From the Tucson Medical Center, Tucson, AZ.

Abstract

• Objective: To describe a quality improvement project to reduce catheter-associated urinary tract infections (CAUTIs) in an intensive care unit (ICU).
• Methods: Descriptive report.
• Results: CAUTIs are a common health care–associated infection that results in increased length of stay, patient discomfort, excess health care costs, and sometime mortality. However, many cases of CAUTIs are preventable. To address this problem at our institution, we enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) as the platform for our project. This article describes our project implementation, challenges encountered, and the lasting improvement we have achieved at our facility.
• Conclusion: By challenging the ICU culture, providing nursing with alternatives to urinary catheters, and promoting physician engagement, we were able to reduce catheter utilization and CAUTI rates in the ICU.

Hospital-acquired infections (HAIs) are important causes of morbidity and mortality in the United States [1]. Among HAIs, urinary tract infections are the 4th most common, with almost all cases caused by urethral instrumentation [2]. Catheter-associated urinary tract infections (CAUTIs) are associated with an increased hospital length of stay of 2 to 4 days and a cost of $400 million to $500 million annually [3]. As of 2015, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treating CAUTIs.

CAUTIs are a particular challenge in the intensive care unit (ICU) due to the high urinary catheter utilization rates. In our mixed medical/surgical ICU, the catheter utilization rate was 84% in 2012 and was the setting for the majority of CAUTIs in our hospital. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible; that catheters are placed using proper aseptic technique; and that the closed sterile drainage system is maintained. In 2013 we launched a project to improve our CAUTI rates and enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) [4] as the platform for our project. This article describes our project implementation, the challenges we encountered, and the lasting improvement we have achieved.

Setting

Tucson Medical Center is a 600-bed tertiary care hospital, the largest in southern Arizona, with over 1000 independent medical providers. The medical center is a locally governed, nonprofit teaching hospital that has been providing care to the city of Tucson, southern Arizona, southwest New Mexico, and northern Mexico for the past 70 years. There are 2 adult critical care units: a cardiovascular ICU and a mixed medical/surgical ICU. We focused our efforts and interventions on the mixed ICU, a 16-bed unit that includes medical, surgical (neuro, general and vascular), and neurological patient populations that had 19 CAUTIs in 2012, versus 2 CAUTIs in the cardiovascular ICU.

Project

Initial Phase

The first steps in our project were to develop our unit-based team, identify project goals, and review our current nursing practice and processes. First, using the template from the CUSP platform, we assembled a team that consisted of the chief nursing officer (executive sponsor), ICU medical director, nurse manager, infection control manager, infection control nurse, 4 nurse champions (2 two night shift 2 day shift), and a patient care technician.

The second step was to identify a realistic and achievable goal. A goal of a 20% reduction from our current utilization rate was selected. As our catheter utilization rates were consistently above 90%, we aimed to for a rate of less than 70%. In addition, we sought to reduce our CAUTI standardized infection ratio (number of health care–associated infections observed divided by the national predicted number) from 3.875 to less than 1.0.

In reviewing our current nursing practice and processes, we utilized the CUSP data collection tool and adapted it to meet our institutional needs. Figure 1 shows the original CUSP data collection tool, which is organized around 5 key questions about the catheter (eg, Is catheter present? Where it was placed? Why does the patient has a catheter today?) as well as lists appropriate and inappropriate indications. 

To implement the guidelines, we provided education to the nursing staff via emails, placed posters on the unit, and discussed appropriate and inappropriate indications during bedside conversations using the audit tool. As the project continued, these guidelines were reinforced daily when the question “why does your patient have a catheter today?” was posed to the nurses during the audit. Our chief nursing officer supported our implementation efforts by including a CAUTI prevention lecture with her monthly house-wide nursing education series called “lunch and learn.”

We added additional questions to the tool as we learned more about the practices and processes that were currently in use. For example, “accurate measurement of urinary output in the critically ill patient” was the most common reason given by nurses for keeping a catheter in. Upon further questioning, however, the common response was that “the doctor ordered it.” By adding “MD order” to the audit tool, we were able to track actual orders versus nurses falling back on old patterns. This data collection item also provided us the names and groups of physicians to approach and educate on our project goals. Two other helpful items added to the tool related to the catheter seal and stat lock (catheter securement device) placement. The data provided by these questions helped us recognize areas for improvement in nursing practice, supply issues, and the impact of other departments. For example, auditing showed that most of our catheters were placed in the emergency department (ED) and surgery. This gave us an opportunity to reach out to these units to discuss CAUTI reduction strategies. For example, after review of the ED catheter supplies, we discovered that they did not have a closed catheter insertion system with a urometer drainage bag. Therefore, when a patient was transferred to the ICU, the integrity of the urinary collection system had to be broken to place a urometer. Evidence has shown that breaking the integrity of the system increases a patient’s risk for a CAUTI [1]. Once this problem was identified, the ED inventory was changed to include the urometer as part of the closed system urinary insertion kit.

Active Phase

After the implementation phase, the next 15 months were dedicated to daily rounding and bedside auditing, the foundation of our project. Rounding was done by the unit manager or nurse champion and involved talking with the bedside nurse and completing the audit tool. These bedside conversations were an opportunity to review the HICPAC guidelines, identify education needs, and reinforce best practices. During these discussions, the nurses often would identify reasons to remove catheters.

The CAUTI team met monthly to review the previous month’s data, other observed opportunities for improvement, and any patient CAUTI information provided by our infection control nurse liaison. We conducted root cause analysis when CAUTIs developed, in which we reviewed the patient’s chart and sought to identify possible interventions that could have reduced the number of catheter days. Our findings were shared in staff meetings, newsletters, and through quality bulletin boards. We also recognized improved performance. Tokens that could be cashed in at the cafeteria for snacks or drinks were awarded to nurses who removed a urinary catheter. We also organized a celebration on the unit the first time we had 3 months without a CAUTI.

Challenges Encountered

Culture change is challenging. The entrenched mindset was that “If a patient is sick enough to be in an ICU, then they are sick enough to need a urinary catheter.” Standard nursing practice typically included placement of a urinary catheter immediately on arrival to the ICU if not already present. Over the years, placing a urinary catheter had become the norm in the ICU, with nurses noting concern about obtaining accurate measurement of urine output and prevention of skin breakdown from incontinence. We had to continually address these concerns to make progress on the project. By providing alternatives to urinary catheters, such as incontinence pads, external male collection devices in varying sizes, moisture barrier products, and scales to measure urine output, nurses were more willing to comply with catheter removal.

We worked with our wound and ostomy nurses to ensure we were providing the proper moisture barrier products and presented research to support that incontinence did not need to lead to pressure ulcers. The wound care team helped with guiding the use of products for incontinent patients to prevent incontinence-associated dermatitis and potential skin breakdown. Our administration financially supported our program, allowing us to bring in and trial supplies. As we identified products for use, we were able to place them into floor stock and make them easily available to nursing. Items such as wicking pads, skin protective creams, and alternatives to catheters were a vital part of our bedside toolkit to maintain our patient’s skin integrity.

Both nurses and physicians were concerned about accurate measurement of output, specifically in surgical patients. The use of scales to weigh and measure output from an incontinent patient’s pads was helpful but sometimes inconvenient. From our surgeons' perspective, not having immediate hourly measurements of urine output to monitor risk for hypovolemia from third spacing of fluid or from abdominal compartment syndrome was not acceptable. Because of this concern, we did not see a decrease in early catheter removal among surgical patients. Daily conversations with nurses and surgeons at the bedside continue to be key to removing catheters as soon as the surgeon is comfortable that the patient is out of risk for hypovolemia.

Outcomes

Within the first month we saw an immediate drop in catheter utilization and had zero CAUTIs, but during the next 2 months there was a return to our previous rates (Figure 2 and Figure 3 [figures show combined mixed and cardiovascular ICU rates due to reporting requirements]). 

Although nursing is at the heart of this engagement, it is the combined efforts of all disciplines that promote the reduction of CAUTIs and improve patient outcomes. When our CAUTI counts plateaued at 10 annually in 2014–2015, we reached out to physicians and found that we had not adequately educated our medical and surgical staff of our project and goals. With the backing of a supportive and vocal ICU director, physician engagement has increased and there is more attention paid to catheter removal by our ICU intensivists. This collaborative approach has helped lower our rates even further in 2016 (n = 3). We achieved our CAUTI SIR goal of less than 1.0 , and changed our current goal to less than 0.5 (Figure 3).

In addition to greater intensivist engagement, the ED reduced their urinary catheter insertion rate from 12% to 4% for all patients transferring to an inpatient status. As previously mentioned, they are now placing catheters from kits that include urometers, so we do not have to break the integrity of the closed system after the patient it transferred to the ICU. We are also collaborating with surgical services to reduce catheter use. This is still a work in progress that requires collaboration with surgeons and hospitalists in changing departmental norms.

Conclusion

Through a combined effort involving a number of departments across the hospital, we were able to reduce catheter utilization and CAUTI rates in the ICU. We have seen a culture shift, with more ICU nursing staff questioning the use of catheters and requesting to have them removed during daily bedside rounds or simply removing them based on our nursing-driven protocol. Currently, both critical care units have been actively working on reducing CAUTI rates and have gone 310 days without a CAUTI.

Reluctance among ICU nurses to remove urinary catheters has declined; however, it is easy to fall back on the convenience of catheters. We have found that each rise in utilization rates and CAUTIs pointed to the need to refocus our effort on the daily bedside conversations. Unless we can eliminate the need for urinary catheters, there will always be a risk of a CAUTI. However, with advances in catheter technology, alternatives to catheters, and nursing education, the reduction in this hospital-acquired infection can be realized.

Acknowledgments: The author thanks our devoted infection control manager (now director), Nina Espinoza Mazzola, BSM, CIC. Our attaining success at the bedside is a reflection of her commitment as a resource and in providing support for nursing practice.

Corresponding author: Jennifer C. Tuttle, RN, MSNEd, CNRN, Tucson Medical Center, 5301 E. Grant Rd, Tucson, AZ 85712.

Financial disclosures: None.

From the Tucson Medical Center, Tucson, AZ.

Abstract

• Objective: To describe a quality improvement project to reduce catheter-associated urinary tract infections (CAUTIs) in an intensive care unit (ICU).
• Methods: Descriptive report.
• Results: CAUTIs are a common health care–associated infection that results in increased length of stay, patient discomfort, excess health care costs, and sometime mortality. However, many cases of CAUTIs are preventable. To address this problem at our institution, we enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) as the platform for our project. This article describes our project implementation, challenges encountered, and the lasting improvement we have achieved at our facility.
• Conclusion: By challenging the ICU culture, providing nursing with alternatives to urinary catheters, and promoting physician engagement, we were able to reduce catheter utilization and CAUTI rates in the ICU.

Hospital-acquired infections (HAIs) are important causes of morbidity and mortality in the United States [1]. Among HAIs, urinary tract infections are the 4th most common, with almost all cases caused by urethral instrumentation [2]. Catheter-associated urinary tract infections (CAUTIs) are associated with an increased hospital length of stay of 2 to 4 days and a cost of $400 million to $500 million annually [3]. As of 2015, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treating CAUTIs.

CAUTIs are a particular challenge in the intensive care unit (ICU) due to the high urinary catheter utilization rates. In our mixed medical/surgical ICU, the catheter utilization rate was 84% in 2012 and was the setting for the majority of CAUTIs in our hospital. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible; that catheters are placed using proper aseptic technique; and that the closed sterile drainage system is maintained. In 2013 we launched a project to improve our CAUTI rates and enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) [4] as the platform for our project. This article describes our project implementation, the challenges we encountered, and the lasting improvement we have achieved.

Setting

Tucson Medical Center is a 600-bed tertiary care hospital, the largest in southern Arizona, with over 1000 independent medical providers. The medical center is a locally governed, nonprofit teaching hospital that has been providing care to the city of Tucson, southern Arizona, southwest New Mexico, and northern Mexico for the past 70 years. There are 2 adult critical care units: a cardiovascular ICU and a mixed medical/surgical ICU. We focused our efforts and interventions on the mixed ICU, a 16-bed unit that includes medical, surgical (neuro, general and vascular), and neurological patient populations that had 19 CAUTIs in 2012, versus 2 CAUTIs in the cardiovascular ICU.

Project

Initial Phase

The first steps in our project were to develop our unit-based team, identify project goals, and review our current nursing practice and processes. First, using the template from the CUSP platform, we assembled a team that consisted of the chief nursing officer (executive sponsor), ICU medical director, nurse manager, infection control manager, infection control nurse, 4 nurse champions (2 two night shift 2 day shift), and a patient care technician.

The second step was to identify a realistic and achievable goal. A goal of a 20% reduction from our current utilization rate was selected. As our catheter utilization rates were consistently above 90%, we aimed to for a rate of less than 70%. In addition, we sought to reduce our CAUTI standardized infection ratio (number of health care–associated infections observed divided by the national predicted number) from 3.875 to less than 1.0.

In reviewing our current nursing practice and processes, we utilized the CUSP data collection tool and adapted it to meet our institutional needs. Figure 1 shows the original CUSP data collection tool, which is organized around 5 key questions about the catheter (eg, Is catheter present? Where it was placed? Why does the patient has a catheter today?) as well as lists appropriate and inappropriate indications. 

To implement the guidelines, we provided education to the nursing staff via emails, placed posters on the unit, and discussed appropriate and inappropriate indications during bedside conversations using the audit tool. As the project continued, these guidelines were reinforced daily when the question “why does your patient have a catheter today?” was posed to the nurses during the audit. Our chief nursing officer supported our implementation efforts by including a CAUTI prevention lecture with her monthly house-wide nursing education series called “lunch and learn.”

We added additional questions to the tool as we learned more about the practices and processes that were currently in use. For example, “accurate measurement of urinary output in the critically ill patient” was the most common reason given by nurses for keeping a catheter in. Upon further questioning, however, the common response was that “the doctor ordered it.” By adding “MD order” to the audit tool, we were able to track actual orders versus nurses falling back on old patterns. This data collection item also provided us the names and groups of physicians to approach and educate on our project goals. Two other helpful items added to the tool related to the catheter seal and stat lock (catheter securement device) placement. The data provided by these questions helped us recognize areas for improvement in nursing practice, supply issues, and the impact of other departments. For example, auditing showed that most of our catheters were placed in the emergency department (ED) and surgery. This gave us an opportunity to reach out to these units to discuss CAUTI reduction strategies. For example, after review of the ED catheter supplies, we discovered that they did not have a closed catheter insertion system with a urometer drainage bag. Therefore, when a patient was transferred to the ICU, the integrity of the urinary collection system had to be broken to place a urometer. Evidence has shown that breaking the integrity of the system increases a patient’s risk for a CAUTI [1]. Once this problem was identified, the ED inventory was changed to include the urometer as part of the closed system urinary insertion kit.

Active Phase

After the implementation phase, the next 15 months were dedicated to daily rounding and bedside auditing, the foundation of our project. Rounding was done by the unit manager or nurse champion and involved talking with the bedside nurse and completing the audit tool. These bedside conversations were an opportunity to review the HICPAC guidelines, identify education needs, and reinforce best practices. During these discussions, the nurses often would identify reasons to remove catheters.

The CAUTI team met monthly to review the previous month’s data, other observed opportunities for improvement, and any patient CAUTI information provided by our infection control nurse liaison. We conducted root cause analysis when CAUTIs developed, in which we reviewed the patient’s chart and sought to identify possible interventions that could have reduced the number of catheter days. Our findings were shared in staff meetings, newsletters, and through quality bulletin boards. We also recognized improved performance. Tokens that could be cashed in at the cafeteria for snacks or drinks were awarded to nurses who removed a urinary catheter. We also organized a celebration on the unit the first time we had 3 months without a CAUTI.

Challenges Encountered

Culture change is challenging. The entrenched mindset was that “If a patient is sick enough to be in an ICU, then they are sick enough to need a urinary catheter.” Standard nursing practice typically included placement of a urinary catheter immediately on arrival to the ICU if not already present. Over the years, placing a urinary catheter had become the norm in the ICU, with nurses noting concern about obtaining accurate measurement of urine output and prevention of skin breakdown from incontinence. We had to continually address these concerns to make progress on the project. By providing alternatives to urinary catheters, such as incontinence pads, external male collection devices in varying sizes, moisture barrier products, and scales to measure urine output, nurses were more willing to comply with catheter removal.

We worked with our wound and ostomy nurses to ensure we were providing the proper moisture barrier products and presented research to support that incontinence did not need to lead to pressure ulcers. The wound care team helped with guiding the use of products for incontinent patients to prevent incontinence-associated dermatitis and potential skin breakdown. Our administration financially supported our program, allowing us to bring in and trial supplies. As we identified products for use, we were able to place them into floor stock and make them easily available to nursing. Items such as wicking pads, skin protective creams, and alternatives to catheters were a vital part of our bedside toolkit to maintain our patient’s skin integrity.

Both nurses and physicians were concerned about accurate measurement of output, specifically in surgical patients. The use of scales to weigh and measure output from an incontinent patient’s pads was helpful but sometimes inconvenient. From our surgeons' perspective, not having immediate hourly measurements of urine output to monitor risk for hypovolemia from third spacing of fluid or from abdominal compartment syndrome was not acceptable. Because of this concern, we did not see a decrease in early catheter removal among surgical patients. Daily conversations with nurses and surgeons at the bedside continue to be key to removing catheters as soon as the surgeon is comfortable that the patient is out of risk for hypovolemia.

Outcomes

Within the first month we saw an immediate drop in catheter utilization and had zero CAUTIs, but during the next 2 months there was a return to our previous rates (Figure 2 and Figure 3 [figures show combined mixed and cardiovascular ICU rates due to reporting requirements]). 

Although nursing is at the heart of this engagement, it is the combined efforts of all disciplines that promote the reduction of CAUTIs and improve patient outcomes. When our CAUTI counts plateaued at 10 annually in 2014–2015, we reached out to physicians and found that we had not adequately educated our medical and surgical staff of our project and goals. With the backing of a supportive and vocal ICU director, physician engagement has increased and there is more attention paid to catheter removal by our ICU intensivists. This collaborative approach has helped lower our rates even further in 2016 (n = 3). We achieved our CAUTI SIR goal of less than 1.0 , and changed our current goal to less than 0.5 (Figure 3).

In addition to greater intensivist engagement, the ED reduced their urinary catheter insertion rate from 12% to 4% for all patients transferring to an inpatient status. As previously mentioned, they are now placing catheters from kits that include urometers, so we do not have to break the integrity of the closed system after the patient it transferred to the ICU. We are also collaborating with surgical services to reduce catheter use. This is still a work in progress that requires collaboration with surgeons and hospitalists in changing departmental norms.

Conclusion

Through a combined effort involving a number of departments across the hospital, we were able to reduce catheter utilization and CAUTI rates in the ICU. We have seen a culture shift, with more ICU nursing staff questioning the use of catheters and requesting to have them removed during daily bedside rounds or simply removing them based on our nursing-driven protocol. Currently, both critical care units have been actively working on reducing CAUTI rates and have gone 310 days without a CAUTI.

Reluctance among ICU nurses to remove urinary catheters has declined; however, it is easy to fall back on the convenience of catheters. We have found that each rise in utilization rates and CAUTIs pointed to the need to refocus our effort on the daily bedside conversations. Unless we can eliminate the need for urinary catheters, there will always be a risk of a CAUTI. However, with advances in catheter technology, alternatives to catheters, and nursing education, the reduction in this hospital-acquired infection can be realized.

Acknowledgments: The author thanks our devoted infection control manager (now director), Nina Espinoza Mazzola, BSM, CIC. Our attaining success at the bedside is a reflection of her commitment as a resource and in providing support for nursing practice.

Corresponding author: Jennifer C. Tuttle, RN, MSNEd, CNRN, Tucson Medical Center, 5301 E. Grant Rd, Tucson, AZ 85712.

Financial disclosures: None.

From the Tucson Medical Center, Tucson, AZ.

Abstract

• Objective: To describe a quality improvement project to reduce catheter-associated urinary tract infections (CAUTIs) in an intensive care unit (ICU).
• Methods: Descriptive report.
• Results: CAUTIs are a common health care–associated infection that results in increased length of stay, patient discomfort, excess health care costs, and sometime mortality. However, many cases of CAUTIs are preventable. To address this problem at our institution, we enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) as the platform for our project. This article describes our project implementation, challenges encountered, and the lasting improvement we have achieved at our facility.
• Conclusion: By challenging the ICU culture, providing nursing with alternatives to urinary catheters, and promoting physician engagement, we were able to reduce catheter utilization and CAUTI rates in the ICU.

Hospital-acquired infections (HAIs) are important causes of morbidity and mortality in the United States [1]. Among HAIs, urinary tract infections are the 4th most common, with almost all cases caused by urethral instrumentation [2]. Catheter-associated urinary tract infections (CAUTIs) are associated with an increased hospital length of stay of 2 to 4 days and a cost of $400 million to $500 million annually [3]. As of 2015, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treating CAUTIs.

CAUTIs are a particular challenge in the intensive care unit (ICU) due to the high urinary catheter utilization rates. In our mixed medical/surgical ICU, the catheter utilization rate was 84% in 2012 and was the setting for the majority of CAUTIs in our hospital. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible; that catheters are placed using proper aseptic technique; and that the closed sterile drainage system is maintained. In 2013 we launched a project to improve our CAUTI rates and enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) [4] as the platform for our project. This article describes our project implementation, the challenges we encountered, and the lasting improvement we have achieved.

Setting

Tucson Medical Center is a 600-bed tertiary care hospital, the largest in southern Arizona, with over 1000 independent medical providers. The medical center is a locally governed, nonprofit teaching hospital that has been providing care to the city of Tucson, southern Arizona, southwest New Mexico, and northern Mexico for the past 70 years. There are 2 adult critical care units: a cardiovascular ICU and a mixed medical/surgical ICU. We focused our efforts and interventions on the mixed ICU, a 16-bed unit that includes medical, surgical (neuro, general and vascular), and neurological patient populations that had 19 CAUTIs in 2012, versus 2 CAUTIs in the cardiovascular ICU.

Project

Initial Phase

The first steps in our project were to develop our unit-based team, identify project goals, and review our current nursing practice and processes. First, using the template from the CUSP platform, we assembled a team that consisted of the chief nursing officer (executive sponsor), ICU medical director, nurse manager, infection control manager, infection control nurse, 4 nurse champions (2 two night shift 2 day shift), and a patient care technician.

The second step was to identify a realistic and achievable goal. A goal of a 20% reduction from our current utilization rate was selected. As our catheter utilization rates were consistently above 90%, we aimed to for a rate of less than 70%. In addition, we sought to reduce our CAUTI standardized infection ratio (number of health care–associated infections observed divided by the national predicted number) from 3.875 to less than 1.0.

In reviewing our current nursing practice and processes, we utilized the CUSP data collection tool and adapted it to meet our institutional needs. Figure 1 shows the original CUSP data collection tool, which is organized around 5 key questions about the catheter (eg, Is catheter present? Where it was placed? Why does the patient has a catheter today?) as well as lists appropriate and inappropriate indications. 

To implement the guidelines, we provided education to the nursing staff via emails, placed posters on the unit, and discussed appropriate and inappropriate indications during bedside conversations using the audit tool. As the project continued, these guidelines were reinforced daily when the question “why does your patient have a catheter today?” was posed to the nurses during the audit. Our chief nursing officer supported our implementation efforts by including a CAUTI prevention lecture with her monthly house-wide nursing education series called “lunch and learn.”

We added additional questions to the tool as we learned more about the practices and processes that were currently in use. For example, “accurate measurement of urinary output in the critically ill patient” was the most common reason given by nurses for keeping a catheter in. Upon further questioning, however, the common response was that “the doctor ordered it.” By adding “MD order” to the audit tool, we were able to track actual orders versus nurses falling back on old patterns. This data collection item also provided us the names and groups of physicians to approach and educate on our project goals. Two other helpful items added to the tool related to the catheter seal and stat lock (catheter securement device) placement. The data provided by these questions helped us recognize areas for improvement in nursing practice, supply issues, and the impact of other departments. For example, auditing showed that most of our catheters were placed in the emergency department (ED) and surgery. This gave us an opportunity to reach out to these units to discuss CAUTI reduction strategies. For example, after review of the ED catheter supplies, we discovered that they did not have a closed catheter insertion system with a urometer drainage bag. Therefore, when a patient was transferred to the ICU, the integrity of the urinary collection system had to be broken to place a urometer. Evidence has shown that breaking the integrity of the system increases a patient’s risk for a CAUTI [1]. Once this problem was identified, the ED inventory was changed to include the urometer as part of the closed system urinary insertion kit.

Active Phase

After the implementation phase, the next 15 months were dedicated to daily rounding and bedside auditing, the foundation of our project. Rounding was done by the unit manager or nurse champion and involved talking with the bedside nurse and completing the audit tool. These bedside conversations were an opportunity to review the HICPAC guidelines, identify education needs, and reinforce best practices. During these discussions, the nurses often would identify reasons to remove catheters.

The CAUTI team met monthly to review the previous month’s data, other observed opportunities for improvement, and any patient CAUTI information provided by our infection control nurse liaison. We conducted root cause analysis when CAUTIs developed, in which we reviewed the patient’s chart and sought to identify possible interventions that could have reduced the number of catheter days. Our findings were shared in staff meetings, newsletters, and through quality bulletin boards. We also recognized improved performance. Tokens that could be cashed in at the cafeteria for snacks or drinks were awarded to nurses who removed a urinary catheter. We also organized a celebration on the unit the first time we had 3 months without a CAUTI.

Challenges Encountered

Culture change is challenging. The entrenched mindset was that “If a patient is sick enough to be in an ICU, then they are sick enough to need a urinary catheter.” Standard nursing practice typically included placement of a urinary catheter immediately on arrival to the ICU if not already present. Over the years, placing a urinary catheter had become the norm in the ICU, with nurses noting concern about obtaining accurate measurement of urine output and prevention of skin breakdown from incontinence. We had to continually address these concerns to make progress on the project. By providing alternatives to urinary catheters, such as incontinence pads, external male collection devices in varying sizes, moisture barrier products, and scales to measure urine output, nurses were more willing to comply with catheter removal.

We worked with our wound and ostomy nurses to ensure we were providing the proper moisture barrier products and presented research to support that incontinence did not need to lead to pressure ulcers. The wound care team helped with guiding the use of products for incontinent patients to prevent incontinence-associated dermatitis and potential skin breakdown. Our administration financially supported our program, allowing us to bring in and trial supplies. As we identified products for use, we were able to place them into floor stock and make them easily available to nursing. Items such as wicking pads, skin protective creams, and alternatives to catheters were a vital part of our bedside toolkit to maintain our patient’s skin integrity.

Both nurses and physicians were concerned about accurate measurement of output, specifically in surgical patients. The use of scales to weigh and measure output from an incontinent patient’s pads was helpful but sometimes inconvenient. From our surgeons' perspective, not having immediate hourly measurements of urine output to monitor risk for hypovolemia from third spacing of fluid or from abdominal compartment syndrome was not acceptable. Because of this concern, we did not see a decrease in early catheter removal among surgical patients. Daily conversations with nurses and surgeons at the bedside continue to be key to removing catheters as soon as the surgeon is comfortable that the patient is out of risk for hypovolemia.

Outcomes

Within the first month we saw an immediate drop in catheter utilization and had zero CAUTIs, but during the next 2 months there was a return to our previous rates (Figure 2 and Figure 3 [figures show combined mixed and cardiovascular ICU rates due to reporting requirements]). 

Although nursing is at the heart of this engagement, it is the combined efforts of all disciplines that promote the reduction of CAUTIs and improve patient outcomes. When our CAUTI counts plateaued at 10 annually in 2014–2015, we reached out to physicians and found that we had not adequately educated our medical and surgical staff of our project and goals. With the backing of a supportive and vocal ICU director, physician engagement has increased and there is more attention paid to catheter removal by our ICU intensivists. This collaborative approach has helped lower our rates even further in 2016 (n = 3). We achieved our CAUTI SIR goal of less than 1.0 , and changed our current goal to less than 0.5 (Figure 3).

In addition to greater intensivist engagement, the ED reduced their urinary catheter insertion rate from 12% to 4% for all patients transferring to an inpatient status. As previously mentioned, they are now placing catheters from kits that include urometers, so we do not have to break the integrity of the closed system after the patient it transferred to the ICU. We are also collaborating with surgical services to reduce catheter use. This is still a work in progress that requires collaboration with surgeons and hospitalists in changing departmental norms.

Conclusion

Through a combined effort involving a number of departments across the hospital, we were able to reduce catheter utilization and CAUTI rates in the ICU. We have seen a culture shift, with more ICU nursing staff questioning the use of catheters and requesting to have them removed during daily bedside rounds or simply removing them based on our nursing-driven protocol. Currently, both critical care units have been actively working on reducing CAUTI rates and have gone 310 days without a CAUTI.

Reluctance among ICU nurses to remove urinary catheters has declined; however, it is easy to fall back on the convenience of catheters. We have found that each rise in utilization rates and CAUTIs pointed to the need to refocus our effort on the daily bedside conversations. Unless we can eliminate the need for urinary catheters, there will always be a risk of a CAUTI. However, with advances in catheter technology, alternatives to catheters, and nursing education, the reduction in this hospital-acquired infection can be realized.

Acknowledgments: The author thanks our devoted infection control manager (now director), Nina Espinoza Mazzola, BSM, CIC. Our attaining success at the bedside is a reflection of her commitment as a resource and in providing support for nursing practice.

Corresponding author: Jennifer C. Tuttle, RN, MSNEd, CNRN, Tucson Medical Center, 5301 E. Grant Rd, Tucson, AZ 85712.

Financial disclosures: None.

The number of skin cancer procedures in 2016 was up by 10.5% since 2015 and by 35% since 2012, according to the American Society for Dermatologic Surgery.

Of the estimated 3.5 million skin cancer treatments provided by dermatologic surgeons in 2016, just over 227,000, or 6.5%, were for melanoma – a 4% increase over those diagnosed in 2015. Since 2012, the annual number of melanoma procedures has risen by 55%. The 3.29 million nonmelanoma procedures performed in 2016 represent a 10% increase over 2015, the ASDS said in a report on its 2016 Survey on Dermatologic Procedures.

“The public is increasingly aware of the need to have any new or suspicious lesions checked,” ASDS President Thomas Rohrer, MD, said in a written statement.

In addition to the skin cancer treatments, ASDS members also performed over 7 million cosmetic procedures in 2016, including 2.8 million involving laser, light, and energy-based devices. Additionally, 1.7 million involving neuromodulators, and 1.35 million involved soft-tissue fillers, the ASDS said.

The procedures survey was conducted Jan. 4 to Feb. 8, 2017, and included 627 physicians’ responses, which were then generalized to represent all of the almost 6,100 ASDS members.

The number of skin cancer procedures in 2016 was up by 10.5% since 2015 and by 35% since 2012, according to the American Society for Dermatologic Surgery.

Of the estimated 3.5 million skin cancer treatments provided by dermatologic surgeons in 2016, just over 227,000, or 6.5%, were for melanoma – a 4% increase over those diagnosed in 2015. Since 2012, the annual number of melanoma procedures has risen by 55%. The 3.29 million nonmelanoma procedures performed in 2016 represent a 10% increase over 2015, the ASDS said in a report on its 2016 Survey on Dermatologic Procedures.

“The public is increasingly aware of the need to have any new or suspicious lesions checked,” ASDS President Thomas Rohrer, MD, said in a written statement.

In addition to the skin cancer treatments, ASDS members also performed over 7 million cosmetic procedures in 2016, including 2.8 million involving laser, light, and energy-based devices. Additionally, 1.7 million involving neuromodulators, and 1.35 million involved soft-tissue fillers, the ASDS said.

The procedures survey was conducted Jan. 4 to Feb. 8, 2017, and included 627 physicians’ responses, which were then generalized to represent all of the almost 6,100 ASDS members.

The number of skin cancer procedures in 2016 was up by 10.5% since 2015 and by 35% since 2012, according to the American Society for Dermatologic Surgery.

Of the estimated 3.5 million skin cancer treatments provided by dermatologic surgeons in 2016, just over 227,000, or 6.5%, were for melanoma – a 4% increase over those diagnosed in 2015. Since 2012, the annual number of melanoma procedures has risen by 55%. The 3.29 million nonmelanoma procedures performed in 2016 represent a 10% increase over 2015, the ASDS said in a report on its 2016 Survey on Dermatologic Procedures.

“The public is increasingly aware of the need to have any new or suspicious lesions checked,” ASDS President Thomas Rohrer, MD, said in a written statement.

In addition to the skin cancer treatments, ASDS members also performed over 7 million cosmetic procedures in 2016, including 2.8 million involving laser, light, and energy-based devices. Additionally, 1.7 million involving neuromodulators, and 1.35 million involved soft-tissue fillers, the ASDS said.

The procedures survey was conducted Jan. 4 to Feb. 8, 2017, and included 627 physicians’ responses, which were then generalized to represent all of the almost 6,100 ASDS members.

Mothers with a lower level of education had a stronger intent to vaccinate their teen for human papillomavirus (HPV) than college-educated mothers in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.

Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.

National Cancer Institute

[email protected]

Mothers with a lower level of education had a stronger intent to vaccinate their teen for human papillomavirus (HPV) than college-educated mothers in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.

Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.

National Cancer Institute

[email protected]

Mothers with a lower level of education had a stronger intent to vaccinate their teen for human papillomavirus (HPV) than college-educated mothers in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.

Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.

National Cancer Institute

[email protected]

The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.

This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.

[email protected]

The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.

This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.

[email protected]

The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.

This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.

[email protected]

SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.

The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.

The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.

“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.

For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).

Thinglass/Thinkstock

[email protected]

SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.

The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.

The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.

“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.

For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).

Thinglass/Thinkstock

[email protected]

SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.

The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.

The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.

“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.

For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).

Thinglass/Thinkstock

[email protected]

A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.

Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.

Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.

“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.

Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.

They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”

The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.

[email protected]

A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.

Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.

Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.

“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.

Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.

They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”

The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.

[email protected]

A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.

Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.

Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.

“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.

Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.

They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”

The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.

[email protected]

Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.

The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.

© Sean Locke/iStockphoto.com

[email protected]

Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.

The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.

© Sean Locke/iStockphoto.com

[email protected]

Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.

The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.

© Sean Locke/iStockphoto.com

[email protected]

As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.

Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.

Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.

“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.

Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.

Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.

Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.

CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.

“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”

If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.

Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.

Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.

Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.

Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.

While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.

“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”

After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.

Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
 

Using ‘Those Powers For Good’

Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.

His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”

Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.

Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.

“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.

“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”

At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.

Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.

CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.

Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.

Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.

That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
 

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.

Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.

Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.

“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.

Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.

Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.

Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.

CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.

“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”

If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.

Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.

Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.

Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.

Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.

While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.

“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”

After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.

Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
 

Using ‘Those Powers For Good’

Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.

His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”

Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.

Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.

“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.

“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”

At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.

Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.

CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.

Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.

Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.

That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
 

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.

Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.

Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.

“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.

Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.

Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.

Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.

CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.

“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”

If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.

Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.

Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.

Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.

Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.

While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.

“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”

After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.

Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
 

Using ‘Those Powers For Good’

Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.

His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”

Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.

Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.

“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.

“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”

At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.

Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.

CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.

Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.

Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.

That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
 

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.

Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.

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Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.

Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.

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Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.

Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.

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A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.

To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.

A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.

To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.

A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.

To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.