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Economic and medicaladverse effects of a national policy

to control the spread of highly-resistant micro-organisms.

G Birgand a, M Schwarzinger b, A Perozziello c, C Pelat b, L Armand-Lefevre, E Ruppé d, JC Buzzi c, A Andremont d , Y Yazdanpanah b, JC Lucet a

a Infection control unit, Bichat-Claude Bernard Hospital, Paris, Franceb ATIP-Avenir, Inserm U738, Paris, France;

c Medical Infomation Systems Program (PMSI), Bichat-Claude Bernard Hospital, Paris, France; d Bacteriology laboratory, Bichat-Claude Bernard Hospital, Paris, France

Disclosure statement

• Financial support: none

• Conflict of interest:– Pfizer: Travel grant for the ICAAC 2011

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IntroductionEpidemiological context

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GRE CPE

E.Faecium VR

EARSS 2011

Kp Carba-R

EARSS 2011

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Introduction French National Recommandations

Patients detected colonised with GRE or CPE:

1. Single room + contact precautions for carriers and contact patients along the entire hospital stay

2. Cohorting of carriers and contact patients in 2 different dedicated areas with dedicated staff 24/7

3. Interruption of transfers of carriers and contact patients + interruption of new admissions

4. Repeated rectal sampling of contact patients: D0, D7, D15

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Introduction Potential consequences of guidelines

• Medical impact:‒ Unintended deleterious adverse effects for patients ?

‒ Disruption for the ward‒ Delays in patient’s care and transfer

• Economical impact:‒ Lost income due to interruption of transfers and

admissions (French daily incomes for 1 hospital day: € 300-400 in medical units to € 1700 - 2000 in ICU)

‒ Cost of lab techniques and contact precautions‒ Cost of additional staff for cohorting

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ObjectivesG. Birgand

From 01/2009 to 06/2012 (3.5 years)in a 1000-bed University Hospital

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Characteristics of hospital stays

The additional hospital costs

Patients colonised with GRE or CPE

€Length of stay

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MethodsStudy design

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• Outcomes: • Length of hospital stay and overall hospital cost

• Retrospective data collection:

• Clinical, microbiological and hospital stay characteristics • Estimated costs of inpatient care based on reimbursement

rates of the DRG (national yearly survey, 2011)• Statistical analysis: • Univariate and multivariate ANOVA (SAS and Stata v10)

ControlsPatient never identified as colonized with GRE or CPE

CasesPatient colonised or infected

with GRE or CPE

Matching criteria: gender, ward, period of hospitalisation (n-1), Age, diagnosis-related group (DRG)

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MethodsStudy population

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107 surviving patients

26 cases colonised

81 Controls never identified

14 GRE 12 CPE1 1 18 6

10 vanA 4 vanB 9 OXA-48 2 KPC 1 NDM-1

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37 Pts identified colonised during the study period:•4 death•7 still hospitalised

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ResultsDescription of cases

Characteristics GRE Ptsn= 14 (%)

CPE Ptsn= 12 (%)

n (%)N= 26

Patients from an episode with secondary cases 8 (57) 3 (25) 11 (42)

Time admission => positive culture, d (IQR) 10 (7-20) 13 (5-21) 11 (7-20)

In ICU at time of positive result 3 (21) 3 (25) 6 (23)

Infection with HDRB 2 (14) 1 (8) 3 (12)

Year of first HDRB identification

2009 2 (14) 1 (8) 3 (12)

2010 3 (21) 2 (17) 5 (19)

2011 5 (36) 5 (42) 10 (38)

2012 (6 months) 4 (29) 4 (33) 8 (31)

Age, median (IQR) 65 (57-77) 65 (56-77) 0.84Female 11 (42) 33 (41) 0.89Diagnosis-related group 1.00

Respiratory diseases 9 (35) 28 (35)Diabetes 3 (12) 8 (10)Vascular diseases 4 (15) 20 (24)Infectious diseases 3 (11) 9 (11)Others 7 (27) 16 (20)

Charlson score, median (IQR) 6 (4-7) 4 (3-6) 0.1Mc Cabe score 0.55

0 7 (27) 28 (36)1 17 (65) 42 (53)2 2 (8) 9 (11)

Ward at the time of identification 0.73 ICU 5 (19) 15 (19)Medical unit 15 (58) 53 (65)Surgical unit 6 (23) 13 (16)

ResultsUnivariate analysis (1)

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Characteristics CasesN= 26 (%)

ControlsN= 81 (%)

P

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Median length of stay 28 (12-94) 11 (8-18) <0.01

Ward at hospital discharge 0,05Intensive care unit 0 0Surgical ward 9 (35) 27 (33)Medical ward 14 (54) 53 (65)Rehabilitation 3 (12) 1 (1)

Destination at dischargeHome 23 (88) 68 (84) 0.57Transfer 3 (12) 13 (16)

Health insurance beneficiaries 18 (69) 67 (83) 0.32

Mean cost of hospitalisation, € (sd) 15,830 (4,320) 8,919 (2,447) <0.01

ResultsUnivariate analysis (2)

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Characteristics CasesN= 26

ControlsN= 81

P

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ResultsMultivariate analysis

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Characteristics Colonised Patients Patients never identified as colonised

Mean cost, € (95%CI) 18,010 (14,561 – 21,469) 11,029 (8,732 – 13,325)

• Final multivariate mixed models of ANOVA:

Characteristics Colonised Patients Patients never identified as colonised

Mean length of stay, days (95%CI) 43 (33 – 54) 21 (14 – 27)

Excess of length of stay = 22 days (12 - 34)

Extra cost = 6,981€ (3,377 – 10,585)

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Discussion - Conclusion• The impact of stringent measures to control HDRB on

hospital stays characteristics was estimated to: – 22 days (12-34) of mean excess LOS per Pt– 6,981€ (3,377 – 10,585) of mean extra costs per Pt

• Strengths of this study:‒ Matching on patients comorbidity and DRG

Most costs are attributable to GRE or CPE

• Limits of this study:‒ Single center study‒ Costs based on DRG and not individual data.

• Perspectives:– Evaluation on a larger population at a multicenter level

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Thank you for your attention