Topic Search Strategy: AHRQ's Healthcare-Associated Infection Program
ycastro01
Estimating_the_Proportion_of_Healthcare.pdf
i n fec ti on c o nt rol a n d h o spi ta l e p idem i olo gy f eb ru a ry 2 011, v o l. 3 2, n o . 2
o r i g i n a l a r t i c l e
Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs
Craig A. Umscheid, MD, MSCE;1,2,3 Matthew D. Mitchell, PhD;1 Jalpa A. Doshi, PhD;1,3
Rajender Agarwal, MD, MPH;1 Kendal Williams, MD, MPH;1,3 Patrick J. Brennan, MD2,3,4
objective. To estimate the proportion of healthcare-associated infections (HAIs) in US hospitals that are “reasonably preventable,” along with their related mortality and costs.
methods. To estimate preventability of catheter-associated bloodstream infections (CABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), we used a federally sponsored systematic review of interventions to reduce HAIs. Ranges of preventability included the lowest and highest risk reductions reported by US studies of “moderate” to “good” quality published in the last 10 years. We used the most recently published national data to determine the annual incidence of HAIs and associated mortality. To estimate incremental cost of HAIs, we performed a systematic review, which included costs from studies in general US patient populations. To calculate ranges for the annual number of preventable infections and deaths and annual costs, we multiplied our infection, mortality, and cost figures with our ranges of preventability for each HAI.
results. As many as 65%–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP. CABSI also has the highest cost impact; costs due to preventable cases of VAP, CAUTI, and SSI are likely less.
conclusions. Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based prevention strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.
Infect Control Hosp Epidemiol 2011;32(2):101-114
Affiliations: 1. Center for Evidence-Based Practice, University of Pennsylvania, Philadelphia, Pennsylvania; 2. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania; 3. Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; 4. Office of the Chief Medical Officer, University of Pennsylvania, Philadelphia, Pennsylvania.
Received May 12, 2010; accepted August 10, 2010; electronically published January 14, 2011. � 2011 by the Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3202-0001$15.00. DOI: 10.1086/657912
In 1999, the Institute of Medicine released its groundbreaking report “To Err Is Human.”1 The report acknowledged the overwhelming incidence and cost of medical errors that occur in our healthcare system and identified healthcare-associated infections (HAIs) as an important patient safety challenge. Subsequent studies have further documented the extent of HAIs in the United States.2
Numerous studies have examined interventions to reduce the most common HAIs: catheter-associated bloodstream in- fection (CABSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and sur- gical site infection (SSI).3,4 These strategies have demonstrated some success, and payers have responded by using financial incentives to encourage hospitals to adopt them. In October 2008, Medicare stopped providing reimbursement for treat- ment of 8 largely preventable conditions, 3 of which it deemed “never events” and 5 “reasonably preventable.”5 Three of the 5 “reasonably preventable” conditions are HAIs; namely,
CABSI, CAUTI, and SSI. VAP is being considered for inclu- sion in an expanded list scheduled for release in 2011.6
Although nonpayment for treatment of HAIs may be an effective incentive for hospitals and physicians to reduce the incidence of HAIs, some have asserted that not all HAIs are preventable and that this new incentive may be a challenge for hospitals that care for patients at high risk for HAIs.5,6 To inform discussions regarding the preventability of HAIs, we estimated the proportion of HAIs that are reasonably pre- ventable in US hospitals, as well as their associated mortality rates and costs.
m e t h o d s
HAI Incidence, Associated Mortality, and Risk Reduction
An accurate estimation of the annual number of preventable HAIs requires accurate estimates of 2 underlying values: the current total annual number of HAIs and the proportion of
1 0 2 i n f e c t i o n c o n t r o l a n d h o s p i t a l e p i d e m i o l o g y f e b ru a ry 2 0 1 1 , v o l . 3 2 , n o . 2
these that are “reasonably preventable.” Likewise, an accurate estimation of the number of preventable HAI-associated deaths requires accurate estimates of the current total annual number of deaths from HAIs and the proportion of these deaths that are “reasonably preventable.” We obtained data for CABSI, VAP, CAUTI, and SSI.
To estimate the number of HAIs and their associated mor- tality rates, we used figures assembled by Klevens et al2 from the National Nosocomial Infections Surveillance (NNIS) sys- tem, the National Hospital Discharge Survey, and the Amer- ican Hospital Association. These estimates include HAIs in infants, children, and adults in and outside of the intensive care unit (ICU) setting. HAIs were defined as infections that occurred during a hospitalization and that were not present prior to hospital admission. Infections had to meet body site– specific criteria. Death was considered associated with an HAI if an infection preventionist determined that the HAI directly contributed to or caused the death.
To estimate the proportion of HAIs that could be pre- vented, we used the estimates of HAI risk reductions resulting from quality improvement strategies reported in an Agency for Healthcare Research and Quality (AHRQ) Evidence-Based Practice Center (EPC) report,3 a systematic review of the published literature on HAI prevention. We used only HAI risk reductions reported in US studies published in the past 10 years that had a controlled or time-series design or were graded as “good” quality by the AHRQ EPC report.3 When there were fewer than 3 studies that met these criteria, we included studies graded as “moderate” quality. Quality ratings were based on answers to questions that pertained to the internal and external validity of the studies.3
We obtained the full text of all studies cited in our report for further detailed analysis. For studies with a simple before- after design, we calculated risk reductions from the reported infection rates before and after the study intervention. For studies with a controlled before-after design, we estimated the risk reduction of the intervention by calculating the dif- ference between the risk reductions in the control arm and the intervention arm. For studies using an interrupted time- series design, we used the risk reductions estimated by mod- eling, if that was available; if modeling was not available, we estimated risk reductions using data from the first and last time periods.
Because the patient populations and interventions tested in the published studies of HAI reduction varied, it was not appropriate to combine the risk reductions into a single sum- mary estimate using meta-analysis. Thus, we used the highest and lowest infection reduction values from US studies for each type of HAI to generate a range of possible risk reduc- tions for each type of HAI. The ranges were multiplied by the estimated number of infections, as reported by Klevens et al,2 to yield an estimated range of the number of reasonably preventable infections for each type of HAI. The ranges were also multiplied by the estimated number of deaths as reported by Klevens et al,2 to yield an estimated range of the number
of reasonably preventable deaths for each type of HAI.2 To estimate the costs associated with each type of HAI, we mul- tiplied the number of potentially preventable infections by the estimated incremental cost for that type of infection.
HAI Cost
Estimating the cost of preventable HAIs requires knowledge of the total incidence of HAIs, the proportion of HAIs that are “reasonably preventable,” and the cost of each type of HAI. The costs of CABSI, VAP, CAUTI, and SSI were obtained from studies identified by a MEDLINE search. Search strat- egies for HAIs were based on those used in the AHRQ EPC report.3 Search strategies for economic impact were based on those used by the Canadian Agency for Drugs and Technol- ogies in Health.7 The 2 search elements were combined, and results were limited to English-language studies published in the 10 years prior to the search; searches were completed in May 2008.
The titles and abstracts of all articles found by the searches were reviewed by a research analyst (M.D.M.), and potentially relevant articles were retrieved. Studies were included in the analysis if they reported original calculations of costs for one of the selected HAIs, were conducted at US hospitals, and included 10 or more patients with infection. Studies from outside the United States were excluded because their cost estimates may not be reflective of those in the United States. Studies of highly specialized or narrow patient populations were also excluded, since our aim was to estimate costs for the general population.
Cost results from each study were reported as the incre- mental cost to the hospital per case patient with an HAI. We calculated confidence intervals for the mean cost per case if these intervals were not reported by study authors and if sufficient information was available to do so. All results were converted to 2009 dollars using the Consumer Price Index (CPI) for Hospital Services (US Bureau of Labor Statistics), except for one study of CABSI,8 which included data from before 1997; for this study, the CPI for Medical Services was used as the inflator, because the CPI for Hospital Services was not published until 1997. Where possible, summary es- timates of cost were based only on studies that used regression models to isolate the costs of the infection from costs that may have been coincident with the infection. Where multiple studies for a particular infection measured costs the same way, we took their range of estimates.
r e s u l t s
Number of HAIs and Associated Mortality
A comprehensive estimate of annual incidence of the mor- tality rates associated with HAIs in US hospitals was reported in 2007 (Appendix Table A1).2 These data suggest that CABSI and VAP cause more than two-thirds of the deaths resulting from HAIs and that they are 5 times as deadly as the other HAIs.
re a s on ab l y p re ve n t a b le h a i s 1 03
Proportion of HAIs and HAI-Associated Deaths That Are Reasonably Preventable
From a total of 4,847 potentially relevant articles identified in the AHRQ EPC report,3 434 articles were retrieved, and 64 ultimately met the inclusion criteria (Appendix Table A2).3
However, the quality of the studies was generally poor. Few were controlled or time-series analyses, and most of the sim- ple before-after studies were categorized by the AHRQ EPC report3 as “moderate” or “poor” quality. They did not grade the quality of controlled and interrupted time-series trials, assuming they were of higher quality than the simple before- after studies. Because there was little consistency among pa- tient groups studied or interventions tested, the AHRQ in- vestigators could not perform any quantitative synthesis of the data, and they did not attempt to make a summary es- timate of the proportion of infections or deaths that could be considered preventable.3 Appendix Table A2 shows the number of studies excluded on quality grounds and for other reasons.
The characteristics of the included studies are summarized in Table 1. All of the good-quality CABSI prevention studies reported in the AHRQ EPC report3 focused on ICU patients. The interventions tested varied from study to study, as did absolute infection rates both before and after the interven- tions, suggesting that either patient populations varied across studies or some centers already had effective infection pre- vention measures in place before their studies commenced. With respect to VAP prevention studies, there were only 2 good-quality before-after studies and no studies utilizing other designs, so we broadened our inclusion criteria to in- clude 3 additional moderate-quality studies. As with CABSI rates, VAP rates also varied from study to study, both before and after implementation of infection prevention programs. In the case of CAUTI prevention studies, there were no avail- able good-quality studies and only 2 studies of moderate quality. The SSI studies tested a variety of interventions, and their results showed more heterogeneity than those seen in studies of any other type of HAI.
Costs of HAIs
The HAI-related costs to hospitals in the included studies are summarized for each type of HAI in Tables 2, 3, 4, and 5. Four studies of the cost of CABSI in ICU patients met our inclusion criteria (Table 2). One study10 identified costs as- sociated with CABSIs by reviewing charts and each line item in patient bills to ascertain whether the cost was attributable to infection. Costs determined by this method were consistent with those from the other studies. Two studies11,12 used re- gression models to isolate incremental costs of CABSI; how- ever, the mean incremental cost was $21,400 in 2009 dollars in one11 and $110,800 in the other.12 The first of these 2 studies was hampered by an extremely wide confidence interval.
For VAP, of the 4 included cost studies (Table 3), 3 reported similar results in unadjusted mean incremental costs per case,
but the other study13 reported a much higher figure. Only the study of Warren and colleagues14 used regression to cal- culate a mean adjusted incremental cost per infection ($23,000).
All 3 studies of CAUTI (Table 4) estimated costs by sum- ming the costs of specific line items associated with CAUTI. One study15 considered only the cost of laboratory tests used to diagnose CAUTI and medications used to treat it. The other 2 studies16,17 counted those costs plus an assumed 0.5- day increase and a 1-day increase in hospital length of stay, respectively. Our summary cost calculation ($1,200–$4,700) is based on the range of estimates in the included studies.
The 4 studies of SSI costs (Table 5) differed considerably in methods. Unadjusted mean or median costs per infection fell in the range of $5,600–$12,900. One study18 also reported adjusted mean incremental costs, which were much lower, at $2,200 per SSI.
To arrive at a national total cost of HAIs, we selected a summary estimate of incremental costs per infection case for each type of infection. To do this, we first used adjusted estimates on the basis of regression models to account for confounding variables. Regression models were available for all infections except CAUTI, for which cost estimates were necessarily based on studies that simply summed line-item costs presumed to be associated with the infection, so we took the range of those estimates as our summary estimate. There were 2 estimates of CABSI costs based on regression models, but they differed widely from each other; therefore, we used their range as the basis for calculating our range of the estimated total cost of CABSI. Only 1 adjusted incre- mental cost estimate was available for VAP and for SSI to be used in our total cost calculations.
Estimates of the Total Impact of HAIs
The literature suggests that as many as 65%–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI are preventable with current evidence-based strategies. CAUTI may be the most preventable HAI; the number of avoidable infections ranges from 95,483 to 387,550 per year. This is followed by CABSI, with 44,762–164,127 preventable infec- tions; VAP, with 95,078–137,613 preventable infections; and SSI, with 75,526–156,862 preventable infections.
Our calculations demonstrate that CABSI is associated with the highest number of preventable deaths, followed by VAP. If best practices in infection control were applied at all US hospitals, the reduction in the number of cases of CABSI could save as many as 5,520–20,239 lives, and for VAP 13,667– 19,782 lives could be saved. The potential to save lives by reducing the number of cases of CAUTI and SSI is smaller: 2,225–9,031 lives annually for CAUTI and 2,133–4,431 lives annually for SSI.
Of the HAIs we examined, preventable cases of CABSI are likely to have the highest associated costs, ranging anywhere from $960 million to $18.2 billion annually. The hospital costs
t a
b l
e 1.
Su m
m ar
ie s
o f
St u
d ie
s o
f P
re ve
n ti
o n
o f
H ea
lt h
ca re
-A ss
o ci
at ed
In fe
ct io
n s
In cl
u d
ed in
th e
P re
se n
t A
n al
ys is
In ci
d en
ce o
r ri
sk o
f in
fe ct
io n
T yp
e o
f H
A I,
st u
d y
St u
d y
d es
ig n
an d
ty p
e o
f p
at ie
n ts
In te
rv en
ti o
n B
ef o
re in
te rv
en ti
o n
A ft
er in
te rv
en ti
o n
R ed
u ct
io n
C A
B SI
(g o
o d
-q u
al it
y st
u d
ie s)
P ro
n o
vo st
et al
2 6
(2 0
0 6)
In te
rr u
p te
d ti
m e-
se ri
es ;
IC U
p at
ie n
ts P
re ve
n ti
ve :
H an
d h
yg ie
n e;
m ax
im u
m st
er il
e b
ar ri
er p
re ca
u ti
o n
s; in
se rt
io n
si te
se le
c- ti
o n
; ch
lo rh
ex id
in e
d is
in fe
ct io
n ;
re m
o va
l o
f u
n n
ec es
sa ry
ca th
et er
s Q
I: C
li n
ic ia
n ed
u ca
ti o
n ,
au d
it ,
an d
fe ed
- b
ac k
; cl
in ic
ia n
re m
in d
er ;
o rg
an iz
at io
n al
ch an
ge
7 .7
ca se
s p
er 1
,0 0
0 C
D s
1 .4
ca se
s p
er 1
,0 0
0 C
D s
6 6
% a
B er
en h
o lt
z et
al 2
7 (2
0 04
) C
o n
tr o
ll ed
b ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
In te
rv en
ti o
n p
er io
d :
P re
ve n
ti ve
: H
an d
h y-
gi en
e; m
ax im
u m
st er
il e
b ar
ri er
p re
ca u
- ti
o n
s; in
se rt
io n
si te
se le
ct io
n ;
ch lo
rh ex
i- d
in e
d is
in fe
ct io
n ;
re m
o va
l o
f u
n n
ec es
sa ry
ca th
et er
s Q
I: C
li n
ic ia
n ed
u ca
ti o
n ,
au d
it ,
an d
fe ed
b ac
k C
o n
tr o
l p
er io
d :
C li
n ic
ia n
ed u
ca ti
o n
o n
ly
In te
rv en
ti o
n p
er io
d :
1 1
.3 ca
se s
p er
1 ,0
00 C
D s;
co n
tr o
l p
er io
d :
5 .7
ca se
s p
er 1
,0 0
0 C
D s
In te
rv en
ti o
n p
er io
d :
0 ca
se s
p er
1 ,0
0 0
C D
s; co
n tr
o l
p er
io d
: 1
.6 ca
se s
p er
1 ,0
0 0
C D
s
2 8
% b
C o
o p
er sm
it h
et al
2 8
(2 0
04 )
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: H
an d
h yg
ie n
e; m
ax im
u m
st er
il e
b ar
ri er
p re
ca u
ti o
n s;
in se
rt io
n si
te se
le ct
io n
Q I:
C li
n ic
ia n
ed u
ca ti
o n
3 .4
ca se
s p
er 1
,0 0
0 C
D s
2 .8
ca se
s p
er 1
,0 0
0 C
D s
1 8
%
W ar
re n
et al
2 9
(2 00
4 )
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: H
an d
h yg
ie n
e; m
ax im
u m
st er
il e
b ar
ri er
p re
ca u
ti o
n s;
in se
rt io
n si
te se
le ct
io n
Q I:
C li
n ic
ia n
ed u
ca ti
o n
, au
d it
, an
d fe
ed b
ac k
9 .4
ca se
s p
er 1
,0 0
0 C
D s
5 .5
ca se
s p
er 1
,0 0
0 C
D s
4 2
%
W ar
re n
et al
3 0
(2 00
3 )
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: M
ax im
u m
st er
il e
b ar
ri er
p re
- ca
u ti
o n
s; in
se rt
io n
si te
se le
ct io
n Q
I: C
li n
ic ia
n ed
u ca
ti o
n ,
au d
it ,
an d
fe ed
b ac
k
4 .9
ca se
s p
er 1
,0 0
0 C
D s
2 .1
ca se
s p
er 1
,0 0
0 C
D s
5 7
%
C o
o p
er sm
it h
et al
3 1
(2 0
02 )
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: H
an d
h yg
ie n
e Q
I: C
li n
ic ia
n ed
u ca
ti o
n ,
au d
it ,
an d
fe ed
b ac
k
1 0
.8 ca
se s
p er
1 ,0
00 C
D s
3 .7
ca se
s p
er 1
,0 0
0 C
D s
6 6
%
Sh er
er tz
et al
3 2
(2 00
0) B
ef o
re -a
ft er
st u
d y;
IC U
p at
ie n
ts P
re ve
n ti
ve :
H an
d h
yg ie
n e;
m ax
im u
m st
er il
e b
ar ri
er p
re ca
u ti
o n
s Q
I: C
li n
ic ia
n ed
u ca
ti o
n
4 .5
1 ca
se s
p er
1 ,0
00 C
D s
2 .9
2 ca
se s
p er
1 ,0
00 C
D s
3 5
%
V A
P (g
o o
d -q
u al
it y
st u
d ie
s) B
ab co
ck et
al 3
3 (2
0 04
) B
ef o
re -a
ft er
st u
d y;
IC U
p at
ie n
ts P
re ve
n ti
ve :
H an
d h
yg ie
n e;
h ea
d o
f b
ed an
- gl
e 1
3 0�
; d
ai ly
in te
rr u
p ti
o n
o f
se d
at io
n Q
I: C
li n
ic ia
n ed
u ca
ti o
n
8 .7
5 ca
se s
p er
1 ,0
00 V
D s
4 .7
4 ca
se s
p er
1 ,0
00 V
D s
4 6
%
Z ac
k et
al 3
4 (2
00 2)
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: H
ea d
o f
b ed
an gl
e 1
3 0�
Q I:
C li
n ic
ia n
ed u
ca ti
o n
1 2
.6 ca
se s
p er
1 ,0
00 V
D s
5 .7
ca se
s p
er 1
,0 0
0 V
D s
5 5
%
V A
P (m
o d
er at
e- q
u al
it y
st u
d ie
s) L
ai et
al 3
5 (2
0 03
) B
ef o
re -a
ft er
st u
d y;
IC U
p at
ie n
ts P
re ve
n ti
ve :
H ea
d o
f b
ed an
gl e
1 3
0� Q
I: C
li n
ic ia
n ed
u ca
ti o
n ,
au d
it ,
an d
fe ed
b ac
k
SI C
U :
4 5
.1 ca
se s
p er
1 ,0
00 V
D s;
M IC
U :
2 2
.4 ca
se s
p er
1 ,0
00 V
D s
SI C
U :
2 7
.9 ca
se s
p er
1 ,0
00 V
D s;
M IC
U :
1 1
.6 ca
se s
p er
1 ,0
00 V
D s
SI C
U :
3 8
% ;
M IC
U :
4 8
%
C A
U T
I (m
o d
er at
e- q
u al
it y
st u
d ie
s) T
o p
al et
al 3
6 (2
0 05
) B
ef o
re -a
ft er
st u
d y;
w ar
d p
at ie
n ts
P re
ve n
ti ve
: R
ed u
ct io
n in
p la
ce m
en t
o f
ca th
et er
s; re
m o
va l
o f
u n
n ec
es sa
ry ca
th et
er s
Q I:
C li
n ic
ia n
ed u
ca ti
o n
; cl
in ic
ia n
re -
m in
d er
; o
rg an
iz at
io n
al ch
an ge
3 6
ca se
s p
er 1
,0 0
0 C
D s
1 1
ca se
s p
er 1
,0 0
0 C
D s
6 9
%
D u
m ig
an et
al 3
7 (1
99 8)
B ef
o re
-a ft
er st
u d
y; IC
U p
at ie
n ts
P re
ve n
ti ve
: A
se p
ti c
in se
rt io
n an
d ca
th et
er ca
re ;
re m
o va
l o
f u
n n
ec es
sa ry
ca th
et er
s Q
I: C
li n
ic ia
n ed
u ca
ti o
n ;
o rg
an iz
at io
n al
ch an
ge
SI C
U :
1 0
.3 ca
se s
p er
1 ,0
00 C
D s;
M IC
U :
1 5
.8 ca
se s
p er
1 ,0
00 C
D s;
C IC
U :
1 5
.1 ca
se s
p er
1 ,0
0 0
C D
s
SI C
U :
8 .6
ca se
s p
er 1
,0 00
C D
s; M
IC U
: 1
1 .2
ca se
s p
er 1
,0 00
C D
s; C
IC U
: 8
.3 ca
se s
p er
1 ,0
0 0
C D
s
SI C
U :
1 7
% ;
M IC
U :
2 9
% ;
C IC
U :
4 5
%
SS I
(m o
d er
at e
q u
al it
y st
u d
ie s)
D el
li n
ge r
et al
3 8
(2 00
5 )
B ef
o re
-a ft
er st
u d
y; ty
p e
o f
p at
ie n
ts n
o t
re p
o rt
ed
P re
ve n
ti ve
: A
p p
ro p
ri at
e u
se o
f p
er io
p er
a- ti
ve an
ti b
io ti
cs ;
d ec
re as
ed u
se o
f p
re o
p -
er at
iv e
sh av
in g;
im p
ro ve
m en
t in
p er
io p
- er
at iv
e gl
u co
se co
n tr
o l
Q I:
A u
d it
an d
fe ed
b ac
k ;
cl in
ic ia
n ed
u ca
- ti
o n
; cl
in ic
ia n
re m
in d
er
2 .3
% 1
.7 %
2 6
%
L u
ta re
w yc
h et
al 3
9 (2
0 04
) B
ef o
re -a
ft er
st u
d y;
ty p
e o
f p
at ie
n ts
n o
t re
p o
rt ed
P re
ve n
ti ve
: Im
p ro
ve m
en t
in p
er io
p er
at iv
e gl
u co
se co
n tr
o l
Q I:
A u
d it
an d
fe ed
b ac
k ;
cl in
ic ia
n ed
u ca
- ti
o n
; p
at ie
n t
ed u
ca ti
o n
7 .5
8% 3
.4 7%
5 4
%
R ao
et al
4 0
(2 00
4) B
ef o
re -a
ft er
st u
d y;
ty p
e o
f p
at ie
n ts
n o
t re
p o
rt ed
P re
ve n
ti ve
: A
p p
ro p
ri at
e u
se o
f p
er io
p er
a- ti
ve an
ti b
io ti
cs ;
d ec
re as
ed u
se o
f p
re o
p -
er at
iv e
sh av
in g;
im p
ro ve
m en
t in
p er
io p
- er
at iv
e gl
u co
se co
n tr
o l
Q I:
C li
n ic
ia n
ed u
ca ti
o n
, cl
in ic
ia n
re m
in d
er
2 .1
% 1
.5 %
2 9
%
n o
t e.
C A
B SI
, ca
th et
er -a
ss o
ci at
ed b
lo o
d st
re am
in fe
ct io
n ;
C A
U T
I, ca
th et
er -a
ss o
ci at
ed u
ri n
ar y
tr ac
t in
fe ct
io n
; C
D ,
ca th
et er
-d ay
; IC
U ,
in te
n si
ve ca
re u
n it
; C
IC U
, ca
rd io
lo gy
IC U
; M
IC U
, m
ed ic
al IC
U ;
Q I,
q u
al it
y in
it ia
ti ve
; SI
C U
, su
rg ic
al IC
U ;
SS I,
su rg
ic al
si te
in fe
ct io
n ;
V A
P, ve
n ti
la to
r- as
so ci
at ed
p n
eu m
o n
ia ;
V D
, ve
n ti
la to
r- d
ay .
a R
ep o
rt ed
ri sk
re d
u ct
io n
re su
lt in
g fr
o m
in te
rr u
p te
d ti
m e-
se ri
es m
o d
el in
g. b
R is
k re
d u
ct io
n ca
lc u
la te
d b
y ta
k in
g th
e d
if fe
re n
ce b
et w
ee n
th e
ri sk
re d
u ct
io n
s o
f th
e in
te rv
en ti
o n
ar m
an d
th e
co n
tr o
l ar
m .
t a
b l
e 2
. Su
m m
ar y
o f
4 St
u d
ie s
o f
th e
C o
st s
A ss
o ci
at ed
w it
h C
at h
et er
-A ss
o ci
at ed
B lo
o d
st re
am In
fe ct
io n
(C A
B SI
)
V ar
ia b
le Sh
an n
o n
et al
1 0
W ar
re n
et al
1 1
D im
ic k
et al
1 2
D iG
io vi
n e
et al
8
C it
y P
it ts
b u
rg h
, PA
St .
L o
u is
, M
O B
al ti
m o
re ,
M D
A n
n A
rb o
r, M
I T
yp e
o f
p at
ie n
ts ,
b y
h o
sp it
al si
te M
ed ic
al an
d co
ro n
ar y
IC U
Su rg
ic al
an d
m ed
ic al
IC U
Su rg
ic al
IC U
M ed
ic al
IC U
N o
. o
f p
at ie
n ts
a 5
4 4
1 8
6 6
8 C
o st
an al
ys is
p ri
m ar
y o
r se
co n
d ar
y ai
m ?
P ri
m ar
y P
ri m
ar y
P ri
m ar
y Se
co n
d ar
y
P u
rp o
se o
f ec
o n
o m
ic an
al ys
is C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n M
et h
o d
o f
d efi
n in
g in
fe ct
io n
N o
t re
p o
rt ed
B y
in fe
ct io
n co
n tr
o l
te am
u si
n g
C D
C cr
it er
ia C
o lo
n iz
at io
n o
f ca
th et
er ( 1
1 5
C F
U )
w it
h o
rg an
is m
fo u
n d
in p
er ip
h -
er al
b lo
o d
sp ec
im en
B y
in fe
ct io
n co
n tr
o l
te am
u si
n g
C D
C cr
it er
ia
C o
n tr
o l
gr o
u p
N o
n e
IC U
p at
ie n
ts w
it h
o u
t in
fe ct
io n
IC U
p at
ie n
ts w
it h
o u
t in
fe ct
io n
M at
ch ed
co n
tr o
l su
b je
ct s;
m at
ch in
g b
as ed
o n
p re
d ic
te d
m o
rt al
it y,
se x,
ag e,
ra ce
, ad
m it
ti n
g d
ia gn
o -
si s,
an d
ch ro
n ic
h ea
lt h
M et
h o
d o
f d
et er
m in
in g
co st
C li
n ic
ia n
s’ re
tr o
sp ec
ti ve
re vi
ew o
f ch
ar ts
, b
il ls
, an
d p
ay m
en ts
M u
lt ip
le li
n ea
r re
gr es
si o
n m
o d
el M
u lt
ip le
li n
ea r
re gr
es si
o n
m o
d el
B y
L O
S an
d b
y to
ta l
d ir
ec t
co st
s; w
h ic
h co
st s
w er
e re
p o
rt ed
is n
o t
st at
ed So
u rc
e o
f co
st d
at a
(b as
el in
e ye
ar )
H o
sp it
al co
st re
p o
rt s,
2 00
2– 20
05 d
o ll
ar s
H o
sp it
al co
st ac
co u
n ti
n g
d at
ab as
e, 2
00 0
d o
ll ar
s H
o sp
it al
ch ar
ge s
co n
ve rt
ed to
co st
s, 1
9 98
d o
ll ar
s H
o sp
it al
co st
ac co
u n
ti n
g d
at ab
as e,
1 9
94 –
1 99
6 d
o ll
ar s
C o
st s
m ea
su re
d L
in e
it em
co st
s o
f ca
re at
tr ib
u ta
b le
to C
A B
SI (e
g, ad
d it
io n
al h
o sp
it al
d ay
s, an
ti b
io ti
cs ,
an d
te st
s) an
d /o
r it
s co
m p
li ca
ti o
n s
(e g,
ex p
lo ra
to ry
la p
ar o
to m
y, h
em o
d ia
ly si
s)
A ll
co st
s in
h o
sp it
al ac
co u
n ti
n g
d at
ab as
e, in
cl u
d in
g o
ve rh
ea d
co st
s A
ll co
st s
in h
o sp
it al
b il
li n
g d
at ab
as e;
o ve
rh ea
d co
st s
n o
t re
p o
rt ed
C o
st an
al ys
is m
et h
o d
s am
b ig
u o
u s;
it ap
p ea
rs th
at o
n ly
d ir
ec t
co st
s fo
r IC
U ca
re w
er e
co n
si d
er ed
P er
sp ec
ti ve
H o
sp it
al H
o sp
it al
H o
sp it
al H
o sp
it al
T im
e h
o ri
zo n
In p
at ie
n t
st ay
In p
at ie
n t
st ay
In p
at ie
n t
st ay
IC U
co m
p o
n en
t o
f st
ay M
ai n
ec o
n o
m ic
o u
tc o
m e
M ea
n in
cr em
en ta
l d
ir ec
t co
st p
er h
o sp
it al
i- za
ti o
n at
tr ib
u ta
b le
to th
e C
A B
SI A
d ju
st ed
m ea
n in
cr em
en ta
l to
ta l
co st
p er
h o
sp it
al iz
at io
n at
tr ib
u ta
b le
to th
e C
A B
SI
A d
ju st
ed m
ea n
in cr
em en
ta l
to ta
l co
st p
er h
o sp
it al
iz at
io n
at tr
ib u
ta -
b le
to th
e C
A B
SI
M ea
n in
cr em
en ta
l IC
U co
st at
tr ib
- u
ta b
le to
th e
C A
B SI
M u
lt iv
ar ia
te ad
ju st
m en
t m
ad e
to co
st es
ti m
at es
N o
Y es
; re
gr es
si o
n m
o d
el co
n tr
o ll
ed fo
r A
PA C
H E
II sc
o re
, h
ea rt
fa il
u re
, h
e- m
o d
ia ly
si s,
ve n
ti la
to r-
d ay
s, an
d co
rt i-
co st
er o
id u
se
Y es
; re
gr es
si o
n m
o d
el co
n tr
o ll
ed fo
r A
PA C
H E
II I
sc o
re an
d ag
e N
o
U n
ad ju
st ed
re su
lt s
(a s
p u
b li
sh ed
) M
ea n
, $
40 ,1
79 (S
D n
o t
re p
o rt
ed )
M ed
ia n
, $
63 ,5
72 (7
5 th
– 9
5t h
q u
ar ti
le ra
n ge
, $
39 ,3
14 –
$ 84
,8 71
) M
ed ia
n ,
$ 62
,6 52
(7 5
th –
9 5t
h q
u ar
ti le
ra n
ge ,
$ 17
,4 39
– $
17 0,
79 9
) A
ll p
at ie
n ts
: m
ea n
, $
23 ,7
51 ;
su rv
iv o
rs :
m ea
n ,
$ 34
,5 08
(S D
s n
o t
re p
o rt
ed )
A d
ju st
ed re
su lt
s (a
s p
u b
li sh
ed )
N o
m u
lt iv
ar ia
te an
al ys
is M
ea n
, $1
1, 97
1 (9
5% C
I, $
6, 73
2– $
1 8,
3 52
) M
ea n
, $
56 ,1
67 (9
5 %
C I,
$ 11
,5 2
3– $
1 65
,7 35
) N
o m
u lt
iv ar
ia te
an al
ys is
U n
ad ju
st ed
re su
lt s
(2 00
9 d
o ll
ar s)
M ea
n ,
$ 56
,0 00
(S D
n o
t re
p o
rt ed
) M
ed ia
n ,
$ 11
3, 70
0 (7
5t h
– 9
5 th
q u
ar ti
le ra
n ge
, $
70 ,3
00 –
$ 15
1, 70
0 )
M ed
ia n
, $
12 3,
60 0
(7 5t
h –
9 5
th q
u ar
- ti
le ra
n ge
, $
34 ,4
00 –
$ 3
37 ,0
00 )
A ll
p at
ie n
ts :
m ea
n ,
$ 41
,9 00
; su
rv iv
o rs
: m
ea n
, $
60 ,9
00 (S
D s
n o
t re
p o
rt ed
) A
d ju
st ed
re su
lt s
(2 00
9 d
o ll
ar s)
N o
m u
lt iv
ar ia
te an
al ys
is M
ea n
, $2
1, 40
0 (9
5% C
I, $
12 ,0
00 –
$ 3
2, 8
00 )
M ea
n ,
$ 11
0, 80
0 (9
5% C
I, $
2 2,
7 00
– $
3 27
,0 00
) N
o m
u lt
iv ar
ia te
an al
ys is
C o
m m
en ts
T h
re e
cl in
ic ia
n re
vi ew
er s
h ad
to ag
re e
co st
s w
er e
at tr
ib u
ta b
le to
th e
C A
B SI
o r
it s
co m
p li
ca ti
o n
s fo
r co
st s
to b
e in
cl u
d ed
; av
er ag
e lo
ss to
h o
sp it
al ,
$ 26
,8 8
5
Se p
ar at
e an
al ys
es d
o n
e fo
r al
l p
a- ti
en ts
an d
fo r
p at
ie n
ts w
h o
su r-
vi ve
d to
d is
ch ar
ge
n o
t e.
C o
st s
w er
e co
n ve
rt ed
to 2
0 0
9 d
o ll
ar s
u si
n g
th e
C o
n su
m er
P ri
ce In
d ex
(C P
I) fo
r H
o sp
it al
Se rv
ic es
(U S
B u
re au
o f
L ab
o r
St at
is ti
cs ),
ex ce
p t
fo r
D iG
io vi
n e
et al
,8 fo
r w
h ic
h co
st s
w er
e co
n ve
rt ed
u si
n g
th e
C P
I fo
r M
ed ic
al Se
rv ic
es ,
si n
ce th
e h
o sp
it al
in d
ex w
as n
o t
ca lc
u la
te d
b ef
o re
1 9
9 7
. A
PA C
H E
II ,
A cu
te P
h ys
io lo
gy an
d C
h ro
n ic
H ea
lt h
E va
lu at
io n
II ;
C D
, ca
th et
er -d
ay ;
C D
C ,
C en
te rs
fo r
D is
ea se
C o
n tr
o l
an d
P re
ve n
ti o
n ;
C F
U ,
co lo
n y-
fo rm
in g
u n
it ;
C I,
co n
fi d
en ce
in te
rv al
; IC
U ,
in te
n si
ve ca
re u
n it
; L
O S,
le n
gt h
o f
st ay
; SD
, st
an d
ar d
d ev
ia ti
o n
; V
D ,
ve n
ti la
to r-
d ay
. a
N o
. o
f p
at ie
n ts
w it
h in
fe ct
io n
; ex
cl u
d es
m at
ch ed
co n
tr o
l su
b je
ct s.
t a
b l
e 3.
Su m
m ar
y o
f 4
St u
d ie
s o
f th
e C
o st
s A
ss o
ci at
ed w
it h
V en
ti la
to r-
A ss
o ci
at ed
P n
eu m
o n
ia (V
A P
)
V ar
ia b
le L
an sf
o rd
et al
1 3
C o
ca n
o u
r et
al 4
1 W
ar re
n et
al 1
4 R
el lo
et al
4 2
C it
y K
an sa
s C
it y,
M O
H o
u st
o n
, T
X St
. L
o u
is ,
M O
N at
io n
w id
e T
yp e
o f
p at
ie n
ts ,
b y
h o
sp it
al si
te T
ra u
m a
IC U
T ra
u m
a IC
U Su
rg ic
al an
d m
ed ic
al IC
U s
IC U
N o
. o
f p
at ie
n ts
a 1
3 7
0 1
2 7
8 1
6 C
o st
an al
ys is
p ri
m ar
y o
r se
co n
d ar
y ai
m ?
Se co
n d
ar y
P ri
m ar
y P
ri m
ar y
Se co
n d
ar y
P u
rp o
se o
f ec
o n
o m
ic an
al ys
is C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n M
et h
o d
o f
d efi
n in
g in
fe ct
io n
B y
in fe
ct io
n co
n tr
o l
te am
u si
n g
N N
IS cr
it er
ia B
y in
fe ct
io n
co n
tr o
l te
am u
si n
g N
N IS
cr it
er ia
B y
in fe
ct io
n co
n tr
o l
te am
u si
n g
N N
IS cr
it er
ia N
o t
re p
o rt
ed
C o
n tr
o l
gr o
u p
P at
ie n
ts in
sa m
e IC
U w
it h
o u
t in
fe ct
io n
M at
ch ed
co n
tr o
l su
b je
ct s:
m at
ch in
g b
as ed
o n
ag e
an d
In ju
ry Se
ve ri
ty Sc
o re
P at
ie n
ts in
sa m
e IC
U w
it h
o u
t in
fe ct
io n
M at
ch ed
co n
tr o
l su
b je
ct s:
m at
ch in
g b
as ed
o n
ty p
e o
f ad
m is
si o
n ,
p re
d ic
te d
m o
rt al
- it
y, d
u ra
ti o
n o
f ve
n ti
la ti
o n
, an
d ag
e M
et h
o d
o f
d et
er m
in in
g co
st A
ve ra
ge to
ta l
co st
s fo
r p
at ie
n ts
w it
h V
A P
vs p
at ie
n ts
w it
h o
u t
V A
P A
ve ra
ge to
ta l
co st
s fo
r p
at ie
n ts
w it
h V
A P
vs p
at ie
n ts
w it
h o
u t
V A
P A
ve ra
ge to
ta l
co st
s fo
r p
at ie
n ts
w it
h V
A P
vs p
at ie
n ts
w it
h o
u t
V A
P A
ve ra
ge to
ta l
ch ar
ge s
fo r
p at
ie n
ts w
it h
V A
P vs
p at
ie n
ts w
it h
o u
t V
A P
So u
rc e
o f
co st
d at
a (b
as el
in e
ye ar
) N
o t
re p
o rt
ed ,
20 03
– 20
04 d
o ll
ar s
H o
sp it
al co
st ac
co u
n ti
n g
d at
ab as
e, 2
0 02
– 2
00 3
d o
ll ar
s H
o sp
it al
co st
ac co
u n
ti n
g d
at ab
as e,
1 9
98 –
1 99
9 d
o ll
ar s
H o
sp it
al b
il le
d ch
ar ge
s d
at ab
as e,
1 9
98 –
1 99
9 d
o ll
ar s
C o
st s
m ea
su re
d T
o ta
l h
o sp
it al
co st
s an
d ch
ar ge
s; d
et ai
ls an
d o
ve rh
ea d
co st
s n
o t
re p
o rt
ed T
o ta
l IC
U co
st s;
d et
ai ls
an d
o ve
rh ea
d co
st s
n o
t re
p o
rt ed
A ll
co st
s in
d at
ab as
e, in
cl u
d in
g o
ve rh
ea d
A ll
ch ar
ge s
in d
at ab
as e,
o ve
rh ea
d co
st s
n o
t re
p o
rt ed
P er
sp ec
ti ve
H o
sp it
al H
o sp
it al
H o
sp it
al H
o sp
it al
T im
e h
o ri
zo n
N o
t re
p o
rt ed
IC U
st ay
In p
at ie
n t
st ay
N o
t re
p o
rt ed
M ai
n ec
o n
o m
ic o
u tc
o m
e M
ea n
in cr
em en
ta l
ch ar
ge s
p er
h o
sp i-
ta li
za ti
o n
at tr
ib u
ta b
le to
V A
P M
ea n
in cr
em en
ta l
IC U
co st
s p
er st
ay at
tr ib
u ta
b le
to V
A P
A d
ju st
ed m
ea n
in cr
em en
ta l
co st
s p
er h
o sp
it al
iz at
io n
at tr
ib u
ta b
le to
V A
P M
ea n
in cr
em en
ta l
ch ar
ge s
p er
h o
sp it
al iz
at io
n at
tr ib
u ta
b le
to V
A P
M u
lt iv
ar ia
te ad
ju st
m en
t m
ad e
to co
st es
ti m
at es
N o
N o
Y es
; re
gr es
si o
n m
o d
el co
n tr
o ll
ed fo
r A
PA C
H E
II sc
o re
, h
ea rt
fa il
u re
, C
A B
SI ,
h em
o d
ia ly
si s,
tr ac
h eo
st o
m y,
n u
m b
er o
f C
V C
s, H
2 b
lo ck
er u
se ,
co rt
ic o
st er
o id
u se
N o
U n
ad ju
st ed
re su
lt s
(a s
p u
b li
sh ed
) M
ea n
, $
23 3,
09 9
(9 5%
C I,
$ 1
06 ,2
00 –
$ 3
60 ,0
00 )
M ea
n ,
$ 57
,1 58
(9 5
% C
I, $
39 ,3
0 0–
$ 7
5, 0
00 )
M ea
n ,
$ 48
,9 48
(9 5
% C
I, $
38 ,6
1 7–
$ 5
9, 2
78 )
M ea
n ,
$ 41
,2 94
(9 5
% C
I, $
3 4,
9 00
– $
47 ,7
0 0)
A d
ju st
ed re
su lt
s (a
s p
u b
li sh
ed )
N o
m u
lt iv
ar ia
te an
al ys
is N
o m
u lt
iv ar
ia te
an al
ys is
M ea
n ,
$1 1,
89 7
(9 5%
C I,
$ 5,
26 5–
$ 2
6, 2
14 )
N o
m u
lt iv
ar ia
te an
al ys
is
U n
ad ju
st ed
re su
lt s
(2 00
9 d
o ll
ar s)
M ea
n ,
$ 32
4, 00
0 (9
5% C
I, $
1 48
,0 00
– $
5 00
,0 00
) M
ea n
, $
84 ,7
00 (9
5 %
C I,
$ 58
,2 0
0– $
1 11
,0 00
) M
ea n
, $
94 ,6
00 (9
5 %
C I,
$ 75
,6 0
0– $
1 14
,0 00
) M
ea n
, $
80 ,2
00 (9
5 %
C I,
$ 6
7, 5
00 –
$ 92
,2 0
0) A
d ju
st ed
re su
lt s
(2 00
9 d
o ll
ar s)
N o
m u
lt iv
ar ia
te an
al ys
is N
o m
u lt
iv ar
ia te
an al
ys is
M ea
n ,
$2 3,
00 0
(9 5%
C I,
$ 10
,1 00
– 5
0 ,7
0 0)
N o
m u
lt iv
ar ia
te an
al ys
is
C o
m m
en ts
A rt
ic le
m et
h o
d re
p o
rt s
co st
s, re
su lt
s re
p o
rt ch
ar ge
s
n o
t e.
C o
st s
w er
e co
n ve
rt ed
to 2
0 0
9 d
o ll
ar s
u si
n g
th e
C o
n su
m er
P ri
ce In
d ex
fo r
H o
sp it
al Se
rv ic
es (U
S B
u re
au o
f L
ab o
r St
at is
ti cs
). C
D C
, C
en te
rs fo
r D
is ea
se C
o n
tr o
l an
d P
re ve
n ti
o n
; C
F U
, co
lo n
y- fo
rm in
g u
n it
; C
I, co
n fi
d en
ce in
te rv
al ;
IC U
, in
te n
si ve
ca re
u n
it ;
N N
IS ,
N at
io n
al N
o so
co m
ia l
In fe
ct io
n s
Su rv
ei ll
an ce
. a
N o
. o
f p
at ie
n ts
w it
h in
fe ct
io n
; ex
cl u
d es
m at
ch ed
co n
tr o
l su
b je
ct s.
t a
b l
e 4
. Su
m m
ar y
o f
3 St
u d
ie s
o f
th e
C o
st s
A ss
o ci
at ed
w it
h C
at h
et er
-A ss
o ci
at ed
U ri
n ar
y T
ra ct
In fe
ct io
n (C
A U
T I)
V ar
ia b
le T
am b
ya h
et al
1 5
Sa in
t et
al 1
6 B
o lo
gn a
et al
1 7
C it
y M
ad is
o n
, W
I Se
at tl
e, W
A P
h il
ad el
p h
ia ,
P A
T yp
e o
f p
at ie
n ts
, b
y h
o sp
it al
si te
In p
at ie
n ts
In p
at ie
n ts
IC U
N o
. o
f p
at ie
n ts
a 1
2 3
N o
ca se
s N
o ca
se s
C o
st an
al ys
is p
ri m
ar y
o r
se co
n d
ar y
ai m
? Se
co n
d ar
y Se
co n
d ar
y Se
co n
d ar
y
P u
rp o
se o
f ec
o n
o m
ic an
al ys
is C
o st
id en
ti fi
ca ti
o n
C o
st es
ti m
at io
n C
o st
es ti
m at
io n
M et
h o
d o
f d
efi n
in g
in fe
ct io
n B
ac te
ri a
o r
fu n
gi at
co n
ce n
tr at
io n
o f
1 1
,0 0
0 C
F U
/m L
N o
ca se
s N
o ca
se s
C o
n tr
o l
gr o
u p
N o
co n
tr o
l N
o co
n tr
o l
N o
co n
tr o
l M
et h
o d
o f
d et
er m
in in
g co
st C
li n
ic ia
n s’
re tr
o sp
ec ti
ve re
vi ew
o f
ch ar
ts an
d b
il ls
In ve
st ig
at o
rs ’
es ti
m at
e o
f ad
d it
io n
al le
n gt
h o
f st
ay ,
te st
in g,
an d
tr ea
tm en
t n
ee d
ed
In ve
st ig
at o
rs ’
es ti
m at
e o
f ad
d it
io n
al le
n gt
h o
f st
ay an
d te
st in
g n
ee d
ed
So u
rc e
o f
co st
d at
a (b
as el
in e
ye ar
) N
o t
re p
o rt
ed ;
1 9
98 d
o ll
ar s
St an
d ar
d h
o sp
it al
ch ar
ge m
u lt
ip li
ed b
y co
st /c
h ar
ge ra
ti o
; 1
99 8
d o
ll ar
s N
o t
re p
o rt
ed ,
b as
el in
e ye
ar n
o t
re p
o rt
ed
C o
st s
m ea
su re
d L
ab te
st co
st s
an d
m ed
ic at
io n
co st
s 0
.5 -d
ay in
p at
ie n
t st
ay ,
u ri
n e
an al
ys is
, u
ri n
e cu
lt u
re ,
an d
se n
si ti
vi ty
te st
in g;
an ti
m ic
ro b
ia l
th er
ap y
1 -d
ay IC
U st
ay ,
fe ve
r ev
al u
at io
n
P er
sp ec
ti ve
H o
sp it
al H
o sp
it al
H o
sp it
al T
im e
h o
ri zo
n D
ia gn
o st
ic an
d tr
ea tm
en t
p er
io d
F ix
ed as
0 .5
ad d
it io
n al
in p
at ie
n t
d ay
F ix
ed as
1 ad
d it
io n
al in
p at
ie n
t d
ay M
ai n
ec o
n o
m ic
o u
tc o
m e
C o
st o
f la
b te
st s
an d
m ed
ic at
io n
s u
se d
in m
an ag
em en
t o
f C
A U
T I
C o
st o
f h
o sp
it al
st ay
, la
b o
ra to
ry te
st s,
an d
m ed
ic at
io n
s u
se d
in m
an ag
em en
t o
f C
A U
T I
C o
st o
f IC
U st
ay an
d d
ia gn
o st
ic w
o rk
u p
u se
d in
m an
ag em
en t
o f
C A
U T
I
M u
lt iv
ar ia
te ad
ju st
m en
t m
ad e
to co
st es
ti m
at es
N o
N o
N o
U n
ad ju
st ed
re su
lt s
(a s
p u
b li
sh ed
) M
ea n
, $5
89 E
st im
at e,
$2 ,0
41 E
st im
at e,
$2 ,4
71 A
d ju
st ed
re su
lt s
(a s
p u
b li
sh ed
) N
o m
u lt
iv ar
ia te
an al
ys is
N o
m u
lt iv
ar ia
te an
al ys
is N
o m
u lt
iv ar
ia te
an al
ys is
U n
ad ju
st ed
re su
lt s
(2 0
0 9
d o
ll ar
s) E
st im
at e,
$ 1
,2 0
0 E
st im
at e,
$ 4
,0 0
0 E
st im
at e,
$ 4
,7 0
0 A
d ju
st ed
re su
lt s
(2 00
9 d
o ll
ar s)
N o
m u
lt iv
ar ia
te an
al ys
is N
o m
u lt
iv ar
ia te
an al
ys is
N o
m u
lt iv
ar ia
te an
al ys
is C
o m
m en
ts Ig
n o
re d
ad d
it io
n al
p h
ys ic
ia n
an d
n u
rs in
g co
st s
an d
co st
o f
b lo
o d
- st
re am
in fe
ct io
n s
Ig n
o re
d al
l o
th er
co st
s, su
ch as
n u
rs in
g an
d p
h ys
ic ia
n co
st s;
se le
ct ed
lo w
es ti
m at
es o
f co
st s
P ar
t o
f a
m u
lt ic
en te
r st
u d
y; co
st an
al ys
is fo
r ju
st 1
h o
sp it
al ;
ig n
o re
d tr
ea tm
en t,
o th
er co
st s;
se -
le ct
ed lo
w es
ti m
at e
so as
n o
t to
o ve
re st
im at
e im
p ac
t o
f p
re ve
n ti
o n
m ea
su re
s
n o
t e.
C o
st s
w er
e co
n ve
rt ed
to 2
0 0
9 d
o ll
ar s
u si
n g
th e
C o
n su
m er
P ri
ce In
d ex
fo r
H o
sp it
al Se
rv ic
es (U
S B
u re
au o
f L
ab o
r St
at is
ti cs
). C
F U
, co
lo n
y- fo
rm in
g u
n it
; IC
U ,
in te
n si
ve ca
re u
n it
. a
N o
. o
f p
at ie
n ts
w it
h in
fe ct
io n
; ex
cl u
d es
m at
ch ed
co n
tr o
l su
b je
ct s.
t a
b l
e 5.
Su m
m ar
y o
f 4
St u
d ie
s o
f th
e C
o st
s A
ss o
ci at
ed w
it h
Su rg
ic al
Si te
In fe
ct io
n (S
SI )
V ar
ia b
le H
er w
al d
t et
al 4
3 K
ir k
la n
d et
al 4
4 P
er en
ce vi
ch et
al 4
5 D
im ic
k et
al 4
6
C it
y Io
w a
C it
y, IA
D u
rh am
, N
C B
o st
o n
, M
A A
n n
A rb
o r,
M I
T yp
e o
f p
at ie
n ts
, b
y h
o sp
it al
si te
G en
er al
, ca
rd io
th o
ra ci
c su
rg er
y, o
r n
eu ro
su rg
er y
A ll
su rg
er y
A ll
su rg
er y
G en
er al
o r
va sc
u la
r su
rg er
y
N o
. o
f p
at ie
n ts
a 3
1 6
2 5
5 2
6 7
7 5
C o
st an
al ys
is p
ri m
ar y
o r
se co
n d
ar y
ai m
? Se
co n
d ar
y P
ri m
ar y
P ri
m ar
y P
ri m
ar y
P u
rp o
se o
f ec
o n
o m
ic an
al ys
is C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n C
o st
id en
ti fi
ca ti
o n
C o
st id
en ti
fi ca
ti o
n M
et h
o d
o f
d efi
n in
g in
fe ct
io n
B y
in d
ep en
d en
t p
h ys
ic ia
n s,
u si
n g
C D
C cr
it er
ia B
y in
fe ct
io n
co n
tr o
l n
u rs
e, u
si n
g N
N IS
cr it
er ia
B y
in ve
st ig
at o
r, u
si n
g N
N IS
cr it
er ia
U si
n g
N SQ
IP cr
it er
ia
C o
n tr
o l
gr o
u p
P at
ie n
ts in
sa m
e h
o sp
it al
w it
h o
u t
in fe
ct io
n M
at ch
ed co
n tr
o l
su b
je ct
s: m
at ch
in g
b as
ed o
n N
N IS
ri sk
in d
ex ,
ty p
e o
f p
ro ce
d u
re ,
ag e,
d at
e o
f su
rg er
y, an
d su
rg eo
n
M at
ch ed
co n
tr o
l su
b je
ct s:
m at
ch in
g b
as ed
o n
ty p
e o
f p
ro ce
d u
re ,
ag e,
an d
d u
ra ti
o n
o f
p ro
ce d
u re
P at
ie n
ts in
sa m
e h
o sp
it al
w it
h o
u t
in fe
ct io
n
M et
h o
d o
f d
et er
m in
in g
co st
M ed
ia n
to ta
l co
st s
fo r
p at
ie n
ts w
it h
SS I
vs p
at ie
n ts
w it
h o
u t
SS I
M ea
n to
ta l
co st
s fo
r p
at ie
n ts
w it
h SS
I vs
p at
ie n
ts w
it h
o u
t SS
I M
ea n
to ta
l co
st s
fo r
p at
ie n
ts w
it h
SS I
vs p
at ie
n ts
w it
h o
u t
SS I
M ed
ia n
to ta
l co
st s
fo r
p at
ie n
ts w
it h
SS I
vs p
at ie
n ts
w it
h o
u t
SS I
So u
rc e
o f
co st
d at
a (b
as el
in e
ye ar
) H
o sp
it al
fi n
an ci
al d
ep ar
tm en
t, d
et ai
ls n
o t
re p
o rt
ed ;
1 99
5– 1
9 98
d o
ll ar
s C
o st
ac co
u n
ti n
g d
at ab
as e;
1 99
1 –
1 99
5 d
o ll
ar s
H o
sp it
al ch
ar ge
s m
u lt
ip li
ed b
y co
st /
ch ar
ge ra
ti o
; 1
99 8
d o
ll ar
s C
o st
ac co
u n
ti n
g d
at ab
as e;
2 00
1 –
2 00
2 d
o ll
ar s
C o
st s
m ea
su re
d A
ll h
o sp
it al
co st
s ex
cl u
d in
g p
h ys
ic ia
n s’
fe es
, o
ve rh
ea d
n o
t re
p o
rt ed
D ir
ec t
co st
s: o
ve rh
ea d
ex cl
u d
ed ,
d e-
ta il
s n
o t
re p
o rt
ed A
ll h
o sp
it al
an d
o u
tp at
ie n
t ch
ar ge
s, o
ve rh
ea d
n o
t re
p o
rt ed
L ab
o r
an d
su p
p ly
co st
s, d
et ai
ls n
o t
re -
p o
rt ed
, o
ve rh
ea d
n o
t re
p o
rt ed
P er
sp ec
ti ve
H o
sp it
al H
o sp
it al
H ea
lt h
sy st
em H
o sp
it al
T im
e h
o ri
zo n
3 0
d ay
s af
te r
o p
er at
io n
3 0
d ay
s af
te r
o p
er at
io n
8 w
ee k
s af
te r
d is
ch ar
ge N
o t
re p
o rt
ed M
ai n
ec o
n o
m ic
o u
tc o
m e
T o
ta l
p o
st o
p er
at iv
e co
st s
at tr
ib u
ta b
le to
th e
SS I
M ea
n in
cr em
en ta
l d
ir ec
t co
st p
er h
o sp
it al
iz at
io n
as so
ci at
ed w
it h
th e
SS I
M ea
n in
cr em
en ta
l co
st p
er ca
se as
so -
ci at
ed w
it h
th e
SS I
M ea
n in
cr em
en ta
l co
st p
er h
o sp
it al
iz a-
ti o
n as
so ci
at ed
w it
h in
fe ct
io u
s co
m p
li ca
ti o
n M
u lt
iv ar
ia te
ad ju
st m
en t
m ad
e to
co st
es ti
m at
es Y
es ,
b u
t re
su lt
s re
p o
rt ed
o n
ly as
p er
- ce
n ta
ge s;
re gr
es si
o n
m o
d el
co n
tr o
ll ed
fo r
K ar
n o
fs k
y sc
o re
, N
N IS
ri sk
in -
d ex
, n
u m
b er
o f
co m
o rb
id it
ie s,
o b
e- si
ty ,
p re
o p
er at
iv e
L O
S, an
d ag
e
N o
N o
Y es
; re
gr es
si o
n m
o d
el co
n tr
o ll
ed fo
r p
ro ce
d u
re co
m p
le xi
ty ,
p at
ie n
t ch
ar -
ac te
ri st
ic s
(d et
ai ls
n o
t re
p o
rt ed
), an
d o
th er
co m
p li
ca ti
o n
s
U n
ad ju
st ed
re su
lt s
(a s
p u
b li
sh ed
) M
ed ia
n ,
$ 3,
3 43
In it
ia l
st ay
: m
ea n
, $
3, 08
9 (9
5% C
I, $
2 ,1
3 9–
$ 4,
1 63
); w
it h
re ad
m is
si o
n :
m ea
n ,
$ 5,
0 38
(9 5
% C
I, $
4, 0
20 –
$ 6
,2 8
9)
M ea
n ,
$ 3,
3 82
(9 5%
C I,
$ 1,
3 14
– $
5 ,4
5 0)
M ed
ia n
, $
8, 0
39
A d
ju st
ed re
su lt
s (a
s p
u b
li sh
ed )
In cr
ea se
o f
25 %
– 10
6% b
N o
m u
lt iv
ar ia
te an
al ys
is N
o m
u lt
iv ar
ia te
an al
ys is
M ea
n ,
$ 1,
3 98
(9 5%
C I,
$ 37
7 –
$ 2,
4 18
) U
n ad
ju st
ed re
su lt
s (2
00 9
d o
ll ar
s) M
ed ia
n ,
$ 5,
6 00
In it
ia l
st ay
: m
ea n
, $
6, 00
0 (9
5% C
I, $
4 ,2
0 0–
$ 8,
1 00
); w
it h
re ad
m is
si o
n :
m ea
n ,
$ 9,
8 00
(9 5
% C
I, $
7, 9
00 –
$ 1
2, 3
00 )
M ea
n ,
$ 6,
7 00
(9 5%
C I,
$ 2,
6 00
– $
1 0,
8 00
) M
ed ia
n ,
$ 12
,9 00
A d
ju st
ed re
su lt
s (2
00 9
d o
ll ar
s) In
cr ea
se o
f 25
% –
10 6%
b N
o m
u lt
iv ar
ia te
an al
ys is
N o
m u
lt iv
ar ia
te an
al ys
is M
ea n
, $
2, 2
00 (9
5% C
I, $
60 0
– $
3, 9
00 )
C o
m m
en ts
C o
st m
et h
o d
s gi
ve n
in se
p ar
at e
re p
o rt
4 7
M o
st ca
se s
o f
SS I
ar e
d ia
gn o
se d
af te
r d
is ch
ar ge
In fe
ct io
u s
co m
p li
ca ti
o n
s in
cl u
d ed
4 1
w o
u n
d in
fe ct
io n
s, 1
0 ca
se s
o f
se p
si s,
2 4
ca se
s o
f w
o u
n d
d eh
is ce
n ce
n o
t e.
C o
st s
w er
e co
n ve
rt ed
to 2
0 0
9 d
o ll
ar s
u si
n g
th e
C o
n su
m er
P ri
ce In
d ex
(C P
I) fo
r H
o sp
it al
Se rv
ic es
(U S
B u
re au
o f
L ab
o r
St at
is ti
cs ),
ex ce
p t
fo r
K ir
k la
n d
et al
,4 4
fo r
w h
ic h
co st
s w
er e
co n
ve rt
ed u
si n
g th
e C
P I
fo r
H ea
lt h
ca re
Se rv
ic es
, b
ec au
se th
e h
o sp
it al
se rv
ic es
co m
p o
n en
t w
as n
o t
ca lc
u la
te d
b ef
o re
1 9
9 7
. C
D C
, C
en te
rs fo
r D
is ea
se C
o n
tr o
l an
d P
re ve
n ti
o n
; C
F U
, co
lo n
y- fo
rm in
g u
n it
; C
I, co
n fi
d en
ce in
te rv
al ;
IC U
, in
te n
si ve
ca re
u n
it ;
L O
S, le
n gt
h o
f st
ay ;
N N
IS ,
N at
io n
al N
o so
co m
ia l
In fe
ct io
n s
Su rv
ei ll
an ce
; N
SQ IP
, N
at io
n al
Su rg
ic al
Q u
al it
y Im
p ro
ve m
en t
P ro
gr am
. a
N o
. o
f p
at ie
n ts
w it
h in
fe ct
io n
; ex
cl u
d es
m at
ch ed
co n
tr o
l su
b je
ct s.
b D
ep en
d in
g o
n th
e ty
p e
o f
su rg
er y
an d
w h
et h
er th
e in
fe ct
io n
w as
fa ta
l.
1 1 0 i nf ec ti on c ont ro l a n d h osp ita l e p ide mi ol ogy f eb ru ary 2 0 11, v ol . 3 2, n o. 2
of preventable VAP are estimated to be $2.19 billion to 3.17 billion dollars annually. Costs of preventable CAUTIs are es- timated to be $115 million to $1.82 billion annually, and the costs of preventable SSIs are estimated to be $166 million to $345 million.
d i s c u s s i o n
Past studies have estimated the number of infections pre- vented or lives saved if hospitals followed best practices in infection prevention and control. The Centers for Disease Control and Prevention’s Study on the Efficacy of Nosocomial Infection Control (SENIC) project made such an estimate in 1975.19 Its estimate considered that 30%–35% of most HAIs were preventable with effective surveillance and control pro- grams, including 22% of cases of pneumonia. In a 1985 fol- low-up survey,20 the SENIC project found that only a fraction of those infections were actually being prevented, because many hospitals still had not implemented recommended in- fection control measures. This was still the case in the present decade.21 Our estimated ranges of potential reductions in HAIs are in line with the most recent estimates by Kaye et al.22
The considerable uncertainty in our estimates of prevent- able HAIs and the associated mortality and costs stems from both the component numbers and the calculations them- selves. First, while our estimates of the annual numbers of HAIs and associated deaths are based on broad national sur- veillance systems,2 those data are more than 5 years old and do not capture the possibly lower infection and mortality rates resulting from improved care practices implemented since 2002. If care has improved since that time, the current number of infections and deaths would be lower than those observed in 2002. That would continue the trend observed since 1975–1976, when the total number of HAIs estimated by the SENIC project was 2.15 million.19 Second, there is no definite way to attribute a death to an HAI, because patient deaths frequently have multiple causes, and the role of in- fection may not always be clear. Klevens et al2 attempted to address this by only including deaths for which an infection preventionist determined that the HAI caused or directly con- tributed to the death, but this may overstate the number of deaths of patients with HAI who may have actually died of other causes. However, for some infections—specifically, CABSI—other investigators have provided higher estimates of attributable mortality than Klevens et al.2 Pittet and col- leagues23 estimated an attributable mortality of 35% in sur- gical ICU patients. For other HAIs, such as VAP, recent sys- tematic reviews of the literature have highlighted difficulty of quantifying the attributable mortality.24 Therefore, for most HAIs additional studies are needed to determine the attrib- utable mortality.
Certainty in the estimate of the proportion of HAIs that are “reasonably preventable” is limited by the quality of the HAI reduction studies. None of the studies was randomized, and few were controlled, limiting the validity of reported risk
reductions. Most utilized a simple before-after design, com- paring outcomes before and after an intervention to reduce the incidence of HAIs, a design that cannot control for other changes in patient care between the control period and the intervention period and makes it difficult to attribute the results to the intervention rather than to random variation, patient selection, or other uncontrolled variables. To address this limitation, we only included studies of good or moderate quality in which causality could reasonably be attributed to the intervention. In addition, some of the published studies included in the AHRQ EPC report3 date back a decade or more; infection prevention and control practices examined in these older studies may be standard practice currently, making large HAI reductions resulting from these interven- tions less likely in modern hospitals. To address this limita- tion, our analyses only included studies published in the past decade.
Another source of uncertainty is generalizing from the re- sults of studies in specialized populations, such as ICU pa- tients, to patients on general hospital wards. In our review, all but one of the CABSI, VAP, and CAUTI studies were carried out in an ICU. The one study not performed in an ICU examined CAUTI on a general medical ward.36 If that study were discounted, the upper limit for the percentage of HAIs that were reasonably preventable would fall from 69% to 45%, which corresponds to 134,800 fewer preventable in- fections, 3,100 fewer preventable deaths, and $160 million to $630 million less in costs.
The key uncertainty in estimating “reasonably preventable” HAI deaths is the fact that the studies we reviewed did not directly measure death as an outcome. Instead, we extrapo- lated reductions in death rates from the estimates of reduc- tions in the number of HAIs, which have their own limita- tions. In addition, in multiplying the estimated fraction of HAIs that are preventable by the estimated number of HAI- related deaths, we assume that the proportion of deaths that are preventable is the same as the proportion of infections that are preventable. The true effect on deaths could be larger or smaller, depending on the extent to which preventive mea- sures affect the severity of HAIs and the extent to which preventive measures work for the kinds of patients who are more susceptible to fatal HAIs. In addition, this review fo- cused on HAIs associated with invasive devices and surgical procedures but did not capture data on morbidity and mor- tality associated with other infections, such as Clostridium difficile infection.
Cost estimates are also limited, mostly by the poor design of the available studies. In general, 2 types of cost analyses were available in the published literature. The first was a raw comparison of costs between patients with the HAI in ques- tion and patients without an infection (unadjusted results). Some of these studies attempted to control for confounding variables, such as patient age and disease severity, by selecting uninfected matched control patients for each infected case patient. Others simply compared mean or median costs for
re a s on ab l y p re ve n t a b le h a i s 1 11
all infected patients and uninfected patients, an approach that likely overestimates HAI costs because some of the variables predicting increased risk of infection also predict increased cost irrespective of infection. This limitation on the precision of true cost estimates has been reviewed elsewhere.25 The second type of cost analysis in the literature used regression modeling to account for the effect of multiple variables, in- cluding HAIs, on hospital costs (adjusted results). In all in- stances, adjusted analyses yielded lower incremental costs per infection than did the unadjusted analyses in the same study. We used adjusted estimates if they were available, but in some instances, such as for CAUTI, only a range of unadjusted estimates was available, which increased the risk that we over- estimated incremental costs.
Importantly, the cost objective of our study was to estimate the incremental costs of HAIs to hospitals, not the cost-ef- fectiveness of various interventions or “bundles” of practices to prevent or decrease the incidence of HAIs. Hence, our cost estimates do not factor in the costs of those interventions required to prevent or reduce HAIs, such as those described in the AHRQ EPC report (eg, use of chlorhexidine).3
Our study suggests that, in the patients and settings ex- amined, HAIs have never been 100% preventable, even with the implementation of comprehensive evidence-based infec- tion control strategies. Instead, risk reductions may be limited to 65%–70% for CABSI and CAUTI and approximately 55% for VAP and SSI—reductions that may actually be overesti- mated given the limitations cited above. The magnitude of risk reductions did not appear to be associated with study design or study quality. However, for all HAIs the studies of patients with the highest risk of infection prior to the inter- vention were often the studies that showed the greatest risk reductions, and the studies of patients with the lowest risk were the ones that demonstrated the smallest reductions; this suggests regression to the mean.
Given the difficulty of preventing 100% of HAIs even with
comprehensive evidence-based interventions, it may be ap- propriate to consider reimbursement strategies that encour- age hospitals to reduce the incidence of HAIs while also ac- counting for hospitals’ case mix indices. For example, reimbursement based on a percentage reduction in the in- cidence of an HAI or a reduction of the number of cases of an HAI below a threshold set according to the case mix.
In conclusion, our findings suggest that the goal of pre- venting 100% of HAIs may not be attainable even with use of current evidence-based HAI prevention strategies; how- ever, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars. Given their limi- tations, the figures in our study should not be used as a basis for policy decisions but should prompt future studies with robust designs to measure accurately the impact of HAI re- duction strategies and the incremental cost of HAIs.
acknowledgments
We thank our colleague David Goldmann, MD, at the University of Penn- sylvania, for reviewing the manuscript and for his many thoughtful suggestions.
Potential conflicts of interest. P.J.B. reports that he is chair of the Health- care Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention and past president of SHEA. The authors report no other potential conflicts of interest.
Address reprint requests to Craig A. Umscheid, MD, MSCE, Assistant Professor of Medicine and Epidemiology, Director, Center for Evidence-Based Practice, University of Pennsylvania, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA 19104 ([email protected]
This study was originally performed for the Society for Healthcare Epi- demiology of America (SHEA) and was included in its written testimony to the Committee on Oversight and Government Reform in its “Hearing on Healthcare-Associated Infections: A Preventable Epidemic,” chaired by Henry A. Waxman on April 16, 2008, in Washington, DC. Findings from the man- uscript were subsequently presented at the 19th Annual Scientific Meeting of SHEA in San Diego, California, in 2009.
1 1 2 i nf ec ti on c ont ro l a n d h o sp ita l e p ide mi ol ogy f eb ru ary 2 01 1, v o l . 3 2 , n o. 2
a p p e n d i x a
table a1. Reported Rates of Healthcare-Associated Infections in US Hospitals in 2002
Type of infection No. of
infections No. of deaths from infection
Case fatality rate, %
Catheter-associated bloodstream infection 248,678 30,665 12.3 Ventilator-associated pneumonia 250,205 35,967 14.4 Catheter-associated urinary tract infection 561,667 13,088 2.3 Surgical site infection 290,485 8,205 2.8 Other 386,090 11,062 2.9
Total 1,737,125 98,987 5.7
note. Data are from Klevens et al.2
table a2. Evaluation of Studies of Prevention of Healthcare-Associated Infections in US Hospitals Reported in the Agency for Healthcare Research and Quality (AHRQ) Report and in the Present Report
No. of studies included, by type of HAI
Variable CABSI VAP CAUTI SSI
EPC report Controlled studies 2 0 3 4 Time-series studies 1 0 0 2 “Good” pre-post studies 6 3 0 1 “Moderate” pre-post studies 2 4 6 6 “Poor” pre-post studies 8 5 1 15
Total 19 12 10 28 Present report
Excluded from analysis Because quality was low 10 5 1 15 Because more than 10 years old 0 1 3 3 Because only reported process outcomes 0 1 2 2 Because from outside US 2 2 2 5
Included in analysis 7 3 2 3
note. Data are from the AHRQ report by Ranji et al.3 CABSI, catheter-associated bloodstream infection; CAUTI, catheter-associated urinary tract infection; EPC, evi- dence-based practice center; SSI, surgical site infection; VAP, ventilator-associated pneu- monia; US, United States.
re a s on ab l y p re ve n t a b le h a i s 1 13
r e f e r e n c e s
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. National Academy of Sciences, 2000.
2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Pub- lic Health Rep 2007;122(2):160–166.
3. Ranji SR, Shetty K, Posley KA, et al. Volume 6: prevention of healthcare-associated infections. Rockville, MD: Agency for Healthcare Research and Quality; 2007 January 2007. AHRQ publication 04(07)-0051-6.
4. Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1): S12–S21.
5. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA 2007;298(23):2782–2784.
6. Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for “preventable complications.” JAMA 2008;299(18):2197–2199.
7. Brown A, Wells P, Jaffey J, et al. Point-of-care monitoring devices for long-term oral anticoagulation therapy: clinical and cost effectiveness. Ottawa: Canadian Agency for Drugs and Tech- nologies in Health, 2007. Technology report 72.
8. DiGiovine B, Chenoweth C, Watts C, Higgins M. The attrib- utable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 1999;160(3):976–981.
9. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: An overview of published reports. J Hosp Infect 2003;54(4):258–266.
10. Shannon RP, Patel B, Cummins D, Shannon AH, Ganguli G, Lu Y. Economics of central line–associated bloodstream infec- tions. Am J Med Qual 2006;21(suppl 6):7S-16S.
11. Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hos- pital. Crit Care Med 2006;34(8):2084–2089.
12. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-re- lated bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136(2):229–234.
13. Lansford T, Moncure M, Carlton E, et al. Efficacy of a pneu- monia prevention protocol in the reduction of ventilator-as- sociated pneumonia in trauma patients. Surg Infect (Larchmt) 2007;8(5):505–510.
14. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attrib- utable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003;31(5):1312–1317.
15. Tambyah PA, Knasinski V, Maki DG. The direct costs of nos- ocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol 2002;23(1):27–31.
16. Saint S, Veenstra DL, Sullivan SD, Chenoweth C, Fendrick AM. The potential clinical and economic benefits of silver alloy uri- nary catheters in preventing urinary tract infection. Arch Intern Med 2000;160(17):2670–2675.
17. Bologna RA, Tu LM, Polansky M, Fraimow HD, Gordon DA,
Whitmore KE. Hydrogel/silver ion-coated urinary catheter re- duces nosocomial urinary tract infection rates in intensive care unit patients: a multicenter study. Urology 1999;54(6):982–987.
18. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical com- plications: a report from the private-sector national surgical quality improvement program. J Am Coll Surg 2004;199(4):531– 537.
19. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital sta- tistics. Am J Epidemiol 1985;121(2):159–167.
20. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121(2):182–205.
21. Braun BI, Kritchevsky SB, Wong ES, et al. Preventing central venous catheter-associated primary bloodstream infections: characteristics of practices among hospitals participating in the evaluation of processes and indicators in infection control (EPIC) study. Infect Control Hosp Epidemiol 2003;24(12):926– 935.
22. Kaye KS, Engemann JJ, Fulmer EM, Clark CC, Noga EM, Sexton DJ. Favorable impact of an infection control network on nos- ocomial infection rates in community hospitals. Infect Control Hosp Epidemiol 2006;27(3):228–232.
23. Pittet D, Harbarth S. What techniques for diagnosis of venti- lator-associated pneumonia? [see comment]. Lancet 1998; 352(9122):83–84.
24. Melsen WG, Rovers MM, Bonten MJ. Ventilator-associated pneumonia and mortality: a systematic review of observational studies. Crit Care Med 2009;37(10):2709–2718.
25. Perencevich EN, Stone PW, Wright SB, et al. Raising standards while watching the bottom line: making a business case for infection control. Infect Control Hosp Epidemiol 2007;28(10): 1121–1133.
26. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355(26):2725–2732.
27. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating cath- eter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014–2020.
28. Coopersmith CM, Zack JE, Ward MR, et al. The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Arch Surg 2004;139(2):131–136.
29. Warren DK, Zack JE, Mayfield JL, et al. The effect of an edu- cation program on the incidence of central venous catheter- associated bloodstream infection in a medical ICU. Chest 2004; 126(5):1612–1618.
30. Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An ed- ucational intervention to prevent catheter-associated blood- stream infections in a nonteaching, community medical center. Crit Care Med 2003;31(7):1959–1963.
31. Coopersmith CM, Rebmann TL, Zack JE, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002; 30(1):59–64.
32. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of phy- sicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132(8):641–648.
33. Babcock HM, Zack JE, Garrison T, et al. An educational inter- vention to reduce ventilator-associated pneumonia in an inte-
1 1 4 i nf ect i on c ont ro l a n d h o sp ita l e p idem i olo gy f eb ru a ry 2 01 1, v o l. 3 2 , n o . 2
grated health system: a comparison of effects. Chest 2004;125(6): 2224–2231.
34. Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-asso- ciated pneumonia. Crit Care Med 2002;30(11):2407–2412.
35. Lai KK, Baker SP, Fontecchio SA. Impact of a program of in- tensive surveillance and interventions targeting ventilated pa- tients in the reduction of ventilator-associated pneumonia and its cost-effectiveness. Infect Control Hosp Epidemiol 2003;24(11): 859–863.
36. Topal J, Conklin S, Camp K, Morris V, Balcezak T, Herbert P. Prevention of nosocomial catheter-associated urinary tract in- fections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual 2005;20(3):121–126.
37. Dumigan DG, Kohan CA, Reed CR, Jekel JF, Fikrig MK. Utilizing national nosocomial infection surveillance system data to im- prove urinary tract infection rates in three intensive-care units. Clin Perform Qual Health Care 1998;6(4):172–178.
38. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals col- laborate to decrease surgical site infections. Am J Surg 2005; 190(1):9–15.
39. Lutarewych M, Morgan SP, Hall MM. Improving outcomes of coronary artery bypass graft infections with multiple interven- tions: putting science and data to the test. Infect Control Hosp Epidemiol 2004;25(6):517–519.
40. Rao N, Schilling D, Rice J, Ridenour M, Mook W, Santa E.
Prevention of postoperative mediastinitis: a clinical process im- provement model. J Healthc Qual 2004;26(1):22–27.
41. Cocanour CS, Ostrosky-Zeichner L, Peninger M, et al. Cost of a ventilator-associated pneumonia in a shock trauma intensive care unit. Surg Infect (Larchmt) 2005;6(1):65–72.
42. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and out- comes of ventilator-associated pneumonia in a large US data- base. Chest 2002;122(6):2115–2121.
43. Herwaldt LA, Cullen JJ, Scholz D, et al. A prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. Infect Control Hosp Epidemiol 2006;27(12):1291–1298.
44. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20(11):725–730.
45. Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003;9(2): 196–203.
46. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J Am Coll Surg 2003;196(5):671–678.
47. Herwaldt LA, Swartzendruber SK, Edmond MB, et al. The ep- idemiology of hemorrhage related to cardiothoracic operations. Infect Control Hosp Epidemiol 1998;19(1):9–16.
View publication statsView publication stats
