Cost Analysis of an Intervention to Prevent Methicillin-Resistant Staphylococcus Aureus (MRSA) Transmission

Introduction

Our objective was to assess the cost implications of a vertical MRSA prevention program that led to a reduction in MRSA bacteremia.

Methods

We performed a matched historical cohort study and cost analysis in a single hospital in Israel for the years 2005-2011. The cost of MRSA bacteremia was calculated as total hospital cost for patients admitted with bacteremia and for patients with hospital-acquired bacteremia, the difference in cost compared to matched controls. The cost of prevention was calculated as the sum of the cost of microbiology tests, single-use equipment used for patients in isolation, and infection control personnel.

Results

An average of 20,000 patients were screened yearly. The cost of prevention was $208,100 per year, with the major contributor being laboratory cost. We calculated that our intervention averted 34 cases of bacteremia yearly: 17 presenting on admission and 17 acquired in the hospital. The average cost of a case admitted with bacteremia was $14,500, and the net cost attributable to nosocomial bacteremia was $9,400. Antibiotics contributed only 0.4% of the total disease management cost. When the annual cost of averted cases of bacteremia and that of prevention were compared, the intervention resulted in annual cost savings of $199,600.

Conclusions

A vertical MRSA prevention program targeted at high-risk patients, which was highly effective in preventing bacteremia, is cost saving. These results suggest that allocating resources to targeted prevention efforts might be beneficial even in a single institution in a high incidence country.     

Cost of management of patients with haemophilia.

The cost of managing 114 adult haemophiliacs in the west of Scotland was assessed for the period 1 March 1971 to 28 February 1974. Altogether 23 of them (20%) accounted for 80% of the resources used. The cost of hospital treatment of these patients during the period was compared with the predicted cost of home treatment, given the availability of freeze-dried factor VIII concentrate in sufficient amounts. We calculate that adequate on-demand home treatment would cost only 16% more than the present treatment, which is substantially less efficient.     

How patients use domiciliary oxygen.

Forty-five patients in Southampton who received domiciliary oxygen were visited at home to find out how they used and coped with their oxygen. Generally, the organisation and administration of supplies presented no problems, nearly all the apparatus complied with the drug tariff, and most patients coped well with the equipment. Only two patients were taking oxygen for prescribed periods; the others were taking it when necessary for symptomatic relief. No patient received oxygen for over five hours daily. Most patients thought that they were helped by oxygen, but only four said that it allowed them to increase their level of activity, and the overall benefit seemed slight. This was partly because oxygen was usually limited to one room, so patients used oxygen after rather than during exercise. The amount of oxygen consumed differed widely, ranging from three and a half cylinders a week in three patients to less than one cylinder in six months in 17 patients. The average yearly cost of oxygen per patient ranged from 500 pounds in patients consuming one cylinder or more per week, to 15 pounds in those consuming less than one cylinder in six months. The main cost of domiciliary oxygen is determined by the number of cylinder refills, so patients who use it infrequently are a relatively small drain on resources.     

Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease: life table method applied to health authority population.

OBJECTIVES--To estimate the cost effectiveness of statins in lowering serum cholesterol concentration in people at varying risk of fatal cardiovascular disease and to explore the implications of changing the criteria for intervention on cost and cost effectiveness for a purchasing authority. DESIGN--A life table method was used to model the effect of treatment with a statin on survival over 10 years in men and women aged 45-64. The costs of intervention were estimated from the direct costs of treatment, offset by savings associated with a reduction in coronary angiographies, non-fatal myocardial infarctions, and revascularisation procedures. The robustness of the model to various assumptions was tested in a sensitivity analysis. SETTING--Population of a typical district health authority. MAIN OUTCOME MEASURE--Cost per life year saved. RESULTS--The average cost effectiveness of treating men aged 45-64 with no history of coronary heart disease and a cholesterol concentration > 6.5 mmol/l for 10 years with a statin was 136,000 pounds per life year saved. The average cost effectiveness for patients with pre-existing coronary heart disease and a cholesterol concentration > 5.4 mmol/l was 32,000 pounds. These averages hide enormous differences in cost effectiveness between groups at different risk, ranging from 6000 pounds per life year in men aged 55-64 who have had a myocardial infarction and whose cholesterol concentration is above 7.2 mmol/l to 361,000 pounds per life year saved in women aged 45-54 with angina and a cholesterol concentration of 5.5-6.0 mmol/l. CONCLUSIONS--Lowering serum cholesterol concentration in patients with and without preexisting coronary heart disease is effective and safe, but treatment for all those in whom treatment is likely to be effective is not sustainable within current NHS resources. Data on cost effectiveness data should be taken into account when assessing who should be eligible for treatment.     

The costs of crest induction for Daphnia carinata

The effects of notonectid-induced crests on growth and reproduction, and resource allocation to crest construction, moult losses and eggs of Daphnia carinata were measured. An attempt was made to elucidate the mechanisms of physiological costs of crest induction for this species. The crested morph of d. carinata reached a significantly larger size than the uncrested form. Reproductive output was similar in early instars, but the crested morph produced more eggs in latter broods. Instar duration was longer for the crested morph and age at first reproduction was delayed. Survival was also lower in this form. Crest construction required significant resources (equivalent to 60 eggs over a life time) but evidence is presented that these resources were obtained primarily by re-allocation of available material rather than collection of extra resources. The crested morph allocated significantly more resources to moulting than its uncrested counter-parts. The uncrested morph produced large eggs in early instars and progressively smaller ones in later instars. The crested morph produced only small eggs. The hypothesis is presented that the crest-induction strategy of D. carinata involves at least two separate sets of responses, each with its own costs and trade-offs. The first response is production of the crest. The cost of crest production is an increased cost of moulting. D. carinata off sets this cost by increasing instar duration and thus age at reproduction. The second response is increased size. D. carinata achieves this by reducing the fraction of available resources allocated to reproduction. The cost is lower reproductive output.     

A cost-benefit analysis of using cloud computing to extend the capacity of clusters

In this paper, we investigate the benefits that organisations can reap by using “Cloud Computing” providers to augment the computing capacity of their local infrastructure. We evaluate the cost of seven scheduling strategies used by an organisation that operates a cluster managed by virtual machine technology and seeks to utilise resources from a remote Infrastructure as a Service (IaaS) provider to reduce the response time of its user requests. Requests for virtual machines are submitted to the organisation’s cluster, but additional virtual machines are instantiated in the remote provider and added to the local cluster when there are insufficient resources to serve the users’ requests. Naïve scheduling strategies can have a great impact on the amount paid by the organisation for using the remote resources, potentially increasing the overall cost with the use of IaaS. Therefore, in this work we investigate seven scheduling strategies that consider the use of resources from the “Cloud”, to understand how these strategies achieve a balance between performance and usage cost, and how much they improve the requests’ response times.     

Economic Impact of a New Rapid PCR Assay for Detecting Influenza Virus in an Emergency Department and Hospitalized Patients

Seasonal influenza causes significant morbidity and mortality and has a substantial economic impact on the healthcare system. The main objective of this study was to compare the cost per patient for a rapid commercial PCR assay (Xpert^® Flu) with an in-house real-time PCR test for detecting influenza virus. Community patients with influenza like-illness attending the Emergency Department (ED) as well as hospitalized patients in the Hospital Clínic of Barcelona were included. Costs were evaluated from the perspective of the hospital considering the use of resources directly related to influenza testing and treatment. For the purpose of this study, 366 and 691 patients were tested in 2013 and 2014, respectively. The Xpert^® Flu test reduced the mean waiting time for patients in the ED by 9.1 hours and decreased the mean isolation time of hospitalized patients by 23.7 hours. This was associated with a 103€ (or about $113) reduction in the cost per patient tested in the ED and 64€ ($70) per hospitalized patient. Sensitivity analyses showed that Xpert^® Flu is likely to be cost-saving in hospitals with different contexts and prices.     

A System for Cost and Reimbursement Control in Hospitals

This paper approaches the design of a regional or statewide hospital rate-setting system as the underpinning of a larger system which permits a regulatory agency to satisfy the requirements of various public laws now on the books or in process. It aims to generate valid interinstitutional monitoring on the three parameters of cost, utilization, and quality review. Such an approach requires the extension of the usual departmental cost and budgeting system to include consideration of the mix of patients treated and the utilization of various resources, including patient days, in the treatment of these patients. A sampling framework for the application of process-based quality studies and the generation of selected performance measurements is also included.     

旅游资源使用价值评估的ZTCM和TCIA方法比较——以北京奥林匹克森林公园为例

分区旅行费用模型(ZTCM)和旅行费用区间模型(TCIA)是两种常用的旅游资源使用价值评估方法,但两种模型因构建的出发点不同而可能导致不同的研究结果.比较两种方法的评估结果对于准确评估旅游资源使用价值具有重要意义.本文采用问卷调查,应用ZTCM和TCIA对北京奥林匹克森林公园的使用价值进行评估.结果表明: 基于ZTCM,研究区的景观使用价值为162.36亿元;基于TCIA,景观使用价值为37.32亿元.与ZTCM相比,TCIA对追加费用和旅游人数的拟合度更高.对于同一出发地旅行费用差异较大的样本,TCIA可以有效改进ZTCM假设同一出发地平均消费一致的前提,研究结果更符合实际,更适合准确评估旅游资源的使用价值.     

Reuse of haemodialysis equipment: convenience and cost effectiveness.

The shortage of resources for providing renal replacement makes it essential to reduce revenue costs wherever possible. Assuming that haemodialysis is likely to remain a mainstay of renal replacement, a policy of reusing the expensive disposable dialysers and blood lines could offer substantial cost savings. Such reuse has been shown to be safe and to maintain efficiency, but it must also take account of convenience to the patient, especially those dialysing at home. A survey of patients treated with home dialysis shows that the rate of reuse of the complete extracorporeal circuit was highest for those patients who had automated reuse systems.     

Acquisition and allocation of resources in two waterlogging-tolerant grasses

This study focuses on the following questions: (i) whether reductions in root:shoot ratio have a cost in terms of nutrient balance of the plant, and (ii) whether changes in resource-allocation patterns are proportional among different resources. Our approach was to analyse the variations in the allocation pattern induced by soil waterlogging. A pot experiment was conducted to analyse the effects of waterlogging on biomass, phosphorus (P) and nitrogen (N) accumulation of Paspalum dilatatum and Danthonia montevidensis , two waterlogging-tolerant grasses. When changing from oxic to anoxic conditions, a common response of these and other waterlogging-tolerant grasses is a reduction in allocation to below-ground resources. It was observed that (i) the reduction in root:shoot ratio caused by waterlogging did not have a cost in terms of capacity for nutrient uptake; (ii) resource partitioning within aerial parts was less sensitive to treatments than partitioning between roots and shoots; and (iii) biomass does not appear to be a useful currency for evaluating nutrient-allocation patterns, as the allocation of P and N was inadequately represented by biomass. The results presented here indicate that the existence of compensation mechanisms reduces the predictive value of the partition of resources for the capacity of plants to acquire resources. Data on the allocation of nutrients in relation to biomass suggest that the assumptions of independence in the allocation pattern between biomass and limiting nutrients under the effects of environmental factors can be extended.     

Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial

Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain.Design Economic evaluation alongside a pragmatic randomised controlled trial.Setting Secondary care.Participants 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002.Main outcome measures Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY.Results At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 (–0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be £48 588 per QALY gained (–£279 883 to £372 406).Conclusion Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change—for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.     

Phenotypic plasticity in life-history traits of femaleThalassoma bifasciatum (Pisces: Labridae): 2. Correlation of fecundity and growth rate in comparative studies

Synopsis The cost of reproduction is a central concept in theories of life-history evolution. One way to empirically examine the tradeoff between current reproduction and future reproductive prospects is to use natural intraspecific variation in life-history traits. However, this approach is complicated by the sensitivity of life-history traits to variation in the level of resources. We report here an attempt to measure the cost of increasing reproductive activity in populations of female bluehead wrasse,Thalassoma bifasciatum, a coral-reef fish. All of the significant correlations of fecundity and growth rate were positive, in contradiction to the tradeoff predicted by the cost concept. In one of two regions studied, the populations with relatively high mean growth rate had a relatively large mean fecundity. The trait means were also positively associated over time: in months of rapid growth, female reproductive activity was high. Even after removing the effects of habitat and time period in a comparison of individual traits, no growth cost to reproduction appears. Variation in the abundance of resources over space and time is likely to interfere with the measurement of the cost of reproduction in many natural systems.     

Costs and cost effectiveness of cardiovascular screening and intervention: the British family heart study.

OBJECTIVE--To measure costs and cost effectiveness of the British family heart study cardiovascular screening and intervention programme. DESIGN--Cost effectiveness analysis of randomised controlled trial. Clinical and resource use data taken from trial and unit cost data from external estimates. SETTING--13 general practices across Britain. SUBJECTS--4185 men aged 40-59 and their 2827 partners. INTERVENTION--Nurse led programme using a family centered approach, with follow up according to degree of risk. MAIN OUTCOME MEASURES--Cost of the programme it self; overall short term cost to NHS; cost per 1% reduction in coronary risk at one year. RESULTS--Estimated cost of putting the programme into practice for one year was 63 pounds per person (95% confidence interval 60 pounds to 65 pounds). The overall short term cost to the health service was 77 pounds per man (29 pounds to 124 pounds) but only 13 pounds per woman (-48 pounds to 74 pounds), owing to differences in utilisation of other health service resources. The cost per 1% reduction in risk was 5.08 pounds per man (5.92 pounds including broader health service costs) and 5.78 pounds per woman (1.28 pounds taking into account wider health service savings). CONCLUSIONS--The direct cost of the programme to a four partner practice of 7500 patients would be approximately 58,000 pounds. Annually, 8300 pounds would currently be paid to a practice of this size working to the maximum target on the health promotion bands, plus any additional reimbursement of practice staff salaries for which the practice qualified. The broader short term costs to the NHS may augment these costs for men but offset them considerably for women.     

Impact of cardiovascular illness on hospitalization costs in patients with rheumatoid arthritis

The causes of admission and the distribution of direct medical costs were examined to establish the clinical predictors of high hospitalization costs in patients with rheumatoid arthritis. This retrospective study included all rheumatoid arthritis patients who were hospitalized in the Clínica Universitaria Bolivariana in Medellín, Colombia, between January 1999 and June 2003. Data were obtained from the medical records and from the hospital statistical section using a cost-analysis spreadsheet. A total of 41 patients were hospitalized 62 times (0.34 hospitalization per patient per year). Disease activity was the most important cause of admission (60%), followed by surgery (18%), and infection (10%). In 30 (48%) hospitalizations, at least one comorbidity was recorded, with cardiovascular disease being the most frequent (32%). The mean length of stay per patient was 5+/-6 days. The mean total cost was 1,277 US dollars, and the mean cost per day of hospitalization was 235 US dollars. Medications represented 54% of the total cost, whereas that representing medical care was only 3%. Variance analysis disclosed cardiovascular disease as the most important determinant of high costs (p<0.01). In conclusion, the direct costs for inpatients with rheumatoid arthritis were considerable, and arose mainly from organic complications. Prevention and treatment of cardiovascular disease are indispensable not only to reduce the economic burden of rheumatoid arthitis, but also to diminish the risk of mortality. These data assist in the estimation of health care resources and in the selection of public health policies for the improvement of patient outcomes.     

Female reproduction bears no survival cost in captivity for gray mouse lemurs

The survival cost of reproduction has been revealed in many free‐ranging vertebrates. However, recent studies on captive populations failed to detect this cost. Theoretically, this lack of survival/reproduction trade‐off is expected when resources are not limiting, but these studies may have failed to detect the cost, as they may not have fully accounted for potential confounding effects, in particular interindividual heterogeneity. Here, we investigated the effects of current and past reproductive effort on later survival in captive females of a small primate, the gray mouse lemur. Survival analyses showed no cost of reproduction in females; and the pattern was even in the opposite direction: the higher the reproductive effort, the higher the chances of survival until the next reproductive event. These conclusions hold even while accounting for interindividual heterogeneity. In agreement with aforementioned studies on captive vertebrates, these results remind us that reproduction is expected to be traded against body maintenance and the survival prospect only when resources are so limiting that they induce an allocation trade‐off. Thus, the cost of reproduction has a major extrinsic component driven by environmental conditions.     

Resource implications and health benefits of primary prevention strategies for cardiovascular disease in people aged 30 to 74: mathematical modelling study

ObjectiveTo develop a model to determine resource costs and health benefits of implementing guidelines for the prevention of cardiovascular disease in primary care.DesignModelling of data from six strategies for prevention of cardiovascular disease. Strategies incorporated two ways of identifying patients for assessment: traditional (assessment of all adults) and novel (preselection of patients for assessment using a prior estimate of their risk of cardiovascular disease). Three treatment strategies were modelled in conjunction with each identification strategy.SettingEngland.SubjectsPatients aged 30 to 74 eligible for primary prevention strategies for cardiovascular disease who were selected from a hypothetical population of 2000.ResultsNovel strategies prevented more cardiovascular disease, at lower cost, than traditional strategies. Some treatment strategies prevent more cardiovascular disease with fewer resources than others. The findings were robust across a range of different assumptions about workload.ConclusionPreselecting patients for assessment makes better use of staff time than assessing all adults. Treating many patients with low cost drugs is more efficient than prescribing a few patients intensive antihypertensives and statins. Authors of guidelines should model workload implications and health benefits of following their recommendations.

What is already known on this topic

It is possible to estimate patients'' risk of cardiovascular disease and their probability of benefiting from treatmentThere are data on the distribution of cardiovascular risk factors in the population

What this study adds

A model estimated the efficiency of six strategies for primary prevention of cardiovascular disease: three strategies followed guidelines and three prioritised patients for assessment on the basis of a prior estimate of cardiovascular riskStrategies that prioritise patients for risk assessment may reduce staff time to the extent that more patients can be treated and more disease prevented within available resourcesStatins and angiotensin converting enzyme inhibitors cost more than identifying and treating new patients, so strategies avoiding these may allow more disease to be prevented within available resources     

Nonionic contrast media: economic analysis and health policy development.

The replacement of old radiologic contrast media with supposedly safer but more expensive media has created a dilemma for radiologists and hospital administrators. To quantitate the nature of this trade-off we performed a cost-utility analysis using optimistic assumptions that favoured the new media. A complete conversion to the new media would result in an incremental cost of at least $65,000 to gain 1 quality-adjusted life-year (QALY). For a selective strategy in which only high-risk patients would receive the new media the cost would be about $23,000 per QALY gained. However, the incremental cost for low-risk patients is over $220,000 per QALY gained. Conversion to the new contrast media, although not necessarily the most efficient use of scarce resources, has already occurred in Ontario, primarily because of press publicity, pressure from insurers and a political unwillingness of policymakers to decide the fate of identifiable victims. We found that funding of a new intervention associated with a high cost-utility ratio rather than interventions with lower ratios might save some identifiable victims at the expense of a larger number of unidentifiable ones.     

Population dynamics of prey exhibiting inducible defenses: the role of associated costs and density-dependence

The effect of antipredator behavior on the dynamics of a resource-consumer model was analyzed in relation to the magnitude of associated costs, and the strength of density-dependence. For this purpose, I present a deterministic continuous resource-consumer model that exhibits biomass conversion, structural homogeneity, and competition for renewable and fixed resources as separate processes. Antipredator behavior is incorporated as an inducible response to consumer density, and has metabolic and feeding costs. By means of numerical methods, I show: (1) that antipredator behavior is stabilizing for certain parameter ranges, where other stabilizing forces do not dominate the dynamics; (2) intraspecific competition for both fixed and renewable resources have a stabilizing role; (3) metabolic cost is always stabilizing, and feeding cost can be stabilizing or destabilizing, depending on the relative strength of the two competition forces.