Strategies for Improving Antimicrobial Use and the Role of Antimicrobial Stewardship Programs

Thomas M. File Jr () 1 2 3 Joseph S. Solomkin 0 2 Sara E. Cosgrove 2 4 0 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio 1 Department of Internal Medicine, Infectious Disease Service, Summa Health System , Akron, Ohio 2 Disease Service, Summa Health System , 75 Arch St, Ste 506, Akron, OH 44304 3 Department of Internal Medicine, Infectious Disease Section, Northeastern Ohio Universities, Colleges of Medicine and Pharmacy , Rootstown, Ohio 4 Department of Medicine, Division of Infectious Diseases, Antibiotic Management Program, Johns Hopkins Medical Institutions , Baltimore, Maryland CENTERS FOR MEDICARE AND MEDICAID SERVICES PERFORMANCE MEASURES AND QUALITY OF CARE INITIATIVES Improving Antimicrobial Use Through Antimicrobial Stewardship Programs d CID 2011:53 (Suppl 1) d S15 - To evaluate the quality of patient care in specific disease states, the Centers for Medicare and Medicaid Services (CMS) tracks hospital adherence to specific evidencebased performance measures. The performance measures are processes of care for which there is a strong link between the process and patient outcomes; they provide objective evaluations of hospital performance and patient care. Currently, CMS supports initiatives in several areas: heart failure, myocardial infarction, community-acquired pneumonia (CAP), and postsurgical complications (through the Surgical Care Improvement Project [SCIP]). CMS performance measures, as well as other quality-improvement initiatives, work synergistically with antimicrobial stewardship programs (ASPs), which are also strategies for improving drug use and patient care. Like ASPs, core performance strategies, among other goals, promote appropriate antimicrobial selection and use. Thus, performance measures can bolster the influence of ASPs, and ASPs can facilitate the implementation of performance measures. This article reviews CAP performance measures, SCIP, and strategies for genitourinary infections, and their intersection with ASPs. To evaluate the quality of patient care and provide objective means to assess improvement in care in specific disease states, the Centers for Medicare and Medicaid Services (CMS) tracks hospital adherence to specific, evidencebased performance measures. The performance measures are processes of care for which there is a strong link between the process and patient outcomes [1, 2]. Performance measures are based on processes of care (eg, choice of diagnostic studies or antimicrobials), which are encounters between patients and health care workers (HCW) that are tangible, quantitative, and within the control of the HCW. They are based on evidence-based guidelines; as such they provide objective evaluations of hospital performance and patient care. Process of care measures are unlike measurements of patient outcomes, which are often dependent on factors outside the control of the HCW (eg, patients comorbid status, lifestyle choices, and adherence to prescribed medications) [1]. Currently, CMS supports quality improvement initiatives in several resource-intensive diseases: heart failure, myocardial infarction, communityacquired pneumonia (CAP), and prevention of postsurgical complications (the Surgical Care Improvement Project [SCIP]). Ideally, CMS performance measures, as well as other quality improvement initiatives, should work synergistically with antimicrobial stewardship programs (ASPs), which are, in themselves, strategies for improving drug use and patient care. Like ASPs, core performance strategies, in addition to promoting smoking cessation counseling, vaccination, and education, are designed to promote appropriate antimicrobial selection and use. Thus, performance measures issued and supported by government agencies and/or professional societies can help bolster the influence of ASPs and ASPs, in turn, can facilitate and control the implementation of performance measures. COMMUNITY-ACQUIRED PNEUMONIA: CENTERS FOR MEDICARE AND MEDICAID SERVICES CORE PERFORMANCE MEASURES In 2007, pneumonia/influenza was the eighth leading cause of death in the United States, accounting for 52 717 deaths or 2.2% of all deaths and 1.1 million hospital discharges [3, 4]. Although this represented a 9% decrease in deaths from 2006, the crude pneumonia/influenza-associated mortality rate was, nevertheless, 17.5 per 100 000 population. The economic burden associated with CAP remains substantial at $17 billion annually in the United States [5]. The current CMS performance measures for CAP include blood cultures, timely antimicrobial therapy, appropriate antimicrobial selection, smoking cessation, vaccination, and measuring mortality (Table 1) [3]. The recommendations are based on the most recent Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) CAP guidelines, and some are used to determine hospital eligibility for reimbursement (Table 1). The implementation of performance measures is variable, and there is a potential for unintended consequences [7]. The goal for rates of compliance of these measures should have a realistic benchmark limit instead of 100% since they were not designed to cover all possible host and epidemiological settings. Deviation from a performance measure should be acceptable if it is well documented in the chart and based on sound reason. National comparative rates of compliance of the specific core measures are listed in Table 2 indicating significant improvement over the past decade. Indeed, in light of the very high compliance rate of measurement of blood gases or pulse oximetry, this measure was retired in 2009. Measures of particular relevance to ASPs are the recommendations for antimicrobial timing and antimicrobial selection. Presently, the timing measure lists that antimicrobial therapy be initiated within 6 hours of presentation to the institution. The rational underlying specific timing was based on to 2 large (.10 000 patient databases), multicenter, retrospective cohort studies in Medicare-recipient inpatients [8, 9]. Initially, the time listed was 8 hours and then changed to 4 hours on the basis of the second trial, suggesting additional benefit [9]. However, the 4-hour measure was viewed by many as possibly Measure Blood cultures Antimicrobial therapy within 6 hours of presentation Antimicrobial selection according to guideline recommendations Measurement of blood gases or pulse oximetry Assessment/administration of pneumococcal and influenza vaccine Smoking-cessation counseling CAP mortality b Applicable patient groups a d All ICU patients, those with active alcohol abuse, and those with pleural effusion d Optional for patients in general wards d Taken prior to antimicrobial treatment if obtained in emergency department All patients All patients (exceptions: pathogen-directed therapy, clinical studies, diagnostic uncertainty) All patients All patients admitted to hospital (universal measure) Status Current Reimbursement measur (...truncated)