Given that doctors' decisions account for the vast majority of all health care dollars spent, physician decision-making has been targeted by strategies or measures aimed at controlling health care spending. The use of antimicrobial agents has drawn much of this focus, according to John P. Burke, MD, chief of clinical epidemiology, LDS Hospital, Salt Lake City, UT. Efforts to control the use of antibiotics in order to improve it have had mixed results so far.

Dr. Burke was one of four infectious disease experts who spoke to 60 participants at a seminar entitled, Cost Reduction in Antimicrobial Therapy, held this past March in Baltimore, MD. The seminar was jointly sponsored by the National Foundation for Infectious Diseases (NFID) and the Johns Hopkins University (JHU) School of Medicine.

The seminar allowed the speakers to outline recent studies and innovative methods with which they have been involved. Topics addressed included controlling costs in managed care settings, the use of outpatient infusion centers, the potential role of information technology, and the significance of adverse drug events.

For over a decade, Dr. Burke has been involved with the development of strategies which attempt to inform, rather than control, medical decisions. He has also tried to develop programs that sought continual quality improvement. "Such strategies are centered around the idea that antibiotic misuse and the resulting poor quality of care are a matter of poor information and guidance rather than bad behavior," said Dr. Burke. "Physicians spend inordinate amounts of time piecing together and interpreting patient-specific information rather than providing care to patients."

Dr. Burke and his colleagues were able to show in a recently completed seven-year study that using antibiotic practice guidelines derived from local clinicians through a computer support system can significantly reduce costs while improving quality of care on a consistent basis. His presentation provided an update as to how well that system has been transplanted to several other hospitals.

NFID Director John G. Bartlett, MD, chief, Division of Infectious Diseases, JHU School of Medicine, Baltimore, MD, outlined the issues underlying the control of infectious disease costs in a managed care setting.

Dr. Bartlett was recently involved in a study of cost reduction efforts in the JHU HIV/AIDS Care Program. The study highlighted the complexity of issues surrounding the provision of managed care, since financial, ethical, and quality assurance considerations all impacted the study. Dr. Bartlett reported that some of the most significant cost savings revealed by the study came through better control of pharmacy procedures.

Alan D. Tice, MD, another NFID director, as well as clinical assistant professor, University of Washington, and infectious diseases consultant, Infections Limited, P.S., Tacoma, WA, discussed the benefits of outpatient parenteral antimicrobial therapy (OPAT), which "has the potential to provide both better patient care as well as cost savings."

Dr. Tice said the use of OPAT has grown rapidly over the past 20 years. Nearly 300,000 Americans receive OPAT annually. "Cost savings has been the major impetus to growth as outpatient care is less expensive than hospitalization," Dr. Tice said. However, other reasons for its growth are technological improvements and newer antibiotics. Patients also benefit from being in the home environment, receiving individualized care, and avoiding nosocomial infections, he added.

But Dr. Tice also noted the critical role that a physician plays in developing an OPAT program, a role which determines the fulfillment of OPAT's potential. "The physician should be involved for maximal efficiency and quality. They are ultimately responsible for diagnosing the infection, selecting the appropriate antibiotic, and determining whether hospitalization is appropriate or not," he said. "They can be an effective team leader, assure the quality of the program, and oversee utilization."

His conclusion was that OPAT offers unique potential for cost savings and improved quality of care. Although relatively new as a method, OPAT "should become increasingly used and valued," according to Dr. Tice.

The final presentation of the evening was made by Timothy McNamara, MD, MPH, TM, vice president for research, Multum Information Services, Inc., Denver, CO. "Adverse drug events (ADEs) represent an enormous threat to the health and well-being of patients in the United States and around the world," Dr. McNamara said. "Moreover, ADEs pose significant economic burdens on those institutions and individuals that pay for health care." Treatment costs and malpractice claims are particularly high for ADEs.

According to Dr. McNamara, not only is antimicrobial therapy responsible for a disproportionate share of the harms caused by ADEs, but most of those ADEs "are dose dependent and are predictable, provided that clinicians have easy access to the information they need at the time they make drug selection and drug dosing decisions." ADEs due to antimicrobial therapy are "particularly amenable to information interventions because the selection and dosage of antimicrobial therapy is generally based on objective data and findings," he added.

Dr. McNamara concluded with a discussion of the advantages and limitations of various types of technologies which can be useful in reducing the number of, or mitigating the harms of, ADEs.

This seminar was supported by unrestricted educational grants from Pharmacia & Upjohn, Inc., Bristol-Myers Squibb Company, and Abbott Laboratories.

The International Society for Vaccines (ISV) is sponsoring the 1997 ISV Symposium on Vaccinology to be held September 8-12, 1997 at the Xerox Conference Center in Leesburg, VA. The conference will focus on the latest developments in vaccine science and will include forum discussions on immunization policy and research priorities. For more information, contact Robert C. LaGasse, President, ISV, 10210 Leatherleaf Ct., Manassas, VA 20111-4245, (703) 257-0936, Fax: (703) 257-0213, e-mail: AssnCtr@idsonline.com.