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Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes.

ABSTRACT: OBJECTIVE:To assess the economic effect and cost effectiveness of a targeted catheter-associated urinary tract infection (CAUTI) prevention intervention in the nursing home (NH) setting. DESIGN:Randomized clinical trial. SETTING:Community-based NHs (N=12). PARTICIPANTS:NH residents with indwelling urinary catheters (N=418). INTERVENTION:Standard care versus infection prevention program involving barrier precautions, active surveillance, and NH staff education. MEASUREMENTS:Costs of the intervention, costs of disease, and health outcomes were used to calculate an incremental cost-effectiveness ratio for the intervention. Data came from intervention results and the literature and outcomes were analyzed over one year. RESULTS:A 120-bed NH would have program costs of $20,279/year. The cost of disease treatment would be reduced by $54,316 per year, resulting in a $34,037 net cost savings. Most of this savings would come from fewer CAUTI hospitalizations ($39,180), with $15,136 in savings from CAUTI care within the NH. The intervention also yielded a gain of 0.197 quality-adjusted life-years (QALYs). Taking into account uncertainty in all parameters suggests there is an 85% chance that the intervention is cost-saving. CONCLUSIONS:The CAUTI prevention program is expected to benefit payers by reducing costs and improving health outcomes. Because the savings accrue to payers and not to NHs, payers such as Medicare and private insurers may want to provide incentives for NHs to implement such programs. TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT01062841.

SUBMITTER: Hutton DW

PROVIDER: S-EPMC6374025 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes.

Hutton David W DW Krein Sarah L SL Saint Sanjay S Graves Nicholas N Kolli Ajay A Lynem Raymond R Mody Lona L

Journal of the American Geriatrics Society 20180228 4

<h4>Objective</h4>To assess the economic effect and cost effectiveness of a targeted catheter-associated urinary tract infection (CAUTI) prevention intervention in the nursing home (NH) setting.<h4>Design</h4>Randomized clinical trial.<h4>Setting</h4>Community-based NHs (N=12).<h4>Participants</h4>NH residents with indwelling urinary catheters (N=418).<h4>Intervention</h4>Standard care versus infection prevention program involving barrier precautions, active surveillance, and NH staff education. ...[more]

PMID: 29489017

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Project description:INTRODUCTION:Urinary tract infections range among the most frequent infections not only in hospital patients but also in residents of long-term care facilities for the elderly. Urinary catheters are the greatest risk factor for urinary tract infections. In the guidance paper on the "prevention of infections in nursing homes" (2005) as well as in the updated recommendations for the "prevention and control of catheter-associated urinary tract infections" (2015), the Commission for Hospital Hygiene and Infection Prevention (KRINKO) has recommended adequate preventive measures. In 2015, the implementation of these KRINKO recommendations was investigated. METHOD:All of Frankfurt's 40 nursing homes were evaluated using a checklist based on the KRINKO recommendations. The evaluation included assessing the availability of operating instructions, appropriate indications for the placement of catheters etc. Age, sex and duration of catheterization, as well as current and previous infections within the past 6 months were documented for every resident with a catheter. RESULTS:In 35 (87.5%) of the nursing homes, operating instructions for the handling of urinary tract catheters were available. The decision as to whether a catheter is indicated is made by physicians, while its placement is often delegated to the nursing service. Typically, silicon catheters are used. In three-quarters of the nursing homes, regular intervals of 4-6 weeks for changing catheters were reported. On the respective survey day, 7.3% of the residents were catheterized. On the survey day, 3.6% (4.2%) and in the previous 6 months a total of 28% (28.9%) of the residents had a urinary tract infection (prevalence of antibiotic therapy in parentheses). Ciprofloxacin was used most often followed by cefuroxime and cotrimoxazole. DISCUSSION:In the current evaluation, fewer nursing home residents were catheterized than in previous years and the rate of urinary tract infections was low. This indicates an increasingly cautious and apparently appropriate usage of urinary tract catheters. Also, the prevalence of antibiotic therapy was low for residents with urinary tract catheters (4.2%). However, broad spectrum antibiotics are still preferentially administered (particularly quinolones), which may favor the high rate of colonization with ESBL-producing bacteria and 3MRGN. Given this background, a coordinated approach including resistance-based antibiotic stewardship appears increasingly important in nursing homes and other health care facilities.

Project description:Importance:Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective:To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants:A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions:The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures:Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results:In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance:In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Project description:BackgroundImplementation evaluations based on a hybrid deductive-inductive approach provide a detailed understanding of organizational choices to introduce and implement complex interventions and may help explain implementation success or failure. However, such evaluations may not be feasible due to resource constraints. Qualitative analyses of artifacts collected for other purposes during implementation may represent a cost-effective method to understand program implementation when robust evaluations are not feasible. This study used a work systems evaluation of how nursing homes (NHs) implemented a urinary tract infection (UTI) recognition and management improvement toolkit.MethodsThirty NHs participated in a randomized control trial in which intervention NHs (n = 12) were assigned a clinical coach who employed a standard template to structure coach calls with the NH champion. A hybrid inductive-deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) model, characterized three action domains related to (1) engagement of staff and providers, (2) distribution of toolkit elements, and (3) toolkit use.ResultsA total of 369 coded segments from 148 coach notes generated by three coaches working with 18 NH champions were examined. Planned changes (n = 203) were more frequent compared to actual changes (n = 169). While most NHs quickly engaged staff and providers, which leadership appeared to support, engagement actions were hindered in some NHs due to champion instability or extended champion or medical director absences. Dissemination of materials to family and providers and distribution of tools to staff occurred quickly in 75% of NHs, although delays were encountered in some NHs, usually because of champion instability.ConclusionsImplementing NH practice change is challenging, and studies examining actions to support planned versus actual change in this setting are limited. The application of the SEIPS model to coach notes collected during the implementation of a structured behavioral intervention to improve the recognition and management of UTI in NHs generated unique insights into the work system and how staff attempted to implement changes. This study identified several factors that interfered with progression from planning to actual change. Future studies are needed to better understand how to best support change interventions in NHs.Trial registrationClinicalTrials.gov, NCT03520010 , Registered May 9, 2018.

Dataset Information

Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes.

Publications

Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes.

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