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Hartati A, Jarrett M, McDougall B, Kent M, Ljubojevic M, Stolzenhein K. Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia. Int J Integr Care 2024; 24:7. [PMID: 39005965 PMCID: PMC11243760 DOI: 10.5334/ijic.7739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 06/19/2024] [Indexed: 07/16/2024] Open
Abstract
Intro Complex and siloed health and social service systems can be difficult for people to navigate. The fragmented and poorly linked services leads to ineffective communication between care teams, delayed access to services, concerns regarding quality and safety of patient care, as well as patient frustration and disengagement. Description Planned Care for Better Health (PCBH) is a community-based care navigation and coordination program for people with complex health and psychosocial needs who are at risk of future hospitalisation. It focuses on early identification and holistic care to remove barriers and improve access to healthcare. By including a persons', family and carers in planning, listening to their needs, supporting the person to achieve their goals, and empowering them to make decisions on their own health, PCBH aims to enhance clients' healthcare experience and reduce preventable hospital utilisation. Discussion Building trusting and collaborative relationships with clients, families, carers, and health service providers requires commitment. Acknowledging and addressing psychosocial needs is critical for enhancing health outcomes. Equipping patients with self-management skills and knowledge to navigate and engage support services may generate lasting effects, even post-program enrolment. Conclusion PCBH is associated with a notable reduction in unplanned hospitalisations and total bed days. However, reduction in ED presentations is similar between the intervention and comparison cohorts. Future initiatives should focus on a shared vision of integrated care, robust leadership, and participative co-creation with service-level stakeholders. Sustained program establishment, a multidisciplinary care coordinator team, and an early creation of robust evaluation strategy must be considered.
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Affiliation(s)
- Anita Hartati
- Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, AU
| | - Madison Jarrett
- Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, US
| | - Brendon McDougall
- Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, AU
| | - Megan Kent
- Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, AU
| | - Maja Ljubojevic
- Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, AU
| | - Kylie Stolzenhein
- Primary and Community Health, South Western Sydney Local Health District, AU
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Tronstad O, Zangerl B, Patterson S, Flaws D, Yerkovich S, Szollosi I, White N, Garcia-Hansen V, Leonard FR, Weger BD, Gachon F, Brain D, Lavana J, Hodgson C, Fraser JF. The effect of an improved ICU physical environment on outcomes and post-ICU recovery-a protocol. Trials 2024; 25:376. [PMID: 38863018 PMCID: PMC11167845 DOI: 10.1186/s13063-024-08222-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by similar advances in ICU bedspace design. Environmental factors including excessive noise, suboptimal lighting, and lack of natural lights and views can adversely impact staff wellbeing and short- and long-term patient outcomes. The personal, social, and economic costs associated with this are potentially large. The ICU of the Future project was conceived to address these issues. This is a mixed-method project, aiming to improve the ICU bedspace environment and assess impact on patient outcomes. Two innovative and adaptive ICU bedspaces capable of being individualised to patients' personal and changing needs were co-designed and implemented. The aim of this study is to evaluate the effect of an improved ICU bedspace environment on patient outcomes and operational impact. METHODS This is a prospective multi-component, mixed methods study including a randomised controlled trial. Over a 2-year study period, the two upgraded bedspaces will serve as intervention beds, while the remaining 25 bedspaces in the study ICU function as control beds. Study components encompass (1) an objective environmental assessment; (2) a qualitative investigation of the ICU environment and its impact from the perspective of patients, families, and staff; (3) sleep investigations; (4) circadian rhythm investigations; (5) delirium measurements; (6) assessment of medium-term patient outcomes; and (7) a health economic evaluation. DISCUSSION Despite growing evidence of the negative impact the ICU environment can have on patient recovery, this is an area of critical care medicine that is understudied and commonly not considered when ICUs are being designed. This study will provide new information on how an improved ICU environment impact holistic patient recovery and outcomes, potentially influencing ICU design worldwide. TRIAL REGISTRATION ACTRN12623000541606. Registered on May 22, 2023. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385845&isReview=true .
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Australia.
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - Barbara Zangerl
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia
| | - Sue Patterson
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia
- School of Dentistry, University of Queensland, Brisbane, Australia
| | - Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia
- Department of Mental Health, Metro North Mental Health, Caboolture Hospital, Caboolture, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Stephanie Yerkovich
- Menzies School of Health Research and Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Irene Szollosi
- Sleep Disorders Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Nicole White
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Veronica Garcia-Hansen
- School of Architecture and Built Environment, Faculty of Engineering, Queensland University of Technology, Brisbane, Australia
| | - Francisca Rodriguez Leonard
- School of Architecture and Built Environment, Faculty of Engineering, Queensland University of Technology, Brisbane, Australia
| | - Benjamin D Weger
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Frédéric Gachon
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - David Brain
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Jayshree Lavana
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Division of Clinical Trial and Cohort Studies, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Physiotherapy Department, Alfred Hospital, Melbourne, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Rode Road, Chermside, Brisbane, Qld, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
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Seo H, Ahn I, Gwon H, Kang H, Kim Y, Choi H, Kim M, Han J, Kee G, Park S, Ko S, Jung H, Kim B, Oh J, Jun TJ, Kim YH. Forecasting Hospital Room and Ward Occupancy Using Static and Dynamic Information Concurrently: Retrospective Single-Center Cohort Study. JMIR Med Inform 2024; 12:e53400. [PMID: 38513229 PMCID: PMC10995785 DOI: 10.2196/53400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/20/2023] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Predicting the bed occupancy rate (BOR) is essential for efficient hospital resource management, long-term budget planning, and patient care planning. Although macro-level BOR prediction for the entire hospital is crucial, predicting occupancy at a detailed level, such as specific wards and rooms, is more practical and useful for hospital scheduling. OBJECTIVE The aim of this study was to develop a web-based support tool that allows hospital administrators to grasp the BOR for each ward and room according to different time periods. METHODS We trained time-series models based on long short-term memory (LSTM) using individual bed data aggregated hourly each day to predict the BOR for each ward and room in the hospital. Ward training involved 2 models with 7- and 30-day time windows, and room training involved models with 3- and 7-day time windows for shorter-term planning. To further improve prediction performance, we added 2 models trained by concatenating dynamic data with static data representing room-specific details. RESULTS We confirmed the results of a total of 12 models using bidirectional long short-term memory (Bi-LSTM) and LSTM, and the model based on Bi-LSTM showed better performance. The ward-level prediction model had a mean absolute error (MAE) of 0.067, mean square error (MSE) of 0.009, root mean square error (RMSE) of 0.094, and R2 score of 0.544. Among the room-level prediction models, the model that combined static data exhibited superior performance, with a MAE of 0.129, MSE of 0.050, RMSE of 0.227, and R2 score of 0.600. Model results can be displayed on an electronic dashboard for easy access via the web. CONCLUSIONS We have proposed predictive BOR models for individual wards and rooms that demonstrate high performance. The results can be visualized through a web-based dashboard, aiding hospital administrators in bed operation planning. This contributes to resource optimization and the reduction of hospital resource use.
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Affiliation(s)
- Hyeram Seo
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Imjin Ahn
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hansle Gwon
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heejun Kang
- Division of Cardiology, Asan Medical Center, Seoul, Republic of Korea
| | - Yunha Kim
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heejung Choi
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Minkyoung Kim
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiye Han
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gaeun Kee
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seohyun Park
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Soyoung Ko
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - HyoJe Jung
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Byeolhee Kim
- Department of Information Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jungsik Oh
- Department of Digital Innovation, Asan Medical Center, Seoul, Republic of Korea
| | - Tae Joon Jun
- Big Data Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Young-Hak Kim
- Division of Cardiology, Department of Information Medicine, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Republic of Korea
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Bear NL, Wilson A, Blackmore AM, Geelhoed E, Simpson S, Langdon K. The cost of respiratory hospitalizations in children with cerebral palsy. Dev Med Child Neurol 2024; 66:344-352. [PMID: 37491764 DOI: 10.1111/dmcn.15714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/18/2023] [Accepted: 06/14/2023] [Indexed: 07/27/2023]
Abstract
AIM To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations. METHOD A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years). RESULTS In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater. INTERPRETATION Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP. WHAT THIS PAPER ADDS Respiratory illness is the most costly area for unplanned, emergency hospitalizations for children and young people with cerebral palsy. The top 5% of individuals with the highest total inpatient costs account for a disproportionate amount of health care costs.
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Affiliation(s)
- Natasha L Bear
- Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Andrew Wilson
- Curtin School of Allied Health, Curtin University, Perth, WA, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia
- Telethon Kids Institute, Nedlands, WA, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Crawley, WA, Australia
| | | | - Elizabeth Geelhoed
- School of Allied Health, The University of Western Australia, Crawley, WA, Australia
| | - Shannon Simpson
- Curtin School of Allied Health, Curtin University, Perth, WA, Australia
- Telethon Kids Institute, Nedlands, WA, Australia
| | - Katherine Langdon
- Telethon Kids Institute, Nedlands, WA, Australia
- Kids' Rehab WA, Perth Children's Hospital, Nedlands, WA, Australia
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Cai Y, Philips EC, Arora S, Sim JXY, Chow W, Nazeha N, Whiteley S, Auw MYX, Tiang DC, Neo SL, Hong W, Venkatachalam I, Graves N. Cost-effectiveness of a real-time spatiotemporal mapping surveillance system for meticillin-resistant Staphylococcus aureus prevention. J Hosp Infect 2024; 143:178-185. [PMID: 37774929 DOI: 10.1016/j.jhin.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES An infection surveillance system based on a hospital's digital twin [4D-Disease Outbreak Surveillance System (4D-DOSS)] is being developed in Singapore. It offers near-real-time infection surveillance and mapping capabilities. This early economic modelling study was conducted, using meticillin-resistant Staphylococcus aureus (MRSA) as the pathogen of interest, to assess the potential cost-effectiveness of 4D-DOSS. METHODS A Markov model that simulates the likelihood of MRSA colonization and infection was developed to evaluate the cost-effectiveness of adopting 4D-DOSS for MRSA surveillance from the hospital perspective, compared with current practice. The cycle duration was 1 day, and the model horizon was 30 days. Probabilistic sensitivity analysis was conducted, and the probability of cost-effectiveness was reported. Scenario analyses and a value of information analysis were performed. RESULTS In the base-case scenario, with 10-year implementation/maintenance costs of 4D-DOSS of $0, there was 68.6% chance that 4D-DOSS would be cost-effective. In a more pessimistic but plausible scenario where the effectiveness of 4D-DOSS in reducing MRSA transmission was one-quarter of the base-case scenario with 10-year implementation/maintenance costs of $1 million, there was 47.7% chance that adoption of 4D-DOSS would be cost-effective. The value of information analysis showed that uncertainty in MRSA costs made the greatest contribution to model uncertainty. CONCLUSIONS This early-stage modelling study revealed the circumstances for which 4D-DOSS is likely to be cost-effective at the current willingness-to-pay threshold, and identified the parameters for which further research will be worthwhile to reduce model uncertainty. Inclusion of other drug-resistant organisms will provide a more thorough assessment of the cost-effectiveness of 4D-DOSS.
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Affiliation(s)
- Y Cai
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - E C Philips
- Department of Infection Prevention and Epidemiology, Singapore General Hospital, Singapore
| | - S Arora
- Department of Infection Prevention and Epidemiology, Singapore General Hospital, Singapore
| | - J X Y Sim
- Department of Infection Prevention and Epidemiology, Singapore General Hospital, Singapore; Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - W Chow
- Department of Cardiology, Changi General Hospital, Singapore
| | - N Nazeha
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | | | - D C Tiang
- Office for Service Transformation, SingHealth, Singapore
| | - S L Neo
- Office of Digital Strategy, SingHealth, Singapore
| | - W Hong
- Office for Service Transformation, SingHealth, Singapore
| | - I Venkatachalam
- Department of Infection Prevention and Epidemiology, Singapore General Hospital, Singapore; Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - N Graves
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
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Goh OQM, Xin X, Lim WT, Tan MWJ, Kan JYL, Osman HB, Kee W, Teo TY, Tan WB, Kang ML, Graves N. Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems. JAMA Netw Open 2023; 6:e2334936. [PMID: 37738050 PMCID: PMC10517377 DOI: 10.1001/jamanetworkopen.2023.34936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/13/2023] [Indexed: 09/23/2023] Open
Abstract
Importance During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking. Objective To compare personnel costs of HaH and ACT with inpatient care. Design, Setting, and Participants In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore. Exposures HaH for dengue and ACT for chest pain. Main Outcomes and Measures A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs. Results Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%. Conclusions and Relevance This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.
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Affiliation(s)
- Orlanda Q. M. Goh
- Department of Internal Medicine, Singapore General Hospital, Singapore
- Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
- Health Services Research Unit, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Global Health Institute, Singapore
| | - Xiaohui Xin
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Wan Tin Lim
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Michelle W. J. Tan
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Juliana Y. L. Kan
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Hartini Bte Osman
- Department of Nursing Administration, Singapore General Hospital, Singapore
| | - Wanyi Kee
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Tse Yean Teo
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Wee Boon Tan
- Population Health and Integrated Care Office, Singapore General Hospital
| | - Mei Ling Kang
- Department of Internal Medicine, Singapore General Hospital, Singapore
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Nicholas Graves
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Chen X, Dong Y, Wu M. Medical capacity investment for epidemic disease: The effects of policymaker's confidence and public trust. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2023; 43:1187-1211. [PMID: 35822620 DOI: 10.1111/risa.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Due to the server bed shortage, which has raised ethical dilemmas in the earliest days of the COVID-19 crisis, medical capacity investment has become a vital decision-making issue in the attempt to contain the epidemic. Furthermore, economic strength has failed to explain the significant performance difference across countries in combatting COVID-19. Unlike common diseases, epidemic diseases add substantial unpredictability, complexity, and uncertainty to decision-making. Knowledge miscalibration on epidemiological uncertainties by policymaker's over- and underconfidence can seriously impact policymaking. Ineffective risk communication may lead to conflicting and incoherent information transmission. As a result, public reactions and attitudes could be influenced by policymakers' confidence due to the level of public trust, which eventually affects the degree to which an epidemic spreads. To uncover the impacts of policymakers' confidence and public trust on the medical capacity investment, we establish epidemic diffusion models to characterize how transmission evolves with (and without) vaccination and frame the capacity investment problem as a newsvendor problem. Our results show that if the public fully trusts the public health experts, the policymaker's behavioral bias is always harmful, but its effect on cost increment is marginal. If a policymaker's behavior induces public reactions due to public trust, both the spread of the epidemic and the overall performance will be significantly affected, but such impacts are not always harmful. Decision bias may be beneficial when policymakers are pessimistic or highly overconfident. Having an opportunity to amend initially biased decisions can debias a particular topic but has a limited cost-saving effect.
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Affiliation(s)
- Xin Chen
- School of Business Administration, South China University of Technology, Guangzhou, China
| | - Yucheng Dong
- Center for Network Big Data and Decision-Making, Business School, Sichuan University, Chengdu, China
| | - Meng Wu
- Business School, Sichuan University, Chengdu, China
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White NM, Carter HE, Kularatna S, Borg DN, Brain DC, Tariq A, Abell B, Blythe R, McPhail SM. Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice. J Am Med Inform Assoc 2023; 30:1205-1218. [PMID: 36972263 PMCID: PMC10198542 DOI: 10.1093/jamia/ocad040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/23/2023] [Accepted: 03/03/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations. MATERIALS AND METHODS A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist. RESULTS Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups. DISCUSSION AND CONCLUSION Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.
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Affiliation(s)
- Nicole M White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David N Borg
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David C Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Amina Tariq
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robin Blythe
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, Queensland, Australia
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9
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Kapoor R, Standaert B, Pezalla EJ, Demarteau N, Sutton K, Tichy E, Bungey G, Arnetorp S, Bergenheim K, Darroch-Thompson D, Meeraus W, Okumura LM, Tiene de Carvalho Yokota R, Gani R, Nolan T. Identification of an Optimal COVID-19 Booster Allocation Strategy to Minimize Hospital Bed-Days with a Fixed Healthcare Budget. Vaccines (Basel) 2023; 11:vaccines11020377. [PMID: 36851254 PMCID: PMC9965991 DOI: 10.3390/vaccines11020377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
Healthcare decision-makers face difficult decisions regarding COVID-19 booster selection given limited budgets and the need to maximize healthcare gain. A constrained optimization (CO) model was developed to identify booster allocation strategies that minimize bed-days by varying the proportion of the eligible population receiving different boosters, stratified by age, and given limited healthcare expenditure. Three booster options were included: B1, costing US $1 per dose, B2, costing US $2, and no booster (NB), costing US $0. B1 and B2 were assumed to be 55%/75% effective against mild/moderate COVID-19, respectively, and 90% effective against severe/critical COVID-19. Healthcare expenditure was limited to US$2.10 per person; the minimum expected expense using B1, B2, or NB for all. Brazil was the base-case country. The model demonstrated that B1 for those aged <70 years and B2 for those ≥70 years were optimal for minimizing bed-days. Compared with NB, bed-days were reduced by 75%, hospital admissions by 68%, and intensive care unit admissions by 90%. Total costs were reduced by 60% with medical resource use reduced by 81%. This illustrates that the CO model can be used by healthcare decision-makers to implement vaccine booster allocation strategies that provide the best healthcare outcomes in a broad range of contexts.
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Affiliation(s)
- Ritika Kapoor
- Evidera, PPD Singapore, 08–11, 1 Fusionopolis Walk, Singapore 138628, Singapore
| | - Baudouin Standaert
- Faculty of Medicine and Life Sciences, University of Hasselt, Agoralaan, 3590 Diepenbeek, Belgium
| | - Edmund J. Pezalla
- Enlightenment Bioconsult, LLC, 140 S Beach Street, Suite 310, Daytona Beach, FL 32114, USA
| | | | | | | | - George Bungey
- Evidera, PPD the Ark, 2nd Floor, 201 Talgarth Road, London W6 8BJ, UK
| | - Sofie Arnetorp
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, 431 83 Gothenberg, Sweden
| | - Klas Bergenheim
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, 431 83 Gothenberg, Sweden
| | - Duncan Darroch-Thompson
- International Market Access, Vaccines and Immune Therapies, AstraZeneca, Singapore 339510, Singapore
| | - Wilhelmine Meeraus
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca, Cambridge CB2 8PA, UK
| | - Lucas M. Okumura
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, São Paulo 06709-000, Brazil
| | - Renata Tiene de Carvalho Yokota
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca, Cambridge CB2 8PA, UK
- P95 Epidemiology & Pharmacovigilance, 3001 Leuven, Belgium
| | - Ray Gani
- Evidera, PPD the Ark, 2nd Floor, 201 Talgarth Road, London W6 8BJ, UK
- Correspondence: ; Tel.: +44-(0)-7720088940
| | - Terry Nolan
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC 3010, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
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10
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Parkes-Smith J, Bergh H, Harris PNA. Assessing the performance of the Cepheid Xpert in identifying and differentiating methicillin-susceptible Staphylococcus aureus and methicillin-resistant Staphylococcus aureus from blood culture bottles. Pathology 2023; 55:113-116. [PMID: 36130845 DOI: 10.1016/j.pathol.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 01/11/2023]
Abstract
Staphylococcus aureus bacteraemia is associated with a high morbidity and mortality. Time to effective antibiotics is key to reducing mortality. Current practices yield preliminary susceptibilities approximately 16-18 h after blood culture positivity. Molecular diagnostics could reduce the time from blood culture positivity to organism identification as MRSA or MSSA. The objective was to assess the performance of the GeneXpert in identifying MRSA/MSSA from blood culture bottles in the BACT/ALERT VIRTUO system. Eighty-eight blood culture bottles with Gram-positive cocci resembling staphylococci were analysed at Pathology Queensland using the Cepheid Xpert MRSA/SA BC system. The identification and susceptibilities from standard operating procedures were compared with the results from the Xpert MRSA/SA Blood Culture assay and routine laboratory practice. The overall positive percent agreement between the GeneXpert and standard laboratory practice was 94.1% (95% CI 85.6-98.37%) and the negative percent agreement was 100% (95% CI 83.16-100%). The Cepheid Xpert accurately identifies MRSA, MSSA and coagulase-negative staphylococci. The discordant results were from rarely occurring clinical isolates and were expected limitations of the assay. This kit has the potential to reduce the time to effective antibiotics and minimise the use of unnecessary antibiotics and associated costs.
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Affiliation(s)
- Jill Parkes-Smith
- Pathology Queensland, Central Microbiology, Queensland Health, RBWH Herston Campus, Herston, Qld, Australia
| | - Haakon Bergh
- Pathology Queensland, Central Microbiology, Queensland Health, RBWH Herston Campus, Herston, Qld, Australia
| | - Patrick N A Harris
- Pathology Queensland, Central Microbiology, Queensland Health, RBWH Herston Campus, Herston, Qld, Australia; University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, RBWH Herston Campus, Qld, Australia.
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11
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Kwan BPM, Hill AM, Elliott M, van der Lee L. A retrospective study of physiotherapy management for patients with pneumonia requiring invasive ventilation in a single-center Australian ICU. Hong Kong Physiother J 2022; 42:55-64. [PMID: 35782697 PMCID: PMC9244597 DOI: 10.1142/s1013702522500068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Pneumonia is a frequent diagnosis for patients admitted to Australian intensive care units (ICUs) for invasive ventilation. Physiotherapists in ICU provide interventions to enhance respiratory function and physical recovery. Objective: This retrospective cohort study aimed to describe physiotherapy management of adults with pneumonia who require invasive mechanical ventilation in a single Level 3 ICU in a quaternary teaching hospital. Methods: All adults admitted with a medical diagnosis of pneumonia requiring invasive mechanical ventilation over a two-year period were included. Demographic and clinical data, including APACHE II score, ventilator-free days (VFDs) to day 28, ICU length of stay (LOS), and type and frequency of physiotherapy episodes of care delivered in ICU, were collected from electronic medical records. Correlations between VFDs to day 28 and the frequency of physiotherapy interventions delivered per subject were examined using Spearman’s rho analysis. Results: From 208 records screened, 66 subjects with an ICU admission diagnosis of pneumonia, who required invasive mechanical ventilation, were included. Median (IQR) ICU LOS was 10 (5–17) days, and mortality rate was 15.2% (n=10). The cohort had a median of 20.5 (IQR 2–25) VFDs to day 28. Community-acquired pneumonia (66.7%, n=44) was the most frequent type of pneumonia diagnosis. There were 1110 episodes of physiotherapy care, with patients receiving a median of 13.5 (IQR 6.8–21.3) episodes during their ICU stay, with a median rate of 1.2 (IQR 1.0–1.6) episodes per day. Over 96.7% of patients with pneumonia received physiotherapy treatment during their ICU stay. Overall, physiotherapy treatments consisting only of respiratory techniques were most commonly provided (55.1%, n=612). Airway suctioning (92.4%, n=61), patient positioning (72.7%, n=48) or positioning advice to nurses (77.3%, n=51), and hyperinflation techniques (63.6%, n=42) were among the respiratory techniques most delivered. Conclusion: This study described the current intensive care physiotherapy management in a single center for adults with pneumonia who required invasive mechanical ventilation, demonstrating that respiratory physiotherapy interventions are often provided for this ICU patient cohort. Further research is warranted to determine the efficacy of respiratory physiotherapy interventions to justify their use for ICU patients with pneumonia receiving invasive mechanical ventilation.
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Affiliation(s)
- Baldwin Pok Man Kwan
- Discipline of Physiotherapy, School of Allied Health, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| | - Anne-Marie Hill
- Discipline of Physiotherapy, School of Allied Health, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
| | - Mercedes Elliott
- Physiotherapy Department, Fiona Stanley Hospital Perth, Locked Bag 100, Palmyra DC, WA 6961, Australia
| | - Lisa van der Lee
- Physiotherapy Department, Fiona Stanley Hospital Perth, Locked Bag 100, Palmyra DC, WA 6961, Australia
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12
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Kamran F, Tang S, Otles E, McEvoy DS, Saleh SN, Gong J, Li BY, Dutta S, Liu X, Medford RJ, Valley TS, West LR, Singh K, Blumberg S, Donnelly JP, Shenoy ES, Ayanian JZ, Nallamothu BK, Sjoding MW, Wiens J. Early identification of patients admitted to hospital for covid-19 at risk of clinical deterioration: model development and multisite external validation study. BMJ 2022; 376:e068576. [PMID: 35177406 PMCID: PMC8850910 DOI: 10.1136/bmj-2021-068576] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To create and validate a simple and transferable machine learning model from electronic health record data to accurately predict clinical deterioration in patients with covid-19 across institutions, through use of a novel paradigm for model development and code sharing. DESIGN Retrospective cohort study. SETTING One US hospital during 2015-21 was used for model training and internal validation. External validation was conducted on patients admitted to hospital with covid-19 at 12 other US medical centers during 2020-21. PARTICIPANTS 33 119 adults (≥18 years) admitted to hospital with respiratory distress or covid-19. MAIN OUTCOME MEASURES An ensemble of linear models was trained on the development cohort to predict a composite outcome of clinical deterioration within the first five days of hospital admission, defined as in-hospital mortality or any of three treatments indicating severe illness: mechanical ventilation, heated high flow nasal cannula, or intravenous vasopressors. The model was based on nine clinical and personal characteristic variables selected from 2686 variables available in the electronic health record. Internal and external validation performance was measured using the area under the receiver operating characteristic curve (AUROC) and the expected calibration error-the difference between predicted risk and actual risk. Potential bed day savings were estimated by calculating how many bed days hospitals could save per patient if low risk patients identified by the model were discharged early. RESULTS 9291 covid-19 related hospital admissions at 13 medical centers were used for model validation, of which 1510 (16.3%) were related to the primary outcome. When the model was applied to the internal validation cohort, it achieved an AUROC of 0.80 (95% confidence interval 0.77 to 0.84) and an expected calibration error of 0.01 (95% confidence interval 0.00 to 0.02). Performance was consistent when validated in the 12 external medical centers (AUROC range 0.77-0.84), across subgroups of sex, age, race, and ethnicity (AUROC range 0.78-0.84), and across quarters (AUROC range 0.73-0.83). Using the model to triage low risk patients could potentially save up to 7.8 bed days per patient resulting from early discharge. CONCLUSION A model to predict clinical deterioration was developed rapidly in response to the covid-19 pandemic at a single hospital, was applied externally without the sharing of data, and performed well across multiple medical centers, patient subgroups, and time periods, showing its potential as a tool for use in optimizing healthcare resources.
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Affiliation(s)
- Fahad Kamran
- Division of Computer Science and Engineering, University of Michigan College of Engineering, Ann Arbor, MI 48109, USA
- Joint first authors
| | - Shengpu Tang
- Division of Computer Science and Engineering, University of Michigan College of Engineering, Ann Arbor, MI 48109, USA
- Joint first authors
| | - Erkin Otles
- Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dustin S McEvoy
- Mass General Brigham Digital Health eCare, Somerville, MA, USA
| | - Sameh N Saleh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jen Gong
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco, CA, USA
| | - Benjamin Y Li
- Division of Computer Science and Engineering, University of Michigan College of Engineering, Ann Arbor, MI 48109, USA
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sayon Dutta
- Mass General Brigham Digital Health eCare, Somerville, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Xinran Liu
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Richard J Medford
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas S Valley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lauren R West
- Infection Control Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Karandeep Singh
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Seth Blumberg
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
| | - John P Donnelly
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Erica S Shenoy
- Infection Control Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brahmajee K Nallamothu
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Joint senior authors
| | - Jenna Wiens
- Division of Computer Science and Engineering, University of Michigan College of Engineering, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Joint senior authors
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13
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Cai Y, Hoo GSR, Lee W, Tan BH, Yoong J, Teo YY, Graves N, Lye D, Kwa AL. Estimating the economic cost of carbapenem resistant Enterobacterales healthcare associated infections in Singapore acute-care hospitals. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001311. [PMID: 36962882 PMCID: PMC10021918 DOI: 10.1371/journal.pgph.0001311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/30/2022] [Indexed: 12/12/2022]
Abstract
Quantifying the costs of hospital associated infections (HAIs) caused by carbapenem-resistant Enterobacterales (CRE) can aid hospital decision makers in infection prevention and control decisions. We estimate the costs of a CRE HAI by infection type and the annual costs of CRE HAIs to acute-care hospitals in Singapore. We used tree diagrams to estimate the costs (in Singapore dollar) of different CRE HAI types from the health service perspective and compared them to the costs of carbapenem-susceptible HAIs. We used two approaches to estimate costs-direct costs of consumables for infection prevention and treatment; and costs associated with lost bed days. Cost of a HAI were extrapolated to annual CRE HAI incidence in Singapore acute-care hospitals to estimate the annual cost to the hospitals. We found that the cost of a CRE HAI based on direct cost and lost bed days are SGD$9,913 (95% CI, SGD$9,431-10,395) and SGD$10,044 (95% CI, SGD$9,789-10,300) respectively. CRE HAIs are markedly higher than the carbapenem-susceptible HAIs for all infection types. In both approaches, CRE pneumonia was the costliest infection. Based on a CRE HAI incidence of 233 per 100,000 inpatient admissions, CRE HAIs costed SGD$12.16M (95% CI, SGD$11.84-12.48M) annually based on direct costs, and SGD$12.33M (95% CI, SGD$12.01-12.64M) annually based on lost bed days. In conclusion, we described the cost of CRE HAIs in Singapore hospitals and identified infections with the highest costs. The findings may be useful in informing future economic evaluations of competing CRE HAI prevention and treatment programmes.
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Affiliation(s)
- Yiying Cai
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Grace S R Hoo
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Winnie Lee
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Joanne Yoong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Research for Impact, Singapore, Singapore
| | - Yik-Ying Teo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Nicholas Graves
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - David Lye
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Andrea L Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Singhealth Duke-NUS Medicine Academic Clinical Programme, Singapore, Singapore
- Emerging Infectious Diseases, Duke-National University of Singapore, Singapore, Singapore
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14
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Nelson RE, Hyun D, Jezek A, Samore MH. Mortality, Length of Stay, and Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Elderly Hospitalized Patients in the United States. Clin Infect Dis 2021; 74:1070-1080. [PMID: 34617118 PMCID: PMC8946701 DOI: 10.1093/cid/ciab696] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND This study reports estimates of the healthcare costs, length of stay, and mortality associated with infections due to multidrug-resistant bacteria among elderly individuals in the United States. METHODS We conducted a retrospective cohort analysis of patients aged ≥65 admitted for inpatient stays in the Department of Veterans Affairs healthcare system between 1/2007-12/2018. We identified those with positive cultures for multidrug-resistant bacteria and matched each infected patient to ≤10 control patients. We then performed multivariable regression models to estimate the attributable cost and mortality due to the infection. We also constructed multistate models to estimate the attributable length of stay due to the infection. Finally, we multiplied these pathogen-specific attributable cost, length of stay, and mortality estimates by national case counts from hospitalized patients in 2017. RESULTS Our cohort consisted of 87 509 patients with infections and 835 048 matched controls. Costs were higher for hospital-onset invasive infections, with attributable costs ranging from $22 293 (95% confidence interval: $19 101-$24 485) for methicillin-resistant Staphylococcus aureus (MRSA) to $57 390 ($34 070-$80 710) for carbapenem-resistant (CR) Acinetobacter. Similarly, for hospital-onset invasive infections, attributable mortality estimates ranged from 14.2% (12.2-16.2%) for MRSA to 24.1% (12.1-36.0%) for CR Acinetobacter. The aggregate cost of these infections was an estimated $1.9 billion ($1.3 billion-$2.5 billion) with 11 852 (8719-14 985) deaths and 448 224 (354 513-541 934) inpatient days in 2017. CONCLUSIONS Efforts to prevent these infections due to multidrug-resistant bacteria could save a significant number of lives and healthcare resources.
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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
| | - David Hyun
- The Pew Charitable Trusts, Washington, DC, USA
| | - Amanda Jezek
- Infectious Diseases Society of America, Arlington, Virginia, 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
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15
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Elliott TM, Hurst C, Doidge M, Hurst T, Harris PN, Gordon LG. Unexpected benefit of COVID-19 hospital restrictions: Reduction in patients isolating with multidrug resistant organisms after restrictions were lifted. Infect Dis Health 2021; 27:10-14. [PMID: 34507923 PMCID: PMC8372517 DOI: 10.1016/j.idh.2021.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
Background During the COVID-19 pandemic, measures to prevent microorganism transmission were implemented across hospitals, including wearing compulsory surgical masks, minimising non-urgent procedures and restricting visitors. Previously, concerns have been raised that MRO-associated deaths could rise during a future pandemic through superimposed bacterial infections, inappropriate antibiotic use and reduced focus on preventing MRO infections. Methods In the state of Queensland, Australia with a population of 5 million, only a short first wave of coronavirus cases occurred and restrictions were quickly scaled back. This presented a natural experiment of pre-, during and post-COVID-19 restriction timings to evaluate the effectiveness of heightened prevention measures on multidrug resistant organism (MRO) infections. Patient isolation days and MRO types were collected weekly from routine infection control reports, at a large public hospital, from 28th January 2020 to 24th July 2020. In this interrupted time series design, we employed Poisson mixed effect regression modelling to evaluate the difference in incidence of patient isolation days between time periods. Results Compared to pre-COVID, patient isolation days reduced during COVID restrictions (incidence rate ratio 0.65, 95%CI: 0.59, 0.70; p < 0.001) and increased again post-COVID restrictions, but did not return to pre-COVID levels (0.87, 95%CI: 0.80, 0.95; p = 0.001). The efficiency of isolating patients improved after COVID-19 with fewer bed closures required. Conclusion Heightened infection control awareness, hand sanitation and mask wearing after COVID-19 restrictions were lifted appear to effectively prevent common hospital-acquired MRO infections.
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Affiliation(s)
- Thomas M Elliott
- QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, QLD 4006, Australia.
| | - Cameron Hurst
- QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, QLD 4006, Australia
| | - Michelle Doidge
- Infectious Diseases Unit, Royal Brisbane and Womens' Hospital, Herston, Brisbane, QLD 4029, Australia
| | - Trish Hurst
- Infectious Diseases Unit, Royal Brisbane and Womens' Hospital, Herston, Brisbane, QLD 4029, Australia; The University of Queensland, Centre for Clinical Research, Herston, Brisbane, QLD 4006, Australia
| | - Patrick Na Harris
- The University of Queensland, Centre for Clinical Research, Herston, Brisbane, QLD 4006, Australia; Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD 4029, Australia
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, QLD 4006, Australia; The University of Queensland, School of Public Health, Brisbane, QLD 4006, Australia; Queensland University of Technology, School of Nursing, Kelvin Grove, Brisbane, QLD 4059, Australia. https://twitter.com/@louisagord
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16
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Manoukian S, Stewart S, Graves N, Mason H, Robertson C, Kennedy S, Pan J, Kavanagh K, Haahr L, Adil M, Dancer SJ, Cook B, Reilly J. Bed-days and costs associated with the inpatient burden of healthcare-associated infection in the UK. J Hosp Infect 2021; 114:43-50. [PMID: 34301395 DOI: 10.1016/j.jhin.2020.12.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Healthcare-associated infection (HAI) is associated with increased morbidity and mortality resulting in excess costs. AIM To investigate the impact of all types of HAI on the inpatient cost of HAI using different approaches. METHODS The incidence, types of HAI, and excess length of stay were estimated using data collected as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. Scottish NHS reference costs were used to estimate unit costs for bed-days. Variable (cash) costs associated with infection prevention and control (IPC) measures and treatment were calculated for each HAI type and overall. The inpatient cost of HAI is presented in terms of bed-days lost, bed-day costs, and cash costs. FINDINGS In Scotland 58,010 (95% confidence interval: 41,730-74,840) bed-days were estimated to be lost to HAI during 2018/19, costing £46.4 million (19m-129m). The total annual cost in the UK is estimated to be £774 million (328m-2,192m). Bloodstream infection and pneumonia were the most costly HAI types per case. Cash costs are a small proportion of the total cost of HAI, contributing 2.4% of total costs. CONCLUSION Reliable estimates of the cost burden of HAI management are important for assessing the cost-effectiveness of IPC programmes. This unique study presents robust economic data, demonstrating that HAI remains a burden to the UK NHS and bed-days capture the majority of inpatient costs. These findings can be used to inform the economic evaluation and decision analytic modelling of competing IPC programmes at local and national level.
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Affiliation(s)
- S Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - S Stewart
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK.
| | - N Graves
- Duke-NUS Medical School, Singapore
| | - H Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - C Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - S Kennedy
- HPS Stats Support, Public Health Scotland, Glasgow, UK
| | - J Pan
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - K Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - L Haahr
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK
| | - M Adil
- Public Health Scotland, Edinburgh, UK
| | - S J Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, UK; School of Applied Science, Edinburgh Napier University, Edinburgh, UK
| | - B Cook
- Departments of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J Reilly
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK; National Services Scotland (NSS), UK
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17
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Lee XJ, Stewardson AJ, Worth LJ, Graves N, Wozniak TM. Attributable Length of Stay, Mortality Risk, and Costs of Bacterial Health Care-Associated Infections in Australia: A Retrospective Case-cohort Study. Clin Infect Dis 2021; 72:e506-e514. [PMID: 32822465 PMCID: PMC8130032 DOI: 10.1093/cid/ciaa1228] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022] Open
Abstract
Background Unbiased estimates of the health and economic impacts of health care–associated infections (HAIs) are scarce and focus largely on patients with bloodstream infections (BSIs). We sought to estimate the hospital length of stay (LOS), mortality rate, and costs of HAIs and the differential effects on patients with an antimicrobial-resistant infection. Methods We conducted a multisite, retrospective case-cohort of all acute-care hospital admissions with a positive culture of 1 of the 5 organisms of interest (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, or Enterococcus faecium) from 1 January 2012 through 30 December 2016. Data linkage was used to generate a data set of statewide hospital admissions and pathology data. Patients with bloodstream, urinary, or respiratory tract infections were included in the analysis and matched to a sample of uninfected patients. We used multistate survival models to generate LOS, and logistic regression to derive mortality estimates. Results We matched 20 390 cases to 75 635 uninfected control patients. The overall incidence of infections due to the 5 studied organisms was 116.9 cases per 100 000 patient days, with E. coli urinary tract infections (UTIs) contributing the largest proportion (51 cases per 100 000 patient days). The impact of a UTI on LOS was moderate across the 5 studied pathogens. Resistance significantly increased LOS for patients with third-generation cephalosporin-resistant K. pneumoniae BSIs (extra 4.6 days) and methicillin-resistant S. aureus BSIs (extra 2.9 days). Consequently, the health-care costs of these infections were higher, compared to corresponding drug-sensitive strains. Conclusions The health burden remains highest for BSIs; however, UTIs and respiratory tract infections contributed most to the health-care system expenditure.
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Affiliation(s)
- X J Lee
- Australian Centre for Health Services Innovation, Queensland University of Technology, Queensland, Australia
| | - A J Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School.,Monash University, Victoria, Australia
| | - L J Worth
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Doherty Institute, Victoria, Australia.,National Centre for Infections in Cancer, Sir Peter MacCallum Department of Medicine, University of Melbourne, Victoria, Australia
| | - N Graves
- Duke University and the National University of Singapore Medical School, Singapore
| | - T M Wozniak
- Charles Darwin University, Menzies School of Health Research, Global & Tropical Health Division, Northern Territory, Australia
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Ladbrook E, Khaw D, Bouchoucha S, Hutchinson A. A systematic scoping review of the cost-impact of ventilator-associated pneumonia (VAP) intervention bundles in intensive care. Am J Infect Control 2021; 49:928-936. [PMID: 33301781 DOI: 10.1016/j.ajic.2020.11.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Evidence-based economic decision making is key in health care. Presently, however, studies reporting financial outcomes of ventilator-associated pneumonia (VAP) care bundles have not been systematically evaluated. METHOD This scoping review investigated the characteristics and findings of studies of the economic impact of VAP bundle implementation. A systematic search of electronic databases (MEDLINE, CINAHL) for relevant English language studies was undertaken (January 2000-February 2020). Methodological quality was evaluated using a Joanna Briggs Institute quality appraisal checklist. Article screening and quality appraisals were performed by 2 reviewers. Reference lists of included studies were hand-searched for additional articles. Reporting followed PRISMA Extension for Scoping Reviews (PRISMA-ScR) standards. RESULTS From 181 citations, 10 articles met inclusion criteria. Eight studies evaluated cost impacts on acute care and there were 2 cost-modeling studies. Results consistently indicated that effective VAP bundle implementation decreased healthcare costs. However, studies were heterogeneous with respect to research methods and objectives and were judged to have a moderate-to-high risk of bias. DISCUSSION Effective implementation of VAP care bundles was associated with superior clinical and economic outcomes. However, despite finding a moderate volume of research, study heterogeneity inhibited strong conclusions being drawn regarding the degree of associated cost savings. CONCLUSION Additional research involving multisite/multijurisdiction studies using experimental designs are needed to progress the field and overcome gaps in the existing literature.
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Elliott TM, Hare N, Hajkowicz K, Hurst T, Doidge M, Harris PN, Gordon LG. Evaluating the economic effects of genomic sequencing of pathogens to prioritise hospital patients competing for isolation beds. AUST HEALTH REV 2021; 45:59-65. [PMID: 33049199 DOI: 10.1071/ah20071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/18/2020] [Indexed: 11/23/2022]
Abstract
Objective This study compared the costs and patient movements of a new hospital protocol to discontinue contact precautions for patients with non-multiresistant methicillin-resistant Staphylococcus aureus (nmMRSA), based on whole-genome sequencing (WGS) of pathogens with current practice. Methods A hybrid simulation model was constructed and analysed over a 12-month time horizon. Six multidrug-resistant organisms and influenza were modelled concurrently where infected patients competed for isolation beds. Model inputs included pathogen incidence, resources for WGS, staff and contact precautions, hospital processes, room allocations and their associated costs. Data were sourced from aggregated records of patient admissions during 2017-18, clinical records and published reports. Results The WGS protocol resulted in 389 patients isolated (44% of current practice), 5223 'isolation bed days' (56%) and 268 closed-bed days (88%). Over 1 year, the mean (±s.d.) total cost for the WGS protocol was A$749243±126667; compared with current practice, the overall cost savings were A$690864±300464. Conclusion Using WGS to inform infection control teams of pathogen transmission averts patients from isolation rooms and reduces significant resources involved in implementing contact precautions. What is known about the topic? There are an estimated 265000 hospital-acquired infections (HAI) in Australia each year. WGS can accurately identify the genetic lineage among HAIs and determine transmission clusters that can help infection control staff manage patients. Economic appraisals are lacking to inform whether pathogen genomics services should be adopted within already-stretched hospital budgets. What does this paper add? An isolation protocol using pathogen genomics to provide additional information on the relatedness of a pathogen between colonised patients showed favourable results for healthcare costs and patient flow. Using WGS, in a confirmatory role, to discontinue certain patients from contact precautions and isolation rooms resulted in cost savings of A$690864 across 1 year for a single major hospital. What are the implications for practitioners? Using pathogen WGS services for infection control potentially curbs hospital spending, averts patient isolations and improves patient flow within hospitals.
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Affiliation(s)
- Thomas M Elliott
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Qld 4006, Australia. ; ; and Corresponding author.
| | - Nicole Hare
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Qld 4006, Australia. ;
| | - Krispin Hajkowicz
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia. ; ; ; and The University of Queensland, Centre for Clinical Research, Building 71/918, Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
| | - Trish Hurst
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia. ; ;
| | - Michelle Doidge
- Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia. ; ;
| | - Patrick N Harris
- The University of Queensland, Centre for Clinical Research, Building 71/918, Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Qld 4006, Australia. ; ; and The University of Queensland, School of Public Health, 266 Herston Road, Herston, Qld 4006, Australia; and Queensland University of Technology, School of Nursing, QUT N Block, Ring Road, Kelvin Grove, Qld 4059, Australia
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20
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Estimating the excess bed days and economic burden of healthcare-associated infections in Singapore public acute-care hospitals. Infect Control Hosp Epidemiol 2021; 43:1245-1248. [PMID: 34016198 DOI: 10.1017/ice.2021.165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We estimated the annual bed days lost and economic burden of healthcare-associated infections to Singapore hospitals using Monte Carlo simulation. The mean (standard deviation) cost of a single healthcare-associated infection was S$1,809 (S$440) [or US$1,362 (US$331)]. This translated to annual lost bed days and economic burden of 55,978 (20,506) days and S$152.0 million (S$37.1 million) [or US$114.4 million (US$27.9 million)], respectively.
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21
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Gordon LG, Elliott TM, Forde B, Mitchell B, Russo PL, Paterson DL, Harris PNA. Budget impact analysis of routinely using whole-genomic sequencing of six multidrug-resistant bacterial pathogens in Queensland, Australia. BMJ Open 2021; 11:e041968. [PMID: 33526501 PMCID: PMC7852923 DOI: 10.1136/bmjopen-2020-041968] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To predict the cost and health effects of routine use of whole-genome sequencing (WGS) of bacterial pathogens compared with those of standard of care. DESIGN Budget impact analysis was performed over the following 5 years. Data were primarily from sequencing results on clusters of multidrug-resistant organisms across 27 hospitals. Model inputs were derived from hospitalisation and sequencing data, and epidemiological and costing reports, and included multidrug resistance rates and their trends. SETTING Queensland, Australia. PARTICIPANTS Hospitalised patients. INTERVENTIONS WGS surveillance of six common multidrug-resistant organisms (Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Klebsiella pneumoniae, Enterobacter sp and Acinetobacter baumannii) compared with standard of care or routine microbiology testing. PRIMARY AND SECONDARY OUTCOMES Expected hospital costs, counts of patient infections and colonisations, and deaths from bloodstream infections. RESULTS In 2021, 97 539 patients in Queensland are expected to be infected or colonised with one of six multidrug-resistant organisms with standard of care testing. WGS surveillance strategy and earlier infection control measures could avoid 36 726 infected or colonised patients and avoid 650 deaths. The total cost under standard of care was $A170.8 million in 2021. WGS surveillance costs an additional $A26.8 million but was offset by fewer costs for cleaning, nursing, personal protective equipment, shorter hospital stays and antimicrobials to produce an overall cost savings of $30.9 million in 2021. Sensitivity analyses showed cost savings remained when input values were varied at 95% confidence limits. CONCLUSIONS Compared with standard of care, WGS surveillance at a state-wide level could prevent a substantial number of hospital patients infected with multidrug-resistant organisms and related deaths and save healthcare costs. Primary prevention through routine use of WGS is an investment priority for the control of serious hospital-associated infections.
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Affiliation(s)
- Louisa G Gordon
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Thomas M Elliott
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Brian Forde
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- The University of Queensland, Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Brett Mitchell
- School of Nursing and Midwifery, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Philip L Russo
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
| | - David L Paterson
- The University of Queensland, Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Patrick N A Harris
- The University of Queensland, Centre for Clinical Research, Brisbane, Queensland, Australia
- Pathology Queensland, Queensland Health, Brisbane, Queensland, Australia
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Austin EJ, Neukirch J, Ong TD, Simpson L, Berger GN, Keller CS, Flum DR, Giusti E, Azen J, Davidson GH. Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care. J Gen Intern Med 2021; 36:358-365. [PMID: 32869191 PMCID: PMC7878619 DOI: 10.1007/s11606-020-06140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.
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Affiliation(s)
- Elizabeth J. Austin
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jen Neukirch
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Thuan D. Ong
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, WA USA
| | - Louise Simpson
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Gabrielle N. Berger
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Carolyn Sy Keller
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - David R Flum
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Elaine Giusti
- Center for Clinical Excellence, University of Washington, Seattle, WA USA
| | - Jennifer Azen
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Giana H. Davidson
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
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23
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Cost-effectiveness analysis of whole-genome sequencing during an outbreak of carbapenem-resistant Acinetobacter baumannii. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e62. [PMID: 36168472 PMCID: PMC9495627 DOI: 10.1017/ash.2021.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/12/2022]
Abstract
Background: Whole-genome sequencing (WGS) shotgun metagenomics (metagenomics) attempts to sequence the entire genetic content straight from the sample. Diagnostic advantages lie in the ability to detect unsuspected, uncultivatable, or very slow-growing organisms. Objective: To evaluate the clinical and economic effects of using WGS and metagenomics for outbreak management in a large metropolitan hospital. Design: Cost-effectiveness study. Setting: Intensive care unit and burn unit of large metropolitan hospital. Patients: Simulated intensive care unit and burn unit patients. Methods: We built a complex simulation model to estimate pathogen transmission, associated hospital costs, and quality-adjusted life years (QALYs) during a 32-month outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). Model parameters were determined using microbiology surveillance data, genome sequencing results, hospital admission databases, and local clinical knowledge. The model was calibrated to the actual pathogen spread within the intensive care unit and burn unit (scenario 1) and compared with early use of WGS (scenario 2) and early use of WGS and metagenomics (scenario 3) to determine their respective cost-effectiveness. Sensitivity analyses were performed to address model uncertainty. Results: On average compared with scenario 1, scenario 2 resulted in 14 fewer patients with CRAB, 59 additional QALYs, and $75,099 cost savings. Scenario 3, compared with scenario 1, resulted in 18 fewer patients with CRAB, 74 additional QALYs, and $93,822 in hospital cost savings. The likelihoods that scenario 2 and scenario 3 were cost-effective were 57% and 60%, respectively. Conclusions: The use of WGS and metagenomics in infection control processes were predicted to produce favorable economic and clinical outcomes.
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Lee XJ, Elliott TM, Harris PNA, Douglas J, Henderson B, Watson C, Paterson DL, Schofield DS, Graves N, Gordon LG. Clinical and Economic Outcomes of Genome Sequencing Availability on Containing a Hospital Outbreak of Resistant Escherichia coli in Australia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:994-1002. [PMID: 32828227 DOI: 10.1016/j.jval.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/12/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate the outbreak size and hospital cost effects of bacterial whole-genome sequencing availability in managing a large-scale hospital outbreak. METHODS We built a hybrid discrete event/agent-based simulation model to replicate a serious bacterial outbreak of resistant Escherichia coli in a large metropolitan public hospital during 2017. We tested the 3 strategies of using whole-genome sequencing early, late (actual outbreak), or not using it and assessed their associated outbreak size and hospital cost. The model included ward dynamics, pathogen transmission, and associated hospital costs during a 5-month outbreak. Model parameters were determined using data from the Queensland Hospital Admitted Patient Data Collection (N = 4809 patient admissions) and local clinical knowledge. Sensitivity analyses were performed to address model and parameter uncertainty. RESULTS An estimated 197 patients were colonized during the outbreak, with 75 patients detected. The total outbreak cost was A$460 137 (US$317 117), with 6.1% spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients, costing A$766 921 (US$528 547). With earlier detection from use of routine sequencing, the estimated outbreak size was 3 patients and cost A$65 374 (US$45 054). CONCLUSIONS Using whole-genome sequencing in hospital outbreak management was associated with smaller outbreaks and cost savings, with sequencing costs as a small fraction of total hospital costs, supporting the further investigation of the use of routine whole-genome sequencing in hospitals.
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Affiliation(s)
- Xing J Lee
- Queensland University of Technology (QUT), Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovations, Kelvin Grove, Queensland, Australia
| | - Thomas M Elliott
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Patrick N A Harris
- Queensland Health, Pathology Queensland, Herston, Queensland, Australia; University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | - Joel Douglas
- Queensland Health, Pathology Queensland, Herston, Queensland, Australia
| | - Belinda Henderson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Catherine Watson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | | | - Nicholas Graves
- Queensland University of Technology (QUT), Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovations, Kelvin Grove, Queensland, Australia
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia; Queensland Health, Pathology Queensland, Herston, Queensland, Australia; Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Queensland, Australia; School of Public Health, The University of Queensland, Herston, Queensland, Australia.
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25
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White NM, Barnett AG, Hall L, Mitchell BG, Farrington A, Halton K, Paterson DL, Riley TV, Gardner A, Page K, Gericke CA, Graves N. Cost-effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare-associated Infections. Clin Infect Dis 2020; 70:2461-2468. [PMID: 31359053 PMCID: PMC7286366 DOI: 10.1093/cid/ciz717] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/29/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. METHODS A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. RESULTS Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. CONCLUSIONS A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.
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Affiliation(s)
- Nicole M White
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Western Australia
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Western Australia
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - Lisa Hall
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
- School of Public Health, University of Queensland, Brisbane, Western Australia
| | - Brett G Mitchell
- Discipline of Nursing, Avondale College of Higher Education, Wahroonga, New South Wales, Western Australia
- School of Nursing and Midwifery, University of Newcastle, New South Wales, Western Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Western Australia
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - Kate Halton
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Crawley, Western Australia
| | - Thomas V Riley
- School of Biomedical Sciences, The University of Western Australia, Crawley, Western Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia
- School of Veterinary and Life Sciences, Murdoch University, Western Australia,, Cairns, Queensland, Australia
| | - Anne Gardner
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - Katie Page
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
| | - Christian A Gericke
- School of Clinical Medicine, University of Queensland, Cairns, Queensland, Brisbane, Australia
- College of Public Health, Medical and Veterinary Sciences, and College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Western Australia
- School of Public Healt, New South Wales,h and Social Work, Queensland University of Technology, Brisbane, Western Australia
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26
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Elliott TM, Lee XJ, Foeglein A, Harris PN, Gordon LG. A hybrid simulation model approach to examine bacterial genome sequencing during a hospital outbreak. BMC Infect Dis 2020; 20:72. [PMID: 31973703 PMCID: PMC6979342 DOI: 10.1186/s12879-019-4743-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/27/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital infection control requires timely detection and identification of organisms, and their antimicrobial susceptibility. We describe a hybrid modeling approach to evaluate whole genome sequencing of pathogens for improving clinical decisions during a 2017 hospital outbreak of OXA-181 carbapenemase-producing Escherichia coli and the associated economic effects. Methods Combining agent-based and discrete-event paradigms, we built a hybrid simulation model to assess hospital ward dynamics, pathogen transmission and colonizations. The model was calibrated to exactly replicate the real-life outcomes of the outbreak at the ward-level. Seven scenarios were assessed including genome sequencing (early or late) and no sequencing (usual care). Model inputs included extent of microbiology and sequencing tests, patient-level data on length of stay, hospital ward movement, cost data and local clinical knowledge. The main outcomes were outbreak size and hospital costs. Model validation and sensitivity analyses were performed to address uncertainty around data inputs and calibration. Results An estimated 197 patients were colonized during the outbreak with 75 patients detected. The total outbreak cost was US$318,654 with 6.1% of total costs spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients costing US$531,109. Microbiology tests were the largest cost component across all scenarios. Conclusion A hybrid simulation approach using the advantages of both agent-based and discrete-event modeling successfully replicated a real-life bacterial hospital outbreak as a foundation for evaluating clinical outcomes and efficiency of outbreak management. Whole genome sequencing of a potentially serious pathogen appears effective in containing an outbreak and minimizing hospital costs.
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Affiliation(s)
- Thomas M Elliott
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, Q4006, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, 4059, Australia
| | - Anna Foeglein
- Heisenberg Analytics, Indooroopilly, QLD, 4068, Australia
| | - Patrick N Harris
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - Louisa G Gordon
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, Q4006, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia.,School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Q4059, Australia
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Mohan K, Ellanti P, Hadidi O, Moore DC, Hogan N, McCarthy T. Predisposing Factors and Outcomes After Prolonged Admission Following Hip Fracture. Cureus 2019; 11:e6044. [PMID: 31824810 PMCID: PMC6886651 DOI: 10.7759/cureus.6044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/30/2019] [Indexed: 01/02/2023] Open
Abstract
Introduction Hip fractures are increasingly prevalent and can result in substantial morbidity, mortality, and cost. Despite the existence of enhanced management strategies, prolonged hip fracture admissions persist. This study's objective was to ascertain characteristics associated with a prolonged length of stay (LOS) and quantify return to baseline once discharged. Methods A retrospective audit of hip fractures over a four-year period was conducted, identifying patients with a LOS over 100 days. Demographics, comorbidities, pre- and post-admission function, and status were assessed. Patients sustaining inpatient hip fractures were excluded to negate the effect of initial admission on LOS. Results Seven hundred and eleven hip fractures were treated, of which 48 (6.8%) were suitable for inclusion. The patients' median age and LOS was 83.5 years and 153 days, respectively. Preoperative American Society of Anesthesiologists - Physical Status (ASA-PS) Grades II and III predominated at 41.7% and 39.6%, respectively. Eighteen of patients had a diagnosis of dementia before admission, increasing to 29 on discharge (P = 0.0026). One patient was in long-term care prior to admission, rising to 30 on discharge (P < 0.0001), with only 25.6% returning to pre-admission residential status (P < 0.0001). Nineteen patients were mobilising unaided prior to admission, decreasing to only two following discharge, with a mere 37.1% returning to their pre-admission mobility baseline (P < 0.0001). Discussion Hip fracture patients with multiple comorbidities or a diagnosis of dementia were most likely to have a prolonged LOS which, in turn, impacted upon return to baseline mobility, cognitive status, and independence. Early identification and management of this cohort may help reduce the potential disease burden and economic effects that a prolonged LOS creates.
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Affiliation(s)
- Kunal Mohan
- Orthopaedics, St. James's Hospital, Dublin, IRL
| | | | - Omar Hadidi
- Orthopaedics, St. James's Hospital, Dublin, IRL
| | | | - Niall Hogan
- Orthopaedics and Trauma, St. James's Hospital, Dublin, IRL
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Blythe R, Kularatna S, White N, Graves N, Clark K, Middleton H, Grimley R. Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP). Age Ageing 2019; 48:745-750. [PMID: 31297515 DOI: 10.1093/ageing/afz086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/15/2019] [Accepted: 06/19/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions. METHODS a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort. RESULTS pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode. CONCLUSION the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.
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Affiliation(s)
- Robin Blythe
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queenland University of Technology, Kelvin Grove, Queensland, Australia
| | - Kevin Clark
- Metro North Hospital and Health Service, Brisbane, Australia
| | | | - Rohan Grimley
- Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
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Mohan K, Ellanti P, French H, Hogan N, McCarthy T. Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review. Orthop Rev (Pavia) 2019; 11:7963. [PMID: 31316738 PMCID: PMC6603431 DOI: 10.4081/or.2019.7963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 01/10/2023] Open
Abstract
Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.
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Affiliation(s)
- Kunal Mohan
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Prasad Ellanti
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
| | - Helen French
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niall Hogan
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
| | - Tom McCarthy
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
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Mitchell BG, Fasugba O, Cheng AC, Gregory V, Koerner J, Collignon P, Gardner A, Graves N. Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis. Int J Nurs Stud 2019; 97:1-6. [PMID: 31129443 DOI: 10.1016/j.ijnurstu.2019.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Catheter associated urinary tract infections are one of the most common infections acquired in hospital. A recent randomised control study demonstrated the benefit of using chlorhexidine (0.1%) for meatal cleaning prior to urinary catheter insertion, by reducing both catheter associated asymptomatic bacteriuria and infection. These findings raise the important question of whether a decision to switch from saline to chlorhexidine was likely to be cost-effective. The aim of this paper was to evaluate the cost-effectiveness of adopting routine use of chlorhexidine for meatal cleaning prior to urinary catheter insertion METHODS: The outcomes of this cost-effectiveness study are changes to health service costs in $AUD and changes to quality adjusted life years from a decision to adopt 0.1% chlorhexidine for meatal cleaning prior to urinary catheter insertion as compared to saline. Effectiveness outcomes for this study were taken from a 32 week stepped wedge randomised controlled study conducted in three Australian hospitals. RESULTS The changes in health costs from switching from saline to 0.1% chlorhexidine per 100,000 catheterisations would save hospitals AUD$387,909 per 100,000 catherisations, prevent 70 cases of catheter associated urinary tract infections, release 282 bed days and provide a small improvement in health benefits of 1.43 quality adjusted life years. Using a maximum willingness to pay for a marginal quality adjusted life year threshold of AUD$28,000 per 100,000 catherisations, suggests that adopting chlorhexidine would be cost effective and potentially cost-saving. CONCLUSION The findings from our work provide evidence to health system administrators and those responsible for drafting catheter associated urinary tract infections prevention guidelines that investing in switching from saline to chlorhexidine is not only clinically effective but also a sensible decision in the context of allocating finite healthcare resources.
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Affiliation(s)
- Brett G Mitchell
- Faculty of Arts, Nursing and Theology, Avondale College of Higher Education, 185 Fox Valley Road, Wahroonga, New South Wales 2076, Australia; School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia.
| | - Oyebola Fasugba
- Nursing Research Institute, Australian Catholic University & St Vincent's Health Australia Sydney, New South Wales, Australia; Lifestyle Research Centre, Avondale College of Higher Education, Cooranbong, New South Wales, Australia
| | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Infectious Prevention and Healthcare Epidemiology Unit, Alfred Hospital, Melbourne, Australia
| | - Victoria Gregory
- Faculty of Arts, Nursing and Theology, Avondale College of Higher Education, 185 Fox Valley Road, Wahroonga, New South Wales 2076, Australia
| | - Jane Koerner
- School of Nursing, Midwifery and Paramedicine Australian Catholic University, Watson Australia
| | - Peter Collignon
- Australian Capital Territory Pathology, Canberra Hospital and Health Services, Yamba Drive, Garran, Australian Capital Territory 2605, Australia; Medical School, Australian National University, Acton, Australian Capital Territory 2601, Australia
| | - Anne Gardner
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
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Brain D, Tulleners R, Lee X, Cheng Q, Graves N, Pacella R. Cost-effectiveness analysis of an innovative model of care for chronic wounds patients. PLoS One 2019; 14:e0212366. [PMID: 30840658 PMCID: PMC6402622 DOI: 10.1371/journal.pone.0212366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/31/2019] [Indexed: 11/27/2022] Open
Abstract
Current provision of services for the care of chronic wounds in Australia is disjointed and costly. There is large variability in the way that services are provided, and little evidence regarding the cost-effectiveness of a specialist model of care for treatment and management. A decision-analytic model to evaluate the cost-effectiveness of a specialist wound care clinic as compared to usual care for chronic wounds is presented. We use retrospective and prospective data from a cohort of patients as well as information from administrative databases and published literature. Our results show specialist wound clinics are cost-effective for the management of chronic wounds. On average, specialist clinics were $3,947 cheaper than usual clinics and resulted in a quality adjusted life year gain of 0.04 per patient, per year. Specialist clinics were the best option under multiple scenarios including a different cost perspective and when the cost of a hospital admission was reduced. Current models of care are inefficient and represent low value care, and specialist wound clinics represent a good investment compared to current approaches for the management of chronic wounds in Australia.
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Affiliation(s)
- David Brain
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Wound Management Innovations Cooperative Research Centre, Brisbane, Australia
- * E-mail:
| | - Ruth Tulleners
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Wound Management Innovations Cooperative Research Centre, Brisbane, Australia
| | - Xing Lee
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Qinglu Cheng
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Wound Management Innovations Cooperative Research Centre, Brisbane, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Wound Management Innovations Cooperative Research Centre, Brisbane, Australia
| | - Rosana Pacella
- Australian Centre for Health Services Innovation (AusHSI), Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Wound Management Innovations Cooperative Research Centre, Brisbane, Australia
- The University of Chichester, West Sussex, United Kingdom
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Wozniak TM, Barnsbee L, Lee XJ, Pacella RE. Using the best available data to estimate the cost of antimicrobial resistance: a systematic review. Antimicrob Resist Infect Control 2019; 8:26. [PMID: 30733860 PMCID: PMC6359818 DOI: 10.1186/s13756-019-0472-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/14/2019] [Indexed: 12/02/2022] Open
Abstract
Background Valuation of the economic cost of antimicrobial resistance (AMR) is important for decision making and should be estimated accurately. Highly variable or erroneous estimates may alarm policy makers and hospital administrators to act, but they also create confusion as to what the most reliable estimates are and how these should be assessed. This study aimed to assess the quality of methods used in studies that quantify the costs of AMR and to determine the best available evidence of the incremental cost of these infections. Methods In this systematic review, we searched PubMed, Embase, Cinahl, Cochrane databases and grey literature sources published between January 2012 and October 2016. Articles reporting the additional burden of Enterococcus spp., Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) resistant versus susceptible infections were sourced. The included studies were broadly classified as reporting oncosts from the healthcare/hospital/hospital charges perspective or societal perspective. Risk of bias was assessed based on three methodological components: (1) adjustment for length of stay prior to infection onset and consideration of time-dependent bias, (2) adjustment for comorbidities or severity of disease, and (3) adjustment for inappropriate antibiotic therapy. Results Of 1094 identified studies, we identified 12 peer-reviewed articles and two reports that quantified the economic burden of clinically important resistant infections. Two studies used multi-state modelling to account for the timing of infection minimising the risk of time dependent bias and these were considered to generate the best available cost estimates. Studies report an additional CHF 9473 per extended-spectrum beta-lactamases -resistant Enterobacteriaceae bloodstream infections (BSI); additional €3200 per third-generation cephalosporin resistant Enterobacteriaceae BSI; and additional €1600 per methicillin-resistant S. aureus (MRSA) BSI. The remaining studies either partially adjusted or did not consider the timing of infection in their analysis. Conclusions Implementation of AMR policy and decision-making should be guided only by reliable, unbiased estimates of effect size. Generating these estimates requires a thorough understanding of important biases and their impact on measured outcomes. This will ensure that researchers, clinicians, and other key decision makers concerned with increasing public health threat of AMR are accurately guided by the best available evidence. Electronic supplementary material The online version of this article (10.1186/s13756-019-0472-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Teresa M Wozniak
- 1Centre for Research Excellence in Reducing Healthcare Associated Infections, Queensland University of Technology (QUT), Brisbane, QLD Australia.,3Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Brisbane, QLD Australia.,5Menzies School of Health Research, Royal Darwin Hospital, Rocklands Drive, Tiwi, Darwin, Northern Territory 0810 Australia
| | - Louise Barnsbee
- 1Centre for Research Excellence in Reducing Healthcare Associated Infections, Queensland University of Technology (QUT), Brisbane, QLD Australia.,2Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, QLD Australia.,3Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Brisbane, QLD Australia
| | - Xing J Lee
- 1Centre for Research Excellence in Reducing Healthcare Associated Infections, Queensland University of Technology (QUT), Brisbane, QLD Australia.,2Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, QLD Australia.,3Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Brisbane, QLD Australia
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Osborne S, Harrison G, O'Malia A, Barnett AG, Carter HE, Graves N. Cohort study of a specialist social worker intervention on hospital use for patients at risk of long stay. BMJ Open 2018; 8:e023127. [PMID: 30580267 PMCID: PMC6307584 DOI: 10.1136/bmjopen-2018-023127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Long-stay patients in acute hospitals commonly present with complex psychosocial needs and use high levels of hospital resources. OBJECTIVE To determine whether a specialist social worker-led model of care was associated with a reduction in length of stay for medically stable patients with complex psychosocial needs who were at risk of long stay, and to determine the economic value of this model relative to the decision makers' willingness to pay for bed days released. DESIGN A prospective, matched cohort study with historical controls. SETTING A large, tertiary teaching and referral hospital in metropolitan Southeast Queensland, Australia. METHODS Length of hospital stay for a cohort of patients seen under the specialist social worker-led model of care was compared with a matched control group of patients admitted to the hospital prior to the introduction of the new model of care using a multistate model with the social worker model of care as an intermediate event. Costs associated with the model of care were calculated and an estimate of the 'cost per bed day' was produced. RESULTS The model of care reduced mean length of stay by 33 days. This translated to 9999 bed days released over 12 months. The cost to achieve this was estimated to be $A229 000 over 12 months. The cost per bed day released was $23, which is below estimates of hospital decision makers' willingness to pay for a bed day to be released for an alternate use. CONCLUSIONS The specialist social worker-led model of care was associated with a reduced length of stay at a relatively low cost. This is likely to represent a cost-effective use of hospital resources. The limitations of our historic control cohort selection mean that results should be interpreted with caution. Further research is needed to confirm these findings.
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Affiliation(s)
- Sonya Osborne
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Gai Harrison
- Department of Social Work, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Angela O'Malia
- Department of Social Work, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Adrian Gerard Barnett
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Graves N. Make economics your friend. J Hosp Infect 2018; 100:123-129. [DOI: 10.1016/j.jhin.2018.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/30/2022]
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Hübner C, Ried W, Flessa S. Assessing the opportunity costs of patients with multidrug-resistant organisms in hospitals. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:1009-1017. [PMID: 29247340 DOI: 10.1007/s10198-017-0949-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/07/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The concept of opportunity cost can be applied to the utilization of hospital beds with special focus on patients colonized or infected with multidrug-resistant organisms. Blocked beds due to isolation measures or increased length of stay may result in opportunity costs if newly arriving patients have to be rejected and the hospital is confronted with revenue foregone. However, the amount of these costs is unclear, since different approaches are used in the literature to determine the respective costs. Our paper develops a concept to assess opportunity costs from the perspective of a hospital. METHODS The analysis is two-stage. In a first step, the probability of rejecting a patient due to over-occupancy in a hospital is calculated with a queuing model and a Monte Carlo simulation taking various assumptions into account. In a second step, the amount of the opportunity costs is calculated as an expected value applying a stochastic approach based on a potential patient pool. RESULTS Opportunity costs will occur only with a probability that is influenced, among others, by current bed occupancy rates. They have to be measured by average net revenue foregone, i.e., by the difference between average revenue foregone and average costs avoided. CONCLUSIONS Previous studies have a tendency of overestimating the occurrence or the size of opportunity costs with regard to the use of hospital beds. Nonetheless, its influence on the hospital budget is crucial and should be determined exactly.
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Affiliation(s)
- Claudia Hübner
- Chair of Health Care Management, Faculty of Law and Economics, University of Greifswald, F.-Loeffler-Str. 70, Greifswald, Germany.
| | - Walter Ried
- Chair of Public Finance, Faculty of Law and Economics, University of Greifswald, Greifswald, Germany
| | - Steffen Flessa
- Chair of Health Care Management, Faculty of Law and Economics, University of Greifswald, F.-Loeffler-Str. 70, Greifswald, Germany
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Barnett AG, Stewart I, Beevers A, Fraser JF, Platts D. Thermal clothing to reduce heart failure morbidity during winter: a randomised controlled trial. BMJ Open 2017; 7:e017592. [PMID: 28993390 PMCID: PMC5640030 DOI: 10.1136/bmjopen-2017-017592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To examine whether providing thermal clothing improved the health of patients with heart failure during winter. DESIGN Parallel group randomised controlled trial. SETTING Large public hospital in Brisbane during winter 2016. PARTICIPANTS 91 patients with systolic or diastolic heart failure who were over 50 years old. INTERVENTION 47 patients were randomised to receive thermal clothes (socks, top and hat) and 44 received usual care. Patients could not be blinded to their randomised group. All patients' data were available for the primary outcome which was collected blind to randomised group. MAIN OUTCOME MEASURES The primary outcome was the mean number of days in hospital during winter. Secondary outcomes included quality of life and sleep, and blood tests were collected for cardiovascular risk factors. Participants completed clothing diaries in midwinter which were used to estimate their overall clothing insulation using the 'clo'. Monitors inside the participants' homes recorded indoor temperatures throughout winter. RESULTS The mean number of days in hospital during winter was 4.2 in the usual care group and 3.0 in the thermal clothing group (mean difference -1.2 days, 95% CI -4.8 to 2.5 days). Most participants (85%) in the thermal clothing group reported using the thermals. There was an increase in overall clothing insulation at night in the thermal clothing group (mean difference 0.13 clo, 95% CI 0.03 to 0.23). Most participants in both groups did not wear sufficient clothing (defined as a clo below 1) and regularly experienced indoor temperatures below 18°C during midwinter. CONCLUSIONS There was no clear statistical improvement in health in the thermal clothing group. Efforts to improve health during winter may need to focus on passive interventions such as home insulation rather than interventions that target behaviour change. TRIAL REGISTRATION NUMBER ACTRN12615001023549; Results.
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Affiliation(s)
- Adrian Gerard Barnett
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Ian Stewart
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Andrea Beevers
- Queensland Health, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - John F Fraser
- Critical Care Research Group (CCRG), The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - David Platts
- Critical Care Research Group (CCRG), The Prince Charles Hospital, Brisbane, Queensland, Australia
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