- Email: [email protected]
Assessing the Value of Pediatric Consultation Services as Bundled Payments Evolve: Infectious Diseases as a Model
Assessing the Value of Pediatric Consultation Services as Bundled Payments Evolve: Infectious Diseases as a Model Valerie P. Castle, MD, and Janet R. Gilsdorf, MD
P
ediatric medical care in the US has become increasingly complicated, with escalating acuity of the illnesses encountered in hospitalized children and with the advent of complex treatment and support modalities required for state-of-the-art medical care. Thus, optimal care of hospitalized children now requires a team of pediatric specialists and subspecialists. As health care financing moves from feefor-service to contract-based reimbursements, financial support for clinical services rendered by subspecialty pediatricians will change and devising strategies to appropriately compensate all members of the clinical care teams will be critical to building effective reimbursement models.
compliance with antibiotic guidelines in intensive care unit patients whose care included consultation with the ID service.3 To assist in managing the many aspects of infections, the Infectious Diseases Society of America has produced a number of evidence-based practice guidelines regarding the proper use of antimicrobial agents as well as strategies to prevent and manage a number of ID. Physicians not trained in ID may not be aware of these valuable resources or how best to apply them in the care of their patients. Two studies document the role of ID consultations in improved compliance with standards of care for patients with Staphylococcus aureus bacteremia.4,5
What Value Does Subspecialty Consultation Bring to Hospitalized Pediatric Patients and to Health Care Systems Serving Children?
Improved Patient Outcomes
Few pediatric-specific studies are available to answer this question. But, because infection remains an important cause of hospitalization and a too-frequent complication of both intensive diagnostic or therapeutic interventions and because pediatric infectious diseases (ID) specialists play central roles in antibiotic stewardship, infection control, and quality improvement efforts in hospitals serving children, the value of pediatric ID consultants serves as an excellent model for considering the value of many subspecialty pediatric services to hospital systems. Data regarding the value of ID consultations for adult patients, although possibly differing in some regards from the pediatric experience, offer important lessons and measures for future studies pertinent to documenting the value of subspecialty pediatricians in caring for ill, hospitalized children.1,2 Studies in adult patients have addressed the value of ID consultations in 4 realms: compliance with established guidelines and protocols, patient outcomes, costs, and appropriateness of antibiotics.
Improved Compliance with Established Guidelines and Protocols In response to Federal mandates and The Joint Commission quality measures, health systems have instituted infection control and antibiotic stewardship programs and have realized variable success in compliance on the part of their employees. A study by Raineri et al documents improved
Improved patient outcomes is the goal of all medical interventions, yet serious infections may and do lead to severe morbidity and even mortality in children. A multivariate analysis by Farinas et al showed that ID consultation reduced treatment failure among patients receiving antibiotics.6 In addition, Yamamoto et al showed that the 6-month relapse rate for patients with endocarditis was 2.2% among those with ID consultation compared with 22.2% for those without.7 Further, 4 studies have documented improved microbe-specific survival rates in patients whose care incorporated ID consultations, including those with candidemia8 and with Staphylococcus aureus invasive infections.9-11
Decreased Costs Decreased length of hospital stay reduces both hospital costs and exposure to iatrogenic complications, including hospitalacquired infections, among patients. Two studies6,12 have documented decreased length of stay in patients using antibiotics who had an ID consultation compared with those without. In addition, ID consultations may reduce both the use of unnecessary diagnostic tests and the costs associated with incorrect interpretation of results from the microbiology laboratory as well as reduce the amounts of antibiotics used.13,14 Further, ID consultants recommend highly effective but less expensive antibiotics,15 and a large multicenter study
From the Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and C. S. Mott Children’s Hospital, Ann Arbor, MI The authors declare no conflicts of interest.
ID
Infectious diseases
0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.07.024
650
Vol. 165, No. 4 October 2014 showed that ID consultation within 2 days of admission significantly reduced Medicare charges and payments.12
Appropriate Use of Antimicrobial Drugs Optimizing antimicrobial therapy depends on a number of patient factors (age, comorbidities, drug metabolism, drug absorption, drug incompatibilities, drug allergies and intolerances, immune competency, vaccination status), infection factors (causative microbe, site of the infection, antimicrobial resistance patterns), and system factors (institutional antimicrobial resistance patterns, community outbreaks, cost). A number of studies have documented the improved appropriateness of antibiotics prescribed among patients whose care included an ID consultation compared with those without.3,8,11,14,16,17
Use of Curbside Consultations Curbside consultations are the bane of consulting services. In the course of these informal discussions, subspecialty physicians are asked to provide advice, suggestions, and, too frequently, recommendations regarding the care of another physician’s patient without gathering first hand a medical history, performing a physical examination, and reviewing all pertinent laboratory work. Importantly, curbside consultants do not provide a consultative recommendation in the medical record. Rates of informal consultations by ID pediatricians are among the highest of the pediatric specialties.18 Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations19 for a number of reasons including incomplete or inaccurate data conveyed during an informal consultation. Among internal medicine hospitalists, 51% of curbside consults included only partial or erroneous information regarding the patient, and 60% of patients had a change in management advice when a formal consultation was obtained.20 Thus, informal consultation cannot be accepted as a substitute for a formal consultation when crafting a diagnostic or management plan for a patient. This is increasingly important today when most patients admitted to children’s hospitals suffer from complicated life threatening diseases and/or chronic multisystem disorders and comorbidities.
Who Should Bear the Cost of Providing Adequate Pediatric Subspecialty Services? Traditionally, in academic institutions, Medical Schools and Departments of Pediatrics have supported the clinical
care activities of pediatric subspecialty physicians through their practice plans. Because reimbursement for consultations in cognitive specialties, including ID, is low, under the fee-for-service model and relative value unit-based payment by discipline, practice plans are forced to subsidize significant salary shortfalls to fund many pediatric subspecialty physicians. As discretionary clinical dollars disappear, this practice is unsustainable. Further, contract-based and bundled payments for medical care will soon supplant the fee-for-service model. This change will no-doubt negatively impact requests for formal consults as primary services strive to maintain hospital margins. Judiciously designed contracts with third party payers should include appropriate payment for subspecialty services as part of a clinical care services bundle. Because hospital systems benefit both directly and indirectly from the activities of all pediatric consultants, they would be wise, for example, to assist in supporting the salaries of ID physicians through the infection control and antibiotic stewardship programs as well as through their oncology, surgical, and transplant programs, service lines whose patients are at high risk for infectious complications and utilization of antimicrobial agents.
Discussion Based on data from adult patients, inpatient consultations by the pediatric ID consulting services in children’s hospitals would be expected to improve compliance with established practice guidelines and with hospital infection control and antibiotic stewardship policies and to reduce costs through the use of more appropriate antimicrobial drugs and ordering more appropriate diagnostic tests in children with infections. This example underscores the need for subspecialty pediatric services to develop methods to define the value their services bring to the medical care of children, both in and out of the hospital. The costs of providing excellent subspecialty pediatric consultations should be borne by all parties that benefit from them, including third party payers and hospital systems. n Reprint requests: Janet R. Gilsdorf, MD, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and C. S. Mott Children’s Hospital, D5101 Medical Professional Building SPC 5718, Ann Arbor, MI 48109-5718. E-mail: [email protected]
References available at www.jpeds.com
651
THE JOURNAL OF PEDIATRICS
www.jpeds.com
References 1. Granwehr BP, Kontoyiannis DP. The impact of infectious diseases consultation on oncology practice. Curr Opin Oncol 2013;25:353-9. 2. Petrak RM, Sexton DJ, Butera ML, Tenenbaum MJ, MacGregor MC, Schmidt ME, et al. The value of an infectious diseases specialist. Clin Infect Dis 2003;36:1013-7. 3. Raineri E, Pan A, Mondello P, Acquarolo A, Candiani A, Crema L. Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit. Am J Infect Control 2008;36:283-90. 4. Jenkins TC, Price CS, Sabel AL, Mehler PS, Burman WJ. Impact of routine infectious diseases service consultation on the evaluation, management, and outcomes of Staphylococcus aureus bacteremia. Clin Infect Dis 2008;46:1000-8. 5. Pragman AA, Kuskowski MA, Abraham JM, Filice GA. Infectious disease consultation for Staphylococcus aureus bacteremia improves patient management and outcomes. Infect Dis Clin Pract 2012;20:261-7. 6. Farinas MC, Saravia G, Calvo-Montes J, Benito N, Martinez-Garde JJ, Farinas-Alvarez C, et al. Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients. BMC Infect Dis 2012;12:292. 7. Yamamoto S, Hosokawa N, Sogi M, Inakaku M, Imoto K, Ohji G, et al. Impact of infectious diseases service consultation on diagnosis of infective endocarditis. Scand J Infect Dis 2012;44:270-5. 8. Takakura S, Fujihara N, Saito T, Kimoto T, Ito Y, Iinuma Y, et al. Improved clinical outcome of patients with Candida bloodstream infections through direct consultation by infectious diseases physicians in a Japanese university hospital. Infect Control Hosp Epidemiol 2006;27:964-8. 9. Honda H, Krauss MJ, Jones JC, Olsen MA, Warren DK. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. Am J Med 2010;123:631-7. 10. Rieg S, Peyerl-Hoffmann G, de With K, Theilacker C, Wagner D, Hubner J, et al. Mortality of S. aureus bacteremia and infectious diseases specialist consultation—a study of 521 patients in Germany. J Infect 2009;59:232-9.
651.e1
Vol. 165, No. 4 11. Choi SH, Cho SY, Park JH, Chung JW. Impact of infectious-disease specialist consultations on outcomes of Staphylococcus aureus bacteremia in a hospital with a low volume of patients with S. aureus bacteremia. J Infect 2011;62:181-5. 12. Schmitt S, McQuillen DP, Nahass R, Martinelli L, Rubin M, Schwebke K, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect Dis 2014; 58:22-8. 13. Doern GV, Westerling JA. Optimum recovery of Mycobacterium avium complex from blood specimens of human immunodeficiency viruspositive patients by using small volumes of isolator concentrate inoculated into BACTEC 12B bottles. J Clin Microbiol 1994;32:2576-7. 14. Uc¸kay I, Vernaz-Hegi N, Harbarth S, Stern R, Legout L, Vauthey L, et al. Activity and impact on antibiotic use and costs of a dedicated infectious diseases consultant on a septic orthopaedic unit. J Infect 2009; 58:205-12. 15. Nathwani D, Davey P, France AJ, Phillips G, Orange G, Parratt D. Impact of an infection consultation service for bacteraemia on clinical management and use of resources. QJM 1996;89:789-97. 16. Kerremans JJ, Verbrugh HA, Vos MC. Frequency of microbiologically correct antibiotic therapy increased by infectious disease consultations and microbiological results. J Clin Microbiol 2012;50:2066-8. 17. Shrestha NK, Bhaskaran A, Scalera NM, Schmitt SK, Rehm SJ, Gordon SM. Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy. J Hosp Med 2012;7:365-9. 18. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA 1998;280:905-9. 19. Forsblom E, Ruotsalainen E, Ollgren J, J€arvinen A. Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus bacteremia. Clin Infect Dis 2013;56: 527-35. 20. Burden M, Sarcone E, Keniston A, Statland B, Taub JA, Allyn RL, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med 2013;8:31-5.
Castle and Gilsdorf
P
ediatric medical care in the US has become increasingly complicated, with escalating acuity of the illnesses encountered in hospitalized children and with the advent of complex treatment and support modalities required for state-of-the-art medical care. Thus, optimal care of hospitalized children now requires a team of pediatric specialists and subspecialists. As health care financing moves from feefor-service to contract-based reimbursements, financial support for clinical services rendered by subspecialty pediatricians will change and devising strategies to appropriately compensate all members of the clinical care teams will be critical to building effective reimbursement models.
compliance with antibiotic guidelines in intensive care unit patients whose care included consultation with the ID service.3 To assist in managing the many aspects of infections, the Infectious Diseases Society of America has produced a number of evidence-based practice guidelines regarding the proper use of antimicrobial agents as well as strategies to prevent and manage a number of ID. Physicians not trained in ID may not be aware of these valuable resources or how best to apply them in the care of their patients. Two studies document the role of ID consultations in improved compliance with standards of care for patients with Staphylococcus aureus bacteremia.4,5
What Value Does Subspecialty Consultation Bring to Hospitalized Pediatric Patients and to Health Care Systems Serving Children?
Improved Patient Outcomes
Few pediatric-specific studies are available to answer this question. But, because infection remains an important cause of hospitalization and a too-frequent complication of both intensive diagnostic or therapeutic interventions and because pediatric infectious diseases (ID) specialists play central roles in antibiotic stewardship, infection control, and quality improvement efforts in hospitals serving children, the value of pediatric ID consultants serves as an excellent model for considering the value of many subspecialty pediatric services to hospital systems. Data regarding the value of ID consultations for adult patients, although possibly differing in some regards from the pediatric experience, offer important lessons and measures for future studies pertinent to documenting the value of subspecialty pediatricians in caring for ill, hospitalized children.1,2 Studies in adult patients have addressed the value of ID consultations in 4 realms: compliance with established guidelines and protocols, patient outcomes, costs, and appropriateness of antibiotics.
Improved Compliance with Established Guidelines and Protocols In response to Federal mandates and The Joint Commission quality measures, health systems have instituted infection control and antibiotic stewardship programs and have realized variable success in compliance on the part of their employees. A study by Raineri et al documents improved
Improved patient outcomes is the goal of all medical interventions, yet serious infections may and do lead to severe morbidity and even mortality in children. A multivariate analysis by Farinas et al showed that ID consultation reduced treatment failure among patients receiving antibiotics.6 In addition, Yamamoto et al showed that the 6-month relapse rate for patients with endocarditis was 2.2% among those with ID consultation compared with 22.2% for those without.7 Further, 4 studies have documented improved microbe-specific survival rates in patients whose care incorporated ID consultations, including those with candidemia8 and with Staphylococcus aureus invasive infections.9-11
Decreased Costs Decreased length of hospital stay reduces both hospital costs and exposure to iatrogenic complications, including hospitalacquired infections, among patients. Two studies6,12 have documented decreased length of stay in patients using antibiotics who had an ID consultation compared with those without. In addition, ID consultations may reduce both the use of unnecessary diagnostic tests and the costs associated with incorrect interpretation of results from the microbiology laboratory as well as reduce the amounts of antibiotics used.13,14 Further, ID consultants recommend highly effective but less expensive antibiotics,15 and a large multicenter study
From the Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and C. S. Mott Children’s Hospital, Ann Arbor, MI The authors declare no conflicts of interest.
ID
Infectious diseases
0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.07.024
650
Vol. 165, No. 4 October 2014 showed that ID consultation within 2 days of admission significantly reduced Medicare charges and payments.12
Appropriate Use of Antimicrobial Drugs Optimizing antimicrobial therapy depends on a number of patient factors (age, comorbidities, drug metabolism, drug absorption, drug incompatibilities, drug allergies and intolerances, immune competency, vaccination status), infection factors (causative microbe, site of the infection, antimicrobial resistance patterns), and system factors (institutional antimicrobial resistance patterns, community outbreaks, cost). A number of studies have documented the improved appropriateness of antibiotics prescribed among patients whose care included an ID consultation compared with those without.3,8,11,14,16,17
Use of Curbside Consultations Curbside consultations are the bane of consulting services. In the course of these informal discussions, subspecialty physicians are asked to provide advice, suggestions, and, too frequently, recommendations regarding the care of another physician’s patient without gathering first hand a medical history, performing a physical examination, and reviewing all pertinent laboratory work. Importantly, curbside consultants do not provide a consultative recommendation in the medical record. Rates of informal consultations by ID pediatricians are among the highest of the pediatric specialties.18 Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations19 for a number of reasons including incomplete or inaccurate data conveyed during an informal consultation. Among internal medicine hospitalists, 51% of curbside consults included only partial or erroneous information regarding the patient, and 60% of patients had a change in management advice when a formal consultation was obtained.20 Thus, informal consultation cannot be accepted as a substitute for a formal consultation when crafting a diagnostic or management plan for a patient. This is increasingly important today when most patients admitted to children’s hospitals suffer from complicated life threatening diseases and/or chronic multisystem disorders and comorbidities.
Who Should Bear the Cost of Providing Adequate Pediatric Subspecialty Services? Traditionally, in academic institutions, Medical Schools and Departments of Pediatrics have supported the clinical
care activities of pediatric subspecialty physicians through their practice plans. Because reimbursement for consultations in cognitive specialties, including ID, is low, under the fee-for-service model and relative value unit-based payment by discipline, practice plans are forced to subsidize significant salary shortfalls to fund many pediatric subspecialty physicians. As discretionary clinical dollars disappear, this practice is unsustainable. Further, contract-based and bundled payments for medical care will soon supplant the fee-for-service model. This change will no-doubt negatively impact requests for formal consults as primary services strive to maintain hospital margins. Judiciously designed contracts with third party payers should include appropriate payment for subspecialty services as part of a clinical care services bundle. Because hospital systems benefit both directly and indirectly from the activities of all pediatric consultants, they would be wise, for example, to assist in supporting the salaries of ID physicians through the infection control and antibiotic stewardship programs as well as through their oncology, surgical, and transplant programs, service lines whose patients are at high risk for infectious complications and utilization of antimicrobial agents.
Discussion Based on data from adult patients, inpatient consultations by the pediatric ID consulting services in children’s hospitals would be expected to improve compliance with established practice guidelines and with hospital infection control and antibiotic stewardship policies and to reduce costs through the use of more appropriate antimicrobial drugs and ordering more appropriate diagnostic tests in children with infections. This example underscores the need for subspecialty pediatric services to develop methods to define the value their services bring to the medical care of children, both in and out of the hospital. The costs of providing excellent subspecialty pediatric consultations should be borne by all parties that benefit from them, including third party payers and hospital systems. n Reprint requests: Janet R. Gilsdorf, MD, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and C. S. Mott Children’s Hospital, D5101 Medical Professional Building SPC 5718, Ann Arbor, MI 48109-5718. E-mail: [email protected]
References available at www.jpeds.com
651
THE JOURNAL OF PEDIATRICS
www.jpeds.com
References 1. Granwehr BP, Kontoyiannis DP. The impact of infectious diseases consultation on oncology practice. Curr Opin Oncol 2013;25:353-9. 2. Petrak RM, Sexton DJ, Butera ML, Tenenbaum MJ, MacGregor MC, Schmidt ME, et al. The value of an infectious diseases specialist. Clin Infect Dis 2003;36:1013-7. 3. Raineri E, Pan A, Mondello P, Acquarolo A, Candiani A, Crema L. Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit. Am J Infect Control 2008;36:283-90. 4. Jenkins TC, Price CS, Sabel AL, Mehler PS, Burman WJ. Impact of routine infectious diseases service consultation on the evaluation, management, and outcomes of Staphylococcus aureus bacteremia. Clin Infect Dis 2008;46:1000-8. 5. Pragman AA, Kuskowski MA, Abraham JM, Filice GA. Infectious disease consultation for Staphylococcus aureus bacteremia improves patient management and outcomes. Infect Dis Clin Pract 2012;20:261-7. 6. Farinas MC, Saravia G, Calvo-Montes J, Benito N, Martinez-Garde JJ, Farinas-Alvarez C, et al. Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients. BMC Infect Dis 2012;12:292. 7. Yamamoto S, Hosokawa N, Sogi M, Inakaku M, Imoto K, Ohji G, et al. Impact of infectious diseases service consultation on diagnosis of infective endocarditis. Scand J Infect Dis 2012;44:270-5. 8. Takakura S, Fujihara N, Saito T, Kimoto T, Ito Y, Iinuma Y, et al. Improved clinical outcome of patients with Candida bloodstream infections through direct consultation by infectious diseases physicians in a Japanese university hospital. Infect Control Hosp Epidemiol 2006;27:964-8. 9. Honda H, Krauss MJ, Jones JC, Olsen MA, Warren DK. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. Am J Med 2010;123:631-7. 10. Rieg S, Peyerl-Hoffmann G, de With K, Theilacker C, Wagner D, Hubner J, et al. Mortality of S. aureus bacteremia and infectious diseases specialist consultation—a study of 521 patients in Germany. J Infect 2009;59:232-9.
651.e1
Vol. 165, No. 4 11. Choi SH, Cho SY, Park JH, Chung JW. Impact of infectious-disease specialist consultations on outcomes of Staphylococcus aureus bacteremia in a hospital with a low volume of patients with S. aureus bacteremia. J Infect 2011;62:181-5. 12. Schmitt S, McQuillen DP, Nahass R, Martinelli L, Rubin M, Schwebke K, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect Dis 2014; 58:22-8. 13. Doern GV, Westerling JA. Optimum recovery of Mycobacterium avium complex from blood specimens of human immunodeficiency viruspositive patients by using small volumes of isolator concentrate inoculated into BACTEC 12B bottles. J Clin Microbiol 1994;32:2576-7. 14. Uc¸kay I, Vernaz-Hegi N, Harbarth S, Stern R, Legout L, Vauthey L, et al. Activity and impact on antibiotic use and costs of a dedicated infectious diseases consultant on a septic orthopaedic unit. J Infect 2009; 58:205-12. 15. Nathwani D, Davey P, France AJ, Phillips G, Orange G, Parratt D. Impact of an infection consultation service for bacteraemia on clinical management and use of resources. QJM 1996;89:789-97. 16. Kerremans JJ, Verbrugh HA, Vos MC. Frequency of microbiologically correct antibiotic therapy increased by infectious disease consultations and microbiological results. J Clin Microbiol 2012;50:2066-8. 17. Shrestha NK, Bhaskaran A, Scalera NM, Schmitt SK, Rehm SJ, Gordon SM. Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy. J Hosp Med 2012;7:365-9. 18. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA 1998;280:905-9. 19. Forsblom E, Ruotsalainen E, Ollgren J, J€arvinen A. Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus bacteremia. Clin Infect Dis 2013;56: 527-35. 20. Burden M, Sarcone E, Keniston A, Statland B, Taub JA, Allyn RL, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med 2013;8:31-5.
Castle and Gilsdorf