Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients

Abstract

Rationale: Limitations in methods for the rapid diagnosis of hospitalacquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections.Objectives: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. Methods:The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. Measurements and Main Results:In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved.Conclusions: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a costeffectiveness framework for future test development.

Robust classification of bacterial and viral infections via integrated host gene expression diagnostics

“…Moreover, these test characteristics assume no knowledge of the patient and so are only estimates of the real-world clinical utility of such a test, because patient history, physical examination, vital signs, and laboratory values would all assist in a diagnosis as well. Even given these caveats, a recent economic decision model of screening ICU patients for hospital-acquired infections suggested that a test such as the IADM that can accurately diagnose bacterial and viral infections could be cost-effective (57). Ultimately, only interventional trials will be able to establish cost-effectiveness and clinical utility of a diagnostic test.…”

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“…The authors screened a total of 15,588 patients, out of which 7,579 (48.6%) had a hospital-acquired infections (HAIs) [ 28 ]. HAIs, also called nosocomial infections, affect the clinical outcomes in hospitalized patients and represent a serious concern worldwide [ 29 ]. Tsalik et al reported in 2016 [ 29 ] that infection poses a substantial risk to hospitalized patients, particularly those in intensive care units (ICUs).…”

“…HAIs, also called nosocomial infections, affect the clinical outcomes in hospitalized patients and represent a serious concern worldwide [ 29 ]. Tsalik et al reported in 2016 [ 29 ] that infection poses a substantial risk to hospitalized patients, particularly those in intensive care units (ICUs). Recent estimates indicate that 1.7 million HAIs occur annually in US hospitals, costing $9.8 billion and causing approximately 100,000 deaths.…”

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“…Common examples of such infections may include central line-associated blood stream infection (CLABSI), surgical site infections (SSI), Urinary Tract Infection (UTI), and Methicillin-resistant Staphylococcus aureus (MRSA) infection. These infections increase patient's stay at hospital causing additional burden on the healthcare management by occupying more resources and increasing cost of care [5]. Therefore, there is a need to have an efficient clinical surveillance program (CSP), which will investigate the patients' data and provide useful insights for predicting possibility of such infections.…”