Microbiology of cardiac implantable electronic device infections in Calgary, Canada.

The microbiology of cardiac implantable electronic device (CIED) infections in Calgary, Alberta was described, identifying 50 infections from 2013 to 2019. The majority were Staphylococcus aureus (40.0%). There is significant economic burden, mostly related to inpatient costs, associated with CIED infections. However, there were no significant differences in costs stratified by organism.

The economic burden of cardiac implantable electronic device infections in Alberta, Canada: a population-based study using validated administrative data.

BACKGROUND: Cardiac implantable electronic devices (CIED) are being inserted with increasing frequency. Severe surgical site infections (SSI) that occur after device implantation substantially impact patient morbidity and mortality and can result in multiple hospital admissions and repeat surgeries. It is important to understand the costs associated with these infections as well as healthcare utilization. Therefore, we conducted a population-based study in the province of Alberta, Canada to understand the economic burden of these infections. METHODS: A cohort of adult patients in Alberta who had CIEDs inserted or generators replaced between January 1, 2011 and December 31, 2019 was used. A validated algorithm of International Classification of Diseases (ICD) codes to identify complex (deep/organ space) SSIs that occurred within the subsequent year was applied to the cohort. The overall mean 12-month inpatient and outpatient costs for the infection and non-infection groups were assessed. In order to control for variables that may influence costs, propensity score matching was completed and incremental costs between those with and without infection were calculated. As secondary outcomes, number of outpatient visits, hospitalizations and length of stay were assessed. RESULTS: There were 26,049 procedures performed during our study period, of which 320 (1.23%) resulted in SSIs. In both unadjusted costs and propensity score matched costs the infection group was associated with increased costs. Overall mean cost was $145,312 in the infection group versus $34,264 in the non-infection group. The incremental difference in those with infection versus those without in the propensity score match was $90,620 (Standard deviation $190,185). Approximately 70% of costs were driven by inpatient hospitalizations. Inpatients hospitalizations, length of stay and outpatient visits were all increased in the infection group. CONCLUSIONS: CIED infections are associated with increased costs and are a burden to the healthcare system. This highlights a need to recognize increasing SSI rates and implement measures to minimize infection risk. Further studies should endeavor to apply this work to full economic evaluations to better understand and identify cost-effective infection mitigation strategies.

Machine learning risk estimation and prediction of death in continuing care facilities using administrative data.

In this study, we aimed to identify the factors that were associated with mortality among continuing care residents in Alberta, during the coronavirus disease 2019 (COVID-19) pandemic. We achieved this by leveraging and linking various administrative datasets together. Then, we examined pre-processing methods in terms of prediction performance. Finally, we developed several machine learning models and compared the results of these models in terms of performance. We conducted a retrospective cohort study of all continuing care residents in Alberta, Canada, from March 1, 2020, to March 31, 2021. We used a univariable and a multivariable logistic regression (LR) model to identify predictive factors of 60-day all-cause mortality by estimating odds ratios (ORs) with a 95% confidence interval. To determine the best sensitivity-specificity cut-off point, the Youden index was employed. We developed several machine learning models to determine the best model regarding performance. In this cohort study, increased age, male sex, symptoms, previous admissions, and some specific comorbidities were associated with increased mortality. Machine learning and pre-processing approaches offer a potentially valuable method for improving risk prediction for mortality, but more work is needed to show improvement beyond standard risk factors.

Economic evaluation in cardiac electrophysiology: Determining the value of emerging technologies.

Cardiac electrophysiology is a constantly evolving speciality that has benefited from technological innovation and refinements over the past several decades. Despite the potential of these technologies to reshape patient care, their upfront costs pose a challenge to health policymakers who are responsible for the assessment of the novel technology in the context of increasingly limited resources. In this context, it is critical for new therapies or technologies to demonstrate that the measured improvement in patients' outcomes for the cost of achieving that improvement is within conventional benchmarks for acceptable health care value. The field of Health Economics, specifically economic evaluation methods, facilitates this assessment of value in health care. In this review, we provide an overview of the basic principles of economic evaluation and provide historical applications within the field of cardiac electrophysiology. Specifically, the cost-effectiveness of catheter ablation for both atrial fibrillation (AF) and ventricular tachycardia, novel oral anticoagulants for stroke prevention in AF, left atrial appendage occlusion devices, implantable cardioverter defibrillators, and cardiac resynchronization therapy will be reviewed.

Healthcare utilization and adverse outcomes stratified by sex, age and long-term care residency using the Alberta COVID-19 Analytics and Research Database (ACARD): a population-based descriptive study.

BACKGROUND: Understanding the epidemiology of Coronavirus Disease of 2019 (COVID-19) in a local context is valuable for both future pandemic preparedness and potential increases in COVID-19 case volume, particularly due to variant strains. METHODS: Our work allowed us to complete a population-based study on patients who tested positive for COVID-19 in Alberta from March 1, 2020 to December 15, 2021. We completed a multi-centre, retrospective population-based descriptive study using secondary data sources in Alberta, Canada. We identified all adult patients (≥ 18 years of age) tested and subsequently positive for COVID-19 (including only the first incident case of COVID-19) on a laboratory test. We determined positive COVID-19 tests, gender, age, comorbidities, residency in a long-term care (LTC) facility, time to hospitalization, length of stay (LOS) in hospital, and mortality. Patients were followed for 60 days from a COVID-19 positive test. RESULTS: Between March 1, 2020 and December 15, 2021, 255,037 adults were identified with COVID-19 in Alberta. Most confirmed cases occurred among those less than 60 years of age (84.3%); however, most deaths (89.3%) occurred among those older than 60 years. Overall hospitalization rate among those who tested positive was 5.9%. Being a resident of LTC was associated with substantial mortality of 24.6% within 60 days of a positive COVID-19 test. The most common comorbidity among those with COVID-19 was depression. Across all patients 17.3% of males and 18.6% of females had an unplanned ambulatory visit subsequent to their positive COVID-19 test. CONCLUSIONS: COVID-19 is associated with extensive healthcare utilization. Residents of LTC were substantially impacted during the COVID-19 pandemic with high associated mortality. Further work should be done to better understand the economic burden associated with related healthcare utilization following a COVID-19 infection to inform healthcare system resource allocation, planning, and forecasting.

Complex cardiac implantable electronic device infections in Alberta, Canada: An epidemiologic cohort study of validated administrative data.

OBJECTIVE: To establish the epidemiology of cardiac implantable electronic device (CIED) infections in Alberta, Canada, using validated administrative data. DESIGN: Retrospective, population-based cohort study. SETTING: Alberta Health Services is a province-wide health system that services all of Alberta, Canada. PARTICIPANTS: Adult patients who underwent first-time CIED implantation or generator replacement in Alberta, Canada, between January 1, 2011, and December 31, 2019. METHODS: CIED implant patients were identified from the Paceart database. Patients who developed an infection within 1 year of the index procedure were identified through validated administrative data (International Classification of Diseases, Tenth Revision in Canada). Demographic characteristics of patients were summarized. Logistic regression models were used to analyze device type, comorbidities, and demographics associated with infection rates and mortality. RESULTS: Among 27,830 CIED implants, there were 205 infections (0.74%). Having 2 or more comorbidities was associated with higher infection risk. Generator replacement procedures (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.34-0.84; P = .008), age increase of every 10 years (OR, 0.73; 95% CI, 0.66-0.82; P ≤ .001), and index procedure after 2014 were associated with decreased risk. Comparing the infected to uninfected groups, the hospitalization rates were 2.63 compared to 0.69, and the mortality rates were 10.73% compared to 3.49%, respectively (P < .001). CONCLUSIONS: There is a slightly lower overall rate of CIED infections Alberta, Canada compared to previously described epidemiology. Implants after 2014, and generator replacements showed a decreased burden of infection. Patients with younger age, and 2 or more comorbidities are at greatest risk of CIED infection. The burden of hospitalization and mortality is substantially higher in infected patients.

Impact of Clostridioides difficile length of treatment on rates of recurrence in patients on concurrent antibiotics.

BACKGROUND: Clostridioides difficile infection (CDI) is principally health care-associated, with a substantial impact on morbidity and mortality. The guidelines recommend CDI therapy for 10 days; however, it is often extended in practice when concurrent antibiotics are used. The impact of the extended duration of therapy remains unclear. OBJECTIVE: To compare the rates of CDI recurrence in patients receiving standard duration of therapy (SDT) with those receiving extended duration of therapy (EDT) for the treatment of hospital-acquired CDI (HA-CDI) while receiving concurrent antibiotics. METHODS: A retrospective chart review was conducted between October 2017 and 2019. Adult HA-CDI patients who received a minimum 10 days of CDI therapy and were on concurrent antibiotics were stratified into SDT and EDT groups. Rates of CDI recurrence (at 90 and 180 days) and incidence of new-onset vancomycin-resistant enterococcus (VRE) were compared. RESULTS: Two hundred twenty-three patients met the inclusion criteria (SD-106, EDT-117). CDI recurrence rates at 90 and 180 days were not statistically significant between SDT and EDT groups (22% vs 26%, P = .40% and 26% vs 31%, P = .47). Although the incidence of VRE within the extended group was higher, it was not statistically significant (6% vs 9%, P = .29). CONCLUSIONS: No significant difference in rates of recurrence or new-onset VRE was observed between SDT and EDT in HA-CDI patients.

Pilot study evaluating intravenous amoxicillin-clavulanate as an alternative to piperacillin-tazobactam for general surgery patients.

In this point-prevalence survey followed by prospective audit and feedback at 4 tertiary-care hospitals in Calgary, Alberta, Canada, we evaluated whether intravenous amoxicillin-clavulanate may be used as a narrower-spectrum alternative to intravenous piperacillin-tazobactam for patients admitted to general surgery services.

Surveillance for SARS-CoV-2 and its variants in wastewater of tertiary care hospitals correlates with increasing case burden and outbreaks.

Wastewater-based SARS-CoV-2 surveillance enables unbiased and comprehensive monitoring of defined sewersheds. We performed real-time monitoring of hospital wastewater that differentiated Delta and Omicron variants within total SARS-CoV-2-RNA, enabling correlation to COVID-19 cases from three tertiary-care facilities with >2100 inpatient beds in Calgary, Canada. RNA was extracted from hospital wastewater between August/2021 and January/2022, and SARS-CoV-2 quantified using RT-qPCR. Assays targeting R203M and R203K/G204R established the proportional abundance of Delta and Omicron, respectively. Total and variant-specific SARS-CoV-2 in wastewater was compared to data for variant specific COVID-19 hospitalizations, hospital-acquired infections, and outbreaks. Ninety-six percent (188/196) of wastewater samples were SARS-CoV-2 positive. Total SARS-CoV-2 RNA levels in wastewater increased in tandem with total prevalent cases (Delta plus Omicron). Variant-specific assessments showed this increase to be mainly driven by Omicron. Hospital-acquired cases of COVID-19 were associated with large spikes in wastewater SARS-CoV-2 and levels were significantly increased during outbreaks relative to nonoutbreak periods for total SARS-CoV2, Delta and Omicron. SARS-CoV-2 in hospital wastewater was significantly higher during the Omicron-wave irrespective of outbreaks. Wastewater-based monitoring of SARS-CoV-2 and its variants represents a novel tool for passive COVID-19 infection surveillance, case identification, containment, and potentially to mitigate viral spread in hospitals.

Validating administrative data to identify complex surgical site infections following cardiac implantable electronic device implantation: a comparison of traditional methods and machine learning.

BACKGROUND: Cardiac implantable electronic device (CIED) surgical site infections (SSIs) have been outpacing the increases in implantation of these devices. While traditional surveillance of these SSIs by infection prevention and control would likely be the most accurate, this is not practical in many centers where resources are constrained. Therefore, we explored the validity of administrative data at identifying these SSIs. METHODS: We used a cohort of all patients with CIED implantation in Calgary, Alberta where traditional surveillance was done for infections from Jan 1, 2013 to December 31, 2019. We used this infection subgroup as our "gold standard" and then utilized various combinations of administrative data to determine which best optimized the sensitivity and specificity at identifying infection. We evaluated six approaches to identifying CIED infection using administrative data, which included four algorithms using International Classification of Diseases codes and/or Canadian Classification of Health Intervention codes, and two machine learning models. A secondary objective of our study was to assess if machine learning techniques with training of logistic regression models would outperform our pre-selected codes. RESULTS: We determined that all of the pre-selected algorithms performed well at identifying CIED infections but the machine learning model was able to produce the optimal method of identification with an area under the receiver operating characteristic curve (AUC) of 96.8%. The best performing pre-selected algorithm yielded an AUC of 94.6%. CONCLUSIONS: Our findings suggest that administrative data can be used to effectively identify CIED infections. While machine learning performed the most optimally, in centers with limited analytic capabilities a simpler algorithm of pre-selected codes also has excellent yield. This can be valuable for centers without traditional surveillance to follow trends in SSIs over time and identify when rates of infection are increasing. This can lead to enhanced interventions for prevention of SSIs.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada.

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: −0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: −0.8, p < 0.001); and doxycycline (−0.2, p = 0.005) and penicillin (−0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

Economic Burden of Surgical Management of Prosthetic Joint Infections Following Hip and Knee Replacements in Alberta, Canada: An analysis and comparison of two major urban centers.

BACKGROUND: Complex surgical site infections (SSIs) and revisions for these infectious complications following total knee and hip arthroplasties are associated with significant economic costs. AIM: To evaluate the cost of one-stage and two-stage revisions; debridement, antibiotic, and implant retention (DAIR) and DAIR with liner exchange for complex hip or knee SSIs in Alberta, Canada. METHODS: We used the Alberta Health Services Infection Prevention and Control database to identify individuals >18 years old from the two major urban centers in Alberta, Calgary, and Edmonton zone, with complex hip or knee SSIs who underwent surgical intervention between April 1, 2012, and March 31, 2019. Micro-costing and gross-costing methods were used to estimate 12 and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse gaussian and gamma regression analysis were used to evaluate the associations of the revision procedure, age, sex, and comorbidities on cost. FINDINGS: A total of 382 patients with complex SSIs were identified with a mean age of 66.1 years. DAIR and DAIR with liner exchange resulted in the lowest 12- and 24-month costs at $53,197 (95% CI, $38,006 - $68,388) and $57,340 (95% CI, $48,576 - $66,105), respectively; two-stage revision was the costliest procedure. Most of the incurred costs (>98%) were accrued within the first 12 months following the initial procedure. CONCLUSIONS: Medical costs are highest 12 months following initial arthroplasty and for two-stage revisions in hip and knee complex SSI.

Antimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019-June 2021).

BACKGROUND: Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR). OBJECTIVES: We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings. METHODS: We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences. RESULTS: Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8-40%; n = 25 studies: I2 = 99%) and 0.3% (95% CI 0.1-0.6%; n = 8 studies: I2 = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism. CONCLUSIONS: During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally.

Economic burden of surgical management of surgical site infections following hip and knee replacements in Calgary, Alberta, Canada.

OBJECTIVE: To evaluate the cost of 1-stage and 2-stage revisions, debridement, antibiotic and implant retention (DAIR) and DAIR with liner exchange for complex surgical site infections (SSIs) following hip and knee replacements. DESIGN: Retrospective population-based economic analysis of patients undergoing intervention for SSIs between April 1, 2012 and March 31, 2019. SETTING: The study was conducted in the Calgary zone of Alberta Health Services (AHS) in Canada. PARTICIPANTS: Individuals >18 years with complex SSI following hip or knee replacement. METHODS: Patients with complex SSIs were identified using the AHS infection prevention and control database. A combination of microcosting and gross costing methods were used to estimate 12- and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse Gaussian and γ regression analyses were used to evaluate the impact of age and comorbidities on cost. RESULTS: In total, 142 patients with complex SSIs were identified, with a mean age of 66.8 years. Total direct medical costs in United States dollars of 2-stage revisions were ($100,992 (95% CI, 34,587-167,396) at 12 months. The 1-stage revision ($41,176; 95% CI, 23,361-58,991), DAIR with liner exchange ($41,267; 95% CI, 29,923-52,612) and DAIR ($46,605; 95% CI, 15,277-76,844) were associated with fewer costs at 12 months. Age >65 years and chronic complications of diabetes and hypertension were associated with increased costs in subgroup and regression analysis. CONCLUSIONS: Medical costs are highest at 12 months and for 2-stage revisions in hip and knee complex SSI cases. Further work should explore surgical outcomes correlated with costs to enhance patient care.

Mathematical model of the cost-effectiveness of the BioFire FilmArray Blood Culture Identification (BCID) Panel molecular rapid diagnostic test compared with conventional methods for identification of Escherichia coli bloodstream infections.

BACKGROUND: Gram-negative pathogens, such as Escherichia coli, are common causes of bloodstream infections (BSIs) and increasingly demonstrate antimicrobial resistance. Molecular rapid diagnostic tests (mRDTs) offer faster pathogen identification and susceptibility results, but higher costs compared with conventional methods. We determined the cost-effectiveness of the BioFire FilmArray Blood Culture Identification (BCID) Panel, as a type of mRDT, compared with conventional methods in the identification of E. coli BSIs. METHODS: We constructed a decision analytic model comparing BCID with conventional methods in the identification and susceptibility testing of hospitalized patients with E. coli BSIs from the perspective of the public healthcare payer. Model inputs were obtained from published literature. Cost-effectiveness was calculated by determining the per-patient admission cost, the QALYs garnered and the incremental cost-effectiveness ratios (ICERs) where applicable. Monte Carlo probabilistic sensitivity analyses and one-way sensitivity analyses were conducted to assess the robustness of the model. All costs reflect 2019 Canadian dollars. RESULTS: The Monte Carlo probabilistic analyses resulted in cost savings ($27 070.83 versus $35 649.81) and improved QALYs (8.65 versus 7.10) in favour of BCID. At a willingness to pay up to $100 000, BCID had a 72.6%-83.8% chance of being cost-effective. One-way sensitivity analyses revealed length of stay and cost per day of hospitalization to have the most substantial impact on costs and QALYs. CONCLUSIONS: BCID was found to be cost-saving when used to diagnose E. coli BSI compared with conventional testing. Cost savings were most influenced by length of stay and cost per day of hospitalization.

Knowledge Gaps in the Understanding of Antimicrobial Resistance in Canada.

Current limitations in the understanding and control of antimicrobial resistance (AMR) in Canada are described through a comprehensive review focusing on: (1) treatment optimization; (2) surveillance of antimicrobial use and AMR; and (3) prevention of transmission of AMR. Without addressing gaps in identified areas, sustained progress in AMR mitigation is unlikely. Expert opinions and perspectives contributed to prioritizing identified gaps. Using Canada as an example, this review emphasizes the importance and necessity of a One Health approach for understanding and mitigating AMR. Specifically, antimicrobial use in human, animal, crop, and environmental sectors cannot be regarded as independent; therefore, a One Health approach is needed in AMR research and understanding, current surveillance efforts, and policy. Discussions regarding addressing described knowledge gaps are separated into four categories: (1) further research; (2) increased capacity/resources; (3) increased prescriber/end-user knowledge; and (4) policy development/enforcement. This review highlights the research and increased capacity and resources to generate new knowledge and implement recommendations needed to address all identified gaps, including economic, social, and environmental considerations. More prescriber/end-user knowledge and policy development/enforcement are needed, but must be informed by realistic recommendations, with input from all relevant stakeholders. For most knowledge gaps, important next steps are uncertain. In conclusion, identified knowledge gaps underlined the need for AMR policy decisions to be considered in a One Health framework, while highlighting critical needs to achieve realistic and meaningful progress.

The impact of COVID-19 on hospital admissions and emergency department visits: A population-based study.

BACKGROUND: As a result of the novel coronavirus disease 2019 (COVID-19), there have been widespread changes in healthcare access. We conducted a retrospective population-based study in Alberta, Canada (population 4.4 million), where there have been approximately 1550 hospital admissions for COVID-19, to determine the impact of COVID-19 on hospital admissions and emergency department (ED visits), following initiation of a public health emergency act on March 15, 2020. METHODS: We used multivariable negative binomial regression models to compare daily numbers of medical/surgical hospital admissions via the ED between March 16-September 23, 2019 (pre COVID-19) and March 16-September 23, 2020 (post COVID-19 public health measures). We compared the most frequent diagnoses for hospital admissions pre/post COVID-19 public health measures. A similar analysis was completed for numbers of daily ED visits for any reason with a particular focus on ambulatory care sensitive conditions (ACSC). FINDINGS: There was a significant reduction in both daily medical (incident rate ratio (IRR) 0.86, p<0.001) and surgical (IRR 0.82, p<0.001) admissions through the ED in Alberta post COVID-19 public health measures. There was a significant decline in daily ED visits (IRR 0.65, p<0.001) including ACSC (IRR 0.75, p<0.001). The most common medical/surgical diagnoses for hospital admissions did not vary substantially pre and post COVID-19 public health measures, though there was a significant reduction in admissions for chronic obstructive pulmonary disease and a significant increase in admissions for mental and behavioral disorders due to use of alcohol. CONCLUSIONS: Despite a relatively low volume of COVID-19 hospital admissions in Alberta, there was an extensive impact on our healthcare system with fewer admissions to hospital and ED visits. This work generates hypotheses around causes for reduced hospital admissions and ED visits which warrant further investigation. As most publicly funded health systems struggle with health-system capacity routinely, understanding how these reductions can be safely sustained will be critical.

Economic evaluation of an absorbable antibiotic envelope for prevention of cardiac implantable electronic device infection.

AIMS: Recent evidence suggests that an antibiotic impregnated envelope inserted at time of cardiac implantable electronic device (CIED) implantation may reduce risk of subsequent CIED infection compared with standard of care (SoC). The objective of the current work was to perform a cost-effectiveness analysis comparing an antibiotic impregnated envelope with SoC at time of CIED insertion. METHODS AND RESULTS: Decision analytic models were used to project healthcare costs and benefits of two strategies, an antibiotic impregnated envelope plus SoC (Env+SoC) vs. SoC alone, in a cohort of patients undergoing CIED implantation over a 1-year time horizon. Evidence from published literature informed the model inputs. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was the incremental cost per infection prevented, assessed from the Canadian healthcare system perspective. Envelope plus SoC was associated with fewer CIED infection (7 CIED infections/1000 patients) at higher total costs ($29 033 000/1000 patients) compared with SoC (11 CIED infections and $27 926 000/1000 patients). The incremental cost per infection prevented over 1 year was $274 416. Use of Env+SoC was cost saving only when baseline CIED infection risk was increased to 6% (vs. base case of 1.2%). CONCLUSIONS: A strategy of Env+SoC was not economically favourable compared with SoC alone, and the opportunity cost of widescale implementation should be considered. Future work is required to develop validated risk stratification tools to identify patients at greatest risk of CIED infection. The value proposition of Env+SoC improves when applying this intervention to patients at greatest infection risk.