Appropriate is the new byword in hospitals
AHA project aims to curb overuse of key treatments
There have been several efforts by various groups to curb overuse of healthcare treatments in different settings — use of antibiotics for uncomplicated ear infections in children, for example, and the use of surgery to correct back problems that might be resolved without it. Official projects include the Choosing Wisely campaign by the American Board of Internal Medicine Foundation (http://www.choosingwisely.org) and the National Physicians Alliance’s Promoting Good Stewardship in Medicine project (http://npalliance.org/promoting-good-stewardship-in-medicine-project/). The American Hospital Association (AHA) stepped up, focusing on hospital-based issues in healthcare that have the potential to be overused. The Appropriate Use campaign was launched at the end of 2013 with the following five focus points, according to the AHA white paper Appropriate Use of Medical Resources:
- "appropriate blood management in inpatient services;
- "appropriate antimicrobial stewardship;
- "reducing inpatient admissions for ambulatory-sensitive conditions (i.e., low back pain, asthma, uncomplicated pneumonia);
- "appropriate use of elective percutaneous coronary intervention; and
- "appropriate use of the intensive care unit for imminently terminal illness (including encouraging early intervention and discussion about priorities for medical care in the context of progressive disease)."
By the spring of 2015, each of them will have a toolkit for hospitals to use that will help them assess where they are and where they need to improve. To date, kits for blood management and antimicrobial stewardship have been released. The next, reducing inpatient admissions for ambulatory-sensitive conditions, comes out later this month, followed by one in January and another in March. The first two have been downloaded more than 2,000 times each, and the AHA is eager to continue to spread the word about the resources available to hospitals that want to examine their practices in these areas, says John R. Combes, MD, senior vice president at the AHA and the president of the Center for Healthcare Governance.
He says the committee who got together to create the white paper on appropriate use (available at http://www.ahaphysicianforum.org/resources/appropriate-use/index.shtml) was determined to focus on things that were completely in a hospital’s control. While there was no "top 10" list that was whittled down, nor items that were "voted off the island," there were issues that were left off the list for now.
Combes says that in a year or so, the group will return to work to add additional items for consideration. For example, one item of concern is complex imaging procedures and how to reduce the number of images a patient has. "The caveat remains that these must be things that are under the hospital’s influence, not the physician. We will trace this first list, and add some later. But for now, this is a good place to start."
Everything on the list piqued the interest of the committee members, Combes says, but the final item — appropriate use of the intensive care unit for patients with early terminal illness — is something that people really talked a lot about. "It costs a lot of money, takes a lot of resources, and the care is not really beneficial in terms of the patient’s quality of life."
It is a hard thing, though, to talk to patients about: that there is nothing that the best medical care in the world can do for you, or your loved one. The toolkit being created for hospitals to use surrounding the issue should help provide resources for that kind of discussion.
The first toolkit created, for appropriate use of blood products (http://www.ahaphysicianforum.org/resources/appropriate-use/blood-management/index.shtml), was released in March. It includes a readiness assessment for leadership, a webinar and iPhone app for clinicians that includes a transfusion data card summarizing clinical practice guidelines for adult and pediatric patients, a card on managing transfusion reactions, and a review of licensed and some unlicensed blood components, their use, and various precautions and potential side effects. There is also a patient handout.
Combes says that sitting down with physician leaders and your leadership team to discuss what your blood management system looks like now, and what might make it look better is a good place to start before beginning with the toolkit.
The antimicrobial management toolkit (http://www.ahaphysicianforum.org/resources/appropriate-use/antimicrobial/index.shtml), released in July, includes a hospital assessment for leadership, evidence-based guidelines for physicians and a webinar, as well as supporting articles, and for patients, handouts and brochures to help them understand the reasoning behind the choices physicians are making on their behalf.
The suggested program looks almost exactly like what is in use at Blanchard Valley Health System of Findlay, OH, says its president and CEO, Scot Malaney. They started in 2005, and for the past six years have had every single patient receiving antibiotics reviewed. "When the toolkit came out, we were pleased to find we were already doing the same things they suggested," he says.
They have a strong interdisciplinary team including infection prevention, an advanced degree dietitian, infectious disease physician, advanced degree pharmacist, as well as leadership and nursing. The motto is "the right drug for the right bug," and every patient is cultured, with wide-spectrum antibiotics avoided.
"Sometimes, we have to talk through options, because good docs can disagree with each other," says Malaney. But the approach was approved by widely respected people — the Purdue-educated director of pharmacy, says Malaney, and infectious disease physicians who had "cred" with the staff. Added to that were data that showed the staff that more expensive drugs weren’t having better outcomes than cheaper ones. "We haven’t used a single high-priced antibiotic this year," he says, "not even for C. diff."
If an antibiotic stops working, the staff take it off the formulary for a year. Once it has been rested, they try it again to see if it is efficacious again, he says. "We have learned to be careful with our antibiotics, and we will bench something if it does not work."
Like the AHA program, they have also worked at Blanchard to educate the community about antibiotics, aiming at new parents in particular, hoping that knowing antibiotics might not be good for their child in the long run might be enough to keep parents from insisting on them at the first sign of ear infections.
The hospital’s dietary staff have also started giving probiotic-enhanced yogurt to all patients on antibiotics. Although the science is not clear on whether this works, the experience of patients in the hospital seems to be positive: fewer stomach ailments related to antibiotics since the yogurt push started.
"We have a goal of no reportable defects. I do not think you can ignore antibiotic overuse in that. If you do not get it right, it is a strike against us."
Malaney may be harder on himself than Combes would be. But he approves the effort to embrace the aims of the toolkit.
The AHA will track data with the help of partners for each of the domains. The American Association of Blood Banks will keep track of transfusion rates, blood products used, and costs, among other data. For antimicrobial use, the Centers for Disease Control and Prevention will look at the number of antimicrobial stewardship programs in operation. It will also monitor those programs’ effectiveness, and rates of infections with bugs like C. difficile.
Combes is hopeful that people will change their behaviors as a result of these efforts, and that there will be less risk to patients, less unnecessary care and cost. He has good reason to be hopeful, he says. "Every one of these kits has scientific evidence behind it. When you show people what works and why, and how it is clearly shown in the literature, they tend to adopt those practices."
For more information on this topic, contact:
- John R. Combes, MD, Senior Vice President, American Hospital Association, Chicago, IL. Telephone: (312) 422-3000.
- Scott Malaney, President and Chief Executive Officer, Blanchard Valley Health System, Findlay, OH. Telephone: (419) 423-4500.