Telehealth stewardship, addiction consults

Summaries from ACP Hospitalist Weekly.

Telehealth-based antimicrobial stewardship program worked in two community hospitals

Through a partnership between two health systems, two community hospitals went from having no formal antimicrobial stewardship program to seeing positive results from a telehealth-based stewardship program.

The hospitals implemented a stewardship program in which local pharmacists were trained to conduct prospective audit and feedback. As part of the intervention, infectious disease physicians from a separate health system remotely reviewed patients on broad-spectrum antibiotics and those admitted with lower respiratory tract infections and skin and soft-tissue infections with the local pharmacists for about 60 minutes three times weekly at the 285-bed hospital and two times weekly at the 176-bed hospital. The pharmacists tracked the physicians' recommendations for antimicrobial stewardship program interventions and relayed them to primary teams.

Researchers measured antimicrobial utilization in days of therapy per 1,000 patient-days for a 12-month baseline period and a six-month intervention period and also estimated antimicrobial cost savings. Results were published online on Sept. 5, 2019, by Clinical Infectious Diseases.

During the six-month intervention period, 1,419 infectious disease physician recommendations were made, and 1,262 (88.9%) were accepted. Compared to baseline, broad-spectrum antibiotic use decreased by 24.4% (342.1 vs. 258.7 days of therapy per 1,000 patient-days; P<0.001) during the intervention period. Infectious disease consults increased by 40.2% (15.4 consults per 1,000 patient-days vs. 21.5 consults per 1,000 patient-days; P=0.001). Estimated savings on antimicrobial expenditures were $142,629.83 per year.

Limitations of the study were its nonrandomized design and its focus on overall antimicrobial utilization, rather than on appropriateness of therapy or patient outcomes, the authors noted. Nonetheless, the intervention “represents a unique and viable strategy by which community hospitals not affiliated with a large system may gain access to robust stewardship support, and a mechanism by which larger institutions with such infrastructure may assist unaffiliated hospitals with expansion of [antimicrobial stewardship program] efforts,” they concluded.

In-hospital addiction consults may increase treatment of substance use disorder postdischarge

Patients who receive hospital-based addiction medicine consults may have higher rates of substance use disorder treatment after discharge.

Image by Getty Images
Image by Getty Images

Researchers in Oregon performed a cohort study comparing patients treated by the Improving Addiction Care Team (IMPACT) service, a hospital-based addiction medicine consult service at one large academic hospital, with propensity-matched controls from other hospitals in Oregon. The goal of the study was to determine if IMPACT had an effect on posthospital engagement with treatment for substance use disorder. IMPACT patients received pharmacotherapy, behavioral treatments, and harm reduction services from a multidisciplinary team while hospitalized, as well as linkage to substance use disorder treatment after discharge. The study's main outcome was the Healthcare Effectiveness Data and Information Set (HEDIS) measure of engagement with substance use disorder treatment, which was defined as two or more claims on two separate days within 34 days of discharge. Results were published Aug. 13, 2019, by the Journal of General Internal Medicine and appeared in the December 2019 issue.

Patients were included in the study if they were 18 to 64 years of age, had Oregon Medicaid insurance, had at least one diagnosis of a substance use disorder (excluding tobacco), and were hospitalized in Oregon between July 1, 2015, and Sept. 30, 2016. Two hundred eight study patients participated in IMPACT, and they were compared to 416 controls. Among all patients, 60.3% were men, 54.7% were at least 40 years of age, and 29.8% had a diagnosis of substance use disorder involving opioids. Before hospitalization, 17.2% of patients were receiving treatment for substance use disorder. After discharge, substance use disorder treatment was more common in IMPACT patients than in controls (38.9% vs. 23.3%; adjusted odds ratio, 2.15 [95% CI, 1.29 to 3.58]). This association persisted when the sample was limited to patients who were not receiving substance use disorder treatment before hospitalization (adjusted odds ratio, 2.63; 95% CI, 1.46 to 4.72). Treatment engagement after discharge was also more likely in patients with an opioid use disorder than in those without (adjusted odds ratio, 1.83; 95% CI, 1.03 to 3.24).

The researchers noted that claims may not accurately reflect all diagnoses and do not include nonbillable substance use disorder services or prescriptions dispensed from a hospital pharmacy on the day of discharge. In addition, among other limitations, their study was not blinded and was not a randomized controlled trial. The authors concluded that hospital-based addiction treatment can help improve engagement with substance use disorder treatment after discharge and that national expansion of such models can help close this treatment gap. They called for future studies to define which components of hospital-based addiction care are most important and how IMPACT can be adapted to different settings with different resources. “Finally, future research is needed to assess the effect of hospital-based addiction medicine consultation on patient experience, [substance use disorder] severity, against medical advice discharge rates, physical health outcomes, hospital readmissions, healthcare costs, and mortality,” they wrote.

Observation, ED treat-and-discharge visits rose in parallel with drop in readmissions

Reductions in readmissions seen under the Hospital Readmissions Reduction Program (HRRP) may be explained by more patients being treated under observation status or discharged from the ED when they return to the hospital, a recent study found.

The retrospective cohort study looked at more than 3 million fee-for-service Medicare admissions for heart failure (n=1,357,620), acute myocardial infarction (n=634,795), and pneumonia (n=1,046,325) between Jan. 1, 2012, and Oct. 1, 2015. The main outcome was total hospital revisits within 30 days of discharge, analyzed by type of revisit: treat-and-discharge from an ED, observation stay (not leading to inpatient readmission), and inpatient readmission. Results were published by The BMJ on Aug. 12, 2019.

For the three targeted conditions, the total number of hospital revisits per 100 patient discharges increased over the study period (monthly increase, 0.023 visit per 100 patient discharges; 95% CI, 0.010 to 0.035). This change was due to monthly increases in treat-and-discharge ED visits (0.023 per 100 patient discharges; 95% CI, 0.015 to 0.032) and observation stays (0.022 per 100 patient discharges; 95% CI, 0.020 to 0.025). Those increases were only partly offset by declines in readmissions (monthly change, −0.023 per 100 patient discharges; 95% CI, −0.035 to −0.012). Observation stays increased more among nonwhite patients than white patients. No significant change was seen in 30-day mortality (monthly change, −0.0034 per 100 patient discharges; 95% CI,−0.012 to 0.0054).

The findings suggest that the apparent success of the HRRP in reducing readmissions for targeted conditions “could be illusory because total hospital revisits after discharge are, in fact, rising,” the study authors said. The HRRP's effects may be explained by hospitals and clinicians increasing their efforts not to admit returning patients, rather than improving discharge planning or care transitions, they said.

The authors noted that increases in observation and ED treat-and-discharge visits could be a good thing if they were due to patients returning with less severe illness. However, other research has shown that more frequently discharging patients from the ED rather than admitting them is associated with higher mortality, and this association might explain other studies' recent findings of increased mortality from some conditions targeted by the HRRP.

The study's results highlight problems with the use of 30-day readmission rate as a quality metric and financial incentive, the authors said. They suggested that replacing it with a 30-day return-to-hospital metric, which would include observation stays and ED revisits, “could instead provide a more comprehensive, accurate, and fair assessment of provider and hospital care quality.”

Guideline Corner: Diagnosing fungal infections

The American Thoracic Society published a clinical practice guideline on diagnosing fungal infections in pulmonary and critical care medicine.

The guideline focuses on the use of common laboratory tests to diagnose invasive pulmonary aspergillosis, invasive candidiasis, and the three most common endemic mycoses: blastomycosis, coccidioidomycosis, and histoplasmosis. It was produced by an expert panel and was based on a systematic review of studies published from 1980 to April 2016. The guideline was published in the Sept. 1, 2019, American Journal of Respiratory and Critical Care Medicine.

Diagnostic methods for fungal infections include antigen testing in urine, blood, and bronchoalveolar lavage (BAL) fluid; serological testing to detect antibodies to fungal components; and nucleic acid-based assays using polymerase chain reaction (PCR). Specific recommendations include the following:

  • Use serum galactomannan (GM) testing in severely immunocompromised patients with suspected invasive pulmonary aspergillosis, such as those with neutropenia or hematological malignancy or recipients of hematological stem-cell or solid-organ transplants who present with unexplained lung infiltrates (strong recommendation, high-quality evidence).
  • Use BAL testing with GM in patients with suspected invasive fungal diseases, including those with a negative serum GM but strong risk factors for invasive aspergillosis or those with a positive serum GM but confounding factors for false-positive GM results (strong recommendation, high-quality evidence).
  • Use blood or serum Aspergillus PCR testing in severely immunocompromised patients, such as those with hematological malignancy or recipients of hematological stem-cell or solid organ transplants, with suspected invasive pulmonary aspergillosis (strong recommendation, high-quality evidence).
  • Include Aspergillus PCR on BAL testing as part of the evaluation of severely immunocompromised patients with suspected invasive pulmonary aspergillosis (strong recommendation, high-quality evidence).
  • Do not rely solely on results of serum β-d-glucan testing alone for diagnostic decision making in critically ill patients for whom there is clinical concern for invasive candidiasis (conditional recommendation, low-quality evidence).
  • Use more than one diagnostic test, including direct visualization and culture of sputum BAL or other biopsy material, urine antigen testing, and serum antibody testing, in patients with appropriate geographic exposure and illness compatible with infection or pneumonia due to blastomycosis or coccidioidomycosis. The current evidence does not support a single best test as being sensitive enough to be ordered in isolation from other testing. Tailor the approach based on severity of illness, clinical context, and availability of tests (conditional recommendation, moderate-quality evidence).
  • Use urinary antigen testing for blastomycosis together with clinical and epidemiological data to establish the diagnosis in patients with suspected blastomycosis, particularly immunocompromised patients (conditional recommendation, moderate-quality evidence).
  • Perform urinary and serum antigen testing to aid in establishing the diagnosis in patients with suspected coccidioidomycosis, particularly immunocompromised patients (conditional recommendation, moderate-quality evidence).
  • Use Histoplasma antigen in urine or serum for rapid diagnosis of suspected disseminated and acute pulmonary histoplasmosis when timely diagnosis and treatment are of paramount importance to patient outcomes (strong recommendation, high-quality evidence).