Pre-protocol Periods Research Articles

Abstract T P14: In-Hospital Cost Analysis of the Addition of Hyperacute MRI for Selection of Patients for Endovascular Stroke Therapy

Background: Patient selection is important for acute endovascular stroke therapy. We previously reported that a hyperacute MRI protocol for patient selection was associated with decreased utilization of endovascular stroke therapy and improved outcomes. A cost analysis comparing the pre and post-MRI protocol periods was performed to determine if the previous findings translated into cost savings. Methods: We retrospectively identified patients considered for endovascular stroke therapy from January 2008 to August 2012 who were ≤8 hours from stroke symptoms onset. Prior to April 30, 2010 selection was based on results of the CT/CTA alone (pre-hyperacute), whereas afterwards selection was based on results of MRI (hyperacute MRI). Demographic, outcomes and financial information was collected. Log-transformed average daily direct costs were regressed on time period. The regression model included demographic and clinical covariates as potential confounders. Multiple imputation was used to account for missing data. Results: We identified 267 patients, 88 in pre-hyperacute MRI and 179 in hyperacute MRI protocol. Length of stay was not significantly different in both groups (10.6 vs. 9.9 days; p< 0.42). The median of average daily direct costs was reduced by 24.5% (95% CI = 14.1% to 33.7%; p<0.001). Decreases in the proportion of cost from imaging (including endovascular intervention) and anesthesia services was seen, whereas increases were seen in the neurological and pharmacy charges (Figure). Conclusions: Use of the hyperacute MRI protocol translated into reduced costs, in addition to reduced utilization of the invasive therapy and better outcomes. MRI selection of patients is an effective strategy, both for patient and hospital systems.

Economical impact associated with a biological therapy prioritization protocol in patients with rheumatoid arthritis in the Hospital of Sagunto

Background: Until 2010 the cost of biological treatments in Rheumatoid Arthritis (RA) was increasing annually by 15% in our hospital. In 1st January 2011, a Hospital Commission of Biological Therapies involving rheumatology and pharmacy services was created to improve the management of biological drugs and a biological therapy prioritization protocol in RA patients was also established to improve the efficient usage of biological drugs in RA.Objective: To evaluate the economic impact associated with a biological therapy prioritization protocol for RA patients in the Hospital of Sagunto.Methods: Observational, ambispective study comparing the associated cost of RA patients treated with biological drugs in the pre-protocol (2009 – 2010) versus post-protocol periods (2011 – 2012). RA patients treated with Abatacept (ABA), Adalimumab (ADA), Etanercept (ETN) or Infliximab (IFX) for at least 6 months during the study period (2009 – 2012) were included. In 2012, Tocilizumab (TCZ) was also included in the prioritization protocol. Prioritization protocol was established based on both clinical and economical aspects and supervised case by case by our Commission. Cost savings and economic impact were calculated using Spanish official prices.Results: In the pre-protocol period (2009 – 2010), total expenses were increasing by €110,000, up to €1,761,000 in 2010 (€11,362 pat/year). After protocol implementation, total expenses decreased by 53,676€ on the 2010 – 2011 period, and 149,200€ on the 2011 – 2012 period. On the 2010 – 2011 period the cost of biological therapy per patient-year decreased 355€ (11,007€ pat/year) and additional 653€ (up to 10,354€ pat/year) by 2012, with a cumulative effect of the protocol implementation of 1,008€ per patient-year. In the pre-protocol period (2009), the annual cost/patient was 10.812€ with ETN, 10.942€ with IFX, 12.961€ with ADA and 12.739€ with ABA. By 1st January 2013, the annual cost per patient was 9,469€ with ETN, 10,579€ with IFX, 11,117€ with ADA, 13,540€ with ABA and 14,932€ with TCZ.Conclusions: The creation of our Commission of Biological Therapies is key to rational management of RA patients and optimization of resources, allowing us to save 200,000€ after 2-year efficiency protocol implementation.

Cost Effectiveness of Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) in an Intensive Care Unit at a 200-Bed Community Hospital with Low Prevalence of These Antibiotic-Resistant Organisms

BACKGROUND/OBJECTIVES: Antibiotic-resistant organisms are a common cause of hospital-acquired infections. Infections caused by MRSA and VRE are a source of morbidity and mortality, prolonged hospital stay, and higher costs of care when compared to antibiotic-susceptible strains. The mean attributable cost per MRSA infection was reported to be $35,367 in one meta-analysis. A Society for Healthcare Epidemiology of America (SHEA) guideline recommends screening of high-risk patients for colonization or infection with MRSA and VRE as a means of isolating reservoirs and preventing transmission to others. The cost/benefit of implementing this strategy in a community hospital setting with relatively low prevalence of these epidemiologically significant organisms was uncertain. METHODS: A screening protocol was implemented with the opening of a new 12-bed medical/surgical intensive care unit (M/SICU). Surveillance cultures (MRSA - nares and open chronic wounds if present; VRE - rectal) were collected on admission, every seven days, and on discharge from the unit when length of stay was ≥ to 4 days. Contact Precautions were instituted pending report of negative initial screening cultures. RESULTS: During the protocol period (July 2004-July 2005), one patient acquired a MRSA infection (0.47 patients/1000 patient days). In the one-year period preceding protocol implementation, five patients developed nosocomial infection related to MRSA in the critical care unit (3.3 infections/1000 patient days). Using the pre-protocol rate of infection (3.3 infections/1000 patient days) applied to patient days during the protocol period (2117), an estimated six MRSA infections were averted. No VRE infections were identified during either the pre-protocol or protocol periods. With the mean attributable cost associated with MRSA infection of $35,367, an estimated $212,000 in excess infection-associated cost was averted. The estimated direct cost (material and labor) for conducting the surveillance protocol was $40,000. CONCLUSIONS: Even in the setting of a community hospital with relatively low prevalence of MRSA (34%), implementation of an active surveillance program for MRSA was shown to be a cost-effective strategy, reducing the risk of acquiring MRSA infection and avoiding associated excess cost of care. Although VRE colonization was identified, VRE was not found to be a significant nosocomial pathogen in our institution. The cost associated with VRE screening represented 50% of the protocol cost and was not considered a cost-effective strategy in this setting.

Prevention of Pulmonary Morbidity for Patients With Neuromuscular Disease

To evaluate the effects of a respiratory muscle aid protocol on hospitalization rates for respiratory complications of neuromuscular disease. A retrospective cohort study. A home protocol was developed in which oxyhemoglobin desaturation was prevented or reversed by the use of noninvasive intermittent positive-pressure ventilation and manually and mechanically assisted coughing as needed. The patients who had more than one episode of respiratory failure before having access to the protocol were considered to have had preprotocol periods (group 1). Other patients were given access to the protocol when their assisted peak cough flows decreased to < 270 L/min before any episodes of respiratory distress (group 2). The number of hospitalizations and days hospitalized were compared longitudinally for preprotocol and protocol access periods (group 1). In addition, avoided hospitalizations were identified as "episodes" of need for continuous ventilatory support and desaturations reversed by assisted coughing that were managed at home. Data were segregated by access to protocol and by extent of baseline ventilator use. Of the 47 group 1 patients with preprotocol periods who have subsequently had episodes, 10 had episodes before requiring ongoing ventilator use. They had 1.06 +/- 0.84 preprotocol hospitalizations per year per patient and 20.76 +/- 36.01 hospitalization days per year per patient over 3.42 +/- 3.36 years per patient vs 0.03 +/- 0.11 hospitalizations per year per patient and 0.06 +/- 0.20 hospitalization days per year per patient with protocol use over 1.94 +/- 0.74 years per patient. Of these 47 group 1 patients, 33 eventually required part-time ventilatory aid and, using the protocol as needed, had 0.08 +/- 0.17 hospitalizations per year per patient and 1.43 +/- 3.71 hospitalization days per year per patient over 3.91 +/- 3.50 years per patient, as opposed to 1.40 +/- 1.96 hospitalizations per year per patient and 20.14 +/- 41.15 hospitalization days per year per patient preprotocol and preventilator use over 5.89 +/- 6.89 years per patient. Twelve patients in group 1 eventually required continuous noninvasive ventilation and, using the protocol as needed, had 0.07 +/- 0.14 hospitalizations per year per patient and 0.39 +/- 0.73 hospitalization days per year per patient over 5.35 +/- 5.10 years per patient by comparison with 0.97 +/- 0.74 hospitalizations per year per patient and 10.39 +/- 8.66 hospitalization days per year per patient over 2.18 +/- 1.91 years per patient preprotocol and preventilator use. For the 94 patients overall when having access to the protocol, 1.02 +/- 0.99 hospitalizations per year per patient were avoided by 14 patients before requiring ongoing ventilator use over 4.82 +/- 1.61 years, 0.99 +/- 1.12 hospitalizations per year per patient were avoided by 73 part-time ventilator users over 3.21 +/- 3.15 years, and 0.80 +/- 0.85 hospitalizations per year per patient were avoided by 31 full-time ventilator users over 4.78 +/- 4.88 years. All preprotocol and protocol rate comparisons were statistically significant at p < 0.004. Patients have significantly fewer hospitalizations per year and days per year when using the protocol as needed than without the protocol. The use of inspiratory and expiratory aids can significantly decrease hospitalization rates for respiratory complications of neuromuscular disease.

Cost-effectiveness impact of iron dextran on hemodialysis patients' use of epoetin alfa and blood.

The cost-effectiveness impact of iron dextran administration on the use of epoetin alfa and blood in hemodialysis patients was studied. Subjects were ambulatory hemodialysis patients who had been receiving hemodialysis for at least six months before the start of an iron dextran protocol and who had been given epoetin alfa for at least four of those six months. Clinical data were collected for six months before and six months after the protocol was implemented. Successful treatment was defined as a hematocrit of 33-36%, a transferrin saturation of >10%, a ferritin concentration of >100 ng/mL, and no blood use except for acute blood loss. A total of 33 patients completed the study. Fifty units of blood were used in the first six months and nine units in the second six months. There was significant improvement in mean hematocrit, ferritin, and transferrin saturation values after the protocol began. Average epoetin alfa doses did not change significantly. There was significant improvement in success rates for ferritin and blood use and in the overall success rate. Ten patients met all success criteria in the preprotocol period, versus 27 in the postprotocol period. Monthly cost-effectiveness analysis for the preprotocol and postprotocol periods indicated costs of $1350 and $526, per successful treatment, respectively. The incremental cost-effectiveness of iron dextran was $42 per successful treatment. Iron dextran improved iron indices and reduced the need for blood transfusions but did not reduce the average dose of epoetin alfa. The additional cost of therapy per month seemed justified by the clinical benefits.