Estimating the proportion of reasonably preventable hospitalacquired infections and associated mortality and costs

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Estimating the proportion of reasonably preventable hospitalacquired infections and associated mortality and costs CA Umscheid, MD, MSCE; MD Mitchell, PhD; JA Doshi, PhD; R Agarwal, MD, MPH; K Williams,
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Estimating the proportion of reasonably preventable hospitalacquired infections and associated mortality and costs CA Umscheid, MD, MSCE; MD Mitchell, PhD; JA Doshi, PhD; R Agarwal, MD, MPH; K Williams, MD, MPH; and PJ Brennan, MD Center for Evidence Based Practice Office of the Chief Medical Officer University of Pennsylvania Health System No disclosures Background Hospital acquired infections (s) are common, and numerous strategies to prevent them have been studied In Oct 08, Medicare began to encourage hospitals to adopt these strategies by instituting a policy of nonpayment for reasonably preventable s Some have asserted that not all s are preventable, and that this new incentive punishes hospitals that care for patients at high risk of s Objectives To inform discussions regarding the preventability of s, we estimated: ) the proportion of reasonably preventable s in US hospitals ) mortality and costs associated with reasonably preventable s Methods Range of preventability (%) X Annual number of s and deaths = Range of annual number of preventable s and deaths Range of annual number of preventable s X Incremental cost of s = Range of annual avoidable costs Methods. Range of preventability Use an AHRQ systematic review that examined published interventions to reduce,,, and We constructed ranges of preventability for each by using the lowest and highest risk reductions reported in the AHRQ review for higher quality US studies published in last decade. Annual number of s and deaths Use most recently published national data. Incremental cost of an Perform a systematic review of the published literature Use data from US studies reporting comprehensive cost analyses adjusted for confounders 5 Results: AHRQ Systematic Review Infection type Total studies included in AHRQ report Excluded on quality grounds Excluded: more than 0 years old Excluded: didn t report risk reductions for infections Excluded: non-us Included in this analysis studies included in our analysis Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin CM, et al. Volume 6--prevention of healthcareassociated infections. Rockville, MD: Agency for Healthcare Research and Quality; 007 January 007. Report No.: AHRQ Publication No. 0(07) Prevention Studies Author Year Study Design Setting Intervention Comp Risk before Risk after Risk Red. Good quality Babcock 00 Beforeafter study ICU Hand hygiene HOB 0 Daily interruption of sedation Clinician education Previous care % Zack 00 Beforeafter study ICU HOB 0 Clinician education Previous care % Moderate quality Lai 00 Beforeafter study ICU HOB 0 Clinician education Audit & feedback Previous care SICU: 5. MICU:. SICU: 7.9 MICU:.6 8% 8% Range of Risk Reductions = 8-55% 7 Range of Risk Reductions for all s Reduction in risk with QI 8% 66% 8% 55% 7% 69% 6% 5% 8 Hospital-acquired infections in 00 Type of Number of s 8,678 50,05 56,667 90,85 Deaths from s 0,665 5,967,088 8,05 Klevens RM, Edwards JR, Richards CL,Jr, Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 00. Public Health Rep. 007 Mar-Apr;(): Estimating s and Deaths s Deaths Reduction in risk with QI s deaths 50,05 5,967 8% 55% 95,078 7,6,667 9,78 0 5 Summary estimates of preventable s and deaths for all s s Deaths Reduction in infection risk with QI infections deaths 8,678 0,665 8% 66% 8,55 0,96 0,6-5,5 50,05 5,967 8% 55% 95,078 7,6,667 9,78 56,667,088 7% 69% 95,8 87,550,5 9,0 90,85 8,05 6% 5% 75,56 56,86,, Example Search: Cost Studies Search Syntax (exp Respiration, Artificial/ or mechanically ventilated$.ti. or intubated$.ti. or mechanical ventilation$.ti. or ventilator associated$.ti.) and (exp Cross infection/ or exp bacteremia/ or nosocomial$.ti,ab. or healthcare associated$.ti,ab. or hospital acquired$.ti,ab. or bundle$.ti,ab.) ((((Economics.mp. or exp Costs/) and Cost Analysis/) or Value of Life.mp. or exp Economics, Medical/ or exp Economics, Hospital/ or exp Economics, Nursing/ or exp Economics, Pharmaceutical/ or exp Fees/) and Charges/) or Budgets.mp. or exp Models, Economic/ or Markov Chains.mp. or Monte Carlo Method.mp. or Decision Trees.mp. or Quality of Life.mp. or Patient Satisfaction.mp. or Quality-Adjusted Life Years.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (econom$ or cost or costly or costing or costed or costs or price or prices or pricing or priced or discount or discounts or discounted or discounting or expenditure or expenditures or budget$ or afford$ or pharmacoeconomic$ or (pharmaco adj economic$) or (decision adj (tree$ or analy$ or model?)) or ((value or values or valuation) adj (money or monetary or life or lives)) or QOL or QOLY or QOLYs or HRQOL or QALY or QALYs or (quality adj life) or (willingness adj pay) or (quality adj adjusted?life?year?)).mp. and ( or ) Pneumonia, Ventilator-Associated/ec exp Respiration, Articifial/ae and exp Respiration, Artificial/ec or 5 or 6 Limit to (English language and yr= ) Articles retrieved Included in analysis Hits,60 79,85 55, Systematic Review to Estimate Incremental Cost of s Type of infection Number of initial hits Number of included articles 5 studies included in our analysis Cost Studies Author Lansford 007 () Cocanour 006 (8) Warren 00 () Rello 00 (9) Setting Kansas City Trauma ICU Houston Trauma ICU St. Louis Med/Surg ICUs Nationwide ICUs N Primary or secondary? Secondary Primary Primary Secondary Type Cost identification Cost identification Cost identification Cost identification Definition of infection By infection control team using NNISS criteria By infection control team using NNISS criteria By infection control team using NNISS criteria Not reported Control group Patients in same ICU without infection Matched on age and Injury Severity Score. Patients in same ICU without infection Matched on type of admission, predicted mortality, duration of ventilation, and age. Study design (cost component of study) Average total costs for patients with vs. patients without Average total costs for patients with vs. patients without Average total costs for patients with vs. patients without Average total charges for patients with vs. patients without Source of cost data (baseline year) Not reported 00-0 dollars Hospital cost accounting database, 00-0 dollars Hospital cost accounting database, dollars Hospital billed charges database, dollars Costs measured Total hospital costs/charges: details and overhead costs not reported Total ICU costs: details and overhead costs not reported All costs in database, including overhead All charges in database, overhead costs not reported Perspective / Horizon Hospital / Not reported Hospital/ ICU stay Hospital / Inpatient stay Hospital / Not reported Main economic outcome Mean incremental charges per hospitalization attributable to Mean incremental ICU costs per stay attributable to Adjusted mean incremental costs per hospitalization attributable to Mean incremental charges per hospitalization attributable to Adjusted results (008 dollars) No multivariate analysis No multivariate analysis mean: $,800 95% CI: $7,00-5,500 No multivariate analysis 7 Estimated incremental cost per Infection type Estimated cost per infection case (008 dollars) $0,00-$0,800 $,800 $,750 $,00 5 Summary estimates of preventable s, deaths, and costs s Deaths Reduction in infection risk with QI infections deaths Estimated cost per infection case (008 dollars) Avoidable costs (millions of 008 dollars) 50,05 5,967 8% 55% 95,078 7,6,667 9,78 $,800 $,07M- $,000M 6 8 Summary estimates of preventable infections, deaths, and costs for all s s 8,678 Deaths 0,665 Reduction in infection risk with QI 8% 66% infections 8,55 0,96 deaths 0,6-5,5 Estimated cost per infection case (008 dollars) $0,00- $0,800 Avoidable costs (millions of 008 dollars) $,708M-$,70M 50,05 5,967 8% 55% 95,078 7,6,667 9,78 $,800 $,07M-$,000M 56,667,088 7% 69% 95,8 87,550,5 9,0 $,750 $58M-$,5M 90,85 8,05 6% 5% 75,56 56,86,, $,00 $59M-$9M 7 Limitations Survey data we use to calculate number of s and deaths is from 00 Difficulty in attributing a death to s Quality of the reduction and cost studies Lack of reduction studies that have directly measured death as an outcome 8 9 Conclusions In those settings examined, reductions in s have never achieved 00%, even with evidence-based infection control strategies Instead, an upper bound of 65 to 70% risk reduction may exist for and, and approximately 55% for and 9 Conclusions Even though 00% preventability may not be attainable, evidence-based infection control strategies could prevent hundreds of thousands of s, and save tens of thousands of lives and billions of dollars One should not base policy decisions on these estimates without understanding their limitations 0 0 Implications Given the difficulty in preventing 00% of s, it may be more appropriate to use strategies other than the current payment schemes to encourage reduction Newer strategies could lessen the bias of current payment schemes against medical centers that care for the most medically complex patients
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