Affiliations
- Department of Internal Medicine, University of Michigan, Ann Arbor.
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison.
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison.
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison.
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.
Abstract
Importance: Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile.
Objective: To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles.
Design, setting, and participants: This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature.
Interventions: Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers.
Main outcomes and measures: Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY).
Results: In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively.
Conclusions and relevance: The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.
Figures
Figure 1.. Incremental Cost vs Quality-Adjusted Life-Years (QALYs) and Hospital-Onset Clostridioides difficile Infections Averted for Enhanced Interventions, Compared With Baseline
Figure 2.. Acceptability Curve Based on 5000 Runs of Each Intervention at 21 Willingness-to-Pay Thresholds
