Education and Outreach
Educational and outreach activities are important components for strengthening infectious disease surveillance, research, and prevention. Establishment of principles and guidelines for educational and outreach efforts in the health care industry has become more difficult in the changing health care environment. Health care trade associations can provide a mechanism for the coordination of such activities. The managed care industry must contend with conflicting policies arising from its economic imperatives. Inconsistent and sometimes conflicting communication of educational versus economic benefits can place undue burdens on physicians who are trying to achieve balance between good practices and economic pressures. Infectious disease management under such conditions can be a difficult and challenging task. However, efforts to revamp the system to encourage educational outreach programs not only for health care professionals but also for the general public are under way.
The following presentations discuss the effects of managed care on educational and outreach efforts in addressing emerging and reemerging infectious diseases.
COORDINATING HEALTH PLAN RESEARCH AND EDUCATIONAL EFFORTS
Presented by Richard Platt, M.D.
Director of Research, Harvard Pilgrim Health Care
The American Association of Health Plans (AAHP), a trade association for managed care organizations, is active in developing principles for participating members that conduct research and demonstration projects. AAHP fosters col-
laborations between managed care organizations and traditional sponsors of research, such as the National Institutes of Health (NIH), the Agency for Health Care Policy and Research, and the Centers for Disease Control and Prevention (CDC), and facilitates the development of joint research agendas. Because of its large and diverse membership, AAHP can assist in assessing many aspects of the delivery of health care. Additionally, AAHP is responsible for testing the measures developed in the public health sector, such as CDC's immunization record system, and for developing demonstration programs in managed care organizations, such as the Tuberculosis Surveillance Program.
Given its position, AAHP can also pursue other educational and outreach opportunities through the managed care industry. Not only can AAHP encourage the dissemination of methods on behalf of the managed care industry, for example, by facilitating the creation of managed care guidelines, but it can also use data for the purpose of monitoring health care. For instance, AAHP could play an important facilitating role in the development and implementation of standards for dispensing data on antibiotic use. This would be an important development, since information about antibiotic use could be available (in theory) for a large and growing fraction of the U.S. population. In addition, data from managed care organizations could serve as a surveillance tool to monitor and address potential emerging infections.
IMPACTS OF MANAGED CARE SYSTEM'S EDUCATIONAL EFFORTS ON CONTROL OF ANTIBIOTIC USE
Presented by Benjamin Schwartz, M.D.
Deputy Director of the Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention
The CDC and its National Center for Infectious Diseases recognize that managed care organizations are well positioned to provide infectious disease-related health care education to providers and patients. This is facilitated by the availability of defined panels of providers with whom there is ongoing communication and a defined population of subscribers with whom communication may contribute to satisfaction and retention. Managed care organizations may also reap short-and long-term benefits from the provision of infectious disease-related health care education to providers and patients, including improved quality of care, significant cost savings, improved health care practices, and better member satisfaction. Despite these incentives, however, barriers must be overcome before a managed care organization can effectively implement infectious disease-related health care education activities. First, managed care organizations must judge the significance of a problem and determine the relative costs and benefits of intervention. Often, data that would allow organizations to choose where best to focus their efforts are lacking. Second, managed care or-
ganizations may be unable or may be perceived to be unable to provide appropriate educational messages. Providers and patients may feel—in some cases correctly—that interventions are more focused on cost savings than on quality of care. Perhaps most importantly, organizations may retain policies that perpetuate the very behavior that educational initiatives are trying to change. For example, imperatives for clinicians to see more patients per day may conflict with providers' ability and availability to explain the rationale for treatment decisions.
Efforts to decrease the spread of antibiotic resistance through improved antibiotic use practices illustrate the importance of managed care systems in the education of patients. The development and spread of antibiotic resistance were not considered major problems by managed care organizations. Now, however, many such organizations recognize the threat of hospital-acquired resistant pathogens and also realize that this threat is a growing problem among patients with community-acquired infections. Rising concern has resulted from increased rates of resistance and treatment failures, and the medical and public health communities have placed a greater focus on these problems. For example, pneumococci, which are the leading cause of community-acquired meningitis, the second leading cause of bloodstream infections, and the leading cause of pneumonia and otitis media, are increasingly resistant to antibiotics. Currently, in some areas of the United States, more than a third of invasive pneumococcal isolates are resistant to one or more antibiotics. In other instances, some strains are not susceptible to any oral antibiotic, raising the specter that common infections, like ear infections or sinusitis, will require parenteral therapy.
Clinicians who work in managed care settings recognize that a major factor contributing to the spread of antibiotic resistance is the widespread and frequently unnecessary use of antimicrobial agents. Nevertheless, they continue to prescribe them for viral infections, which do not respond to antibiotics. Each year, up to 50 million courses of antibiotics may be prescribed unnecessarily for the treatment of the common cold, acute bronchitis, sore throat not caused by streptococcus, fluid in the middle ear that does not represent infection, and purulent runny nose that has been misdiagnosed as sinusitis. These antibiotic courses contribute nothing to patient care but do select for resistant pneumococci and other pathogens that can then spread or that can later cause more severe or difficult-to-treat infections.
Overall, physicians who work in managed care organizations are aware that they are overprescribing antibiotics. In focus group discussions with these physicians (conducted by CDC without physician knowledge of the sponsoring organization), participants reported that they could decrease antibiotic use in their own practices by 10 to 50 percent without having a negative impact on patient care (Barden et al., 1998). A number of reasons for the overuse of antimicrobial agents have been proposed. Studies indicate that economic factors influence the prescription practices of physicians who work in managed care organizations. For example, some studies suggest that physicians in managed care prescribed more antibiotics and performed fewer laboratory tests for patients with respiratory infections than their fee-for-service colleagues. This may have resulted in
response to pressures to decrease costs (thus, fewer tests) and to increase patient satisfaction (thus, responding to perceived demands for antibiotics) (Hueston et al., 1997). Additionally, physicians who work in managed care are encouraged to increase the number of patients whom they treat on any given day, resulting in decreased time with each patient and subsequently less time to discuss with patients situations in which antibiotics are not useful. Because physicians may receive a bonus for patient satisfaction, they may also prescribe antibiotics for patients who demand them, even when the physician knows that treatment will be ineffective but that patient satisfaction will likely result from the prescription of an antibiotic.
Controlling antibiotic use and resistance will entail effective communication to managed care organizations that judicious antibiotic use is beneficial to them. Physicians must understand that controlled use is feasible even in the context of a busy practice and is consistent with high levels of patient satisfaction. Patients must understand that controlled use will protect them from the harms associated with antibiotic resistance. Targets for educational interventions therefore include managed care administrators, health care providers, and patients. Reducing conflicting messages and providing incentives for good clinical practice will be important to achieving behavioral changes and reducing the rates of antibiotic resistance.
As an example, the principles of judicious antibiotic use for pediatric upper respiratory tract infections were published in the journal Pediatrics in January 1998 and provide a basis for educating physicians about optimal diagnostic and management practices. These principles, developed by CDC, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians, provide guidance to physicians on how to improve diagnostic and management skills to avoid the unnecessary dispensing of antibiotics. Development of these principles and other types of documents alone, however, cannot promote behavioral change. Although managed care organizations may be required to make financial investments, other, more proactive approaches are also necessary to promote changes in behavior. These may include provision of supporting materials, active promotion of desired behaviors through peer education, and provision of feedback to physicians on their own antibiotic use practices.
Besides educating the prescribing physician, CDC recognizes that it is important to educate the public. In an effort to communicate ways to combat antimicrobial resistance, CDC, in collaboration with AAP and the American Society for Microbiology, has produced a pamphlet entitled Your Child and Antibiotics. This pamphlet, published in both English and Spanish, relays two principal messages to parents: that antibiotics are not needed for all types of infections, and, when used unnecessarily, antibiotics can be harmful, More than a million copies of this pamphlet have been given to patients, and many copies have been distributed by managed care organizations.
In addition to providing educational materials and information to facilitate provider-patient communication, managed care organizations can take other actions to increase the impacts of judicious antibiotic use programs. For exam-
ple, they have a responsibility to provide adequate time as well as incentives for physicians to participate in educational activities. Some managed care organizations have developed practice guidelines based on published principles. Other professional organizations are tracking the rates of antibiotic use among physicians and are directing their interventions toward those providers who prescribe the most antibiotics. For example, Kaiser Permanente provides economic incentives by reimbursing patients for medications judiciously prescribed in an effort to reduce the level of prescription medication use. In Michigan and Tennessee, the driving force for educational initiatives has primarily come from health plan purchasers. In Colorado, a statewide coalition that addresses antibiotic resistance was established after the state legislature considered a bill that would have punished physicians for antibiotic overuse. Various approaches to intervention can be effective in changing practices. Because managed care organizations have an incentive to reduce inappropriate antibiotic use, as well as halt the spread and mitigate the impact of antimicrobial resistance, they should be encouraged to address this problem in ways that fit their capabilities. Considering the range of policies that affect antibiotic use practices, changing those that act as disincentives to judicious antibiotic use may also be an important component of an intervention (IOM, 1998).
EDUCATION AND OUTREACH PERSPECTIVES OF THE NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES
Presented by Karl Western, M.D.
Assistant Director for International Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health
Unlike health maintenance organizations and managed care organizations, the National Institute of Allergy and Infectious Diseases (NIAID) has focused on promoting the basic scientific underpinnings of clinical research instead of direct educational and outreach activities to the medical community. In response to public concern, NIAID has encouraged the development of strengthened capabilities in research on emerging and reemerging infectious diseases. It has primarily exercised such efforts by providing targeted administrative supplements to extramural research awards and by encouraging investigators and centers to submit Emerging and Reemerging Infectious Diseases applications in response to program announcements or requests for applications. These efforts specifically call for networking of the scientific community and have resulted in three new Emerging Virus Centers and four Hepatitis C Research Centers, which will form a research network in those areas.
Additionally, emerging infections were a prominent feature in NIAID's International Collaboration in Infectious Disease Research. Through these and other initiatives, NIAID hopes to prepare NIH-supported groups to cooperate
with local physicians and public health agencies in dealing with new or unforeseen problems. It is also anticipated that future increases in NIH's budget will provide additional funding for research on emerging infections.
MANAGED CARE SYSTEMS AND EMERGING INFECTIONS: EDUCATION AND OUTREACH
Presented by William B. Baine, M.D.
Senior Medical Advisor, Center for Outcomes and Effectiveness Research, Agency for Health Care Policy and Research
Although in everyday parlance ''costs" may be conceived of in terms of monetary payments, economic theory considers the costs of medical care to be the resources—physicians and nursing time, chemical and biological products, supplies and equipment, vehicles, and buildings—that are used for patient care instead of other purposes (Garber et al., 1996). Managed care has reduced the level of spending for medical care, but reduced spending is not synonymous with reductions in the underlying cost of that care (Chernew et al., 1997). It is left to the provider to cope with decreased payments for services (Kuttner, 1998). Essentially, providers achieve this by increasing efficiency (e.g., reducing costs themselves) or by reducing care per capita (e.g., abbreviated patient care encounters and the use of fewer diagnostic tests and referrals). In addition, providers attempt to minimize uncompensated care and forego the treatment of patients who have no coverage (insurance) for medical care. They also try to reassign the professional roles of physicians, nurses, and medical technicians, resulting in a broadening of responsibilities, cross-coverage, and decreased specialization. Medical practices and hospitals may also gravitate toward consolidation or even merge to achieve greater economies of scale and to enhance their advantage in contracting with managed care organizations.
These activities pose educational barriers to physicians and other clinical staff, which in turn could hinder the ability to respond to issues dealing with emerging infections. The clinician may have less exposure to patients with infectious diseases, which are more prevalent in uncovered (uninsured) populations; less interaction with subspecialists; less continuity of care and fewer follow-up visits; and less autonomy because of managed care protocols. In addition, interactions between the primary care physician and consultants, as well as continuing education, may be reduced because of the pressures of increased patient volumes. Managed care systems may also foster an atmosphere in which physicians have less time to educate trainees or patients as emphasis is placed on reducing the number of patient encounters and increasing the amount of time spent on documentation. Essentially, the outcome may result in increased dependence on protocols and transforming the functional role of the physician in terms of how much autonomy and judgment are practiced in patient care.
Economic challenges in managed care settings are also prevalent in educational outreach efforts. There is a potential risk of biased enrollment, with capitated plans preferentially seeking low-risk clients who require less care. There is also the risk of disincentives in which capitated plans may limit costly services, for example, to patients with human immunodeficiency virus infection.
These scenarios could present dire problems in managed care. Certain drawbacks, however, might mitigate the restrictions imposed by managed care organizations. These include expansion of insurance coverage as well as provision of educational subsidies to physicians who take the time to educate their patients. These methods, however, cost money and may therefore not be attractive alternatives to some. Another concept is risk adjustment, in which reimbursement is tailored to the degree of difficulty involved in patient care. Current models, however, are still in rudimentary stages. In addition, these risk adjustment models also tend to resemble fee-for-service techniques, which managed care systems are attempting to avoid because of the economic implications resuiting from this reimbursement method. Other possibilities include self-referral to a subspecialist, application of outcomes research to guidelines themselves in an effort to ensure that compliance with guidelines does not displace attention to other clinical problems, and lastly, the controversial approach of forming provider-based managed care organizations.
SUMMARY OF CHALLENGES AND OPPORTUNITIES
Jonathan R. Davis, Ph.D., Editor
Managed care systems are in a stage of a rapid transition. Assistance with the delivery of health care and building strength in support of educational efforts is necessary to effectively deal with the myriad issues associated with the coordination of health plan research and educational and outreach efforts.
Widespread, unnecessary use of antibiotic agents is a major contributing factor in the spread of antibiotic resistance. Economic factors largely influence the prescription practices of managed care physicians, and patients do not fully understand when it is appropriate to take antibiotics. Emphasis on controlling costs in managed care can lead to incorrect diagnoses, underreporting of some infectious disease conditions, and inadequate follow-up care. The essential role that physicians can play in accurately reporting diseases is generally not adequately communicated. Managed care organizations are increasingly able to be accountable for the appropriateness and quality of clinical care. Not only do they have the infrastructure to improve infectious disease surveillance through the systematic collection of encounter-level data and the standardization of computerized systems for the monitoring of data on health care, but they are also equipped to educate providers on the importance of their role in accurate disease reporting. Not only does this accuracy improve the quality of clinical care, but it also helps control the spread of diseases by providing the best available treatment.
Promote Professional Education Efforts
Professional education efforts are needed to control this trend of rising rates of antibiotic resistance among microorganisms. Working with the managed care industry, organizations and associations such as AAHP can foster collaborations between managed care organizations and sponsors of research (e.g., CDC and NIH) to formulate priorities, encourage multipurpose dissemination of methods for the support of educational efforts, and better use data for the monitoring of health care. For instance, by playing a facilitating role in the development and implementation of standards for the dissemination of antibiotic use data, professional organizations could serve an instrumental role in ensuring that information about antibiotic use is readily available, In turn, this could be instrumental in serving as a surveillance tool to monitor and address potential emerging infectious diseases.
Encourage Judicious Antibiotic Use
More judicious antibiotic use behavior should be encouraged, and patients need to be better informed about appropriate antibiotic use. To facilitate this, managed care organizations must resolve the conflicting messages and the sometimes competing incentives of good clinical practice and cost control. Targets for educational interventions include managed care administrators, providers, and patients. Although the Forum cannot make recommendations, Forum members acknowledged that the following suggestions identified during the workshop discussion are key factors in controlling the indiscriminant use of antibiotics:
Communicate to managed care organizations that judicious antibiotic use is beneficial to managed care industries.
Encourage managed care organizations to provide adequate time and incentives for physicians to participate in educational activities.
Convey to managed care physicians that judicious antibiotic use is feasible in the context of a busy practice and is consistent with a high degree of patient satisfaction when patients are adequately advised on proper antibiotic use.
Provide guidance to physicians on ways to improve their diagnostic and management skills to avoid unnecessary dispensation of antibiotics. These principles have already been developed and are readily available to educate physicians about such practices.
Use professional organizations to identify physicians who are prescribing the most antibiotics, and then focus interventions on those providers.
Educate patients that antibiotics are not needed for all types of infections, and that when they are used unnecessarily in some circumstances, antibiotics may even do more harm than good to the individual patient. Managed care organizations could distribute such educational materials to all of their patients, or
such material could be provided at physicians' offices, which would also help facilitate provider-patient communication.
Invest in Educational Programs
Although the strengths of the educational programs of certain managed care organizations have been significantly enhanced, most such organizations have limited or suboptimum educational and outreach efforts in terms of emerging infections. Managed care organizations have the responsibility to educate providers regarding their critical role in accurate infectious disease reporting. Managed care organizations should invest in educational efforts on emerging infections and initiate partnerships with buyers to identify key educational program opportunities and increase the level of awareness of emerging infections beyond antimicrobial resistance.
The workshop participants recognized that managed care organizations could have positive impacts on education efforts. The guidelines developed by AAHP for the participation of member plans in research and demonstration projects is one example of the way in which coordinated efforts to develop and implement guidelines have been successful. In addition, several plans have collaborated in their efforts to identify problems and change physician behavior, for example, in the prescribing of antibiotics. The access to large numbers of physicians, patients, and families through managed care could be useful in other education and outreach efforts. However, not all managed care organizations have the same capability to participate in educational and outreach programs. Continued action and investment by NIH and CDC will be important to broadening the base of cooperation.
In contrast, several characteristics of managed care could have a negative effect on education and outreach efforts. Primarily, infectious diseases are often a health concern among the populations that are not covered by managed care organizations. Biased enrollment into managed care organizations often results in managed care physicians having less exposure to emerging infections, and the nature of their practice gives them fewer opportunities for consultation with specialists and reduced incentives for continuing education in the current diagnosis and therapy of infections diseases.
Panelists at the workshop felt that there was a need for increased investment in education and outreach for all health professionals in the area of emerging infections and the closely related area of antimicrobial resistance. NIH, CDC, and the pharmaceutical industry are pursuing multidisciplinary approaches to educating medical and public health professionals, but more programs are needed. Major purchasers of managed care also have an important role to play in
promoting the values of education and outreach, including free (protected) time or subsidies for continuing education and bonuses for judicious antibiotic prescription behavior. Other potential tools recognized include differential copaymerits, expanded self-referral, and assessments of collateral effects.