1
|
Lim J, Russell WA, El-Sheikh M, Buckeridge DL, Panagiotoglou D. Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach. Harm Reduct J 2024; 21:126. [PMID: 38943164 PMCID: PMC11212409 DOI: 10.1186/s12954-024-01037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID. METHODS We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks. RESULTS The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI. CONCLUSIONS Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.
Collapse
Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - W Alton Russell
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Mariam El-Sheikh
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada.
| |
Collapse
|
2
|
Allel K, Hernández-Leal MJ, Naylor NR, Undurraga EA, Abou Jaoude GJ, Bhandari P, Flanagan E, Haghparast-Bidgoli H, Pouwels KB, Yakob L. Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review. BMJ Glob Health 2024; 9:e013205. [PMID: 38423548 PMCID: PMC10910705 DOI: 10.1136/bmjgh-2023-013205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs CONCLUSION Robust information on ABR interventions is critical for efficient resource allocation. We highlight cost-effective strategies for mitigating ABR in hospitals, emphasising substantial knowledge gaps, especially in low-income and middle-income countries. Our study serves as a resource for guiding future cost-effectiveness study design and analyses.PROSPERO registration number CRD42020341827 and CRD42022340064.
Collapse
Affiliation(s)
- Kasim Allel
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
- Institute for Global Health, University College London, London, UK
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - María José Hernández-Leal
- Department of Community, Maternity and Paediatric Nursing, University of Navarra, Pamplona, Spain
- Millennium Nucleus on Sociomedicine, Santiago, Chile
| | - Nichola R Naylor
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London, UK
| | - Eduardo A Undurraga
- Escuela de Gobierno, Pontificia Universidad Catolica de Chile, Santiago, Chile
- CIFAR Azrieli Global Scholars program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
| | | | - Priyanka Bhandari
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ellen Flanagan
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Koen B Pouwels
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Laith Yakob
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
3
|
Eckert KA, Fife CE, Carter MJ. The Impact of Underlying Conditions on Quality-of-Life Measurement Among Patients with Chronic Wounds, as Measured by Utility Values: A Review with an Additional Study. Adv Wound Care (New Rochelle) 2023; 12:680-695. [PMID: 37815559 PMCID: PMC10615090 DOI: 10.1089/wound.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/27/2023] [Indexed: 10/11/2023] Open
Abstract
Significance: Quality of life (QoL) is important to patients with chronic wounds and is rarely formally evaluated. Understanding what comorbidities most affect the individual versus their wounds could be a key metric. Recent Advances: The last 20 years have seen substantial advances in QoL instruments and conversion of patient data to a single value known as the health utilities index (HUI). We review these advances, along with wound-related QoL, and analyze real-world comorbidities challenging wound care. Critical Issues: To understand the impact of underlying comorbidities in a real-world patient population, we examined a convenience sample of 382 patients seen at a hospital-based outpatient wound center. This quality reporting study falls outside the regulations that govern human subject research. Comorbid conditions were used to calculate HUIs using a variety of literature-reported approaches, while Wound-Quality-of-Life (W-QoL) questionnaire data were collected from patients during their first visit. The mean number of conditions per patient was 8; 229 patients (59.9%) had utility values for comorbidities/conditions, which were worse/lower than their wounds' values. Sixty-three (16.5%) patients had depression and/or anxiety, 64 (16.8%) had morbid obesity, and 204 (53.4%) had gait and mobility disorders, all of which could have affected W-QoL scoring. The mean minimum utility value (0.5) was within 0.05 units of an average of 13 studies reporting health utilities from wound care populations using the EuroQol 5 Dimension instrument. Future Directions: The comorbidity associated with the lowest utility value is what might most influence the QoL of patients with chronic wounds. This finding needs further investigation.
Collapse
Affiliation(s)
| | - Caroline E. Fife
- Intellicure, LLC, The Woodlands, Texas, USA
- U.S. Wound Registry (501 3C Nonprofit), The Woodlands, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | | |
Collapse
|
4
|
Ong SWX, Zhabokritsky A, Daneman N, Tong SYC, Wijeysundera HC. Evaluating the use of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in the workup of Staphylococcus aureus bacteraemia: a cost-utility analysis. Clin Microbiol Infect 2023; 29:1417-1423. [PMID: 37353076 DOI: 10.1016/j.cmi.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES The use of positron emission tomography/computed tomography (PET/CT) in the evaluation of patients with Staphylococcus aureus bacteraemia can improve the diagnosis of infectious foci and guide clinical management. We aimed to evaluate the cost-utility of PET/CT among adults hospitalized with Staphylococcus aureus bacteraemia. METHODS A cost-utility analysis was conducted from the healthcare payer perspective using a probabilistic Markov cohort model assessing three diagnostic strategies: (a) PET/CT in all patients, (b) PET/CT in high-risk patients only, and (c) routine diagnostic workup. Primary outcomes were quality-adjusted life years (QALYs), costs in Canadian dollars, and an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to evaluate parameter uncertainty. RESULTS Routine workup resulted in an average of 16.64 QALYs from the time of diagnosis at a lifetime cost of $209 060/patient. This was dominated by PET/CT in high-risk patients (i.e. greater effectiveness at lower costs) with average 16.88 QALYs at a cost of $199 552. Compared with PET/CT in high-risk patients only, PET/CT for all patients cost on average $11 960 more but resulted in 0.14 more QALYs, giving an incremental cost-effectiveness ratio of $83 500 (cost per additional QALY gained); however, there was a high degree of uncertainty comparing these two strategies. At a willingness-to-pay threshold of $50 000/QALY, PET/CT in high-risk patients was the most cost-effective strategy in 58.6% of simulations vs. 37.9% for PET/CT in all patients. DISCUSSION Our findings suggest that a strategy of using PET/CT in high-risk patients is more cost-effective than no PET/CT. Randomized controlled trials should be conducted to evaluate the use of PET/CT in different patient groups.
Collapse
Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
| | - Alice Zhabokritsky
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
5
|
Manoukian S, Stewart S, Dancer SJ, Mason H, Graves N, Robertson C, Leonard A, Kennedy S, Kavanagh K, Parcell B, Reilly J. Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1173-1185. [PMID: 34932169 PMCID: PMC8689289 DOI: 10.1007/s10198-021-01419-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. OBJECTIVE We assess the relative cost-effectiveness of screening programmes compared with no- screening. METHODS A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. RESULTS In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. CONCLUSION The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.
Collapse
Affiliation(s)
- Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Sally Stewart
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Stephanie J Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire and School of Applied Sciences, Edinburgh Napier University, Edinburgh, Scotland, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK
| | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | | | - Sharon Kennedy
- Information Services Division, Public Health Scotland, Edinburgh, Scotland, UK
| | - Kim Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | - Benjamin Parcell
- Medical Microbiology, NHS Tayside, Ninewells Hospital and School of Medicine, Dundee, Scotland, UK
| | - Jacqui Reilly
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
| |
Collapse
|
6
|
Cost-effectiveness analysis of whole-genome sequencing during an outbreak of carbapenem-resistant Acinetobacter baumannii. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e62. [PMID: 36168472 PMCID: PMC9495627 DOI: 10.1017/ash.2021.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/12/2022]
Abstract
Background: Whole-genome sequencing (WGS) shotgun metagenomics (metagenomics) attempts to sequence the entire genetic content straight from the sample. Diagnostic advantages lie in the ability to detect unsuspected, uncultivatable, or very slow-growing organisms. Objective: To evaluate the clinical and economic effects of using WGS and metagenomics for outbreak management in a large metropolitan hospital. Design: Cost-effectiveness study. Setting: Intensive care unit and burn unit of large metropolitan hospital. Patients: Simulated intensive care unit and burn unit patients. Methods: We built a complex simulation model to estimate pathogen transmission, associated hospital costs, and quality-adjusted life years (QALYs) during a 32-month outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). Model parameters were determined using microbiology surveillance data, genome sequencing results, hospital admission databases, and local clinical knowledge. The model was calibrated to the actual pathogen spread within the intensive care unit and burn unit (scenario 1) and compared with early use of WGS (scenario 2) and early use of WGS and metagenomics (scenario 3) to determine their respective cost-effectiveness. Sensitivity analyses were performed to address model uncertainty. Results: On average compared with scenario 1, scenario 2 resulted in 14 fewer patients with CRAB, 59 additional QALYs, and $75,099 cost savings. Scenario 3, compared with scenario 1, resulted in 18 fewer patients with CRAB, 74 additional QALYs, and $93,822 in hospital cost savings. The likelihoods that scenario 2 and scenario 3 were cost-effective were 57% and 60%, respectively. Conclusions: The use of WGS and metagenomics in infection control processes were predicted to produce favorable economic and clinical outcomes.
Collapse
|
7
|
Schulz M, Calabrese S, Hausladen F, Wurm H, Drossart D, Stock K, Sobieraj AM, Eichenseher F, Loessner MJ, Schmelcher M, Gerhardts A, Goetz U, Handel M, Serr A, Haecker G, Li J, Specht M, Koch P, Meyer M, Tepper P, Rother R, Jehle M, Wadle S, Zengerle R, von Stetten F, Paust N, Borst N. Point-of-care testing system for digital single cell detection of MRSA directly from nasal swabs. LAB ON A CHIP 2020; 20:2549-2561. [PMID: 32568322 DOI: 10.1039/d0lc00294a] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
We present an automated point-of-care testing (POCT) system for rapid detection of species- and resistance markers in methicillin-resistant Staphylococcus aureus (MRSA) at the level of single cells, directly from nasal swab samples. Our novel system allows clear differentiation between MRSA, methicillin-sensitive S. aureus (MSSA) and methicillin-resistant coagulase-negative staphylococci (MR-CoNS), which is not the case for currently used real-time quantitative PCR based systems. On top, the novel approach outcompetes the culture-based methods in terms of its short time-to-result (1 h vs. up to 60 h) and reduces manual labor. The walk-away test is fully automated on the centrifugal microfluidic LabDisk platform. The LabDisk cartridge comprises the unit operations swab-uptake, reagent pre-storage, distribution of the sample into 20 000 droplets, specific enzymatic lysis of Staphylococcus spp. and recombinase polymerase amplification (RPA) of species (vicK) - and resistance (mecA) -markers. LabDisk actuation, incubation and multi-channel fluorescence detection is demonstrated with a clinical isolate and spiked nasal swab samples down to a limit of detection (LOD) of 3 ± 0.3 CFU μl-1 for MRSA. The novel approach of the digital single cell detection is suggested to improve hospital admission screening, timely decision making, and goal-oriented antibiotic therapy. The implementation of a higher degree of multiplexing is required to translate the results into clinical practice.
Collapse
Affiliation(s)
- Martin Schulz
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Parise H, Espinosa R, Dea K, Anaya P, Montoya G, Ng DB. Cost Effectiveness of Mirabegron Compared with Antimuscarinic Agents for the Treatment of Adults with Overactive Bladder in Colombia. PHARMACOECONOMICS - OPEN 2020; 4:79-90. [PMID: 31168754 PMCID: PMC7018934 DOI: 10.1007/s41669-019-0149-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost effectiveness of mirabegron relative to two antimuscarinics, oxybutynin extended release (ER) and tolterodine ER, in patients with overactive bladder (OAB) from the perspective of a third-party payer in Colombia. METHODS A Markov model simulated the therapeutic management, disease course, and complications in hypothetical cohorts of OAB patients over a 5-year period. The model predicted costs and three outcomes: quality-adjusted life-years (QALYs), micturition state improvement (MSI), and incontinence state improvement (ISI). In each 1-month cycle, patients could transition between different health states reflecting symptom severity. Transition probabilities were estimated from a published mirabegron trial and mixed treatment comparison. Other inputs such as treatment discontinuation based on treatment-specific rates of persistence, resource use and costs, anticholinergic burden, comorbidity treatment, and drug acquisition were obtained from Società Italiana Scienze Mediche, Instituto de Seguros Sociales Tariff Manual, published literature, and expert opinion. Deterministic and probabilistic sensitivity analyses were conducted. Costs are presented in 2017 Colombia Pesos (COP). RESULTS Mirabegron was cost effective for all outcome measures at a willingness-to-pay threshold of 124,919,725 COP, which is three times the per capita gross domestic product (GDP). Using QALYs as the measure of effect, mirabegron had an incremental cost-effectiveness ratio (ICER) of 85,802,036 COP/QALY (26,365 USD/QALY) and 66,360,134 COP/QALY (20,384 USD/QALY) versus oxybutynin and tolterodine, respectively. Probabilistic sensitivity analyses showed that mirabegron was cost effective in 99.5% and 100% of simulations compared with oxybutynin and tolterodine, respectively. Using MSI and ISI as the measure of effects yielded ICERs below one GDP. CONCLUSIONS Mirabegron is a cost effective alternative to oxybutynin and tolterodine from the perspective of a third-party payer in Colombia.
Collapse
Affiliation(s)
- Hélène Parise
- Medicus Economics LLC, 2 Stonehill Ln, Milton, MA, 02186, USA
| | - Robert Espinosa
- Medicus Economics LLC, 2 Stonehill Ln, Milton, MA, 02186, USA.
| | - Katherine Dea
- Medicus Economics LLC, 2 Stonehill Ln, Milton, MA, 02186, USA
| | | | | | - Daniel Bin Ng
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| |
Collapse
|
9
|
Mac S, Fitzpatrick T, Johnstone J, Sander B. Vancomycin-resistant enterococci (VRE) screening and isolation in the general medicine ward: a cost-effectiveness analysis. Antimicrob Resist Infect Control 2019; 8:168. [PMID: 31687132 PMCID: PMC6820905 DOI: 10.1186/s13756-019-0628-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background Vancomycin-resistant enterococci (VRE) are a serious antimicrobial resistant threat in the healthcare setting. We assessed the cost-effectiveness of VRE screening and isolation for patients at high-risk for colonisation on a general medicine ward compared to no VRE screening and isolation from the healthcare payer perspective. Methods We developed a microsimulation model using local data and VRE literature, to simulate a 20-bed general medicine ward at a tertiary-care hospital with up to 1000 admissions, approximating 1 year. Primary outcomes were accrued over the patient's lifetime, discounted at 1.5%, and included expected health outcomes (VRE colonisations, VRE infections, VRE-related bacteremia, and deaths subsequent to VRE infection), quality-adjusted life years (QALYs), healthcare costs, and incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analysis (PSA) and scenario analyses were conducted to assess parameter uncertainty. Results In our base-case analysis, VRE screening and isolation prevented six healthcare-associated VRE colonisations per 1000 admissions (6/1000), 0.6/1000 VRE-related infections, 0.2/1000 VRE-related bacteremia, and 0.1/1000 deaths subsequent to VRE infection. VRE screening and isolation accrued 0.0142 incremental QALYs at an incremental cost of $112, affording an ICER of $7850 per QALY. VRE screening and isolation practice was more likely to be cost-effective (> 50%) at a cost-effectiveness threshold of $50,000/QALY. Stochasticity (randomness) had a significant impact on the cost-effectiveness. Conclusion VRE screening and isolation can be cost-effective in majority of model simulations at commonly used cost-effectiveness thresholds, and is likely economically attractive in general medicine settings. Our findings strengthen the understanding of VRE prevention strategies and are of importance to hospital program planners and infection prevention and control.
Collapse
Affiliation(s)
- Stephen Mac
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6 Canada.,2Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor, Room 247, Toronto, ON M5G 2C4 Canada
| | - Tiffany Fitzpatrick
- 3Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7 Canada
| | - Jennie Johnstone
- 3Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7 Canada.,4Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8 Canada.,5Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2 Canada
| | - Beate Sander
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6 Canada.,2Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor, Room 247, Toronto, ON M5G 2C4 Canada.,5Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2 Canada.,6ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| |
Collapse
|
10
|
Impact of MRSA Transmission and Infection in a Neonatal Intensive Care Unit in China: A Bundle Intervention Study during 2014-2017. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5490413. [PMID: 31380430 PMCID: PMC6652075 DOI: 10.1155/2019/5490413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023]
Abstract
Objective. To evaluate the efficacy of bundle intervention on healthcare-associated (HA) methicillin-resistant Staphylococcus Aureus (MRSA) infection in the neonatal intensive care unit (NICU). Methods. In this study, 11,277 infants having undergone treatment at the NICU in Xiamen, China, from January 2014 to February 2017 were recruited. We retrospectively reviewed patients' demographic and clinical information. Patients from 2014 to 2015 were treated as the control group and those from 2016 to 2017 were classified as the experimental group. Bundle intervention measures were performed, including screening for MRSA, isolation precautions, training of hand hygiene, cleaning protocols, and decontamination of isolation ward. The HA-MRSA data and compliance of infection control measures between both groups were analyzed. Results. Through bundle interventions, the compliance with the isolation of MRSA raised from 55.88% to 92.86% and hand hygiene compliance increased from 90.07% to 93.23% (P < 0.05). The HA infection decreased from 1.87% to 1.71% (P > 0.05) and HA detection rate of MRSA declined from 2.63‰ to 1.00‰, respectively (P < 0.05). Conclusion. Multifaceted interventions can effectively prevent MRSA infection and transmission; this includes active surveillance, isolation precautions, increased hand hygiene compliance, environmental cleaning, and decontamination.
Collapse
|
11
|
Cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections. Int Urogynecol J 2019; 31:285-289. [PMID: 31263916 DOI: 10.1007/s00192-019-04034-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We evaluate the cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections. MATERIALS AND METHODS A decision tree model was used to assess the cost-effectiveness of prophylactic antibiotics in preventing catheter-associated urinary tract infections for patients with a short-term indwelling urinary catheter. The model accounted for incidence of urinary tract infections with and without the use of prophylactic antibiotics, incidence of antibiotic-resistant urinary tract infections, as well as costs associated with diagnosis and treatment of urinary tract infections and antibiotic-resistant urinary tract infections. Costs were calculated from the health care system's perspective. We conducted one-way sensitivity analyses. RESULTS The base case analysis showed that the use of prophylactic antibiotics is cost-saving in preventing catheter-associated urinary tract infections. The use of prophylactic antibiotics resulted in lower costs and higher quality-adjusted life-years compared with no prophylactic antibiotics. Sensitivity analyses showed that the optimal strategy changes to no prophylactic antibiotics when the incidence of urinary tract infections after prophylactic antibiotics exceeds 22% or the incidence of developing urinary tract infections without prophylactic antibiotics is less than 12%. Varying the costs of prophylactic antibiotics, urinary tract infection treatment, or antibiotic-resistant urinary tract infection treatment within a reasonable range did not change the optimal strategy. CONCLUSIONS Prophylactic antibiotic use to prevent catheter-associated urinary tract infections is cost-effective under most conditions. These results were sensitive to the likelihood of developing catheter-associated urinary tract infections with and without prophylactic antibiotics. Our results are limited to the cost-effectiveness perspective on this clinical practice.
Collapse
|
12
|
Kaplan JRM, Slullitel G, Lopez V. Should Routine Methicillin-Resistant Staphylococcus aureus ( S. aureus), or MRSA, Screening Be in Place Prior to Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:4S-6S. [PMID: 31322934 DOI: 10.1177/1071100719857090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Unknown. The role of screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization prior to total ankle arthroplasty (TAA) remains unclear. Further data are needed to support this practice in TAA, which can be costly and logistically difficult to implement. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
Collapse
Affiliation(s)
| | - Gaston Slullitel
- 2 Department of Foot and Ankle Surgery, J. Slullitel Institute of Orthopaedics, San Luis, Argentina
| | - Valeria Lopez
- 2 Department of Foot and Ankle Surgery, J. Slullitel Institute of Orthopaedics, San Luis, Argentina
| |
Collapse
|
13
|
Farah SM, Alshehri MA, Alfawaz TS, Alasmeri FA, Alageel AA, Alshahrani DA. Trends in antimicrobial susceptibility patterns in King Fahad Medical City, Riyadh, Saudi Arabia. Saudi Med J 2019; 40:252-259. [PMID: 30834420 PMCID: PMC6468207 DOI: 10.15537/smj.2019.3.23947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives: To describe and interpret local antibiograms from a single tertiary care center to monitor the trends of antimicrobial resistance (AMR) patterns and establish baseline data for further surveillance. Methods: We performed a retrospective descriptive review of antibiograms data between January 2010 and December 2015 from King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia. Results: A total of 51,491 isolates were identified, and most were gram-negative (76.2%). Escherichia coli was the most frequently isolated organism (36.8%), followed by Coagulase-negative Staphylococcus (28.4%) and Staphylococcus aureus (27.5%). The detection of antibiotic-resistant organisms, especially extended-spectrum beta-lactamase-producing Escherichia coli (31%-41%), increased over time. The sensitivity of Streptococcus pneumoniae to penicillin improved from 66% to 100% (p<0.001). Gram-negative isolates had excellent overall susceptibility to amikacin, variable susceptibility to piperacillin-tazobactam and carbapenems, and declining susceptibility to ceftazidime, ciprofloxacin, and cefepime. Conclusion: Streptococcus pneumoniae susceptibility to penicillin significantly improved over time, which might be because of the introduction of the pneumococcal vaccine. Conversely, the upward trend in resistant gram-negative organisms is worrisome and warrants the implementation of antimicrobial stewardship programs.
Collapse
Affiliation(s)
- Sara M Farah
- Department of Pediatric Infectious Diseases, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
| | | | | | | | | | | |
Collapse
|
14
|
Niewiadomska AM, Jayabalasingham B, Seidman JC, Willem L, Grenfell B, Spiro D, Viboud C. Population-level mathematical modeling of antimicrobial resistance: a systematic review. BMC Med 2019; 17:81. [PMID: 31014341 PMCID: PMC6480522 DOI: 10.1186/s12916-019-1314-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/25/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mathematical transmission models are increasingly used to guide public health interventions for infectious diseases, particularly in the context of emerging pathogens; however, the contribution of modeling to the growing issue of antimicrobial resistance (AMR) remains unclear. Here, we systematically evaluate publications on population-level transmission models of AMR over a recent period (2006-2016) to gauge the state of research and identify gaps warranting further work. METHODS We performed a systematic literature search of relevant databases to identify transmission studies of AMR in viral, bacterial, and parasitic disease systems. We analyzed the temporal, geographic, and subject matter trends, described the predominant medical and behavioral interventions studied, and identified central findings relating to key pathogens. RESULTS We identified 273 modeling studies; the majority of which (> 70%) focused on 5 infectious diseases (human immunodeficiency virus (HIV), influenza virus, Plasmodium falciparum (malaria), Mycobacterium tuberculosis (TB), and methicillin-resistant Staphylococcus aureus (MRSA)). AMR studies of influenza and nosocomial pathogens were mainly set in industrialized nations, while HIV, TB, and malaria studies were heavily skewed towards developing countries. The majority of articles focused on AMR exclusively in humans (89%), either in community (58%) or healthcare (27%) settings. Model systems were largely compartmental (76%) and deterministic (66%). Only 43% of models were calibrated against epidemiological data, and few were validated against out-of-sample datasets (14%). The interventions considered were primarily the impact of different drug regimens, hygiene and infection control measures, screening, and diagnostics, while few studies addressed de novo resistance, vaccination strategies, economic, or behavioral changes to reduce antibiotic use in humans and animals. CONCLUSIONS The AMR modeling literature concentrates on disease systems where resistance has been long-established, while few studies pro-actively address recent rise in resistance in new pathogens or explore upstream strategies to reduce overall antibiotic consumption. Notable gaps include research on emerging resistance in Enterobacteriaceae and Neisseria gonorrhoeae; AMR transmission at the animal-human interface, particularly in agricultural and veterinary settings; transmission between hospitals and the community; the role of environmental factors in AMR transmission; and the potential of vaccines to combat AMR.
Collapse
Affiliation(s)
- Anna Maria Niewiadomska
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| | - Bamini Jayabalasingham
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA.,Present Address: Elsevier Inc., 230 Park Ave, Suite B00, New York, NY, 10169, USA
| | - Jessica C Seidman
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| | | | - Bryan Grenfell
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA.,Princeton University, Princeton, NJ, USA
| | - David Spiro
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA
| | - Cecile Viboud
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, USA.
| |
Collapse
|
15
|
Varghese S, Ramakrishnan D, Rajahamsan J, Balakrishnan SK, Mercybai IR, Valamparampil MJ, Mohan A, Rajeevan A. Staphylococcus aureus carrier state among surgery and orthopedics health care personnel of a tertiary care center. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2018. [DOI: 10.1016/j.cegh.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
16
|
Chisholm RH, Campbell PT, Wu Y, Tong SYC, McVernon J, Geard N. Implications of asymptomatic carriers for infectious disease transmission and control. ROYAL SOCIETY OPEN SCIENCE 2018; 5:172341. [PMID: 29515909 PMCID: PMC5830799 DOI: 10.1098/rsos.172341] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 05/19/2023]
Abstract
For infectious pathogens such as Staphylococcus aureus and Streptococcus pneumoniae, some hosts may carry the pathogen and transmit it to others, yet display no symptoms themselves. These asymptomatic carriers contribute to the spread of disease but go largely undetected and can therefore undermine efforts to control transmission. Understanding the natural history of carriage and its relationship to disease is important for the design of effective interventions to control transmission. Mathematical models of infectious diseases are frequently used to inform decisions about control and should therefore accurately capture the role played by asymptomatic carriers. In practice, incorporating asymptomatic carriers into models is challenging due to the sparsity of direct evidence. This absence of data leads to uncertainty in estimates of model parameters and, more fundamentally, in the selection of an appropriate model structure. To assess the implications of this uncertainty, we systematically reviewed published models of carriage and propose a new model of disease transmission with asymptomatic carriage. Analysis of our model shows how different assumptions about the role of asymptomatic carriers can lead to different conclusions about the transmission and control of disease. Critically, selecting an inappropriate model structure, even when parameters are correctly estimated, may lead to over- or under-estimates of intervention effectiveness. Our results provide a more complete understanding of the role of asymptomatic carriers in transmission and highlight the importance of accurately incorporating carriers into models used to make decisions about disease control.
Collapse
Affiliation(s)
- Rebecca H. Chisholm
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Author for correspondence: Nicholas Geard e-mail:
| | - Patricia T. Campbell
- Modelling and Simulation Research Group, Murdoch Childrens Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Yue Wu
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia
| | - Steven Y. C. Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and the University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Jodie McVernon
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Modelling and Simulation Research Group, Murdoch Childrens Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Geard
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- School of Computing and Information Systems, Melbourne School of Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
17
|
Multicenter Evaluation of the Xpert MRSA NxG Assay for Detection of Methicillin-Resistant Staphylococcus aureus in Nasal Swabs. J Clin Microbiol 2017; 56:JCM.01381-17. [PMID: 29118165 DOI: 10.1128/jcm.01381-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/28/2017] [Indexed: 12/25/2022] Open
Abstract
Health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections are a burden on the health care system. Clinical laboratories play a key role in reducing this burden, as the timely identification of MRSA colonization or infection facilitates infection control practices that are effective at limiting invasive MRSA infections. The Xpert MRSA NxG assay recently received FDA clearance for the direct detection of MRSA from nasal swabs. This multicenter study evaluated the clinical performance characteristics of the Xpert MRSA NxG assay with prospectively collected rayon nasal swabs (n = 1,103) and flocked swab (ESwab) nasal specimens (n = 846). Culture-based identification methods and antimicrobial susceptibility testing were used as the reference standards for comparison. According to the reference method, the positivity rates for MRSA in the population evaluated were 11.1% (122/1,103) for rayon swabs and 11.6% (98/846) for flocked swabs. The overall sensitivity and specificity of the rayon swabs were 91.0% (95% confidence interval [CI], 84.6 to 94.9%) and 96.9% (95% CI, 95.7 to 97.8%), respectively, across eight testing sites. The flocked swab specimens were 92.9% sensitive (95% CI, 86.0 to 96.5%) and 97.6% specific (95% CI, 96.2 to 98.5%) for MRSA detection across six testing sites. The sensitivity and specificity of the combined flocked and rayon swab data were 91.8% (95% CI, 87.4 to 94.8%) and 97.2% (95% CI, 96.3 to 97.9%), respectively. The positive predictive value (PPV) for rayon swabs was 78.7%, versus 83.5% for ESwabs. The negative predictive values (NPVs) for rayon swabs and ESwab specimens were 98.9% and 99.1%, respectively. In conclusion, the Xpert MRSA NxG assay is a sensitive and specific assay for the direct detection of MRSA from nasal swab specimens.
Collapse
|
18
|
Lapointe-Shaw L, Voruganti T, Kohler P, Thein HH, Sander B, McGeer A. Cost-effectiveness analysis of universal screening for carbapenemase-producing Enterobacteriaceae in hospital inpatients. Eur J Clin Microbiol Infect Dis 2017; 36:1047-1055. [PMID: 28078557 DOI: 10.1007/s10096-016-2890-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/22/2016] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to assess the cost-effectiveness of screening all hospital inpatients for carbapenemase-producing Enterobacteriaceae (CPE) at the time of hospital admission, compared to not screening, from a US hospital perspective. We used a linked transmission/Markov model to compare outcomes for a typical hospitalized medical patient, from a community with a colonization prevalence of 0.05%. Outcomes were number of colonized patients, CPE-related clinical infections and deaths, expected quality-adjusted life years (QALYs), cost, and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to assess the effect of parameter uncertainty, using a willingness-to-pay threshold of $100,000 per QALY gained. Screening prevented six CPE colonization cases per 1000 patients (1/1000 colonized with screening, 7/1000 without screening), over half of all symptomatic CPE infections (2/10,000 symptomatic with screening, 5/10,000 symptomatic without screening), and nearly half of all CPE-related deaths (8/100,000 deaths with screening, 15/100,000 deaths without screening). Screening accrued 0.0009 additional QALYs and cost an additional $24.68, compared to not screening, and was cost-effective (ICER $26,283 per QALY gained). Our results were sensitive to uncertainty in prevalence and the number of secondary colonizations per colonized patient. Screening was not cost-effective at a prevalence below 0.015% or if transmission to fewer than 0.9 new patients occurred for each colonized patient. At prevalence levels above 0.3%, screening was cost-saving compared to not screening. Screening inpatients for CPE carriage is likely cost-effective, and may be cost-saving, depending on the local prevalence of carriage.
Collapse
Affiliation(s)
- L Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Canada.
- Toronto General Hospital, 14 EN room 213, 200 Elizabeth St., Toronto, ON, M5G 2C4, Canada.
| | - T Voruganti
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - P Kohler
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - H-H Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - B Sander
- Public Health Ontario, Toronto, Canada
| | - A McGeer
- Sinai Health System, Toronto, Canada
| |
Collapse
|
19
|
Bartsch SM, McKinnell JA, Mueller LE, Miller LG, Gohil SK, Huang SS, Lee BY. Potential economic burden of carbapenem-resistant Enterobacteriaceae (CRE) in the United States. Clin Microbiol Infect 2017; 23:48.e9-48.e16. [PMID: 27642178 PMCID: PMC5547745 DOI: 10.1016/j.cmi.2016.09.003] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention considers carbapenem-resistant Enterobacteriaceae (CRE) an urgent public health threat; however, its economic burden is unknown. METHODS We developed a CRE clinical and economics outcomes model to determine the cost of CRE infection from the hospital, third-party payer, and societal, perspectives and to evaluate the health and economic burden of CRE to the USA. RESULTS Depending on the infection type, the median cost of a single CRE infection can range from $22 484 to $66 031 for hospitals, $10 440 to $31 621 for third-party payers, and $37 778 to $83 512 for society. An infection incidence of 2.93 per 100 000 population in the USA (9418 infections) would cost hospitals $275 million (95% CR $217-334 million), third-party payers $147 million (95% CR $129-172 million), and society $553 million (95% CR $303-1593 million) with a 25% attributable mortality, and would result in the loss of 8841 (95% CR 5805-12 420) quality-adjusted life years. An incidence of 15 per 100 000 (48 213 infections) would cost hospitals $1.4 billion (95% CR $1.1-1.7 billion), third-party payers $0.8 billion (95% CR $0.6-0.8 billion), and society $2.8 billion (95% CR $1.6-8.2 billion), and result in the loss of 45 261 quality-adjusted life years. CONCLUSIONS The cost of CRE is higher than the annual cost of many chronic diseases and of many acute diseases. Costs rise proportionally with the incidence of CRE, increasing by 2.0 times, 3.4 times, and 5.1 times for incidence rates of 6, 10, and 15 per 100 000 persons.
Collapse
Affiliation(s)
- S M Bartsch
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J A McKinnell
- Infectious Disease Clinical Outcomes Research Unit (ID-CORE), Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA; Torrance Memorial Medical Center, Torrance, CA, USA
| | - L E Mueller
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - L G Miller
- Infectious Disease Clinical Outcomes Research Unit (ID-CORE), Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - S K Gohil
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine Health School of Medicine, Irvine, CA, USA
| | - S S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine Health School of Medicine, Irvine, CA, USA
| | - B Y Lee
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
20
|
Wielage RC, Perk S, Campbell NL, Klein TM, Posta LM, Yuran T, Klein RW, Ng DB. Mirabegron for the treatment of overactive bladder: cost-effectiveness from US commercial health-plan and Medicare Advantage perspectives. J Med Econ 2016; 19:1135-1143. [PMID: 27326725 DOI: 10.1080/13696998.2016.1204307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVE The first class of oral pharmacologic treatments for overactive bladder (OAB) are antimuscarinics that are associated with poor persistence, anticholinergic adverse events, and increased anticholinergic burden (ACB) with risk of cognitive impairment. Mirabegron, a β3-adrenoceptor agonist, is an oral treatment that does not contribute to ACB and has early evidence of improved persistence. The objective of the analysis was to assess the cost-effectiveness of mirabegron for OAB vs six antimuscarinics in the US. METHODS A Markov state-transition model assessed US commercial health-plan and Medicare Advantage perspectives over a 3-year time horizon in an OAB patient population. Transition probabilities between five micturition and five incontinence severity states were derived from a network meta-analysis of 44 trials of oral OAB treatments. Therapy beginning with an oral OAB agent could discontinue or switch to another oral agent and could be followed by tibial nerve stimulation, sacral neuromodulation, or onabotulinumtoxinA. The primary outcome was cost per quality-adjusted life year (QALY). Utilities were mapped from incontinence and micturition frequencies as well as demographics. Based on analysis of data from a large healthcare system, elevated ACB was associated with increased healthcare utilization and probability of cognitive impairment. RESULTS From both commercial and Medicare Advantage perspectives, mirabegron was the most clinically effective treatment, while oxybutynin was the least expensive. Tolterodine immediate release (IR) was also on the cost-effectiveness frontier. The analysis estimated costs per QALY of $59,690 and $66,347 for mirabegron from commercial health plan and Medicare Advantage perspectives, respectively, compared to tolterodine IR. Other antimuscarinics were dominated. CONCLUSIONS This analysis estimated that mirabegron is a cost-effective treatment for OAB from US commercial health plan and Medicare Advantage perspectives, due to fewer projected adverse events and comorbidities, and data suggesting better persistence.
Collapse
Affiliation(s)
| | - Sinem Perk
- a Medical Decision Modeling Inc. , Indianapolis IN , USA
| | - Noll L Campbell
- b Center for Aging Research, Regenstrief Institute Inc. , Indianapolis IN , USA
- c Purdue University College of Pharmacy , West Lafayette IN , USA
| | | | - Linda M Posta
- d Medical Affairs, Americas, Astellas Pharma Global Development , Northbrook IL , USA
| | - Thomas Yuran
- d Medical Affairs, Americas, Astellas Pharma Global Development , Northbrook IL , USA
| | - Robert W Klein
- a Medical Decision Modeling Inc. , Indianapolis IN , USA
| | - Daniel B Ng
- d Medical Affairs, Americas, Astellas Pharma Global Development , Northbrook IL , USA
| |
Collapse
|
21
|
Roth VR, Longpre T, Coyle D, Suh KN, Taljaard M, Muldoon KA, Ramotar K, Forster A. Cost Analysis of Universal Screening vs. Risk Factor-Based Screening for Methicillin-Resistant Staphylococcus aureus (MRSA). PLoS One 2016; 11:e0159667. [PMID: 27462905 PMCID: PMC4963093 DOI: 10.1371/journal.pone.0159667] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/05/2016] [Indexed: 12/03/2022] Open
Abstract
Background The literature remains conflicted regarding the most effective way to screen for MRSA. This study was designed to assess costs associated with universal versus risk factor-based screening for the reduction of nosocomial MRSA transmission. Methods The study was conducted at The Ottawa Hospital, a large multi-centre tertiary care facility with approximately 47,000 admissions annually. From January 2006-December 2007, patients underwent risk factor-based screening for MRSA on admission. From January 2008 to August 2009 universal MRSA screening was implemented. A comparison of costs incurred during risk factor-based screening and universal screening was conducted. The model incorporated probabilities relating to the likelihood of being tested and the results of polymerase chain reaction (PCR) testing with associated effects in terms of MRSA bacteremia and true positive and negative test results. Inputted costs included laboratory testing, contact precautions and infection control, private room costs, housekeeping, and length of hospital stay. Deterministic sensitivity analyses were conducted. Results The risk factor-based MRSA screening program screened approximately 30% of admitted patients and cost the hospital over $780 000 annually. The universal screening program screened approximately 83% of admitted patients and cost over $1.94 million dollars, representing an excess cost of $1.16 million per year. The estimated additional cost per patient screened was $17.76. Conclusion This analysis demonstrated that a universal MRSA screening program was costly from a hospital perspective and was previously known to not be clinically effective at reducing MRSA transmission. These results may be useful to inform future model-based economic analyses of MRSA interventions.
Collapse
Affiliation(s)
- Virginia R. Roth
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
| | - Tara Longpre
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, United Kingdom
| | - Kathryn N. Suh
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katherine A. Muldoon
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karamchand Ramotar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
22
|
Hübner C, Hübner NO, Wegner C, Flessa S. Impact of different diagnostic technologies for MRSA admission screening in hospitals - a decision tree analysis. Antimicrob Resist Infect Control 2015; 4:50. [PMID: 26635952 PMCID: PMC4668619 DOI: 10.1186/s13756-015-0093-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/12/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospital infections with multiresistant bacteria, e.g., Methicillin-resistant Staphylococcus aureus (MRSA), cause heavy financial burden worldwide. Rapid and precise identification of MRSA carriage in combination with targeted hygienic management are proven to be effective but incur relevant extra costs. Therefore, health care providers have to decide which MRSA screening strategy and which diagnostic technology should be applied according to economic criteria. AIM The aim of this study was to determine which MRSA admission screening and infection control management strategy causes the lowest expected cost for a hospital. Focus was set on the Point-of-Care Testing (PoC). METHODS A decision tree analytic cost model was developed, primarily based on data from peer-reviewed literature. In addition, univariate sensitivity analyses of the different input parameters were conducted to study the robustness of the results. FINDINGS In the basic analysis, risk-based PoC screening showed the highest mean cost savings with 14.98 € per admission in comparison to no screening. Rapid universal screening methods became favorable at high MRSA prevalence, while in situations with low MRSA transmission rates omission of screening may be favorable. CONCLUSION Early detection of MRSA by rapid PoC or PCR technologies and consistent implementation of appropriate hygienic measures lead to high economic efficiency of MRSA management. Whether general or targeted screening is more efficient depends mainly on epidemiological and infrastructural parameters.
Collapse
Affiliation(s)
- Claudia Hübner
- />Institute of Health Care Management, University of Greifswald, Friedrich-Loeffler-Str. 70, 17489 Greifswald, Germany
| | - Nils-Olaf Hübner
- />Institute of Hygiene and Environmental Health, University Medicine of Greifswald, Greifswald, Germany
- />IMD laboratory network, MVZ Greifswald GmbH, Greifswald, Germany
| | - Christian Wegner
- />Institute of Hygiene and Environmental Health, University Medicine of Greifswald, Greifswald, Germany
| | - Steffen Flessa
- />Institute of Health Care Management, University of Greifswald, Friedrich-Loeffler-Str. 70, 17489 Greifswald, Germany
| |
Collapse
|
23
|
Affiliation(s)
- Emily W Gottenborg
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Leprino Building, 4th Floor, Mailstop F-782, 12401 East 17th Avenue, Aurora, CO 80045, USA
| | - Michelle A Barron
- Division of Infectious Diseases, Department of Medicine, University of Colorado Hospital Infection Prevention and Control, University of Colorado Anschutz Medical Campus, 12700 East 19th Avenue, B168, Aurora, CO 80045, USA
| |
Collapse
|
24
|
Cost-benefit analysis from the hospital perspective of universal active screening followed by contact precautions for methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol 2015; 36:2-13. [PMID: 25627755 DOI: 10.1017/ice.2014.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To explore the economic impact to a hospital of universal methicillin-resistant Staphylococcus aureus (MRSA) screening. METHODS We used a decision tree model to estimate the direct economic impact to an individual hospital of starting universal MRSA screening and contact precautions. Projected costs and benefits were based on literature-derived data. Our model examined outcomes of several strategies including non-nares MRSA screening and comparison of culture versus polymerase chain reaction-based screening. RESULTS Under baseline conditions, the costs of universal MRSA screening and contact precautions outweighed the projected benefits generated by preventing MRSA-related infections, resulting in economic costs of $104,000 per 10,000 admissions (95% CI, $83,000-$126,000). Cost-savings occurred only when the model used estimates at the extremes of our key parameters. Non-nares screening and polymerase chain reaction-based testing, both of which identified more MRSA-colonized persons, resulted in more MRSA infections averted but increased economic costs of the screening program. CONCLUSIONS We found that universal MRSA screening, although providing potential benefit in preventing MRSA infection, is relatively costly and may be economically burdensome for a hospital. Policy makers should consider the economic burden of MRSA screening and contact precautions in relation to other interventions when choosing programs to improve patient safety and outcomes.
Collapse
|
25
|
Universal vs Risk Factor Screening for Methicillin-Resistant Staphylococcus aureus in a Large Multicenter Tertiary Care Facility in Canada. Infect Control Hosp Epidemiol 2015; 37:41-8. [PMID: 26470820 DOI: 10.1017/ice.2015.230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the clinical effectiveness of a universal screening program compared with a risk factor-based program in reducing the rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) among admitted patients at the Ottawa Hospital. DESIGN Quasi-experimental study. SETTING Ottawa Hospital, a multicenter tertiary care facility with 3 main campuses, approximately 47,000 admissions per year, and 1,200 beds. METHODS From January 1, 2006 through December 31, 2007 (24 months), admitted patients underwent risk factor-based MRSA screening. From January 1, 2008 through August 31, 2009 (20 months), all patients admitted underwent universal MRSA screening. To measure the effectiveness of this intervention, segmented regression modeling was used to examine monthly nosocomial MRSA incidence rates per 100,000 patient-days before and during the intervention period. To assess secular trends, nosocomial Clostridium difficile infection, mupirocin prescriptions, and regional MRSA rates were investigated as controls. RESULTS The nosocomial MRSA incidence rate was 46.79 cases per 100,000 patient-days, with no significant differences before and after intervention. The MRSA detection rate per 1,000 admissions increased from 9.8 during risk factor-based screening to 26.2 during universal screening. A total of 644 new nosocomial MRSA cases were observed in 1,448,488 patient-days, 323 during risk factor-based screening and 321 during universal screening. Secular trends in C. difficile infection rates and mupirocin prescriptions remained stable after the intervention whereas population-level MRSA rates decreased. CONCLUSION At Ottawa Hospital, the introduction of universal MRSA admission screening did not significantly affect the rates of nosocomial MRSA compared with risk factor-based screening. Infect. Control Hosp. Epidemiol. 2015;37(1):41-48.
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW To describe the latest evidence for methicillin-resistant Staphylococcus aureus (MRSA) infection control strategies, with particular emphasis on active surveillance cultures with contact precautions and targeted decolonization, and their impact. RECENT FINDINGS Several major trials published last year questioned the effectiveness of universal screening and contact precautions in controlling MRSA. These trials generally recommend universal decolonization as part of bundles to control MRSA, especially in ICUs, with some even concluding that universal decolonization should replace active screening and contact precautions. However, emerging resistance to agents used for decolonization, such as mupirocin and chlorhexidine, is a major concern. Several other studies confirmed a combination of hand hygiene enhancement, screening, contact precaution and targeted decolonization as a more viable MRSA infection control strategy for specific population groups. SUMMARY Universal decolonization is an acceptable MRSA control strategy for intensive care units; however, close monitoring of chlorhexidine and mupirocin resistance is warranted. As a strategy, screening and contact precautions are suitable for hospital-wide MRSA control. Targeted decolonization is a proven measure for patients undergoing clean surgery. Enhancement of hand hygiene is a core measure regardless of the strategy.
Collapse
|
27
|
McKinnell JA, Bartsch SM, Lee BY, Huang SS, Miller LG. Reply to O'Riordan et al. Infect Control Hosp Epidemiol 2015; 36:857-8. [PMID: 26081999 PMCID: PMC5676467 DOI: 10.1017/ice.2015.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
- Torrance Memorial Medical Center, Torrance, California
| | - Sarah M. Bartsch
- Public Health Computational and Operations Research Group, Johns Hopkins Bloomberg School of Public Health, Balti-more, Maryland
| | - Bruce Y. Lee
- Public Health Computational and Operations Research Group, Johns Hopkins Bloomberg School of Public Health, Balti-more, Maryland
| | - Susan S. Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Loren G. Miller
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| |
Collapse
|
28
|
Economic analysis of universal active surveillance screening for methicillin-resistant Staphylococcus aureus: perspective matters. Infect Control Hosp Epidemiol 2015; 36:14-6. [PMID: 25627756 DOI: 10.1017/ice.2014.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
29
|
Kang J, Mandsager P, Biddle AK, Weber DJ. Cost-Effectiveness Analysis of Active Surveillance Screening for Methicillin-Resistant Staphylococcus aureus in an Academic Hospital Setting. Infect Control Hosp Epidemiol 2015; 33:477-86. [DOI: 10.1086/665315] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objective.To evaluate the cost-effectiveness of 3 alternative active screening strategies for methicillin-resistant Staphylococcus aureus (MRSA): universal surveillance screening for all hospital admissions, targeted surveillance screening for intensive care unit admissions, and no surveillance screening.Design.Cost-effectiveness analysis using decision modeling.Methods.Cost-effectiveness was evaluated from the perspective of an 800-bed academic hospital with 40,000 annual admissions over the time horizon of a hospitalization. All input probabilities, costs, and outcome data were obtained through a comprehensive literature review. Effectiveness outcome was MRSA healthcare-associated infections (HAIs). One-way and probabilistic sensitivity analyses were conducted.Results.In the base case, targeted surveillance screening was a dominant strategy (ie, was associated with lower costs and resulted in better outcomes) for preventing MRSA HAL Universal surveillance screening was associated with an incremental cost-effectiveness ratio of $14,955 per MRSA HAL In one-way sensitivity analysis, targeted surveillance screening was a dominant strategy across most parameter ranges. Probabilistic sensitivity analysis also demonstrated that targeted surveillance screening was the most cost-effective strategy when willingness to pay to prevent a case of MRSA HAI was less than $71,300.Conclusion.Targeted active surveillance screening for MRSA is the most cost-effective screening strategy in an academic hospital setting. Additional studies that are based on actual hospital data are needed to validate this model. However, the model supports current recommendations to use active surveillance to detect MRSA.
Collapse
|
30
|
You JHS, Chan CY, Wong MY, Ip M. Active Surveillance and Decolonization of Methicillin-Resistant Staphylococcus aureus on Admission to Neonatal Intensive Care Units in Hong Kong: A Cost-Effectiveness Analysis. Infect Control Hosp Epidemiol 2015; 33:1024-30. [DOI: 10.1086/667735] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective.To examine potential clinical outcomes and cost of active methicillin-resistant Staphylococcus aureus (MRSA) surveillance with and without decolonization in neonatal intensive care units (NICUs) from the perspective of healthcare providers in Hong Kong.Design.Decision analysis modeling.Setting.NICU.Patients.Hypothetical cohort of patients admitted to an NICU.Methods.We designed a decision tree to simulate potential outcomes of active MRSA surveillance with and without decolonization in patients admitted to an NICU. Outcome measures included total direct medical cost per patient, MRSA infection rate, and MRSA-associated mortality rate. Model inputs were derived from the literature. Sensitivity analyses evaluated the impact of uncertainty in all model variables.Results.In the base-case analysis, active surveillance plus decolonization showed a lower expected MRSA infection rate (0.911% vs 1.759%), MRSA-associated mortality rate (0.223% vs 0.431%), and total cost per patient (USD 47,294 vs USD 48,031) compared with active surveillance alone. Sensitivity analyses showed that active surveillance plus decolonization cost less and had lower event rates if the incidence risk ratio of acquiring MRSA infections in carriers after decolonization was less than 0.997. In 10,000 Monte Carlo simulations, active surveillance plus decolonization was significantly less costly than active surveillance alone 99.9% of the time, and both the MRSA infection rate and the MRSA-associated mortality rate were significantly lower 99.9% of the time.Conclusions.Active surveillance plus decolonization for patients admitted to NICUs appears to be cost saving and effective in reducing the MRSA infection rate and the MRSA-associated mortality rate if addition of decolonization to active surveillance reduces the risk of MRSA infection.Infect Control Hosp Epidemiol 2012;33(10):1024-1030
Collapse
|
31
|
Utility of surveillance cultures for antimicrobial resistant organisms in infants transferred to the neonatal intensive care unit. Pediatr Infect Dis J 2013; 32:e443-50. [PMID: 23811747 DOI: 10.1097/inf.0b013e3182a1d77f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Infections with antibiotic resistant organisms (AROs) are an important source of morbidity and mortality among infants hospitalized in the neonatal intensive care unit (NICU). To identify potential reservoirs of AROs in the NICU, active surveillance strategies have been adopted by many NICUs to detect infants colonized with AROs. However, the yield, risks, benefits and costs of different strategies have not been fully evaluated. METHODS We conducted a retrospective study in 2 level III NICUs from 2004 to 2010 to investigate the yield of surveillance cultures obtained from infants transferred to the NICU from other hospitals. Cultures were processed for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods. Risk factors, selected outcomes and laboratory costs associated with ARO colonization were assessed. RESULTS Among 1751 infants studied, the rate of colonization for methicillin-resistant S. aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods was 3%, 1.7% and 1%, respectively. Age at transfer was the strongest predictor of ARO colonization; infants transferred at ≥ 7 days of life had 5.8 increased odds of ARO colonization compared with infants <7 days of age. Transferred infants who were colonized had similar rates of mortality, ARO infection and duration of hospitalization compared with those who were not colonized. The laboratory cost of surveillance cultures during the study period was $58,425. CONCLUSIONS The rate of colonization with AROs at transfer was low particularly in infants <7 days old. Future studies should examine the safety of targeted surveillance strategies focused on older infants.
Collapse
|
32
|
McKinnell JA, Miller LG, Eells SJ, Cui E, Huang SS. A systematic literature review and meta-analysis of factors associated with methicillin-resistant Staphylococcus aureus colonization at time of hospital or intensive care unit admission. Infect Control Hosp Epidemiol 2013; 34:1077-86. [PMID: 24018925 DOI: 10.1086/673157] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Screening for methicillin-resistant Staphylococcus aureus (MRSA) in high-risk patients is a legislative mandate in 9 US states and has been adopted by many hospitals. Definitions of high risk differ among hospitals and state laws. A systematic evaluation of factors associated with colonization is lacking. We performed a systematic review of the literature to assess factors associated with MRSA colonization at hospital admission. DESIGN We searched MEDLINE from 1966 to 2012 for articles comparing MRSA colonized and noncolonized patients on hospital or intensive care unit (ICU) admission. Data were extracted using a standardized instrument. Meta-analyses were performed to identify factors associated with MRSA colonization. RESULTS We reviewed 4,381 abstracts; 29 articles met inclusion criteria (n = 76,913 patients). MRSA colonization at hospital admission was associated with recent prior hospitalization (odds ratio [OR], 2.4 [95% confidence interval (CI), 1.3-4.7]; P < .01), nursing home exposure (OR, 3.8 [95% CI, 2.3-6.3]; P < .01), and history of exposure to healthcare-associated pathogens (MRSA carriage: OR, 8.0 [95% CI, 4.2-15.1]; Clostridium difficile infection: OR, 3.4 [95% CI, 2.2-5.3]; vancomycin-resistant Enterococci carriage: OR, 3.1 [95% CI, 2.5-4.0]; P < .01 for all). Select comorbidities were associated with MRSA colonization (congestive heart failure, diabetes, pulmonary disease, immunosuppression, and renal failure; P < .01 for all), while others were not (human immunodeficiency virus, cirrhosis, and malignancy). ICU admission was not associated with an increased risk of MRSA colonization (OR, 1.1 [95% CI, 0.6-1.8]; P = .87). CONCLUSIONS MRSA colonization on hospital admission was associated with healthcare contact, previous healthcare-associated pathogens, and select comorbid conditions. ICU admission was not associated with MRSA colonization, although this is commonly used in state mandates for MRSA screening. Infection prevention programs utilizing targeted MRSA screening may consider our results to define patients likely to have MRSA colonization.
Collapse
Affiliation(s)
- James A McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute at Harbor-University of California-Los Angeles Medical Center, Torrance, California
| | | | | | | | | |
Collapse
|
33
|
Abstract
Healthy children are high transmitters of influenza and can experience poor influenza outcomes. Many questions remain about the efficacy and impect of preventive measures because most existing studies report imprecise proxies of influenza incidence, do not follow subjects throughout the entire influenza season and across multiple influenza seasons, or do not control for important factors such as timing of implementation and social contact patterns. Modeling and simulation are key methodologies to answer questions regarding influenza prevention. While vaccination may be the most efficacious existing intervention, variations in circulating strains and children's immune systems keep current vaccines from being fully protective, necessitating further clinical and economic studies and technology improvements. Hand hygiene appears to be an important adjunct but improving compliance, standardizing regimens and quantifying its impact remain challenging. Future studies should help better define the specific indications and circumstances for antiviral use and the role of nutritional supplements and nonpharmaceutical interventions.
Collapse
Affiliation(s)
- Bruce Y Lee
- Public Health Computational and Operations Research, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, USA.
| | | |
Collapse
|
34
|
Methicillin-resistant staphylococcus aureus nasal colonization prevalence among Emergency Medical Services personnel. Prehosp Disaster Med 2013; 28:348-52. [PMID: 23611021 DOI: 10.1017/s1049023x13003476] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization among Emergency Medical Services (EMS) personnel is not well studied. Methicillin-resistant Staphylococcus aureus colonization can be a health hazard for both EMS personnel and patients. The aim of this study was to quantify the prevalence of MRSA colonization among EMS personnel. This study will help the scientific community understand the extent of this condition so that further protocols and policies can be developed to support the health and wellbeing of EMS personnel. Hypothesis/ Problem The hypothesis of this study was that the prevalence of MRSA colonization among EMS personnel is significantly higher than among the general population. METHODS This was a cross-sectional study. A total of 110 subjects were selected from two major US Mid-Atlantic fire departments. Methicillin-resistant Staphylococcus aureus colonization was detected by nasal swabbing. Nasal swabs were inoculated onto a special agar medium (C-MRSAgar) with polymerase chain reaction testing performed. One-sided binomial distribution at the Study Size 2.0 Web calculator was used. Using the Web calculator, p (H0 proportion) = 1.5%; a difference (H1-H0) 'Δ' = 4.53% can be detected at α = 5% and power = 80% with N = 110. RESULTS Samples were collected from 110 volunteers. Seven samples were positive for MRSA, resulting in a prevalence of 7/110 or 6.4% (95% CI, 1.8%-11%; P < .0003) compared with a 1.5% prevalence of MRSA colonization among the general population. CONCLUSION There is evidence that EMS personnel have a higher prevalence of MRSA colonization than the general population. This can be a risk to patients and can be recognized as an occupational hazard.
Collapse
|
35
|
Lee BY, Bartsch SM, Wong KF, Yilmaz SL, Avery TR, Singh A, Song Y, Kim DS, Brown ST, Potter MA, Platt R, Huang SS. Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone. Health Aff (Millwood) 2013; 31:2295-303. [PMID: 23048111 DOI: 10.1377/hlthaff.2011.0992] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Efforts to control life-threatening infections, such as with methicillin-resistant Staphylococcus aureus (MRSA), can be complicated when patients are transferred from one hospital to another. Using a detailed computer simulation model of all hospitals in Orange County, California, we explored the effects when combinations of hospitals tested all patients at admission for MRSA and adopted procedures to limit transmission among patients who tested positive. Called "contact isolation," these procedures specify precautions for health care workers interacting with an infected patient, such as wearing gloves and gowns. Our simulation demonstrated that each hospital's decision to test for MRSA and implement contact isolation procedures could affect the MRSA prevalence in all other hospitals. Thus, our study makes the case that further cooperation among hospitals--which is already reflected in a few limited collaborative infection control efforts under way--could help individual hospitals achieve better infection control than they could achieve on their own.
Collapse
Affiliation(s)
- Bruce Y Lee
- University of Pittsburgh, Pennsylvania, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Tannic acid inhibits Staphylococcus aureus surface colonization in an IsaA-dependent manner. Infect Immun 2012. [PMID: 23208606 DOI: 10.1128/iai.00877-12] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Staphylococcus aureus is a human commensal and pathogen that is capable of forming biofilms on a variety of host tissues and implanted medical devices. Biofilm-associated infections resist antimicrobial chemotherapy and attack from the host immune system, making these infections particularly difficult to treat. In order to gain insight into environmental conditions that influence S. aureus biofilm development, we screened a library of small molecules for the ability to inhibit S. aureus biofilm formation. This led to the finding that the polyphenolic compound tannic acid inhibits S. aureus biofilm formation in multiple biofilm models without inhibiting bacterial growth. We present evidence that tannic acid inhibits S. aureus biofilm formation via a mechanism dependent upon the putative transglycosylase IsaA. Tannic acid did not inhibit biofilm formation of an isaA mutant. Overexpression of wild-type IsaA inhibited biofilm formation, whereas overexpression of a catalytically dead IsaA had no effect. Tannin-containing drinks like tea have been found to reduce methicillin-resistant S. aureus nasal colonization. We found that black tea inhibited S. aureus biofilm development and that an isaA mutant resisted this inhibition. Antibiofilm activity was eliminated from tea when milk was added to precipitate the tannic acid. Finally, we developed a rodent model for S. aureus throat colonization and found that tea consumption reduced S. aureus throat colonization via an isaA-dependent mechanism. These findings provide insight into a molecular mechanism by which commonly consumed polyphenolic compounds, such as tannins, influence S. aureus surface colonization.
Collapse
|
37
|
Bartsch SM, Curry SR, Harrison LH, Lee BY. The potential economic value of screening hospital admissions for Clostridium difficile. Eur J Clin Microbiol Infect Dis 2012; 31:3163-71. [PMID: 22752150 DOI: 10.1007/s10096-012-1681-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/11/2012] [Indexed: 12/18/2022]
Abstract
Asymptomatic Clostridium difficile carriage has a prevalence reported as high as 51-85 %; with up to 84 % of incident hospital-acquired infections linked to carriers. Accurately identifying carriers may limit the spread of Clostridium difficile. Since new technology adoption depends heavily on its economic value, we developed an analytic simulation model to determine the cost-effectiveness screening hospital admissions for Clostridium difficile from the hospital and third party payer perspectives. Isolation precautions were applied to patients testing positive, preventing transmission. Sensitivity analyses varied Clostridium difficile colonization rate, infection probability among secondary cases, contact isolation compliance, and screening cost. Screening was cost-effective (i.e., incremental cost-effectiveness ratio [ICER] ≤ $50,000/QALY) for every scenario tested; all ICER values were ≤ $256/QALY. Screening was economically dominant (i.e., saved costs and provided health benefits) with a ≥10.3 % colonization rate and ≥5.88 % infection probability when contact isolation compliance was ≥25 % (hospital perspective). Under some conditions screening led to cost savings per case averted (range, $53-272). Clostridium difficile screening, coupled with isolation precautions, may be a cost-effective intervention to hospitals and third party payers, based on prevalence. Limiting Clostridium difficile transmission can reduce the number of infections, thereby reducing its economic burden to the healthcare system.
Collapse
Affiliation(s)
- S M Bartsch
- Public Health Computational and Operations Research (PHICOR), University of Pittsburgh, 3520 Forbes Avenue, First Floor, Pittsburgh, PA, 15213, USA.
| | | | | | | |
Collapse
|
38
|
Matheson A, Christie P, Stari T, Kavanagh K, Gould IM, Masterton R, Reilly JS. Nasal swab screening for methicillin-resistant Staphylococcus aureus--how well does it perform? A cross-sectional study. Infect Control Hosp Epidemiol 2012; 33:803-8. [PMID: 22759548 DOI: 10.1086/666639] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) detections identified by nasal swabbing using agar culture in comparison with multiple body site testing using agar and nutrient broth culture. DESIGN Cross-sectional study. PATIENTS Adult patients admitted to 36 general specialty wards of 2 large hospitals in Scotland. METHODS Patients were screened for MRSA via multiple body site swabs (nasal, throat, axillary, perineal, and wound/invasive device sites) cultured individually on chromogenic agar and pooled in nutrient broth. Combined results from all sites and cultures provided a gold-standard estimate of true MRSA prevalence. RESULTS This study found that nasal screening performed better than throat, axillary, or perineal screening but at best identified only 66% of true MRSA carriers against the gold standard at an overall prevalence of 2.9%. Axillary screening performed least well. Combining nasal and perineal swabs gave the best 2-site combination (82%). When combined with realistic screening compliance rates of 80%-90%, nasal swabbing alone probably detects just over half of true colonization in practice. Swabbing of clinically relevant sites (wounds, indwelling devices, etc) is important for a small but high-prevalence group. CONCLUSIONS Nasal swabbing is the standard method in many locations for MRSA screening. Its diagnostic efficiency in practice appears to be limited, however, and the resource implications of multiple body site screening have to be balanced against a potential clinical benefit whose magnitude and nature remains unclear.
Collapse
Affiliation(s)
- Ann Matheson
- Health Protection Scotland, Glasgow, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
39
|
Song Y, Tai JH, Bartsch SM, Zimmerman RK, Muder RR, Lee BY. The potential economic value of a Staphylococcus aureus vaccine among hemodialysis patients. Vaccine 2012; 30:3675-82. [PMID: 22464963 PMCID: PMC3371356 DOI: 10.1016/j.vaccine.2012.03.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 01/20/2012] [Accepted: 03/15/2012] [Indexed: 01/08/2023]
Abstract
Staphylococcus aureus infections are a substantial problem for hemodialysis patients. Several vaccine candidates are currently under development, with hemodialysis patients being one possible target population. To determine the potential economic value of an S. aureus vaccine among hemodialysis patients, we developed a Markov decision analytic computer simulation model. When S. aureus colonization prevalence was 1%, the incremental cost-effectiveness ratio (ICER) of vaccination was ≤$25,217/quality-adjusted life year (QALY). Vaccination became more cost-effective as colonization prevalence, vaccine efficacy, or vaccine protection duration increased or vaccine cost decreased. Even at 10% colonization prevalence, a 25% efficacious vaccine costing $100 prevented 29 infections, 21 infection-related hospitalizations, and 9 inpatient deaths per 1000 vaccinated HD patients. Our results suggest that an S. aureus vaccine would be cost-effective (i.e., ICERs ≤ $50,000/QALY) among hemodialysis patients over a wide range of S. aureus prevalence, vaccine costs and efficacies, and vaccine protection durations and delineate potential target parameters for such a vaccine.
Collapse
Affiliation(s)
- Yeohan Song
- Public Health Computational and Operations Research (PHICOR), University of Pittsburgh 3520 Forbes Avenue, First Floor Pittsburgh, PA 15213, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Pittsburgh, PA 15260, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| | - Julie H.Y. Tai
- Public Health Computational and Operations Research (PHICOR), University of Pittsburgh 3520 Forbes Avenue, First Floor Pittsburgh, PA 15213, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Pittsburgh, PA 15260, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| | - Sarah M. Bartsch
- Public Health Computational and Operations Research (PHICOR), University of Pittsburgh 3520 Forbes Avenue, First Floor Pittsburgh, PA 15213, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Pittsburgh, PA 15260, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| | - Richard K. Zimmerman
- Department of Family Medicine, University of Pittsburgh School of Medicine, 3518 Fifth Avenue, Pittsburgh, PA 15261, USA
| | - Robert R. Muder
- Division of Infectious Diseases, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA
| | - Bruce Y. Lee
- Public Health Computational and Operations Research (PHICOR), University of Pittsburgh 3520 Forbes Avenue, First Floor Pittsburgh, PA 15213, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Pittsburgh, PA 15260, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| |
Collapse
|
40
|
Kipp F, Köck R, Roeder N, Mellmann A. Effizientes MRSA-Management. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-011-0889-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
41
|
Lawes T, Edwards B, López-Lozano JM, Gould I. Trends in Staphylococcus aureus bacteraemia and impacts of infection control practices including universal MRSA admission screening in a hospital in Scotland, 2006-2010: retrospective cohort study and time-series intervention analysis. BMJ Open 2012; 2:bmjopen-2011-000797. [PMID: 22685226 PMCID: PMC3378947 DOI: 10.1136/bmjopen-2011-000797] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To describe secular trends in Staphylococcus aureus bacteraemia (SAB) and to assess the impacts of infection control practices, including universal methicillin-resistant Staphylococcus aureus (MRSA) admission screening on associated clinical burdens. DESIGN Retrospective cohort study and multivariate time-series analysis linking microbiology, patient management and health intelligence databases. SETTING Teaching hospital in North East Scotland. PARTICIPANTS All patients admitted to Aberdeen Royal Infirmary between 1 January 2006 and 31 December 2010: n=420 452 admissions and 1 430 052 acute occupied bed days (AOBDs). INTERVENTION Universal admission screening programme for MRSA (August 2008) incorporating isolation and decolonisation. PRIMARY AND SECONDARY MEASURES: Hospital-wide prevalence density, hospital-associated incidence density and death within 30 days of MRSA or methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia. RESULTS Between 2006 and 2010, prevalence density of all SAB declined by 41%, from 0.73 to 0.50 cases/1000 AOBDs (p=0.002 for trend), and 30-day mortality from 26% to 14% (p=0.013). Significant reductions were observed in MRSA bacteraemia only. Overnight admissions screened for MRSA rose from 43% during selective screening to >90% within 4 months of universal screening. In multivariate time-series analysis (R(2) 0.45 to 0.68), universal screening was associated with a 19% reduction in prevalence density of MRSA bacteraemia (-0.035, 95% CI -0.049 to -0.021/1000 AOBDs; p<0.001), a 29% fall in hospital-associated incidence density (-0.029, 95% CI -0.035 to -0.023/1000 AOBDs; p<0.001) and a 46% reduction in 30-day mortality (-15.6, 95% CI -24.1% to -7.1%; p<0.001). Positive associations with fluoroquinolone and cephalosporin use suggested that antibiotic stewardship reduced prevalence density of MRSA bacteraemia by 0.027 (95% CI 0.015 to 0.039)/1000 AOBDs. Rates of MSSA bacteraemia were not significantly affected by screening or antibiotic use. CONCLUSIONS Declining clinical burdens from SAB were attributable to reductions in MRSA infections. Universal admission screening and antibiotic stewardship were associated with decreases in MRSA bacteraemia and associated early mortality. Control of MSSA bacteraemia remains a priority.
Collapse
Affiliation(s)
- Timothy Lawes
- Department of Paediatrics, Raigmore Hospital, Inverness, UK
| | - Becky Edwards
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Ian Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, UK
| |
Collapse
|
42
|
Lee BY, Assi TM, Rajgopal J, Norman BA, Chen SI, Brown ST, Slayton RB, Kone S, Kenea H, Welling JS, Connor DL, Wateska AR, Jana A, Wiringa AE, Van Panhuis WG, Burke DS. Impact of introducing the pneumococcal and rotavirus vaccines into the routine immunization program in Niger. Am J Public Health 2011; 102:269-76. [PMID: 21940923 DOI: 10.2105/ajph.2011.300218] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We investigated whether introducing the rotavirus and pneumococcal vaccines, which are greatly needed in West Africa, would overwhelm existing supply chains (i.e., the series of steps required to get a vaccine from the manufacturers to the target population) in Niger. METHODS As part of the Bill and Melinda Gates Foundation-funded Vaccine Modeling Initiative, we developed a computational model to determine the impact of introducing these new vaccines to Niger's Expanded Program on Immunization vaccine supply chain. RESULTS Introducing either the rotavirus vaccine or the 7-valent pneumococcal conjugate vaccine could overwhelm available storage and transport refrigerator space, creating bottlenecks that would prevent the flow of vaccines down to the clinics. As a result, the availability of all World Health Organization Expanded Program on Immunization vaccines to patients might decrease from an average of 69% to 28.2% (range = 10%-51%). Addition of refrigerator and transport capacity could alleviate this bottleneck. CONCLUSIONS Our results suggest that the effects on the vaccine supply chain should be considered when introducing a new vaccine and that computational models can help assess evolving needs and prevent problems with vaccine delivery.
Collapse
Affiliation(s)
- Bruce Y Lee
- University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Ghazal SS, Hakawi AM, Demeter CV, Joseph MV, Mukahal MA. Intervention to reduce the incidence of healthcare-associated methicillin-resistant Staphylococcus aureus infection in a Tertiary Care Hospital in Saudi Arabia. Infect Control Hosp Epidemiol 2011; 32:411-3. [PMID: 21460502 DOI: 10.1086/659256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
44
|
Kavanagh K, Abusalem S. Mounting evidence supports universal surveillance for MRSA in preoperative patients. J Am Coll Surg 2011; 213:335-6. [PMID: 21787990 DOI: 10.1016/j.jamcollsurg.2011.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 05/01/2011] [Accepted: 05/01/2011] [Indexed: 10/18/2022]
|
45
|
Kellie SM, Timmins A, Brown C. A statewide collaborative to reduce methicillin-resistant Staphylococcus aureus bacteremias in New Mexico. Jt Comm J Qual Patient Saf 2011; 37:154-62. [PMID: 21500715 DOI: 10.1016/s1553-7250(11)37019-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infection control guidelines recommend multiple concurrent interventions to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections. A quasi-experimental study was conducted to investigate the effect of an infection control collaborative conducted from July 1, 2008, through June 30, 2009, to decrease the rate of hospital-onset bacteremias by 40%. METHODS An MRSA curriculum was developed and delivered during three learning sessions. Guidelines, key literature, policies, and educational tools were disseminated. Teams were surveyed at the end of the collaborative and again 18 months later. RESULTS Teams were recruited from 12 acute care hospitals and 1 long-term acute care hospital, with capacities ranging from 22 to 623 licensed beds. Hospital intervention teams reported 44 hospital-onset, 18 health care-associated, and 122 community-onset MRSA bacteremias in the baseline year, yielding a hospital-onset rate of 0.79 per 10,000 patient-days. By the second six months of the intervention, this rate fell to 0.41, representing an aggregate 48% decline--but a nonsignificant result. Rates of health care-associated and community-onset bacteremias were unchanged. At baseline, 4 hospitals routinely performed active surveillance testing (AST) on 241 beds, which increased to 7 hospitals and 369 beds by July 2009. A follow-up survey completed by 11 hospitals indicated that barriers were similar for large and small facilities. A final survey performed 18 months postcollaborative indicated that 2 additional hospitals had initiated AST, 5 had expanded the use of AST, and only 1 had discontinued AST. CONCLUSIONS A collaborative model was successfully used to engage a diverse group of hospitals in a rural state to produce measurable improvement and sustained changes in processes of care.
Collapse
Affiliation(s)
- Susan M Kellie
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA.
| | | | | |
Collapse
|
46
|
Lee BY, Song Y, McGlone SM, Bailey RR, Feura JM, Tai JHY, Lewis GJ, Wiringa AE, Smith KJ, Muder RR, Harrison LH, Piraino B. The economic value of screening haemodialysis patients for methicillin-resistant Staphylococcus aureus in the USA. Clin Microbiol Infect 2011; 17:1717-26. [PMID: 21595796 DOI: 10.1111/j.1469-0691.2011.03525.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) can cause severe infections in patients undergoing haemodialysis. Routine periodic testing of haemodialysis patients and attempting to decolonize those who test positive may be a strategy to prevent MRSA infections. The economic value of such a strategy has not yet been estimated. We constructed a Markov computer simulation model to evaluate the economic value of employing routine testing (agar-based or PCR) at different MRSA prevalence, spontaneous clearance, costs of decolonization and decolonization success rates, performed every 3, 6 or 12 months. The model showed periodic MRSA surveillance with either test to be cost-effective (incremental cost-effectiveness ratio ≤$50 000/quality-adjusted life-year) for all conditions tested. Agar surveillance was dominant (i.e. less costly and more effective) at an MRSA prevalence ≥10% and a decolonization success rate ≥25% for all decolonization treatment costs tested with no spontaneous clearance. PCR surveillance was dominant when the MRSA prevalence was ≥20% and decolonization success rate was ≥75% with no spontaneous clearance. Routine periodic testing and decolonization of haemodialysis patients for MRSA may be a cost-effective strategy over a wide range of MRSA prevalences, decolonization success rates, and testing intervals.
Collapse
Affiliation(s)
- B Y Lee
- Public Health Computational and Operations Research (PHICOR), VA Pittsburgh Health Care System, Pittsburgh, PA, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ, Roselle GA. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011; 364:1419-30. [PMID: 21488764 DOI: 10.1056/nejmoa1007474] [Citation(s) in RCA: 381] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals. METHODS A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections. RESULTS From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend). CONCLUSIONS A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.
Collapse
Affiliation(s)
- Rajiv Jain
- Patient Care Services, Veterans Affairs Central Office, and the VA Pittsburgh Healthcare System, Pittsburgh, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Lee BY, McGlone SM, Doi Y, Bailey RR, Harrison LH. Economic value of Acinetobacter baumannii screening in the intensive care unit. Clin Microbiol Infect 2011; 17:1691-7. [PMID: 21463394 DOI: 10.1111/j.1469-0691.2011.03491.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Although Acinetobacter baumannii (A. baumannii) is an increasingly common nosocomial pathogen that can cause serious infections in the intensive care unit (ICU), most ICUs do not actively screen admissions for this pathogen. We developed an economic computer simulation model to determine the potential cost-consequences to the hospital of implementing routine A. baumannii screening of ICU admissions and isolating those patients who tested positive, comparing two screening methods, sponge and swab, with each other and no screening. Sensitivity analyses varied the colonization prevalence, percentage of colonized individuals who had active A. baumannii infections, A. baumannii reproductive rate (R), and contact isolation efficacy. Both screening methods were cost-effective for almost all scenarios tested, yielding cost-savings ranging from -$1 to -$1563. Sponge screening was not cost-saving when colonization prevalence was ≤1%, probability of infection ≤30%, R ≤ 0.25, and contact isolation efficacy ≤25%. Swab screening was not cost-saving under these same conditions when the probability of infection was ≤40%. Sponge screening tended to be more cost-saving than swab screening (additional savings ranged from $1 to $421). Routine A. baumannii screening of ICU patients may save costs for hospitals.
Collapse
Affiliation(s)
- B Y Lee
- Public Health Computational and Operations Research, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | | | | | | | | |
Collapse
|
49
|
Clinical implications of methicillin-resistant Staphylococcus aureus in pregnancy. Curr Opin Obstet Gynecol 2011; 23:82-6. [DOI: 10.1097/gco.0b013e328342b719] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
50
|
Surveillance, characterisation, and preservation of multidrug-resistant bacteria. THE LANCET. INFECTIOUS DISEASES 2011; 11:8-10. [DOI: 10.1016/s1473-3099(10)70261-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|