Morbidity and cost burden of prenatal myelomeningocele repair.

OBJECTIVE: This study compared the morbidities and financial burden associated with prenatal open myelomeningocele repair versus postnatal repair. MATERIALS AND METHODS: The retrospective study cohort included 23 mother-infant dyads undergoing prenatal repair and 30 with postnatal repair. Financial, demographic, and medical information were obtained for mother-infant dyads from each infant's birth through the first year of life. RESULTS: Infants in the prenatal repair group were significantly affected by sequelae of prematurity, including apnea, bronchopulmonary dysplasia, and retinopathy of prematurity. Importantly, fewer of these infants required ventriculoperitoneal shunt procedures and the overall improved composite outcome of shunting or death. Infants in the postnatal repair group required more hospital readmissions in the first year of life. Financial costs for mother-infant dyads in the prenatal repair group were higher, driven by the length of stay in the neonatal intensive care unit and maternal hospital admissions. Kaplan-Meier curves analyzing the relative contributions of the length of stay and total charges in the population were constructed. The maternal contribution was markedly different between groups due to postoperative hospitalization, readmission, and close fetal surveillance required. Though these differences did not reach statistical significance, it highlights an important burden on families and the medical system. CONCLUSIONS: This is the first study to report the contributions of prematurity in relation to maternal and infant morbidity and financial costs. The benefits of prenatal myelomeningocele repair include lower risk for ventriculoperitoneal shunting and fewer hospital readmissions. The risk of preterm birth and its neonatal sequelae continue to be a significant burden.

The investment case for preventing NICU-associated infections.

BACKGROUND: Nosocomial [hospital-associated or neonatal intensive care unit (NICU)-associated] infections occur in as many as 10 to 36% of very low-birth-weight infants cared for in NICUs. OBJECTIVE: To determine the potentially avoidable, incremental costs of care associated with NICU-associated bloodstream infections. STUDY DESIGN: This retrospective study included all NICU admissions of infants weighing 401 to 1500 g at birth in the greater Cincinnati region from January 1, 2005, through December 31, 2007. Nonphysician costs of care were compared between infants who developed at least one bacterial bloodstream infection prior to NICU discharge or death and infants who did not. Costs were adjusted for clinical and demographic characteristics that are present in the first 3 days of life and are known associates of infection. RESULTS: Among 900 study infants with no congenital anomaly and no major surgery, 82 (9.1%) developed at least one bacterial bloodstream infection. On average, the cost of NICU care was $16,800 greater per infant who experienced NICU-associated bloodstream infection. CONCLUSION: Potentially avoidable costs of care associated with bloodstream infection can be used to justify investments in the reliable implementation of evidence-based interventions designed to prevent these infections.

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: Business case for quality improvement.

OBJECTIVE: To determine whether catheter-associated bloodstream infections were associated with increased lengths of stay in pediatric intensive care units and hospitals and increased healthcare costs in critically ill children. Previous studies have shown that hospital-acquired bloodstream infections are associated with longer stays in pediatric intensive care units, increased hospital costs, and increased hospital mortality. Catheter-associated bloodstream infections comprise the vast majority of hospital-acquired bloodstream infections. DESIGN: Retrospective, case-matched, cohort study and financial analysis. SETTING: University-affiliated children's medical center. PATIENTS: Twenty-two critically ill children with catheter-associated bloodstream infections and their matched controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the length of stay, mortality, and hospital costs in critically ill children with catheter-associated bloodstream infections and matched controls. The presence of catheter-associated bloodstream infections extended the entire hospital length of stay by 9 days (6.5 days while in the pediatric intensive care unit) and increased hospital costs by $33,039, primarily driven by the increase in length of stay days. Quality improvement efforts directed at reducing the prevalence of catheter-associated bloodstream infections during the period of study decreased total hospital days by 354, reduced total hospital costs by $1,298,271, and reduced total costs to payers by $1,415,676. CONCLUSION: The potential cost savings from reducing or eliminating catheter-associated bloodstream infections in the pediatric intensive care unit are significant. Elimination of catheter-associated bloodstream infections will directly reduce hospital costs, improve asset utilization, and most importantly, improve clinical care.

The business case for preventing ventilator-associated pneumonia in pediatric intensive care unit patients.

BACKGROUND: A retrospective matched (1:1) case-control study was conducted to compare the financial impact and costs attributable to ventilator-associated pneumonia (VAP) in a 25-bed pediatric intensive care unit (PICU) in a 475-bed quaternary-care pediatric hospital from the perspective of multiple stakeholders, including the hospital and payors. METHODS: For PICU patients with VAP from January 1 2005, to December 31, 2005, 13 patients were matched to 13 control patients by age, sex, severity of illness, primary diagnosis, underlying illness, surgical procedures, and duration of mechanical ventilation. RESULTS: The mean hospital length of stay (LOS) for VAP patients was 26.5 +/- 13.1 days compared with 17.8 +/- 4.7 days for non-VAP patients (p = .032). The hospital LOS attributable to VAP was 8.7 days. The mean hospital costs for VAP patients was $156,110 +/- $80,688 compared with $104,953 +/- $59,191 for non-VAP patients (p = 0.026). The attributable VAP costs were $51,157. After implementation of the VAP prevention bundle, VAP rates decreased from 7.8 cases per 1,000 ventilator days in fiscal year (FY) 2005 to 0.5 cases per 1,000 ventilator days in FY 2007 (VAP infections: 24 in FY 2005, 9 in FY 2006, 2 in FY 2007; p < 0.001). This reduced hospital days by 400, reduced unreimbursed cost of care by $442,789, reduced hospital costs by $2,353,222, and reduced cost to payors by $2,653,710 for FY 2006 and FY 2007 combined. DISCUSSION: This study provides the first demonstration of significant, sustained reductions in pediatric VAP rates following the implementation of the VAP prevention bundle and the first business case analysis of this pediatric-specific intervention as described from the perspective of multiple stakeholders. A return on investment may speed health care organizations' investment in patient safety and quality improvement.

Financial impact of failing to prevent surgical site infections.

BACKGROUND: Despite advances in infection-control practices, surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, and increased costs among hospitalized patients. METHODS: We used a matched cohort design to compare costs and length of stay for 16 pediatric patients with an SSI with those of 16 matched control patients who had a similar operative procedure during the same time period but in whom an SSI did not develop. RESULTS: On average, length of stay was increased by 10.6 days (P = .02) and costs were increased by $27,288 (P = .01) for each patient with a potentially preventable SSI. On the day of the surgical procedure, costs between study patients and matched controls differed by only 1.4%. By day 3, however, costs were 36% higher for patients with an SSI. CONCLUSIONS: While matching study patients and control patients requires significant time from financial and clinical staff, this approach and the resulting data analysis strengthened and focused our efforts to prevent future SSIs and aligned initiatives to reduce SSIs with the business case for quality.