who economic impact of hai teleclass slides, june.6.12

Prof. Dr. Ata Nevzat Yalçın, MDProf. Dr. Ata Nevzat Yalçın, MDAkdeniz University, Medicine FacultyAkdeniz University, Medicine Faculty

Dept. Infectious Dis. and Clinical MicrobiologyDept. Infectious Dis. and Clinical MicrobiologyAntalya-TURKEYAntalya-TURKEY

www.webbertraining.com June 6, 2012

Sponsored by WHO Patient Safety Challenge

Clean Care is Safer Care

Economic impact of healthcare-associated infections in low and

middle-income countries

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• Healthcare-associated infections (HAI) Healthcare-associated infections (HAI) represent an important public health problem represent an important public health problem in developing countries as in developed ones in developing countries as in developed ones today as a major cause of high morbidity, today as a major cause of high morbidity, mortality and economic consequences in mortality and economic consequences in hospitalized patients.hospitalized patients.

Healthcare-associated infectionsHealthcare-associated infections

Jarvis WR. Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-7 1996;17: 552-7

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Importance of Healthcare-Importance of Healthcare-associated infectionsassociated infections

The burden of Healthcare-associated infectionsThe burden of Healthcare-associated infections ((HAIs) is substantial in developed countries, where it HAIs) is substantial in developed countries, where it affects from 5% to 15% of hospitalized patients in affects from 5% to 15% of hospitalized patients in regular wards, and as many as 50% or more of regular wards, and as many as 50% or more of patients in intensive care units (ICUs).patients in intensive care units (ICUs).

The incidence of HAIs is between 25% and 40% in The incidence of HAIs is between 25% and 40% in developing countries.developing countries.

HAIsHAIs increase length of stay in hospital.increase length of stay in hospital. HAIsHAIs increase costs.increase costs. HAIsHAIs increase mortality.increase mortality.

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Points of This TalkPoints of This Talk

Incidence of HAI and costIncidence of HAI and cost Pharmacoeconomical analysisPharmacoeconomical analysis Excess costExcess cost Excess cost in HAIExcess cost in HAI Cost of antibioticsCost of antibiotics Extra length of stay Extra length of stay Extra mortalityExtra mortality

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Healthcare-associated infectionsHealthcare-associated infections

Germany Germany → → 525.000-800.000 cases525.000-800.000 cases

~ 20.000- 40.000 deaths~ 20.000- 40.000 deaths UKUK → → 500.000-1.000.000 cases500.000-1.000.000 cases

~ 5.000 deaths~ 5.000 deaths USAUSA → → 2.220.000 cases2.220.000 cases

~ 100.000 deaths~ 100.000 deaths EUEU → → 4.500.000 cases4.500.000 cases

~ 111.000 deaths~ 111.000 deaths

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Excess Cost of Healthcare-Excess Cost of Healthcare-associated Infectionsassociated Infections

NorwayNorway → → → → 132 Million Dollars132 Million Dollars Scotland Scotland → → → → 168 Million Pounds168 Million Pounds EnglandEngland → → → → 1,7 Billion Dollars1,7 Billion Dollars FranceFrance → → → → 3-5 Billion Franks3-5 Billion Franks USAUSA → → → → 7,7 (16,6 ??7,7 (16,6 ????) Billion Dollars) Billion Dollars EUEU → → → → 7 Billion Euros7 Billion Euros TurkeyTurkey → → → → 1-1,5 Billion Dollars ???1-1,5 Billion Dollars ??? Andersen BM, et al. Andersen BM, et al. Infect Control Hosp Epidemiol Infect Control Hosp Epidemiol 1998;19: 805-71998;19: 805-7

Astagneau P, et al. Astagneau P, et al. J Hosp InfectJ Hosp Infect 1999; 42 : 303-12 1999; 42 : 303-12Plowman R, et al. Plowman R, et al. J Hosp InfectJ Hosp Infect 2001;47: 198-207 2001;47: 198-207

Graves N. Graves N. Emerg Infect DisEmerg Infect Dis 2004;10: 561-6 2004;10: 561-6ECDC Annual Report 2008: 16-38ECDC Annual Report 2008: 16-38

Dickema DJ, et al. Dickema DJ, et al. JAMAJAMA 2008;299:1190-2 2008;299:1190-2Hassan M, et al. Hassan M, et al. Hospital TopicsHospital Topics 2010;88:82-9 2010;88:82-9

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• Pneumonias → → 35,967Pneumonias → → 35,967• Bloodstream inf. → → 30,655Bloodstream inf. → → 30,655• Urinary tract inf. → → 8,225Urinary tract inf. → → 8,225• Surgical site inf. → →13,088Surgical site inf. → →13,088• Others → →12,085Others → →12,085• TOTAL → →100,000TOTAL → →100,000

Healthcare-associated Infections Healthcare-associated Infections and mortality and mortality

(US Department of Health and Human Services (DHHS-2009)(US Department of Health and Human Services (DHHS-2009)

Stone PW. Stone PW. Expert Rev Pharmacoecon Outcomes ResExpert Rev Pharmacoecon Outcomes Res 2009;9:417-22 2009;9:417-22

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Calculating costsCalculating costs(Methodological subjects-1)(Methodological subjects-1)

Study designStudy design Patient group (incidence,prevalence,epidemics)Patient group (incidence,prevalence,epidemics) Location (hospital, follow-up after discharge)Location (hospital, follow-up after discharge) Dimension of the study (hospital, country, Dimension of the study (hospital, country,

developing countries, pathogens, interventions)developing countries, pathogens, interventions)

Wilcox MH, et al. Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-4 2000;45:81-4

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Calculating costsCalculating costs(Methodological subjects-2)(Methodological subjects-2)

Extra cost and design of length of stayExtra cost and design of length of stay Costs (hospital charges, deaths, antibiotics Costs (hospital charges, deaths, antibiotics

utilisation, antibiotic resistance, environmental utilisation, antibiotic resistance, environmental damage)damage)

Conclusion statistics (mean, median, percent, total)Conclusion statistics (mean, median, percent, total) Design of analysisDesign of analysis

Wilcox MH, et al. Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-4 2000;45:81-4

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Costs

1. Well described costs associated with healthcare-associated infections

2. Poorly described costs associated with healthcare-associated infections

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Well described costs Well described costs associated with HAIassociated with HAI

Drug (antibiotics) acquisitionDrug (antibiotics) acquisition

Increased hospital stayIncreased hospital stay

Wilcox MH, et al. Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-4 2000;45:81-4

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Poorly described costs associated Poorly described costs associated with HAIwith HAI

Control measures (isolation facilities, Control measures (isolation facilities, commitees, policies)commitees, policies)

Impaired hospital activity (ward closing, etc.)Impaired hospital activity (ward closing, etc.) Confidence, performance of staffConfidence, performance of staff LitigationLitigation Effects on communityEffects on community MorbidityMorbidity MortalityMortality

Wilcox MH, et al. Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-4 2000;45:81-4

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Excess costs of HAI Excess costs of HAI (Adults)-(US Dollars)(Adults)-(US Dollars)

Study Year Country Cost ($$))

Westwood JCN 1974 USA 1,650

Haley RW 1980 USA 1,018

Coello R 1993 England 1,759

Diaz Molina C 1993 Spain 1,909

Yalcin AN 1997 Turkey 1,582

Orrett FA 1998 Trinidad 1,910

Andersen BM 1998 Norway 2,200

Esatoglu AZ 2001 Turkey 2,298

Chen YY 2003 Taiwan 3,306

Yalcin AN. Yalcin AN. Indian J Med SciIndian J Med Sci 2003;57:450-6 2003;57:450-6

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Excess costs of HAI Excess costs of HAI (Pediatrics)-(US Dollars)(Pediatrics)-(US Dollars)

Study Year Country Cost ($$))

Leroyer A 1997 France 10,440

Navarette D 1999 Mexico 11,682

Mahieu LM 2001 Belgium 12,399

Yalcin AN. Yalcin AN. Indian J Med SciIndian J Med Sci 2003;57:450-6 2003;57:450-6

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Studies on excess costs in Studies on excess costs in healthcare-associated infectionshealthcare-associated infections

Surgical site infectionsSurgical site infections Bloodstream infectionsBloodstream infections Catheter-related bloodstream infectionsCatheter-related bloodstream infections PneumoniasPneumonias Ventilator-associated pneumoniasVentilator-associated pneumonias

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Surgical site infections

Songklanagarind Hospital, Chiang Mai University, Thailand,1998-2003

140 matched pairs of case and control Procedures:Appendectomy, herniorrhaphy,

mastectomy, cholecystectomy, colostomy and craniotomy

Mean extra hospital charge………43,658 Baht (95 % C.l;30,228-57,088 Baht ) (p(p<< 0.001) 0.001)

Mean excess postoperative stay…..21,3 days (95 % C.l;16,6-26,0 days) (p(p<< 0.001) 0.001)

Kasatpibal N, et al. Kasatpibal N, et al. J Med Assoc ThaiJ Med Assoc Thai 2005;88:1083-91 2005;88:1083-91

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Surgical site infections

Tikur Anbessa Hospital, Adid Ababa, Ethiopia, 1999 1754 surgical patients and controls Infection rate: 14,8% Mean excess postoperative stay…..19,6 days (cases)

11,3 days (controls) Mortality rates:10,8% (cases)….3,9 % (controls)

Taye M. Taye M. Ethiop Med Ethiop Med 2005;43:167-74 2005;43:167-74

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Healthcare-associated Healthcare-associated bloodstream infections bloodstream infections

(Neonatal-ICU)(Neonatal-ICU) University Hospital of Blida, Zabana, Blida,

Algeria, 2004-7 83 neonates and 166 controls Excess hospitalization: 9,2 days Excess hospitalization: 9,2 days

Excess cost: Excess cost: $$ 1,315 ( 1,315 ($$ 2,584 vs 2,584 vs $$ 1,269) 1,269)

Atif ML, et al. Atif ML, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2008;29:1066-70 2008;29:1066-70

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Healthcare-associated Healthcare-associated bloodstream infections (ICU)bloodstream infections (ICU)

Dr BL Kapur Memorial Hospital, New Delhi, India, 2006 24 patients and 48 controls Excess hospitalization: 11,6 days Excess hospitalization: 11,6 days (p(p<< 0.0001) 0.0001)

Mortality : 54 % Mortality : 54 % (p(p<< 0.0001) 0.0001)

Excess cost: Excess cost: $$14,818 (10,663 -18,974), (14,818 (10,663 -18,974), (pp<< 0.0001) 0.0001)

Kothari A, et al. Kothari A, et al. J Hosp InfectJ Hosp Infect 2009;71:143-8 2009;71:143-8

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Central catheter-related Central catheter-related bloodstream infectionsbloodstream infections

Six ICU, Buenos Aires, Argentina, 1997-2002Six ICU, Buenos Aires, Argentina, 1997-2002 142 patients, 142 controls142 patients, 142 controls Excess hospitalization: 11,9 days Excess hospitalization: 11,9 days Excess mortality: 24,6 %Excess mortality: 24,6 % Excess cost: Excess cost: $$4,8884,888 Excess antibiotics cost: Excess antibiotics cost: $$1,9131,913

Rosenthal VD, et al. Rosenthal VD, et al. Am J Infect ControlAm J Infect Control 2003;31:475-80 2003;31:475-80

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Central venous catheter-associated Central venous catheter-associated

bloodstream infections (ICU)bloodstream infections (ICU) General Hospital, Specialties Intituto Mexicano del General Hospital, Specialties Intituto Mexicano del Seguro Social Hospital, Gabriel Mancera Hospital, Seguro Social Hospital, Gabriel Mancera Hospital, Mexico City, Mexico, 2002-3Mexico City, Mexico, 2002-3

55 patients, 55 controls55 patients, 55 controls Excess hospitalization: 6,1 days Excess hospitalization: 6,1 days Excess mortality: 20%Excess mortality: 20% Excess cost (mean): Excess cost (mean): $$11,59111,591 Excess antibiotics cost (mean): Excess antibiotics cost (mean): $$598598

Higuera F, et al. Higuera F, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2007;28:31-5 2007;28:31-5

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Healthcare-associated Healthcare-associated pneumoniaspneumonias

Six ICU, Buenos Aires, Argentina, 2001-2005Six ICU, Buenos Aires, Argentina, 2001-2005 307 n. pneumonias, 307 controls307 n. pneumonias, 307 controls Excess cost → $ 2,255Excess cost → $ 2,255 Excess antibiotic cost → $ 996 Excess antibiotic cost → $ 996 Extra length of stay → 8,95 daysExtra length of stay → 8,95 days Extra mortality → 30,3 %Extra mortality → 30,3 %

Rosenthal D, et al. Am J Rosenthal D, et al. Am J Infect Control Infect Control 2005;33:157-612005;33:157-61

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StudyStudy

(period)(period)CountryCountry NumberNumber

VAP/VAP/

ControlControl

CostCost

VAPVAP

(($$))

CostCost

Control Control (($$))

pp

Hugonnet SHugonnet S

(1995-1997)(1995-1997)SwitzerlandSwitzerland 97/9797/97 24 72724 727 17 43817 438 ‹ ‹ 0.0010.001

Warren DKWarren DK

(1998-1999)(1998-1999)USAUSA 127/692127/692 70 56870 568 21 62021 620 ‹ ‹ 0.0010.001

Cocanour CSCocanour CS

(2002-2003)(2002-2003)USAUSA 70/7070/70 82 19582 195 25 03725 037 ‹ ‹ 0.050.05

Karaoğlan HKaraoğlan H

(2004-2005)(2004-2005)TurkeyTurkey

(Antalya)(Antalya)81/8181/81 8 6028 602 2 6212 621 ‹ ‹ 0.00010.0001

Kollef MAKollef MA

(2008-2009)(2008-2009)USA 2144/2144 133 371 74 729 ‹ ‹ 0.00010.0001

Ventilator-associated pneumonias

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Costs of HAI (ICU)Costs of HAI (ICU)

Mexico City, Mexico, 1998Mexico City, Mexico, 1998

Sanchez-Sanchez-Velazquez LD, et al. Velazquez LD, et al. Arch Med Res Arch Med Res 2006; 37: 370-5 2006; 37: 370-5

CasesCases

(n: 43)(n: 43)ControlsControls

(n: 86)(n: 86)pp

LOS in ICULOS in ICU 16,3 days16,3 days 10,8 days10,8 days 0.0010.001

Daily cost in Daily cost in ICUICU

$$ 3,715 3,715 $$ 1,935 1,935 0.0010.001

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Attributable costs of HAI (US Attributable costs of HAI (US $$))

Infection type Attributable costs(Mean)

Range(Minimum-maximum)

Surgical site infection

17,944 7,874-26,668

Bloodstream infection

18,432 3,592-34,410

Ventilator-associated pneumonia

22,875 9,986-54,503

Urinary tract infection

1,257 804-1,710

Yokoe DS, et al. Yokoe DS, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2008; 29 (Suppl. 1):S3-S11 2008; 29 (Suppl. 1):S3-S11

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Costs of Healthcare-associated Costs of Healthcare-associated infectionsinfections

HAIHAI ControlControl BedBed 464 464 214 214 LaboratoryLaboratory 417 417 249 249 AntibioticsAntibiotics 1190 1190 54 54 OthersOthers 209 209 181 181 TOTAL TOTAL $ 2280 $ 698 $ 2280 $ 698

Yalcin AN, et al. Yalcin AN, et al. J ChemotherJ Chemother 1997; 9:411-4 1997; 9:411-4

(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)

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Distribution of costs in Distribution of costs in Healthcare-associated infectionsHealthcare-associated infections

Yalcin AN, et al. Yalcin AN, et al. J Chemother J Chemother 1997; 9: 411- 4 1997; 9: 411- 4

(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)

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Distribution of cost (VAP)($)

Costs Costs of VAP Group ± SD (min-

max)

Costs of Control Group ± SD (min-

max)

P value

Bed 1193.7±679.8 (176-3140) 381.0±382.2 (154-3320) <0.0001

Antibiotics 837.1±472.9 (40-2140) 8.5±11.0 (0-40) <0.0001

Drugs and medical materials

2305.0±1347.6 (330-8143)

816.7±645.9 (125-4125) <0.0001

Laboratory 1647.0±1004.5 (248-8068)

546.4±442.4 (34-2335) <0.0001

Radiology 269.9±222.1 (36-1683) 156.8±160.9 (16-806) <0.0001

Operation 628.2±1190.1 (0-7280) 302.4±535.3 (0-2523) <0.05

Intervention 1024.6±973.8 (135-7794) 254.3±271.7 (43-1579) <0.0001

Care 696.7±613.1 (72-3753) 155.4±192.8 (23-1524) <0.0001

Total 8602.7±5045.5 2621.9±2053.3 <0.0001

Karaoğlan H,Yalcin AN, et al. Karaoğlan H,Yalcin AN, et al. Infez Med Infez Med 2010;18:248-552010;18:248-55

(Akdeniz University Hospital, Antalya, Turkey, 2006-7)(Akdeniz University Hospital, Antalya, Turkey, 2006-7)

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Daily antibiotic cost in Daily antibiotic cost in healthcare-associated infectionshealthcare-associated infections

Urinary tract infectionsUrinary tract infections 96-203 FF 96-203 FF PnemoniasPnemonias 108-219 FF108-219 FF Surgical site infectionsSurgical site infections 116-220 FF116-220 FF Bloodstream infectionsBloodstream infections 165-287 FF165-287 FF

Astagneau P, et al. Astagneau P, et al. J Hosp Infect J Hosp Infect 1999;42:303-12 1999;42:303-12

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Daily antibiotic cost in healthcareDaily antibiotic cost in healthcareassociated infectionsassociated infections

Yalçın AN, et al. Yalçın AN, et al. Turk J Hosp Inf Turk J Hosp Inf 2002;6:41-5 2002;6:41-5

(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)

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Daily antibiotic cost in Daily antibiotic cost in healthcare-associated infectionshealthcare-associated infections

MS-KNSMS-KNS $ 44,9 $ 44,9 MSMS-S.aureus-S.aureus $$ 46,7 46,7 E.coliE.coli $ 48,5 $ 48,5 EnterobacterEnterobacter spp. spp. $ 63,8 $ 63,8 MR-MR-S.aureusS.aureus $ 80,0 $ 80,0 P.aeruginosaP.aeruginosa $ 111,7 $ 111,7

Yalçın AN, et al. Yalçın AN, et al. Turk J Hosp Inf Turk J Hosp Inf 2002;6: 41-5 2002;6: 41-5

(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)

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Daily antibiotic cost in healthcare-Daily antibiotic cost in healthcare-associated infectionsassociated infections

Inan D, et al. Inan D, et al. BMC Infect Dis BMC Infect Dis 2005; 5 :1-5 2005; 5 :1-5

(Akdeniz University Hospital, Antalya, Turkey, 2004)(Akdeniz University Hospital, Antalya, Turkey, 2004)

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Costs of HAI with gram Costs of HAI with gram negativenegative non-fermentative rodsnon-fermentative rods

Aşık Z,Yalçın AN et al. (Aşık Z,Yalçın AN et al. (Turk J Hosp Inf.Turk J Hosp Inf. in press-2012)in press-2012)

(Akdeniz University Hospital, Antalya, Turkey, 2011)(Akdeniz University Hospital, Antalya, Turkey, 2011)

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Excess length of stay in Excess length of stay in healthcare-associated infectionshealthcare-associated infections

Study Year Country LOS (days)

Westwood JCN 1974 USA 22,0

Haley RW 1980 USA 13,4

French GL 1991 Hong Kong 23,4

Yalcin AN 1997 Turkey 20,3

Orrett FA 1998 Trinidad 33,5

Sanou J 1999 Burkina Faso 10,0

Esatoglu AZ 2001 Turkey 25,0

Askarian M 2003 Iran 6,2

Sanchez-V LD 2006 Mexico 10,0

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Excess length of stay in healthcare-Excess length of stay in healthcare-associated infectionsassociated infections

Infection type Excess length of stay (days)

Urinary tract infection 1-4

Surgical site infection 7-8,2

Bloodstream infection 7-21

Pneumonias 6,8-30

Jarvis WR. Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-7 1996;17: 552-7

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Excess length of stay in HAIExcess length of stay in HAI (days)(days)

UTIUTI VAPVAP CR-BSICR-BSI

ArgentinaArgentina 7.97.9 8.78.7 9.39.3

BrasilBrasil 8.98.9 9.19.1 7.87.8

MexicoMexico 5.95.9 10.710.7 7.17.1

TurkeyTurkey 8.78.7 8.38.3 9.59.5

IndiaIndia 4.24.2 5.45.4 2.02.0

INICC Project (ICAAC-2005) posters :K-1916, K-1920, K-1922, K-1923, K-1924INICC Project (ICAAC-2005) posters :K-1916, K-1920, K-1922, K-1923, K-1924

Extra mortality in healthcare-Extra mortality in healthcare-associated infections (%)associated infections (%)

Study Year Country Mortality rate

Spengler RF 1978 USA 32,1

French GL 1991 Hong Kong 7,4

Dinkel RH 1994 USA 4,1

Yalcin AN 1997 Turkey 16,7

Martin M 2001 Spain 21,3

Sanchez-V LD 2006 Mexico 16,3

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Economical analysis studies in Economical analysis studies in Healthcare-associated infectionsHealthcare-associated infections

Use of guidelines for authors and editors on Use of guidelines for authors and editors on conducting an economic analysis,conducting an economic analysis,

Continued development of more sophisticated Continued development of more sophisticated mathematical models,mathematical models,

Training of infection control professionals in Training of infection control professionals in economic methods ……economic methods ……

Stone PW, et al. Stone PW, et al. Am J Infect ControlAm J Infect Control 2005; 33:501-9 2005; 33:501-9

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Thanks……..

anyalcin@yahoo.com

anyalcin@akdeniz.edu.tr

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