Shelly A McNeil, MD on behalf of the SOS Network of the Canadian Immunization Research Network (CIRN) CIC 2016 Dec 6-8, 2016 Ottawa, ON

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1 Resource Utilization and Cost of Laboratory Confirmed Influenza Requiring Hospitalization in Canadian Adults A Study from the Serious Outcomes Surveillance (SOS) Network of the Canadian Immunization Research Network (CIRN) Shelly A McNeil, MD on behalf of the SOS Network of the Canadian Immunization Research Network (CIRN) CIC 2016 Dec 6-8, 2016 Ottawa, ON

2 Disclosure of Relationship Disclosure Statement I am a member of an Advisory Board or equivalent with a commercial organization. I am a member of a Speaker Bureau. I have received payment from a commercial organization (including gifts or other consideration or in kind compensation). I have received a grant(s) or an honorarium from a commercial organization. I hold a patent for a product referred to in the CME/CPD program or that is marketing by a commercial organization I hold investments in a pharmaceutical organization, medical devices company or communications firms. I am currently participating in or have participated in a clinical trial within the past two years.). Company/Organization Pfizer, Merck GSK, Pfizer, Sanofi GSK, Pfizer, Sanofi, Merck

3 Disclosures This study was funded through a health outcomes research agreement with GlaxoSmithKline Inc. Authors Carita Ng, Lingyun Ye, Stephen Noorduyn, Margaret Hux, Edward Thommes, Ron Goeree, Ardith Ambrose, Melissa K Andrew, Todd Hatchette, Guy Boivin, William Bowie, May ElSherif, Karen Green, Jennie Johnstone, Kevin Katz, Jason Leblanc, Mark Loeb, Donna MacKinnon- Cameron, Anne McCarthy, Janet E McElhaney, Allison McGeer, Andre Poirier, Jeff Powis, David Richardson, Makeda Semret, Rohita Sharma, Stephanie Smith, Daniel Smyth, Grant Stiver, Sylvie Trottier, Louis Valiquette, Duncan Webster, Shelly A McNeil; on behalf of the Canadian Immunization Research Network (CIRN) Serious Outcomes Surveillance Network Investigators and the Toronto Invasive Bacterial Diseases Network (TIBDN) Investigators

4 Background Hospitalizations represent the largest component in influenza treatment costs Published estimates have focused on influenza admission or discharge diagnoses and have not required laboratory confirmation There have been no recent Canadian studies estimating the cost of influenza hospitalizations in Canada, particularly laboratory confirmed influenza

5 Objectives Estimate average total cost of laboratory-confirmed influenza in adults requiring hospitalization in Canada using costs for resource utilization collected before, during, and 30 days following discharge Examine the effect of patient and disease characteristics, treatment, and outcomes on cost Explore variations in costs across Canada

6 The CIRN SOS Network: 2010: 10 hospitals in 6 provinces, 6,000 beds 2011: 40 hospitals in 6 provinces, 15,000 beds 2012: 45 hospitals in 7 provinces, 18,000 beds 2009 Sites 2010 Sites 2011 Sites 2012 Sites Vancouver Winnipeg Moncton Trois Riviere Saint John Sudbury Quebec City Halifax Montreal Sherbrooke Ottawa Toronto Hamilton Toronto- TIBDN

7 Methods Clinical and resource utilization data was obtained from the CIRN SOS Network (2010/ /2013): Active hospital surveillance for influenza infection in adults ( 16 years of age) Laboratory-confirmed influenza cases enrolled in the study Influenza cases had data collected on: Clinical data: age, sex, influenza type and strain, comorbidity, and risk factors Clinical outcomes: 30-day mortality, readmission within 30 days Resource utilization: ambulatory, in-hospital resource use

8 Applying unit price weights to labconfirmed influenza patients Linkage of influenza-related resource use of patients enrolled in the SOS Network to a set of unit price weights/case, regardless of hospital where treatment was received Costs for unit prices were derived from the following sources: Hospital Resource Use: Hamilton Health Sciences Ward per diem, diagnostic testing and procedures, ED visit: Ontario hospital with a fully allocated costing system (i.e. including both direct and overhead costs) Physician fees: 2015 Ontario Schedule of Benefits Outpatient medication costs: Ontario Drug Benefit formulary Inpatient medication costs: QEII Health Sciences Centre (Nova Scotia)

9 Analysis Total cost per case was calculated based on: Cost prior to admission: outpatient physician visits, emergency department (ED) visits, outpatient prescription medications Cost during hospitalization: stay in general wards, stay in intensive care unit (ICU), laboratory tests, culture tests, diagnostic imaging, procedures, medications in hospital (including antiviral and antibiotic costs) Cost post discharge: intensive and general ward stay for readmission within 30 days Multiple imputation generated estimated component of cost in years when certain resource utilization items were not collected in SOS Network Costs are presented in $2015 CDN

10 Clinical Characteristics of Influenza Cases Across Canada ( ) Characteristic N (%) Characteristic N (%) Sex Age Any comorbid condition Male 1,400 (47.57) No 286 (9.72) Female 1,543 (52.43) Yes 2,657 (90.28) Chronic respiratory illness (16.34) No 1,676 (56.95) (17.60) Yes 1,267 (43.05) (18.38) Medical complication >75 1,403 (47.67) No 1,126 (38.26) Influenza type Yes 1,813 (61.60) Influenza A 2,392 (81.28) Survival Influenza B 548 (18.62) Yes 2,670 (90.72) Unknown Type 3 (0.10) No 273 (9.28)

11 Mean Length of Stay of Influenza Cases in SOS Network ( ) Mean SD Median Min Max ICU days General ward days Total hospital days

12 Treatment and Outcomes of Influenza Cases across Regions ( ) Pre-admission Western Region N=147 Ontario N=1966 Quebec N=633 Eastern Region N=197 Full Population N=2943 Physician visit (n, %) 60 (40.8%) 607 (31.2%) 120 (19.9%) 52 (26.4%) 839 (29.0%) ED visit (n, %) 19 (12.9%) 227 (11.6%) 72 (11.4%) 26 (13.2%) 344 (11.7%) During Hospital Stay Antibiotics on admission (n, %) 138 (93.9%) 1647 (83.8%) 536 (84.7%) 167 (84.8%) 2488 (84.5%) General ward days (mean, sd)* 9.0 (9.7) 8.6 (10.5) 11.5 (16.7) 10.8 (9.7) 9.4 (12.1) ICU stay (n, %) 41 (27.9%) 264 (13.4%) 88 (13.9%) 31 (15.7%) 424 (14.4%) ICU days if in ICU (mean, sd) 3.5 (9.9) 1.4 (6.4) 0.8 (2.9) 1.9 (6.4) 1.4 (6.1) Mechanically ventilated (n, %) 30 (20.4%) 161 (8.2%) 49 (7.7%) 13 (6.6%) 253 (8.6%) Following discharge Readmission days (mean, sd) 0.6 ( 3.2) 0.4 ( 2.5) 0.5 ( 3.0) 0.1 ( 1.0) 0.4 ( 2.6) Outcomes Complications in hospital (n, %) 79 (53.7%) 1433 (73.0%) 179 (28.4%) 122 (61.9%) 1813 (61.7%) 30-day readmission (n, %) 11 (13.1%) 101 (5.8%) 27 (5.2%) 5 (2.7%) 144 (5.7%) Mortality (n, %) 16 (10.9%) 193 (9.8%) 48 (7.6%) 16 (8.1%) 273 (9.3%) *For some participating QC hospitals, ALC days were included in overall LOS, while all other sites excluded ALC

13 Mean Costs per Influenza Case in SOS Network ( ) Mean ($) Lower 95% Upper 95% CI** ($) CI** ($) Pre-hospital admission Physician visit ED visit 109 Medications Pre-hospital admission costs During hospital admission ED visit leading to admission 453 Hospital ward stay ICU stay 3,772 General ward * 7,720 Laboratory tests Culture tests VRE screens MRSA screens Diagnostic tests Procedures Medications During admission costs 14,031 13,295 14,768 Readmission within 30 days Readmission hospitalization Readmission ICU 126 Readmission costs Total treatment cost 14,612 13,852 15,372 * General ward stay includes general or intermediate care wards and also includes days in admitting hospital if transferred to reporting hospital ** Costs with missing lower and upper 95% CIs are based on resource use that includes imputed values

14 Average hospitalized influenzacase costs across Canada

15 Comparison of SOS Network Estimated Costs and OCCI Estimated Costs Ontario Case Costing Initiative* Serious Outcomes Surveillance Cost ($) Cost ($) Cost/ LOS Mean LCI UCI Day ($) Mean LCI UCI Cost/ Day ($) Age LOS group ,604 4,960 8, ,887 N/A N/A N/A N/A N/A ,771 4,257 11, ,439 13,626 12,320 14, , ,900 7,483 10, ,113 13,481 12,658 14, ,114 All 7,876 6,656 9, ,338 13,542 12,815 14, ,254 *OCCI estimates inflated to 2015 CAN $ for comparison SOS cost per case is higher than other known estimates in Canada, but cost per day is similar

16 Summary The overall mean cost per hospitalized influenza case in Canada was $14,612 (ranging from a mean of $13,711 to $20,808) Hospitalizations in Western Canada cost significantly more than those in Quebec Higher hospitalization costs calculated using the SOS data were driven by the inclusion of pre-and post-admission costs, physician fees, but mostly from the longer LOS LOS is higher than previously published Canadian estimates outside of the SOS study, but is consistent with American estimates (1,2) (1) Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292(11): (2) Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 2007;25(27):

17 Conclusions Overall, the SOS Network reports higher cost per hospitalization than other national estimates, largely driven by longer LOS, rather than higher cost/day Laboratory-confirmed influenza-related hospitalizations represent a large economic burden on the healthcare system in Canada, which may have been previously underestimated

18 Questions?