Antibiotic-Free Meat Purchasing at University Hospitals: A Case Study

1. Antibiotic-free meat purchasing at University Hospitals: a case study from the front lines Aparna Bole, MD Ankita Desai, MD

2. University Hospitals (UH) – System • Founded in 1866, UH serves the needs of patients through an integrated network of 18 hospitals, more than 40 major outpatient health centers and 200 physician offices in 15 counties throughout northern Ohio. • The system’s flagship academic medical center, UH Cleveland Medical Center, located on a 35-acre campus in Cleveland’s University Circle, is affiliated with Case Western Reserve University School of Medicine. • UH’s main campus includes Rainbow Babies & Children's Hospital, ranked among the top children’s hospitals in the nation; MacDonald Women's Hospital, Ohio's only hospital for women; and Seidman Cancer Center, part of the NCI-designated Case Comprehensive Cancer Center at Case Western Reserve University. • UH is the second largest employer in northern Ohio with 26,000 employees. To Heal. To Teach. To Discover.

3. Operating Well Living Well Building Well Buying Well

4. Nutrition Committee: Nutrition Services, Supply Chain, ACO, Sustainability Negotiation with produce distributors & aggregation of local demand Introduction of antibiotic free meats

5. “ Less meat, better meat” • Balanced menus • Reduce meat purchasing by 20% relative to baseline • Americans eat 4x more meat than global average • Aside from energy, beef purchasing represents biggest environmental impact of a typical hospital’s purchasing

6. Extending antibiotic stewardship to food purchasing practices • Systemwide antibiotic stewardship initiative • Intentional engagement of antibiotic stewardship & infection control leadership – an easy case to make: • >300 organizations(e.g. AMA, APHA, IDSA) strongly advocate ending the non-therapeutic use of antibiotics in agriculture • >80% of antibiotics used in US are used in animal agriculture, many same classes as those used for human therapy • Studies from Europe (e.g. Denmark) support contention that restricting antibiotic use in agriculture leads to decline in antibiotic resistant human pathogens

7. Implementing antibiotic-free meat purchasing “As clinical leaders of our antibiotic stewardship and infection control programs, we recommend that UH phase out the purchase of meat produced using non-therapeutic antibiotics.” • Drafted letter to senior leadership, citing professional organizations & primary sources • Chairs of Adult & Pediatric Infection Control & Antibiotic Stewardship Committees signed • Sent to our system CMO, who shared with system Exec Committee • Exec Committee communicated support to Directors of Operations

8. Letter

9. Results • As of end of 2014: all ground beef and chicken breast in UH system antibiotic free (~20% by weight of meat we purchase, from virtually 0 at beginning of year) • Price impact: none for ground beef, slight increase in retail café prices of chicken entrees (< 25 cents per meal) • Communication with stakeholders • CDC Get Smart About Antibiotics Week • Focus of Food Day • Strengthened relationship with infection control leaders has far-reaching benefits • e.g. safer chemicals collaboration such as triclosan free soap & green cleaning practices

10. Collective impact • Healthcare Without Harm’s (HCWH) Healthy Food in Healthcare program • Food Day 2015 • National pledge to serve meals using abx-free meat • ~300 participating hospitals • ~235K meals featuring abx-free meat • Clinician Champions in Comprehensive Antibiotic Stewardship (CCCAS) Collaborative • joint effort of HCWH, PIDS, SHARPS • https://noharm-uscanada.org/cccas - includes links to ours & other sample resolutions & letters to leadership

12. Challenges • Initially told by vendors no sources for antibiotic-free chicken • Limited by our contractual requirements with GPO • Anticipated cost increases, failure to meet purchasing targets • “Balancing” reduced meat purchasing with more sustainable meat sourcing has not been a compelling business case for us • Slight increased price approved because of clinical relevance, but concern about cost impact on patients & staff, especially in certain locations • Still get feedback that there are limited sourcing options – how can we continue to improve?

13. Next steps • Collective action across sectors slowly changing marketplace • Cage-free eggs – currently challenged in identifying sources of cage-free liquid eggs • Current goals: • Decreasing beef purchasing • Increasing local purchasing – a significant challenge when primarily working w/large distributors • Starting with catering & employee events • Align with wellness program goals

14. Patient food program Pediatric resident education: Spotlight on food systems, food insecurity, & links to obesity and chronic disease

15. Thank you! http://www.uhhospitals.org/about/greening-uh

16. Thank You! Ankita Desai, MD Medical Director of Antimicrobial Stewardship Assistant Professor, Division of Pediatric Infectious Diseases Rainbow Babies and Children's Hospital 11100 Euclid Avenue Cleveland, OH 44106 (216) 844 – 3611 (office) ankita.desai@uhhospitals.org Aparna Bole, MD, FAAP Medical Director, Community Integration UH Rainbow Babies & Children’s Hospital Sustainability Advisor, University Hospitals 11100 Euclid Avenue, Mailstop 6019 Cleveland, OH 44106 216-844-5738 (office) aparna.bole@uhhospitals.org