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Manoukian S, Stewart S, Dancer SJ, Mason H, Graves N, Robertson C, Leonard A, Kennedy S, Kavanagh K, Parcell B, Reilly J. Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1173-1185. [PMID: 34932169 PMCID: PMC8689289 DOI: 10.1007/s10198-021-01419-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. OBJECTIVE We assess the relative cost-effectiveness of screening programmes compared with no- screening. METHODS A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. RESULTS In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. CONCLUSION The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.
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Affiliation(s)
- Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Sally Stewart
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Stephanie J Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire and School of Applied Sciences, Edinburgh Napier University, Edinburgh, Scotland, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK
| | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | | | - Sharon Kennedy
- Information Services Division, Public Health Scotland, Edinburgh, Scotland, UK
| | - Kim Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | - Benjamin Parcell
- Medical Microbiology, NHS Tayside, Ninewells Hospital and School of Medicine, Dundee, Scotland, UK
| | - Jacqui Reilly
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
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Jamal AJ, Faheem A, Farooqi L, Zhong XZ, Armstrong I, Boyd DA, Borgundvaag E, Coleman BL, Green K, Jayasinghe K, Johnstone J, Katz K, Kohler P, Li AX, Mataseje L, Melano R, Muller MP, Mulvey MR, Nayani S, Patel SN, Paterson A, Poutanen S, Rebbapragada A, Richardson D, Sarabia A, Shafinaz S, Simor AE, Willey BM, Wisely L, McGeer AJ. Household Transmission of Carbapenemase-producing Enterobacterales in Ontario, Canada. Clin Infect Dis 2021; 73:e4607-e4615. [PMID: 32869855 PMCID: PMC8662791 DOI: 10.1093/cid/ciaa1295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/27/2020] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Data on household transmission of carbapenemase-producing Enterobacterales (CPE) remain limited. We studied risk of CPE household co-colonization and transmission in Ontario, Canada. METHODS We enrolled CPE index cases (identified via population-based surveillance from January 2015 to October 2018) and their household contacts. At months 0, 3, 6, 9, and 12, participants provided rectal and groin swabs. Swabs were cultured for CPE until September 2017, when direct polymerase chain reaction (PCR; with culture of specimens if a carbapenemase gene was detected) replaced culture. CPE risk factor data were collected by interview and combined with isolate whole-genome sequencing to determine likelihood of household transmission. Risk factors for household contact colonization were explored using a multivariable logistic regression model with generalized estimating equations. RESULTS Ninety-five households with 177 household contacts participated. Sixteen (9%) household contacts in 16 (17%) households were CPE-colonized. Household transmission was confirmed in 3/177 (2%) cases, probable in 2/177 (1%), possible in 9/177 (5%), and unlikely in 2/177 (1%). Household contacts were more likely to be colonized if they were the index case's spouse (odds ratio [OR], 6.17; 95% confidence interval [CI], 1.05-36.35), if their index case remained CPE-colonized at household enrollment (OR, 7.00; 95% CI, 1.92-25.49), or if they had at least 1 set of specimens processed after direct PCR was introduced (OR, 6.46; 95% CI, 1.52-27.40). CONCLUSIONS Nine percent of household contacts were CPE-colonized; 3% were a result of household transmission. Hospitals may consider admission screening for patients known to have CPE-colonized household contacts.
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Affiliation(s)
- Alainna J Jamal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Amna Faheem
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Lubna Farooqi
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Xi Zoe Zhong
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Irene Armstrong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Communicable Disease Control, Toronto Public Health, Toronto, Ontario, Canada
| | - David A Boyd
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Emily Borgundvaag
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Brenda L Coleman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Karen Green
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | | | - Jennie Johnstone
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Kevin Katz
- Department of Infection Prevention and Control, North York General Hospital, Toronto, Ontario, Canada
| | - Philipp Kohler
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Angel X Li
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Laura Mataseje
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Roberto Melano
- Bacteriology, Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Matthew P Muller
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Infection Prevention and Control, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael R Mulvey
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Sarah Nayani
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Samir N Patel
- Bacteriology, Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Aimee Paterson
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Susan Poutanen
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Anu Rebbapragada
- Scientific Affairs and Market Access, Hologic Inc., Toronto, Ontario, Canada
| | - David Richardson
- Department of Infection Prevention and Control, William Osler Health System, Brampton, Ontario, Canada
| | - Alicia Sarabia
- Department of Infection Prevention and Control, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Shumona Shafinaz
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Andrew E Simor
- Department of Infection Prevention and Control, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Barbara M Willey
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Laura Wisely
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Allison J McGeer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
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Bartsch SM, Wong KF, Mueller LE, Gussin GM, McKinnell JA, Tjoa T, Wedlock PT, He J, Chang J, Gohil SK, Miller LG, Huang SS, Lee BY. Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region. JAMA Netw Open 2021; 4:e2119212. [PMID: 34347060 PMCID: PMC8339938 DOI: 10.1001/jamanetworkopen.2021.19212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement. OBJECTIVE To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California. DESIGN, SETTING, AND PARTICIPANTS An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses. EXPOSURES Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities. MAIN OUTCOMES AND MEASURES MRSA and CRE prevalence and number of new carriers (ie, transmission events). RESULTS Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events). CONCLUSIONS AND RELEVANCE The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.
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Affiliation(s)
- Sarah M. Bartsch
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Kim F. Wong
- Center for Simulation and Modeling, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie E. Mueller
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Gabrielle M. Gussin
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Torrance Memorial Medical Center, Torrance, California
| | - Thomas Tjoa
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Patrick T. Wedlock
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Jiayi He
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Justin Chang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Shruti K. Gohil
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | | | - Susan S. Huang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Bruce Y. Lee
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
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Lee BY, Bartsch SM, Lin MY, Asti L, Welling J, Mueller LE, Leonard J, Brown ST, Doshi K, Kemble SK, Mitgang EA, Weinstein RA, Trick WE, Hayden MK. How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study. Am J Epidemiol 2021; 190:448-458. [PMID: 33145594 DOI: 10.1093/aje/kwaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/14/2022] Open
Abstract
Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%-17.1%, averted 1,090-2,795 new carriers, 273-722 infections and 37-87 deaths over 3 years and saved $30.5-$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.
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