Table 3.
Detailed summary of systematic review
| Study, methodologic feature score | Design | Method for estimating attributable cost | Resources measured | Source of resource cost (currency, year) | Sample population (time horizon) | Case definition | Incidence | Attributable LOS | Estimated attributable cost |
|---|---|---|---|---|---|---|---|---|---|
| General studies of adverse events and adverse drug events | |||||||||
| Hoonhout13 Methodologic feature score = 16 | Retrospective cohort | Multivariate multilevel analysis | Direct medical costs, based on additional LOS and additional medical procedures | Dutch guideline prices of 2003, corrected for 2004 (€, 2004) | 7926 patients of which 451 patients with AEs in 21 Dutch hospitals (Aug 2005–Oct 2006) | Any AE: an unintended injury resulting in temporary/ permanent disability, death, extra LOS, caused by health care | 5.7% | University hospitals: 10.1 additional days General: 8.9 additional days |
Attributable costs of all AEs: mean €4446 per AE Excess costs of preventable AEs: mean €3634 per AE |
| Ehsani14 Methodologic feature score = 13 | Retrospective cohort | Simple linear regression modeling | Total cost of per-patient care from database (not further described) | Patient-level costing dataset of the Victorian Department of Human Services (AU$, year unclear) | Of 979,834 admissions, 67,609 had an AE, 45 hospitals in Victoria, Australia (Jun 2003– Jul 2004) | Any AE, identified via diagnosis codes | 6.9% had at least 1 AE | 10 additional days | AU$11,846 per AE |
| New15 Methodologic feature score = 12 | Retrospective cohort | Ordinary least squares regression analysis | LOS, surgical and medical procedures, laboratory tests | Hospital accounting database (AU$, 2004) | Of 1605 SCI patients, 610 with one complication, in 45 campuses of 26 AU health services (Jun 2003–Jun 2004) | At least one AE or HAC in a patient with SCI | 38% of multiday SCI episodes had at least 1 incident complication | 32 additional days | Additional costs, any complication: AU$7359 UTI: AU$23,705 Procedural complications: AU$21,821 Anemia: AU$18,047 Pressure ulcer: AU$17,882 |
| Pappas16 Methodologic feature score = 12 | Retrospective cohort | Regression analysis | Nursing staff hours per patient day, clinical outcomes, patient-level data | Cost accounting system/ l Eclipsys TSI (US$, year unstated) | Of 3200 inpatients. Medical patients: 688 Surgical patients: 461; 2 hospitals from hospital databases (24 month) |
Nosocomial AEs including medication error, fall, UTI, pneumonia, and pressure ulcer | Medical patients: 21.5% surgical patients: 14.4% | Not available | Medical patients: $1029 per AE Surgical patients: $903 per AE |
| Morris17 Methodologic feature score = 12 | Retrospective cohort | Unclear | Hospital charges, costs, legal fees and indemnity payments, legal write-offs | Unclear (assumed US$, year unstated) | 130 cases out of 32,100 patients over age 13 (Jan 1, 1995–Dec 6, 1999) | Surgical AEs, not further specified | 0.4% | Not available | Total legal payment for the study group (126) was $8.2 million |
| Aoki18 Methodologic feature score = 15 | Case series | Multivariate logistic analysis | Legal compensation in medical disputes | Medical dispute records (US$, 2007; converted from JP yen) | 155 resolved medical dispute cases in Japan (1989–1998) | Any medical dispute case resolved during the study period | Not available | Not available | Legal compensation for an AE claim was mean $38,937, median $7417 |
| Kaushal19 Methodologic feature score = 14 | Prospective with nested case control | Matched case-control, linear regression model | Charges, actual variable costs, actual fixed costs, actual direct variable costs and actual direct fixed costs | Hospital TSI database (US$, 2003) | 108 cases matched with 375 controls in 1 hospital MICU and cardiac care unit (Jul 2002–Jun 2003) | Any AE, detected via observation, reports, and guided implicit chart abstraction | Not available | MICU, AEs: 0.77 additional days Cardiac care unit AEs: 1.08 additional days |
$3961 in the MICU, $3857 in the cardiac care unit |
| Senst20 Methodologic feature score = 13 | Prospective with nested case control | Case control, multiple linear regression model | Charges converted to costs | Prospectively recorded charges (US$, year unclear) | Of 3187 admissions 134 had an ADE, in 1 US health care network including 4 hospitals and 26 clinics (53-day study period, 1998) | ADE: an injury caused by the use, disuse or misuse of a drug via error or despite proper usage | 4.2% | 1.2 additional days | $2162 per ADE |
| Nosocomial infections (not otherwise specified)a | |||||||||
| Chen21 Methodologic feature score = 15 | Retrospective analytic cohort | Stratified analysis and regression model | LOS, physician services, medical and surgical procedures, lab and radiology, unit costs | Hospital database (US$, 2001) | 778 patients admitted to 3 ICUs in 1 hospital between Oct 2001 and Jun 2002 | Any nosocomial infection (such as BSI, UTI, SSI) confirmed by culture, symptoms and an attending physician | 10.2% had at least one nosocomial infection | 18.2 additional days | $3306 additional costs per nosocomial infection |
| Chen22 Methodologic feature score = 15 | Retrospective analysis of a prospectively assembled cohort | Generalized linear modeling | Medical and surgical procedures, medications, lab investigation, ICU bed-days | Hospital database, microcosting (US$, 2007, converted from Taiwanese dollars) | 401 NIs in 320 of 2757 patients, in 4 ICUs in one hospital in Taiwan (2003–2004) |
BSI, UTI, SSI, respiratory tract infection “and others” diagnosed ≥ 48 hours after admission to ICU | 14.5 NI episodes per 100 admissions | Not available | $10,015 attributable cost per case |
| Roberts23 Methodologic feature score = 16 | Retrospective cohort | Ordinary least-squares regression and economic models | Location of care (ICU, ward, etc), lab and radiography tests, procedures, consultations and medication | Data abstracted from medical records, microcosting (US$, 1998) | 25 patients with HAI in one urban teaching hospital (Jan–Dec 1998) | Any HAIs, according to the CDC’s NNIS | 15.2% | 10.7 additional days | Incremental costs attributable to suspected HAI: $6767 confirmed HAI: $15,275 |
| Kilgore24 Methodologic feature score = 13 | Retrospective cohort | Multivariable regression models and restricted models | Total, variable costs of inpatient care, LOS | Cardinal Health-MedMined database (US$, 2007) | Of 1,355,647 admissions, 58,293 had an NIM. Over 69 months from 55 hospital databases (Mar 2001–Jan 2006) | Any nosocomial infection, identified via NIM | Overall NIM rate was 4.3% | 5.4 additional days | NIMs are associated with attributable costs of US$12,197 |
| Esatoglu25 Methodologic feature score = 12 | Retrospective case control | Matched 1:1 by age, sex, clinic, primary diagnosis of the infected patients | LOS, medical goods/materials, drugs, tests, beds, treatments and other costs. | Unspecified, presumably hospital accounting database (US$, 2001) | 57 patients with HAI matched 1:1, in one hospital in Ankara, Turkey (Sep–Dec 2001) | Any HAI, not further described | Not available | Mean 23 additional days | HAI mean additional cost: US$2026.70 |
| Sheng26 Methodologic feature score = 12 | Retrospective case control | Matched 1:1 by age ± 2, sex, underlying illness, operation(s), admission date 28 days, ward, diagnosis and severity | Costs of stay, medication, lab procedures, materials and services, nursing care | Hospital finance departments (US$, 2002) | 273 adult case-control pairs, from 2 community hospitals and 1 tertiary medical center (Oct–Dec 2002) | Patients aged ≥ 16 years with onset of any infection ≥ 48 hours after admission or within 1 week of discharge | Not available | 19.67 additional days | US$5189 in mean additional costs |
| Plowman27 Methodologic feature score = 16 | Prospective cohort | Linear regression model | Resources, LOS, care and treatment, paid staff time, nursing costs, unit costs for lab, radiology and other diagnostic procedures | Costs estimated for specialty via interviewing health care professionals, hospital database (GBP, year unclear) | 4000 adults in one general hospital in London, England, of which 312 had an HAI (Apr 1994– May 1995) | Any HAI | Incidence of HAIs: 7.8% | 14.1 additional days | Mean additional costs due to HAI at any site: £3154 (model estimate £2917) |
| Lee28 Methodologic feature score = 13 | Retrospective cohort | Linear regression models | Third part payer’s overall hospital costs, increased LOS (postsurgical), antibiotic costs | Quality Indicator/Improvement Project database (US$, 2007, converted from JP yen) | 1058 gastrectomy patients from 10 JP hospitals, of which 215 had any HAI (Apr 2004–Jan 2007) | Diagnosed with any HAI | HAI incidence 20.3% | 10.6 days attributable | Attributable HAI costs: US$2767 (range $1035–$6513) |
| Mahieu29 Methodologic feature score = 15 | Retrospective cohort with nested case control | Matched by gestational age and early post-natal co-morbidity factors | Charges and LOS | Charges from hospital discharge abstracts and patient files (€, 1995) | Of 515 neonates in one Belgian NICU, 69 had one or more HAI (Oct 1993–Dec 1995) | Infections ≥ 48 hours after admission to NICU and treated with IV antibiotics for 5+ days were considered nosocomial | 13% incidence of one or more HAI | Mean 24 additional days | Mean extra charge with HAI was €11,750 |
| Graves30 Methodologic feature score = 15 | Decision model | Monte Carlo simulation | Estimated literature cost per bed-day, literature estimates of increased LOS, medical and surgical services | Database and literature values for NZ hospitals (US$, year unstated) | Any/all recorded admissions, NZ hospitals (1998–1999) | HAI reported in database | No overall incidence reported | Not collected in study | Not reported per case. Estimated national costs of HAI over fiscal year in NZ, medical patients: NZ$4,569,826. Surgical: NZ$3,900,922 |
| Surgical site infections | |||||||||
| Chen22 Methodologic feature score = 15 | Retrospective analysis of a prospectively assembled cohort | Generalized linear modeling | Medical and surgical procedures, medications, lab investigation, ICU bed-days | Hospital database, microcosting (US$, 2007, converted from Taiwanese dollars) | 401 NIs in 320 of 2,757 patients, in 4 ICUs in one hospital in Taiwan (2003–2004) |
BSI, UTI, SSI, respiratory tract infection “and others” diagnosed ≥ 48 hours after admission to ICU | 14.5 NI episodes per 100 admissions | Not available | US$10,015 attributable cost per case |
| Defez31 Methodologic feature score = 15 | Retrospective case control | Matched 1:1 by age, sex, ward, LOS before infection, DRG, and McCabe index | Lab tests, radiology, surgery, antimicrobial agents, rate per day of hospital bed | Reimbursement from La Nomeclature Générale des Actes Professionnels and hospital pharmacy accounting database (€, 2004) | 1703 infected patients from previous study; 30 randomly chosen for each infection site, total 150. One French hospital. (2001–2003) | Patients with single-site nosocomial infection | Not available | Not available | Attributable cost (mean €) by site of infection, UTI: €574 Surgical site: €1814 Respiratory tract: €2421 Bloodstream: €953 Other: €1259 |
| Weber32 Methodologic feature score = 17 | Prospective with nested case control | Matched 1:1 by age ± 5 years, procedure code, and NNIS risk index | LOS, ICU LOS, patient charges, antibiotic costs | Microcosting from hospital accounting database (Swiss franc, assumed 2001) | 6283 surgical procedures in one Swiss hospital, 187 with SSI (2000–2001) | All surgical site infections at one Swiss hospital | 3.0% | 16.8 additional days | Mean additional hospital cost was 19,638 Swiss francs |
| Whitehouse33 Methodologic feature score = 13 | Prospective case control | Matched 1:1 by type of operative procedure, NNIS risk index, age ± 5, surgery within the same year, surgeon | Total direct costs from database, representing sum of costs required to provide health care services | Hospital accounting database, microcosting (US$, 1997) | 59 cases, each matched with 1 control, in one US hospital (1997–1998) | Orthopedic SSI: superficial incisional, deep incisional, or organ/space | Literature rates of SSI following orthopedic surgery: 0.7% (low-risk, hip replacement) to 7.9% (high-risk, spinal fusion) | Median 1 extra day during initial hospital stay, median of 14 extra days during follow-up period | Median direct cost was US$24,344 for a case, compared with US$6636 for uninfected patients |
| Mahmoud34 Methodologic feature score = 12 | Retrospective analytic cohort | Logistic regression | Medical and surgical procedures, hotel costs, nursing, pharmacy, ICU, supplies, lab procedures | Large US hospital database: Premier Perspective database (US$, 2005/6) | 25,825 patients undergoing colorectal procedures, of which 956 have SSI, in US database of 196 hospitals (Jan 2005–Jun 2006) | Incisional SSIs, superficial or deep as defined by the US CDC | SSI incidence: 3.7% | LOS with postoperative complications is 3–11 days longer than without | Mean total direct costs incurred by treating SSI: US$13,746 |
| Penel35 Methodologic feature score = 15 | Prospective cohort with a post hoc analysis | Unclear | LOS. Estimation of per diem cost, including rooming, lab, medications and procedure costs | Macro costing: LOS multiplied by estimation of per diem cost (€, 2005) | 261 head/neck cancer surgery patients in one hospital SSI: 94 PP: 34 SSI and PP: 13 (Jan 1997–Dec 1999) |
Based on the CDC 1992; SSI, PP | SSI: 36% PP: 13% SSI and PP: 5% |
SSI: 16 days in additional mean LOS PP: 17 days SSI and PP: 31 days |
SSI: €16,000 increase in mean direct medical costs PP: €17,000 Both SSI and PP: €35,000 |
| Jenney36 Methodologic feature score = 11 | Retrospective cohort with nested case control | Matched 1:1 by sex, age ± 5, NNIS risk index scores | LOS, antibiotic costs, salaries, utilities and overhead costs | Hospital finance department (AU$, 1999) | 1377 CABG procedures, of which 956 had a SSI; 125 cases in an AU hospital (1996–1998) | SSI after CABG, defined according to the CDC | SSI incidence: 9.1% | 1.36 mean additional days | Mean excess cost: AU$12,419/case |
| Olsen37 Methodologic feature score = 12 | Retrospective cohort | Generalized least squares and propensity score matched-pairs | Department actual cost components multiplied by patient charge codes (pharmacy, room and board, procedures) | Barnes-Jewish Hospital cost accounting database (US$, 2008) | 1616 women who under-went low transverse cesarean delivery at one tertiary care hospital, SSI: 81 EM: 123 (Jul 1999–Jun 2001) |
Patients diagnosed with SSI and/or EM after surgery | Incidence of SSI: 5.0% EM: 7.6% | Not available | SSI: attributable cost US$3529 by generalized least squares, US$2852 by propensity method. EM: US$3956 by generalized least squares, US$3842 by propensity method |
| Nosocomial bloodstream infections | |||||||||
| Chen22 Methodologic feature score = 15 | Retrospective analysis of a prospectively assembled cohort | Generalized linear modeling | Medical and surgical procedures, medications, lab investigation, ICU bed-days | Hospital database, microcosting (US$, 2007, converted from Taiwanese dollars) | 401 NIs in 320 of 2757 patients, in 4 ICUs in one hospital in Taiwan (2003–2004) | BSI, UTI, SSI, respiratory tract infection “and others” diagnosed ≥ 48 hours after admission to ICU | 14.5 NI episodes per 100 admissions | Not available | US$10,015 attributable cost per case |
| Defez31 Methodologic feature score = 15 | Retrospective case control | Matched 1:1 by age, sex, ward, LOS before infection, DRG, and McCabe index | Lab tests, radiology, surgery, antimicrobial agents, rate per day of hospital bed | Reimbursement from La Nomeclature Générale des Actes Professionnels and hospital pharmacy accounting database (€, 2004) | 1703 infected patients from previous study; 30 randomly chosen for each infection site, total 150. One French hospital. (2001–2003) |
Patients with single-site nosocomial infection | Not available | Not available | Attributable cost (mean €) by site of infection, UTI: €574 Surgical site: €1814 Respiratory tract: €2421 Bloodstream: €953 Other: €1259 |
| Blot38 Methodologic feature score = 18 | Retrospective case control | Linear regression analysis, and matched 1:1 or 1:2 by APACHE II score, principal diagnosis, ICU LOS | Duration of mechanical ventilation, LOS, hospital costs | Patient hospital invoices (€, 2002) | 36,836 patients (192 cases) were admitted to one general ICU in Belgium. (1992–2002) | Catheter-related bloodstream infection: positive culture results and clinical signs of sepsis | 5.2 cases BSI per 1000 admissions, or 1 case per 1000 catheter-days | 10 days attributable | Attributable costs €13,585 |
| Orsi39 Methodologic feature score = 15 | Retrospective case control | Matched 1:2 by pre-infection LOS, primary diagnosis, ward, CVC, age ± 5, sex | Single-day hospital cost, increased LOS | Data from clinical and micro-biological records collected by infection control team (€, year unclear) | 105 included cases, each matched with 2 controls at one teaching hospital in Rome, Italy (Jan 1994–Jun 1995) | Bloodstream infection: isolated pathogen(s) in the blood, plus one or more related symptom, ≥48 hours after admission | Diagnosed in 2% of screened patients | Attributable LOS 19.1–19.8 days (mean), 13–15 days (median) | Attributable €15,413 expenditure per case |
| Pirson40 Methodologic feature score = 9 | Retrospective case control | Matched (ratio unstated) by APR-DRG | Administrative, general services costs, medical charges, LOS, drugs | Hospital cost centers, medical records data and invoicing data (€, 2001) | 46 cases of HAB in one Belgian hospital (2001) | An infection of bacteremia developed ≥ 48 hours after admission | 0.56% incidence | 21.1 additional days | Average attributable costs: €12,853 |
| Pirson41 Methodologic feature score = 12 | Retrospective case control | Matched 1:1 by APR-DRG and severity of illness | Salaries, hotel costs, drugs, ICU, medical and surgical procedures, laboratory, diagnostics | Université Libre de Bruxelles costing database (€, 2003) | 326 cases in 2003 and 277 cases in 2004; 3 Belgian hospitals (2003 and 2004) | Cases were defined as bacteremia that developed ≥ 48 hours after admission | Incidence of HAB: 1.4% and 1.2% in 2003 and 2004 | Attributable LOS: 6.1 days (ICU); 30 days (non-ICU) | Mean additional cost of HAB was €16,709 |
| Kilgore42 Methodologic feature score = 12 | Retrospective cohort | Regression analysis | “Fixed and variable costs of care” | Hospital accounting database (US$, 2006) | 1,355,647 admissions during 69 months from 55 hospital databases (Mar 2001– Jan 2006) | Nosocomial BSIs, nonduplicate isolate collected ≥ 3 days after admission | Nosocomial BSIs identified in 0.93% of admissions | Not available | Incremental costs: US$19,427 |
| Elward43 Methodologic feature score = 15 | Prospective cohort | Multiple linear regression analysis | Direct medical costs of pediatric ICU and hospital-stay | Hospital accounting database (US$, 1999/2000) | 911 admissions, including 56 case patients under age 18 in one US PICU (Sep 1, 1999–May 31, 2000) | Bloodstream infections in PICU patients, recognized pathogen isolated from blood > 48 hours postadmission | Rate of BSI: 13.8 per 1000 central venous catheter days | Not available | Attributable PICU direct costs: US$39,219 |
| Payne44 Methodologic feature score = 15 | Retrospective cohort | Multiple regression | Charges converted to costs | Hospital charges (converted to costs), Centers for Medicare and Medicaid Services (US$, 1999) | 2809 VLBW infants in 17 NICUs, 553 with nosocomial BSI (1998–1999) | BSI after 3rd postnatal day, with symptoms of infection and 5+ days antibiotic treatment after diagnosis | Nosocomial BSI: 19.7% | The mean additional LOS of VLBW infants with BSI was 32.5 days | The mean attributable cost was US$54,539 |
| Chu45 Methodologic feature score = 16 | Prospective case series | Not stated | All infection-related diagnostic tests and surgical procedures, inpatient and outpatient costs | Hospital accounting system (US$, 2002) | 298 patients with a prosthetic implant and S. aureus bacteremia (nosocomial acquired) (Sep 1994–Sep 2002) | Positive blood culture for S. aureus bacteremia, ≥72 hours postadmission, in a patient with ≥1 prosthetic implant | Not available | Mean 33 additional days | Attributable cost per case: US$67,439 |
| Nosocomial sepsis | |||||||||
| Adrie46 Methodologic feature score = 20 | Retrospective analytic cohort of prospective database | Model, multiple linear regression | Direct ICU and medical costs, unit costs of ICU resources, overheads and other fixed costs | Prospective database, microcosting (€, 2001. 1€ = 1 US$) | Of 1698 patients hospitalized for more than 48 hours in 6 ICUs, 340 had sepsis. (Apr 1997–Dec 2000) | Severe sepsis: infection, ≥2 criteria for systemic inflammatory response syndrome and ≥1 criterion for organ dysfunction | 20.0% | Not available | US$27,510 |
| Brun-Buisson47 Methodologic feature score = 15 | Prospective cohort with retrospective measurement of costs | Costing model (Chaix et al, 1999) | All resources used and direct costs (of fluids, drugs, blood products and procedures) | Hospital accounting database and previously built costing model created in this ICU (€, 2001) | 424 patients in one Paris, France ICU (1997–1998) | Patients with sepsis, clinically or microbiologically documented, ≥48 hours after admission | ICU-acquired sepsis: 23% | 19 additional days compared to patients with no sepsis | Nosocomial cases incurred average total costs were €39,908 higher than patients with no sepsis |
| Nosocomial rotavirus infection | |||||||||
| Festini48 Methodologic feature score = 14 | Prospective cohort | Unclear | LOS, estimated cost of hospital day based on DRG, lost productivity of patients’ parents | Hospital accounting databases, wage data provided by Italian Central Bank (€, year unclear) | 608 children under 30 months of age in four Italian hospitals (2006–2008) | Hospital-acquired, positive rapid rotavirus testing | Incidence of nRVI was 5.3% | 1.7 attributable days | National burden of nosocomial rotavirus in Italy, based on attributable LOS, is estimated at €8,019,155 |
| Fruhwirth49 Methodologic feature score = 13 | Prospective case series | Unclear | Direct medical costs, direct nonmedical eg, food, indirect costs eg, productivity loss | Hospital database, microcosting (€, 1997/1998) | 33 cases of nosocomial rotavirus infection in children < 48 months, in Austria (Dec 1997– May 1998) | Rotavirus-positive diarrhea, nosocomial if onset was >48 hours after admission | Risk for contracting nRVI was 2.59 per 1000 hospital days during peak rotovirus season (Dec–May), <48 months of age | Not available | Case cost average €2442 |
| Piednoir50 Methodologic feature score = 15 | Prospective cohort with nested case control | Matched 1:1 by primary diagnoses, date of admission ± 7 days, age ± 3 months, sex, pre-infection LOS | All expenses sustained by the hospital: medical, preventative, staff costs and fixed costs | Medical records and hospital accounting database (€, 2001/2002) | 23 cases matched 1:1, in one French pediatric hospital (Dec 1, 2001– Mar 31, 2002) | Rotavirus-positive stool via qualitative enzyme-linked immunosorbent assay (ELISA) ≥48 hours postadmission | Attack rate: 6.6% Incidence: 15.8 per 1000 hospital days | 4.9 additional days | Mean attributable cost due to nosocomial rotavirus infection: €1930 |
| Nosocomial urinary tract infections | |||||||||
| Chen22 Methodologic feature score = 15 |
Retrospective analysis of a prospectively assembled cohort | Generalized linear modeling | Medical and surgical procedures, medications, lab investigation, ICU bed-days | Hospital database, microcosting (US$, 2007, converted from Taiwanese dollars) | 401 NIs in 320 of 2,757 patients, in 4 ICUs in one hospital in Taiwan (2003–2004) | BSI, UTI, SSI, respiratory tract infection “and others” diagnosed ≥ 48 hours after admission to ICU | 14.5 NI episodes per 100 admissions | Not available | US$10,015 attributable cost per case |
| Defez31 Methodologic feature score = 15 | Retrospective case control | Matched 1:1 by age, sex, ward, LOS before infection, DRG, and McCabe index | Lab tests, radiology, surgery, antimicrobial agents, rate per day of hospital bed | Reimbursement from La Nomeclature Générale des Actes Professionnels and hospital pharmacy accounting database (€, 2004) | 1703 infected patients from previous study; 30 randomly chosen for each infection site, total 150. One French hospital. (2001–2003) |
Patients with single-site nosocomial infection | Not available | Not available | Attributable cost (mean €) by site of infection UTI: €574 Surgical site: €1814 Respiratory tract: €2421 Bloodstream: €953 Other: €1259 |
| Tambyah51 Methodologic feature score = 15 | Prospective cohort data analyzed retrospectively | Patient records reviewed by investigators | Laboratory costs, LOS, medications | Hospital charges were converted to costs via cost-to-charge ratio (US$, 1998) | 1497 catheterized patients in one US university hospital, of which 223 had UTI (1997–1998) | Nosocomial UTI, defined as new bacteriuria or funguria exceeding 103 CsFU/mL | 14.9% of catheterized patients | Not available | Average attributable treatment cost: US$589 |
| Morse52 Methodologic feature score = 9 | Retrospective cohort | Unclear | Only “overall costs” of hospital stay after operation; not detailed further | Hospital case costing system (US$, year unstated) | 118 bowel surgery patients aged 65 to 79, and 33 aged > 80, with Medicare in one hospital; total of 64 patients experience a “never event” (Jan 2008–Mar 2009) | “Never events:” hospital-acquired complications that are not reimbursed by Medicare | 42.4% of study patients experienced a “never event” | Not available | Catheter-related UTI: US$14,300 extra costs; vascular catheter infection: US$16,400 extra costs |
| Nosocomial pneumonia | |||||||||
| Rosenthal53 Methodologic feature score = 13 | Prospective with nested case control | Matched 1:1 by ICU type, hospital and year of admittance, sex, age, and severity of illness score | Fixed cost per bed-day, defined daily antibiotic doses, LOS | Hospital finance department (Argentinian pesos [$], year unclear) | 307 case patients (pneumonia), 307 control patients in 3 hospitals over 5 years (1998–2002) | Nosocomial pneumonia according to definition from the CDC | 5.79% developed nosocomial pneumonia | Mean 8.95 additional days | Mean attributable cost for cases was ARS$2255 |
| Penel35 Methodologic feature score = 15 | Prospective cohort with a post hoc analysis | Unclear | LOS. Estimation of per diem cost, including rooming, lab, medications and procedure costs | Macro costing: LOS multiplied by estimation of per diem cost (€, 2005) | 261 head/neck cancer surgery patients in one hospital SSI: 94 PP: 34 SSI and PP: 13 (Jan 1997–Dec 1999) |
Based on the CDC 1992; SSI, PP | SSI: 36% PP: 13% SSI and PP: 5% |
SSI: 16 days in additional mean LOS PP: 17 days SSI and PP: 31 days |
SSI: €16,000 increase in mean direct medical costs PP: €17,000 Both SSI and PP: €35,000 |
| Dietrich54,b Methodologic feature score = 14 | Prospective case control | Matched 1:1 based on severity of disease, age, primary ward, status of ventilation, immunosuppression, sex, LOS | All resources consumed for diagnosis, treatment, nursing and hospital stay, including materials and personnel | Hospital accounting database (DM, 1998/1999) | 48 cases and 66 controls (resulting in 29 matched pairs) in one German teaching hospital, 5 ICUs (May 1998– Mar 1999) | Nosocomial pneumonia, diagnosed according to the criteria of the CDC | Not available | 5.00 additional ventilation days, 6.55 additional days in ICU and 7.40 additional days in hospital | Attributable cost per case: DM 14,606 from the hospital perspective |
| Dietrich54,b Methodologic feature score = 14 | Retrospective case control | Matched 1:1 based on severity of disease, age, primary ward, status of ventilation, immunosuppression, sex, LOS | All resources consumed for diagnosis, treatment, nursing and hospital stay, including materials and personnel | Hospital accounting database (DM, 1998/1999) | 37 matched pairs in one German teaching hospital, admitted to one of 2 neurosurgical wards (Feb 1997–Dec 1998) | Nosocomial pneumonia, diagnosed according to the criteria of the CDC | Not available | 5.00 additional ventilation days, 14.03 additional days in ICU and 10.14 additional days in hospital excess days | Attributable cost per case: DM 29,610 from hospital perspective |
| Brilli55 Methodologic feature score = 15 | Retrospective case control | Matched by primary and underlying diagnoses, ventilation days. When possible: surgical procedure, PRISM score, age, sex | Hotel costs, surgical, medical and laboratory procedures, supplies, blood products, radiology, other professional fees | Microcosting from hospital accounting database (US$, year unspecified) | 13 case patients matched to control patients 1:1 in one pediatric ICU (FY 2005–FY 2007) | Pediatric ICU patients with VAP | 7.8 cases per 1000 ventilator days in FY 2005 | 8.7 attributable days | Attributable VAP costs per patient: US$51,157. |
| Nosocomial respiratory tract infection | |||||||||
| Defez31 Methodologic feature score = 15 | Retrospective case control | Matched 1:1 by age, sex, ward, LOS before infection, DRG, and McCabe index | Lab tests, radiology, surgery, antimicrobial agents, rate per day of hospital bed | Reimbursement from La Nomeclature Générale des Actes Professionnels and hospital pharmacy accounting database (€, 2004) | 1703 infected patients from previous study; 30 randomly chosen for each infection site, total 150. One French hospital. (2001–2003) | Patients with single-site nosocomial infection | Not available | Not available | Attributable cost (mean €) by site of infection, UTI: €574 Surgical site: €1814 Respiratory tract: €2421 Bloodstream: €953 Other: €1259 |
| Chen22 Methodologic feature score = 15 | Retrospective analysis of a prospectively assembled cohort | Generalized linear modeling | Medical and surgical procedures, medications, lab investigation, ICU bed-days | Hospital database, microcosting (US$, 2007, converted from Taiwanese dollars) | 401 NIs in 320 of 2757 patients, in 4 ICUs in one hospital in Taiwan (2003–2004) | BSI, UTI, SSI, respiratory tract infection “and others” diagnosed ≥ 48 hours after admission to ICU | 14.5 NI episodes per 100 admissions | Not available | US$10,015 attributable cost per case |
| McCartney56 Methodologic feature score = 15 | Case control | Matched 1:1 by age, principal discharge diagnosis, same RSV season, number of secondary diagnoses | Direct medical costs | Hospital accounting database (US$, 1996) | All patients admitted to one Philadelphia pediatric hospital over 8 RSV seasons (1988–1996) | Nosocomial RSV infection | 88 nosocomial RSV cases out of 90,174 patients | Attributable LOS for nosocomial RSV was 7.8 days | Mean attributable cost to hospital per RSV NI was US$9419/case |
| Miscellaneous nosocomial infections | |||||||||
| Bou57 Methodologic feature score = 13 | Retrospective case series | Multiple linear regression analysis | ICU hospital costs only: treatments and diagnostic procedures | Hospital finance department, microcosting (€, year unspecified) | 67 ICU patients during a P. aeruginosa outbreak at one ICU in Spain (Jul– Sep 2003) | Any patient who developed the infection after ≥48 hours mechanical ventilation | Incidence of outbreak associated with pseudomonas infection; 17/67 | 38 additional days | €18,408 average extra ICU costs per case patient |
| Fretz58 Methodologic feature score = 16 | Retrospective case series | Unclear | Revenue loss, nursing, diagnostic procedures, pharmacy, costs of creating an isolation ward | Hospital department-specific costs (€, year unspecified) | 90 infected patients and staff of an Austrian hospital during a norovirus outbreak (Dec 2006– Feb 2007) | Positive stool specimen for norovirus ≥ 48 hours following admission | Not applicable | Not available | The total cost of the outbreak for the Department of Internal Medicine was €80,138 |
| Zingg59 Methodologic feature score = 17 | Retrospective case control | Matched 1:2 by age, sex, LOS, underlying disease category | Direct impact on hospital resources: loss of revenue, additional microbiological diagnosis | Hospital database, microcosting (US$, 2002) | 16 case patients and 32 control patients during a norovirus outbreak (2001 and 2002) | A person who developed acute diarrhea, nausea and vomiting during the norovirus outbreak | Attack rate 13.9% among patients and 29.5% among health care workers | Not available | US$2452 per case (derived from US$40,675 total direct outbreak costs ÷ 16 case patients) |
| Anil60 Methodologic feature score = 12 | Retrospective case control | Matched 1:1 based on birth weight ± 10%, sex, gestational age ± 2 weeks, ventilation, anti-microbial therapy, use of CVC/TPN | Charges per patient and actual financial burden of outbreak; not detailed further | Hospital discharge abstracts via the hospital’s central finance service (US$, assumed 2005) | 22 cases in one Turkish NICU, drug-resistant S. typhimurium outbreak (Mar 15–29, 2005) | Positive stool/rectal swab or fluid culture for S. typhimurium | Attack rate 30.5% | 9.8 additional days | US$1081.84 more charges per case compared to control |
| Baggett61 Methodologic feature score = 18 | Retrospective case series | Interviews with hospital staff and review of contact tracing logs | Direct costs: personnel time, laboratory and medication costs; Indirect: hospital staff furloughs | Hospital database, microcosting (US$, 2004) | Two hospitals experiencing a nosocomial pertussis outbreak (Jul 25– Sep 15, 2004) | A cough illness lasting ≥ 14 days with symptoms of whooping cough and/or isolation of B. pertussis or confirmed by PCR or culture | Incidence was 10/1475 persons exposed | Not available | Attributable cost per nosocomial case, Hospital A: US$43,893 Hospital B: US$30,282 |
| Spearing62 Methodologic feature score = 15 | Retrospective cohort | Unclear | Direct costs including medical costs, outbreak investigation, lost productivity costs, and misc | Medical records data and Medicare costs (AU$, 1996) | 52 cases in a 600-bed tertiary care complex during an outbreak of Salmonella (Dec 1996) | Not detailed; cases of Salmonella during the outbreak | Not available | Not available | AU$2308 (US$1827) per case (total outbreak cost AU$120,000 or US$95,000 ÷ 52 cases) |
| Wilson63 Methodologic feature score = 13 | Retrospective with nested case control | Matched 1:1 to controls with ≥20% total body surface burns | Hospital charges converted to costs | Hospital finance department; unclear costing methods (US$, 2001) | 34 burn patients (Jan–Dec 2004) | Hospital-acquired nosocomial MDRAB infection | 16% of 217 burn patients acquired MDRAB infection | 11 additional days | Mean additional cost: US$98,575 |
| Watters64 Methodologic feature score = 13 | Retrospective cohort | Unclear | Antibiotics, high dependency unit and intensive therapy unit facility use, prolonged LOS | Unspecified, presumably hospital accounting/finance database (GBP, year unstated) | 55 patients who had undergone head and neck surgery in one Irish hospital (over 1 year; year unspecified) | Positive MRSA screening in postoperative period after head and neck surgery | 25 patients (45%) became MRSA positive in the postoperative period | Difference in mean LOS: 45 days | Attributable cost: £6485 Mean extra antibiotic cost: £1700 |
| Mauldin65 Methodologic feature score = 17 | Retrospective case series | Segmented regression analysis for interrupted time series, univariate and multivariate | LOS, ICU LOS, drug costs, lab and medical procedures, adjusted hospital charges | Hospital database (US$, 2005) | 187 patients with MRSA, 19 patients with VRE infections in one US hospital (2000–2005) | Patients diagnosed with either VRE or MRSA | Not available | Not available | Total mean costs, MRSA patients: US$110,493 VRE patients: US$115,260 |
| Vonberg66 Methodologic feature score = 13 | Prospective with nested case control | Matched 1:3 by DRG in 2006, pre-infection LOS, Charlson comorbidity index | “General charge for each day of care,” and “some patient costs” (unclear) | Hospital finance department (€, year unstated) | 45 CDAD cases, 1:3 case: control in one German tertiary care hospital (Jan–Dec 2006) | Positive EIA or culture for CDAD, nosocomial if onset is ≥72 hours after admission | 10%–16% of patients are carriers of C. difficule, at risk for CDAD; incidence of CDAD not available | Median 7 additional days | Median incremental cost: €7147/CDAD case |
| Puzniak67 Methodologic feature score = 20 | Case control | Matched 1:1 by DRG, APACHE II score, age | Patient’s total hospitalization costs, microbiology costs, health care staff time, LOS, and MICU LOS | Hospital database, step-down cost allocation system (US$, year unstated) | Patients admitted ≥ 24 hours to a US MICU (Jul 1, 1997–Dec 31, 1999) | Positive screening for VRE | Not available | 4 attributable MICU days 8.3 attributable hospital days | MICU: US$7873 attributable Hospital: US$11,989 attributable |
| Fuller68 Methodologic feature score = 14 | Retrospective cohort | Linear regression model | Charges converted to costs | Health Services and Cost Review Commission, Maryland; Office of Statewide Planning and Development, California (US$, 2008) | Of 2,496,212 admissions about 139,788 had a complication 54,971 had multiple complications (Maryland: FY2008; California: FY2006) | Any negative event or outcome that results from the process of inpatient care | 4.0%–5.6% of patients had 1 hospital-acquired potentially preventable complication; Another 1.6%–2.2% had multiple complications | Not available | Maryland: US$626,416,710 (9.63% of total claims) associated with potentially preventable complications |
| Nosocomial venous thromboembolism | |||||||||
| Caprini69 Methodologic feature score = 18 | Decision analysis (Markov) | Univariate analysis | Patient care protocols, health care staff time, diagnostic tests, supplies, hospitalizations, procedures | Literature data (US$, year unstated) | Two hypothetical cohorts similar to all US patients undergoing total hip replacement surgery in the US (1995–1996) | DVT | Unclear | Unclear | Annual per-patient cost of DVT: US$3798 |
| MacDougall70 Methodologic feature score = 16 | Retrospective observational cohort study | Linear model with log-link function and gamma distribution | Treatment strategy, length of hospital stay, physician office, emergency room, outpatient claims, ancillary services, pharmacy utilization | Actual health care plan payments for services only | 16,063 DVT alone, 7889 PE alone, 3006 DVT and PE (Jan 1, 1997–Mar 31, 2004) | DVT and PE | Unclear | Mean LOS DVT = 10 days, PE = 9 days, DVT and PE = 10 days |
Annual direct medical costs of US$16,832 ($24,411 CAN) for DVT, US$18,221 ($26,426 CAN) for PE, US$24,874 ($36,074 CAN) for combined DVT and PE, and US$4726 ($6854 CAN) |
| Nosocomial related falls | |||||||||
| Nadkarni71 Methodologic feature score = 12 | Case series | Unclear | Operation procedures, nonoperative treatment, LOS | Southport and Ormskirk Hospital Risk Management Department; Hospital Finance Department (GBP, year unspecified) | 42 cases, of Southport and Ormskirk Hospital Risk Management Department incident forms (Jan 2000–Dec 2002) | Orthopedic injuries sustained by in-patients falling on the hospital wards | Not available | Mean 4.1, median 3 additional weeks | £1667 per case (total £70,000/42 cases) |
| Oliver72 Methodologic feature score = 13 | Case series | N/A | Legal payments | NHS Litigation Authority Database of clinical negligence claims (GBP, year unspecified) | 479 clinical negligence claims resulting from in-hospital falls in England (1995–2006) | Any closed clinical negligence claim resulting from in-hospital falls within the time period | Not applicable | Not applicable | 60.5% of claims resulted in payment of costs or damages, with mean payment £12,945/claim |
| Nurmi73 Methodologic feature score = 13 | Prospective cohort | Unclear | Emergency room visits, outpatient visits, LOS, radiology | Hospital accounting database (€, 1999) | 554 falls occurred among 218 patients treated in four institutions in Finland during study period (Feb 1, 1993–Jan 31, 1994) | Falls among ambulatory patients over 60 years within the study period | 1398 falls per 1000 person years. 30% of falls resulted in injury | Not available | Average cost per treating a fall: €944 |
Notes:
a
61 studies in total, of which three reported outcomes for more than one type of infection, therefore the total listed in Table 2 is 68;
b
Dietrich, 2002 is one paper detailing two different studies. The studies were separated in this table for clarity;
*
only gives incidence of PTS, PEs given post-surgical DVT.
Abbreviations: ADE, adverse drug event; AE, adverse event; APACHE, Acute Physiology and Chronic Health Evaluation; APR, all patient refined; ARS, Argentine peso; AU, Australian; BSI, blood stream infection; CABG, coronary artery bypass graft; CDAD, Clostridium difficile-associated disease; CDC, Centers for Disease Control and Prevention; CVC/TPN, central venous catheter/total parenteral nurtition; DM, Deutsche Mark; DRG, disease-related group; DVT, deep vein thrombosis; EM, endometriosis; FY, financial year; GBP, Great Britain Pound; HAB, hospital-acquired bacteremia; HAC, hospital-acquired complication; HAI, hospital-acquired infection; ICU, intensive care unit; JP, Japanese; LOS, length of stay; MICU, medical intensive care unit; MDRAB, multidrug-resistant Acinetobacter bowmanii; MRSA, methicillin-resistant Staphylococcus aureus; NHS, National Health Service; NI, nosocomial infection; NICU, neonatal ICU; NIM, Nosocomial Infection Marker; NNIS, National Nosocomial Infections Surveillance; nRVI, nosocomial rotovirus infection; NZ, New Zealand; PE, pulmonary embolism; PICU, perinatal ICU; PP, postoperative pneumonia; PTS, postthrombotic syndrome; RSV, respiratory syntactical virus; SCI, spinal cord injury; SSI, surgical site infection; SSTI, skin soft tissue infection; TSI, Transition Systems Incorporated; UTI, urinary tract infection; VAP, ventilator-associated pneumonia; VLBW, very low birth weight; VRE, vancomycin-resistant Enterococcus.