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    Four steps managed care can take to promote antimicrobial stewardship

    The call for antimicrobial stewardship is growing in the healthcare landscape. Reports of pan–drug-resistant infections have occurred and, without action, society risks returning to the pre-antibiotic era. An underlying cause of resistant bacteria is the overuse of antibiotics. The Centers for Disease Control and Prevention (CDC) estimates that 30% of antibiotic prescriptions are unnecessary. The federal government’s National Action Plan for Combating Antibiotic-Resistant Bacteria was released to provide guidance on reducing antibiotic use in unnecessary situations and help stem resistance development. The report’s goals include slowing the emergence and spread of resistant infections, strengthening resistance-prevention efforts, and accelerating the development of new treatments.

    Health plans and PBMs face complications in how to contribute to antimicrobial stewardship. Patients receiving antimicrobials often receive a short course of treatment, require a specific product based on the infectious organism and site, and may be transitioning home to finish therapy from a healthcare facility where therapy was started. These factors make traditional management techniques difficult. In addition, antimicrobials tend to be generic and inexpensive, which reduces a payer’s focus and resources in managing antimicrobials. 

    Challenges aside, payers nonetheless have capabilities to assist in antimicrobial stewardship. The following four steps, when enacted by payers, may help facilitate appropriate antimicrobial use and reduce the rise of resistant bacteria and other microbes, such as drug-resistant fungi. Health plans may wish to include any or all of these steps in their quality improvement programs and work plans.

    Step 1: Reward antimicrobial stewardship

    In November 2016, augmenting previously issued guidance for antibiotic stewardship in hospitals and nursing homes, the CDC released the Core Elements of Outpatient Antibiotic Stewardship. The outpatient core elements include commitment, taking action for policy and practice, tracking and reporting, and education and expertise. The guidance provides recommendations on optimizing antimicrobial use, setting policies for effective antimicrobial prescribing, tracking success, and providing education to clinicians and staff. A payer can engage by rewarding network health systems that have a documented antimicrobial stewardship program and demonstrating improvement in outcomes. Payers can monitor participating systems’ bacteria resistance rates and overall antimicrobial usage as performance end points. Rewards could include improved reimbursement rates or preferred network status.   

    Step 2: Leverage quality scores

    The National Committee for Quality Assurance (NCQA) includes quality measures related to appropriate antimicrobial use within its Healthcare Effectiveness Data and Information Set (HEDIS® ) for health plans. Measures include:

    ·      Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

    ·      Appropriate Testing for Children With Pharyngitis

    ·      Appropriate Treatment for Children With Upper Respiratory Infection

    Performance on each measure generally improves with appropriate antibiotic use. Evaluating performance on the Plan All-Cause Readmissions quality measure may be beneficial as well, considering that infection is a frequent cause of rehospitalization. Payers should assess their quality scores on these measures and identify practices, hospitals, or prescribers that may be contributing to suboptimal performance. The payer could notify providers of poor performance, reinforce the importance of antimicrobial stewardship, and provide guidance on how to improve. Repeat poor performers could be subject to penalties, including reduced reimbursement, exclusion from preferred high performance networks, or network decredentialing. Payers may encourage adoption or advancement of antimicrobial stewardship initiatives further with incentives to health systems and hospitals.

    NCQA included in HEDIS 2017 a new measure, the Standardized Healthcare-Associated Infection Ratio. This measure is used to evaluate a potential infection risk for members admitted to hospitals within the plan’s networks.   The four healthcare-associated infections addressed by the measure are (ratios publicly reported by CMS):

    ·      Central line-associated bloodstream infections (CLABSI)

    ·      Catheter-associated urinary tract infections (CAUTI)

    ·      Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections

    ·      Clostridium difficile (CDIFF) intestinal infections

    The measure stratifies facilities’ standardized infection ratios (SIRs) by risks of exposure (high, moderate, low or unavailable) and estimates a member’s potential infection risk based on the percentage of discharges that fall within each risk classification. The measure also reports a plan-weighted SIR that facilitates comparisons among plans for infection exposure risk.

    Payers can monitor performance on the new measure as data become available and  identify facilities contributing to sub-optimal performance. Payers may request action plans for performance improvement from these facilities, many of which are subject, as of January 1, 2017, to The Joint Commission’s new Antimicrobial Stewardship Standard. Facility hospitals performing well on the measure or demonstrating improvement could be rewarded as noted previously. Performance data on healthcare-acquired infections among Medicare-certified hospitals is presently available through Hospital Compare (according to CMS) and through other quality metric and performance aggregator tools such as Qnav. Plans may wish to review the performance of high-volume hospitals within their network and proactively develop strategic collaborations on infection reduction and antimicrobial stewardship initiatives.  Collaborations could potentially include health systems and other stakeholders, such as employer coalitions, patient safety advocacy groups, and pharmaceutical companies.

    Next: Steps #3 and #4



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