Surgical site infections are the most frequently occurring HAI, accounting for one-third of the annual cost or about $3.3 billion. But central line-associated bloodstream infections are the most expensive, researchers report.
Hospital leaders can claim some success in preventing healthcare-associated infections in the past few years, but more than 440,000 adult patients still get these serious adverse events annually, at a cost to the healthcare system of between $9.8 billion and $11.4 billion.
"It's critical to get these numbers out there, because they're always much higher than people appreciate," says lead author Eyal Zimlichman, MD, of the Center for Patient Safety Research and Practice at Brigham & Women's Hospital. "Actually, these numbers are staggering."
His report is published in Monday's JAMA Internal Medicine.
Among the five types of infections evaluated, those infecting surgical sites, (SSIs) are the most frequently occurring, accounting for one-third of the cost or about $3.3 billion. The others are: ventilator-associated pneumonia ($3.09 billion), central line-associated bloodstream infections ($1.85 billion), Clostridium difficile infections ($1.5 billion), and catheter-associated urinary tract infections ($27.9 million).
Zimlichman says that surgical site infections are most certainly underreported, because symptoms often appear after the patient is discharged. "We need to have better surveillance of these, with feedback to the hospitals, so they know exactly what their rates are and can work on interventions to decrease these," he says.
By itself, a central line-associated bloodstream infection (CLABSI) is the most expensive healthcare-associated infection, costing $45,814 each and requiring a 10.4-day length of stay, 6.9 of them in the intensive care unit the researchers found. That's much higher than the per infection cost of an SSI, which is about $20,785. But if the CLABSI is from methicillin-resistant staphylococcus aureus, the cost per CLABSI goes up about $13,000 per infection, the report said.
Zimlichman and his colleagues performed a literature search of studies between 1986 and 2013 to estimate the costs of treating these infections, saying that even though experts have proof that they can reduce these infections dramatically, many hospital leaders may not justify a prevention expense because until recently, public policy penalties have been extremely limited.
Under authority of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services stopped paying for extra care required for eight types of hospital-acquired conditions, starting Oct. 1, 2008. But that has resulted in paltry federal savings, estimated at no more than about $20 million a year, because most of these patients are so sick, they receive outlier diagnostic group billing code.
Other incentives in payment policy are looming, Zimlichman acknowledges.
Under the Patient Protection and Affordable Care Act, the value-based purchasing incentive payment will soon include a CLABSI measure in the algorithm, joined in another one or two years by catheter-associated urinary tract infections.
Starting Oct. 1, 2014, a 1% penalty will penalize hospitals with the highest rates of preventable infections, and rates of CAUTI and CLABSI account for 50% of the score.
Another incentive, passed last year, requires state Medicaid programs to each formulate their own policies to deny payment for certain preventable adverse events such as healthcare-associated infections.
For further reductions of healthcare-associated infections, hospitals need greater incentives, such as expanded Medicare penalties, and adding to a list of adverse events won't be reimbursed by all payers including health plans, and a shift from fee-for-service to bundled payments, Zimlichman says.
"Obviously, as we slowly phase out of our fee-for-service approach, we're going to see hospitals investing much more in efforts to battle these complications, and there's no doubt about that. But again, if we're just showing the numbers, and there's no policy change, and no risk to the providers, it's doubtful how much difference this is going to make."
He adds that some progress is happening, although slowly. Some heath plans are adopting policies to refuse reimbursement for avoidable adverse events, such as preventable infections. "The game is starting to change," he says. "We know for example that 75% of infections are preventable," and special initiatives such as Michigan's keystone project have reduced CLABSI to zero.
In an accompanying editorial, journal editor Mitchell Katz, MD, wrote that healthcare administrators need motivation "to invest in the necessary systems to decrease these infections." Such costs might include information technology systems to minor rates following interventions, education of clinicians, time to continually reassess patients' need for catheters, lines, and ventilator support, and effectiveness of measures such as chlorhexidine baths.
"This study will enable hospital administrators to better prioritize their spending by allowing them to compare the costs of interventions with the savings accrued by avoiding infections," Katz wrote.
As expensive and numerous as these infections are, Zimlichman cautions that the research project left out numerous types of infections. For example, the paper is limited to only to five types of infections that occur only in certain types of hospitals paid under Medicare's Inpatient Prospective Payment System. It excludes infections acquired in long-term care, cancer specialty, pediatric, inpatient rehabilitation, psychiatric, critical access hospitals, and most hospitals in the state of Maryland.
The Centers for Disease Control and Prevention has estimated the full roster of costs would be between $20 billion to $40 billion a year, with 1.7 million patients infected annually.
Zimlichman says policy changes should focus on three areas. First, he says, there's a need for more federal financial support for infection surveillance and quality improvement initiatives. Second, Medicare's non-payment policies should include more types of infections.
And third, payers should move more quickly to bundled payment and accountable care organization arrangements so hospitals have more incentive to prevent these costly adverse events.