Value-Added Activities in Antibiotic Stewardship

Because antibiotic stewardship is so closely associated with clinical quality, the Quality Payment Program (QPP) includes several process measures related to appropriate antibiotic use. Antibiotic Stewardship is a proven strategy to improve clinical outcomes; promote patient safety; prevent adverse drug events and curtail the emergence of antibiotic-resistant bacteria

MIPS Quality Measures

As part of the QPP, eligible clinicians are expected to report a total of six quality measures, including an outcome measure. There are several measures that involve antibiotic stewardship. Some measures involve antibiotic prescribing for children, while other measures focus on prescribing for adults or specialty settings. Quality measures comprise 50% of the final MIPS score. A few measures that relate to antibiotic stewardship are listed below:

  • Quality ID 021 – Perioperative care: Selection of prophylactic antibiotic – First OR Second generation cephalosporin
  • Quality ID 065 – Appropriate treatment for children with upper respiratory infection
  • Quality ID 066 – Appropriate testing for children with pharyngitis
  • Quality ID 091 – Acute otitis externa (AOE): Topical therapy
  • Quality ID 093 – Acute otitis externa (AOE): Systemic antimicrobial therapy – Avoidance of inappropriate use
  • Quality ID 110 – Preventive care and screening: Influenza immunization
  • Quality ID 111 – Pneumococcal vaccination status for older adults
  • Quality ID 116 – Avoidance of antibiotic treatment in adults with acute bronchitis
  • Quality ID 331 – Adult sinusitis: Antibiotic prescribed for acute sinusitis (Overuse)
  • Quality ID 332 – Adult sinusitis: Appropriate choice of antibiotic: Amoxicillin, with or without clavulanate, prescribed for patients with acute bacterial sinusitis (Appropriate Use)
  • Quality ID 407 – Appropriate treatment of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia

These quality measures consider whether appropriate diagnostic testing was performed; whether the appropriate drug type was prescribed when antibiotics were indicated; and whether antibiotics were prescribed for conditions that did not merit antibiotic therapy. Two measures reflect the percentage of patients who received vaccinations for influenza and pneumococcal disease. There is a measure for appropriate pre-op antibiotic selection, and a measure focused on optimal treatment for a particular type of bloodstream infection.

Information about data submission for these quality measures may be found on the QPP website: https://qpp.cms.gov/mips/quality-measures

Clinical Practice Improvement Activities

Improvement Activities (IAs) are another part of the QPP, comprising 15% of the final MIPS score. Antibiotic stewardship activities can help satisfy the following IAs in the Patient Safety and Practice Assessment (PSPA), Population Management (PM) and Beneficiary Engagement (BE) subcategories.

  • IA_PSPA_15: Implementation of an antibiotic stewardship program
  • IA_PSPA_16: Use of decision support and standardized treatment protocols
  • IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
  • IA_PM_16: Implementation of medication management practice improvements
  • IA_BE_12: Use evidence-based decision aids to support shared decision-making

Information about data submission for these improvement activities may be found on the QPP website: https://qpp.cms.gov/mips/improvement-activities

Implementation of an antibiotic stewardship program can count as a medium-weight clinical practice improvement activity (IA) under the Patient Safety and Practice Assessment category. To get credit for this IA, the antibiotic stewardship program should involve measuring the appropriate use of antibiotics for several different conditions. These conditions include upper respiratory infection (URI) in children, diagnosis of pharyngitis, and diagnosis of bronchitis in adults. Antibiotic prescribing should be evaluated in the context of clinical guidelines for diagnostics and therapeutics.

Antibiotic use can also be integrated into several other improvement activities (IA). One of these is “Implementation of Medication Management Practice Improvements.” Attesting to this IA means that the clinician is implementing practices to manage medication to maximize efficiency, effectiveness and safety. Reconciling patients’ medication, including recent antibiotic use, helps to coordinate and manage medication use across transition of care settings and among clinicians or groups. This IA can include integration of a pharmacist into the care team and/or conducting periodic, structured medication reviews. This activity can help identify potential medication interactions, inappropriate drug/dose/duration, and make sure patients receive optimal care.

The CDC published “The Core Elements of Outpatient Antibiotic Stewardship” in 2016 to help guide efforts to improve antibiotic use in clinics, urgent care centers, emergency departments, dental practices, community pharmacies, and other settings involved in outpatient care. The 4 core elements of outpatient antibiotic stewardship are:

  • Commitment
  • Action
  • Tracking & Reporting
  • Education & Expertise

The CMS Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) are currently supporting outpatient settings in an initiative to implement all 4 core elements of outpatient antibiotic stewardship. The initiative is formally called “Combating Antibiotic-Resistant Bacteria through Antibiotic Stewardship in Communities” and incorporates activities, data reports, and technical assistance consistent with the CDC guidelines. As settings/providers implement the core elements of antibiotic stewardship, they are on track to fulfill various components of the Quality Payment Program (QPP).

Antibiotic use is a substantial patient safety issue. A study recently published in the Journal of General Internal Medicine outlined statistics about rates of emergency department (ED) visits by adults for antibiotic adverse events (AEs). Types of adverse events include allergic reactions, side effects, and interactions with other prescription or nonprescription medications. Antibiotic reactions are the leading cause of emergency department visits for adverse drug events (ADEs) in children. The risk of unintended harm from antibiotics means that clinicians should be diligent in making sure they are appropriately used, and not prescribed “just in case.”

The benefits of antibiotic stewardship extend across every segment of health care. Stewardship activities can help reduce hospital readmissions, improve patient satisfaction, and decrease the incidence of Clostridium difficile infections. Proper sepsis management includes antibiotic stewardship as clinicians initiate broad-spectrum therapy and then appropriately adjust the antibiotic treatment regimen as cultures or lab tests are available to help pinpoint the source of infection.

The Gut Microbiome

The crux of why antibiotics have so many implications for health is their effect on microorganisms in the gastrointestinal tract. The microbes in the GI tract play a role in metabolism, nutrient absorption, serotonin production, and the immune system, among countless other bodily processes. Antibiotics can disrupt the microbiome and have implications for mental and physical health. Antibiotic misuse is associated with higher rates of depression, obesity, Type 2 diabetes, asthma, allergies, and various autoimmune and inflammatory diseases. Antibiotic use is a major risk factor for Clostridium difficile infection (CDI), which usually results when the levels of beneficial microbes are diminished, allowing the toxin-producing C. diff bacteria to proliferate and destroy the lining of the colon. Antibiotic stewardship is a vital part of health promotion and disease prevention.

Sepsis

What is the role of antibiotic stewardship in the context of sepsis management? Some medical providers have expressed anxiety over the pressure they feel to be good antibiotic stewards when also confronted with the need to respond rapidly with broad-spectrum antibiotics when sepsis is suspected. Proper sepsis management is consistent with good stewardship. If a patient has a life-threatening infectious condition, such as sepsis, appropriate treatment may include rapid administration of broad-spectrum antibiotics. Good stewardship also means that the antibiotic regimen should be de-escalated or refined once more test results are available to confirm the type of infection, antibiotic susceptibility, etc. By all means, treat the sepsis; but continually evaluate the clinical situation to identify opportunities to back off of broad-spectrum antibiotics if/when appropriate.

Antibiotics are the most important tool we have for fighting life-threatening bacterial infections, and yet resistance to these drugs is now one of the world’s most pressing public health threats. There are free resources available to educate patients about appropriate antibiotic use. Public awareness campaigns are hoping to shape the expectation that some people have about receiving an antibiotic prescription for common conditions, such as acute sinusitis, acute bronchitis, influenza, and non-Strep pharyngitis.

An example of one tool is Treating Sinus Problems, Don’t rush to antibiotics.

The CDC’s “Be Antibiotics Aware” campaign asks people not to insist on getting antibiotics if their doctor says they don’t need them, and not to take antibiotics prescribed for someone else.

Antibiotic stewardship has a key role in the “One Health” concept, which recognizes the interconnectedness of the health of people, animals, and the environment. Stewardship principles help to ensure that infectious diseases are promptly identified and properly treated while being mindful of ways that various disciplines must work together across human health professionals, veterinary medicine, agriculture, and environmental scientists.

Antibiotic stewardship activities are advantageous, in terms of cost savings, combating antibiotic-resistant bacteria, and considering that patients may get upset if they realize they suffered side effects of medications they didn’t really need. Adherence to current treatment guidelines can help protect the reputations of facilities/providers. When properly implemented, antibiotic stewardship activities add value by promoting safety, improving clinical outcomes, curtailing excess healthcare costs, and enhancing patient satisfaction. The use of quality measures and improvement activities, as specified in the Quality Payment Program, offer targeted, meaningful strategies for incorporating the tenets of antibiotic stewardship into any practice setting. Antibiotic stewardship activities can help your clinic meet the 2018 Quality Payment Program requirements, while also bringing value to your practice and reinforcing best practices for optimal antibiotic use and safe care.

Antibiotic Awareness Week 2018

Antibiotic Awareness Week is November 12-18, 2018. The CDC has promotional materials, educational resources, and suggested activities on their website.

 

Helpful Resources:

The Core Elements of Outpatient Antibiotic Stewardship

Summary of current national clinical practice guidelines for common outpatient infections in children and adults

Choosing Wisely

IDSA – Practice Guidelines

(FREE) Online CME Course – To Prescribe or Not to Prescribe? Antibiotics and Outpatient Infections

SHEA – Primer on Healthcare Epidemiology, Infection Control & Antimicrobial Stewardship (CME available)

American Academy of Family Physicians (AAFP) – Use of Antibiotics for Acute Respiratory Tract Infection

One Health