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Original Investigation |

Health Care–Associated Infections:  A Meta-analysis of Costs and Financial Impact on the US Health Care System

Eyal Zimlichman, MD, MSc1,2; Daniel Henderson, MD, MPH1; Orly Tamir, PhD, MSc, MHA1; Calvin Franz, PhD3; Peter Song, BSE1; Cyrus K. Yamin, MD1,4; Carol Keohane, BSN, RN1,5; Charles R. Denham, MD6; David W. Bates, MD, MSc1,7
[+] Author Affiliations
1Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
2Sheba Medical Center, Ramat-Gan, Israel
3Eastern Research Group, Lexington, Massachusetts
4Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
5Controlled Risk Insurance Company, Cambridge, Massachusetts
6Texas Medical Institute of Technology, Austin
7Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2013;173(22):2039-2046. doi:10.1001/jamainternmed.2013.9763.
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Importance  Health care–associated infections (HAIs) account for a large proportion of the harms caused by health care and are associated with high costs. Better evaluation of the costs of these infections could help providers and payers to justify investing in prevention.

Objective  To estimate costs associated with the most significant and targetable HAIs.

Data Sources  For estimation of attributable costs, we conducted a systematic review of the literature using PubMed for the years 1986 through April 2013. For HAI incidence estimates, we used the National Healthcare Safety Network of the Centers for Disease Control and Prevention (CDC).

Study Selection  Studies performed outside the United States were excluded. Inclusion criteria included a robust method of comparison using a matched control group or an appropriate regression strategy, generalizable populations typical of inpatient wards and critical care units, methodologic consistency with CDC definitions, and soundness of handling economic outcomes.

Data Extraction and Synthesis  Three review cycles were completed, with the final iteration carried out from July 2011 to April 2013. Selected publications underwent a secondary review by the research team.

Main Outcomes and Measures  Costs, inflated to 2012 US dollars.

Results  Using Monte Carlo simulation, we generated point estimates and 95% CIs for attributable costs and length of hospital stay. On a per-case basis, central line–associated bloodstream infections were found to be the most costly HAIs at $45 814 (95% CI, $30 919-$65 245), followed by ventilator-associated pneumonia at $40 144 (95% CI, $36 286-$44 220), surgical site infections at $20 785 (95% CI, $18 902-$22 667), Clostridium difficile infection at $11 285 (95% CI, $9118-$13 574), and catheter-associated urinary tract infections at $896 (95% CI, $603-$1189). The total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3-$11.5 billion), with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1%).

Conclusions and Relevance  While quality improvement initiatives have decreased HAI incidence and costs, much more remains to be done. As hospitals realize savings from prevention of these complications under payment reforms, they may be more likely to invest in such strategies.

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Figure.
Search Results for Major Procedure–Associated or Device–Associated Health Care–Associated Infection

The first set of limiting criteria were publication in the last 25 years; study design either randomized clinical trial, clinical trial, or meta-analysis; and English language publication. For complete search strategy and limit strategy, see eTable 1 in the Supplement. CAUTI indicates catheter-associated urinary tract infection; CDI, Clostridium difficile infections; CLABSI, central line–associated bloodstream infections; LOS, length of stay; SSI, surgical site infections; VAP, ventilator-associated pneumonia.

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