In the News

Inpatient antibiotic prescribing, bundled payments and joint replacement costs, and more.

Overall inpatient antibiotic prescribing unchanged from 2006 to 2012

Inpatient use of antibiotics remained steady from 2006 to 2012, but the use of broad-spectrum antibiotics increased significantly, a recent large study found.

The retrospective analysis used data from more than 300 acute care hospitals, covering 166 million adult and pediatric patient-days between 2006 and 2012. Across the entire time period, 55.1% of the patients received at least 1 dose of antibiotics during their hospital stay and there were 755 days of antibiotic therapy per 1,000 patient-days. The study was published in the November JAMA Internal Medicine.

The rate of antibiotic use did not change significantly over the study period. However, there were significant increases in the use of certain antibiotic classes: third- and fourth-generation cephalosporins (mean change, 10.3), macrolides (4.8), glycopeptides (22.4), beta-lactam/beta-lactamase inhibitor combinations (18.0), carbapenems (7.4), and tetracyclines (3.3). The authors noted that these increases were offset by decreases in certain classes, including first- and second-generation cephalosporins and fluoroquinolones, although the latter remained the most commonly used antibiotic class.

The lack of change in overall use and increase in the use of broad-spectrum antibiotics “is worrisome in light of the rising challenge of antibiotic resistance,” the study authors concluded. They noted that antibiotic use in the U.S. differs substantially from that in the United Kingdom and France and suggested that U.S. hospitals could potentially benefit by following other countries' models, for example, replacing some fluoroquinolone and cephalosporin use with penicillin to reduce Clostridium difficile risk.

An accompanying commentary offered additional solutions to reduce antibiotic prescribing, including reframing overuse from a public health issue to an individual patient concern and using social psychology and behavioral science strategies (such as order entry systems and peer comparison feedback) on physicians. “The overuse of antibiotics is not a knowledge problem or a diagnostic problem; it is largely a psychological problem,” the commentary said.

Bundled payment initiative may have reduced costs of joint replacement

Medicare payments for lower-extremity joint replacement episodes declined more in hospitals participating in Bundled Payments for Care Improvement (BPCI) than in comparison hospitals, without a significant change in quality outcomes, a study found.

Researchers estimated the change in outcomes for Medicare fee-for-service beneficiaries who had a lower-extremity joint replacement (primarily hips and knees) at a BPCI-participating hospital between the baseline period of October 2011 through September 2012 and the intervention period of October 2013 through June 2015 and compared outcomes to patients undergoing the same surgical procedure at matched comparison hospitals. Results were published in the Sept. 27 JAMA.

There were 29,441 lower-extremity joint replacements in the baseline period and 31,700 in the intervention period at 176 BPCI-participating hospitals. There were 29,440 procedures in the baseline period (768 hospitals) and 31,696 in the intervention period (841 hospitals) at matched comparison hospitals.

In BPCI hospitals, mean Medicare joint replacement episode payments were $30,551 (95% CI, $30,201 to $30,901) in the baseline period. They declined by $3,286 to $27,265 (95% CI, $26,838 to $27,692) in the intervention period. The mean payments in comparison hospitals were $30,057 (95% CI, $29,765 to $30,350) in the baseline period. They declined by $2,119 to $27,938 (95% CI, $27,639 to $28,237) during the intervention. The mean Medicare episode payments declined by an estimated $1,166 more (95% CI, −$1,634 to −$699; P<0.001) for BPCI episodes than for comparison episodes, primarily due to reduced use of institutional postacute care, the study found.

There were no statistical differences between hospital groups in the claims-based quality measures, which included unplanned readmissions, emergency department visits, and postdischarge mortality, all measured at 30 and 90 days. The authors wrote, “This analysis of lower-extremity joint replacement episodes, which account for more than 450,000 Medicare hospitalizations per year, significantly extends the evidence on the use of payment incentives to reduce spending for episodes of care, while maintaining or improving quality.”

An editorial noted that using a different end point that takes volume into account—mean total joint replacement payments per hospital—showed that total spending actually declined less in BPCI hospitals than in comparison hospitals, specifically, a 6.3% decrease. In the comparison hospitals, there was a 7.7% decrease. The data seem consistent with a greater shift toward healthier patients in the BPCI hospitals than in the comparison group, the editorial continued.

“It is thus too soon to tell whether the portion of the BPCI initiative focused on lower extremity joint replacement is actually improving care and achieving savings for the Medicare program,” the editorial stated, adding that the new Comprehensive Care for Joint Replacement (CJR) initiative will include more hospitals and provide more rigorous evaluation of the effects.

A viewpoint challenged that the CJR model occurs in the setting of a disproportionate rate of arthritis-related activity, work limitations, and severe pain affecting African-American patients compared with white patients, even though whites have higher rates of elective joint replacement (41.5 per 10,000 for black patients vs 68.8 per 10,000 for white patients; P<0.001).

“The CJR program will move the health care payment system away from fee-for-service to alternative payment models that could in the long run improve patient outcomes while lowering the cost of care,” stated the viewpoint. “However, there is always potential for unintended consequences, including the potential widening of racial disparities in utilization of joint replacement surgery. Evaluation of the policy should include specific assessments on how implementation of the model affects the existing racial disparity in joint replacement use and outcomes and how the model could be fine-tuned to address an important disparity in elective surgical care.”

Antibiotic duration excessive in hospitalized VA patients with CAP and HCAP

The majority of veterans hospitalized with uncomplicated pneumonia received antibiotics for longer than guidelines recommend, according to a recent study.

The retrospective study reviewed records from 30 Veterans Affairs medical centers for inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or health care-associated pneumonia (HCAP) in 2013. Duration of therapy was compared to guidelines from the Infectious Disease Society of America and American Thoracic Society. Appropriate duration of therapy was defined as 8 days for HCAP, and at least 5 days, with up to 3 additional days after clinical stability, for CAP. Results were published by the Journal of Hospital Medicine on Aug. 16.

Only 13.9% of the 1,739 studied patients received therapy of an appropriate duration: 6.9% of CAP patients and 29% of HCAP patients. Patients spent a median of 4 days on inpatient IV antibiotics, 1 day on inpatient oral, and 6 days on outpatient oral (interquartile ranges 3-6 days, 0-3 days, and 4-8 days, respectively). Researchers noted that 97.1% of the patients met clinical stability criteria before day 4 of hospitalization, yet the median duration of IV therapy was 4 days. There were no significant associations between duration of therapy and rates of readmission and mortality.

The results show that antimicrobials were commonly prescribed for longer than recommended, and that about half of excess therapy occurs after discharge, the study authors concluded. Other significant findings include that only 41% of patients had a respiratory tract culture collected and that fluoroquinolones were frequently used for outpatient therapy, they noted. Limitations include that the study was conducted entirely in the patient population of the Veterans Affairs system, which is predominantly elderly and male.

The findings could potentially be used to expand and target antibiotic stewardship efforts, according to the authors. “Pivotal time points for antimicrobial stewardship intervention include day 2 to 3 of hospitalization when conveying suggestions for antimicrobial de-escalation and/or IV to [oral] conversion, and toward the end of hospitalization during discharge planning,” they wrote.