Public Health in Action: Dr. Demetre Daskalakis

There's an excellent article in The Atlantic on Demetre Daskalakis, MD, MPH. He's an infectious diseases doctor, former ID fellowship director at NYU, former faculty member at Mt. Sinai, and now the Assistant Commissioner of the New York City Department of Public Health. He describes himself as an activist clinician providing cutting edge care and prevention to a very marginalized population of HIV positive and negative men who have sex with men. He's become well known for his creative interventions utilizing social media, as well as old fashioned public health in the trenches. It's worth a read.

Finally, the outbreak of meetings!

We’ve done a lot of blogging about the insidious M. chimaera outbreak linked to heater-cooler units (HCUs). Still, the general awareness of this problem lags, despite the fact that an untold number of HCUs are affected, and an unknown number of people are suffering with an undiagnosed granulomatous inflammatory process that has a crude mortality rate in excess of 50%. We heard excellent talks about the issue at SHEA 2016 from Emily Cooper at Wellspan (10 cases, 6 deaths), from Dr. Ray Chinn in the “Challenging Cases in Infection Prevention” session, and I gave a late-breaker on Friday evening (slides to follow in an upcoming post). By the way, SHEA 2016 was EXCELLENT, and the slide image above is from Bob Weinstein’s talk in the SHEA/CDC Training Course. 

Well, the FDA is hosting a meeting on this problem, details of which can be found here. I will be presenting about our experience at Iowa, but others with more expertise will be there as well, from US and Europe. I’m hoping to come away with a better sense of the way forward, which in my view must address (1) better case finding: improved clinician awareness via national patient and provider notifications, so that clinicians everywhere recognize exposure to cardiopulmonary bypass as a risk factor for disseminated MAC infection among patients with implants (valves, grafts), and creative approaches to identify potential cases who currently carry other diagnoses (e.g. sarcoidosis); (2) improved management of existing cases: we desperately need more clinical information about management approaches and outcomes, to help guide decision making for patients and their physicians; and (3) prevention of additional cases: the HCU has been revealed to be a bioaerosol generator that is too risky to share air with an open chest—the make/model implicated in this particular outbreak must obviously be removed from ORs, and other devices that include fans and water sources should also be scrutinized for the risk they may pose.

VA Funds Two New Antimicrobial Resistance and HAI Prevention Programs

Dr. Nasia Safdar

It wasn't long ago, that many of us were concerned about the lack of attention that antimicrobial resistance was receiving, particularly in regard to funding for research and also infection prevention programs. Yet over the last few years, there has been increased attention throughout the US including the release of the National Action Plan to Combat Antibiotic-Resistant Bacteria and increased funding for CDC, NIH and AHRQ. Besides the lack of novel interventions that extra research funding will help tackle, another huge barrier to preventing MDRO and HAI is lack of information on how to successfully implement the few interventions we have within hospitals and healthcare systems.

It is this gap between efficacy and effectiveness that VA's Quality Enhancement Research Initiative (QUERI) seeks to fill. QUERI's mission is to "improve the health of Veterans by supporting the more rapid implementation of effective clinical practices into routine care." And it is the goal of QUERI investigators to "ask crucial questions regarding the intended and unintended impacts of implementing new treatments or programs – and the best strategies for speeding their adoption into practice."

Dr. Charlesnika Evans

With that background it is incredibly exciting to announce that VA has funded two new QUERI programs that target MDRO and HAI.

The first program titled "Building Implementation Science for VA Healthcare-Associated Infection Prevention" is led by Dr. Nasia Safdar in Madison. Dr. Safdar and her team partnered with VA's National Center for Patient Safety to achieve two broad aims. First, they will implement and evaluate an evidence-based intervention - daily chlorhexidine bathing of hospitalized Veterans for prevention of HAI. Second, they will establish a VHIN (VA Healthcare-Associated Infection Prevention Network) and assess current practices and needs related to HAI prevention. The long-term goal is to utilize the VHIN as a platform for VA facilities seeking to undertake pragmatic implementation science initiatives related to HAI prevention. You can read much more about her program that began in October 2015, here.

Dr. Michael Rubin

The second program titled "Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence" or CARRIAGE is set to begin in October 2016 and aims to address the growing concern of antimicrobial resistance through strategies implemented across VA patient care settings. The three projects will evaluate hand hygiene surveillance methods, enhance the implementation of new CRE prevention guidelines and promote judicious use of antibiotics through a multi-hospital antibiotic timeout program. The program directors are Michael Rubin, MD PhD (Salt Lake City) Charlesnika Evans, PhD, MPH (Hines, IL); and Eli Perencevich, MD MS (COI alert)

The next few years promise to be an exciting time for MDRO and HAI prevention in VA and throughout the US as we develop, test and implement new methods to enhance patient safety.

At first he was only prescribed for me, now he's messing around with EVERYBODY !

Watch this video! It will change your life and the future of the world!

The overselling of science can be pretty hilarious when described by John Oliver, yet it infects not just the media but also scientific journals and professional conferences. One of the aims of this blog has always been to question the latest fad sweeping infection prevention nation; see Dan's recent post on ADI for CDI or my talk on public reporting of HAIs. In addition to highlighting the bit at the end of the video that notes the 70% increase in authority that descends upon those wearing a white coat, I've pulled out these quotes for you to ponder:

"Just because a study is industry funded or its sample size was small or it was done on mice doesn't mean it's automatically flawed, but it is something the media reporting on it should probably tell you about." - John Oliver

"I think the way to live your life is to find the study that sounds best to you and you go with that" - Al Roker

Training Course in Healthcare Epidemiology and Infection Control (Bochum Germany)

Happy 2015 ESCMID-SHEA Training Course Students and Faculty

The ESCMID-SHEA Training Course in Healthcare Epidemiology and Infection Control has been redesigned. Instead of predominately lectures, the new course model now includes three distinct tracks. The first track is an interactive and practical exercise on how to analyze and respond to a high-rate of surgical site infections in your hospital. The second track covers data analysis of a possible outbreak of C. difficile infections. The third track includes 4 interactive masterclasses led by highly experienced hospital epidemiologists covering topics such as outbreaks, responding to high endemic rates of HAIs, infections in surgical populations and other topics. 

The course was pilot tested last year in Cairns, Australia with great success (see above) and the instructors can't wait to build on that success this fall in Europe. We hope you can join us 4-7 October 2016 in Bochum, Germany. Registration is via the Aesculap Akademie website.

May The 5th Be With You - #SafeSurgicalHands

There are so many commemorative days, that I sometimes get them confused. We just missed Star Wars Day and today (May 5th) is even International Day of the Midwife, which seems appropriate if you understand the Semmelweis story - his control group was a maternity ward staffed by female midwives with one-fifth the mortality compared to the doctor/medical student ward.

Which brings us to a very important day in infection prevention - 5th of May - WHO Hand Hygiene Day! I can't do better than Professor Didier Pittet when talking about hand hygiene, so I've added his video above and provided his letter with important links for #SafeSurgicalHands below.  Thank you all for what you're doing to create a safer healthcare environment starting with clean hands.

Dear All,

I am pleased to invite you to celebrate the WHO Hand Hygiene Day in Healthcare on 5 May 2016.

The 2016 year campaign promotes #SafeSurgicalHands on Twitter and Instagram.

All WHO tools to participate are available at: www.tinyurl.com/WHOtool5May16

Post your photos/selfies at : www.cleanhandssavelives.org/safesurgicalhands/

Safe Hands in Surgery-WHO 2016 message together with colleagues surgeons: www.tinyurl.com/WHOadd2016

#SafeSurgicalHands Pictures' Wall (updated in real time): https://walls.io/SafeSurgicalHands

Additional educative videos are accessible at:

• Your WHO 5 moments for Hand Hygiene along the patient journey in surgery www.tinyurl.com/5momentsSurgery
• WHO surgical hand preparation technique www.tinyurl.com/SurgScrubTech
• For those who want to conduct a Hand Sanitizing Relay: http://tinyurl.com/HHRelay
• Any information at handhygienerelay@cleanhandssavelives.org
• Or see the best relays in 2015 : http://tinyurl.com/GlobalHandSanitizingRelay2015
• Or simply look at 10 years of Clean Care is Safer Care http://tinyurl.com/CleanHands10

I am looking forward to seeing you all participating.
Let’s improve hand hygiene, reduce infections, limit resistance and save lives.

With best wishes,
Professor Didier Pittet

IDSA response: Guest post by Dr. Dan McQuillen

The following is a guest post from Dr. Daniel McQuillen, IDSA Chair for the IDWeek 2016 Program Committee, and President of the Massachusetts Infectious Diseases Society.

With the acknowledgement that IDSA needs to expand communication/marketing efforts in this area, I wanted to offer some information on ongoing activities our society has been engaged in for several years, beginning with IDSA’s leadership level membership in the Cognitive Care Alliance, an organization that has evolved from a loose coalition to a more formal structure last January. The Alliance hopes to take advantage of the collective power and footprint of cognitive specialties to advance the agenda that the current payment system seriously undervalues cognitive services. Change is slow and incremental in this area, but some of the reforms in payment delivery coming along offer opportunities for ID to improve our reimbursement position in the clinical arena and more importantly in the non-clinical arena (antibiotic stewardship programs (ASP), infection prevention (IP), overall system quality). You'll note that the Alliance member who signed this letter to the Senate Finance Committee (John Goodson from SGIM) is also the author of the recent NEJM article regarding fixing the Medicare Fee Schedule.

IDSA representatives to the AMA CPT/RUC committees have been involved in development and valuation of codes for physician supervision of OPAT infusion, RVU revaluation (upwards) of Evaluation & Management codes and transitional/continuing care codes. In addition, the IDSA Board approved a partnership between the Valuation Workgroup that I lead and The Advisory Board, a consulting group with a healthcare focus, to formally develop the concept of an ID Hospital Efficiency Improvement Program. Such a program will contain ID service lines that are threads throughout healthcare systems, and can serve as templates for members to use when they are proposing new or expanded ASP, IP and OPAT programs to their hospitals or systems. The IDSA Board of Directors previously funded our work with an external expert valuation firm to establish that the benchmarks for “fair market value (FMV)” for ID executive compensation should be higher than the FMV numbers usually thrown out by hospital executives at ID docs. The compensation survey just published by the IDSA Clinical Affairs Committee (CAC) complements this and represents an effort to generate accurate data to counter the inaccurate data promulgated by MGMA and Medscape, not a ‘spin’ that everything is fine. It is just one piece of a broad effort to bolster the value of ID specialists to the systems they work in and support. I note that SHEA has recently surveyed its membership on compensation and await a report on the findings in hopes that it serves as another more accurate benchmark reference. The FMV data along with examples of medical executive co-management agreements for non-clinical activities with sample contracts can be found in the “Value of ID Specialists Toolkit” on the IDSA website (membership login required).

A major thrust of what the IDSA Clinical Affairs Committee, Value Task Force, and Valuation Workgroup have been doing for several years is to establish a robust set of tools with supporting evidence that will serve to increase the benchmarks for what we get paid for our non-patient care activities. New trainees coming out of fellowship have little idea how to establish the value of and negotiate for fair compensation for those activities (I know I had no clue). Success in these efforts will go a long way to increasing overall compensation and have potential to yield far more reward than increasing payments for E&M services would. Our specialty’s inherent altruistic nature, especially in academic settings but still in many clinical practice settings, gives our expertise away with too much ease. We have to change that.

Finally, two IDWeek plugs: the IDSA CAC has organized a session for several years that explores the issues of Health Care Reform as they affect our specialty. This year will feature talks on Health Care Reform trends by a speaker from The Advisory Board, ID-led ASP, and how ID specialists fit in a bundled payment environment. Second, in lieu of their annual Business Meetings, the Presidents of IDSA and HIVMA will be hosting an ID “State of the Specialty” Town Hall Meeting Friday evening at IDWeek. Please attend with suggestions in hand.

The importance of considering time when evaluating risks of base jumping (and maybe even antibiotics)

This is a guest post by L. Silvia Munoz-Price, MD, PhD. Associate Professor of Medicine at the Medical College of Wisconsin. Enterprise Epidemiologist at Froedtert Health. Milwaukee.

Over a month ago, Eli asked me to write this piece to discuss my recent CID paper on handling time dependent variables. I knew this had to be done with an analogy but after several weeks of mulling over this, I was still uncertain on how to colloquially explain this concept to you. So, as I was almost ready to forget about this post while on a plane to Miami, I had sudden inspiration as I was about to nap! I really hope this helps everyone understand this statistical concept. If not, then I'm not sure reading the CID paper will help you much either…stick to 2x2 tables (sorry!!).

Setting: Let’s imagine Eli and his wife invited my hubby and me to go base jumping in New Zealand for a week (See figure…Eli take note!!). So, now let’s observe our jumping habits: of course, I would jump once and be done with it for lifetime. My hubby would probably not jump at all and just enjoy watching crazy people jump. Let’s say Eli decides to jump every day (two days he jumps twice!) and his wife jumps three consecutive days.

Study design: Ok. Not to be morbid, but the easiest outcome to evaluate is mortality (binary variable; 1: dead or 0:alive) by the end of the vacation. The exposure variable of interest is base jumping. 

Option 1: The easiest way to look at this association is to construct a 2x2 table: Did you jump? (yes/no) Did you die? (yes/no). See, the problem with this analysis is that it ignores the intensity of the exposure as Eli, his wife, and I would be considered as a “yes” and only my husband would be a “no”. But, is it reasonable to analyze the exposures for Eli, his wife and I the same way? Intuitively, we probably could say no.

Option 2: A tad more elaborate way to look at this would be to count the number of jumps per person and enter these numbers in the analysis. So, Eli would have 9, his wife would have 3, I would have 1, and my husband would have 0. What is the problem with this approach? Well, it completely disregards time of exposures, correct? It is like having all those jumps in only one day. We need to ask: when was “that” day that all those exposures got summed? Was it at the beginning of the week or towards the end? Did the outcome happen at the beginning of the week, in the middle or at the end? Is it reasonable to analyze all those jumps clustered in time within a single day? Intuitively, I would say no. A similar problem happens with number of days that jumps occurred, especially for me. When did my one jump happen (at the beginning of the trip or towards the end?).

Option 3: A more elaborate way to determine the association between jumping and mortality is to account for the richness of the exposures. Not just taking into account the specific days the jumps occurred, but how many jumps occurred each day and from which different altitudes these jumps took place. Then we can calculate the hazard of dying on a daily basis based on the previous 24 hours of jumps. Let’s go over this a bit further. The hazard on day 1 would be calculated using 3 people. Assuming we all survived, on day 2 the hazard would be calculated only among the people that jumped (2). On day 3, assuming we all survived, the hazard would be calculated again only among the people who jumped that day (2 jumps). On day 4, assuming we all survived the hazard would be calculated only among the people who jumped (1). If any of us were to arrive to the outcome during the observation, then that person would be removed from the analysis. This is the concept of time dependent exposures. You measure the outcome as the exposure occurs over time. This is in contrast to what we usually do in our hospital epi studies: exposure treated as binary variable (yes/no) or exposure treated as number of days exposed (9 or 3 or 1) or even as number of jumps performed. More concerning, the outcome on the latter examples is fixed towards the end of the observation rather than measured as time progresses.

Bringing it home: ANTIBIOTIC EXPOSURES. Antibiotics are such rich exposures. Think about it. They can be given during many different days throughout the hospital stay and there are many types of antibiotics, with various doses and routes. Outcome variables, such as acquiring a multidrug resistant organism or even developing an infection by this organism also vary in time during hospitalization. Is it reasonable to analyze all those antibiotic exposures clustered in time within a single day or even worse as binary variables? Is it optimal to fix the outcome variable as happening at the end of hospitalization? Intuitively, I would say no to both. There are a couple of examples in the ID literature that compare these analyses. One of them by my co-author Marc Bonten. However, specifically for antibiotics it is not fully clear to me if the associations found would justify the additional cost and time of obtaining all this rich information about exposures and outcomes (note: think about relooking at your cohort datasets using this method).

Let’s end this post here [so that I can take a quick nap before landing] and see the feedback I get with this example. If the feedback is good then I will explain the biases that can occur by not accounting for time in your analyses, and maybe go over delayed effect of antibiotics. In the meantime, I will be sipping a mojito with my hubby while enjoying Miami. Salud!

The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs...  I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its 8th year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the ID workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli, Dan, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely RVU-based compensation plan, and the toll this took on teaching and morale. At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists. In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries. I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, one respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the AAMC data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:

• Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around. 
• Consider shortening the ID fellowship to positively affect the cost-benefit calculus of additional training. Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities? 
• Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training with hospitalist practice). Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship. This would increase the fellow’s salary, and even if the total duration of training were extended, may entice more residents to consider ID training. Some would probably continue this model beyond training into employment. 
• If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is--a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause. 

Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match.