Robert A. Weinstein, MD Stroger (Cook County) Hospital Rush Medical College April 6, Disclosure: Grant funding from CDC & Sage Products, Inc.

Transcription

1 Robert A. Weinstein, MD Stroger (Cook County) Hospital Rush Medical College April 6, 2010 Disclosure: Grant funding from CDC & Sage Products, Inc.

2 How the BLEEP should I know? Only problem how we gonna pay for this Joey? And I ve asked you please don t call me Joey!

3 Streptococci Staphylococci Gram-negative rods MDROs MRSA VRE ESBL, Acinetobacter, Pseudomonas VISA, VRSA

4 The forest plot shows a 4-fold higher risk of infection after colonization with MRSA than MSSA. Safdar & Bradley, Am J Med 2008; 121:310-5.

5 THE RESULT A DECADE OF SCRUTINY Corrigan J, National Academy Press, 1 st edition (April 15, 2000).

6 BABY STEPS National Healthcare-Associated Infection (HAI) Surveillance Initiatives Yokoe DS & Classen D, Infect Control Hosp Epidemiol 2008; 29:S3 S11.

7 FINALLY, GRAPPLING WITH OUTCOMES National Healthcare-Associated Infection Prevention Initiatives Yokoe DS & Classen D, Infect Control Hosp Epidemiol 2008; 29:S3 S11.

8 National Healthcare-Associated Infection Prevention Initiatives (cont d.) Yokoe DS & Classen D, Infect Control Hosp Epidemiol 2008; 29:S3 S11.

9 Medical Hospitalization Complications Legal? Appeals of Guilty Verdicts Automotive? Until Lemon Laws Other? Built-in obsolescence Intra-industry Price-fixing Inter-industry Collusion

10 To Make a Decision: Buy or sell something Start-up or stop services Compare between services Cost Definitions: Hospital Direct : Hospital costs Hospital bills Payer Direct : Insurance Society Indirect :Loss of Life Lost Productivity Reduced QOL Opportunity Cost : Redirected care

11 THE BOTTOM-LINE Attributable Costs of Healthcare- Associated Infections Yokoe DS & Classen D, Infect Control Hops Epidemiol 2008; 29:S3 S11.

12 Antibiotic Resistance Has Additional Clinical and Economic Impact Outcome measures Relative risk of worse outcome for infections with resistant compared to susceptible bacteria* Hospital length of stay Hospital charges Mortality * Gram-negative bacilli, Staphylococcus aureus, Enterococci. Adapted from Cosgrove, Clin Infect Dis 2006; 42:S82 9.

13 Lengths of stay: Major cost drive (beware timedependent bias) Cost vs charge: Sometimes confused Data sources: Paper charts, Electronic Medical Records, Administrative data Fixed vs variable costs: What can be saved and when (accountant vs economist view) Population means or patient-specific costs Whose perspective: Hospital, Patient, Payer, Society Face validity: Smell test

14 National average costs Charge-cost conversions Relative value unit (RVU) costs Length of stay X average costs Direct chart review Electronic medical record review Costs of infrastructure (reiterative costing)

15 Cases (AR HAIs) vs controls (non-ar HAIs) Propensity models (risk strategy to match controls) Regression and other statistical analyses (analyze randomly sampled population, that may be enriched for risk)

16 EXAMPLES OF STATISTICAL APPROACH AFFECTING COST RESULTS Attributable Total Costs of Surgical Site Infection and Endometritis After Low Transverse Cesarean Section Calculated by 2 Different Methods Note. CI, confidence interval; GLS, generalized least squares. Costs are the medians and 95% CIs based on the binomial distribution. Olsen et al, Infect Control Hosp Epidemiol 2010; 31:

17 Roberts et al, Clin Infect Dis 2009; 49:

18 THE BOTTOM-LINE DETAILS Patient Characteristics Stratified by Presence of Antimicrobial-Resistant Infection (ARI) Roberts et al, Clin Infect Dis 2009; 49:

19 YES ICU use Laboratory tests Medication use Blood transfusions Radiology tests NO Procedures Consults *CCH data ranked by magnitude of effect; R. Roberts, MD

20 Mean Cost and Length of Stay for Patients with Antimicrobial-Resistant Infection (ARI), Compared with Matched Control Subjects Roberts et al, Clin Infect Dis 2009; 49:

21 Antimicrobial-Resistant Organism Subgroup Distribution, Mean Medical Costs, and Attributable Costs NOTE. All parameter estimates for cost and all overall economic model significance tests and F statistics were significant at P <.001, unless otherwise indicated. ARI, Antimicrobial-Resistant Infection; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci; AREK, Escherichia coli resistant to fluoroquinolones or third-generation cephalosporins or Klebsiella species resistant to third-generation cephalosporins; AIR, amikacin or imipenem resistant Enterobacter, Pseudomonas, or Acinetobacter species; SD, standard deviation. a Patients infected with 11 antimicrobial-resistant organisms. Roberts et al, Clin Infect Dis 2009; 49:

22 SOCIETAL COST LOST WORK FORCE Predicted Mortality for Patients With and Without Antimicrobial-resistant resistant Infection (ARI) APACHE, Acute Physiology and Chronic Health Evaluation Roberts et al, Clin Infect Dis 2009; 49:

23 Projected Cost Savings if Antimicrobial-resistant resistant Infection (ARI) Rates were Reduced from 13.5% to 10% Roberts et al, Clin Infect Dis 2009; 49:

24 Hospital Service Measures Length of Stay? Where? What Happened? Patient Factors What is wrong? How sick? Treatment Plans? Usually measured in days ICU, Ward, LTC, Observation Procedures, laboratory, pharmacy, radiology, blood transfusion Diagnosis, comorbidities Severity of illness, complications, age New cancer diagnosis vs DNR patient

25 Over Chart Review TIME (real-time review possible) Sample size (not constrained) Over Administrative Databases Absolute not relative data? BOTTOM-LINE EMR real-time cost determination Economic complement to CDC s NHSN to measure HAI costs For healthcare reform to work, we must control costs; to control costs, we must be able to measure them. EMR can facilitate this.

26 EMR calculations best if use patient service measurements of cost effectors EMR underestimates for most costly stays EMR overestimates for least costly stays EMR-PCR difference ~10% *Based on 6 years of CCH data and a validation cohort laboriously collected & analyzed by R. Roberts, MD & colleagues.

27 Laboratory/Radiology: Algorithms for determining comorbidities, adverse events (HAI, ARI, glucose abnormalities, DVT) and rates of patient improvement Pharmacy: Can link above results to specific treatments given to improve treatment guidelines MDRO: Algorithms in place, could also use past medication and procedure profiles to search for preventable causes CRBSI: Have well-tested e-algorithms Other Device-related Infections: (VAP, SSI, UTI) Algorithms in testing Real-time vital signs: Plus pharmacy & test results Could lead to early determination of patient failure

28 A DECADE- PLUS OF GUIDELINES WHAT ARE THE COSTS OF CONTROL MEASURES?

29 HAND HYGIENE Alcohol is good for you CVC-BSI CHG prep & barrier precautions; CHG cleansing; CVC removal PIV Observe site daily; change post ED insertion & q 3 days VAP Oral CHG & sedation vacations (tube removal); positioning 45º UTI Closed system & catheter removal SSI Skin prep, antibiotic prophylaxis timing, & capable surgeon Silver-coatings? Worth their weight in gold? *Qualifier: RAW s views

30 Take Home Messages Healthcare-acquired infections (HAIs) increase costs of care (LOS, mortality, $s: ~2X) Antimicrobial resistance (AR) further increases these costs (~2X more) Many nuances to measuring these costs Leveraging electronic medical records to track costs could provide a key complement to CDC s HAI and AR tracking data Measurement is not enough