MEASURING ANTIBIOTIC USE IN LTCFS ELIZABETH DODDS ASHLEY, PHARMD, MHS LIAISON CLINICAL PHARMACIST ASSOCIATE PROFESSOR OF MEDICINE
Objectives - Compare and contrast advantages and disadvantages to various measures of antimicrobial use -Describe unique approaches to measuring antibiotic use in long-term care facilities and describe best practices - Outline key considerations for data validation - Describe strategies to implement change based on antibiotic consumption data
Measures of Antibiotic Use What we know from acute care hospitals 3
Top 10 Antibiotics: By Cost
Financial Data Target audience: Administrators Most common measure of antibiotic use Must choose between purchases vs. billing data Pros: Easily available data Often tied to institutional goals for stewardship programs Likely to be a win given historical effect of stewardship on this measure Cons/Limitations: Must remember to consider changes in contract pricing Non-administrators less likely to be influenced by results
Top 10 Antibiotics: By Number of Patients Treated
Defined Daily Dose Target Audience: Administrators and Epidemiologists Standardized definition of daily antibiotic dose Created by the World Health Organization Correction factor: Total Units (i.e. mg) Drug Pros: DDD Correction Factor Cons: Attempts to convert raw Not everyone agrees with the purchasing data into utilization DDD correction factors data Many use institution-specific Allows comparisons with other correction factors (prescribed institutions daily dose) Easy to calculate Not patient level information
http://www.whocc.no/atc_ddd_index/
Why do the work yourself? ABC Calc 9
DDD vs. DOT (Defined Daily Dose vs Days of Therapy) DDD DOT Pros: Standard comparisons using aggregate utilization data Will change estimate of drug use if high doses are use, but standard is not changed Cons: Not a surrogate for DOT when dose is different than standard: Cannot be used for: children, renal dysfunction DDD can change with time Pros: Can be used in children Not influenced by changes in the DDD standards Not subject to differences in institutional preference Patient-specific information Cons: Overestimates use for drugs given multiple times per day More difficult to measure without computerized records Polk RE. Clin Infect Dis 2007; 44:664-70.
DDD vs. DOT Polk RE. Clin Infect Dis 2007; 44:664-70.
DDD vs. DOT (/1,000 Patient Days) 90.00 80.00 70.00 60.00 50.00 40.00 30.00 DOT DDD 20.00 10.00 0.00
Time Trends More Useful University of Rochester Medical Center
Getting to the bottom of the problem. Measures of antibiotic use are difficult to interpret and compared when examined alone DDD DOT Cost Numerator Values A denominator is needed to standardize measurement of antibiotic use! 14
Available Denominators for Measuring Antibiotic Use Admissions: CDC Definition: The aggregate number of patients admitted to the facility starting on the first day of each month through the end of the calendar month Patient Days: CDC Definition: A daily count of the number of patients in the patient care location during a time period. To calculate patient days, for each day of the month, at the same time each day, record the number of patients. Days Present: CDC Definition: number of patients present in a given location for any portion of any day 15
HOW MUCH IS ENOUGH? WHAT ARE OTHERS DOING? dason.medicine.duke.edu
Total Antibiotic DOT/1000 PD Total DOT/1000 PD by Hospital 900 850 800 750 700 650 600 550 500 1Q122Q123Q124Q121Q132Q133Q134Q131Q142Q143Q144Q14 A B C D* *Carbapenem data not included
Example Benchmark Data
What will we do with standardized data? US Benchmarking Efforts CDC- Antimicrobial Use and Resistance module Objective: The primary objective of Antimicrobial Use option is to facilitate risk-adjusted inter- and intra-facility benchmarking of antimicrobial usage. Secondary objective: to evaluate trends of antimicrobial usage over time at the facility and national levels. Primary metric: antimicrobial days/ 1000 days present Data source: electronic MAR (with or without barcode medication administration) 19
Observed to Expected Ratios Polk R et al. Clin Infect Dis 2011;53:1100-10.
http://www.health.sa.gov.au/infectioncontrol 21
But what about differences between facilities? Efforts underway to standardize antibiotic use in acute care hospitals Similar to Standardized Infection Ratio (SIR) for US Summary measure used to track HAIs Summary statistic that compares a rate to baseline US experience adjusting for known risk factors Proposed measure is Standardized Antibiotic Administration Ratio (SAAR) Compares actual to expected antibiotic use after controlling for facility-level factors www.qualityforum.org 5/20/15 meeting slides
DOT/1,000 Patient Days January through June 2013 140 120 100 80 60 40 20 0
Knowing Why Helps Too: Ciprofloxacin Top 10 Indications Hospital A Hospital B UTI Intrabdominal Other SSTI Prophy (Non-surg) BSI Empiric - F&N Prophy (Surgical) Empiric - Unclear Bone/Joint 0 2000 4000 6000 # of Orders DOT UTI Intraabdominal Prophy (Surgical) SSTI Other Pneumonia-Other BSI Bone/Joint Not Specified Empiric-Unclear 0 500 1000 1500 # of Orders DOT
Biggest Lesson we have Learned = 25
CAN THIS BE DONE IN LONG TERM CARE FACILITIES? dason.medicine.duke.edu
dason.medicine.duke.edu
Sources for Antibiotic Data in Nursing Homes Purchasing data -Can be difficult for dispensing from a central pharmacy location to many facilities Dispensing data Can be difficult with a lot of floor stock Electronic MAR Paper and pencil Point prevalence survey 28
Are Additional Metrics Available? Courses/starts per 1,000 resident days Advantages: easier to measure Disadvantages: does not tell the whole picture- what about durations and overall exposure Remember- a single course of chronic UTI prophylaxis is only started once!!! Benoit SR et al. JAGS 2008;56:2039-44.
Are Additional Metrics Available? Number (or percentage) of patients receiving antimicrobials Advantages: This number can help target education. Disadvantages: This can still underestimate key prescribing practices. Myelotte JM and Neff M. AJIC 2003;18-25. 30
Are Additional Metrics Available? Number of antibiotic days Note: this is not the same as Days of Therapy ADMIT DAY 1 2 3 4 D/C 1 2 P/T 3 4 5 6 VANC O DOT: Piperacillin/tazobactam= 2 Vancomycin = 4 Antibiotic days: Overall = 4 Polk et al. CID 2011;53(11):1100 10
Data Example DRUG NAME SIG DATE WRITTEN TAKE ONE CAPSULE PO DOXYCYCLINE 100 MG CAPSULE TWICE DAILY X 7 DAYS (BRONCHITIS/COPD) 27-Jan-16 14 14 CIPROFLOXACIN 500MG TABS(*) ONE TABLET PO TWICE DAILY. (OSTEOMYELITIS) (DC 2/8/16) 4-Jan-16 70 55 VANCOMYCIN 1 GM ADD-VAN VIA INFUSE 1GM I.V. EVERY 12 HOURS OVER 60-90 MINUTES (*Activate before use*) 12-Jan-16 60 8 VANCOMYCIN 1 GM ADD-VAN VIA INFUSE 1GM I.V. EVERY 12 HOURS OVER 60-90 MINUTES (*Activate before use*) 25-Jan-16 28 8 SULFAMETHOXAZOLE/TMP DS TAB TAKE 1 TABLET BY MOUTH TWICE DAILY X 14 DAYS. (PYELONEPHRITIS) 11-Jan-16 28 2 CEFPODOXIME 200 MG TABLET TAKE ONE TABLET PO EVERY 12 HOURS FOR 10 DAYS (PYELONEPHRITIS) 12-Jan-16 20 5 QTY AUTH QTY DISP Calculations: Doxycycline: 7 DOT Ciprofloxacin: 55/2= 27.5-28 DOT Vancomycin: 8/2= 4 DOT QTY DRUG NAME SIG DATE WRITTEN AUTH DOT TAKE ONE CAPSULE PO DOXYCYCLINE 100 MG CAPSULE TWICE DAILY X 7 DAYS (BRONCHITIS/COPD) 27-Jan-16 14 14 7 CIPROFLOXACIN 500MG TABS(*) ONE TABLET PO TWICE DAILY. (OSTEOMYELITIS) (DC 2/8/16) 4-Jan-16 70 55 28 HOURS OVER 60-90 VANCOMYCIN 1 GM ADD-VAN VIA INFUSE 1GM I.V. EVERY 12 MINUTES (*Activate before use*) 12-Jan-16 60 8 4 VANCOMYCIN 1 GM ADD-VAN VIA INFUSE 1GM I.V. EVERY 12 HOURS OVER 60-90 MINUTES (*Activate before use*) 25-Jan-16 28 8 4 SULFAMETHOXAZOLE/TMP DS TAB TAKE 1 TABLET BY MOUTH TWICE DAILY X 14 DAYS. (PYELONEPHRITIS) 11-Jan-16 28 2 1 CEFPODOXIME 200 MG TABLET TAKE ONE TABLET PO EVERY 12 HOURS FOR 10 DAYS (PYELONEPHRITIS) 12-Jan-16 20 5 3 QTY DISP 32
DDD/10,000 resident days Antibiotic Use by Nursing Home 800 700 600 500 400 300 200 100 0 1 2 3 4 5 Based on Aggregate Purchasing Data
DDD vs. DOT (/1,000 Patient Days)- Experience at a Single Nursing Home 90.00 80.00 70.00 60.00 50.00 40.00 30.00 DOT DDD 20.00 10.00 0.00
Days of Therapy/1,000 Patient Days 200 180 160 140 120 100 80 60 A A no TCC E 40 20 0 2014 Q1 2014 Q2 2014 Q3 2014 Q4 Based on Dispensing Data
Understanding Why Antibiotics are Used Benoit SR et al. JAGS 2008;56:2039-44. 36
There is no substitute for chart review (in some cases) CDC. Core Elements of Antibiotic Stewardship in Nursing Homes- Appendix B 2015. 37
Most Common Indication for Antibiotic Use In Nursing Homes Intra-abdominal Wound infection C. diff Thrush Bone/joint infection Pneumonia Cellulitis UTI 0 50 100 150 200 250 300 Based on Dispensing Data
Beyond Just How Much Drug.. CDC. Core Elements of Antibiotic Stewardship in Nursing Homes- Appendix B 2015.
SO WE HAVE DATA- WHAT DO WE DO NEXT? dason.medicine.duke.edu 40
CDC. Core Elements of Antibiotic Stewardship in Nursing Homes- Appendix B 2015. 41
Do we know our target? Less is better: Daneman N et al. JAMA Internal Medicine 2015;175:1331-9. 42
Making the Data Actionable Data alone will not answer all the questions, but is allows more refined reviews Who?- Who is writing for the antibiotics? What?- What is the most frequently used antibiotic? Where?- Are there units that tend to use the most antibiotics? When?- Are there times when antibiotics are most likely to be prescribed? Why? - What is the most common reason antibiotics are used? From there Conversations become more productive Guidelines for use can be created with provider input Remember- always ask why- the reasons behind the use might not be what you had guessed!
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