https://www.ucaoa.org/?cuc_overview. Accessed June 30th, 2018. 14. 8. DocuTAP. Urgent Care Reimbursement Trends 2013-2016. https://docutap.com/blog/urgent-care-reimbursement-trends-2013-2016. Accessed July 1st, 2018. Page 7 of 7