Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.
Abstract
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, and 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 four-site, observational, clinical study. Extensive sensitivity analyses
were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2%
of nonventilated 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/d. 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 $1,640 per patient, resulting in an incremental cost-effectiveness ratio
of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality
decreased from 7.3 to 7.1% and costs increased by $1,381 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.
Type
Journal articleSubject
cost-benefit analysiscross infection
early diagnosis
ventilator-associated pneumonia
Adult
Aged
Aged, 80 and over
Cost-Benefit Analysis
Critical Illness
Cross Infection
Decision Support Techniques
Early Diagnosis
Female
Humans
Male
Middle Aged
North Carolina
Pneumonia, Ventilator-Associated
Prospective Studies
Quality-Adjusted Life Years
Young Adult
Permalink
https://hdl.handle.net/10161/12538Published Version (Please cite this version)
10.1513/AnnalsATS.201504-205OCPublication Info
Tsalik, Ephraim L; Li, Yanhong; Hudson, Lori L; Chu, Vivian H; Himmel, Tiffany; Limkakeng,
Alex T; ... Reed, Shelby D (2016). Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection
in Critically Ill Patients. Ann Am Thorac Soc, 13(3). pp. 401-413. 10.1513/AnnalsATS.201504-205OC. Retrieved from https://hdl.handle.net/10161/12538.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
Collections
More Info
Show full item recordScholars@Duke
Vivian Hou Chu
Associate Professor
Dr. Chu's clinical research is focused on staphylococci and endocarditis (IE). She
is the director of the International Collaboration on Endocarditis (ICE), a group
of investigators from 78 sites in 32 countries worldwide that is dedicated to further
the understanding of infective endocarditis. The ICE database comprises > 5000
cases of endocarditis and is designed to answer questions that could not be answered
from a single-center study. The current focus of this group is surgica
Vance Garrison Fowler Jr.
Florence McAlister Distinguished Professor of Medicine
Determinants of Outcome in Patients with Staphylococcus aureus Bacteremia Antibacterial
ResistancePathogenesis of Bacterial Infections Tropical medicine/International Health
Geoffrey Steven Ginsburg
Professor of Medicine
Dr. Geoffrey S. Ginsburg's research interests are in the development of novel paradigms
for developing and translating genomic information into medical practice and the integration
of personalized medicine into health care.
Jason Neil Katz
Instructor in the Department of Medicine
Alexander Tan Limkakeng Jr.
Professor of Surgery
My personal research interest is finding new ways to diagnose acute coronary syndrome.
In particular, I am interested in novel biomarkers and precision medicine approaches
to this problem. I also have an interest in sepsis and empirical bioethics. As Vice
Chief of Research for the Duke Division of Emergency Medicine, I also work with researchers
from many fields spanning global health, innovation, clinical trials, basic discovery,
and translational research. The
Micah Thomas McClain
Associate Professor of Medicine
Shelby Derene Reed
Professor in Population Health Sciences
Shelby Reed, PhD, RPh is Professor in Population Health Sciences and Medicine at Duke
University and Director of the Preference Evaluation Research (PrefER) Group at the
Duke Clinical Research Institute. She also is core faculty and serves on the executive
committee at the Duke-Margolis Center for Health Policy. Dr. Reed has 20 years of
experience leading multidisciplinary health outcomes research studies. Dr. Reed has
extensive expertise in designing and conducting trial-based and mode
Ephraim Tsalik
Associate Professor of Medicine
My research is focused on understanding the dynamic between host and pathogen so as
to discover and develop host-response markers that can diagnose and predict health
and disease. This new and evolving approach to diagnosing illness has the potential
to significantly impact individual as well as public health considering the rise of
antibiotic resistance.
With any potential infectious disease diagnosis, it is difficult, if not impossible,
to determine at the time of presentation
Karen Elizabeth Welty-Wolf
Professor of Medicine
Dr. Welty-Wolf studies (1) pathophysiology and treatment of acute lung injury and
(2) multiple organ failure and disordered energy metabolism in sepsis. Injury models
include hyperoxic lung injury and ARDS with multiple organ failure due to sepsis.
In addition to evaluating mechanisms of lung injury in sepsis, current studies are
being conducted to evaluate the potential role of monoclinal antibodies to neutrophil
adhesion molecules in the prevention of this injury. Other sepsis work inc
Christopher Wildrick Woods
Professor of Medicine
1. Emerging Infections 2. Global Health 3. Epidemiology of infectious diseases
4. Clinical microbiology and diagnostics 5. Bioterrorism Preparedness 6. Surveillance
for communicable diseases 7. Antimicrobial resistance
Alphabetical list of authors with Scholars@Duke profiles.

Articles written by Duke faculty are made available through the campus open access policy. For more information see: Duke Open Access Policy
Rights for Collection: Scholarly Articles