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
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
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”
Case Study: 72 Year Old Diabetic Woman
Emergency
Dept.
Day 0
Presents with
fever and
painful, red foot
Nursing
Home
Hospital
Day 1
Day 2
Day 3
Day 4
Day 11 Day 12
Day 13 Day 14
After 12 days in hospital, patient
discharged to Nursing Home
Treated with
broad-spectrum
antibiotics
Fever not better,
Abx changed
Develops
diarrhea
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.
Case Analysis
Emergency
Dept.
Day 0
Presents with
fever and
painful, red foot


Potentially avoidable
complication of
antimicrobial
therapy leading to
lengthy stay
Numerous
antibiotics – most of
which not needed 
Nursing
Home
Hospital
Day 1
Day 2
Day 3
Day 4
Day 13 Day 14
After 12 days in hospital, patient
discharged to Nursing Home
Treated with
broad-spectrum
antibiotics
Fever not better,
Abx changed
Develops
diarrhea
ID
Called
Late consultation
with infectious
disease
Day 11 Day 12
• 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.

Wrong
initial
diagnosis

Prolonged
recovery
including
sub-acute
stay
Key Take-Aways
• Inappropriate diagnosis and
treatment for infectious diseases is
costly to the patient and system
• Late consultation with ID specialist is
costly
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
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.hcupus.ahrq.gov/reports/statbriefs/sb160.pdf.
Infection Related Health Care
Admissions
•
Primary Diagnosis
–
–
–
–
•
Pneumonia
Septicemia
Complications of implant
Skin and subcutaneous tissue infection
Ranking*
1
4
7
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.
Infection Related Health Care
Re-Admissions
•
Primary Diagnosis
–
–
–
–
–
•
Pneumonia
Septicemia
Complications of implant
Skin and subcutaneous tissue infection
Urinary tract infections
Ranking*
1
4
8
9
12
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.
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
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
NATIONAL
SUMMARY
ATA
Estimated minimum number of illnesses and
deaths caused by antibiotic resistance*:
2,049,442
23,000
At least
illnesses,
deaths
*bacteria and fungus included
in this report
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:
At least
W Ant mo to and
250,000
14,000
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.
The Infectious Diseases Service
Line Is A Solution
•
•
•
•
•
•
Antimicrobial Stewardship
Clinical Care
Infection Prevention
Microbiology Laboratory
Employee Health
Resource Management
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/
2. Anderson DJ, Moehring RW, Sloane R, Schmader KE, Weber DJ, et al. (2014)
Bloodstream Infections in Community Hospitals in the 21st Century: A Multicenter
Cohort Study. PLoS ONE 9(3): e91713. doi:10.1371/journal.pone.0091713
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
Stewardship Creates Value
ID Specialists Improve Outcomes
and Reduce Cost – Clinical Care
Early ID Clinician Engagement for
clinical care is critical to achieve
the best outcomes
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
Improving Outcomes and
Reducing Costs
• Infection Prevention Intervention
Clostridium difficile at Rhode
Island Hospital
Metric
2006
2012
Incidence/1000
discharges
12.2
3.6
Mortality (N)
52
19
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.
ID Clinicians Offer A Unique System
and Population Orientation
• Long-term focus of risk reduction and safety through systemwide 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
The Infectious Diseases Service
Line Is the Solution
Clinical Care
ID
Specialist-led
Interventions
Efficient
Resource
Utilization
Early ID consults
Infection Control &
Prevention
Judicious use of
radiology services,
micro/lab services
Rescue ID
Antimicrobial
Stewardship
Hazardous waste
(“red bag”)
management
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
Hospital
Bundled Payment
Total Knee Replacement
Payer
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
$$$$$
There is a Better Way to
Mitigate Risk
Hospital
Bundled Payment
Total Knee Replacement
Co-Management Agreement or
Gain-sharing agreement with your
ID Clinicians
ID Services
ID
Specialist-led
Interventions
Efficient
Resource
Utilization
Early ID
consults
Infection
Control &
Prevention
Judicious use of
Imaging/ Labs
Rescue ID
Antimicrobial
Stewardship
Hazardous
waste
management
Clinical Care
Payer
Link payment to Quality:
•
Metrics for acute care
– Antibiotic utilization
– Resistant organism prevalence
– C. difficile rates
– CLASBI, CAUTI, SSI
•
Metrics for population management
– Readmissions
– Vaccination rates
Strategies to Limit Hospitalization and
Cost Without Sacrificing Outcomes
• Acute infection diagnosis
– Acute infection medical service
• Out patient – Alternate site care
• Early ID Consultation
• Rescue care
• Readmission
– Focused programs on septicemia, pneumonia, UTI
and surgical wound disruptions at LTC
Case Study – Alternate Site Care
•
•
54 yo man with fever for 2 weeks had blood cultures performed by his
doctor.
He was seen by ID doctor because of long duration of fever.
–
–
•
•
•
Blood cultures positive for Streptococcus bacteremia. IV antibiotic treatment started as outpatient.
Workup and treatment for endocarditis complicated as outpatient
Total savings = $10,000 (Based on Millman and hospital per diem)
Patient Satisfaction = High
Risks = marked reduction for HAI
ED/Hosp
Option 1 – Send patient to ED
$$$$$
Option 2 – OPAT and care
management under ID
$$
PCP
Outpatient ID
The Infectious Diseases Service
Line
• Is a solution for
– Quality
– Cost
– Outcomes
VALUE
Final Key Messages
Aligning incentives through gain
sharing and co-management for the ID
Service line provides a mechanism to
achieve greater value
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
THANK YOU!
QUESTIONS or COMMENTS?