Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients. Annals of the American Thoracic Society, December 23, 2015. Ephraim L Tsalik, Yanhong Li, Lori L Hudson, Vivian H Chu, Tiffany Himmel, Alex T Limkakeng, Jason N Katz, Seth W Glickman, Micah T McClain, Karen E Welty-Wolf, Vance G Fowler, Geoffrey S Ginsburg, Christopher W Woods, and Shelby D Reed.
Durham VA Medical Center, Emergency Medicine Service, Durham, North Carolina, United States; Duke University Medical Center, Department of Medicine, Durham, North Carolina, United States; Duke University Medical Center, Center for Applied Genomics & Precision Medicine, Durham, North Carolina, United States
Rationale: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. Objectives: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. Methods: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a 4-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of non-ventilated patients develop hospital-acquired infection, and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true positive results and increased by 50% (to 43.1%) among patients with false negative results using a hypothetical biomarker assay. Cost of testing was set at $110/day. Measurements and Main Results: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3% to 11.9% and increased mean costs by $1640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among non-ventilated patients, inpatient mortality decreased from 7.3% to 7.1% and costs increased by $1381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4% and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. Conclusions: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.