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Reducing Invasive Fungal Infections and Reducing Cost. Presenter: Lee Hamley Hospital: THE ALFRED – Vic. Key problem. In 2007-08 haematologists noted increasing invasive fungal infections (IFI) in acute leukaemia and stem cell transplant patients - PowerPoint PPT Presentation
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Reducing Invasive Fungal Infections and Reducing Cost
Presenter: Lee Hamley
Hospital: THE ALFRED – Vic
Key problem
• In 2007-08 haematologists noted increasing invasive fungal infections (IFI) in acute leukaemia and stem cell transplant patients
• This is a difficult problem to measure due to definitional issues related to IFI
• At the same time, Pharmacy recorded LARGE increases in the use of anti-fungal agents, which can be extremely expensive
• Alfred Health realised we had a problem!
2
Proven Probable Possible
Overall IFI = proven + probable
Clinical IFI = proven + probable + possible
Ascioglu et al CID 2002;34 p7-13Pauw et al 2008 CID 2008: 46 p1813
Host factors&
Clinical/radiology(eg HRCT – dense lesions +/- halo)
&Micro criteria
(eg fungi from sputum/BAL)
Host factors&
Clinical/radiology(eg HRCT – dense lesions +/- halo)
(ie no micro results)
Fungi in histology, micro from a sterile site
or BC
(ie need biopsy)
Audit definitions of IFI
3
Aim of this Innovation
• To decrease invasive fungal infections in patients with acute leukaemia or stem cell transplantation from a baseline level of around 15% (proven & probable IFI) to best practice levels reported in the literature.
4
Haem & SCT use >80% of The Alfred’s Ambisome
Allografts = 20 Allografts = 23
Baseline Ambisome costs at The Alfred
5
Key changes implemented
• Changes to clinical practice – see next slide• Changes to the environment and related systems – see
next slide• Collaborative project for the introduction of in house
drug levels – These were not available in Victoria– Levels either not done or sent interstate– Very slow turn around time for results
6
2007 2008 2009 2010 2011
Allo-SCT Itra→posa posa→VoriVori
Vori Vori/Posa
AMLItra→posa posa→Vori
Vori Vori Posa
ALLItra→posa posa→Vori
Azole/Amb Azole/Amb Azole/Amb
Environmental
HEPA filter Ward cleaning
Policies
Renovation 7EAST
Audit Audit & feedback
Patient selection Modified allo-SCT selection criteria
Increased number of patients treated on OP clinical trials for AML
Key changes to clinical practice
7
Invasive fungal disease (proven + probable IFD)
2007n = 73
2008n = 89
2009n = 69
2010n = 92
2011n =75
Allograft 26% 0% 5% 4% 5%
AML 6% 15% 5% 5% 5%
ALL 17% 4% 0% 0% 0%
OVERALL RATE
15.1% 8% 4% 4% 4%
Clinical invasive fungal disease(proven + probable + possible IFD)
2007n = 73
2008n = 89
2009n=69
2010n =92
2011n = 75
52% 7% 8% 10% 7%
41% 33% 20% 21% 18%
34% 30% 20% 0% 33%
42% 25% 16% 14% 13%
Overall Rates IFI all groups 2007-2011
8
Outcomes
• Significant reduction in IFI in the target groups to levels reported in the literature
• Large cost savings in high cost antifungal drugs, estimated to be approximately $1million per annum
• On site drug monitoring now available
9
2007n = 23
2008n = 27
2009n = 39
2010n = 48
2011n = 43
Ambisome 15 (65%) 7 (30%) 7 (18%) 2 (4%) 2 (5%)
Voriconazole IV 10 (48%) 6 (22%) 9 (23%) 1 (2%)
Voriconazole oral 12 (52%) 5 (18%) 10 (25%) 1 (2%) 1 (2%)
Caspofungin 8 (35%) 1 (3.7%) 1 (2.5%) 0
Posaconazole 1 (2%)
Overall on treatment dose antifungals
19 (83%) 8 (30%) 12 (31%) 5 (10%) 3 (7%)
Allo-SCT – treatment dose antifungals
10
0
2
4
6
8
10
12
14
Nu
mb
er o
f pat
ien
ts/c
ases
patients in ward fungal infections
2007 2008 2009 2010 2011
11
Figure 2: cost of treatment dose antifungals for high risk patients
$2,173,305
$1,064,302
$801,668
$195,056
$-
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
2007 2008 2009 2010
An
tifu
ng
al c
os
ts
12
$-
$500,000
$1,000,000
$1,500,000
$2,000,000
Ambisome Voriconazole IV Voriconazole oral caspofungin
Figure 3: total (treatment and prophylaxis) costs of antifungals for high risk patients
13
Lessons learned
• Fungal infections have significant consequences, both clinical and economic
• Measurement is critical – if you don’t measure you don’t know!
• For complex problems, solutions often cross Departments e.g. Haematology, Pharmacy, Ward, Engineering, Pathology etc
• Executive support is essential to facilitate this.
• Big gains can be made where you may least expect them, both in terms of patient safety and financial
14
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