1988 Passage in Piglets of a Coronavirus Associated with Porcine Epidemic Diarrhea
associated diarrhea and - Hospital Quality Institute
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0 2 4 6 8 10 12 Modeling the cost savings from a multipronged approach to minimize antibiotic- associated diarrhea and C. difficile infections at Sharp Coronado Hospital Bridget Olson RPh 1 , Yanick Presseault 2 , Noam Ship PhD 2 . 1 Sharp Coronado Hospital, Sharp HealthCare, Coronado, California, USA. 2 Bio-K Plus International, Inc., Laval, Quebec, Canada. Overview Antibiotics are frequently used in the hospital setting and antibiotic-associated diarrhea (AAD) is a common side effect that slows recovery. 1,4 Clostridioides (Clostridium) difficile infections (CDI) are the most dangerous consequence of antibiotics leading to persistent diarrhea, extended length-of-stay and a high risk of mortality. 4,10 AAD and CDI are the result of collateral damage from antibiotics to the patient’s own intestinal microbiota. 4 To curb the number of cases, the Centers for Medicare & Medicaid Services (CMS) now disincentives Hospital Acquired Conditions. Sharp Coronado Hospital is a non-profit 59-bed acute care community hospital in San Diego county. A multipronged approach is used to reduce antibiotic side effects, with much success. 5 The number of hospital-onset (HO) CDI cases has remained low, despite a recent shift in the patient mix towards a higher intensity of care and antibiotic days of therapy (DOT). Here we model the cost of antibiotic-associated diarrhea (AAD) including CDI, with special emphasis on an innovative type of prophylaxis. Bio-K+ is a probiotic comprised of 3 strains of bacteria (L. acidophilus CL1285®, L. casei LBC80R®, L. rhamnosus CLR2®) proven effective for the primary prevention of AAD and HO-CDI. 4 Cost model assumptions The model uses actual figures from Sharp Coronado when possible. Reference costs for non -profit California hospitals were preferred, but certain costs and rates from Canada 3 and the UK 1 are also applied. CMS adjustments not included. Figure 1. Annual number of hospital- onset CDI cases (blue) and thousands of antibiotic DOT (yellow, dashed; since 2010) in acute care. Emphasis on the HO-CDI cases (open circle): 2010, A; 2016 benchmark predicted by CMS, B; and 2016, C. Model input Source Figure (range) Antibiotics, daily doses Actual 2010/2016 5,896 / 4,537 Hospital-onset CDI cases Actual 2010/2016 4 / 2 CDI tests Neg:Pos Various 7,8 , CD testing intensity 5:1 (4:1 - 15:1) Diarrhea, no test Various 1,6 , % of all Diarrhea 50% (42-67%) Bio-K+ daily doses Actual, 2016-17 2,805 Daily cost of Bio-K+/pt Actual $4.06 Conclusions The multipronged approach has kept the number of hospital-onset C. difficile infections low at Sharp Coronado Hospital since 2009. The cost of antibiotic-associated diarrhea, including CDI, in 2016 was $148,000 (38%) lower than predicted by the CMS benchmark and $239,000 (50%) lower than 2010. Each antibiotic DOT resulted in an average of $49 in excess costs to the hospital from diarrhea and CDI in 2016. Bio-K+, a probiotic used in prophylaxis on each day of antibiotics to prevent AAD and CDI, costs $4 per DOT. Table 4. Data and sources used in the model References 1. Allen SJ, Wareham K, Wang D, et al . Health Technol Assess 2013; 17(57). 2. American Hospital Association Survey, 2015 [accessed at www.kff.org, August 2018]. 3. Leal JR, Heitman SJ, Conly JM, Henderson EA, Manns BJ. Infect Control Hosp Epidemiol 2016; 37(9). 4. McFarland LV, Ship N, Auclair J, Millette M. J Hosp Inf 2018; 99(4):443-452. 5. Olson B, Floyd RA, Howard J et al. J Clin Outcom Man 2015; 22(9):398-406. 6. Sampalis J, Psaradellis E, Rampakakis E. Arch Med Sci 2010;6(1):56-64. 7. Schroeder LF, Robilotti E, Peterson LR, Banaei N, Dowdy DW. J Clin Microbiol 2014;52(2):489-96. 8. Tartof SY, Rieg GK, Wei R, Tseng HF, Jacobsen SJ, Yu KC. Infect Control Hosp Epidemiol 2015;36(12):1409-16. 9. Trick WE, Sokalski SJ, Johnson S, et al. Infect Control Hosp Epidemiol 2018;39(7):765-770. 10.Zhang S, Palazuelos-Munoz S, Balsells EM, Nair H, Chit A, Kyaw MH. BMC Infect Dis. 2016;16(1):447. Severity of diarrhea- related harm Cost, source AAD Moderate Diarrhea No CD test CDI- Persistent Diarrhea CDI test, negative CDI+ Persistent Diarrhea Confirmed CDI Excess days in hospital Allen 1 , Zhang 10 1 3 8 Average cost /day a AHA 2015 2 $3,752.00 $3,752.00 $3,752.00 Room cleaning/patient Leal 3 $24.68 $24.68 $24.68 Nurse time/day Leal 3 $34.83 $34.83 $34.83 CDI Testing Actual $17.50 $17.50 Isolation/day Leal 3 $41.67 $41.67 Gowns, gloves/day Leal 3 $29.03 $29.03 Antibiotics /day b Actual, Leal 3 $4.76 Excess cost/patient $3,811.50 $11,614.77 $30,940.50 Table 2. Model of incidence and cost of antibiotic-associated diarrhea including HO-CDI CDI rate model AAD CDI- CDI+ Antibiotic DOT (actual) Total cost Excess vs. 2016 Diarrhea costs per antibiotic DOT A: 2010 24 20 4 (actual) 5,896 $447,534 $223,767 $76 B: 2016 (CMS) 19.4 16.2 3.239 (predicted) 4,537 $362,390 $138,624 $80 C: 2016 12 10 2 (actual) 4,537 $223,767 - $49 Table 1. Multipronged approach to minimize antibiotic-associated diarrhea and C. difficile infections Reduce patient exposure to pathogens Cleaning 1. Hand washing, hygiene compliance 2. Daily cleaning of high touch areas 3. Terminal room cleaning with bleach Contact precautions for affected patients C. difficile lab testing algorithm [3 loose stools in 24 h, without laxative] 1. Enzyme immunoassay: GDH, CD Toxin A, B 2. PCR (Verigene): CD Toxin A, B Table 3. Cost of antibiotic-associated diarrhea and HO-CDI DOT (actual) Annual cost Cost per Bio-K+ DOT a 2,805 $11,388 $4.06 Primary prevention with Bio-K+ Capsules are administered on each day of antibiotic treatment, plus an additional 7 days. Surgical patients taking antibiotics as prophylaxis for <24h are not included. Implementation first started in 2012 5 . Now this is applied as a hospital -wide policy with high patient compliance. Presented at the HQI Annual Conference, Huntington Beach, CA, October 28-30, 2018. Acknowledgements and disclosure : Bridget Olson did not receive any sponsorship to prepare this poster, but has received an educational grant from Bio-K Plus to attend the HQI meeting. Yanick Presseault and Noam Ship are full-time employees of Bio-K Plus International, Inc., the manufacturer of the probiotic discussed herein. Increase patient resiliency to infection Reduce antibiotic pressure 1. Antimicrobial Stewardship Program 2. Standardized treatment algorithms 3. Staff and prescriber education Reduce excessive stomach acid suppression: Switch PPI to H2RA for GI prophylaxis Supplement the intestinal microbiota: Bio-K+ probiotic prophylaxis with antibiotic administration A B a - includes all operating and non-operating expenses, non-profit California hospitals; b - vancomycin 125 mg q6. a - includes acquisition, dispensing and administration of two 50 Billion capsules. Cases / 1000s of DOT C
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Modeling the cost savings from a multipronged approach to minimize antibiotic-associated diarrhea and C. difficile infections at Sharp Coronado Hospital
Bridget Olson RPh1, Yanick Presseault2, Noam Ship PhD2. 1 Sharp Coronado Hospital, Sharp HealthCare, Coronado, California, USA. 2 Bio-K Plus International, Inc., Laval, Quebec, Canada.
Overview
Antibiotics are frequently used in the hospital
setting and antibiotic-associated diarrhea (AAD)
is a common side effect that slows recovery.1,4
Clostridioides (Clostridium) difficile infections
(CDI) are the most dangerous consequence of
antibiotics leading to persistent diarrhea,
extended length-of-stay and a high risk of
mortality.4,10 AAD and CDI are the result of
collateral damage from antibiotics to the
patient’s own intestinal microbiota.4 To curb the
number of cases, the Centers for Medicare &
Medicaid Services (CMS) now disincentives
Hospital Acquired Conditions.
Sharp Coronado Hospital is a non-profit 59-bed
acute care community hospital in San Diego
county. A multipronged approach is used to
reduce antibiotic side effects, with much
success.5 The number of hospital-onset (HO) CDI
cases has remained low, despite a recent shift in
the patient mix towards a higher intensity of
care and antibiotic days of therapy (DOT).
Here we model the cost of antibiotic-associated
diarrhea (AAD) including CDI, with special
emphasis on an innovative type of prophylaxis.
Bio-K+ is a probiotic comprised of 3 strains of
bacteria (L. acidophilus CL1285®, L. casei
LBC80R®, L. rhamnosus CLR2®) proven effective
for the primary prevention of AAD and HO-CDI.4
Cost model assumptions The model uses actual figures from Sharp Coronado when possible. Reference costs for non-profit California hospitals were preferred, but certain costs and rates from Canada3 and the UK1 are also applied. CMS adjustments not included.
Figure 1. Annual number of hospital-onset CDI cases (blue) and thousands of antibiotic DOT (yellow, dashed; since 2010) in acute care. Emphasis on the HO-CDI cases (open circle): 2010, A; 2016 benchmark predicted by CMS, B; and 2016, C.
Model input Source Figure (range)
Antibiotics, daily doses Actual 2010/2016 5,896 / 4,537
Hospital-onset CDI cases Actual 2010/2016 4 / 2
CDI tests Neg:Pos Various7,8, CD testing intensity 5:1 (4:1 - 15:1)
Diarrhea, no test Various1,6, % of all Diarrhea 50% (42-67%)
Bio-K+ daily doses Actual, 2016-17 2,805
Daily cost of Bio-K+/pt Actual $4.06
Conclusions
The multipronged approach has kept
the number of hospital-onset C. difficile
infections low at Sharp Coronado
Hospital since 2009.
The cost of antibiotic-associated
diarrhea, including CDI, in 2016 was
$148,000 (38%) lower than predicted by
the CMS benchmark and $239,000 (50%)
lower than 2010.
Each antibiotic DOT resulted in an
average of $49 in excess costs to the
hospital from diarrhea and CDI in 2016.
Bio-K+, a probiotic used in prophylaxis
on each day of antibiotics to prevent
AAD and CDI, costs $4 per DOT.
Table 4. Data and sources used in the model
References
1. Allen SJ, Wareham K, Wang D, et al. Health Technol Assess 2013; 17(57).
2. American Hospital Association Survey, 2015 [accessed at www.kff.org, August 2018].
3. Leal JR, Heitman SJ, Conly JM, Henderson EA, Manns BJ. Infect Control Hosp Epidemiol 2016; 37(9).
4. McFarland LV, Ship N, Auclair J, Millette M. J Hosp Inf 2018; 99(4):443-452.
5. Olson B, Floyd RA, Howard J et al. J Clin Outcom Man 2015; 22(9):398-406.
6. Sampalis J, Psaradellis E, Rampakakis E. Arch Med Sci 2010;6(1):56-64.
7. Schroeder LF, Robilotti E, Peterson LR, Banaei N, Dowdy DW. J Clin Microbiol 2014;52(2):489-96.
8. Tartof SY, Rieg GK, Wei R, Tseng HF, Jacobsen SJ, Yu KC. Infect Control Hosp Epidemiol 2015;36(12):1409-16.
9. Trick WE, Sokalski SJ, Johnson S, et al. Infect Control Hosp Epidemiol 2018;39(7):765-770.
10.Zhang S, Palazuelos-Munoz S, Balsells EM, Nair H, Chit A, Kyaw MH. BMC Infect Dis. 2016;16(1):447.
Severity of diarrhea-related harm
Cost, source
AAD
Moderate Diarrhea
No CD test
CDI-
Persistent Diarrhea
CDI test, negative
CDI+
Persistent Diarrhea
Confirmed CDI
Excess days in hospital Allen1, Zhang10 1 3 8
Average cost /daya AHA 20152 $3,752.00 $3,752.00 $3,752.00
Room cleaning/patient Leal3 $24.68 $24.68 $24.68
Nurse time/day Leal3 $34.83 $34.83 $34.83
CDI Testing Actual $17.50 $17.50
Isolation/day Leal3 $41.67 $41.67
Gowns, gloves/day Leal3 $29.03 $29.03
Antibiotics /dayb Actual, Leal3 $4.76
Excess cost/patient $3,811.50 $11,614.77 $30,940.50
Table 2. Model of incidence and cost of antibiotic-associated diarrhea including HO-CDI
CDI rate model
AAD CDI- CDI+ Antibiotic
DOT (actual)
Total cost Excess
vs. 2016
Diarrhea costs per antibiotic
DOT
A: 2010 24 20 4 (actual)
5,896 $447,534 $223,767 $76
B: 2016 (CMS)
19.4 16.2 3.239(predicted)
4,537 $362,390 $138,624 $80
C: 2016 12 10 2 (actual)
4,537 $223,767 - $49
Table 1. Multipronged approach to minimize antibiotic-associated diarrhea and C. difficile infections
Reduce patient exposure to pathogens
Cleaning
1. Hand washing, hygiene compliance
2. Daily cleaning of high touch areas
3. Terminal room cleaning with bleach
Contact precautions for affected patients
C. difficile lab testing algorithm
[3 loose stools in 24 h, without laxative]
1. Enzyme immunoassay: GDH, CD Toxin A, B
2. PCR (Verigene): CD Toxin A, B
Table 3. Cost of antibiotic-associated diarrhea and HO-CDI
DOT(actual)
Annual cost
Cost per Bio-K+ DOTa
2,805 $11,388 $4.06
Primary prevention with Bio-K+ Capsules are administered on each day of antibiotic treatment, plus an additional 7 days. Surgical patients taking antibiotics as prophylaxis for <24h are not included. Implementation first started in 20125. Now this is applied as a hospital-wide policy with high patient compliance.
Presented at the HQI Annual Conference, Huntington Beach, CA, October 28-30, 2018.
Acknowledgements and disclosure : Bridget Olson did not receive any sponsorship to
prepare this poster, but has received an educational grant from Bio-K Plus to attend
the HQI meeting. Yanick Presseault and Noam Ship are full-time employees of Bio-K
Plus International, Inc., the manufacturer of the probiotic discussed herein.
Increase patient resiliency to infection
Reduce antibiotic pressure
1. Antimicrobial Stewardship Program
2. Standardized treatment algorithms
3. Staff and prescriber education
Reduce excessive stomach acid suppression:
Switch PPI to H2RA for GI prophylaxis
Supplement the intestinal microbiota:
Bio-K+ probiotic prophylaxis with antibiotic administration
A B
a - includes all operating and non-operating expenses, non-profit California hospitals; b - vancomycin 125 mg q6.
a - includes acquisition, dispensing and administration of two 50 Billion capsules.
Case
s /
1000s
of
DO
T
C
