RAMANAN LAXMINARAYAN and ANUP MALANI with David Howard and David L. Smith EXTENDING THE CURE Policy responses to the growing threat of antibiotic resistance EXTENDING THE CURE RAMANAN LAXMINARAYAN and ANUP MALANI with David Howard and David L. Smith EXTENDING THE CURE Policy responses to the growing threat of antibiotic resistance © Resources for the Future 2007. All rights reserved. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Laxminarayan, Ramanan. Extending the cure : policy responses to the growing threat of antibiotic resistance / by Ramanan Laxminarayan and Anup Malani ; with David Howard and David L. Smith. p. ; cm. Includes bibliographical references. ISBN 978-1-933115-57-3 (pbk. : alk. Paper) 1. Drug resistance in microorganisms—United States. 2. Drug resistance in microorganisms—Government policy—United States. I. Malani, Anup. II. Title. III. Title: Policy responses to the growing threat of antibiotic resistance. [DNLM: 1. Drug Resistance, Bacterial—United States. 2. Anti-Bacterial Agents—United States. 3. Drug Utilization—United States. 4. Health Policy—United States. QW 52 L425e 2007] QR177.L39 2007 616.9`041—dc22 2007008949 RESOURCES FOR THE FUTURE 1616 P Street, NW Washington, DC 20036-1400 USA www.rff.org ABOUT RESOURCES FOR THE FUTURE RFF is a nonprofit and nonpartisan organization that conducts independent research—rooted primarily in economics and other social sciences—on environmental, energy, natural resources, and public health issues. RFF is headquartered in Washington, D.C., but its research scope comprises programs in nations around the world. Founded in 1952, RFF pioneered the application of economics as a tool to develop more effective policy for the use and conservation of natural resources. Its scholars employ social science methods to analyze critical issues concerning antibiotic and antimalarial resistance, pollution control, energy policy, land and water use, hazardous waste, climate change, and the environmental and health challenges of developing countries. DISCLAIMER The statements in this book represent the opinions of the authors; the statements do not and should not be construed to represent official policy statements or endorsements by Resources for the Future, the Robert Wood Johnson Foundation, the Fogarty International Center, the National Institutes of Health, the Department of Health and Human Services, or the U.S. federal government. What does not destroy me makes me stronger. —Nietzsche, 1899 It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body… —Alexander Fleming, 1945 Contents Foreword | Philip Sharp ............................................................................................................................................................................. xiii Executive Summary .............................................................................................................................................................................................1 Introduction | Ramanan Laxminarayan ........................................................................................................................................... 17 CHAPTER 1 Antibiotic resistance: The unfolding crisis | Ramanan Laxminarayan ...................................... 25 CHAPTER 2 The epidemiology of antibiotic resistance: Policy levers | David L. Smith .......................... 39 CHAPTER 3 Patient and physician demand for antibiotics | David Howard .................................................... 69 CHAPTER 4 The role of health care facilities | Ramanan Laxminarayan .............................................................. 87 CHAPTER 5 The role of the federal government | Ramanan Laxminarayan ................................................. 103 CHAPTER 6 The role of health insurance | Anup Malani .............................................................................................. 115 CHAPTER 7 Supply-side strategies for tackling resistance | Anup Malani ..................................................... 133 CHAPTER 8 Next steps | Ramanan Laxminarayan ............................................................................................................. 157 Acronyms and Abbreviations ................................................................................................................................................................ 167 Biographies ......................................................................................................................................................................................................... 169 Consultation Participants ......................................................................................................................................................................... 173 THE EXTENDING THE CURE PROJECT This report was prepared by a team led by Ramanan Laxminarayan and comprising Anup Malani, David Howard, and David L. Smith, Eili Klein, and Sarah Darley. An advisory committee chaired by Kenneth J. Arrow and comprising Donald Kennedy, Simon A. Levin, Saul Levmore, and John E. McGowan, Jr., provided valuable guidance at all stages of the report’s preparation. Preparation of this report was immensely aided input to the report, but they were not asked to by the contributions of participants in a series endorse its conclusions and did not see the final of consultations; the names of participants are version before it was published. The authors bear listed at the end of this report. The team also full responsibility for the final content. received useful input at various stages of the Eili Klein provided extensive substantive input, research process from Judy Cahill, Neil Fishman, including preparation of graphs, tables, and text Clarissa Long, Dean Lueck, Sharlene Matten, boxes for the report. Sarah Darley coordinated Tom Nachbar, Dennis O’Leary, Bill Sage, and logistics for the consultations and overall report Robert Wise. John Bartlett, Ed Belongia, Carl production. Hellen Gelband, Piper Kerman, Bergstrom, Marty Blaser, Barry Eisenstein, Neil and Ed Walz provided significant input on the Fishman, Eric Kades, Keith Klugman, Lou Rice, executive summary. The report was edited by Ed Septimus, Brad Spellberg, and Jim Wilen Sally Atwater, Felicia Day and Sarah Beam. provided helpful reviews on the final draft. Report review by infectious disease experts The Extending the Cure project and this report was coordinated by the Infectious Diseases were made possible by financial support from Society of America. Consultation participants the Robert Wood Johnson Foundation’s Pioneer and reviewers provided substantive and valuable Portfolio. Foreword Few public health developments present greater challenges to modern society than the growing resistance of many infectious diseases to antibiotics. In a sense, medical research has become a victim of its own success: creating wonder drugs that heal millions yet could be rendered obsolete through sheer overuse. At a time when cases of drug-resistant infections continue to parents, doctors, clinics, and patients about the threat of drug- accumulate, Extending the Cure provides a rational and clear resistant infections. strategy to deal with this impending crisis—and policymakers From my 20 years of service on the House Energy and would be wise to heed the advice before it is too late. Commerce Committee, which has jurisdiction over health In this report, Ramanan Laxminarayan and his colleagues matters, I know how critical it is to have information that suggest a range of efforts that can restructure incentives and has been thoroughly analyzed and vetted. The authors of this lead to significant changes in how patients, doctors, hospitals, report have carried out a vital first step, assessing the array of and drug companies regard and use antibiotics. There is a policy options, and providing a range of practical options for role for insurance companies in employing reimbursement consideration. Of course, genuine change will only come methods that do not encourage overuse of antibiotics. There from public pressure and political compromise, but Extending is a role for physicians and medical associations to adopt the Cure offers a long-overdue assessment of options for a standards that would discourage inappropriate antibiotic use. successful policy outcome. And there is a clear role for government—to promote careful Resources for the Future is grateful to the members of the demonstration projects, including providing incentives, to Extending the Cure Advisory Committee, who provided push hospitals to engage in better infection control and valuable guidance, and to the Robert Wood Johnson pharmaceutical makers to boost antibiotic research. Just as Foundation for its commitment to support this important important, public awareness campaigns are needed to educate research. PhILIP ShARP President, Resources for the Future FOREWORD xiii Executive Summary Modern medicine depends on effective antibiotics to control bacterial infections. Since the first of these wonder drugs appeared a mere 65 years ago, they have transformed the practice of medicine and saved millions of lives. But today, at the start of the 21st century, the rapid rate of emergence and spread of bacterial pathogens resistant to antibiotics threatens to return us to an era when common infections were untreatable. The growing