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Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review.

ABSTRACT: Importance:Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain. Objective:To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals. Evidence Review:A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year. Findings:Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100?000-increase in program cost was associated with $315?000 greater savings (95% CI, $166?000-$464?000; P?

SUBMITTER: Nuckols TK

PROVIDER: S-EPMC6710008 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review.

Nuckols Teryl K TK Keeler Emmett E Morton Sally C SC Anderson Laura L Doyle Brian B Booth Marika M Shanman Roberta R Grein Jonathan J Shekelle Paul P

JAMA internal medicine 20161201 12

<h4>Importance</h4>Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain.<h4>Objective</h4>To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals.<h4>Evidence review</h4>A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey ...[more]

PMID: 27775764

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Project description:Importance:National Healthcare Safety Network methods for central line-associated bloodstream infection (CLABSI) surveillance do not account for potential additive risk for CLABSI associated with use of 2 central venous catheters (CVCs) at the same time (concurrent CVCs); facilities that serve patients requiring high acuity care with medically indicated concurrent CVC use likely disproportionally incur Centers for Medicare & Medicaid Services payment penalties for higher CLABSI rates. Objective:To quantify the risk for CLABSI associated with concurrent use of a second CVC. Design, Setting, and Participants:This retrospective cohort study included adult patients with 2 or more days with a CVC at 4 geographically separated general acute care hospitals in the Atlanta, Georgia, area that varied in size from 110 to 580 beds, from January 1, 2012, to December 31, 2017. Variables included clinical conditions, central line-days, and concurrent CVC use. Patients were propensity score-matched for likelihood of concurrence (limited to 2 CVCs), and conditional logistic regression modeling was performed to estimate the risk of CLABSI associated with concurrence. Episodes of CVC were categorized as low or high risk and single vs concurrent use to evaluate time to CLABSI with Cox proportional hazards regression models. Data were analyzed from January to June 2019. Exposures:Two CVCs present at the same time. Main Outcomes and Measures:Hospitalizations in which a patient developed a CLABSI, allowing estimation of patient risk for CLABSI and daily hazard for a CVC episode ending in CLABSI. Results:Among a total of 50?254 patients (median [interquartile range] age, 59 [45-69] years; 26?661 [53.1%] women), 64?575 CVCs were used and 647 CLABSIs were recorded. Concurrent CVC use was recorded in 6877 patients (13.7%); the most frequent indications for concurrent CVC use were nutrition (554 patients [14.1%]) or hemodialysis (1706 patients [43.4%]). In the propensity score-matched cohort, 74 of 3932 patients with concurrent CVC use (1.9%) developed CLABSI, compared with 81 of 7864 patients with single CVC use (1.0%). Having 2 CVCs for longer than two-thirds of a patient's CVC use duration was associated with increased likelihood of developing a CLABSI, adjusting for central line-days and comorbidities (adjusted risk ratio, 1.62; 95% CI, 1.10-2.33; P?=?.001). In survival analysis adjusting for sex, receipt of chemotherapy or total parenteral nutrition, and facility, compared with a single CVC, the daily hazard for 2 low-risk CVCs was 1.78 (95% CI, 1.35-2.34; P?<?.001), while the daily hazard for 1 low-risk and 1 high-risk CVC was 1.80 (95% CI, 1.42-2.28; P?<?.001), and the daily hazard for 2 high-risk CVCs was 1.78 (95% CI, 1.14-2.77; P?=?.01). Conclusions and Relevance:These findings suggest that concurrent CVC use is associated with nearly 2-fold the risk of CLABSI compared with use of a single low-risk CVC. Performance metrics for CLABSI should change to account for variations of this intrinsic patient risk among facilities to reduce biased comparisons and resultant penalties applied to facilities that are caring for more patients with medically indicated concurrent CVC use.

Project description:ImportanceQuality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.ObjectiveTo systematically review economic evaluations of QI interventions designed to reduce readmissions.Data sourcesDatabases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).Study selectionDual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.Data extraction and synthesisDual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.Main outcomes and measuresMain outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.ResultsOf 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006).Conclusions and relevanceMulticomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

Dataset Information

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review.

Publications

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review.

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