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Scott RD, Culler SD, Baggs J, Reddy SC, Slifka KJ, Magill SS, Kazakova SV, Jernigan JA, Nelson RE, Rosenman RE, Wandschneider PR. Measuring the Direct Medical Costs of Hospital-Onset Infections Using an Analogy Costing Framework. PHARMACOECONOMICS 2024; 42:1127-1144. [PMID: 38967909 PMCID: PMC11405445 DOI: 10.1007/s40273-024-01400-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The majority of recent estimates on the direct medical cost attributable to hospital-onset infections (HOIs) has focused on device- or procedure-associated HOIs. The attributable costs of HOIs that are not associated with device use or procedures have not been extensively studied. OBJECTIVE We developed simulation models of attributable cost for 16 HOIs and estimated the total direct medical cost, including nondevice-related HOIs in the USA for 2011 and 2015. DATA AND METHODS We used total discharge costs associated with HOI-related hospitalization from the National Inpatient Sample and applied an analogy costing methodology to develop simulation models of the costs attributable to HOIs. The mean attributable cost estimate from the simulation analysis was then multiplied by previously published estimates of the number of HOIs for 2011 and 2015 to generate national estimates of direct medical costs. RESULTS After adjusting all estimates to 2017 US dollars, attributable cost estimates for select nondevice-related infections attributable cost estimates ranged from $7661 for ear, eye, nose, throat, and mouth (EENTM) infections to $27,709 for cardiovascular system infections in 2011; and from $8394 for EENTM to $26,445 for central nervous system infections in 2016 (based on 2015 incidence data). The national direct medical costs for all HOIs were $14.6 billion in 2011 and $12.1 billion in 2016. Nondevice- and nonprocedure-associated HOIs comprise approximately 26-28% of total HOI costs. CONCLUSION Results suggest that nondevice- and nonprocedure-related HOIs result in considerable costs to the healthcare system.
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Affiliation(s)
- R Douglas Scott
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA.
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - James Baggs
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - Kara Jacobs Slifka
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - Shelley S Magill
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - Sophia V Kazakova
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - John A Jernigan
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-3, Atlanta, GA, 30329-4027, USA
| | - Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert E Rosenman
- Emeritus professor, The School of Economic Sciences, Washington State University, Pullman, WA, USA
- The Institute for Research and Education to Advance Community Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Philip R Wandschneider
- Emeritus professor, The School of Economic Sciences, Washington State University, Pullman, WA, USA
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Nahra R, Darvish S, Gandhi S, Gould S, Floyd D, Devine K, Fraimow H, Dibato JE, Rachoin JS. Impact of Povidone Application to Nares in Addition to Chlorhexidine Bath in Critically Ill Patients on Nosocomial Bacteremia and Central Line Blood Stream Infection. J Clin Med 2024; 13:2647. [PMID: 38731176 PMCID: PMC11084507 DOI: 10.3390/jcm13092647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.
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Affiliation(s)
- Raquel Nahra
- Division of Infectious Diseases, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA;
- Division of Critical Care Medicine, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA; (S.G.)
- Department of Infection Prevention, Cooper University Healthcare, Camden, NJ 08103, USA;
| | - Shahrzad Darvish
- Department of Infection Prevention, Cooper University Healthcare, Camden, NJ 08103, USA;
| | - Snehal Gandhi
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA; (S.G.)
- Division of Hospital Medicine, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA
| | | | - Diane Floyd
- Department of Nursing, Cooper University Healthcare, Camden, NJ 08103, USA
| | - Kathy Devine
- Department of Nursing, Cooper University Healthcare, Camden, NJ 08103, USA
| | - Henry Fraimow
- Division of Infectious Diseases, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA;
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA; (S.G.)
| | - John E. Dibato
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA; (S.G.)
- Cooper University Healthcare, Camden, NJ 08103, USA
| | - Jean-Sebastien Rachoin
- Division of Critical Care Medicine, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA; (S.G.)
- Division of Hospital Medicine, Department of Medicine, Cooper University Healthcare, Camden, NJ 08103, USA
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3
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Graves N, Maiti R, Aloweni FAB, Yi Zhen N, Yuh AS, Bishnoi P, Chong TT, Carmody D, Harding K. Retrospective matched cohort study of incidence rates and excess length of hospital stay owing to pressure injuries in an Asian setting. HEALTH CARE SCIENCE 2023; 2:82-93. [PMID: 38938768 PMCID: PMC11080845 DOI: 10.1002/hcs2.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 06/29/2024]
Abstract
Background Little is known about stage 1 and 2 pressure injuries that are health care-acquired. We report incidence rates of health care-acquired stage 1 and stage 2 pressure injuries, and, estimate the excess length of stay using four competing analytic methods. We discuss the merits of the different approaches. Methods We calculated monthly incidence rates for stage 1 and 2 health care-acquired pressure injuries occurring in a large Singapore acute care hospital. To estimate excess stay, we conducted unadjusted comparisons with a control cohort, performed linear regression and then generalized linear regression with a gamma distribution. Finally, we fitted a simple state-based model. The design for the cost attribution work was a retrospective matched cohort study. Results Incidence rates in 2016 were 0.553% (95% confidence interval [CI] 0.55, 0.557) and 0.469% (95% CI 0.466, 0.472) in 2017. For data censored at 60 days' maximum stay, the unadjusted comparisons showed the highest excess stay at 17.68 (16.43-18.93) days and multi-state models showed the lowest at 1.22 (0.19, 2.23) days. Conclusions Poor-quality methods for attribution of excess length of stay to pressure injury generate inflated estimates that could mislead decision makers. The findings from the multi-state model, which is an appropriate method, are plausible and illustrate the likely bed-days saved from lowering the risk of these events. Stage 1 and 2 pressure injuries are common and increase costs by prolonging the length of stay. There will be economic value investing in prevention. Using biased estimates of excess length of stay will overstate the potential value of prevention.
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Affiliation(s)
- Nicholas Graves
- Health Services and Systems ResearchDuke‐NUS Medical SchoolSingaporeSingapore
| | - Raju Maiti
- Centre for Quantitative MedicineDuke‐NUS Medical SchoolSingaporeSingapore
| | | | - Ng Yi Zhen
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR)SingaporeSingapore
| | | | - Priya Bishnoi
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR)SingaporeSingapore
| | | | | | - Keith Harding
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR)SingaporeSingapore
- Wound Care Innovation for the Tropics ProgrammeSingaporeSingapore
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Linz MS, Mattappallil A, Finkel D, Parker D. Clinical Impact of Staphylococcus aureus Skin and Soft Tissue Infections. Antibiotics (Basel) 2023; 12:557. [PMID: 36978425 PMCID: PMC10044708 DOI: 10.3390/antibiotics12030557] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/03/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
The pathogenic bacterium Staphylococcus aureus is the most common pathogen isolated in skin-and-soft-tissue infections (SSTIs) in the United States. Most S. aureus SSTIs are caused by the epidemic clone USA300 in the USA. These infections can be serious; in 2019, SSTIs with S. aureus were associated with an all-cause, age-standardized mortality rate of 0.5 globally. Clinical presentations of S. aureus SSTIs vary from superficial infections with local symptoms to monomicrobial necrotizing fasciitis, which can cause systemic manifestations and may lead to serious complications or death. In order to cause skin infections, S. aureus employs a host of virulence factors including cytolytic proteins, superantigenic factors, cell wall-anchored proteins, and molecules used for immune evasion. The immune response to S. aureus SSTIs involves initial responders such as keratinocytes and neutrophils, which are supported by dendritic cells and T-lymphocytes later during infection. Treatment for S. aureus SSTIs is usually oral therapy, with parenteral therapy reserved for severe presentations; it ranges from cephalosporins and penicillin agents such as oxacillin, which is generally used for methicillin-sensitive S. aureus (MSSA), to vancomycin for methicillin-resistant S. aureus (MRSA). Treatment challenges include adverse effects, risk for Clostridioides difficile infection, and potential for antibiotic resistance.
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Affiliation(s)
- Matthew S. Linz
- Department of Pathology, Immunology and Laboratory Medicine, Center for Immunity and Inflammation, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Arun Mattappallil
- Department of Pharmaceutical Services, University Hospital, Newark, NJ 07103, USA
| | - Diana Finkel
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Dane Parker
- Department of Pathology, Immunology and Laboratory Medicine, Center for Immunity and Inflammation, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
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5
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Estimating excess length of stay due to healthcare-associated infections by applying and comparing three time-varying approaches: multistate model, survival regression and matched case control methods. J Hosp Infect 2022; 126:44-51. [DOI: 10.1016/j.jhin.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/24/2022] [Accepted: 04/03/2022] [Indexed: 11/21/2022]
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6
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Association between antibiotic resistance in intensive care unit (ICU)-acquired infections and excess resource utilization: Evidence from Spain, Italy, and Portugal. Infect Control Hosp Epidemiol 2021; 43:1360-1367. [PMID: 34657648 DOI: 10.1017/ice.2021.429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired infections with antibiotic-resistant bacteria have been associated with substantial health and economic costs. Moreover, southern Europe has historically reported high levels of antimicrobial resistance. OBJECTIVES We estimated the attributable economic burden of ICU-acquired infections due to resistant bacteria based upon hospital excess length of stay (LOS) in a selected sample of southern European countries. METHODS We studied a cohort of adult patients admitted to the ICU who developed an ICU-acquired infection related to an invasive procedure in a sample of Spanish, Italian, and Portuguese hospitals between 2008 and 2016, using data from The European Surveillance System (TESSy) released by the European Centers for Disease Control (ECDC). We analyzed the association between infections with selected antibiotic-resistant bacteria of public health importance and excess LOS using regression, matching, and time-to-event methods. We controlled for several confounding factors as well as time-dependent biases. We also computed the associated economic burden of excess resource utilization for each selected country. RESULTS In total, 13,441 patients with at least 1 ICU-acquired infection were included in the analysis: 4,106 patients (30.5%) were infected with antimicrobial-resistant bacteria, whereas 9,335 patients (69.5%) were infected with susceptible bacteria. The unadjusted association between resistance status and excess LOS was 7 days (95% CI, 6.13-7.87; P < .001). Fully adjusted models yielded significantly lower estimates: 2.76 days (95% CI, 1.98-3.54; P < .001) in the regression model, 2.60 days (95% CI, 1.66-3.55; P < .001) in the genetic matching model, and a hazard ratio of 1.15 (95% CI, 1.11-1.19; P < .001) in the adjusted Cox regression model. These estimates, alongside the prevalence of resistance, translated into direct hospitalization attributable costs per ICU-acquired infection of 5,224€ (95% CI, 3,691-6,757) for Spain, 4,461€ (95% CI, 1,948-6,974) for Portugal, and 4,320€ (95% CI, 1,662-6,977) for Italy. CONCLUSIONS ICU-acquired infections associated with antibiotic-resistant bacteria are substantially associated with a 15% increase in excess LOS and resource utilization in 3 southern European countries. However, failure to appropriately control for significant confounders inflates estimates by ∼2.5-fold.
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7
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Munro SC, Baker D, Giuliano KK, Sullivan SC, Haber J, Jones BE, Crist MB, Nelson RE, Carey E, Lounsbury O, Lucatorto M, Miller R, Pauley B, Klompas M. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol 2021; 42:991-996. [PMID: 34103108 PMCID: PMC10947501 DOI: 10.1017/ice.2021.239] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
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Affiliation(s)
- Shannon C. Munro
- Research and Development, Salem Veterans’ Affairs Medical Center, Salem
| | - Dian Baker
- School of Nursing, California State University, Sacramento, California
| | - Karen K. Giuliano
- College of Nursing & Institute for Applied Life Sciences, University of Massachusetts–Amherst, Amherst, Massachusetts
| | - Sheila C. Sullivan
- Research, Evidence Based Practice and Analytics, Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Judith Haber
- Oral Health Nursing Education and Practice, Rory Meyers College of Nursing, New York University, New York, New York
| | - Barbara E. Jones
- Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah
- Salt Lake City Veterans’ Affairs Healthcare System, Salt Lake City, Utah
| | - Matthew B. Crist
- Division of Health Care Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard E. Nelson
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
- George E. Wahlen Department of Veterans’ Affairs Medical Center, Salt Lake City, Utah
| | - Evan Carey
- Research and Development, Rocky Mountain Regional Veterans’ Affairs Medical Center, Aurora, Colorado
| | | | - Michelle Lucatorto
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Ryan Miller
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Brian Pauley
- Geriatrics & Extended Care, Veterans’ Affairs Pacific Islands Healthcare System, Honolulu, Hawaii
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
- Department of Medicine, Brigham and Women’s Hospital, Boston
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8
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Iskandar K, Roques C, Hallit S, Husni-Samaha R, Dirani N, Rizk R, Abdo R, Yared Y, Matta M, Mostafa I, Matta R, Salameh P, Molinier L. The healthcare costs of antimicrobial resistance in Lebanon: a multi-centre prospective cohort study from the payer perspective. BMC Infect Dis 2021; 21:404. [PMID: 33933013 PMCID: PMC8088567 DOI: 10.1186/s12879-021-06084-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/16/2021] [Indexed: 12/03/2022] Open
Abstract
Background Our aim was to examine whether the length of stay, hospital charges and in-hospital mortality attributable to healthcare- and community-associated infections due to antimicrobial-resistant bacteria were higher compared with those due to susceptible bacteria in the Lebanese healthcare settings using different methodology of analysis from the payer perspective . Methods We performed a multi-centre prospective cohort study in ten hospitals across Lebanon. The sample size consisted of 1289 patients with documented healthcare-associated infection (HAI) or community-associated infection (CAI). We conducted three separate analysis to adjust for confounders and time-dependent bias: (1) Post-HAIs in which we included the excess LOS and hospital charges incurred after infection and (2) Matched cohort, in which we matched the patients based on propensity score estimates (3) The conventional method, in which we considered the entire hospital stay and allocated charges attributable to CAI. The linear regression models accounted for multiple confounders. Results HAIs and CAIs with resistant versus susceptible bacteria were associated with a significant excess length of hospital stay (2.69 days [95% CI,1.5–3.9]; p < 0.001) and (2.2 days [95% CI,1.2–3.3]; p < 0.001) and resulted in additional hospital charges ($1807 [95% CI, 1046–2569]; p < 0.001) and ($889 [95% CI, 378–1400]; p = 0.001) respectively. Compared with the post-HAIs analysis, the matched cohort method showed a reduction by 26 and 13% in hospital charges and LOS estimates respectively. Infections with resistant bacteria did not decrease the time to in-hospital mortality, for both healthcare- or community-associated infections. Resistant cases in the post-HAIs analysis showed a significantly higher risk of in-hospital mortality (odds ratio, 0.517 [95% CI, 0.327–0.820]; p = 0.05). Conclusion This is the first nationwide study that quantifies the healthcare costs of antimicrobial resistance in Lebanon. For cases with HAIs, matched cohort analysis showed more conservative estimates compared with post-HAIs method. The differences in estimates highlight the need for a unified methodology to estimate the burden of antimicrobial resistance in order to accurately advise health policy makers and prioritize resources expenditure.
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Affiliation(s)
- Katia Iskandar
- Department of Mathématiques Informatique et Télécommunications, Université Toulouse III, Paul Sabatier, INSERM, UMR 1295, F-31000, Toulouse, France. .,INSPECT-LB: Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban, Beirut, Lebanon. .,Department of Pharmacy, Lebanese University, Mount Lebanon, Beirut, Lebanon.
| | - Christine Roques
- Department of Bioprocédés et Systèmes Microbiens, Laboratoire de Génie Chimique, Université Paul Sabatier Toulouse III, UMR 5503, Toulouse, France.,Department of Bactériologie-Hygiène, Centre Hospitalier Universitaire, Toulouse, Hôpital Purpan, Toulouse, France
| | - Souheil Hallit
- INSPECT-LB: Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban, Beirut, Lebanon.,Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Rola Husni-Samaha
- Department of Medicine, Lebanese American University, Byblos, Lebanon.,Department of Infection Control, Lebanese American University Medical Center, Beirut, Lebanon
| | - Natalia Dirani
- Department of Infectious Diseases, Dar El Amal University Hospital, Baalbeck, Lebanon
| | - Rana Rizk
- INSPECT-LB: Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban, Beirut, Lebanon.,Department of Health Services Research, School CAPHRI, Care and Public Health Research Institute, Maastricht University, 6200, MD, Maastricht, The Netherlands
| | - Rachel Abdo
- INSPECT-LB: Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban, Beirut, Lebanon.,Medical School, University of Nicosia, Nicosia, Cyprus
| | - Yasmina Yared
- Department of Clinical Pharmacy, Geitaoui Hospital, Beirut, Lebanon
| | - Matta Matta
- Department of Medicine, St Joseph University, Beirut, Lebanon
| | - Inas Mostafa
- Department of Quality and Safety, Nabatieh Governmental Hospital, Nabatieh, Lebanon
| | - Roula Matta
- Department of Pharmacy, Lebanese University, Mount Lebanon, Beirut, Lebanon
| | - Pascale Salameh
- INSPECT-LB: Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban, Beirut, Lebanon.,Department of Pharmacy, Lebanese University, Mount Lebanon, Beirut, Lebanon.,Medical School, University of Nicosia, Nicosia, Cyprus
| | - Laurent Molinier
- Department of Medical Information, Centre Hospitalier Universitaire, INSERM, UMR 1027, Université Paul Sabatier Toulouse III, F-31000, Toulouse, France
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Sampling designs for rare time-dependent exposures: a comparison of the nested exposure case-control design and exposure density sampling. Epidemiol Infect 2021; 149:e122. [PMID: 33888170 PMCID: PMC8165129 DOI: 10.1017/s095026882100090x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In extensive cohort studies, the ascertainment of covariate information on all individuals can be challenging. In hospital epidemiology, an additional issue is often the time-dependency of the exposure of interest. We revisit and compare two sampling designs constructed for rare time-dependent exposures and possibly common outcomes – the nested exposure case-control design and exposure density sampling. Both designs enable efficient hazard ratio estimation by sampling all exposed individuals but only a small fraction of the unexposed ones. Moreover, they account for time-dependent exposure to avoid immortal time bias. We evaluate and compare their performance using data of patients hospitalised in the neuro-intensive care unit at the Burdenko Neurosurgery Institute in Moscow, Russia. Three different types of hospital-acquired infections with different prevalence are considered. Additionally, inflation factors, a primary performance measure, are discussed. We enhance both designs to allow for a competitive analysis of combined and competing endpoints compared to the full cohort approach while substantially reducing the amount of necessary information. Nonetheless, exposure density sampling outperforms the nested exposure case-control design concerning efficiency and accuracy in most considered settings.
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10
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Nelson RE, Hatfield KM, Wolford H, Samore MH, Scott RD, Reddy SC, Olubajo B, Paul P, Jernigan JA, Baggs J. National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States. Clin Infect Dis 2021; 72:S17-S26. [DOI: 10.1093/cid/ciaa1581] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/14/2020] [Indexed: 01/12/2023] Open
Abstract
Abstract
Background
Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US).
Methods
We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections.
Results
Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272–$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377–$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370–$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion–$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined.
Conclusions
We found that antimicrobial-resistant infections led to substantial healthcare costs.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kelly M Hatfield
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hannah Wolford
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew H Samore
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - R Douglas Scott
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sujan C Reddy
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Babatunde Olubajo
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Prabasaj Paul
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John A Jernigan
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James Baggs
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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11
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Nelson RE, Lautenbach E, Chang N, Jones M, Willson T, David M, Linkin D, Glick H, Doshi JA, Stevens VW. Attributable Cost of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infection in a Long-term Care Center. Clin Infect Dis 2021; 72:S27-S33. [PMID: 33512522 DOI: 10.1093/cid/ciaa1582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies have shown that healthcare-associated infections (HAIs) due to methicillin-resistant Staphylococcus aureus (MRSA) can lead to substantial healthcare costs in acute care settings. However, little is known regarding the consequences of these infections on patients in long-term care centers (LTCCs). The purpose of this study was to estimate the attributable cost of MRSA HAIs in LTCCs within the Department of Veterans Affairs (VA). METHODS We performed a retrospective cohort study of patients admitted to VA LTCCs between 1 January 2009 and 30 September 2015. MRSA HAIs were defined as a positive clinical culture at least 48 hours after LTCC admission so as to exclude community-acquired infections. Positive cultures were further classified by site (sterile or nonsterile). We used multivariable generalized linear models and 2-part models to compare the LTCC and acute care costs between patients with and without an MRSA HAI. RESULTS In our primary analysis, there was no difference in LTCC costs between patients with and without a MRSA HAI. There was, however, a significant increase in the odds of being transferred to an acute care facility (odds ratio, 4.40 [95% confidence interval {CI}, 3.40-5.67]) and in acute care costs ($9711 [95% CI, $6961-$12 462]). CONCLUSIONS Our findings of high cost and increased risk of transfer from LTCC to acute care are important because they highlight the substantial clinical and economic impact of MRSA infections in this population.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ebbing Lautenbach
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nelson Chang
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Makoto Jones
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tina Willson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael David
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darren Linkin
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Henry Glick
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jalpa A Doshi
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa W Stevens
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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12
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Wang YC, Shih SM, Chen YT, Hsiung CA, Kuo SC. Clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan: a nationwide population-based retrospective cohort study. BMJ Open 2020; 10:e037484. [PMID: 33243790 PMCID: PMC7692834 DOI: 10.1136/bmjopen-2020-037484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To estimate the clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan. DESIGN Retrospective cohort study. SETTING Nationwide Taiwanese population in the National Health Insurance Research Database and the Taiwan Nosocomial Infections Surveillance (2007-2015) dataset. PARTICIPANTS The first episodes of intensive care unit-acquired bloodstream infections in patients ≥20 years of age in the datasets. Propensity score-matching (1:2) of demographic data, comorbidities and disease severity was performed to select a comparison cohort from a pool of intensive care unit patients without intensive care unit-acquired infections from the same datasets. PRIMARY AND SECONDARY OUTCOME MEASURES The mortality rate, length of hospitalisation and healthcare cost. RESULTS After matching, the in-hospital mortality of 14 234 patients with intensive care unit-acquired bloodstream infections was 44.23%, compared with 33.48% for 28 468 intensive care unit patients without infections. The 14-day mortality rate was also higher in the bloodstream infections cohort (4323, 30.37% vs 6766 deaths, 23.77%, respectively; p<0.001). Furthermore, the patients with intensive care unit-acquired bloodstream infections had a prolonged length of hospitalisation after their index date (18 days (IQR 7-39) vs 10 days (IQR 4-21), respectively; p<0.001) and a higher healthcare cost (US$16 038 (IQR 9667-25 946) vs US$10 372 (IQR 6289-16 932), respectively; p<0.001). The excessive hospital stay and healthcare cost per case were 12.69 days and US$7669, respectively. Similar results were observed in subgroup analyses of various WHO's priority pathogens and Candida spp. CONCLUSIONS Intensive care unit-acquired bloodstream infections in critically ill patients were associated with increased mortality, longer hospital stays and higher healthcare costs.
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Affiliation(s)
- Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Man Shih
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Yung-Tai Chen
- Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
- University of Taipei, Taipei, Taiwan
- Divisions of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao Agnes Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Shu-Chen Kuo
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
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13
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Tchouaket Nguemeleu E, Boivin S, Robins S, Sia D, Kilpatrick K, Brousseau S, Dubreuil B, Larouche C, Parisien N. Development and validation of a time and motion guide to assess the costs of prevention and control interventions for nosocomial infections: A Delphi method among experts. PLoS One 2020; 15:e0242212. [PMID: 33180833 PMCID: PMC7660509 DOI: 10.1371/journal.pone.0242212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Nosocomial infections place a heavy burden on patients and healthcare providers and impact health care institutions financially. Reducing nosocomial infections requires an integrated program of prevention and control using key clinical best care practices. No instrument currently exists that measures these practices in terms of personnel time and material costs. OBJECTIVE To develop and validate an instrument that would measure nosocomial infection control and prevention best care practice costs, including estimates of human and material resources. METHODS An evaluation of the literature identified four practices essential for the control of pathogens: hand hygiene, hygiene and sanitation, screening and additional precaution. To reflect time, materials and products used in these practices, our team developed a time and motion guide. Iterations of the guide were assessed in a Delphi technique; content validity was established using the content validity index and reliability was assessed using Kruskall Wallis one-way ANOVA of rank test. RESULTS Two rounds of Delphi review were required; 88% of invited experts completed the assessment. The final version of the guide contains eight dimensions: Identification [83 items]; Personnel [5 items]; Additional Precautions [1 item]; Hand Hygiene [2 items]; Personal Protective Equipment [14 items]; Screening [4 items]; Cleaning and Disinfection of Patient Care Equipment [33 items]; and Hygiene and Sanitation [24 items]. The content validity index obtained for all dimensions was acceptable (> 80%). Experts statistically agreed on six of the eight dimensions. DISCUSSION/CONCLUSION This study developed and validated a new instrument based on expert opinion, the time and motion guide, for the systematic assessment of costs relating to the human and material resources used in nosocomial infection prevention and control. This guide will prove useful to measure the intensity of the application of prevention and control measures taken before, during and after outbreak periods or during pandemics such as COVID-19.
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Affiliation(s)
| | - Sandra Boivin
- Centre Intégré de Santé et de Services de Sociaux des Laurentides, Direction de la Santé Publique, Saint-Jérôme, Québec, Canada
| | - Stephanie Robins
- Université du Québec en Outaouais, Department of Nursing Research, Saint-Jérôme, QC, Canada
| | - Drissa Sia
- Université du Québec en Outaouais, Department of Nursing Research, Saint-Jérôme, QC, Canada
| | - Kelley Kilpatrick
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada
| | - Sylvain Brousseau
- Université du Québec en Outaouais, Department of Nursing Research, Saint-Jérôme, QC, Canada
| | - Bruno Dubreuil
- Institut de Cardiologie, Montreal Heart Institute, Montréal, Québec, Canada
| | - Catherine Larouche
- Centre Intégré Universitaire de Santé et de Services Sociaux du Saguenay, Lac-Saint-Jean, Québec, Canada
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14
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Clinical and economic impact of methicillin-resistant Staphylococcus aureus: a multicentre study in China. Sci Rep 2020; 10:3900. [PMID: 32127606 PMCID: PMC7054446 DOI: 10.1038/s41598-020-60825-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/17/2020] [Indexed: 11/14/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become a serious threat to global health. In China, the proportion of S. aureus isolates that were MRSA was 44.6% in 2014. The clinical and economic impact of MRSA in China remains largely uninvestigated. This study aims to compare the differences in hospital costs, length of hospital stay, and hospital mortality rate between MRSA and methicillin-susceptible S. aureus (MSSA) colonization or infection and between MRSA cases and those without an S. aureus infection. A retrospective and multicentre study was conducted in four tertiary hospitals in China between 2013 and 2015. Inpatient characteristics and hospital costs were collected from electronic medical records. We conducted propensity score matching (PSM) to eliminate selection bias by balancing the potential confounding variables between the two groups. The main indicators included hospital costs, length of hospital stay, and hospital mortality rate. A total of 1,335 inpatients with MRSA, 1,397 with MSSA, and 33,606 without an S. aureus infection were included. PSM obtained 954 and 1,313 pairs between the MRSA and MSSA groups and between the MRSA and S. aureus-free groups, respectively. After PSM, MRSA colonization or infection is associated with an increased total hospital cost ranging from $3,220 to $9,606, an excess length of hospital stay of 6 days–14 days, and an attributable hospital mortality rate of 0–3.58%. Between the MRSA and MSSA groups, MRSA colonization or infection was significantly associated with a higher total hospital cost and longer length of hospital stay among survivors but not among non-survivors; however, there were no differences in the hospital mortality rate between these two groups. Between the MRSA and the S. aureus-free groups, MRSA colonization or infection was significantly associated with an increased total hospital cost, a prolonged length of hospital stay and a higher hospital mortality rate among both survivors and non-survivors. It is critical to quantify the clinical and economic impact of MRSA to justify resource allocation for the development of strategies to improve clinical outcomes and to reduce the economic burden.
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15
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Kaier K, Heister T, Götting T, Wolkewitz M, Mutters NT. Measuring the in-hospital costs of Pseudomonas aeruginosa pneumonia: methodology and results from a German teaching hospital. BMC Infect Dis 2019; 19:1028. [PMID: 31795953 PMCID: PMC6888947 DOI: 10.1186/s12879-019-4660-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/25/2019] [Indexed: 11/16/2022] Open
Abstract
Background Pseudomonas aeruginosa-related pneumonia is an ongoing healthcare challenge. Estimating its financial burden is complicated by the time-dependent nature of the disease. Methods Two hundred thirty-six cases of Pseudomonas aeruginosa-related pneumonia were recorded at a 2000 bed German teaching hospital between 2011 and 2014. Thirty-five cases (15%) were multidrug-resistant (MDR) Pseudomonas aeruginosa. Hospital- and community-acquired cases were distinguished by main diagnoses and exposure time. The impact of Pseudomonas aeruginosa-related pneumonia on the three endpoints cost, reimbursement, and length of stay was analyzed, taking into account (1) the time-dependent nature of exposure, (2) clustering of costs within diagnostic groups, and (3) additional confounders. Results Pseudomonas aeruginosa pneumonia is associated with substantial additional costs that are not fully reimbursed. Costs are highest for hospital-acquired cases (€19,000 increase over uninfected controls). However, community-acquired cases are also associated with a substantial burden (€8400 when Pseudomonas aeruginosa pneumonia is the main reason for hospitalization, and €6700 when not). Sensitivity analyses for hospital-acquired cases showed that ignoring or incorrectly adjusting for time-dependency substantially biases results. Furthermore, multidrug-resistance was rare and only showed a measurable impact on the cost of community-acquired cases. Conclusions Pseudomonas aeruginosa pneumonia creates a substantial financial burden for hospitals. This is particularly the case for nosocomial infections. Infection control interventions could yield significant cost reductions. However, to evaluate the potential effectiveness of different interventions, the time-dependent aspects of incremental costs must be considered to avoid introduction of bias.
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Affiliation(s)
- Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.
| | - Thomas Heister
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Tim Götting
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Nico T Mutters
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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16
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Kirwin E, Varughese M, Waldner D, Simmonds K, Joffe AM, Smith S. Comparing methods to estimate incremental inpatient costs and length of stay due to methicillin-resistant Staphylococcus aureus in Alberta, Canada. BMC Health Serv Res 2019; 19:743. [PMID: 31651305 PMCID: PMC6813095 DOI: 10.1186/s12913-019-4578-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022] Open
Abstract
Background Methicillin-resistant Staphylococcus aureus (MRSA) is an opportunistic bacterial organism resistant to first line antibiotics. Acquisition of MRSA is often classified as either healthcare-associated or community-acquired. It has been shown that both healthcare-associated and community-acquired infections contribute to the spread of MRSA within healthcare facilities. The objective of this study was to estimate the incremental inpatient cost and length of stay for individuals colonized or infected with MRSA. Common analytical methods were compared to ensure the quality of the estimate generated. This study was performed at Alberta Ministry of Health (Edmonton, Alberta), with access to clinical MRSA data collected at two Edmonton hospitals, and ministerial administrative data holdings. Methods A retrospective cohort study of patients with MRSA was identified using a provincial infection prevention and control database. A coarsened exact matching algorithm, and two regression models (semilogarithmic ordinary least squares model and log linked generalized linear model) were evaluated. A MRSA-free cohort from the same facilities and care units was identified for the matched method; all records were used for the regression models. Records span from January 1, 2011 to December 31, 2015, for individuals 18 or older at discharge. Results Of the models evaluated, the generalized linear model was found to perform the best. Based on this model, the incremental inpatient costs associated with hospital-acquired cases were the most costly at $31,686 (14,169 – 60,158) and $47,016 (23,125 – 86,332) for colonization and infection, respectively. Community-acquired MRSA cases also represent a significant burden, with incremental inpatient costs of $7397 (2924 – 13,180) and $14,847 (8445 – 23,207) for colonization and infection, respectively. All costs are adjusted to 2016 Canadian dollars. Incremental length of stay followed a similar pattern, where hospital-acquired infections had the longest incremental stays of 35.2 (16.3–69.5) days and community-acquired colonization had the shortest incremental stays of 3.0 (0.6–6.3) days. Conclusions MRSA, and in particular, hospital-acquired MRSA, places a significant but preventable cost burden on the Alberta healthcare system. Estimates of cost and length of stay varied by the method of analysis and source of infection, highlighting the importance of selecting the most appropriate method.
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Affiliation(s)
- Erin Kirwin
- Alberta Ministry of Health, Edmonton, Alberta, Canada.
| | | | - David Waldner
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kimberley Simmonds
- Alberta Ministry of Health, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - A Mark Joffe
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Stephanie Smith
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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17
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Zhen X, Lundborg CS, Sun X, Hu X, Dong H. Economic burden of antibiotic resistance in ESKAPE organisms: a systematic review. Antimicrob Resist Infect Control 2019; 8:137. [PMID: 31417673 PMCID: PMC6692939 DOI: 10.1186/s13756-019-0590-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 02/03/2023] Open
Abstract
Background Antibiotic resistance (ABR) is one of the biggest threats to global health. Infections by ESKAPE (Enterococcus, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and E. coli) organisms are the leading cause of healthcare-acquired infections worldwide. ABR in ESKAPE organisms is usually associated with significant higher morbidity, mortality, as well as economic burden. Directing attention towards the ESKAPE organisms can help us to better combat the wide challenge of ABR, especially multi-drug resistance (MDR). Objective This study aims to systematically review and evaluate the evidence of the economic consequences of ABR or MDR ESKAPE organisms compared with susceptible cases or control patients without infection/colonization in order to determine the impact of ABR on economic burden. Methods Both English-language databases and Chinese-language databases up to 16 January, 2019 were searched to identify relevant studies assessing the economic burden of ABR. Studies reported hospital costs (charges) or antibiotic cost during the entire hospitalization and during the period before/after culture among patients with ABR or MDR ESKAPE organisms were included. The costs were converted into 2015 United States Dollars. Disagreements were resolved by a third reviewer. Results Of 13,693 studies identified, 83 eligible studies were included in our review. The most studied organism was S. aureus, followed by Enterococcus, A. baumannii, E. coli, E. coli or/and K. pneumoniae, P. aeruginosa, and K. pneumoniae. There were 71 studies on total hospital cost or charge, 12 on antibiotic cost, 11 on hospital cost or charge after culture, 4 on ICU cost, 2 on hospital cost or charge before culture, and 2 on total direct and indirect cost. In general, ABR or MDR ESKAPE organisms are significantly associated with higher economic burden than those with susceptible organisms or those without infection or colonization. Nonetheless, there were no differences in a few studies between the two groups on total hospital cost or charge (16 studies), antibiotic cost (one study), hospital cost before culture (one study), hospital cost after culture (one study). Even, one reported that costs associated with MSSA infection were higher than the costs for similar MRSA cases. Conclusions ABR in ESKAPE organisms is not always, but usually, associated with significantly higher economic burden. The results without significant differences may lack statistical power to detect a significant association. In addition, study design which controls for severity of illness and same empirical antibiotic therapy in the two groups would be expected to bias the study towards a similar, even negative result. The review also highlights key areas where further research is needed.
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Affiliation(s)
- Xuemei Zhen
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
- Global Health-Health Systems and Policy (HSP): Medicines, focusing antibiotics, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Stålsby Lundborg
- Global Health-Health Systems and Policy (HSP): Medicines, focusing antibiotics, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Xueshan Sun
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
| | - Xiaoqian Hu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, No. N1, Shancheng Avenue, Yiwu City, Zhejiang China
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18
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Heister T, Wolkewitz M, Hehn P, Wolff J, Dettenkofer M, Grundmann H, Kaier K. Costs of hospital-acquired Clostridium difficile infections: an analysis on the effect of time-dependent exposures using routine and surveillance data. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:16. [PMID: 31388335 PMCID: PMC6670202 DOI: 10.1186/s12962-019-0184-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Background Hospital-acquired infections have not only gained increasing attention clinically, but also methodologically, as a time-varying exposure. While methods to appropriately estimate extra length of stay (LOS) have been established and are increasingly used in the literature, proper estimation of cost figures has lagged behind. Methods Analysing the additional costs and reimbursements of Clostridium difficile-infections (CDI), we use a within-main-diagnosis-time-to-exposure stratification approach to incorporate time-varying exposures in a regression model, while at the same time accounting for cost clustering within diagnosis groups. Results We find that CDI is associated with €9000 of extra costs, €7800 of higher reimbursements, and 6.4 days extra length of stay. Using a conventional method, which suffers from time-dependent bias, we derive estimates more than three times as high (€23,000, €8000, 21 days respectively). We discuss our method in the context of recent methodological advances in the estimation of the costs of hospital-acquired infections. Conclusions CDI is associated with sizeable in-hospital costs. Neglecting the methodological particularities of hospital-acquired infections can however substantially bias results. As the data needed for an appropriate analysis are collected routinely in most hospitals, we recommend our approach as a feasible way for estimating the economic impact of time-varying adverse events during hospital stay.
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Affiliation(s)
- Thomas Heister
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Martin Wolkewitz
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Philip Hehn
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Jan Wolff
- 2Department of Psychiatry and Psychotherapy, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus Dettenkofer
- Institute for Hospital Hygiene and Infection Prevention, Gesundheitsverbund Landkreis Konstanz, Radolfzell, Germany
| | - Hajo Grundmann
- 4Division of Infection Control and Hospital Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Klaus Kaier
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
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19
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Attributable costs and length of stay of hospital-acquired Clostridioides difficile: A population-based matched cohort study in Alberta, Canada. Infect Control Hosp Epidemiol 2019; 40:1135-1143. [PMID: 31342884 DOI: 10.1017/ice.2019.178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data. DESIGN A retrospective, population-based, propensity-score-matched cohort study. SETTING Acute-care facilities in Alberta, Canada. PATIENTS Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016. METHODS Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars. RESULTS Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21-1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312-$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07-1.19), which corresponds to an extra 5.6 days (95% CI, 3.10-8.06) in length of hospital stay per HA-CDI case. CONCLUSIONS In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.
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20
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Ohneberg K, Beyersmann J, Schumacher M. Exposure density sampling: Dynamic matching with respect to a time-dependent exposure. Stat Med 2019; 38:4390-4403. [PMID: 31313337 DOI: 10.1002/sim.8305] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 05/16/2019] [Accepted: 06/06/2019] [Indexed: 11/12/2022]
Abstract
Estimating the potential risk associated with an exposure occurring over time requires complex statistical techniques, since ignoring the time from study entry until the exposure leads to potentially seriously biased effect estimates. A prominent example is estimating the effect of hospital-acquired infections on adverse outcomes in patients admitted to the intensive care unit. Exposure density sampling has been proposed as an approach to dynamic matching with respect to a time-dependent exposure. Firstly, exposure density sampling can be useful to reduce the workload of study follow up, as it includes all exposed but only a subset of the not yet exposed individuals. Secondly, it can help to obtain a comparable control group by including propensity score matching. In the present article, we provide the theoretical justification that data obtained by exposure density sampling can be analyzed as a left-truncated cohort. It is shown that exposure density sampling allows estimation of the effect of a time-dependent exposure as well as further baseline covariates on a subsequent event, with only minor loss in precision as compared with a full cohort analysis. The sampling is applied to a real data example (hospital-acquired infections in intensive care units) and in a simulation study. We also provide an estimate of the loss in precision in terms of an increased standard error in the reduced data set after exposure density sampling as compared with the full cohort.
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Affiliation(s)
- Kristin Ohneberg
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,Freiburg Center for Data Analysis and Modeling, University of Freiburg, Freiburg, Germany
| | | | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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21
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Watson D, Spaulding AB, Dreyfus J. Risk-Set Matching to Assess the Impact of Hospital-Acquired Bloodstream Infections. Am J Epidemiol 2019; 188:461-466. [PMID: 30475949 DOI: 10.1093/aje/kwy252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 11/14/2022] Open
Abstract
Hospital-acquired bloodstream infections have a definite impact on patient encounters and cause increased length of stay, costs, and mortality. However, methods for estimating these effects are potentially biased, especially if the time of infection is not incorporated into the estimation strategy. We focused on matching patient encounters in which a hospital-acquired infection occurred to comparable encounters in which an infection did not occur. This matching strategy is susceptible to a selection bias because inpatients that stay longer in the hospital are more likely to acquire an infection and thus also are more likely to have longer and more costly stays. Instead, we have proposed risk-set matching, which matches infected encounters to similar encounters still at risk for infection at the corresponding time of infection. Matching on the one-dimensional propensity score can create comparable pairs for a large number of characteristics; an analogous propensity score is described for risk-set matching. We have presented dramatically different estimates using these 2 approaches with data from a pediatric cohort from the Premier Healthcare Database, United States, 2009-2016. The results suggest that estimates that did not incorporate time of infection exaggerated the impact of hospital-acquired infections with regard to attributed length of stay and costs.
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Affiliation(s)
- David Watson
- Children’s Minnesota Research Institute, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Alicen B Spaulding
- Children’s Minnesota Research Institute, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jill Dreyfus
- Premier Applied Sciences, Premier, Inc., Charlotte, North Carolina
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Choi KB, Suh KN, Muldoon KA, Roth VR, Forster AJ. Hospital-acquired Clostridium difficile infection: an institutional costing analysis. J Hosp Infect 2019; 102:141-147. [PMID: 30690051 DOI: 10.1016/j.jhin.2019.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/21/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Healthcare-acquired Clostridium difficile infection (HA-CDI) is a common infection and a financial burden on the healthcare system. AIM To estimate the hospital-based financial costs of HA-CDI by comparing time-fixed statistical models that attribute cost to the entire hospital stay to time-varying statistical models that adjust for the time between admission, diagnosis of HA-CDI, and discharge and that only attribute HA-CDI costs post diagnosis. METHODS A retrospective cohort study was conducted (April 2008 to March 2011) using clinical and administrative costing data of inpatients (≥15 years) who were admitted to The Ottawa Hospital with stays >72 h. Two time-fixed analyses, ordinary least square regression and generalized linear regression, were contrasted with two time-dependent approaches using Kaplan-Meier survival curve. FINDINGS A total of 49,888 admissions were included and 366 (0.73%) patients developed HA-CDI. Estimated total costs (Canadian dollars) from time-fixed models were as high as $74,928 per patient compared to $28,089 using a time-varying model, and these were 1.47-fold higher compared to a patient without HA-CDI (incremental cost $8,997 per patient). The overall annual institutional cost at The Ottawa Hospital associated with HA-CDI was as high as $10.07 million using time-fixed models and $1.62 million using time-varying models. CONCLUSION When calculating costs associated with HA-CDI, accounting for the time between admission, diagnosis, and discharge can substantially reduce the estimated institutional costs associated with HA-CDI.
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Affiliation(s)
- K B Choi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - K N Suh
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K A Muldoon
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - V R Roth
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - A J Forster
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Attributable Cost and Length of Stay Associated with Nosocomial Gram-Negative Bacterial Cultures. Antimicrob Agents Chemother 2018; 62:AAC.00462-18. [PMID: 30150480 DOI: 10.1128/aac.00462-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/17/2018] [Indexed: 11/20/2022] Open
Abstract
Few studies have estimated the excess inpatient costs due to nosocomial cultures of Gram-negative bacteria (GNB), and those that do are often subject to time-dependent bias. Our objective was to generate estimates of the attributable costs of the underlying infections associated with nosocomial cultures by using a unique inpatient cost data set from the U.S. Department of Veterans Affairs that allowed us to reduce time-dependent bias. Our study included data from inpatient admissions between 1 October 2007 and 30 November 2010. Nosocomial GNB-positive cultures were defined as clinical cultures positive for Acinetobacter, Pseudomonas, or Enterobacteriaceae between 48 h after admission and discharge. Positive cultures were further classified by site and level of resistance. We conducted analyses using both a conventional approach and an approach aimed at reducing the impact of time-dependent bias. In both instances, we used multivariable generalized linear models to compare the inpatient costs and length of stay for patients with and without a nosocomial GNB culture. Of the 404,652 patients included in the conventional analysis, 12,356 had a nosocomial GNB-positive culture. The excess costs of nosocomial GNB-positive cultures were significant, regardless of specific pathogen, site, or resistance level. Estimates generated using the conventional analysis approach were 32.0% to 131.2% greater than those generated using the approach to reduce time-dependent bias. These results are important because they underscore the large financial burden attributable to these infections and provide a baseline that can be used to assess the impact of improvements in infection control.
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Manoukian S, Stewart S, Dancer S, Graves N, Mason H, McFarland A, Robertson C, Reilly J. Estimating excess length of stay due to healthcare-associated infections: a systematic review and meta-analysis of statistical methodology. J Hosp Infect 2018; 100:222-235. [PMID: 29902486 DOI: 10.1016/j.jhin.2018.06.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/05/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Healthcare-associated infection (HCAI) affects millions of patients worldwide. HCAI is associated with increased healthcare costs, owing primarily to increased hospital length of stay (LOS) but calculating these costs is complicated due to time-dependent bias. Accurate estimation of excess LOS due to HCAI is essential to ensure that we invest in cost-effective infection prevention and control (IPC) measures. AIM To identify and review the main statistical methods that have been employed to estimate differential LOS between patients with, and without, HCAI; to highlight and discuss potential biases of all statistical approaches. METHODS A systematic review from 1997 to April 2017 was conducted in PubMed, CINAHL, ProQuest and EconLit databases. Studies were quality-assessed using an adapted Newcastle-Ottawa Scale (NOS). Methods were categorized as time-fixed or time-varying, with the former exhibiting time-dependent bias. Two examples of meta-analysis were used to illustrate how estimates of excess LOS differ between different studies. FINDINGS Ninety-two studies with estimates on excess LOS were identified. The majority of articles employed time-fixed methods (75%). Studies using time-varying methods are of higher quality according to NOS. Studies using time-fixed methods overestimate additional LOS attributable to HCAI. Undertaking meta-analysis is challenging due to a variety of study designs and reporting styles. Study differences are further magnified by heterogeneous populations, case definitions, causative organisms, and susceptibilities. CONCLUSION Methodologies have evolved over the last 20 years but there is still a significant body of evidence reliant upon time-fixed methods. Robust estimates are required to inform investment in cost-effective IPC interventions.
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Affiliation(s)
- S Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK.
| | - S Stewart
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - S Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, UK
| | - N Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - H Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - A McFarland
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - C Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - J Reilly
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
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Wozniak TM. Letter to the editor in response to estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrob Resist Infect Control 2018; 7:91. [PMID: 30083311 PMCID: PMC6069994 DOI: 10.1186/s13756-018-0379-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/06/2018] [Indexed: 11/10/2022] Open
Abstract
The systematic review published by Naylor et al. in April 2018 highlights methodological assumptions and biases that occur in studies investigating the burden of antimicrobial resistance (AMR). They note that, due to both the large diversity of statistical approaches and perspectives chosen, the current evidence base of the burden of AMR is highly variable. Certainly, these conclusions are valid and the authors present a very thorough analysis of the currently published literature with a broad array of drug-bug combinations. But readers are left with limited direction of estimating the current best available estimate of the health and economic burden of AMR. Such estimates are desperately needed to inform clinical management and for priority setting activities and initiative to curbing the global threat of AMR.
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Affiliation(s)
- Teresa M Wozniak
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT 0811 Australia
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26
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Naylor NR, Atun R, Zhu N, Kulasabanathan K, Silva S, Chatterjee A, Knight GM, Robotham JV. Estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrob Resist Infect Control 2018; 7:58. [PMID: 29713465 PMCID: PMC5918775 DOI: 10.1186/s13756-018-0336-y] [Citation(s) in RCA: 283] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/14/2018] [Indexed: 01/02/2023] Open
Abstract
Background Accurate estimates of the burden of antimicrobial resistance (AMR) are needed to establish the magnitude of this global threat in terms of both health and cost, and to paramaterise cost-effectiveness evaluations of interventions aiming to tackle the problem. This review aimed to establish the alternative methodologies used in estimating AMR burden in order to appraise the current evidence base. Methods MEDLINE, EMBASE, Scopus, EconLit, PubMed and grey literature were searched. English language studies evaluating the impact of AMR (from any microbe) on patient, payer/provider and economic burden published between January 2013 and December 2015 were included. Independent screening of title/abstracts followed by full texts was performed using pre-specified criteria. A study quality score (from zero to one) was derived using Newcastle-Ottawa and Philips checklists. Extracted study data were used to compare study method and resulting burden estimate, according to perspective. Monetary costs were converted into 2013 USD. Results Out of 5187 unique retrievals, 214 studies were included. One hundred eighty-seven studies estimated patient health, 75 studies estimated payer/provider and 11 studies estimated economic burden. 64% of included studies were single centre. The majority of studies estimating patient or provider/payer burden used regression techniques. 48% of studies estimating mortality burden found a significant impact from resistance, excess healthcare system costs ranged from non-significance to $1 billion per year, whilst economic burden ranged from $21,832 per case to over $3 trillion in GDP loss. Median quality scores (interquartile range) for patient, payer/provider and economic burden studies were 0.67 (0.56-0.67), 0.56 (0.46-0.67) and 0.53 (0.44-0.60) respectively. Conclusions This study highlights what methodological assumptions and biases can occur dependent on chosen outcome and perspective. Currently, there is considerable variability in burden estimates, which can lead in-turn to inaccurate intervention evaluations and poor policy/investment decisions. Future research should utilise the recommendations presented in this review. Trial registration This systematic review is registered with PROSPERO (PROSPERO CRD42016037510).
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Affiliation(s)
- Nichola R. Naylor
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Rifat Atun
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Kavian Kulasabanathan
- Imperial College London, Sir Alexander Fleming Building, South Kensington Campus, London, UK
| | - Sachin Silva
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Anuja Chatterjee
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Gwenan M. Knight
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Julie V. Robotham
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Modelling and Economics Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
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Puchter L, Chaberny IF, Schwab F, Vonberg RP, Bange FC, Ebadi E. Economic burden of nosocomial infections caused by vancomycin-resistant enterococci. Antimicrob Resist Infect Control 2018; 7:1. [PMID: 29312658 PMCID: PMC5755438 DOI: 10.1186/s13756-017-0291-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background Nosocomial infections due to vancomycin-resistant enterococci (VRE) have become a major problem during the last years. The purpose of this study was to investigate the economic burden of nosocomial VRE infections in a European university hospital. Methods A retrospective matched case-control study was performed including patients who acquired nosocomial infection with either VRE or vancomycin-susceptible enterococci (VSE) within a time period of 3 years. 42 cases with VRE infections and 42 controls with VSE infections were matched for age, gender, admission and discharge within the same year, time at risk for infection, Charlson comorbidity index (±1), stay on intensive care units and non-intensive care units as well as for the type of infection, using criteria of the Centers for Disease Control and Prevention. Results The median overall costs per case were significantly higher than for controls (EUR 57,675 vs. EUR 38,344; p = 0.030). Costs were similar between cases and controls before onset of infection (EUR 17,893 vs. EUR 16,600; p = 0.386), but higher after onset of infection (EUR 37,971 vs. EUR 23,025; p = 0.049). The median attributable costs per case for vancomycin-resistance were EUR 13,157 (p = 0.036). The most significant differences in costs between cases and controls turned out to be for pharmaceuticals (EUR 6030 vs. EUR 2801; p = 0.008) followed by nursing staff (EUR 8956 vs. EUR 4621; p = 0.032), medical products (EUR 3312 vs. EUR 1838; p = 0.020), and for assistant medical technicians (EUR 3766 vs. EUR 2474; p = 0.023). Furthermore, multivariate analysis revealed that costs were driven independently by vancomycin-resistance (1.4 fold; p = 0.034). Conclusions This analysis suggested that nosocomial VRE infections significantly increases hospital costs compared with VSE infections. Therefore, hospital personal should implement control measures to prevent VRE transmission.
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Affiliation(s)
- Laura Puchter
- Department of Anesthesiology and Intensive Care Medicine, KRH Klinikum Hannover, Hannover, Germany
| | - Iris Freya Chaberny
- Institute of Infection Control and Hospital Epidemiology, Leipzig University Hospital, Leipzig, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Franz-Christoph Bange
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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Leal JR, Conly J, Henderson EA, Manns BJ. How externalities impact an evaluation of strategies to prevent antimicrobial resistance in health care organizations. Antimicrob Resist Infect Control 2017; 6:53. [PMID: 28588766 PMCID: PMC5457558 DOI: 10.1186/s13756-017-0211-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/25/2017] [Indexed: 01/21/2023] Open
Abstract
Background The rates of antimicrobial-resistant organisms (ARO) continue to increase for both hospitalized and community patients. Few resources have been allocated to reduce the spread of resistance on global, national and local levels, in part because the broader economic impact of antimicrobial resistance (i.e. the externality) is not fully considered when determining how much to invest to prevent AROs, including strategies to contain antimicrobial resistance, such as antimicrobial stewardship programs. To determine how best to measure and incorporate the impact of externalities associated with the antimicrobial resistance when making resource allocation decisions aimed to reduce antimicrobial resistance within healthcare facilities, we reviewed the literature to identify publications which 1) described the externalities of antimicrobial resistance, 2) described approaches to quantifying the externalities associated with antimicrobial resistance or 3) described macro-level policy options to consider the impact of externalities. Medline was reviewed to identify published studies up to September 2016. Main body An externality is a cost or a benefit associated with one person’s activity that impacts others who did not choose to incur that cost or benefit. We did not identify a well-accepted method of accurately quantifying the externality associated with antimicrobial resistance. We did identify three main methods that have gained popularity to try to take into account the externalities of antimicrobial resistance, including regulation, charges or taxes on the use of antimicrobials, and the right to trade permits or licenses for antimicrobial use. To our knowledge, regulating use of antimicrobials is the only strategy currently being used by health care systems to reduce antimicrobial use, and thereby reduce AROs. To justify expenditures on programs that reduce AROs (i.e. to formally incorporate the impact of the negative externality of antimicrobial resistance associated with antimicrobial use), we propose an alternative approach that quantifies the externalities of antimicrobial use, combining the attributable cost of AROs with time-series analyses showing the relationship between antimicrobial utilization and incidence of AROs. Conclusion Based on the findings of this review, we propose a methodology that healthcare organizations can use to incorporate the impact of negative externalities when making resource allocation decisions on strategies to reduce AROs. Electronic supplementary material The online version of this article (doi:10.1186/s13756-017-0211-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jenine R Leal
- Infection Prevention and Control, Alberta Health Services, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Cumming School of Medicine, University of Calgary, Calgary, Canada.,Health Sciences Centre, Room G236, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - John Conly
- Departments of Medicine, University of Calgary, Calgary, Canada.,Departments of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Canada.,Departments of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Infection Prevention and Control, Alberta Health Services, Calgary, Canada.,Foothills Medical Centre, AGW5, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Elizabeth Ann Henderson
- Department of Community Health Sciences, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Infection Prevention and Control, Alberta Health Services, Calgary, Canada.,Foothills Medical Centre, AGW5, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Braden J Manns
- Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Departments of Medicine, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Foothills Medical Centre, AGW5, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
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Riu M, Chiarello P, Terradas R, Sala M, Garcia-Alzorriz E, Castells X, Grau S, Cots F. Incremental cost of nosocomial bacteremia according to the focus of infection and antibiotic sensitivity of the causative microorganism in a university hospital. Medicine (Baltimore) 2017; 96:e6645. [PMID: 28445264 PMCID: PMC5413229 DOI: 10.1097/md.0000000000006645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 03/09/2017] [Accepted: 03/28/2017] [Indexed: 11/27/2022] Open
Abstract
To estimate the incremental cost of nosocomial bacteremia according to the causative focus and classified by the antibiotic sensitivity of the microorganism.Patients admitted to Hospital del Mar in Barcelona from 2005 to 2012 were included. We analyzed the total hospital costs of patients with nosocomial bacteremia caused by microorganisms with a high prevalence and, often, with multidrug-resistance. A control group was defined by selecting patients without bacteremia in the same diagnosis-related group.Our hospital has a cost accounting system (full-costing) that uses activity-based criteria to estimate per-patient costs. A logistic regression was fitted to estimate the probability of developing bacteremia (propensity score) and was used for propensity-score matching adjustment. This propensity score was included in an econometric model to adjust the incremental cost of patients with bacteremia with differentiation of the causative focus and antibiotic sensitivity.The mean incremental cost was estimated at &OV0556;15,526. The lowest incremental cost corresponded to bacteremia caused by multidrug-sensitive urinary infection (&OV0556;6786) and the highest to primary or unknown sources of bacteremia caused by multidrug-resistant microorganisms (&OV0556;29,186).This is one of the first analyses to include all episodes of bacteremia produced during hospital stays in a single study. The study included accurate information about the focus and antibiotic sensitivity of the causative organism and actual hospital costs. It provides information that could be useful to improve, establish, and prioritize prevention strategies for nosocomial infections.
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Affiliation(s)
- Marta Riu
- Management Control Department, Hospital del Mar
- IMIM (Hospital del Mar Medical Research Institute)
| | - Pietro Chiarello
- Management Control Department, Hospital del Mar
- IMIM (Hospital del Mar Medical Research Institute)
- Doctoral Program in Public Health, Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autònoma de Barcelona (UAB)
| | - Roser Terradas
- IMIM (Hospital del Mar Medical Research Institute)
- School of Nursing
| | - Maria Sala
- IMIM (Hospital del Mar Medical Research Institute)
- Department of Epidemiology and Evaluation, Hospital del Mar
- REDISSEC (Red de Investigación en Servicios Sanitarios en enfermedades crónicas)
- Universitat Autònoma de Barcelona (UAB)
| | - Enric Garcia-Alzorriz
- Management Control Department, Hospital del Mar
- IMIM (Hospital del Mar Medical Research Institute)
| | - Xavier Castells
- IMIM (Hospital del Mar Medical Research Institute)
- Department of Epidemiology and Evaluation, Hospital del Mar
- REDISSEC (Red de Investigación en Servicios Sanitarios en enfermedades crónicas)
- Universitat Autònoma de Barcelona (UAB)
| | - Santiago Grau
- Universitat Autònoma de Barcelona (UAB)
- Department of Pharmacy, Hospital del Mar, Barcelona, Spain
| | - Francesc Cots
- Management Control Department, Hospital del Mar
- IMIM (Hospital del Mar Medical Research Institute)
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Glied S, Cohen B, Liu J, Neidell M, Larson E. Trends in mortality, length of stay, and hospital charges associated with health care-associated infections, 2006-2012. Am J Infect Control 2016; 44:983-9. [PMID: 27207157 DOI: 10.1016/j.ajic.2016.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many factors associated with hospital-acquired infections (HAIs), including reimbursement policies, drug prices, practice patterns, and the distribution of organisms causing infections, change over time. We examined whether outcomes, including mortality, length of stay (LOS), daily charges, and total charges associated with HAIs, changed during 2006-2012. METHODS Electronic data on adults discharged from 2 tertiary-quaternary hospitals and 1 community hospital during 2006-2012 were collected retrospectively. Computerized algorithms identified infections using laboratory and administrative codes. Propensity scores were used to match cases with uninfected controls. Differences in mortality, LOS, daily charges, and total charges were modeled against infection status and time period (2006-2008 vs 2009-2012), including interaction for infection status by time period. RESULTS Among 352,077 discharges, 24,466 HAIs were detected. There was no significant change in mortality. LOS declined only for bloodstream infections (3-day reduction; P < 0.01). Daily charges rose 4% for urinary tract infections but did not change significantly for other HAIs. Total charges declined by 11% for bloodstream infections and 13% for pneumonia. CONCLUSIONS We found no appreciable or consistent improvement in HAI mortality or LOS during 2006-2012. Costs of bloodstream infections and pneumonia have declined, with most of the change occurring before 2008.
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Methicillin-Resistant Staphylococcus aureus Control in the 21st Century: Laboratory Involvement Affecting Disease Impact and Economic Benefit from Large Population Studies. J Clin Microbiol 2016; 54:2647-2654. [PMID: 27307459 DOI: 10.1128/jcm.00698-16] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) infection is a global health care problem. Large studies (e.g., >25,000 patients) show that active surveillance testing (AST) followed by contact precautions for positive patients is an effective approach for MRSA disease control. With this approach, the clinical laboratory will be asked to select what AST method(s) to use and to provide data monitoring outcomes of the infection prevention interventions. This minireview summarizes evidence for MRSA disease control, reviews the involvement of the laboratory, and provides examples of how to undertake a program cost analysis. Health care organizations with total MRSA clinical infections of >0.3/1,000 patient days or bloodstream infections of >0.03/1,000 patient days should implement a MRSA control plan.
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Nelson RE, Stevens VW, Khader K, Jones M, Samore MH, Evans ME, Douglas Scott R, Slayton RB, Schweizer ML, Perencevich EL, Rubin MA. Economic Analysis of Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. Am J Prev Med 2016; 50:S58-S65. [PMID: 27102860 PMCID: PMC7909478 DOI: 10.1016/j.amepre.2015.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/12/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative. METHODS An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained. RESULTS The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million. CONCLUSIONS Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martin E Evans
- Veterans Affairs Medical Center, Lexington, Kentucky; MRSA/MDRO Program, National Infectious Disease Service, Veterans Health Administration, Lexington, Kentucky; Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - R Douglas Scott
- Division of Healthcare Quality Promotion, CDC, Atlanta, Georgia
| | | | - Marin L Schweizer
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Eli L Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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