Judging from the number of Google alerts hitting my inbox, pretty much everyone who blogs in the healthcare space is writing about the CDC report on the threat of antibiotic resistance. Most of this writing is superficial regurgitation of the headline numbers, and is not really very interesting. The report itself is a nice resource that collects a lot of existing data in one place and makes it accessible to the general public, but does not contain any surprises or revelations.
The report rightfully calls for development of new antibiotics and rapid diagnostics to contain the threat. David Shlaes has posted a nice analysis of the short-sighted and flawed thinking at large pharma companies that holds back antibiotic development efforts.
A different, but no less crippling dynamic holds back the development of rapid diagnostics. As I've written before (here and here), the incentives for rapid diagnostics for antibiotic resistance and susceptibility determinations are misaligned, if not lacking altogether. Patients would benefit from their use, but no one in the hospital has a compelling reason to adopt these tests, which do tend to be pricey by the standards of microbiology. That is, they cost more than a Petri dish or a tube of rabbit plasma.
Hospital microbiology labs have to purchase the tests out of budgets that are always under pressure, given their status as cost centers rather than revenue generators. Micro labs in turn bear no responsibility when patients are prescribed inappropriate empirical antibiotics; they get no reward when an inappropriate prescription is avoided, even though this can result in considerable savings.
A well-respected clinical microbiologist once remarked to me that what MicroPhage really needed was for a patients' family to sue a hospital for not using our test, leading the patient to die while on ineffective antibiotics. He imagined the courtroom scene: "You mean that you left the patient on wrong antibiotics for 3 days because you didn't want to spend $50?" The thought of a penny pinching hospital admin squirming on the stand clearly intrigued him.
The unfortunate thing about this situation is that there is, I think, considerable willingness to pay to get it right. We just don't ask the right people - that is, the patients. I visited Shanghai in 2011 to get a sense of whether China might be a potential market for our test. Remarkably for a nominally socialist country, there is no system of socialized medicine, nor is insurance common. Patients pay out of pocket for care, which is one explanation for why their savings rate is so high. I asked ID docs at local hospitals to explain who would order our test and how would it be paid for. They replied that they would go to the patient or their family, tell them that there was a test that would help guide treatment, and ask if the family was willing to pay for it. They were pretty sure the answer would usually be yes, even at the US price of $50.
And I suspect that most families of American patients with S. aureus bacteremia, which has a mortality rate of some 30%, would give the same answer. But nobody is asking them.
Until that changes, or until hospitals start getting sued for inappropriate antibiotic use, the return on investment for developing rapid antibiotic susceptibility tests will remain questionable.
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