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Raising Standards While Watching the Bottom Line Making a Business Case for Infection Control

  • Eli N. Perencevich (a1) (a2), Patricia W. Stone (a3), Sharon B. Wright (a4), Yehuda Carmeli (a5), David N. Fisman (a6) (a7) and Sara E. Cosgrove (a8)...

While society would benefit from a reduced incidence of nosocomial infections, there is currently no direct reimbursement to hospitals for the purpose of infection control, which forces healthcare institutions to make economic decisions about funding infection control activities. Demonstrating value to administrators is an increasingly important function of the hospital epidemiologist because healthcare executives are faced with many demands and shrinking budgets. Aware of the difficulties that face local infection control programs, the Society for Healthcare Epidemiology of America (SHEA) Board of Directors appointed a task force to draft this evidence-based guideline to assist hospital epidemiologists in justifying and expanding their programs. In Part 1, we describe the basic steps needed to complete a business-case analysis for an individual institution. A case study based on a representative infection control intervention is provided. In Part 2, we review important basic economic concepts and describe approaches that can be used to assess the financial impact of infection prevention, surveillance, and control interventions, as well as the attributable costs of specific healthcare-associated infections. Both parts of the guideline aim to provide the hospital epidemiologist, infection control professional, administrator, and researcher with the tools necessary to complete a thorough business-case analysis and to undertake an outcome study of a nosocomial infection or an infection control intervention.

Corresponding author
Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Associate Hospital Epidemiologist, University of Maryland Medical Center, 100 N. Greene St., Lower Level, Baltimore, MD 21201 (
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1. LP Casalino . Markets and medicine: barriers to creating a “business case for quality.” Perspect Biol Med 2003;46:3851.

2. DM Murphy . From expert data collectors to interventionists: changing the focus for infection control professionals. Am J Infect Control 2002;30:120132.

3. JP Burke . Infection control—a problem for patient safety. New Engl J Med 2003;348:651656.

5. DM Murphy , CI Alvarado , H Fawal . The business of infection control and epidemiology. Am J Infect Control 2002;30:7576.

8. PW Stone , BR Schackman , CP Neukermans , et al. A synthesis of cost-utility analysis literature in infectious disease. Lancet Infect Dis 2005;5:383391.

12. S Leatherman , D Berwick , D Iles , et al. The business case for quality: case studies and an analysis. Health Aff (Millwood) 2003;22:1730.

13. PW Stone , D Braccia , E Larson . Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005;33:501509.

14. EC Mansley , MT McKenna . Importance of perspective in economic analyses of cancer screening decisions. Lancet 2001;358:11691173.

15. JC McGregor , E Weekes , GN Forrest , et al. Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial. J Am Med Inform Assoc 2006;13:378384.

19. ES Dietrich , M Demmler , G Schulgen , et al. Nosocomial pneumonia: a cost-of-illness analysis. Infection 2002;30:6167.

21. DK Warren , SJ Shukla , MA Olsen , et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003;31:13121317.

22. J Rello , DA Ollendorf , G Oster , et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:21152121.

23. N Safdar , C Dezfulian , HR Collard , S Saint . Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:21842193.

24. SI Blot , P Depuydt , L Annemans , et al. Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections. Clin Infect Dis 2005;41:15911598.

25. B Digiovine , C Chenoweth , C Watts , M Higgins . The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 1999;160:976981.

26. J Rello , A Ochagavia , E Sabanes , et al. Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit Care Med 2000;162:10271030.

27. R Coello , A Charlett , J Wilson , V Ward , A Pearson , P Bordello . Adverse impact of surgical site infections in English hospitals. J Hosp Infect 2005;60:93103.

28. D Coskun , J Aytac , A Aydinli , A Bayer . Mortality rate, length of stay and extra cost of sternal surgical site infections following coronary artery bypass grafting in a private medical centre in Turkey. J Hosp Infect 2005;60:176179.

29. CS Hollenbeak , DM Murphy , S Koenig , RS Woodward , WC Dunagan , VJ Fraser . The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000;118:397402.

30. AW Jenney , GA Harrington , PL Russo , DW Spelman . Cost of surgical site infections following coronary artery bypass surgery. ANZ J Surg 2001;71:662664.

32. KK Lai , SA Fontecchio . Use of silver-hydrogel urinary catheters on the incidence of catheter-associated urinary tract infections in hospitalized patients. Am J Infect Control 2002;30:221225.

33. JB Dimick , WB Weeks , RJ Karia , S Das , DA Campbell Jr. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg 2006;202:933937.

35. RR Roberts , PW Frutos , GG Ciavarella , et al. Distribution of variable vs fixed costs of hospital care. JAMA 1999;281:644649.

38. JL Guinan , M McGuckin , A Shubin , J Tighe . A descriptive review of malpractice claims for health care-acquired infections in Philadelphia. Am J Infect Control 2005;33:310312.

40. PK Lindenauer , D Remus , S Roman , et al. Public reporting and pay for performance in hospital quality improvement. New Engl J Med 2007;356:486496.

41. EN Perencevich , DN Fisman , M Lipsitch , AD Harris , JG Morris Jr, DL Smith . Projected benefits of active surveillance for vancomycin-resistant enterococci in intensive care units. Clin Infect Dis 2004;38:11081115.

44. G Zanetti , SJ Goldie , R Piatt . Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis: example of coronary artery bypass surgery. Emerg Infect Dis 2001;7:820827.

46. JP Koplan , R Harpaz . Shingles vaccine: effective and costly or cost-effective? Ann Intern Med 2006;145:386387.

48. CM Bell , DR Urbach , JG Ray , et al. Bias in published cost effectiveness studies: systematic review. BMJ 2006;332:699703.

53. JJ Engemann Y Carmeli , SE Cosgrove , et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592598.

54. KS Kaye , JJ Engemann , E Mozaffari , Y Carmeli . Reference group choice and antibiotic resistance outcomes. Emerg Infect Dis 2004;10:11251128.

55. G Schulgen , A Kropec , I Kappstein , F Daschner , M Schumacher . Estimation of extra hospital stay attributable to nosocomial infections: heterogeneity and timing of events. J Clin Epidemiol 2000;53:409417.

56. WA Knaus , EA Draper , DP Wagner , JE Zimmerman . APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818829.

57. LI Iezzoni . The risks of risk adjustment. JAMA 1997;278:16001607.

58. JM Robins . The control of confounding by intermediate variables. Stat Med 1989;8:679701.

59. EN Perencevich . Excess shock and mortality in Staphylococcus aureus related to methicillin resistance. Clin Infect Dis 2000;31:13111313.

60. MJ Schwaber , Y Carmeli . Antimicrobial resistance and patient outcomes: the hazards of adjustment. Crit Care 2006;10:164.

61. ME Charlson , P Pompei , KL Ales , CR MacKenzie . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373383.

62. M Von Korff , EH Wagner , K Saunders . A chronic disease score from automated pharmacy data. J Clin Epidemiol 1992;45:197203.

64. KS Kaye , K Sands , JG Donahue , KA Chan , P Fishman , R Platt . Preoperative drug dispensing as predictor of surgical site infection. Emerg Infect Dis 2001;7:5765.

65. JC McGregor , PW Kim , EN Perencevich , et al. Utility of the Chronic Disease Score and Charlson Comorbidity Index as comorbidity measures for use in epidemiologic studies of antibiotic-resistant organisms. Am J Epidemiol 2005;161:483493.

66. JC McGregor , EN Perencevich , JP Furuno , et al. Comorbidity risk-adjustment measures were developed and validated for studies of antibiotic-resistant infections. J Clin Epidemiol 2006;59:12661273.

67. EN Perencevich , KE Sands , SE Cosgrove , E Guadagnoli , E Meara , R Piatt . Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003;9:196203.

69. RW Haley . Measuring the costs of nosocomial infections: methods for estimating economic burden on the hospital. Am J Med 1991;91:32S38S.

70. SA Finkler . The distinction between cost and charge. Ann Intern Med 1982;96:102109.

71. P Pronovost , DC Angus . Cost reduction and quality improvement: it takes two to tango. Crit Care Med 2000;28:581583.

72. D Howard , R Cordell , JE McGowan Jr, RM Packard , RD Scott 2nd, SL Solomon . Measuring the economic costs of antimicrobial resistance in hospital settings: summary of the Centers for Disease Control and Prevention-Emory Workshop. Clin Infect Dis 2001;33:15731578.

76. E Larson . State-of-the-science—2004: time for a “no excuses/no tolerance” (NET) strategy. Am J Infect Control 2005;33:548557.

77. DC Classen , RS Evans , SL Pestotnik , SD Horn , RL Menlove , JP Burke . The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New Engl J Med 1992;326:281286.

78. K Benson , AJ Hartz . A comparison of observational studies and randomized, controlled trials. Neyv Engl J Med 2000;342:18781886.

79. J Concato , N Shah , RI Horwitz . Randomized, controlled trials, observational studies, and the hierarchy of research designs. New Engl J Med 2000;342:18871892.

80. SJ Pocock , DR Elbourne . Randomized trials or observational tribulations? New Engl J Med 2000;342:19071909.

81. RJ Hayes , ND Alexander , S Bennett , SN Cousens . Design and analysis issues in cluster-randomized trials of interventions against infectious diseases. Stat Methods Med Res 2000;9:95116.

82. N Klar , A Donner . Current and future challenges in the design and analysis of cluster randomization trials. Stat Med 2001;20:37293740.

84. S Bennett , T Parpia , R Hayes , S Cousens . Methods for the analysis of incidence rates in cluster randomized trials. Int J Epidemiol 2002;31:839846.

85. A Donner , N Klar . Pitfalls of and controversies in cluster randomization trials. Am J Public Health 2004;94:416422.

86. DR Elbourne , MK Campbell . Extending the CONSORT statement to cluster randomized trials: for discussion. Stat Med 2001;20;489496.

88. N Rao , S Jacobs , L Joyce . Cost-effective eradication of an outbreak of methicillin-resistant Staphylococcus aureus in a community teaching hospital. Infect Control Hosp Epidemiol 1988;9:255260.

92. DJ Austin , MJ Bonten , RA Weinstein , S Slaughter , RM Anderson . Vancomycin-resistant enterococci in intensive-care hospital settings: transmission dynamics, persistence, and the impact of infection control programs. Proc Natl Acad Sci USA 1999;96:69086913.

93. CT Bergstrom , M Lo , M Lipsitch . Ecological theory suggests that antimicrobial cycling will not reduce antimicrobial resistance in hospitals. Proc Natl Acad Sci USA 2004;101:1328513290.

94. S Bonhoeffer , M Lipsitch , BR Levin . Evaluating treatment protocols to prevent antibiotic resistance. Proc Natl Acad Sci USA 1997;94:1210612111.

95. MC Bootsma , O Diekmann , MJ Bonten . Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci USA 2006;103:56205625.

96. M Lipsitch , T Cohen , B Cooper , et al. Transmission dynamics and control of severe acute respiratory syndrome. Science 2003;300:19661970.

99. M Hunink , P Glasziou , J Siegel , et al. Decision Making in Health and Medicine. 1st ed. Cambridge, United Kingdom: Cambridge University Press;2001.

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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
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