Economic Impact of Ventilator-Associated Pneumonia in a Large Matched Cohort
ABSTRACT To evaluate the economic impact of ventilator-associated pneumonia (VAP) on length of stay and hospital costs. Design. Retrospective matched cohort study.
Premier database of hospitals in the United States.
Eligible patients were admitted to intensive care units (ICUs), received mechanical ventilation for ≥2 calendar-days, and were discharged between October 1, 2008, and December 31, 2009.
VAP was defined by International Classification of Diseases, Ninth Revision (ICD-9), code 997.31 and ventilation charges for ≥2 calendar-days. We matched patients with VAP to patients without VAP by propensity score on the basis of demographics, administrative data, and severity of illness. Cost was based on provider perspective and procedural cost accounting methods.
Of 88,689 eligible patients, 2,238 (2.5%) had VAP; the incidence rate was 1.27 per 1,000 ventilation-days. In the matched cohort, patients with VAP ([Formula: see text]) had longer mean durations of mechanical ventilation (21.8 vs 10.3 days), ICU stay (20.5 vs 11.6 days), and hospitalization (32.6 vs 19.5 days; all [Formula: see text]) than patients without VAP ([Formula: see text]). Mean hospitalization costs were $99,598 for patients with VAP and $59,770 for patients without VAP ([Formula: see text]), resulting in an absolute difference of $39,828. Patients with VAP had a lower in-hospital mortality rate than patients without VAP (482/2,144 [22.5%] vs 630/2,144 [29.4%]; [Formula: see text]).
Our findings suggest that VAP continues to occur as defined by the new specific ICD-9 code and is associated with a statistically significant resource utilization burden, which underscores the need for cost-effective interventions to minimize the occurrence of this complication.
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ABSTRACT: Intensive care is expensive, and thus a body of research has focused on strategies to reduce its costs. However, efforts to reduce the total cost of intensive care have met with limited success, partly because of the challenges of calculating how much a day in the ICU actually costs. We discuss these challenges and introduce the concept of total cost savings as an outcome of critical care trials, assuming statistically negative effects on mortality and quality of life.Critical Care 06/2015; 19(1). DOI:10.1186/s13054-015-0947-0 · 5.04 Impact Factor
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ABSTRACT: Rationale: Diagnosis of ventilator-associated pneumonia (VAP) is imprecise. Objectives: To 1) determine if alternate-day surveillance mini-bronchoalveolar lavage (mini-BAL) in ventilated adults could reduce time to initiation of targeted treatment and 2) evaluate the potential for automated microscopy to reduce analysis time. Methods: Adult ICU patients were included who were anticipated to require ventilation for at least a further 48 h. Mini-BALs were processed for identification, quantitation and antibiotic susceptibility using a) clinical culture (50 ± 7 h) and b) automated microscopy (~5 h plus offline analysis). Measurements and Main Results: 77 mini-BALs were performed in 33 patients. 1 patient (3%) was clinically diagnosed with VAP. Of 73 paired samples, culture identified 7 containing pneumonia panel bacteria >104 CFU/ml from 5 patients (15%) (4 Staphylococcus aureus (3 MRSA), 2 Stenotrophomonas maltophilia, 1 Klebsiella pneumoniae) and resulted in antimicrobial changes/additions to 2/5 (40%) of those patients. Microscopy identified 7/7 microbiologically-positive organisms and 64/66 negative samples compared to culture. Antimicrobial responses were concordant in 4/5 comparisons. Antimicrobial changes/additions would have occurred in 3 of 7 microscopy-positive patients (43%) had those results been clinically available in 5 h, including one patient diagnosed later with VAP despite negative mini-BAL cultures. Conclusions: Microbiological surveillance detected infection in patients at risk for VAP independent of clinical signs, resulting in changes to antimicrobial therapy. Automated microscopy was 100% sensitive and 97% specific for high-risk pneumonia organisms compared to clinical culturing. Rapid microscopy-based surveillance may be informative for treatment and antimicrobial stewardship in patients at risk for VAP. Clinical trial registration available at www.clinicaltrials.gov, ID NCT00938002.American Journal of Respiratory and Critical Care Medicine 01/2015; 191(5). DOI:10.1164/rccm.201408-1468OC · 11.99 Impact Factor
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ABSTRACT: Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia (VAP). However, more evidence of the benefit of this therapy is desired. The Medline, Scopus, EMBASE, Biological Abstracts, CAB Abstracts, Food Science and Technology Abstracts, CENTRAL, Scielo and Lilacs databases were searched to identify randomized controlled trials or matched observational studies that compared nebulized antibiotics with or without intravenous antibiotics to intravenous antibiotics alone for VAP treatment. Two reviewers independently collected data and assessed outcomes and risk of bias. The primary outcome was clinical cure. Secondary outcomes were microbiological cure, ICU and hospital mortality, duration of mechanical ventilation, ICU length of stay and adverse events. A mixed-effect model meta-analysis was performed. Trial sequential analysis was used for the main outcome of interest. Twelve studies were analyzed, including six randomized controlled trials. For the main outcome analysis, 812 patients were included. Nebulized antibiotics were associated with higher rates of clinical cure (risk ratio (RR) = 1.23; 95% confidence interval (CI), 1.05-1.43; I(2) = 34%; D(2) = 45%). Nebulized antibiotics were not associated with microbiological cure (RR = 1.24; 95% CI, 0.95-1.62; I(2) = 62.5), mortality (RR = 0.90; CI 95%, 0.76-1.08; I(2) = 0%), duration of mechanical ventilation (standardized mean difference = -0.10 days; 95% CI, -1.22 to 1.00; I(2) = 96.5%), ICU length of stay (standardized mean difference (SMD) = 0.14 days; 95% CI, -0.46 to 0.73; I(2) = 89.2%) or renal toxicity (RR = 1.05; 95% CI, 0.70 to 1.57; I(2) = 15.6%). Regarding the primary outcome, the number of patients included was below the information size required for a definitive conclusion by trial sequential analysis; therefore, our results regarding this parameter are inconclusive. Nebulized antibiotics seem to be associated with higher rates of clinical cure in the treatment of VAP. However, the apparent benefit in the clinical cure rate observed by traditional meta-analysis does not persist after trial sequential analysis. Additional high-quality studies on this subject are highly warranted. CRD42014009116 . Registered 29 March 2014.Critical care (London, England) 04/2015; 19(1):150. DOI:10.1186/s13054-015-0868-y