Table III.
Summary of articles using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist
| Authors | Chun et al. | Chowers et al. | Bessesen et al. | Hassan et al. | Montecalvo et al. | van rijen et al. | Wassenberg et al. |
|---|---|---|---|---|---|---|---|
| Year of publication | 2016 | 2015 | 2013 | 2007 | 2001 | 2009 | 2011 |
| Country | Republic of South Korea | Israel | USA | UK | USA | The Netherlands | The Netherlands |
| Title | Impact of a hand hygiene campaign in a tertiary hospital in South Korea on the rate of hospital-onset methicillin-resistant Staphylococcus aureus bacteraemia and economic evaluation of the campaign | Cost analysis of an Intervention to prevent methicillin-Resistant Staphylococcus aureus (MRSA) transmission | Comparison of control strategies for methicillin-resistant Staphylococcus aureus | Financial implications of plans to combat methicillin resistant Staphylococcus aureus (MRSA) in an orthopaedic department | Costs and savings associated with infection control measures that reduced transmission of vancomycin-resistant enterococci in an endemic setting | Costs and benefits of the MRSA search and destroy policy in a Dutch hospital | Rapid diagnostic testing (RDT) of methicillin-resistant Staphylococcus aureus carriage at different anatomical sites: costs and benefits of less extensive screening regimens |
| Background and objectives | To assess the effect of a campaign to improve hand hygiene compliance on the incidence of hospital-onset MRSA bacteraemia (MRSAB) and to analyse its economic benefit | Our objective was to assess the cost implications of a vertical MRSA prevention program that led to a reduction in MRSA bacteraemia | We compared results of slightly different MRSA control bundles at 2 geographically similar Department of Veteran Affairs (VA) hospitals with comparable workload, case mix, staffing, and parallel surveillance methods for MRSA colonization to determine whether the use of cover gowns is an essential component of the MRSA control bundle | The aim of this study was to calculate retrospectively the cost of MRSA infections in the elective and trauma orthopaedic population in Rotherham District General Hospital in a 3-month period during 2005 | To determine the costs and savings of a 15-component infection control program that reduced transmission of vancomycin-resistant enterococci (VRE) in an endemic setting | The objective of this study was to determine the costs and benefits of the MRSA Search and Destroy policy in a Dutch hospital during 2001 through 2006 | To determine costs and effects of different MRSA screening regimes using RDT, by varying the number of body sites tested and whether or not conventional back-up cultures were included |
| Target population and subgroups | 372 episodes of MRSA and 470 episodes of MRSA were detected. MRSA was classified into community onset MRSA (n = 225) and hospital onset MRSA (n = 245) | Seventy-three patients were admitted with the infection and 53 developed bacteraemia during hospitalization. In the latter group, i.e. cases with hospital-acquired MRSA bacteraemia, 101 patients were matched as controls | Hospital A, N = 159 Hospital B, N = 145 The patient population was 95% male, and the mean age was 64 years at hospital A. At hospital B, the population was 95% male, and the mean age was 65 years |
686 consecutive patients, admitted to two adult orthopaedic wards were screened for MRSA on admission over a period of 3 months in 2005 in our district general hospital. Ten (10) were infected | Cost based on 520 admissions to the study unit. | During the study period, on average, 38 943 patients were admitted annually to this hospital, with 282 585 patient days per year (mean numbers for the period 2001 through 2006) | Among 1764 patients at risk, MRSA prevalence was 3.3% (N = 59) |
| Setting and location | Seoul National University Bundang Hospital | Meir Medical Center is an academic hospital with 742 beds and approximately 60,000 admissions per year; single hospital in Israel | Two Department of Veterans Affairs tertiary care medical centres. Hospital A has 137 acute care beds; hospital B has 121 acute care beds | Rotherham General Hospital NHS Trust | Adult oncology unit of a 650-bed hospital | Amphia hospital, a teaching hospital with 1370 beds | Study was performed in 14 Dutch hospitals (five university hospitals, nine teaching hospitals) between December 2005 and June 2008 |
| Study perspective | Patient and caregivers | Hospital | Hospital | Hospital | Hospital | Hospital | Hospital |
| Intervention | Hand hygiene campaign | Intervention to prevent MRSA transmission (screening with nasal swab, contact isolation, gloves, gowns, eradication treatment and nasal mupirocin and chlorhexidine body wash) | Control strategies for MRSA | Screening elective cases of MRSA | MRSA screening and confirmation | Different MRSA screening regimes using rapid diagnostic testing (RDT) | |
| Comparators | Pre- (January 2008 to September 2010) and post- (October 2010 to December 2014) campaign | Matched case–control cohort prospective study | Two bundles of measures for contact precautions: contact precautions of CDC and contact precautions use of only gloves | The isolation with ‘nares only’ screening using chromogenic agar, IDI and GeneXpert, respectively, compared with when all body sites had been screened | |||
| Design | We collected retrospective data from the microbiologic laboratory database on patients who had MRSAB | A single-centre, matched, historical cohort study and cost analysis | Prospective study | To calculate retrospectively the cost of MRSA infections | Historical control data | The data of all patients and healthcare workers that were found to be carrying MRSA during the years 2001 through 2006 were prospectively recorded in a database | A prospective multicentre study |
| Time horizon | Annual? (2008–2014) | Annual (2005–2011) | ? | ? (3-month period during 2005) | ? Annual | Annual (2001–2006) | Daily (December 2005 to June 2008) |
| Discount rate | |||||||
| Health outcomes | During the pre-intervention period, monthly performance rates varied substantially but reached a plateau of 90% by 2013. On average, 1000 events were monitored monthly. After the start of the hand hygiene campaign, the procurement of hand sanitizers increased from 8.55 L (January 2008) and reached a maximum of 25.82 L (March 2013) per 1000 patient days. During the intervention period, it averaged 15 L per intervention, we would have expected an average value of 6 L. The median value of hand sanitizer procurement was 5.56 L (interquartile range (IQR), 3.03) during the preintervention period and 14.50 L (IQR, 4.44) during the intervention period. According to the Bayesian model, the incidence of hospital-onset MRSAB decreased by 33% compared with the preintervention period (95% CI, −57% to −7.8%). The median value of the MRSAB incidence rate during the preintervention period was 11.59 (IQR, 8.70), and during the intervention period it was 18.64 (IQR, 12.21). Episodes of HO-MRSAB (observed N = 130; Predicted, N = 195 (95% CI) (145–242)) Total reduction, N = 65 (%) (95% CI) (33) (12–112) |
Reduction of 70% of number of MSRA bacteraemia case yearly (assumption, not estimated) | Significant reduction of MRSA (1.58 per 1000 patients days hospital A and 1.56 hospital B) | Reduction of 6 patients out of 9 per year | Application of the Search and Destroy policy resulted in a transmission rate of 0.30 and was estimated to prevent 36 cases of MRSA bacteraemia per year, resulting in annual savings of €427 356 for the hospital and ten lives per year (95% confidence interval [CI] 8–14). | Isolation day avoided | |
| Measurement of effectiveness | Cost–benefit analysis: Benefit–cost ratio (i.e. benefit/cost) =5.08 (95% CI) (0.94–8.76) | Cost-savings analysis of prevention: $199,600 annually | Cost-minimization analysis | Not clearly defined | Costs and savings analysis. Cost based on 520 admissions to the study unit | Estimation of costs and estimation of benefits for the hospital | Cost-effectiveness analysis assuming isolation measures would have been based on RDT results of different hypothetical screening regimes |
| Estimating resources and costs | Savings because of HO-MRSAB prevention = $851,565 Maintenance costs of the hand hygiene campaign: total hand sanitizer costs = $21 294 Campaign costs = $8182 Personnel costs = $138,019 Total costs =$167,495 |
Prevention costs: microbiology tests, single-use equipment, infection control personnel time: $208 100 per year. Cost/patient mean (SD): (bloodstream infection (BSI) on admission N = 73) M = 14,300 (SD=12,488) $US; (Hospital-acquired BSI N = 53) M = 14,900 (SD=14,137) $US; (Control N = 101) M = 5600 (SD = 10,476) $US; P (hospital acquired vs control) = <0.001 Cost/patient surviving >72 h after BSI mean (SD): (BSI on admission N = 73) M = 16,600 (SD = 12; 136) $US; (Hospital-acquired BSI N = 53) M = 18,500 (SD = 13,615) $US; (Control N = 101) M = 5600 (SD =10,476) $US; P (hospital acquired vs control) <0.001 |
Hospital A cover gown consumption averaged $16,965 per month, whereas average monthly cover gown usage at hospital B was $2385. Average gown cost per package of 10 was $9.02 giving an estimated annual cost of $183,609 at hospital A and $25,812 at hospital B | Cohort nursing; non-selective screening of all admissions to the orthopaedic wards; use of a polymerase chain reaction (PCR) assay as a diagnostic tool; ring-fencing of beds; and separate wound dressing rooms for each ward. The total cost was projected to be £301,000. The cost of the PCR rapid MRSA detection device plus staffing for a year with culture media for the trauma cases will cost £149,000. The cost of screening elective cases is estimated at £12,000. The total cost for the first year would be £301,000; in subsequent years the cost would be £261,000 as the PCR assay will already have been purchased. This should be compared with the annual cost of MRSA infections (£384,000). | The cost of enhanced infection control strategies for 1 year was $116,515. VRE BSI was associated with an increased length of stay of 13.7 days. The savings associated with fewer VRE BSIs ($123,081), fewer patients with VRE colonization ($2755), and reductions in antimicrobial use ($179,997) totaled $305,833. Estimated ranges of costs and savings for enhanced infection control strategies were $97,939–148,883 for costs and $271,531–421,461 for savings. Year cost to the hospital for VRE enhanced infection control strategies (based on 520 admissions to the study unit) Patient–nurse cohorts = nurse assistant (N = 3): cost per item = $22,734/year; total cost = $68,202 Patient–nurse cohorts: cost per Item = $16.28/h; total cost = $704 Gowns: cost per Item = $52.50/100; total cost = $15,276 Gloves: cost per Item = $3.85/100; total cost = $3864 Surveillance cultures: personnel (microbiologist): cost per item = $18.00/h; total cost = $14,040 Surveillance cultures: personnel (nurse): cost per Item = $25.00/h; total cost = $6500 Surveillance cultures: supplies (perianal, new VRE+ (N = 41)): cost per item = $14.97; total cost = $614 Surveillance cultures: supplies (perianal, repeat VRE+ (N = 368)): cost per item = $3.30; total cost = $1214 Surveillance cultures: supplies (perianal, VRE (N = 1231)): cost per item = $1.41; total cost = $1736 Surveillance cultures: supplies (environmental, VRE+ (N =58)): cost per item = $3.30; total cost = $191 Surveillance cultures: supplies (environmental, VRE (N =271)): cost per item = $1.41; total cost = $382 Patient education (nursing time): cost per item = $25.00/h; Total cost = $2167 Antimicrobial control (nurse monitor): cost per item = $25.00/h; total cost = $1625 Total cost = $116,515 One-year actual costs and savings, and the range of estimates for costs and savings of enhanced infection control strategies (1995 $) Cost components: Nurse assistant = $68,202 ($49,725–93,600) Microbiologist = $14,040 ($14,040–19,188) Gowns = $15,276 ($15,276–21,994) Gloves = $3864 ($3765–4116) Surveillance cultures supplies = $4137 ($4137) Admitting personnel time = $704 ($704) Nurse for surveillance cultures patient education and antimicrobial control = $10,292 ($10,292) Total cost = $116,515 ($97,939–148,883) Savings components: Fewer patients with VRE BSI = $123,081 ($118,587–143,247) Gown and gloves = $2755 ($2742–3760) Reduction in antimicrobial use = $130,600 ($93,393–216,104) Administration of antimicrobials = $49,397 ($49,397) Total savings = $313,525 ($271,531–421,461) |
MRSA Search and Destroy policy in a Dutch hospital during 2001 through 2006. Variable costs included costs for isolation, contact tracing, treatment of carriers and closure of wards. Fixed costs were the costs for the building of isolation rooms and the salary of one full-time infection control practitioner. To determine the benefits of the Search and Destroy policy, the transmission rate during the study period was calculated. Furthermore, the number of cases of (MRSA) bacteraemia prevented was estimated, as well as its associated prevented costs and patient lives. The costs of the MRSA policy were estimated to be €215,559 a year, which equals €5.54 per admission. The daily isolation costs for MRSA-suspected and -positive hospitalized patients were €95.59 and €436.62, respectively. Application of the Search and Destroy policy resulted in a transmission rate of 0.30 and was estimated to prevent 36 cases of MRSA bacteraemia per year, resulting in annual savings of €427,356 for the hospital and 10 lives per year (95% CI 8–14) |
Costs per isolation day avoided were calculated for regimes with single or less extensive multiple site RDT regimes without conventional back-up cultures and when PCR would have been performed with pooling of swabs. In all scenarios the negative predictive value was above 98.4%. With back-up cultures of all sites as a reference, the costs per isolation day avoided were €15.19, €30.83 and €45.37 with ‘nares only’ screening using chromogenic agar, IDI and GeneXpert, respectively, as compared with €19.95, €95.77 and €125.43 per isolation day avoided when all body sites had been screened |
| Currency | US dollars | US dollars | US dollars | Pound (£) | US dollars | Euro (€) | Euro (€) |
| Price date | 2015 | From 2005 through 2011? | ? | 2005 | 1995 Dollars | ? 2001–2006 total costs (€) | ? 2005 and June 2008 |
| Choice of model | Bayesian Model | ||||||
| Assumptions | Reduction of 70% of number of MSRA bacteraemia cases yearly (assumptions by author) | ||||||
| Analytic methods | |||||||
| Study parameters | |||||||
| Incremental costs and outcomes | Savings due to HO-MRSAB prevention = $851,565 Maintenance costs of the hand hygiene campaign Total hand sanitizer costs = $21,294 Campaign costs =$8182 Personnel costs =$138,019 Total costs =$167,495 |
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| Characterizing uncertainty | |||||||
| Characterizing heterogeneity | |||||||
| Sensitivity analysis | Bayesian Model and Confidence Interval | Decrease in MRSA bacteraemia cases of 54% and 15% in the percentage of time dedicated to the programme by the ICP team, the total cost of prevention increased from $202 300 to $214 000 | |||||
| Study findings | “Procurement of hand sanitizers increased 134% after the intervention (95% CI 120–149%), compared with the pre intervention period (January 2008–September 2010). In the same manner, hand hygiene compliance improved from 33.2% in September 2010 to 92.2% after the intervention. The incidence of HO MRSAB per 100,000 patient days decreased 33% (95% CI, −57% to −7.8%) after the intervention. Because there was a calculated reduction of 65 HO MRSAB cases during the intervention period, the benefit outweighed the cost (total benefit [$851 565]/total cost [$167,495] = 5.08)” | “A vertical MRSA prevention program targeted at high-risk patients, which was highly effective in preventing bacteraemia, 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.” | “Significant reductions in MRSA HAIs were associated with implementation of the MRSA control bundle. The bundle that included full contact precautions for colonized patients was no more effective in prevention of MRSA transmissions than a similar bundle that omitted the use of cover gowns.” | “The key in the fight against MRSA in the hospital setting is multifactorial and requires a combination of measures. Our solution is: cohort nursing; non-selective screening of all admissions to the orthopaedic wards; use of a PCR as a diagnostic tool; ring-fencing of beds; and separate wound-dressing rooms for each ward. The total cost is projected to be £301,000.” | “The net saving due to enhanced infection control strategies for 1 year was $189,318. Estimates suggest that these strategies would be cost-beneficial for hospital units where the number of patients with VRE BSI is at least six to nine patients per year or if the savings from fewer VRE BSI patients in combination with decreased antimicrobial use equalled $100,000–150,000 per year.” | “The costs of the MRSA policy were estimated to be €215,559 a year, which equals €5.54 per admission. The daily isolation costs for MRSA suspected and positive hospitalized patients were €95.59 and €436.62, respectively. Application of the Search and Destroy policy resulted in a transmission rate of 0.30 and was estimated to prevent 36 cases of MRSA bacteraemia per year, resulting in annual savings of €427,356 for the hospital and 10 lives per year (95% CI 8–14).” | “With back-up cultures of all sites as a reference, the costs per isolation day avoided were €15.19, €30.83 and €45.37 with ‘nares only’ screening using chromogenic agar, IDI and GeneXpert, respectively, as compared with €19.95, €95.77 and €125.43 per isolation day avoided when all body sites had been screened. Without back-up cultures costs per isolation day avoided using chromogenic agar screening added to multiple site conventional cultures is the most cost-effective MRSA screening strategy.” |
| Journal title | American Journal of Infection control | PLOS One | American Journal of Infection control | Annals of the Royal College of Surgeons of England | Infection Control and Hospital Epidemiology | European Journal of Clinical Microbiology & Infectious Diseases | Clinical Microbiology and Infection |
(?) = not defined clearly.
IPC: Nosocomial infections Prevention and Control.