National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States.

BACKGROUND: Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US). METHODS: We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections. RESULTS: Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272-$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377-$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370-$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion-$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined. CONCLUSIONS: We found that antimicrobial-resistant infections led to substantial healthcare costs.

Measuring the Direct Medical Costs of Hospital-Onset Infections Using an Analogy Costing Framework.

BACKGROUND: The majority of recent estimates on the direct medical cost attributable to hospital-onset infections (HOIs) has focused on device- or procedure-associated HOIs. The attributable costs of HOIs that are not associated with device use or procedures have not been extensively studied. OBJECTIVE: We developed simulation models of attributable cost for 16 HOIs and estimated the total direct medical cost, including nondevice-related HOIs in the USA for 2011 and 2015. DATA AND METHODS: We used total discharge costs associated with HOI-related hospitalization from the National Inpatient Sample and applied an analogy costing methodology to develop simulation models of the costs attributable to HOIs. The mean attributable cost estimate from the simulation analysis was then multiplied by previously published estimates of the number of HOIs for 2011 and 2015 to generate national estimates of direct medical costs. RESULTS: After adjusting all estimates to 2017 US dollars, attributable cost estimates for select nondevice-related infections attributable cost estimates ranged from $7661 for ear, eye, nose, throat, and mouth (EENTM) infections to $27,709 for cardiovascular system infections in 2011; and from $8394 for EENTM to $26,445 for central nervous system infections in 2016 (based on 2015 incidence data). The national direct medical costs for all HOIs were $14.6 billion in 2011 and $12.1 billion in 2016. Nondevice- and nonprocedure-associated HOIs comprise approximately 26-28% of total HOI costs. CONCLUSION: Results suggest that nondevice- and nonprocedure-related HOIs result in considerable costs to the healthcare system.

Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods.

BACKGROUND: Hospitals will increasingly bear the costs for healthcare-acquired conditions such as infection. Our goals were to estimate the costs attributable to healthcare-acquired infection (HAI) and conduct a sensitivity analysis comparing analytic methods. METHODS: A random sample of high-risk adults hospitalized in the year 2000 was selected. Measurements included total and variable medical costs, length of stay (LOS), HAI site, APACHE III score, antimicrobial resistance, and mortality. Medical costs were measured from the hospital perspective. Analytic methods included ordinary least squares linear regression and median quantile regression, Winsorizing, propensity score case matching, attributable LOS multiplied by mean daily cost, semi-log transformation, and generalized linear modeling. Three-state proportional hazards modeling was also used for LOS estimation. Attributable mortality was estimated using logistic regression. RESULTS: Among 1253 patients, 159 (12.7%) developed HAI. Using different methods, attributable total costs ranged between $9310 to $21,013, variable costs were $1581 to $6824, LOS was 5.9 to 9.6 days, and attributable mortality was 6.1%. The semi-log transformation regression indicated that HAI doubles hospital cost. The totals for 159 patients were $1.48 to $3.34 million in medical cost and $5.27 million for premature death. Excess LOS totaled 844 to 1373 hospital days. CONCLUSIONS: Costs for HAI were considerable from hospital and societal perspectives. This suggests that HAI prevention expenditures would be balanced by savings in medical costs, lives saved and available hospital days that could be used by overcrowded hospitals to enhance available services. Our results obtained by applying different economic methods to a single detailed dataset may inform future cost analyses.

Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship.

BACKGROUND: Organisms resistant to antimicrobials continue to emerge and spread. This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI). METHODS: A sample of high-risk hospitalized adult patients was selected. Measurements included ARI, total cost, duration of stay, comorbidities, acute pathophysiology, Acute Physiology and Chronic Health Evaluation III score, intensive care unit stay, surgery, health care-acquired infection, and mortality. Hospital services used and outcomes were abstracted from electronic and written medical records. Medical costs were measured from the hospital perspective. A sensitivity analysis including 3 study designs was conducted. Regression was used to adjust for potential confounding in the random sample and in the sample expanded with additional patients with ARI. Propensity scores were used to select matched control subjects for each patient with ARI for a comparison of mean cost for patients with and without ARI. RESULTS: In a sample of 1391 patients, 188 (13.5%) had ARI. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4-12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7-$15.0 million. Using the lowest estimates from the sensitivity analysis resulted in a total cost of $13.35 million in 2008 dollars in this patient cohort. CONCLUSIONS: The attributable medical and societal costs of ARI are considerable. Data from this analysis could form the basis for a more comprehensive evaluation of the cost of resistance and the potential economic benefits of prevention programs.

Understanding the Economic Impact of Health Care-Associated Infections: A Cost Perspective Analysis.

The economic impacts from preventing health care-associated infections (HAIs) can differ for patients, health care providers, third-party payers, and all of society. Previous studies from the provider perspective have estimated an economic burden of approximately $10 billion annually for HAIs. The impact of using a societal cost perspective has been illustrated by modifying a previously published analysis to include the economic value of mortality risk reductions. The resulting costs to society from HAIs exceed $200 billion annually. This article describes an alternative hospital accounting framework outlining the cost of a quality model which can better incorporate the broader societal cost of HAIs into the provider perspective.

Assessing the social cost and benefits of a national requirement establishing antibiotic stewardship programs to prevent Clostridioides difficile infection in US hospitals.

Backgound: Economic evaluations of interventions to prevent healthcare-associated infections in the United States rarely take the societal perspective and thus ignore the potential benefits of morbidity and mortality risk reductions. Using new Department of Health and Human Services guidelines for regulatory impact analysis, we developed a cost-benefit analyses of a national multifaceted, in-hospital Clostridioides difficile infection prevention program (including staffing an antibiotic stewardship program) that incorporated value of statistical life estimates to obtain economic values associated with morbidity and mortality risk reductions. Methods: We used a net present value model to assess costs and benefits associated with antibiotic stewardship programs. Model inputs included treatment costs, intervention costs, healthcare-associated Clostridioides difficile infection cases, attributable deaths, and the value of statistical life which was used to estimate the economic value of morbidity and mortality risk reductions. Results: From 2015 to 2020, total net benefits of the intervention to the healthcare system range from $300 million to $7.6 billion when values for morbidity and mortality risk reductions are ignored. Including these values, the net social benefits of the intervention range from $21 billion to $624 billion with the annualized net benefit of $25.5 billion under our most likely outcome scenario. Conclusions: Incorporating the economic value of morbidity and mortality risk reductions in economic evaluations of healthcare-associated infections will significantly increase the benefits resulting from prevention.

Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.

STUDY OBJECTIVE: We describe cases referred for physician review because of concern about quality of patient care and identify factors that contributed to patient care management problems. METHODS: We performed a retrospective review of 636 cases investigated by an emergency department physician review committee at an urban public teaching hospital over a 15-year period. At referral, cases were initially investigated and analyzed, and specific patient care management problems were noted. Two independent physicians subsequently classified problems into 1 or more of 4 major categories according to the phase of work in which each occurred (diagnosis, treatment, disposition, and public health) and identified contributing factors that likely affected outcome (patient factors, triage, clinical tasks, teamwork, and system). Primary outcome measures were death and disability. Secondary outcome measures included specific life-threatening events and adverse events. Patient outcomes were compared with the expected outcome with ideal care and the likely outcome of no care. RESULTS: Physician reviewers identified multiple problems and contributing factors in the majority of cases (92%). The diagnostic process was the leading phase of work in which problems were observed (71%). Three leading contributing factors were identified: clinical tasks (99%), patient factors (61%), and teamwork (61%). Despite imperfections in care, half of all patients received some benefit from their medical care compared with the likely outcome with no care. CONCLUSION: These reviews suggest that physicians would be especially interested in strategies to improve the diagnostic process and clinical tasks, address patient factors, and develop more effective medical teams. Our investigation allowed us to demonstrate the practical application of a framework for case analysis. We discuss the limitations of retrospective cases analyses and recommend future directions in safety research.

Costs of management of occupational exposures to blood and body fluids.

OBJECTIVE: To determine the cost of management of occupational exposures to blood and body fluids. DESIGN: A convenience sample of 4 healthcare facilities provided information on the cost of management of occupational exposures that varied in type, severity, and exposure source infection status. Detailed information was collected on time spent reporting, managing, and following up the exposures; salaries (including benefits) for representative staff who sustained and who managed exposures; and costs (not charges) for laboratory testing of exposure sources and exposed healthcare personnel, as well as any postexposure prophylaxis taken by the exposed personnel. Resources used were stratified by the phase of exposure management: exposure reporting, initial management, and follow-up. Data for 31 exposure scenarios were analyzed. Costs were given in 2003 US dollars. SETTING: The 4 facilities providing data were a 600-bed public hospital, a 244-bed Veterans Affairs medical center, a 437-bed rural tertiary care hospital, and a 3,500-bed healthcare system. RESULTS: The overall range of costs to manage reported exposures was $71-$4,838. Mean total costs varied greatly by the infection status of the source patient. The overall mean cost for exposures to human immunodeficiency virus (HIV)-infected source patients (n=19, including those coinfected with hepatitis B or C virus) was $2,456 (range, $907-$4,838), whereas the overall mean cost for exposures to source patients with unknown or negative infection status (n=8) was $376 (range, $71-$860). Lastly, the overall mean cost of management of reported exposures for source patients infected with hepatitis C virus (n=4) was $650 (range, $186-$856). CONCLUSIONS: Management of occupational exposures to blood and body fluids is costly; the best way to avoid these costs is by prevention of exposures.

The cost of care for patients with HIV from the provider economic perspective.

Health care costs for HIV infection are often reported from the economic perspective of third party payors and little data exist to show how total costs are distributed across specific health service categories. We used a retrospective cohort design to measure total medical costs for 1 year in a randomly selected sample of 280 patients treated for HIV infection at an urban health care facility. Inpatient and outpatient costs were measured from the economic perspective of the health care provider. Hospital costs included ward, ancillary, and procedure costs. Ambulatory included medications, primary and specialty care, case management, ancillary, and behavioral comorbidity treatment costs. The mean total was $20,114 per patient, of which $6,322 was for inpatient and $13,842 was for ambulatory services. Specific ambulatory costs were: medications, $9,257; primary, specialty and ancillary services, $3,470; and behavioral comorbidity treatment, $1,111. The mean annual outpatient ancillary cost was $841. Over 30% of the total service cost was for building and administrative overhead and approximately 25% of both hospital and clinic costs were for ancillary services. Independent predictors of high cost were CD4 counts, Medicaid eligibility, and behavorial comorbidities. Our outpatient costs were higher, with less variation than previously reported. Increasingly, there has been a shift of HIV care from hospital to ambulatory settings. We postulate that reimbursement rates have not captured the recent flourishing of ambulatory care. If reimbursement is not commensurate with outpatient advances, providers may be paradoxically underreimbursed for improving care.

The economic burden of drug resistance.

In recent years, researchers have made substantial progress in the development of methods to measure the burden of resistance and the application of those methods to the limited data available. Our understanding of the costs incurred by patients infected with resistant strains in hospital settings is much better than it was 10, or even 5, years ago. Research on the impact of resistance in the community is more limited. When multiple treatment options are available and prescribed treatment is empirical, resistance will lead to higher expenditures on drugs but not necessarily to increased patient morbidity and mortality. Understanding to what degree prescribing patterns are driven by real versus perceived limitations of first-line drugs is important for assessing the ability of public health campaigns to change the behavior of patients and providers.

The cost-benefit of federal investment in preventing Clostridium difficile infections through the use of a multifaceted infection control and antimicrobial stewardship program.

OBJECTIVE: To determine the potential epidemiologic and economic value of the implementation of a multifaceted Clostridium difficile infection (CDI) control program at US acute care hospitals DESIGN: Markov model with a 5-year time horizon PARTICIPANTS: Patients whose data were used in our simulations were limited to hospitalized Medicare beneficiaries ≥65 years old. BACKGROUND: CDI is an important public health problem with substantial associated morbidity, mortality, and cost. Multifaceted national prevention efforts in the United Kingdom, including antimicrobial stewardship, patient isolation, hand hygiene, environmental cleaning and disinfection, and audit, resulted in a 59% reduction in CDI cases reported from 2008 to 2012. METHODS: Our analysis was conducted from the federal perspective. The intervention we modeled included the following components: antimicrobial stewardship utilizing the Antimicrobial Use and Resistance module of the National Healthcare Safety Network (NHSN), use of contact precautions, and enhanced environmental cleaning. We parameterized our model using data from CDC surveillance systems, the AHRQ Healthcare Cost and Utilization Project, and literature reviews. To address uncertainty in our parameter estimates, we conducted sensitivity analyses for intervention effectiveness and cost, expenditures by other federal partners, and discount rate. Each simulation represented a cohort of 1,000 hospitalized patients over 1,000 trials. RESULTS In our base case scenario with 50% intervention effectiveness, we estimated that 509,000 CDI cases and 82,000 CDI-attributable deaths would be prevented over a 5-year time horizon. Nationally, the cost savings across all hospitalizations would be $2.5 billion (95% credible interval: $1.2 billion to $4.0 billion). CONCLUSIONS: The potential benefits of a multifaceted national CDI prevention program are sizeable from the federal perspective.

The global impact of drug resistance.

Measuring the impact of drug resistance is an important step in understanding the scope of the problem and formulating policies to limit the emergence and spread of resistant organisms. Studies have focused on measuring the increased costs, morbidity, and mortality in patients with infections due to resistant versus susceptible organisms. These have generally found that resistance worsens outcomes. By focusing only on infected patients, however, they may understate the impact of resistance. It is important to recognize that resistance also affects the treatment of individuals with nonresistant organisms. In areas with high rates of resistance, physicians and governments have changed empiric therapy for malaria, tuberculosis, acute respiratory infections, and other diseases, increasing overall treatment costs. In some instances, these costs may exceed those attributable to treatment failure.

The use of economic modeling to determine the hospital costs associated with nosocomial infections.

Hospital-associated infection is well recognized as a patient safety concern requiring preventive interventions. However, hospitals are closely monitoring expenditures and need accurate estimates of potential cost savings from such prevention programs. We used a retrospective cohort design and economic modeling to determine the excess cost from the hospital perspective for hospital-associated infection in a random sample of adult medical patients. Study patients were classified as being not infected (n=139), having suspected infection (n=8), or having confirmed infection (n=17). Severity of illness and intensive unit care use were both independently associated with increased cost. After controlling for these confounding effects, we found an excess cost of $6767 for suspected infection and $15,275 for confirmed hospital-acquired infection. The economic model explained 56% of the total variability in cost among patients. Hospitals can use these data when evaluating potential cost savings from effective infection-control measures.

Vaccinating first-year college students living in dormitories for Meningococcal disease: an economic analysis.

BACKGROUND: Surveillance of meningococcal disease among U.S. college students found an elevated rate of this disease among first-year students living in dormitories. OBJECTIVE: This study examines the economics of routinely vaccinating a cohort of 591,587 incoming first-year students who will live in dormitories for > or =1 years. METHODS: A cost-benefit model (societal perspective) was constructed to measure the net present value (NPV) of various vaccination scenarios, as well as the cost/case and cost/death averted. Input values included hospitalization costs from $10,924 to $24,030 per hospitalization; immunization costs (vaccine plus administration costs) from $54 to $88 per vaccine; 30 nonfatal, vaccine-preventable cases over a 4-year period (includes 3 with sequelae); 3 premature deaths; value of human life from $1.2 million to $4.8 million; and long-run sequelae costs from $1298 to $14,600. Sensitivity analyses were also conducted on vaccine efficacy (80% to 90%); discount rate (0% to 5%); and coverage (60% to 100%). RESULTS: The costs of vaccination outweighed the benefits gained with NPVs ranging from -$11 million to -$49 million. The net cost per case averted ranged from $0.6 million to $1.9 million. The net cost per death averted ranged from $7 million to $20 million. The break-even costs of vaccination (when NPV=$0) at 60% coverage ranged from $23 (90% vaccine efficacy) to $5 (80% efficacy). CONCLUSIONS: The model showed that the vaccination program is not cost-saving. Key variables influencing the results were the low number of vaccine-preventable cases and the high cost of vaccination. However, from the perspective of students and parents, the cost of vaccination might be worth the real or perceived benefit of reducing the risk to an individual student of developing meningococcal disease.

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 Million during 1990-2008.

The prevention of central line-associated bloodstream infections in patients in hospital critical care units has been a target of efforts by the Centers for Disease Control and Prevention (CDC) since the 1960s. We developed a historical economic model to measure the net economic benefits of preventing these infections in Medicare and Medicaid patients in critical care units for the period 1990-2008-a time when reductions attributable to federal investment resulted primarily from CDC efforts-using the cost perspective of the federal government as a third-party payer. The estimated net economic benefits ranged from $640 million to $1.8 billion, with the corresponding net benefits per case averted ranging from $15,780 to $24,391. The per dollar rate of return on the CDC's investments ranged from $3.88 to $23.85. These findings suggest that investments in CDC programs targeting other health care-associated infections also have the potential to produce savings by lowering Medicare and Medicaid reimbursements.

National estimates of central line-associated bloodstream infections in critical care patients.

UNLABELLED: OBJECTIVE. Recent studies have demonstrated that central line-associated bloodstream infections (CLABSIs) are preventable through implementation of evidence-based prevention practices. Hospitals have reported CLABSI data to the Centers for Disease Control and Prevention (CDC) since the 1970s, providing an opportunity to characterize the national impact of CLABSIs over time. Our objective was to describe changes in the annual number of CLABSIs in critical care patients in the United States. DESIGN: Monte Carlo simulation. Setting. U.S. acute care hospitals. PATIENTS: Nonneonatal critical care patients. METHODS: We obtained administrative data on patient-days for nearly all US hospitals and applied CLABSI rates from the National Nosocomial Infections Surveillance and the National Healthcare Safety Network systems to estimate the annual number of CLABSIs in critical care patients nationally during the period 1990-2010 and the number of CLABSIs prevented since 1990. RESULTS: We estimated that there were between 462,000 and 636,000 CLABSIs in nonneonatal critical care patients in the United States during 1990-2010. CLABSI rate reductions led to between 104,000 and 198,000 fewer CLABSIs than would have occurred if rates had remained unchanged since 1990. There were 15,000 hospital-onset CLABSIs in nonneonatal critical care patients in 2010; 70% occurred in medium and large teaching hospitals. CONCLUSIONS: Substantial progress has been made in reducing the occurrence of CLABSIs in U.S. critical care patients over the past 2 decades. The concentration of critical care CLABSIs in medium and large teaching hospitals suggests that a targeted approach may be warranted to continue achieving reductions in critical care CLABSIs nationally.

Cost-effectiveness of conjugate meningococcal vaccination strategies in the United States.

CONTEXT: The US Food and Drug Administration approved a meningococcal conjugate A/C/Y/W-135 vaccine (MCV-4) for use in persons aged 11 to 55 years in January, 2005; licensure for use in younger age groups is expected in 2 to 4 years. OBJECTIVE: To evaluate and compare the projected health and economic impact of MCV-4 vaccination of US adolescents, toddlers, and infants. DESIGN: Cost-effectiveness analysis from a societal perspective based on data from Active Bacterial Core Surveillance (ABCs) and other published and unpublished sources. Sensitivity analyses in which key input measures were varied over plausible ranges were performed. SETTING AND PATIENTS: A hypothetical 2003 US population cohort of children 11 years of age and a 2003 US birth cohort. INTERVENTIONS: Hypothetical routine vaccination of adolescents (1 dose at 11 years of age), toddlers (1 dose at 1 year of age), and infants (3 doses at 2, 4, and 6 months of age). Each vaccination scenario was compared with a "no-vaccination" scenario. MAIN OUTCOME MEASURES: Meningococcal cases and deaths prevented, cost per case prevented, cost per life-year saved, and cost per quality-adjusted life-year saved. RESULTS: Routine MCV-4 vaccination of US adolescents (11 years of age) would prevent 270 meningococcal cases and 36 deaths in the vaccinated cohort over 22 years, a decrease of 46% in the expected burden of disease. Before program costs are counted, adolescent vaccination would reduce direct disease costs by $18 million and decrease productivity losses by $50 million. At a cost per vaccination (average public-private price per dose plus administration fees) of $82.50, adolescent vaccination would cost society $633000 per meningococcal case prevented and $121000 per life-year saved. Key variables influencing results were disease incidence, case-fatality ratio, and cost per vaccination. The cost-effectiveness of toddler vaccination is essentially equivalent to adolescent vaccination, whereas infant vaccination would be much less cost-effective. CONCLUSIONS: Routine MCV-4 vaccination of US children would reduce the burden of disease in vaccinated cohorts but at a relatively high net societal cost. The projected cost-effectiveness of adolescent vaccination approaches that of recently adopted childhood vaccines under conditions of above-average meningococcal disease incidence or at a lower cost per vaccination.

Collecting data to assess SARS interventions.

With cases of severe acute respiratory syndrome (SARS) occurring across geographic regions, data collection on the effectiveness of intervention strategies should be standardized to facilitate analysis. We propose a minimum dataset to capture data needed to examine the basic reproduction rate, case status and criteria, symptoms, and outcomes of SARS.

West Nile virus economic impact, Louisiana, 2002.

West Nile virus (WNV) is transmitted by mosquitoes and can cause illness in humans ranging from mild fever to encephalitis. In 2002, a total of 4,156 WNV cases were reported in the United States; 329 were in Louisiana. To estimate the economic impact of the 2002 WNV epidemic in Louisiana, we collected data from hospitals, a patient questionnaire, and public offices. Hospital charges were converted to economic costs by using Medicare cost-to-charge ratios. The estimated cost of the Louisiana epidemic was US 20.1 million dollars from June 2002 to February 2003, including a US 10.9 million dollars cost of illness (US 4.4 million dollars medical and US 6.5 million dollars nonmedical costs) and a US 9.2 million dollars cost of public health response. These data indicate a substantial short-term cost of the WNV disease epidemic in Louisiana.