What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research.

Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.

Cardiac Magnetic Resonance in Cardio-Oncology: Advantages, Importance of Expediency, and Considerations to Navigate Pre-Authorization.

Diagnosis of acute and late cardiotoxicity from cancer therapeutics has become increasingly important as the scope of cardio-oncology increases exponentially, both in terms of the number of people affected and the types of therapies it encompasses. Cardiac magnetic resonance (CMR) is a tool that can offer unparalleled diagnostic information compared with other imaging modalities, but its utilization is often delayed, at the expense of patient care, due to the need for insurance pre-authorization. This paper highlights situations in which CMR is preferred as the diagnostic modality and provides examples of diagnoses more likely to be approved by insurance companies. It also provides specific cardio-oncology diagnoses or questions to help the clinical cardio-oncologist navigate the pre-authorization process.

Pre-authorization processes have no effect on patients undergoing knee MRI in a pediatric setting when evaluated by specialists.

OBJECTIVE: Pre-authorization processes are often used by medical insurance companies to reduce costs by managing the utilization of advanced diagnostic imaging, and their impact on patient care is unclear. The purpose of our study is to determine if a pre-authorization process increases the rate of surgically significant abnormal knee MRI and surgical referrals compared with patients referred from pediatric orthopedic specialists who do not undergo a pre-authorization process. MATERIALS AND METHODS: A retrospective study was performed; 124 patients were identified who were referred for knee MRI by a pediatric orthopedist. The study population included patients who underwent an insurance pre-authorization process and the control group consisted of those who did not. The results of the MRI and whether they were deemed surgically significant, in addition to surgical referral, were recorded and compared. RESULTS: The study and control groups showed no statistically significant difference in outcome with regard to surgically significant findings on MRI (p = 0.92) or whether the patient required surgery (p = 0.6). CONCLUSIONS: In this population, there is no difference in the likelihood of an abnormal knee MRI demonstrating surgically significant findings or referral to surgery in patients who did and those who did not undergo an insurance pre-authorization process when patients are referred from a pediatric orthopedic specialist. The insurance pre-authorization process does not appear to have an impact on patient diagnosis and treatment and may unnecessarily add bureaucracy and costs.

Impact of computerized pre-authorization of broad spectrum antibiotics in Pseudomonas aeruginosa at a children's hospital in Japan.

BACKGROUND: The spread of antimicrobial-resistant organisms is a global concern. To stem this tide, an antimicrobial stewardship program at hospitals is essential to optimize the prescription of broad spectrum antibiotics. In this study we examined the impact of computerized pre-authorization for broad spectrum antibiotics for Pseudomonas aeruginosa at a children's hospital. METHODS: An antimicrobial stewardship program at Tokyo Metropolitan Children's Medical Center was assessed between March 2010 and March 2015. A paper-based post-prescription audit was switched to computerized pre-authorization for broad antipseudomonal agents in October 2011. The prescriber was required to obtain approval from physicians in the pediatric infectious diseases division before prescribing restricted antimicrobial agents. Approved prescriptions were processed and logged electronically. We evaluated days of therapy per 1000 patient-days, the cost of antibiotics, and the susceptibility of P. aeruginosa to piperacillin, ceftazidime, cefepime, piperacillin/tazobactam, carbapenems, and ciprofloxacin. Also, the average length of admission and infection-related mortality at 30 days were compared pre- and post-intervention. RESULTS: Administration of carbapenems, piperacillin/tazobactam, and ceftazidime decreased significantly after the introduction of computerized pre-authorization. Antibiotic costs were reduced by JPY2.86 million (USD 26,000) annually. None of the antipseudomonal agents showed decreased sensitivity. The average length of admission was shorter in post-intervention. Infection-related mortality at 30 days showed no difference between the pre- and post-intervention periods. CONCLUSION: An antimicrobial stewardship program using computerized pre-authorization decreased the use and cost of broad spectrum antibiotics without significant difference in infection-related mortality at 30 days, although our study did not improve susceptibilities of P. aeruginosa.

Enforcing Quality Metrics over Equipment Utilization Rates as Means to Reduce Centers for Medicare and Medicaid Services Imaging Costs and Improve Quality of Care.

Radiology has been the focus of efforts to reduce inefficiencies while attempting to lower medical costs. The 2010 Medicare Physician Fee Schedule has reduced Centers for Medicare and Medicaid Services' (CMS) reimbursements related to the technical component of imaging services. By increasing the utilization rate, the cost of equipment spreads over more studies, thus lowering the payments per procedure. Is it beneficial for CMS to focus on equipment utilization as a cost-cutting measure? Can greater financial and quality of care rewards be made by improving metrics like appropriateness criteria and pre-authorization?On examining quality metrics, such as appropriateness criteria and pre-authorization, promising results have ensued. The development and enforcement of appropriateness criteria lowers overutilization of studies without requiring unattainable fixed rates. Pre-authorization educates ordering physicians as to when imaging is indicated.

Antimicrobial stewardship: attempting to preserve a strategic resource.

Antimicrobials hold a unique place in our drug armamentarium. Unfortunately the increase in resistance among both gram-positive and gram-negative pathogens coupled with a lack of new antimicrobial agents is threatening our ability to treat infections. Antimicrobial use is the driving force behind this rise in resistance and much of this use is suboptimal. Antimicrobial stewardship programs (ASP) have been advocated as a strategy to improve antimicrobial use. The goals of ASP are to improve patient outcomes while minimizing toxicity and selection for resistant strains by assisting in the selection of the correct agent, right dose, and best duration. Two major strategies for ASP exist: restriction/pre-authorization that controls use at the time of ordering and audit and feedback that reviews ordered antimicrobials and makes suggestions for improvement. Both strategies have some limitations, but have been effective at achieving stewardship goals. Other supplemental strategies such as education, clinical prediction rules, biomarkers, clinical decision support software, and institutional guidelines have been effective at improving antimicrobial use. The most effective antimicrobial stewardship programs have employed multiple strategies to impact antimicrobial use. Using these strategies stewardship programs have been able to decrease antimicrobial use, the spread of resistant pathogens, the incidence of C. difficile infection, pharmacy costs, and improved patient outcomes.