Patient Safety Tip of the Week

January 22, 2008  More on the Cost of Complications


Our August 21, 2007 Tip of the Week “Costly Complications About to Become Costlier” provided estimates of the costs to hospitals of some common potentially preventable complications. And in our November 2007 “What’s New in the Patient Safety World” column we pointed out an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. It gives good recommendations on putting together a multidisciplinary team to get ready for this. There is also a video and podcast available. Now, more than ever, hospitals need to prevent costly complications because they will bear the full burden for most of those excess costs.



Two recent published studies shed some new light on determining the costs of such complications.



The Costs of Nosocomial Infections by Kilgore et al. in the journal Medical Care is the largest study of its kind. Most previous studies on the costs of nosocomial infections have had small sample sizes and used matched controls taken from similar patient populations that did not have nosocomial infections. That is not an ideal methodology because there are a number of potential biases. One of the biggest issues is the confounding variable of length of stay (LOS). In many cases, excess LOS is due to the nosocomial infection. However, in others excess LOS may simply reflect severity of illness and indicate a patient who is also at risk for nosocomial infections. So they attempted to correct for confounding variables, particularly for LOS. They collected data from over a million admissions at 55 hospitals which utilized a common cost-accounting system. So their cost estimates are true cost estimates, not based on charges or reimbursements or other surrogates.



They found that nosocomial infections, on average, led to $12,197 in incremental costs ($7007 in added variable costs) and 5.4 extra days in LOS. When they performed sensitivity analyses using modified regression models to take into effect the confounding of LOS, the increased cost associated with the average nosocomial infection was $4644. They feel that these two numbers represent the likely true upper and lower limits for estimated cost of nosocomial infections. Obviously, the incremental cost depends on the type of nosocomial infection, with infections of the cerebrospinal fluid or respiratory tract being the most expensive ($31,573 and $24,408 respectively) and urinary tract infections the least at $3936. (UTI’s, however are the most frequent nosocomial infection. See our January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections” for recommendations on how to avoid them.)



The Kilgore study is the best we’ve come across in terms of both size and methodology to better get at the real costs of these serious complications or care.



The second paper deals with the cost of some complications in ICU’s. In our November 2007 “What’s New in the Patient Safety World” column we had noted a paper by Kaushal et al showing the average cost per adverse event for patients in the MICU was $3961 and the attributable increase in LOS was 0.77 days. Corresponding numbers for patients in the CCU were $3857 and 1.08 days. That study included adverse events of all types.



Now, a very interesting paper “Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units” by Nuckols et al. found that IV ADE’s resulted in $6647 higher costs and 4.8 day longer stays compared to control patients in academic ICU’s but no significant difference in cost or LOS in nonacademic ICU’s. There was no significant difference in the preventability or severity of the ADE’s between the two settings and patient characteristic differences did not seem to explain this unexpected disparity. Additional length of stay was largely responsible for the excess costs in the academic setting. Though the authors could not exclude factors such as regional or case mix variations, they ascribed most of the difference to the post-event care in the academic setting. They hypothesize that some of the problems with continuity of care and other inefficiencies found in academic settings may have led to the longer lengths of stay. They suspect that some of the post-event care in the nonacademic settings was simply rendered in the outpatient setting but that in the academic setting there were delays in transfer to floors or discharges.



The findings, if replicated in other studies, would have some significant implications, depending upon whether your facility is primarily an academic setting or a nonacademic one.



For an academic setting, the message is two-fold. 26% of the IV ADE’s were considered preventable and the total post-event costs for preventable IV ADE’s was $8413 higher compared to $5856 higher for nonpreventable IV ADE’s. Therefore, a foucs on prevention of IV ADE’s is clearly important. And the medications involved most often were opiods, propofol, benzodiazepines, anticoagulants, and insulin – all medications that should be part of a facility’s quality improvement and patient safety focus on hi-alert medications. Many of the interventions in the literature to prevent ADE’s (CPOE, bar coding, use of a pharmacist as part of the ICU team, standardized order sets, checklists, etc.) may well have a good return on investment in both human and financial terms. Secondly, it highlights the need for academic centers to improve the coordination and continuity of care with those who will be primarily responsible for care after discharge.



For nonacademic facilities, the implications are less clear. They may mean that it will take longer to recover the costs of some of the hi-tech interventions designed to prevent medication errors. However, programs to prevent the avoidable IV ADE’s are still obviously important to reduce patient morbidity and mortality.



It would be interesting to see how the results of the Nuckols et al study might be altered by applying a statistical methodology similar to the one used by Kilgore et al in the nosocomial infection cost analysis. Particularly since LOS accounted for the majority of the excess cost in the Nuckols et al patient population, one might expect to see less of a true difference between the academic and nonacademic ICU experiences.



By the way, the Kaushal study mentioned earlier was done in an academic setting.







Kilgore ML, Ghosh K, Beavers,C M, Wong DY, Hymel PA, Brossette SE. The Costs of Nosocomial Infections. Medical Care 2008; 46(1):101-104;jsessionid=HJbhVYtmn0fvd9DRL7KRvnyhzxRL2RpBynDsvmbYGvFck3GgqhXB!2092430889!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search



Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Cost of adverse events in intensive care units. Critical Care Med 2007; 35: 2479–2483;jsessionid=HTGGGQPGTkTZpWzDpr4TTTHhTRhtVkQnVknJQtLKTYGdyySFJkp2!607026366!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search



Nuckols TK. MD, Paddock S, Bower AG, Rothschild JM, Fairbanks RJ. Carlson B, Panzer RJ, Hilborne LH. Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units. Medical Care 2008; 46(1):17-24;jsessionid=HT5JTMJQ2NT7bRsxxL194GlZKtDd5YlGbFLfgQLsJ2XD95QyHkTt!607026366!181195629!8091!-1











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