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Systematic review of economic analyses of health care-associated infections
Abstract
Economic evidence is needed to assess the burden of health care-associated infections (HAIs) and cost-effectiveness of interventions aimed at reducing related morbidity and mortality. The objective of this study was conducted to assess the quality of economic evaluations related to HAI and synthesize the evidence.
A systematic review of research published between January 2001 and June 2004 was conducted. Quality of the publication was estimated using a Likert-type scale. All cost estimates were standardized into a common currency. Descriptive statistics and a logistic regression were conducted to identify predictors of high quality.
70 studies were audited. There was wide variation in these cost estimates. Publications estimating the cost attributable to an infection were almost 7 times more likely judged to be of higher quality than studies of the cost of interventions (P < .05). Papers in which the authors stated the perspective (hospital or societal) were twice as likely to be judged as being of high quality (P < .05).
There are more publications and growing interest in estimating the costs of HAI. However, the methods employed vary. We recommend (1) the use of guidelines for authors and editors on conducting an economic analysis, (2) development of more sophisticated mathematical models, and (3) training of infection control professionals in economic methods.
... Además, la mortalidad del grupo de infectados fue del 13% frente al 2% en no infectados. (1,8) En 2010, la revista The Lancet agrupó 220 publicaciones desde 1995 a 2008, incluyendo estudios de las Américas (22%), Europa (20%), Asia sudoriental (16%), Mediterráneo oriental (8%), África (5%) y otras regiones (29%), en donde se evidenció que la prevalencia de las IAAS de los países en desarrollo fue de 15,5 por cada 100 pacientes, llegando a aumentar hasta el 34,2 por cada 1000 paciente/día en pacientes de UCI, triplicando las tasas reportadas en EEUU. (9) En Colombia, el Grupo Nacional de Vigilancia Epidemiológica de las Unidades de Cuidados Intensivos de Colombia (GRUVECO) reportó una tasa de neumonías asociadas al ventilador (NAV) del 7,37 por 1000 días de ventilación mecánica, la tasa de bacteriemias asociadas a catéter (BAC) fue de 1,77 por 1000 días de catéter, y la tasa de infecciones urinarias asociadas a sonda vesical (IUASV), de 3,04 por 1000 días de sonda vesical (4). ...
... He ahí la importancia de realizar una revisión enfocándose en las infecciones asociadas a la atención de la salud diferentes de la ISO, tales como la infección del tracto urinario asociado a sonda vesical, la infección del torrente sanguíneo asociada a catéter y la neumonía asociada al cuidado de la salud, las cuales aumentan el riesgo de discapacidad funcional, alargan la estancia hospitalaria, disminuyen la calidad de vida, y en algunos casos aumentan la mortalidad de los pacientes, lo que conduce a un aumento exagerado en los costos de la atención en salud. (1,2,5,6,8) El objetivo de esta revisión es establecer cuáles son las infecciones asociadas a la atención de la salud en pacientes que se les han realizado algún procedimiento quirúrgico, sin tener en cuenta las infecciones del sitio operatorio (ISO). ...
Objetivo: Establecer las infecciones asociadas a la atención de la salud en pacientes intervenidos quirúrgicamente, sin tener en cuenta las infecciones del sitio operatorio (ISO). Materiales y métodos: Se realizó una búsqueda de la literatura en las bases de datos de MEDLINE, CENTRAL, LILACS además de la literatura gris, para identificar estudios relacionados con infecciones asociadas a la atención de la salud en pacientes adultos que fueron intervenidos quirúrgicamente. Resultados: En la búsqueda realizada se seleccionaron 25 artículos de los cuales se extrajeron los resultados. Las IAAS más frecuentes en los estudios revisados fueron: neumonía asociada al ventilador (36%), neumonía asociada al cuidado de la salud (32%), infecciones de tracto urinario por catéter urinario (48%), infecciones asociadas a catéter venoso (8%). Conclusión: Las infecciones asociadas a la atención de la salud frecuentemente encontradas en pacientes llevados a procedimientos quirúrgicos son la neumonía asociada al ventilador, neumonía asociada al cuidado de la salud, la infección del tracto urinario por catéter y las infecciones asociadas a catéter venoso, sin embargo, las infecciones de sitio operatorio (ISO) son las más documentadas, situación que requiere mayor atención y abordaje a través de otros estudios de investigación.
... The cost of NIs increments with the profundity of the contamination. That is, the costs related with shallow incisional NIs are generally low, but increment with deep NIs, and particularly when organ or space contamination is displayed [1]. ...
... Also, there's no motivating forces for health administrates to stress around the cost of NIs as an additional day went through by the client in hospital has small impact on the running costs. In fact, new patient will cost more than patients remaining within the hospital due to routine services received [1]. Cost measurement can be seen in four ways; in terms of traceability: direct and indirect cost; behaviorbility: variable cost, fixed cost, semi-variable, and semi-fixed costs; controllability: controllable and non-controllable cost; and in terms of future: avoidable cost, sunk cost, etc. ...
... Surgical site infections are the second most common after urinary tract infections, with a frequency of 14% -16% [6]. Surgical patients have more complex comorbidity, the treatment of surgical site infections becomes more complex, and cost increases with the emergence of antimicrobial-resistant pathogens [7] [8] [9] [10]. ...
... In our clinic, costs for hospital stays were approximately 5.450 Euro (USD 6430) higher in patients with SSI compared to patients without SSI [13]. In the United States, additional costs for SSI range between USD 10443 and 25546 [14,15]. ...
1) Background: Surgical site infections (SSIs) are a relevant problem with a 25% incidence rate after elective laparotomy due to inflammatory bowel disease (IBD). The aim of this study was to evaluate whether stricter hygienic measures during the COVID-19 pandemic influenced the rate of SSI. (2) Methods: This is a monocentric, retrospective cohort study comparing the rate of SSI in patients with bowel resection due to IBD during COVID-19 (). (3) Results: The rate of SSI in IBD patients with bowel resection was 25.8% during the COVID-19 pandemic compared to 31.8% pre-COVID-19 (OR 0.94; 95% CI 0.40-2.20; p = 0.881). There were seventeen (17.5%) superficial and four (4.1%) deep incisional and organ/space SSIs, respectively, during the COVID-19 pandemic (p = 0.216). There were more postoperative intra-abdominal abscesses during COVID-19 (7.2% vs. 0.9%; p = 0.021). The strictness of hygienic measures (mild, medium, strict) had no influence on the rate of SSI (p = 0.553). (4) Conclusions: Hygienic regulations in hospitals during COVID-19 did not significantly reduce the rate of SSI in patients with bowel resection due to IBD. A ban on surgery, whereby only emergency surgery was allowed, was likely to delay surgery and exacerbate the disease, which probably contributed to more SSIs and postoperative complications.
... A localized infection is limited to a specific part of the body and has local symptoms, for example, if a surgical wound in the abdomen becomes infected, the area of the wound becomes red, hot, and painful. A generalized infection is one that enters the bloodstream and causes general systemic symptoms such as fever, chills, low blood pressure, or mental confusion [2,3]. ...
The present study was evaluated for the six months (1st October 2014 to 30th March 2015), the proportion of acquired infection in the Al-Imam Hussain Teaching Hospital at Al-Nasiriya province south of Iraq has studied. The relationship also estimated between employments and their variables such as age, gender, residence, medical department, social status and different distribution infections among staff in the hospital. The result showed discrepancy rate of occurrence and recording the incidence of cases. Common causes of hospital-acquired infections include urinary bladder catheterization, respiratory procedures, surgery and wounds and intravenous procedures. The most common bacterial isolates were Staphylococcus spp., Pseudomonas spp., Escherichia coli and Klebseilla spp. respectively. In conclusion, the acquired infection rate is an indicator of quality and safety of care. The development of a surveillance process to monitor this rate is an essential step to identify local problems and priorities, and evaluate the effectiveness of infection control activity.
... We examined the potential reduction of CLABSIs and in ICU all-cause mortality rates in LMICs, employing the 6 components of the INICC multidimensional approach, such as (1) an 11-element infection prevention bundle, (2) education, (3) surveillance of CLABSI rates and clinical outcomes, (4) monitoring compliance with bundle components, (5) feedback of CLABSI rates and clinical outcomes, and (6) performance feedback. The 11-element infection prevention bundle included (1) hand hygiene 7 , (2) maximum sterile barrier precautions 7 , (3) chlorhexidine skin antiseptis 7 , 4) avoiding the femoral site 7,14-16 , (5) reduction of CL-days 7,14-16 , (6) proper insertion site dressing 17-19 , (7) minimization of the length of stay 14-16 , (8) daily chlorhexidine preparation bathing 7 , (9) use of NCs 20,21 , (10) use of collapsible closed IV fluid systems [22][23][24] , and (11) use single-use flushing 20 . ...
... Despite a wealth of evidence demonstrating the importance of cost analysis for decision-making, calculating the cost of HAIs is still challenging [32,33]. A review from 2005 assessing 70 published studies on the cost of HAIs in hospitals found that the economic evidence on HAI control efforts needed to be more compelling because of the variety of study designs and settings, statistical methods and cost outcomes used [34]. Likewise, another systematic audit of economic evidence linking HAIs and preventive measures from 1990 to 2000, also performed by Stone et al. [35], and a recent systematic review by Arefian et al. [36] found that economic evaluation guidelines were not followed; therefore, the quality of the reports, according to the Professional Society for Health Economics and Outcomes Research, was low. ...
... Due to re-entry and prolonged hospitalizations, it weighs on health care systems which are nuisance for both patients and their families 6,7,8 . It is most occurring infection, accounting for more than 31% patients affected in hospital and resulting in increased duration of hospital stay and resource utilization 9,10 . ...
... At 42.4% of all healthcare-associated infections (HAIs) SSIs have emerged as the most common HAIs in the United States (Weiner-Lastinger et al., 2020). Furthermore, patients with SSIs have more complex comorbidities (Fry, 2011) and the emergence of antimicrobial-resistant pathogens increases the cost and challenges of treating SSIs (Stone et al., 2005). This is especially important now when the increasing incidence of antimicrobial resistance is a global healthcare crisis, particularly in surgical settings with high antibiotic usage (Calina et al., 2017;Menz et al., 2021;Sipahi, 2008). ...
Despite significant advances in infection control guidelines and practices, surgical site infections remain a substantial cause of morbidity, prolonged hospitalization, and mortality. The most effective component of SSI reduction strategies is the preoperative administration of intravenous antibiotics; however, systemic antibiotics drug exposure diminishes rapidly and may result in insufficient prophylactic activity against susceptible and resistant SSI pathogens at the wound. D-PLEX100 (D-PLEX) is an antibiotic-releasing drug (doxycycline) that is supplied as a sterile powder for paste reconstitution with sterile saline. D-PLEX paste is administered locally into the incision site along the entire length of soft tissue and sternal bone wound surfaces prior to skin closure. A single D-PLEX administration is intended for 30 days of constant antimicrobial prophylaxis in the prevention of incisional SSIs. We evaluated D-PLEX minimal bactericidal concentration (MBC) against a panel of bacteria that is prevalent in the abdominal wall and sternal surgical procedures including doxycycline susceptible and resistant strains. D-PLEX in vivo efficacy was assessed in incisional infection rabbit models (abdominal wall and sternal) challenged with a similar bacterial panel. The D-PLEX drug exposure profile was determined by in vitro release assay, and in vivo by quantitative pharmacokinetic parameters of local and systemic doxycycline concentrations released from D-PLEX after local administration in incisional rabbit models. Analyses of pathogens and variations in antibiotic resistance from wound isolates were determined from patients who participated in a previously reported prospective randomized trial that assessed the SSI rate in D-PLEX plus standard of care (SOC) versus SOC alone in colorectal resection surgery. The D-PLEX MBC values demonstrated >3- Log10 reduction in all the organisms tested relative to untreated controls, including doxycycline-resistant bacteria (i.e., Methicillin-resistant Staphylococcus aureus (MRSA), K. pneumoniae, and P. aeruginosa). In vivo, D-PLEX significantly reduced the bacterial loads in all the bacteria tested in both animal models (p=0.0001) with a marked impact observed in E. Coli (>6.5 Log10 reduction). D-PLEX exhibited a zero-order release kinetics profile in vitro for 30 days (R2 = 0.971) and the matched in vivo release profile indicated a constant local release of protein-unbound doxycycline for 30 days at 3-5 mcg/mL with significantly lower (>3 orders of magnitudes) systemic levels. In colorectal surgery patients, where significant SSI reduction was observed, analysis of the positive cultures in the overall population indicated similar pathogen diversity and antibiotic resistance rates in both treatment arms. However, almost all the patients with positive culture in the SOC arm were adjudicated as SSI (94%) compared to only 28% in the D-PLEX arm. The SSI-adjudicated D-PLEX patients also exhibited lower resistance rates to the SOC antibiotics and to MDRs compared to patients in the SOC arm. Thus, D-PLEX provides safe and effective prophylaxis activity against the most prevalent SSI pathogens including doxycycline-susceptible and resistant bacteria. Our findings suggest that D-PLEX is a promising addition to SSI prophylactic bundles and may address the gaps in current SSI prophylaxis. D-PLEX is now evaluated in phase 3 clinical trial.
... The up-to-date CDC guidelines suggest an overall incidence rate of SSI to be 1.9% of all surgical procedures in the United States; however, they estimate that this is under-reported [19]. The treatment of SSIs can be costly, both in terms of increased hospital length of stay as well as the treatment required, which is estimated to be between $10,000 and 25,000 [19,20]. ...
Although prophylactic antibiotic use following autologous breast reconstruction post-mastectomy is a common practice, there is no consensus in the literature regarding its duration. Antibiotic stewardship is important to minimise multi-resistant organisms as well as mitigate the associated side effects. Currently, there are no published guidelines regarding the duration of prophylactic antibiotics in autologous breast reconstruction surgery following mastectomy. The authors searched the online literature regarding the administration of antibiotics for autologous breast reconstruction surgery post-mastectomy. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. The primary outcome measure was the incidence of surgical site infections (SSIs). Three studies met the inclusion criteria and included a total of 1,400 patients. Overall, 101 (7.2%) SSIs were observed. There was no significant difference in the rate of SSIs when comparing the use of antibiotics for less than or longer than 24 hours postoperatively (odds ratio = 1.434, p = 0.124). There is no significant difference between SSIs with the use of antibiotics for longer than 24 hours when compared to less than 24 hours. Further studies in the form of randomised controlled trials are required to assess the effects of prophylactic antibiotic duration in autologous breast reconstruction following mastectomy.
... Multinational prospective study of incidence and risk factors for central line-associated bloodstream pediatric intensive care units (ICUs) and from 2.6 to 60.0 CLABSIs per 1000 CL-days in NICU 3 . There was a significant rise in CLABSI rates in ICUs of LMICs during the COVID-19 pandemic 4 .CLABSIs are associated with extra mortality of 12%-25% 8 and extra costs[9][10][11][12] . INICC reported that mortality in ICU patients without any healthcare associated infection (HAI) is 17.1%, with CLABSI is ...
Background:
Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia.
Methods:
From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR).
Results:
A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk.
Conclusions:
The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.
... Multinational prospective study of incidence and risk factors for central line-associated bloodstream pediatric intensive care units (ICUs) and from 2.6 to 60.0 CLABSIs per 1000 CL-days in NICU 3 . There was a significant rise in CLABSI rates in ICUs of LMICs during the COVID-19 pandemic 4 .CLABSIs are associated with extra mortality of 12%-25% 8 and extra costs[9][10][11][12] . INICC reported that mortality in ICU patients without any healthcare associated infection (HAI) is 17.1%, with CLABSI is ...
Objective:
To identify central-line (CL)-associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs).
Design:
From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms.
Setting:
The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries.
Patients:
In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs.
Methods:
For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs).
Results:
The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03-1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03-1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03-1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23-1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31-4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22-3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09-2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11-6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57-3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81-3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71-3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96-2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02-2.18; P = .04).
Conclusions:
The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; and implementing evidence-based CLABSI prevention recommendations.
... Hospital-acquired infections are a problem in intensive care units (ICUs)due to heavy workload, low compliance withprevention and control measures of infection, impaired patient immunity, prolongedadmission and invasive procedures such as mechanical ventilation and central venous catheterization [9,10]. ...
... Healthcare Associated Infections (HAIs) are a worldwide public concern. The Centers for Disease Control and Prevention (CDC) estimate 1.7 million HAIs and 99,000 deaths per year in the United States (Stone et al., 2005) and their cost to be 28-45 billion of dollars (Scott, 2009). The Hospital Infection Control Committee (HICC) is responsible for prevention and treatment of healthcare associated infections (HAIs). ...
Infection control teams collect and produce information on epidemiologic surveillance for prevention of Healthcare Associated Infections (HAIs). Value Stream Mapping (VSM) is a Lean method for developing process through flow efficiency. The aim of the study was to use VSM to identify opportunities for improvement in the infection control department. Flow of information and infection control activities were reviewed using VSM and a questionnaire, where time required for each task was measured. The actual VSM went through multidisciplinary analysis and an ideal VSM was created without considering resource limits. The ideal VSM was reviewed to identify the improvements easily implemented and the ones that would require more time or resources. The actual VSM analysis addressed work overload for Key Performance Indicators (KPI) production, data management (fragmentation, access and redundant work, storage, time between tasks, time typing) and tasks performed retrospectively, when less information is available and with no opportunity to correct protocol deviation. The implementation of the ideal VSM provided a faster and more efficient HAIs analysis, London protocol for HAI cases and surgical prophylaxis evaluation became real time tasks, and all surgical surveillance was improved. A mobile app was proposed as an intervention and became a long-term project. If completely implemented, the ideal VSM would result in 15.7 less work hours/month, having the working time optimized for patient care. VSM is an important tool for epidemiologic surveillance in infection control allowing better data management, continuous workflow, and new information production with potentially fewer work hours.
... As the advances in medicine increase, the burden of resistant organisms becomes inevitable. Hospitalacquired infections complicate the course of the disease, especially the critical one, thereby increasing the mortality, morbidity, length of hospital stay, and cost [1]. According to the Centres for Disease Control and Prevention (CDC), a hospital-acquired infection (HAI) is a localized or systemic condition secondary to the infection that was not present at the time of admission to the health care facility [2]. ...
Health care–associated infections (HAI) directly influence the survival of children in pediatric intensive care units (PICU), the most common being central line–associated bloodstream infection (CLABSI) 25–30%, followed by ventilator-associated pneumonia (VAP) 20–25%, and others such as catheter-associated urinary tract infection (CAUTI) 15%, surgical site infection (SSI) 11%. HAIs complicate the course of the disease, especially the critical one, thereby increasing the mortality, morbidity, length of hospital stay, and cost. The incidence of HAI in Western countries is 6.1–15.1% and in India, it is 10.5 to 19.5%. The advances in healthcare practices have reduced the incidence of HAIs in the recent years which is possible due to strict asepsis, hand hygiene practices, surveillance of infections, antibiotic stewardship, and adherence to bundled care. The burden of drug resistance and emerging infections are increasing with limited antibiotics in hand, is still a dreadful threat. The most common manifestation of HAIs is fever in PICU, hence the appropriate targeted search to identify the cause of fever should be done. Proper isolation practices, judicious handling of devices, regular microbiologic audit, local spectrum of organisms, identification of barriers in compliance of hand hygiene practices, appropriate education and training, all put together in an efficient and sustained system improves patient outcome.
... Several different types of nosocomial infections are described, from skin infections to septicemias. Worryingly, about two million patients acquire nosocomial infection and at least 90,000 of them die, in the United States, every year [3,4]. Severe nosocomial infections are the fifth leading cause of death in critical-care hospitals. ...
Objects touched by patients and healthcare workers in hospitals may harbor pathogens, including multi-drug resistant (MDR) staphylococci, enterococci (VRE), Escherichia coli, Acinetobacter, and Pseudomonas species. Medical devices contaminated by these pathogens may also act as a source of severe and difficult-to-treat human infections, thus becoming a critical public health concern requiring urgent resolutions. To this end, we recently reported the bactericidal effects of a cationic copolymer (CP1). Here, aiming at developing a bactericidal formulation possibly to be used either for surfaces disinfection or to treat skin infections, CP1 was formulated as a hydrogel (CP1_1.1-Hgel). Importantly, even if not cross-linked, CP1 formed the gel upon simple dispersion in water, without requiring gelling agents or other additives which could be skin-incompatible or interfere with CP1 bactericidal effects in possible future topical applications. CP1_1.1-Hgel was characterized by attenuated-total-reflectance Fourier transform infrared (ATR-FTIR) and UV-Vis spectroscopy, as well as optic and scanning electron microscopy (OM and SEM) to investigate its chemical structure and morphology. Its stability was assessed by monitoring its inversion properties over time at room temperature, while its mechanical characteristics were assessed by rheological experiments. Dose-dependent cytotoxicity studies performed on human fibroblasts for 24 h with gel samples obtained by diluting CP_1.1-Hgel at properly selected concentrations established that the 3D network formation did not significantly affect the cytotoxic profile of CP1. Also, microbiologic investigations carried out on two-fold serial dilutions of CP1-gel confirmed the minimum inhibitory concentrations (MICs) previously reported for the not formulated CP1.Selectivity indices values up to 12 were estimated by the values of LD50 and MICs determined here on gel samples.
... Disinfection of an ambulance is a necessity in order to avoid the spread of nosocomial infection. In some areas and sectors of India it has been observed that the disinfection practice is not being practiced properly; hence this study has been undertaken to estimate the Microbiological spectrum in ambulance and the effectiveness of fumigation in controlling these contamination (Galtelli andRogers, 2006 andStone et al., 2005) A regional study (Nigam and Cutter, 2003) examined the levels of bacterial contamination in ambulances over a 3month period on a monthly schedule. The results showed presence of different microbes in the collected samples before cleaning the emergency vehicles. ...
This study presents a microbial infection risk in the pre-hospital environment especially in an ambulance. Ambulances are at a severe risk for nosocomial infection. The objective behind this study was to estimate the contaminants i.e. microbiological spectrum in ambulance to analyse the effectiveness of disinfection in controlling these contamination. The most common organisms isolated from the ambulances were coagulase positive Staphylococcusaureus, Pseudomonas aeruginosa, Bacillus species, Escherichia coli, Listeria species, Enterobacter aerogens, Salmonellaspecies, Klebsiella and coagulase negative Staphylococci. The samples were collected from 10 different ambulances which were active in service, before and after disinfection. The samples were maintained in ambient temperature using thermo-electrical cooler and were transported to the laboratory. Through this project, we recommend the application of disinfection techniques to reduce the infection in the ambulances.
... Hospital-acquired infections (HAIs), also known as nosocomial infections (NIs), are currently one of the most important challenges for modern medicine [1,2]. Patients with HAIs might have prolonged hospital stays and high mortality, thus not only threatening the safety of patients but also causing a significant waste of social and economic resources, representing an important public health problem threatening human health [3][4][5][6]. Nosocomial infection surveillance is an important basis for controlling the occurrence and development of HAIs [6][7][8][9][10]. Hospitals should detect HAI cases and outbreaks of HAIs in a timely manner, analyse causes and take effective prevention and control measures. ...
Abstract Background The systematic collection of valid data related to hospital-acquired infections (HAIs) is considered effective for nosocomial infection prevention and control programs. New strategies to reduce HAIs have recently fueled the adoption of real-time automatic nosocomial infection surveillance systems (RT-NISSs). Although RT-NISSs have been implemented in some hospitals for several years, the effect of RT-NISS on HAI prevention and control needs to be further explored. Methods A retrospective, descriptive analysis of inpatients from January 2017 to December 2019 was performed. We collected hospital-acquired infection (HAI) cases and multidrug resistant organism (MDRO) infection cases by traditional surveillance in period 1 (from January 2017 to December 2017), and these cases were collected in period 2 (from January 2018 to December 2018) and period 3 (from January 2019 to December 2019) using a real-time nosocomial infection surveillance system (RT-NISS). The accuracy of MDRO infection surveillance results over the 3 periods was examined. The trends of antibiotic utilization rates and pathogen culture rates in periods 2 and 3 were also analysed. Results A total of 114,647 inpatients, including 2242 HAI cases, were analysed. The incidence of HAIs in period 2 was significantly greater than that in period 1 (2.28% vs. 1.48%, χ2 = 61.963, p
... Because up to 60% of SSIs were estimated to be preventable with the use of evidence-based measures, SSIs have become a pay-for-performance metric and a target of quality improvement efforts [2]. Surgical patients initially seen with more complex comorbidities [10,11] and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSIs [12][13][14]. ...
Surgical site infections are an increasingly important issue in nosocomial infections. The progressive increase in antibiotic resistance, the ever-increasing number of interventions and the ever-increasing complexity of patients due to their comorbidities amplify this problem. In this perspective, it is necessary to consider all the risk factors and all the current preventive and prophylactic measures which are available. At the same time, given multiresistant microorganisms, it is essential to consider all the possible current therapeutic interventions. Therefore, our review aims to evaluate all the current aspects regarding the management of surgical site infections.
... SSIs are preventable complications that are utilized to measure the quality of care in hospitals. SSIs can lead to increases in the length of hospital stay, readmission, reoperation and mortality [2][3][4][5][6][7]. All these complications are a burden on healthcare costs. ...
Background
Compliance with perioperative antibiotic prophylaxis is crucial for preventing surgical site infection. Anesthesiologists can play a significant role in reducing surgical site infections by following clinical practice guidelines for antibiotic prophylaxis and redosing during surgery. A quality assurance initiative was implemented at a tertiary hospital with the goal of improving cefazolin perioperative antibiotic compliance.
Methods
A multifaceted intervention was initiated to address low compliance with cefazolin redosing. Multifaceted interventions included the development of a perioperative antibiotic guide for anesthesia providers, automated reminders in anesthesia electronic medical records, grand rounds education, survey and email communications, and regular feedback reports to the anesthesia department.
Results
Rates of redose compliance were examined in three time periods: pre-intervention, intervention, and post-intervention. Cefazolin redosing compliance was 58% in the pre-intervention period and 90% in the post-intervention period. There was a significant positive change in the trend of compliance during the intervention period, indicating that the odds of compliance increased by 13% per month in the intervention period compared to the pre-intervention period (odds ratio = 1.13, p<0.001). Redose compliance improvements were sustained a year after the post intervention period (average 91%). Surgical site infection rates for colon, coronary artery bypass graft and hip surgeries did not show any significant trend during these time periods.
Conclusion
Multifaceted interventions led to significant and sustained improvements in cefazolin redosing compliance in the main operating room of a tertiary hospital.
... In developed countries, healthcare-related infections affect about 5-15% of hospitalised patients (Vincent, 2003), and the rate is even greater among those in intensive-care sections, which is between 9-37% (Vincent, 2003;Vincent, 1995). In the USA, the estimated healthcare-related infection frequency in the year 2004 was 4.5%, with a fatality rate of 5% (Stone et al., 2005;Allengranzi & Pittet, 2007). ...
Hospital-related infections are a foremost public health concern which pervades all healthcare facilities and systems around the world regardless of resources available and has received considerable global and public health attention over the years in light of the increasing morbidity and mortality rates occasioned by poor hand-hygiene by healthcare providers, and which has been clearly documented as the major pathway for the spread of nosocomial infections. The object, therefore, was to observe the knowledge and practise of hand-washing and related factors amongst healthcare providers in primary healthcare facilities in Ijebu Ode, Nigeria. The observation adopted descriptive cross-sectional approach and data were collected through structured questionnaire from ninety two (92) consenting participants, purposively selected, and analysed via statistical software for social scientists (version 20.0). The findings demonstrated that a sizeable number of healthcare providers in primary health-care centres in Ijebu Ode had good knowledge and practise of hand-washing with 91.3% and 84.8%, respectively, and that inadequate water supply, forgetfulness, and shortage of hand-washing facilities were the major factors affecting hand-washing practice. Consequently, the work concluded that healthcare givers in primary health-care facilities in Ijebu Ode have good knowledge and practise of hand hygiene, and factors like inadequate water supply, forgetfulness, and deficiency of hand-washing facilities affect hand-washing practice. However, the study recommended that hospital authorities should ensure provision of regular water supply, adequate essential hand washing facilities, and posters at strategic locations to act as a reminder for regular hand washing.
... (1-4) 2(1)(2)(3)(4) 0.085Content courtesy of Springer Nature, terms of use apply. Rights reserved. ...
Peripherally inserted central venous catheters (PICCs) have a potential advantage in preventing central line-associated bloodstream infection (CLABSI) compared with the centrally inserted ones (CICCs). However, due to a limited number of studies with insufficient statistical evaluation, the superiority of PICCs is difficult to be generalized in adult hematology unit. We conducted a single-center retrospective study and compared the risk of CLABSI between 472 CICCs and 557 PICCs inserted in adult patients with hematological disorders through conventional multivariate models and a propensity score-adjusted analysis. The overall CLABSI incidence in CICCs and PICCs was 5.11 and 3.29 per 1000 catheter days (P = 0.024). The multivariate Cox regression analysis (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.31–0.75; P = 0.001) and Fine-Gray subdistribution analysis (HR: 0.59; 95% CI: 0.37–0.93; P = 0.023) demonstrated that PICC was independently associated with a reduced risk of CLABSI. Moreover, the stabilized inverse probability of treatment weighting analysis, which further reduced the selection bias between CICCs and PICCs, showed that PICCs significantly prevented CLABSI (HR: 0.58; 95% CI: 0.35–0.94; P = 0.029). Microbiologically, PICCs showed a significant decrease in gram-positive cocci (P = 0.001) and an increase in gram-positive bacilli (P = 0.002) because of a remarkable reduction in Staphylococci and increase in Corynebacterium species responsible for CLABSI. Our study confirmed that PICC was a superior alternative to CICC in preventing CLABSI in the adult hematology unit, while it posed a microbiological shift in local epidemiology.
... This study has revealed that nurses at the Lagos University Teaching Hospital have good knowledge of hand washing indicated by the finding of (83%). This finding is similar to that reported among healthcare staff in ICU of a Multispecialty hospital in India (90%), but higher than figures reported among nurses in Cairo in Elgalea Government Hospital (73.1%), and Cleopatr a Private Hospital (72.7%) [10][11][12]. It is also much better than the findings at the University of Port Harcourt Teaching Hospital (UPTH) in which more than half of the nurses (55.4%) lack good knowledge of hand washing [13]. ...
... Hospital-acquired infections (HAIs), also known as nosocomial infections (NIs), are currently one of the most important challenges for modern medicine [1,2]. Patients with HAIs might have prolonged hospital stays and high mortality, thus not only threatening the safety of patients but also causing a signi cant waste of social and economic resources, representing an important public health problem threatening human health [3][4][5][6]. Nosocomial infection surveillance is an important basis for controlling the occurrence and development of HAIs [6][7][8][9][10]. Hospitals should detect HAI cases and outbreaks of HAIs in a timely manner, analyse causes and take effective prevention and control measures. ...
Background: The systematic collection of valid data related to hospital-acquired infections (HAIs) is considered effective for nosocomial infection prevention and control programs. New strategies to reduce HAIs have recently fueled the adoption of real-time automatic nosocomial infection surveillance systems (RT-NISSs). Although RT-NISSs have been implemented in some hospitals for several years, the effect of RT-NISS on HAI prevention and control needs to be further explored.
Methods: A retrospective, descriptive analysis of inpatients from January 2017 to December 2019 was performed. We collected hospital-acquired infection (HAI) cases and multidrug resistant organism (MDRO) infection cases by traditional surveillance in period 1 (from January 2017 to December 2017), and these cases were collected in period 2 (from January 2018 to December 2018) and period 3 (from January 2019 to December 2019) using a real-time nosocomial infection surveillance system (RT-NISS). The accuracy of MDRO infection surveillance results over the 3 periods was examined. The trends of antibiotic utilization rates and pathogen culture rates in periods 2 and 3 were also analysed.
Results: A total of 114647 inpatients, including 2242 HAI cases, were analysed. The incidence of HAIs in period 2 was significantly greater than that in period 1 (2.28% vs. 1.48%, c²=61.963, p<0.001) and period 3 (2.28% vs. 2.05%, c²=4.767, p=0.029). The incidence of five HAI sites, including respiratory infection, urinary tract infection (UTI), surgical site infection (SSI), bloodstream infection (BSI) and skin and soft tissue infection, was significantly greater in period 2 compared with period 1 (both p<0.05) but was not significantly different from that in period 3. The incidence of hospital-acquired MDRO infections in period 3 was lower than that in period 2. The identification of MDRO infection cases using the RT-NISS achieved a high level of sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV), especially in period 3 (Se=100%, Sp=100%, PPV=100% and NPV=100%).
Conclusion: The adoption of a RT-NISS to adequately and accurately collect HAI cases is useful to prevent and control HAIs. Furthermore, RT-NISSs improve accuracy in MDRO infection case reporting, which can timely and accurately guide and supervise clinicians in implementing MDRO infection prevention and control measures.
... Nosocomial or healthcare-associated infections (HAIs) are infections that a patient acquires during the period of their stay at a healthcare facility, after getting discharged and also occupational infections among healthcare workers [1]. HAIs are a major cause of morbidity, mortality and economic burden considering it affects millions of people each year [2][3][4]. Evidence has shown that a great proportion of healthcare providers and patients had acquired infections within a healthcare facility [5][6][7]. HAIs incidence rate has been reported to be 15.5 per 100 patients in developing countries as compared to 7 per 100 patients in developed countries [8]. ...
Introduction: HAIs are a major cause of morbidity, mortality and economic burden considering it affects millions of people each year. Evidence has shown that a great proportion of healthcare providers and patients had acquired infections within a healthcare facility.
... The Center for Medicare and Medicaid Services considers operations like elective colorectal surgery, knee replacements, and hysterectomies to be avoidable conditions, hence readmissions are frequently non-reimbursable as SSI. Furthermore, current research suggests that poor post-discharge communication, care fragmentation, and infrequent, late follow-up contribute to these inferior outcomes [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. ...
Infection of the wound after surgery is a regular occurrence. Wound infection is a complicated process that involves a molecular interplay between numerous biological processes. Wound infections are associated with a high rate of morbidity and mortality. Surgical site infections are a common surgical complication that affects approximately 3%-6% of all surgical procedures according to different studies. Surgical site infections (SSIs) cause negative consequences in patients, such as prolonged hospitalization and mortality. Each incision causes wound contamination, however there are established techniques to reduce the incidence of SSI. Improved adherence to evidence-based preventative strategies such as adequate antibiotic prophylaxis, in particular, can help to reduce the rate of SSI. The sort of procedure used determines the correct diagnosis of SSI. Early detection, on the other hand, is critical for good management of all surgical operations. Consistent antibiotic therapy, wound drainage, and, if necessary, vigorous wound debridement are all part of the treatment for SSI. Following that, wound management is determined by the location and nature of the infection. This study aims to: Diagnosis and Management of Surgical Site Infections. In this review we will be looking at surgical site infections epidemiology, etiology, diagnosis and management.
... Hospital Acquired Infections (HAIs) serves as one of the major threat in the medical field even after the beginning of much antimicrobial therapy and progress in supportive care management. 1 The hospital environment, objects/instruments, and health-care workers are likely to get populated by various microbial agents. Disease transmission leads to morbidity and mortality due to contact with things handled by infected and colonized patients and direct communication with such patients 1,2 and also at least 90,000 of them die due to HAI. 3,4 Healthcare-associated infections are the fifth major cause of death in critical-care hospitals. The proportion of HAI patients in developing countries is neither recorded nor appropriately reported due to various reasons like difficulty in collecting reliable data and improper follow-up of HAI surveillance system. ...
The major problem encountered in recent days due to the advent of emerging antimicrobial resistance strains is Hospital Acquired Infections (HAIs). The spread of HAI is mainly through the hospital staff and the hospital settings’ inanimate surfaces. The study includes the surveillance of hospital surfaces, including wards and ICUs, by taking swabs dipped in normal saline. Pseudomonas aeruginosa (53.8%) was found to be the most common pathogen isolated, followed by Klebsiella species (18%), Methicillin-Sensitive Staphylococcus aureus (16%), Coagulase-Negative Staphylococci (6%), Methicillin-Resistant Staphylococcus aureus (3%). The widespread presence of bacterial sensitivity to antimicrobials and the modifications insensitivity forms the basis for designing antibacterial therapy’s practical recommendations and rational use of antimicrobials. Proper display of all Information, Education, and Communication (IEC) materials at appropriate places play a significant role in preventing nosocomial infections. Audiovisual aids and training to the staff play utmost importance in preventing the spread of HAIs. All these can reduce the occurrence and outbreak of nosocomial conditions. Overall, these minimize health care costs.
The rise of antimicrobial resistance (AMR) is a major global public health threat due to excessive and inappropriate use of antibiotics and is responsible for prolonged illness, longer hospital stays, and economic burden to society. This article aims to review the factors, role of antimicrobial stewardship, preventive strategies, and role of various organizations in combating AMR. Three major factors of AMR are inappropriate and excessive utilization of antibiotics, nonadherence to infection control measures, and the emergence of pathogens that are resistant to multiple drugs. Antimicrobial stewardship initiatives play a vital role in promoting judicious and targeted utilization of antimicrobials, thereby safeguarding their efficacy and mitigating the emergence of resistance. Implementing such programs optimizes patient outcomes by ensuring that individuals receive the most suitable therapeutic interventions. International organizations have a vital role to play in addressing AMR by promoting the responsible use of antimicrobials, developing new drugs, and improving surveillance systems. As AMR's impact grows, it is critical to take a collaborative and interdisciplinary approach to mitigate its consequences effectively.
Objective:
To evaluate the efficacy of a new continuously active disinfectant (CAD) to decrease bioburden on high-touch environmental surfaces compared to a standard disinfectant in the intensive care unit.
Design:
A single-blind randomized controlled trial with 1:1 allocation.
Setting:
Medical intensive care unit (MICU) at an urban tertiary-care hospital.
Participants:
Adult patients admitted to the MICU and on contact precautions.
Intervention:
A new CAD wipe used for daily cleaning.
Methods:
Samples were collected from 5 high-touch environmental surfaces before cleaning and at 1, 4, and 24 hours after cleaning. The primary outcome was the mean bioburden 24 hours after cleaning. The secondary outcome was the detection of any epidemiologically important pathogen (EIP) 24 hours after cleaning.
Results:
In total, 843 environmental samples were collected from 43 unique patient rooms. At 24 hours, the mean bioburden recovered from the patient rooms cleaned with the new CAD wipe (intervention) was 52 CFU/mL, and the mean bioburden was 92 CFU/mL in the rooms cleaned the standard disinfectant (control). After log transformation for multivariable analysis, the mean difference in bioburden between the intervention and control arm was -0.59 (95% CI, -1.45 to 0.27). The odds of EIP detection were 14% lower in the rooms cleaned with the CAD wipe (OR, 0.86; 95% CI, 0.31-2.32).
Conclusions:
The bacterial bioburden and odds of detection of EIPs were not statistically different in rooms cleaned with the CAD compared to the standard disinfectant after 24 hours. Although CAD technology appears promising in vitro, larger studies may be warranted to evaluate efficacy in clinical settings.
Background:
Surgical Site Infections (SSI) yield subtle, early signs that are not readily identifiable. This study sought to develop a machine learning algorithm that could identify early SSIs based on thermal images.
Methods:
Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures. Two neural network models were generated to detect SSIs, one using RGB images, and one incorporating thermal images. Accuracy and Jaccard Index were the primary metrics by which models were evaluated.
Results:
Only 5 patients in our cohort developed SSIs (2.8%). Models were instead generated to demarcate the wound site. The models had 89-92% accuracy in predicting pixel class. The Jaccard indices for the RGB and RGB + Thermal models were 66% and 64%, respectively.
Conclusions:
Although the low infection rate precluded the ability of our models to identify surgical site infections, we were able to generate two models to successfully segment wounds. This proof-of-concept study demonstrates that computer vision has the potential to support future surgical applications.
Background:
Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors in Latin-America.
Methods:
From 01/01/2014 to 02/10/2022, we conducted a multinational multicenter prospective cohort study in 58 ICUs of 34 hospitals in 21 cities in 8 Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama). We applied multiple logistic regression. Outcomes are shown as adjusted odds ratios (aOR).
Results:
29,385 patients were hospitalized during 92,956 days, acquired 400 CLABSIs, and pooled CLABSI rate was 4.30 CLABSIs per 1,000 CL-days.,We analyzed following 10 variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization (DU) ratio, CL-type, tracheostomy use, hospitalization type, ICU type, and facility ownership, Following variables were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 3% daily (aOR=1.03;95%CI=1.02-1.04;p<0.0001); number of CL-days before CLABSI acquisition, rising risk 4% per CL-day (aOR=1.04;95%CI=1.03-1.05;p<0.0001); publicly-owned facility (aOR=2.33;95%CI=1.79-3.02;p<0.0001).,ICU with highest risk was medical-surgical (aOR=2.61;95%CI=1.41-4.81;p<0.0001).,CL with the highest risk were femoral (aOR=2.71;95%CI=1.61-4.55;p<0.0001), and internal-jugular (aOR=2.62;95%CI=1.82-3.79;p<0.0001).,PICC (aOR=1.25;95%CI=0.63-2.51;p=0.52) was not associated with CLABSI risk.
Conclusions:
The following identified CLABSI RFs are unlikely to change: facility ownership and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, using PICC instead of femoral or internal-jugular; and implementing evidence-based CLABSI prevention recommendations.
In the world's changing conditions, alternative conflict resolution methods are becoming more critical. Such procedures usually include mediation, conciliation, negotiations, facilitation, restorative justice, arbitration, etc. But it is mediation that is gaining more and more popularity. A large number of international development programs and grants stimulate mediation development. Today, we should pay more attention to understanding the nature of mediation, its concepts and principles. Mediation has become a widespread method of conflict resolution. The parties choose this procedure as an efficient and quick dispute-resolution mechanism. The term "mediation" only indirectly confirms that it is a way of expressing the parties' will and is based on the autonomy of will. This situation determines the practicality of analysing the term "mediation" to define it as a mechanism of manifestation of will by the parties.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
The second edition of Independent and Supplementary Prescribing builds on the success of this classic text by providing a unique resource for prescribing and medicines management for both new and experienced prescribers. This is an essential resource for anyone undertaking the non-medical prescribing programme. The book explores a number of key areas for prescribers, including the ethical and legal issues surrounding prescribing, prescribing within a public health context, evidence-based prescribing, basic pharmacology, medication safety, monitoring skills and drug calculations. Each chapter has been updated for the second edition and an additional chapter 'Minimising the risk of prescribing error' has been added. Written by a group of multi-professional authors working at all stages of the medication management process, this book will be essential reading for all nurses, midwives, pharmacists and allied health professionals qualified to prescribe as independent and/or supplementary prescribers.
Resumen
Las infecciones nosocomiales o infecciones asociadas a la atención sanitaria (IAAS) que complican la cirugía ortopédica se encuentran en constante aumento. Las causas principales de este aumento son el envejecimiento progresivo de la población, que origina un número regularmente creciente de intervenciones quirúrgicas, y la imposibilidad de prevenir por completo estas infecciones a pesar de la profilaxis antibiótica y el respeto de las medidas de higiene. En Francia, la vigilancia de las infecciones asociadas a la atención sanitaria constituye una prioridad nacional en términos de lucha contra las infecciones nosocomiales gracias en particular a los datos del sistema RAISIN (Réseau d’Alerte, d’Investigation et de Surveillance des Infections Nosocomiales). Existen progresos significativos en el tratamiento de los pacientes como la mejora de las técnicas de diagnóstico microbiológico, el desarrollo de cooperaciones medicoquirúrgicas, que permiten un tratamiento pluridisciplinario, y la posibilidad en algunos casos de tratar la infección de las prótesis sin necesidad de retirarlas. Los textos recientes que regulan los procedimientos de denuncia por infección nosocomial han contribuido al aumento considerable del número de solicitudes de indemnización de pacientes que se consideran víctimas de una infección ligada a la atención sanitaria, en particular en cirugía ortopédica. En consecuencia, los cirujanos traumatólogos tienen más que nunca la obligación de conocer los avances relacionados con la prevención, el diagnóstico y el tratamiento de las infecciones nosocomiales en su campo. La organización en rama especializada asociada a una mejor accesibilidad para los pacientes ha originado la certificación, desde septiembre 2008, de nueve centros franceses de referencia coordinadores de las infecciones osteoarticulares complejas (asociados a centros correspondientes que garantizan una cobertura territorial). Una de las misiones de estos centros consiste en coordinar la prevención y el tratamiento de estas infecciones nosocomiales.
Background: Resveratrol has been reported to have synergistic effect with different antibiotics against various kinds of bacteria species. In this study, we investigated if resveratrol can increase the antimicrobial efficacy of polymyxin B against multidrug resistant (MDR) Pseudomonas aeruginosa.7 different MDR Pseudomonas aeruginosa isolates obtained from clinical specimen were tested with broth microdilution method to determine their sensitivity to polymyxin B and resveratrol respectively. Checkerboard analysis was performed to analyze the biological interaction between resveratrol and polymyxin B. Time-kill assays were carried out to monitor the bactericidal activity against Pseudomonas aeruginosa cells. And the biofilm-forming bacteria were selected for biofilm formation analysis.
Results: Though resveratrol showed no intrinsic bactericidal activity against Pseudomonas aeruginosa (MIC >512μg/ml for all isolates), it could effectively increase the sensitivity of those isolates to polymyxin B, with the MIC of polymyxin B reduced by 4-8 fold with 64μg/ml resveratrol. The synergistic effect between resveratrol and polymyxin B on bactericidal activity was also observed with all tested isolates (FICI <0.5). Biofilm formation assay showed that resveratrol in combination with polymyxin B significantly inhibited the biofilm formation of Pseudomonas aeruginosa (P <0.01). With established biofilm, the sensitivity of the tested isolate to polymyxin B was sharply reduced, leading to high concentration polymyxin B resistance (MIC >32μg/ml). The bactericidal activity of polymyxin B against those cells protected by established biofilm could still be promoted by resveratrol (P <0.01).
Conclusions: Resveratrol was able to improve the antimicrobial properties of polymyxin B from various aspects, it may be an ideal partner for the combination therapy of polymyxin B against MDR Pseudomonas aeruginosa.
Centers for Medicare and Medicaid Services (CMS) incentives and penalties have the potential to exert powerful motivating forces on hospital decision makers and can result in major changes in prioritization of hospital resources. Because of this, thoughtful alignment of incentives and penalties with performance metrics that are likely to promote adherence to processes that result in improved patient outcomes is critically important. Although CMS has shifted the focus of pay-for-performance metrics from process to outcome measures, challenges around standardizing application of SSI surveillance definitions and methods and the weaknesses of current risk adjustment methods may limit the utility of SSI outcome measures to drive improvements in practice. Possible modifications and additions to prior Surgical Care Improvement Project (SCIP) process measures are discussed.KeywordsSurgical wound infectionPostoperative complicationsQuality improvementProspective payment systemPerioperative care
Bacterial infection caused by Multidrug-resistant Pseudomonas aeruginosa has become a tricky problem in clinical practice. In recent years, lots of efforts have been made the treatment this type of bacterial infection. Polymyxins, which usually act as the available antibiotic for otherwise untreatable Gram-negative bacteria, can also be useful for the treatment of Multidrug-resistant Pseudomonas aeruginosa infection. However, current pharmacodynamic (PD) and pharmacokinetic (PK) data on polymyxins suggest that polymyxin monotherapy is unlikely to generate reliably efficacious plasma concentrations. Also, polymyxin resistance has been frequently reported, especially among Multidrug-resistant Pseudomonas aeruginosa, which further narrows the availability of polymyxins in clinical practice. A strategy for improving antimicrobial properties of polymyxins and preventing the development of polymyxin resistance is the use of polymyxins in combination with other agents. Indeed, it is increasingly being used clinically. In this study, we have demonstrated that resveratrol, a compound that can be well tolerated by human body, has synergistic effect with polymyxin B on antibacterial and anti-biofilm activities, which suggests that it may be an ideal partner for the combination therapy of polymyxin B against MDR Pseudomonas aeruginosa.
保持手卫生是感染防控的重要策略, 但是如何提高其依从性成为预防传染性疾病和减少医疗机构获得性感染的一大挑战。以行为科学为基础的手卫生助推干预以更“隐性”的方式将洗手转变为一种可自动触发的行为习惯, 弥补了以知识分享和健康宣教为主的传统手卫生干预策略的诸多局限性。基于影响机制的不同,手卫生助推干预策略可分为提供决策信息、优化决策选项、影响决策结构、提醒决策方向4 个大类的框架体系。多模式助推策略的有效性也已在实践中得到印证, 但目前还非常缺乏在中国社会文化情境下开展的助推洗手行为的干预研究, 今后可尝试基于行为科学理论有针对性地在医院、学校和社区等公共场所开展此类干
预研究和实践, 为感染防控、疾病预防和改善公共健康做出相应的贡献。
Maintaining optimal hand hygiene is an important strategy for infection control and prevention. However, how to increase adherence to hand hygiene practices has been a major challenge to prevent infectious diseases and reduce hospital acquired infections (HAIs), especially in the critical period of COVID-19 epidemic regular prevention and control. There are great differences in the effectiveness between different hand hygiene behavior intervention strategies, and the best hand hygiene intervention practice is still in development and requires further investigation. In order to develop intervention strategies for health care researchers and practitioners, the current research systematically summarizes hand hygiene behavior intervention strategies from the perspective of “nudge” for the first time. Traditional hand hygiene interventions are usually based on knowledge sharing and health education, which only produce weak or modest effects on hand hygiene practices. Recent research in behavioral science provides insights for developing effective behavioral interventions to optimize hand hygiene practices by helping people form better hand hygiene habits. Traditional intervention strategies tend to rely on people's ability to engage in rational thinking and the availability of cognitive resources, that is, encouraging people to reflect on their hand hygiene behaviors and enhance their handwashing motivation in a rational and conscious way. The influences of external environmental factors are rarely taken into account in traditional intervention strategies. Similarly, the role of personal psychological factors is often ignored, so this kind of hand hygiene intervention strategy often shows limited effectiveness and low sustainability. In addition, there are many other common obstacles such as limited accessibility of hand hygiene products, people's overconfidence in their immune system to prevent infection, inertia, and habitual forgetting. Many research results show that even if traditional intervention strategies can increase risk awareness of poor hand hygiene and enhance hand washing intention in the target population, they may not lead to effective behavior changes in hand hygiene. Inspired by the research from behavioral sciences, researchers have tried to promote experiential, unconscious, and automatically triggered hand hygiene behavior through interventions of specific psychological or external environmental factors, so as to help people overcome the gap between hand washing intention and behaviors. Based on different influential mechanisms, hand hygiene nudging strategies can be classified into four categories and nine subordinate categories, including providing decision information (simplifying information, providing feedback, and harvesting the impact of social norms), optimizing decision options (simplifying options and making original options more attractive), influencing decision structure (increasing the accessibility and visibility of favorable options), and reminding decision direction (direct reminder and environmental hint). Previous studies have shown that behavioral science-based hand hygiene interventions, in general, achieved positive effects at a fairly low cost, which are worthy of further application. However, there are still many disputes concerning ethics and effectiveness for nudging intervention. Among these disputes, the two points often mentioned are whether nudging limits the decision-makers' freedom of independent choice and damages their ability of independent choice. These two disputes may have a relatively small impact on hand hygiene promotion, and the form of nudging intervention is more easily accepted by the public, which may be due to the fact that handwashing behavior essentially has a certain degree of “injunctive norm” tendency (i.e., the vast majority of people agree with maintaining hand hygiene). In addition, previous research on hand hygiene nudging intervention also has many limitations, including low accuracy of the evaluation criteria, sustainability, and generalizability of nudging strategies. Further research is warranted to develop more effective hand hygiene nudging interventions and apply them to diverse social contexts. The effectiveness of multi-facet nudging strategies has also been confirmed in hand hygiene practices, suggesting that another future research direction is to construct a hand hygiene nudging strategy classification system similar to the Behavior Change Technique (BCT) taxonomy, so as to design multi-facet nudging strategies for promoting hand hygiene in a specific social context. Based on China's national conditions, traditional hand hygiene intervention strategies such as health education cannot be completely abandoned. This kind of comprehensive new model of “traditional intervention + nudging strategies” and the personalization and specialization of nudging intervention strategies might be the focus of hand hygiene behavior promotion intervention in the future. However, there is still a lack of hand hygiene nudging intervention in Chinese sociocultural contexts. Another direction for future research is to carry out such nudging interventions in hospitals, schools, communities, and other public places based on the theory of behavioral change, so as to contribute to the prevention and control of infectious diseases and improve public health.
Background
Healthcare-associated infections (HAIs) are a global public health issue. However, the economic burden attributable to HAIs at a national level is unknown in China. The aim of this systematic review was to estimate the direct economic burden caused by HAIs in China.
Methods
Medline, EMBASE and Chinese Journals Online databases were searched, including studies published from 2009 to 2019. The pooled estimates with 95% Confidential Interval were calculated with Quantile Estimation. The random effect model of the DerSimonian-Laird method was used. The statistical significance was set as P<0.05.
Results
2,756 publications were identified; 6 studies were included in a meta-analysis to calculate the pooled estimates of direct economic burden, while 5 were included in the pooled estimates of the additional economic burden. The pooled median estimates of the total medical expenditure, the medicine expenditure and hospitalisation days per inpatient of patients with HAIs were ¥34,415.62, ¥20,065.21 and 34.01 days, respectively (P <0.0001). The pooled median estimates of the differences of the total medical expenditure, the medicine expenditure and hospitalisation days per inpatient between patients with HAIs and patients without HAIs were ¥24,881.37, ¥9,438.46 and 13.89 days, respectively (P < 0.01).
Conclusions
The cost of care for patients with HAIs was significantly higher than that for those without HAIs. This excess economic burden is likely to impact on patients and their families as well as health service providers and the health care system as a whole. Effective surveillance systems and cost-effective interventions are needed to control HAIs.
Objective.
—To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations.Participants.
—The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS).Evidence.
—The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users.Consensus Process.
—The panel developed recommendations through 21/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists.Conclusions.
—The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the "rule of reason," balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.
Although prophylactic antibiotic medications have been shown to reduce the incidence of postoperative infectious morbidity after cesarean delivery, the most effective regimens have not been established. The purpose of this investigation was to compare the efficacy and costs of prophylaxis with cefazolin alone with cefazolin plus metronidazole.
Women undergoing cesarean delivery were randomized to prophylaxis with 2 g cefazolin (n = 81) or 1 g cefazolin plus 500 mg metronidazole (n = 79). Postoperative infectious morbidity and the duration of hospitalization in the two groups were compared.
Thirty-seven (23%) of 160 patients developed endomyometritis. There was a significant reduction in the number of postoperative infections (14 versus 32%) and hospital days (3.12 versus 4.46) with cefazolin and metronidazole prophylaxis (P = 0.0064 versus P = 0.014) compared with cefazolin alone. The estimated antibiotic prophylaxis cost per person was less with cefazolin and metronidazole than with cefazolin alone (9.12 dollars versus 26.73 dollars).
Antibiotic prophylaxis with metronidazole and cefazolin results in fewer postoperative infections, decreased duration of hospitalization, and lower medication cost than cefazolin alone.
Historically, staphylococci, pseudomonads, and Escherichia coli have been the nosocomial infection troika; nosocomial pneumonia, surgical wound infections, and vascular access-related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance. Acquired antimicrobial resistance is the major problem, and vancomycin-resistant Staphylococcus aureus is the pathogen of greatest concern. The shift to outpatient care is leaving the most vulnerable patients in hospitals. Aging of our population and increasingly aggressive medical and surgical interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, create a cohort of particularly susceptible persons. Renovation of aging hospitals increases risk of airborne fungal and other infections. To prevent and control these emerging nosocomial infections, we need to increase national surveillance, "risk adjust" infection rates so that interhospital comparisons are valid, develop more noninvasive infection-resistant devices, and work with health-care workers on better implementation of existing control measures such as hand washing.
To compare the cost, efficacy and cost efficacy of tazobactam/piperacillin and imipenem/cilastatin in the treatment of intra-abdominal infection.
The analysis was retrospective and based on a decision tree. Effectiveness data were obtained from 19 published clinical trials. Direct costs were quantified per patient from the time the decision was made to administer the antibacterial to the end of the first course of treatment or the end of a subsequent course of treatment, if required. The primary end-point was the cost per successfully treated patient. The cost per life saved was also analysed. Various follow-up times were taken into account.
German National Health Insurance funds.
1744 patients with intra-abdominal infection.
Tazobactam/piperacillin (total daily dosage of 13.5 g/day) and imipenem/cilastatin (total daily dosage of 1.5 to 4 g/day). The mean duration of treatment varied from 5.5 to 8.2 days for tazobactam/piperacillin and 5 to 9.4 days for imipenem/cilastatin.
Compared with imipenem/cilastatin, treatment with tazobactam/piperacillin was more effective and the overall treatment costs were lower. In the base-case analysis, the cost-efficacy ratio (cost per successfully treated patient) was 7881 German deutschmarks (DM) for tazobactam/piperacillin and DM11,390 for imipenem/cilastatin. The incremental cost-efficacy ratio (per life saved) varied between -DM72,567 and -DM350,738 for tazobactam/piperacillin. Sensitivity analyses revealed that the results were robust against various assumptions on cost parameters, clinical outcomes and length of treatment. All costs reflect 1998 values; $US1 = DM1.85.
This study suggests that compared with imipenem/cilastatin, tazobactam/piperacillin is more cost efficacious in the treatment of intra-abdominal infections and that it offers a cost advantage through fewer relapses and lower daily therapeutic costs.
In support of the registration and reregistration processes under FIFRA ‘88, numerical models are used to estimate the dissolved runoff and soil erosion loadings of pesticides to surface waters and the subsequent fate and transport of pesticides in the receiving waters. Uses for simulations include:
1. Helping to determine whether additional studies on the fate and distribution of a candidate chemical in the environment and/or ecological effects may be needed when full chemical characterization is incomplete.
2. Helping to more fully integrate data submissions of laboratory and field observations.
3. Estimating probable fate and distribution of an agrochemical after a severe runoff event.
4. Comparing alternative chemical application rates and methods for the same chemical/soil/crop/environmental combinations.
5. Comparing different soil/crop/environmental combinations representing different geographical areas with the same chemical.
6. Evaluating preliminary designs of proposed field studies.
7. Gaining insight into the environmental fate of modern chemicals that are applied at 1 to 2% of the rates of older chemicals when sampling designs and analytical methods are not available.
The Office of Pesticide Programs (OPP) commonly employs the SWRRB (45, 46) and PRZM (8, 9) models for runoff and EXAMS II (5), a fate and transport model, for surface waters. These three models are used in conjunction with appropriate databases for soils, chemical properties, and meteorological and other environmental parameters. Registrants are encouraged to clearly state assumptions, identify values for parameters by citation, report results of simulations with summary tables and graphics, and interpret their results in relation to current scientific disciplines.
The movement and degradation of agricultural chemicals in soil and groundwater is a complex process, influenced by climatic conditions, site characteristics, chemical properties, and agricultural practices. Because of this complexity, mechanistic models are useful tools in evaluating environmental fate. Although currently available unsaturated zone models often do not provide accurate concentration profiles when compared with field measurements, they can be used to estimate the depth and extent of movement. Another application of modeling is to compare predicted movement under different simulation conditions to determine the significance of the various factors affecting the behavior of agricultural chemicals. When properly designed and interpreted, modeling studies can contribute to the understanding of the environmental fate of agricultural chemicals. When necessary, modeling can also be useful in developing management practices included on the label or in state regulations. Modeling has been a frequently used tool in developing restrictions for minimizing the movement of aldicarb residues into groundwater and preventing residues in drinking water. Examples of model use include optimizing application timing, estimating well setback distances, and identifying vulnerable soils.
To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively. The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). The panel reviewed the theoretical foundations of CEA, current practices, and alternative procedures for measuring and assigning values to resource use and health outcomes. The panel met 11 times during 2 1/2 years with PHS staff and methodologists from federal agencies. Working groups brought issues and preliminary recommendations to the full panel for discussion. Draft recommendations were circulated to outside experts and the federal agencies prior to finalization. The panel's recommendations define a "reference case" cost-effectiveness analysis, a standard set of methods to serve as a point of comparison across studies. The reference case analysis is conducted from the societal perspective and accounts for benefits, harms, and costs to all parties. Although CEA does not reflect every element of importance in health care decisions, the information it provides is critical to informing decisions about the allocation of health care resources.
Background. Central venous catheters are frequently needed for the provision of haemodialysis, but their clinical usefulness is severely limited by infectious complications. The risk of such infections can be reduced by topical application of mupirocin to the exit sites of non-cuffed catheters or by the use of tunnelled, cuffed catheters. Whether mupirocin offers any additional protection against infection in patients with tunnelled, cuffed haemodialysis catheters has not been studied. Methods. An open-label, randomized controlled trial was performed comparing the effect of thrice-weekly exit site application of mupirocin (mupirocin group) vs no ointment (control group) on infection rates and catheter survival in patients receiving haemodialysis via a newly inserted, tunnelled, cuffed central venous catheter. All patients were followed until catheter removal and were monitored for the development of exit site infections and catheter-associated bacteraemias. Results. Fifty patients were enrolled in the study. Both the mupirocin (ns27) and control (ns23) groups were similar at baseline with respect to demographic characteristics, comorbid illnesses and causes of renal failure. Compared with controls, mupirocin-treated patients experienced significantly fewer catheterrelated bacteraemias (7 vs 35%, P-0.01) and a longer time to first bacteraemia (log rank score 8.68, P-0.01). The beneficial effect of mupirocin was entirely attributable to a reduction in staphylococcal infection (log rank 10.69, Ps0.001) and was still observed when only patients without prior nasal Staphylococcus aureus carriage were included in the analysis (log rank score 6.33, Ps0.01). Median catheter survival was also significantly longer in the mupirocin group (108 vs 31 days, log rank score 5.9, P-0.05). Mupirocin use was not associated with any adverse patient effects or the induction of antimicrobial resistance. Conclusions. Thrice-weekly application of mupirocin to tunnelled, cuffed haemodialysis catheter exit sites is associated with a marked reduction in line-related sepsis and a prolongation of catheter survival.
An infectious disease consulting service was set up at a large tertiary university hospital in 1996 to evaluate and to improve antibiotic prescription patterns. Treatment guidelines for the most common bacterial infections were implemented. On daily ward rounds antibiotic therapies without evidence of an infectious disease were stopped and inappropriate regimens were changed by an infectious disease specialist. During a 6-month prospective intervention period, 3,528 patients were studied on 13 wards of the department of internal medicine; 513 of these patients (14.5%) received antibiotic therapy. These treatment courses were evaluated as adequate in 394 cases (76.8%) and incorrect in 119 cases (23.2%). Inadequate antibiotic substances were chosen in 72 out of 119 cases (60.5%) and there was no indication for treatment in 38 out of 119 cases (32%). Pathogen-specific therapies were inadequate significantly more often than empirical antimicrobial therapies (p < 0.001). In addition, the duration of the perioperative prophylaxis could be limited to 1 d. Comparing the intervention period with a 3-month control interval without an infectious disease consulting service, a total of 31,510 Euro (including the costs for the infectious disease specialist) could be saved. No increase in infection-related mortality or length of stay was observed. These data show that an infectious disease consulting service optimizes antibiotic usage, and is cost-effective as a result of a significant cost reduction in hospitals, while not interfering with the quality of medical care.
To assess the methods being used in US hospitals to prevent the spread of contagious illnesses from hospital employees to patients, we analyzed information obtained in the SENIC Project (Study on the Efficacy of Nosocomial Infection Control) from interviews with hospital officials and staff nurses. In general, staff nurses and their first-line supervisors appeared to be unfamiliar with some published recommendations outlining when an illness or exposure should exclude them temporarily from patient contact. The infection control nurse had authority to exclude employees in fewer than half of the hospitals. Although employees would be financially penalized in less than 10% of hospitals for missing work on account of a contagious illness, staff nurses in larger hospitals were more reluctant to consult the employee health service if they believed they would lose pay.
(JAMA 1981;246:962-966)
State public health agencies are charged with providing and overseeing the management of basic public health services on a population-wide basis. These activities have a re-emphasized focus as a result of the events of September 11, 2001, the subsequent anthrax events, and the continuing importance placed on bioterrorism preparedness, West Nile virus, and emerging infectious diseases (eg, monkeypox, SARS). This has added to the tension that exists in budgeting and planning, given the diverse constituencies that are served in each state. State health agencies must be prepared to allocate finite resources in a more formal manner to be able to provide basic public health services on a routine basis, as well as during outbreaks. This article describes the use of an analytical approach to assist financial analysis that is used for budgeting and planning in a state health agency. The combined benefits of decision science and financial analysis are needed to adequately and appropriately plan and budget to meet the diverse needs of the populations within a state. Health and financial indicators are incorporated into a decision model, based on multicriteria decision theory, that has been employed to acquire information about counties and public health programs areas within a county, that reflect the impact of planning and budgeting efforts. This information can be used to allocate resources, to distribute funds for health care services, and to guide public health finance policy formulation and implementation.
Purpose: Cost-utility analysis is a type of cost-effectiveness analysis in which health effects are measured in terms of quality-adjusted life-years (QALYs) gained. Such analyses have become popular for examining the health and economic consequences of health and medical interventions, and they have been recommended by leaders in the field. These recommendations emphasize the importance of good reporting practices. This study determined 1) the quality of reporting in published cost-utility analyses through 1997 and 2) whether reporting practices have improved over time. We examined quality of reporting by journal type and number of cost-utility analyses a journal has published. Data Sources: Computerized databases were searched through 1997 for the Medical Subject Headings or text keywords quality-adjusted, QALY, and cost-utility analysis. Published bibliographies of the field were also searched. Study Selection: Original cost-utility analyses written in English were included. Cost-effectiveness analyses that measured health effects in units other than QALYs and review, editorial, or methodologic articles were excluded. Data Extraction: Each of the 228 articles found was audited independently by two trained readers who used a standard data collection form to determine the quality of reporting in several categories: disclosure of funding, framing, reporting of costs, reporting of preference weights, reporting of results, and discussion. Results: The number of cost-utility analyses in the medical literature increased greatly between 1976 and 1997. Analyses covered a wide range of diseases and interventions. Most studies listed modeling assumptions (82%), described the comparator intervention (83%), reported sensitivity analysis (89%), and noted study limitations (84%). Only 52% clearly stated the study perspective; 34% did not disclose the funding source. Methods of reporting costs and preference weights varied widely. The quality of published analyses improved slightly over time and was higher in general clinical journals and in journals that published more of these analyses. Conclusions: The study results reveal an active and evolving field but also underscore the need for more consistency and clarity in reporting. Better peer review and independent, third-party audits may help in this regard. Future investigations should examine the quality of clinical and economic assumptions used in cost-utility analyses, in addition to whether analysts followed recommended protocols for performance and reporting.
Hypothesis
Catheter-related bloodstream infection (CRBSI) in critically ill surgical patients with prolonged intensive care unit (ICU) stays is associated with a significant increase in health care resource use.
Design
Prospective cohort study.
Setting
Surgical ICU at a large tertiary care center.
Patients
Critically ill surgical patients (N = 260) with projected surgical ICU length of stay greater than 3 days.
Interventions
Central venous catheters were cultured for clinical suspicion of infection.
Main Outcome Measures
Increases in total hospital cost, ICU cost, hospital days, and ICU days attributable to CRBSI were estimated using multiple linear regression after adjusting for demographic factors and severity of illness (APACHE III [Apache Physiology and Chronic Health Evaluation III] score).
Results
The incidence of CRBSI per 1000 catheter-days was 3.6 episodes (95% confidence interval [CI], 2.1-5.8 episodes). Microbiologic isolates were Gram-positive bacteria in 75%, Gram-negative bacteria in 20%, and yeast in 5%. After adjusting for demographic factors and severity of disease, CRBSI was associated with an increase of $56 167 (95% CI, $11 523-$165 735; P = .001) (in 1998 dollars) in total hospital cost, an increase of $71 443 (95% CI, $11 960-$195 628; P<.001) in ICU cost, a 22-day increase in hospital length of stay, and a 20-day increase in ICU length of stay.
Conclusions
For critically ill surgical patients, CRBSI is associated with a profound increase in resource use. Prevention, early diagnosis, and intervention for CRBSI might result in cost savings in this high-risk population.
Objectives: This paper describes the methods used in the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) for conducting systematic reviews of economic evaluations across community health-promotion and disease-prevention interventions. The lack of standardized methods to improve the comparability of results from economic evaluations has hampered the use of data on costs and financial benefits in evidence-based reviews of effectiveness. The methods and instruments developed for the Guide provide an explicit and systematic approach for abstracting economic evaluation data and increase the usefulness of economic information for policy making in health care and public health.Methods: The following steps were taken for systematic reviews of economic evaluations: (1) systematic searches were conducted; (2) studies using economic analytic methods, such as cost analysis or cost-effectiveness, cost-benefit or cost-utility analysis, were selected according to explicit inclusion criteria; (3) economic data were abstracted and adjusted using a standardized abstraction form; and (4) adjusted summary measures were listed in summary tables.Results: These methods were used in a review of 10 interventions designed to improve vaccination coverage in children, adolescents and adults. Ten average costs and 14 cost-effectiveness ratios were abstracted or calculated from data reported in 24 studies and expressed in 1997 USD. The types of costs included in the analysis and intervention definitions varied extensively. Gaps in data were found for many interventions.
Objective.
—To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively.
Objective.
—This article, the third in a 3-part series, describes recommendations for the reporting of cost-effective analyses (CEAs) intended to improve the quality and accessibility of CEA reports.Participants.
—The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, convened by the US Public Health Service.Evidence.
—The panel reviewed the theoretical foundations of CEA, current practices, alternative methods, published critiques of CEAs, and criticisms of general CEA methods and reporting practices.Consensus Process.
—The panel developed recommendations through 21/2 years of discussions. Comments on preliminary drafts were solicited from federal government methodologists, health agency officials, and academic methodologists.Conclusion.
—These recommendations are proposed to enhance the transparency of study methods, assist analysts in providing complete information, and facilitate the presentation of comparable cost-effectiveness results across studies. Adherence to reporting conventions and attention to providing information required to understand and interpret study results will improve the relevance and accessibility of CEAs.
Context: Because human and financial resources are limited, health efforts must focus on prevention strategies that yield the most benefit for the investment. Many current strategies identified in the literature offer opportunities to promote health at a reasonable cost.
This paper examines some of the difficulties in using QALY league tables in priority setting. Such tables sometimes are seen as being ‘the’ way to prioritise in health care and in particular, at present, with respect to priority setting among purchasers in the UK NHS. However the paper highlights the fact that the base on which such tables is built is small—relatively few studies in the English language using CUA have been conducted anywhere. Further, four issues which require handling with care are set out: (i) the relevant measure of cost in QALY league tables has to be restricted to health service resource use; (ii) the relevant measure of benefit in QALY league tables is clearly restricted to QALYs, thereby the utility of health gains and indeed the maximisation of the utility of health gains; (iii) in incorporating the results of CUA studies into QALY league tables there is a need for greater clarification on what the margin constitutes; and (iv) those who might use CUA results in QALY league tables need to ascertain whether the original context of the study will allow the results to be transferred to the local context of the decision maker. The paper suggests that there is a need to be quite clear what goal QALY league tables serve. The authors argue that the only legitimate (and clearly important) goal of QALY league tables is the maximisation of the utility of health gains within a health service budget.
The thinking underlying QALY league tables, adjusted to take account of the caveats in this paper, is the key to rational priority setting at a local level. It is this thinking that is to be emphasised rather than the use of ‘imported’ league tables or the use of results from CUA studies conducted elsewhere in the country or indeed in other countries. If results from elsewhere are to be used, the study context has to be examined carefully to establish the extent of its relevance to the local circumstances facing the purchasing authority.
Slutsky, AS Jha, P Aslanyan, G Bergeron, MG Brown, D Brunham, R D'Alessandro, D Hunkin, J Kain, K Kopelow, J Low, DE McGeer, A Plummer, FA
To assess the methods being used in US hospitals to prevent the spread of contagious illnesses from hospital employees to patients, we analyzed information obtained in the SENIC Project (Study on the Efficacy of Nosocomial Infection Control) from interviews with hospital officials and staff nurses. In general, staff nurses and their first-line supervisors appeared to be unfamiliar with some published recommendations outlining when an illness or exposure should exclude them temporarily from patient contact. The infection control nurse had authority to exclude employees in fewer than half of the hospitals. Although employees would be financially penalized in less than 10% of hospitals for missing work on account of a contagious illness, staff nurses in larger hospitals were more reluctant to consult the employee health service if they believed they would lose pay.
To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively.
The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS).
The panel reviewed the theoretical foundations of CEA, current practices, and alternative procedures for measuring and assigning values to resource use and health outcomes.
The panel met 11 times during 2 1/2 years with PHS staff and methodologists from federal agencies. Working groups brought issues and preliminary recommendations to the full panel for discussion. Draft recommendations were circulated to outside experts and the federal agencies prior to finalization.
The panel's recommendations define a "reference case" cost-effectiveness analysis, a standard set of methods to serve as a point of comparison across studies. The reference case analysis is conducted from the societal perspective and accounts for benefits, harms, and costs to all parties. Although CEA does not reflect every element of importance in health care decisions, the information it provides is critical to informing decisions about the allocation of health care resources.
To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations.
The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS).
The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users.
The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists.
The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ¿rule of reason,¿ balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.
This article, the third in a 3-part series, describes recommendations for the reporting of cost-effective analyses (CEAs) intended to improve the quality and accessibility of CEA reports.
The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, convened by the US Public Health Service.
The panel reviewed the theoretical foundations of CEA, current practices, alternative methods, published critiques of CEAs, and criticisms of general CEA methods and reporting practices.
The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts were solicited from federal government methodologists, health agency officials, and academic methodologists.
These recommendations are proposed to enhance the transparency of study methods, assist analysts in providing complete information, and facilitate the presentation of comparable cost-effectiveness results across studies. Adherence to reporting conventions and attention to providing information required to understand and interpret study results will improve the relevance and accessibility of CEAs.
In recent years QALYs (quality adjusted life years) have achieved considerable fame or perhaps even notoriety in health services policy making. Yet little has been done to date to assess the potential benefit in policy terms of studies that have used cost-utility analysis (CUA). It was in recognition of this fact that this particular investigation was undertaken. An evaluation of 51 cost-utility studies is reported in the paper. Several criteria were applied to each study including aspects of technical and policy relevance. The main findings were: few studies had been undertaken; they were limited to few areas of health care; their technical execution was often of poor quality; the majority of studies used the empirical findings of health state valuations obtained from original developers of different quality of life techniques; and many claimed their results to be 'favourable' (i.e. efficient interventions). This claim, however, is misguided because individual results get fed into generalised QALY league tables which ignore the context of specific studies and use results not performed on a common basis. Consequently, the state of the applied art of CUA is currently open to considerable question.
Because human and financial resources are limited, health efforts must focus on prevention strategies that yield the most benefit for the investment. Many current strategies identified in the literature offer opportunities to promote health at a reasonable cost.
To present a literature-based review of evidence demonstrating that prevention can be an effective and wise use of resources through CDC's An Ounce of Prevention ... What Are the Returns? Second Edition.
Systematic review of cost-effectiveness literature for a selected group of prevention strategies.
Prevention strategies relevant to the U.S. population.
Data indicate that the health conditions considered can be addressed through prevention strategies that are either cost effective or cost saving.
An Ounce of Prevention ... What Are the Returns? Second Edition can be used to conveniently access information on prevention strategies, the diseases and injuries they address, and their cost effectiveness. It also complements other comprehensive prevention guides. However, limitations of the available cost-effectiveness studies indicate that standardized procedures should be followed for studies of all recommended prevention strategies. Researchers must standardize review procedures to improve both the quality and comparability of studies.
Heightened awareness by health care funders of the need to find more efficient ways of using scarce health care resources has led to greater demand for evidence of cost-effectiveness. Implicit in this demand is that evidence is generated using clear reporting and accepted methods. The research reported here updates an earlier review of published cost-utility analyses (CUAs) to address whether previously identified gaps in reporting have diminished over time. Raising CUA standards requires systematic and regular reviews of published material to allow adequate monitoring and evaluation. There is also a need to 'appraise the appraisers' in the sense of reviewing peer-review processes. This is particularly so in those journals which are growing in importance as outlets for economic evaluation information. The findings from this study indicate continuing variation in the quality of reporting. At the lower end of this spectrum improvements could be made in the reporting of comparators, in the clarity of effectiveness evidence, in the assignment of utility weights to health states and in reporting of sensitivity analysis. CUAs published in peer-reviewed specialist medical journals were more likely to be lower in quality suggesting guidance on the appraisal of economic submissions needs to be extended to the editors of these particular journals. These findings could be used to help to target attempts to raise the quality of evidence-based CUA information.
This paper describes the methods used in the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) for conducting systematic reviews of economic evaluations across community health-promotion and disease-prevention interventions. The lack of standardized methods to improve the comparability of results from economic evaluations has hampered the use of data on costs and financial benefits in evidence-based reviews of effectiveness. The methods and instruments developed for the Guide provide an explicit and systematic approach for abstracting economic evaluation data and increase the usefulness of economic information for policy making in health care and public health.
The following steps were taken for systematic reviews of economic evaluations: (1) systematic searches were conducted; (2) studies using economic analytic methods, such as cost analysis or cost-effectiveness, cost-benefit or cost-utility analysis, were selected according to explicit inclusion criteria; (3) economic data were abstracted and adjusted using a standardized abstraction form; and (4) adjusted summary measures were listed in summary tables.
These methods were used in a review of 10 interventions designed to improve vaccination coverage in children, adolescents and adults. Ten average costs and 14 cost-effectiveness ratios were abstracted or calculated from data reported in 24 studies and expressed in 1997 USD. The types of costs included in the analysis and intervention definitions varied extensively. Gaps in data were found for many interventions.
Cost-utility analysis is a type of cost-effectiveness analysis in which health effects are measured in terms of quality-adjusted life-years (QALYs) gained. Such analyses have become popular for examining the health and economic consequences of health and medical interventions, and they have been recommended by leaders in the field. These recommendations emphasize the importance of good reporting practices. This study determined 1) the quality of reporting in published cost-utility analyses through 1997 and 2) whether reporting practices have improved over time. We examined quality of reporting by journal type and number of cost-utility analyses a journal has published.
Computerized databases were searched through 1997 for the Medical Subject Headings or text keywords quality-adjusted, QALY, and cost-utility analysis. Published bibliographies of the field were also searched.
Original cost-utility analyses written in English were included. Cost-effectiveness analyses that measured health effects in units other than QALYs and review, editorial, or methodologic articles were excluded.
Each of the 228 articles found was audited independently by two trained readers who used a standard data collection form to determine the quality of reporting in several categories: disclosure of funding, framing, reporting of costs, reporting of preference weights, reporting of results, and discussion.
The number of cost-utility analyses in the medical literature increased greatly between 1976 and 1997. Analyses covered a wide range of diseases and interventions. Most studies listed modeling assumptions (82%), described the comparator intervention (83%), reported sensitivity analysis (89%), and noted study limitations (84%). Only 52% clearly stated the study perspective; 34% did not disclose the funding source. Methods of reporting costs and preference weights varied widely. The quality of published analyses improved slightly over time and was higher in general clinical journals and in journals that published more of these analyses.
The study results reveal an active and evolving field but also underscore the need for more consistency and clarity in reporting. Better peer review and independent, third-party audits may help in this regard. Future investigations should examine the quality of clinical and economic assumptions used in cost-utility analyses, in addition to whether analysts followed recommended protocols for performance and reporting.
To study the influence of adverse patient occurrences defined as airway complication (AC), vascular complication (VC), and infectious complication (IC) on intensive care unit (ICU) costs and length of stay (LOS).
Retrospective, cohort study
An urban, tertiary care children's hospital in Philadelphia, PA.
All children admitted to a multidisciplinary pediatric ICU during the fiscal year 1994.
None
Demographic data, diagnoses, Pediatric Risk of Mortality scores, LOS, and deaths were recorded. Hospital charges were converted into costs by using cost-to-charge ratios. There were 23 AC, 35 VC, and 40 IC events. Multiple regression in models adjusting for age, Pediatric Risk of Mortality score, mortality, chronic disease, and diagnosis by using AC, VC, and IC indicator variables was performed on the dependent variables of LOS and total costs. IC was associated with an increase in total costs of $50,361.89 (p < .001), an increased LOS of 15.6 days (p < .001), and no significant increase in daily costs. There were no significant increases in costs or LOS seen with the AC and VC variables. In a matched analysis, the total costs attributable to IC averaged $32,040 per patient.
The occurrence of complications in the pediatric ICU is associated with meaningful increases in LOS and hospital costs. ICs are more important predictors of costs than ACs or VCs. Continuing efforts should be made to minimize adverse occurrences to improve patient care and reduce costs.
Catheter-related bloodstream infection (CRBSI) in critically ill surgical patients with prolonged intensive care unit (ICU) stays is associated with a significant increase in health care resource use.
Prospective cohort study.
Surgical ICU at a large tertiary care center.
Critically ill surgical patients (N = 260) with projected surgical ICU length of stay greater than 3 days.
Central venous catheters were cultured for clinical suspicion of infection.
Increases in total hospital cost, ICU cost, hospital days, and ICU days attributable to CRBSI were estimated using multiple linear regression after adjusting for demographic factors and severity of illness (APACHE III [Apache Physiology and Chronic Health Evaluation III] score).
The incidence of CRBSI per 1000 catheter-days was 3.6 episodes (95% confidence interval [CI], 2.1-5.8 episodes). Microbiologic isolates were Gram-positive bacteria in 75%, Gram-negative bacteria in 20%, and yeast in 5%. After adjusting for demographic factors and severity of disease, CRBSI was associated with an increase of $56 167 (95% CI, $11 523-$165 735; P =.001) (in 1998 dollars) in total hospital cost, an increase of $71 443 (95% CI, $11 960-$195 628; P<.001) in ICU cost, a 22-day increase in hospital length of stay, and a 20-day increase in ICU length of stay.
For critically ill surgical patients, CRBSI is associated with a profound increase in resource use. Prevention, early diagnosis, and intervention for CRBSI might result in cost savings in this high-risk population.
To determine the average costs per child for rotavirus (RV) acute gastroenteritis from different perspectives, from the hospital's, third-party payer's, pediatrician's and family's perspectives as well as in summary from the societal one.
This cost-of-illness study is based on data collected alongside a 6-month prospective, laboratory-confirmed epidemiologic study that evaluated the disease burden of RV infection in Austrian children < or =48 months of age. The study population at risk to contract a community- and nosocomially acquired acute gastroenteritis comprised 9,687 children. All of the 51 children with community-acquired and 33 with nosocomially acquired RV acute gastroenteritis were included in this analysis. The annual costs were estimated by means of extrapolation.
For community-acquired RV acute gastroenteritis, the average costs from the hospital's perspective were EURO (EUR) 97.8, from the third party payer's perspective 95.6 EUR, followed by 29.9 EUR and 9.8 EUR from the family's and pediatrician's perspectives, respectively. For nosocomially acquired RV acute gastroenteritis the average costs from the hospital's perspective were 1,494 EUR and from the third party payer's and family's perspectives 831 EUR and 116.8 EUR, respectively. In summary the average costs from the societal point of view for community-acquired RV acute gastroenteritis were 250 EUR and for nosocomial infections 2,442 EUR. After extrapolation the estimated total annual costs were 7.17 EUR million to 0.97 EUR million (13.6%) caused by community-acquired RV acute gastroenteritis and 6.2 EUR million (86.4%) caused by nosocomial RV acute gastroenteritis.
This cost-of-illness study clearly demonstrates the great impact of RV acute gastroenteritis, mainly of nosocomially acquired infection, on medical health care costs in Austria. To cut costs efforts in disease prevention should be encouraged.
To determine the costs associated with the management of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA), and to estimate the economic burden associated with MRSA in Canadian hospitals.
Patient-specific costs were used to determine the attributable cost of MRSA associated with excess hospitalization and concurrent treatment. Excess hospitalization for infected patients was identified using the Appropriateness Evaluation Protocol, a criterion-based chart review process to determine the need for each day of hospitalization. Concurrent treatment costs were identified through chart review for days in isolation, antimicrobial therapy, and MRSA screening tests. The economic burden to Canadian hospitals was estimated based on 3,167,521 hospital discharges for 1996 and 1997 and an incidence of 4.12 MRSA cases per 1,000 admissions. SETtING: A tertiary-care, university-affiliated teaching hospital in Toronto, Ontario, Canada.
Inpatients with at least one culture yielding MRSA between April 1996 and March 1998.
A total of 20 patients with MRSA infections and 79 colonized patients (with 94 admissions) were identified. This represented a rate of 2.9 MRSA cases per 1,000 admissions. The mean number of additional hospital days attributable to MRSA infection was 14, with 11 admissions having at least 1 attributable day. The total attributable cost to treat MRSA infections was $287,200, or $14,360 per patient The cost for isolation and management of colonized patients was $128,095, or $1,363 per admission. Costs for MRSA screening in the hospital were $109,813. Assuming an infection rate of 10% to 20%, we determined the costs associated with MRSA in Canadian hospitals to be $42 million to $59 million annually.
These results indicate that there is a substantial economic burden associated with MRSA in Canadian hospitals. These costs will continue to rise if the incidence of MRSA increases further.
The object of this study was to improve the use of antibiotics at Aker University Hospital, a 600-bed university hospital. We developed and implemented guidelines for antibiotic treatment and prophylaxis. We describe the impact of these guidelines on the use and cost of antibiotics and evaluate compliance with the guidelines. From 1994 to 1996 there was an 11% reduction in the use of antibacterial agents and a 42% reduction in the use of antifungal agents. The use of broad-spectrum antibiotics was reduced by 23%. The use of penicillin V and G increased by 5%, dikloxacillin/kloxacillin by 46% and erythromycin by 33%. Compared with 1994 values there was a 27% reduction in antibiotic costs in 1995, amounting to US$ 319,300, and a 32% reduction in antibiotic costs in 1996, amounting to US$ 380,000. A point-prevalence investigation conducted 18 months after the introduction of the guidelines indicated that compliance was > 95%. It proved possible to reduce the use of broad-spectrum antibacterial and antifungal agents, with significant cost savings. Point-prevalence studies may be a useful tool to detect deviations from guidelines and provide physicians with educational feedback.
Between April 1994 and May 1995 4000 adult patients admitted to selected specialties of a district general hospital were recruited to this study. Hospital-acquired infections presenting during the in-patient stay were identified using previously validated methods of surveillance, and information on daily resource use by both infected and uninfected patients was recorded and estimates of their cost derived. Linear regression modelling techniques were used to estimate how much of the observed variation in resource use and costs could be explained by the presence of an infection. Complete in-patient data sets were obtained for 3980 patients. Of these, 309 patients (7.8%; 95% CI; 7.0, 8.6) presented with one or more hospital-acquired infections during the in-patient period. Infected patients, on average, incurred hospital costs 2.9 (regression model estimate: 2.8; 95% CI; 2.6, 3.0) times higher than uninfected patients, equivalent to an additional pound3154 (regression model estimate pound2917). Both the incidence and the economic impact varied with site of infection and with admission specialty. Estimates of the burden of hospital-acquired infections occurring in adult patients admitted to similar specialties at NHS hospitals in England were derived from the results of this study. An estimated 320 994 (95% CI; 288 071, 353 916) patients per annum acquire one or more infections which present during the in-patient period, and these infections cost the hospital sector an estimated 930.62 million pounds (95% CI; 780.26 pounds; 1080.97 million pounds) per annum. The results presented represent the gross economic benefits that might accrue if these infections are prevented. Further research is required to establish the net benefits of prevention.
To determine if continuous-infusion ceftazidime is more cost-effective and efficacious than intermittent infusion in patients with nosocomial pneumonia.
Prospective, open-label, randomized trial.
Large, community teaching hospital.
Intensive care unit (ICU) patients with nosocomial pneumonia.
Ceftazidime 3 g/day was administered as a continuous infusion or as 2 g 3 times/day by intermittent infusion to treat nosocomial pneumonia in the ICU. Patients also received tobramycin 7 mg/kg once/day.
Thirty-five patients were evaluable; 17 received continuous infusion and 18 intermittent infusion. Clinical efficacy (94% and 83% successful outcomes with continuous and intermittent infusion, respectively), adverse events, and length of stay did not vary significantly between groups. Costs associated with continuous infusion, $627 +/- 388, were significantly lower (p < or = 0.001) than with intermittent infusion, $1007 +/- 430.
Continuous infusion of ceftazidime is a cost-effective alternative to intermittent infusion for nosocomial pneumonia in the ICU.
The increase in costs of hospitalization for patients with drug-resistant infection may be associated with drug resistance
itself or with the severity of the underlying illness that predisposes patients to acquire the drug-resistant infection. To
address this issue, risk factors and cost of hospitalization were compared for patients infected or colonized with vancomycin-susceptible
Enterococcus faecium (VSEF) or vancomycin-resistant E. faecium (VREF) in a large tertiary-care hospital in New York City. From January 1995 through December 1996, 157 patients with VSEF
and 262 patients with VREF were identified. CMI (case-mix index) was assigned to each patient as a measure of severity of
illness, with a CMI of 1 considered to represent illness of average severity. For all patients who were assigned a CMI of
<3, the cost per day of hospitalization for patients with VREF was significantly greater than that for patients with VSEF.
However, for patients with a CMI of >3, there was no difference between cost of hospitalization for patients with VREF and
that for patients with VSEF. These observations indicate that, although vancomycin resistance is associated with an increased
cost of hospitalization for less severely ill patients with VREF, patients with severe underlying illness, regardless of vancomycin
resistance, incur similar hospitalization costs.
Considerable morbidity, mortality, and economic costs result during remission induction therapy for elderly patients with acute myeloid leukemia (AML). In this study, the economic costs of adjunct granulocyte colony stimulating factor (G-CSF) are estimated for AML patients > 55 years of age who received induction chemotherapy on a recently completed Southwest Oncology Group study (SWOG). Clinical data were based on Phase III trial information from 207 AML patients who were randomized to receive either placebo or G-CSF post-induction therapy. Analyses were conducted using a decision analytic model with the primary source of clinical event probabilities based on in-hospital care with or without an active infection requiring intravenous antibiotics. Estimates of average daily costs of care with and without an infection were imputed from a previously reported economic model of a similar population. When compared to AML patients who received placebo, patients who received G-CSF had significantly fewer days on intravenous antibiotics (median 22 vs. 26, p = 0.05), whereas overall duration of hospitalization did not differ (median 29 days). The median cost per day with an active infection that required intravenous antibiotics was estimated to be $1742, whereas the median cost per day without an active infection was estimated to be $1467. Overall, costs were $49,693 for the placebo group and $50,593 for the G-CSF patients. G-CSF during induction chemotherapy for elderly patients with AML had some clinical benefits, but it did not reduce the duration of hospitalization, prolong survival, or reduce the overall cost of supportive care. Whether the benefits of G-CSF therapy justify its use in individual patients with acute leukemia for the present remains a matter of clinical judgment.
The use of prophylactic antibiotics has been shown to decrease the rate of surgical-site infections after clean neurosurgical operations, although previous clinical trials have provided no evidence that one antibiotic is superior to another for this purpose.
This study was undertaken to compare the rates of postoperative infectious complications of neurosurgery with prophylactic ceftriaxone and ampicillin/sulbactam, a less-expensive antibiotic.
Consecutive patients undergoing neurosurgery between January and December 1998 were recruited for the study. Those who had an infectious disease for which antibiotics were required, who received antibiotics within 48 hours before surgery, were aged <12 or >85 years, had an indwelling catheter for the monitoring of intracranial pressure, or had a history of allergy to the study drugs were excluded. Before the operation, eligible patients were randomized to either ampicillin/sulbactam 3 g or ceftriaxone 2 g. Surgeons and patients were blinded to treatment assignment. The study drugs were administered by the anesthesiologist as an IV bolus after induction of general anesthesia. All patients were followed for 6 weeks postoperatively. If reoperation was required within 6 weeks of the original operation, the patient received the same antibiotic as during the first surgery, without further randomization.
Over the 1-year study period, 180 consecutive patients undergoing neurosurgical operations were recruited. Surgical-site infection occurred in 2 (2.3%) patients in the ampicillin/sulbactam group and 3 (3.3%) in the ceftriaxone group; nonsurgical-site infection occurred in 25 (28.4%) patients in the ampicillin/sulbactam group and 15 (16.3%) in the ceftriaxone group. The between-group differences were not statistically significant, with the exception of surgical implantation of foreign material, which was performed sig- nificantly more frequently in the ceftriaxone group (P = 0.045). In addition, 2 of 3 surgical-site infections in the ceftriaxone group involved foreign-material implantation; however, if these operations are omitted from the analysis, the difference between treatments remains nonsignificant.
The results suggest that ampicillin/sulbactam and ceftriaxone are of similar prophylactic efficacy in clean neurosurgical operations. Because the acquisition cost of 2 g ceftriaxone is approximately 3 times greater than that of 3 g ampicillin/sulbactam, the latter may be more cost-effective than the former for neurosurgical prophylaxis; however, other relevant hospital-related costs were not assessed in this study.
To determine the costs and savings of a 15-component infection control program that reduced transmission of vancomycin-resistant enterococci (VRE) in an endemic setting.
Evaluation of costs and savings, using historical control data.
Adult oncology unit of a 650-bed hospital.
Patients with leukemia, lymphoma, and solid tumors, excluding bone marrow transplant recipients.
Costs and savings with estimated ranges were calculated. Excess length of stay (LOS) associated with VRE bloodstream infection (BSI) was determined by matching VRE BSI patients with VRE-negative patients by oncology diagnosis. Differences in LOS between the matched groups were evaluated using a mixed-effect analysis of variance linear-regression model.
The cost of enhanced infection control strategies for 1 year was $116,515. VRE BSI was associated with an increased LOS of 13.7 days. The savings associated with fewer VRE BSI ($123,081), fewer patients with VRE colonization ($2,755), and reductions in antimicrobial use ($179,997) totaled $305,833. Estimated ranges of costs and savings for enhanced infection control strategies were $97,939 to $148,883 for costs and $271,531 to $421,461 for savings.
The net savings due to enhanced infection control strategies for 1 year was $189,318. Estimates suggest that these strategies would be cost-beneficial for hospital units where the number of patients with VRE BSI is at least six to nine patients per year or if the savings from fewer VRE BSI patients in combination with decreased antimicrobial use equalled $100,000 to $150,000 per year.
The objective of this prospective, randomized, double-blind study was to evaluate the effect of the addition of mupirocin to the 'classical' topical SDD regimen (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg) on the development of ICU-acquired infections due to gram-positive bacteria. The study was carried out in an intensive care unit (ICU) of a 1400-bed community hospital. All patients admitted to the ICU during a 16-month period, who were expected to require mechanical ventilation for more than 24 hours, were randomized to receive either the 'classical' SDD regimen (Group A) or a modified regimen with mupirocin (Group B). Data from 223 patients requiring mechanical ventilation for at least 48 hours, who were neither infected nor receiving antibiotics on ICU admission, was analysed. A 2% paste containing tobramycin, polymyxin E and amphotericin B was applied every 6 hours in the oropharynx to the patients in Group A, while in Group B this formula was modified with the addition of 2% mupirocin. In Group B 0.2 ml of a 2% mupirocin ointment was also applied four times daily in both nostrils. Patients in Group A received a soft paraffin ointment as a placebo indistinguishable from mupirocin. Patients in both groups received the classic SDD regimen through the nasogastric tube. Systemic antibiotic prophylaxis was not used. Data on lower airway infection, and blood infection, infections of intravascular catheters, antibiotic consumption and expenditures for antibiotics were analysed. The diagnosis of ventilator-associated pneumonia (VAP) was based on quantitative cultures of protected specimen brush samples (PSB) or on the results of distal broncho-alveolar lavage (BAL). One hundred and four patients received the 'classical' SDD and 119 the modified regimen. Overall 29 patients, 20 in Group A and nine in Group B (p < 0.02) had a total of 33 cases of pneumonia. There were 23 episodes of pneumonia in Group A and 10 in Group B (p < 0.02). Gram-positive bacteria were isolated from samples in 17 episodes in Group A and six in Group B (p < 0.02). Staphylococcus aureus was isolated in nine cases of pneumonia in Group A and once in the 'mupirocin' group (p < 0.05). MRSA were isolated in seven out of nine cases in Group A and in the only case in Group B. There were no differences in the isolation of gram-negative bacilli. Antibiotic consumption and cost were lower in Group B. In conclusion, our data show that the topical use of a modified formula of SDD, with the addition of mupirocin to the oral paste and in the anterior nares, is associated with a reduction in lung infections caused by gram-positives and in a reduction in antibiotic consumption and in the overall expenditure for antibiotics.
Nurse-to-patient ratios in the intensive care unit are associated with postoperative mortality, morbidity, and costs after some high-risk surgery.
To determine if having 1 nurse caring for 1 or 2 patients ("more nurses") versus 1 nurse caring for 3 or more patients ("fewer nurses") in the intensive care unit at night is associated with differences in clinical and economic outcomes after hepatectomy.
Statewide observational cohort study of 569 adults who had hepatic resection, 1994 to 1998. Hospital discharge data were linked to a prospective survey of organizational characteristics in the intensive care unit. Multivariate analysis was used to determine the association of nighttime nurse-to-patient ratios with in-hospital mortality, length of stay, hospital costs, and specific postoperative complications.
A total of 240 patients at 25 hospitals had fewer nurses; 316 patients in 8 hospitals had more nurses. No significant association between nighttime nurse-to-patient ratios and in-hospital mortality was detected. The overall complication rate was 28%. By univariate analysis, patients with fewer nurses had increased risks for pulmonary failure (5.8% vs 1.6%, relative risk, 3.6; 95% CI, 1.3-10.1; P=.006) and reintubation (10.8% vs 1.9%, relative risk, 5.7; 95% CI, 2.4-13.7; P<.001). By multivariate analysis, patients with fewer nurses had increased risk for reintubation (odds ratio, 2.9; 95% CI, 1.0-8.1; P=.04) and a 14% increase (95% CI, 3%-23%; P=.007) or an additional $1248 (95% CI, $384-$2112; P = .005) in total hospital costs.
Fewer nurses at night is associated with increased risk for specific postoperative pulmonary complications and with increased resource use in patients undergoing hepatectomy.
The role of models to support recommendations on the cost-effective use of medical technologies and pharmaceuticals is controversial. At the heart of the controversy is the degree to which experimental or other empirical evidence should be required prior to model use. The controversy stems in part from a misconception that the role of models is to establish truth rather than to guide clinical and policy decisions. In other domains of public policy that involve human life and health, such as environmental protection and defense strategy, models are generally accepted as decision aids, and many models have been formally incorporated into regulatory processes and governmental decision making. We formulate an analytical framework for evaluating the role of models as aids to decision making. Implications for the implementation of Section 114 of the Food and Drug Administration Modernization Act (FDAMA) are derived from this framework.
Little information is available on the financial impact of surgical site infections (SSI) after major surgery. In order to calculate the cost of SSI following coronary artery bypass graft surgery (CABGs), a 2-year retrospective case-control study was undertaken at Alfred Hospital, a university-affiliated tertiary referral centre.
One hundred and eight patients with SSI (cases) after CABGs and 108 patients without SSI (controls) were matched for gender, age, risk index (Centers of Disease Control and Prevention, National Nosocomial Infection Surveillance (NNIS) System) and number of principal comorbidities. The patient's postoperative length of stay (LOS), in both the intensive care unit (ICU) and the non-ICU (general) ward, was obtained from the medical records and the cost of a day in each was provided by the hospital's finance department. The cost of antibiotics prescribed for SSI was provided by the hospital's pharmacy department.
Postoperatively the cases were in ICU for a total of 313 days whereas the controls spent 165 days in ICU, a mean of 2.89 versus 1.53 days, respectively (P = 0.035). In general wards, cases were inpatients for a total of 1651 days and controls for 589 days. This is a mean of 10.8 days for cases and 4.7 days for controls (P = 0.0001). The extra LOS for 108 cases (compared to the controls) was costed at $1 299 082, a mean cost of $12 028 per patient. The total cost of antibiotics prescribed for these SSI was $42 270 (a cost per case of $391). The total excess cost related to increased LOS and antibiotic treatment was $12 419 per patient. In the subgroup analysis for deep sternal site infections the mean excess cost was $31 597 per patient.
Postoperative SSI result in significant patient morbidity and consume considerable resources. In the present study, patients with SSI following CABGs had significant prolongation of hospitalization (both in ICU and general wards). The present study illustrates the potential cost savings of introducing interventions to reduce SSI rates. This is the first time such a study has been undertaken in Australia.
A total of 271 patients were prospectively followed up to determine whether patients whose hospital stay is complicated by
diarrhea due to Clostridium difficile experience differences in cost and length of stay and survival rates when compared with patients whose stay is not complicated
by C. difficile–associated diarrhea. Forty patients (15%) developed nosocomial C. difficile–associated diarrhea. These patients incurred adjusted hospital costs of $3669—that is, 54% (95% confidence interval [CI],
17%–103%)—higher than patients whose course was not complicated by C. difficile–associated diarrhea. The extra length of stay attributable to C. difficile–associated diarrhea was 3.6 days (95% CI, 1.5–6.2). C. difficile–associated diarrhea was not associated with excess 3-month or 1-year mortality after adjustment for age, comorbidity, and
disease severity. On the basis of the findings of this study, a conservative estimate of the cost of this disease in the United
States exceeds $1.1 billion per year.