Dr Gareth S. Kantor is is an Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA.  He is also a practicing anesthesiologist in Cape Town, South Africa and Senior Clinical Consultant to Discovery Health, Sandton, South Africa, the country s largest private health insurance company.  He is speaking at the Global Forum during Strengthening Infection Control and Using Surveillance Data to Best Inform Practice.

In South Africa, health insurance companies (medical aid schemes) are extremely concerned about the rising cost of antibiotics, which now accounts for almost 5% of the cost of an average private hospital admission. Average antibiotic treatment costs per hospital patient rose 23% from 2009 to 2010, with a 36% cost (about $1,000 worth of antibiotics) for the average patient admitted to an intensive care unit.

A standard response might be to identify the antibiotics contributing most to cost increases – for example, teicoplanin, carbapenems, and newer antifungals like caspofungin – and to institute strict clinical criteria on access to funding for those drugs. However, we understand that antibiotic costs are a sentinel, a flag, so while misuse of antibiotics must be addressed urgently, we also know that these costs are an indicator of underlying problems with preventable healthcare-associated infection and rapidly worsening rates of antimicrobial resistance.

Antimicrobial resistance is a major worry, especially with regard to the epidemic of tuberculosis in our communities, but also among gram-negative bacteria found in the hospitals and outside them. For example, NDM-1 Enterobacter has been described from a Johannesburg hospital in a patient with bronchiectasis and another patient had both NDM-1 and KPC Klebsiella. Both patients died.

Our response therefore has been to join with private hospitals and professionals to focus on infection prevention and antibiotic stewardship. The infection prevention initiative is part of a system strengthening endeavor Best Care Always! (BCA) which involves collaborative sharing of best practices, including how to implement care bundles proven to prevent four types of device-related nosocomial infections central-line associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and surgical site infection (SSI). Outcomes and care processes need to be measured routinely. This approach, particularly with respect to CLABSI, has yielded impressive reductions in infection rates, costs and overall morbidity in some hospitals internationally, pioneered by the Institute for Healthcare Improvement (IHI). We hope to replicate these results in South Africa and have seen some early success.

Discovery Health provides financial support to the campaign. We also have large stores of patient level data, which we use to measure antibiotic utilization. Measurement can, in general, have three distinct purposes. Measurement for research needs little explanation to most audiences. Measurement for accountability is a core competence of medical schemes and can be used for discussions with hospitals about these issues and to quantify forward risk.  Measurement for improvement is less familiar to the medical community and embodies methodologies such as those promoted by IHI, which in turn derive from the work of Deming and others in manufacturing industries. Measurement for improvement incorporates statistical methodologies that include timelines in order to determine the impact of changes made in clinical processes.

At Discovery Health we have mapped local pharmaceutical product codes to World Health Organisation DDDs (defined daily dosages)  to help determine days of treatment. DDD-based statistics applied to populations can identify excessive duration of therapy (e.g. > 7 days), as well as estimate hospital-acquired infection rates, overall consumption of antibiotics, and enable comparisons between hospitals and units. Our case-mix tools offer assistance when risk adjusted comparisons are needed, and when apparent, unwarranted variation needs to be explored.

We use measurement to assist hospitals and clinicians in their improvement efforts and to track the success of the BCA campaign. If we and our partners are successful, quality of care should improve. Consequently, fewer hospitalized patients and insurance scheme members will succumb to deadly preventable infections, as infection rates, over-utilization of antibiotics, (including expensive broad spectrum agents) and costs decline.