Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Ni escmid-esgni-kayseri 2015
1. Prof. Dr. Ata Nevzat Yalçın, MDProf. Dr. Ata Nevzat Yalçın, MD
Akdeniz University, Medicine FacultyAkdeniz University, Medicine Faculty
Dept. Infectious Dis. and Clinical MicrobiologyDept. Infectious Dis. and Clinical Microbiology
Antalya-TURKEYAntalya-TURKEY
Economical analysis of
nosocomial infections:
How can we do it?
2. 2
• NosocomialNosocomial infections (infections (NNI) represent anI) represent an
important public health problem in developingimportant public health problem in developing
countries as in developed ones today as acountries as in developed ones today as a
major cause of high morbidity, mortality andmajor cause of high morbidity, mortality and
economic consequences in hospitalizedeconomic consequences in hospitalized
patients.patients.
Nosocomial infectionsNosocomial infections
Jarvis WR.Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-71996;17: 552-7
3. 3
Importance of NosocomialImportance of Nosocomial
infectionsinfections
The burden of Nosocomial infectionsThe burden of Nosocomial infections ((NIs) isNIs) is
substantial in developed countries, where it affectssubstantial in developed countries, where it affects
from 5% to 15% of hospitalized patients in regularfrom 5% to 15% of hospitalized patients in regular
wards, and as many as 50% or more of patients inwards, and as many as 50% or more of patients in
intensive care units (ICUs).intensive care units (ICUs).
The incidence of NIs is between 25% and 40% inThe incidence of NIs is between 25% and 40% in
developing countries.developing countries.
NIsNIs increase length of stay in hospital.increase length of stay in hospital.
NIsNIs increase costs.increase costs.
NIsNIs increase mortality.increase mortality.
4. 4
Points of This TalkPoints of This Talk
Incidence of NI and costIncidence of NI and cost
Pharmacoeconomical analysisPharmacoeconomical analysis
Excess costExcess cost
Excess cost in NIExcess cost in NI
Cost of antibioticsCost of antibiotics
Extra length of stayExtra length of stay
Extra mortalityExtra mortality
6. 6
Excess Cost of NosocomialExcess Cost of Nosocomial
InfectionsInfections
NorwayNorway → →→ → 132 Million Dollars132 Million Dollars
ScotlandScotland → →→ → 168 Million Pounds168 Million Pounds
EnglandEngland → →→ → 1,7 Billion Dollars1,7 Billion Dollars
FranceFrance → →→ → 3-5 Billion Franks3-5 Billion Franks
USAUSA → →→ → 37-45 Billion Dollars37-45 Billion Dollars
EUEU → →→ → 7 Billion Euros7 Billion Euros
TurkeyTurkey → →→ → 1-1,5 Billion Dollars ???1-1,5 Billion Dollars ???
Andersen BM, et al.Andersen BM, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1998;19: 805-71998;19: 805-7
Astagneau P, et al.Astagneau P, et al. J Hosp InfectJ Hosp Infect 1999; 42 : 303-121999; 42 : 303-12
Plowman R, et al.Plowman R, et al. J Hosp InfectJ Hosp Infect 2001;47: 198-2072001;47: 198-207
Graves N.Graves N. Emerg Infect DisEmerg Infect Dis 2004;10: 561-62004;10: 561-6
ECDC Annual Report 2008: 16-38ECDC Annual Report 2008: 16-38
Dickema DJ, et al.Dickema DJ, et al. JAMAJAMA 2008;299:1190-22008;299:1190-2
Hassan M, et al.Hassan M, et al. Hospital TopicsHospital Topics 2010;88:82-92010;88:82-9
Zimlichman E, et al.Zimlichman E, et al. JAMAJAMA Intern MedIntern Med 20132013
Marchetti A. et al.Marchetti A. et al. J Med EconomicsJ Med Economics 2013:1-62013:1-6
Magill SS, et al.Magill SS, et al. NEJMNEJM,2014;370:1198-1208,2014;370:1198-1208
7. Zimlichman E, et al.Zimlichman E, et al. JAMA Intern MedJAMA Intern Med 2013; 173:2039-462013; 173:2039-46
8. 8
• Pneumonias → → 35,967Pneumonias → → 35,967
• Bloodstream inf. → → 30,655Bloodstream inf. → → 30,655
• Urinary tract inf. → → 8,225Urinary tract inf. → → 8,225
• Surgical site inf. → →13,088Surgical site inf. → →13,088
• Others → →12,085Others → →12,085
• TOTAL → →100,000TOTAL → →100,000
Nosocomial Infections andNosocomial Infections and
mortalitymortality
(US Department of Health and Human Services (DHHS-2009)(US Department of Health and Human Services (DHHS-2009)
Stone PW.Stone PW. Expert Rev Pharmacoecon Outcomes ResExpert Rev Pharmacoecon Outcomes Res 2009;9:417-222009;9:417-22
9. 9
Calculating costsCalculating costs
(Methodological subjects-1)(Methodological subjects-1)
Study designStudy design
Patient group (incidence,prevalence,epidemics)Patient group (incidence,prevalence,epidemics)
Location (hospital, follow-up after discharge)Location (hospital, follow-up after discharge)
Dimension of the study (hospital, country,Dimension of the study (hospital, country,
developing countries, pathogens, interventions)developing countries, pathogens, interventions)
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4
10. 10
Calculating costsCalculating costs
(Methodological subjects-2)(Methodological subjects-2)
Extra cost and design of length of stayExtra cost and design of length of stay
Costs (hospital charges, deaths, antibioticsCosts (hospital charges, deaths, antibiotics
utilisation, antibiotic resistance, environmentalutilisation, antibiotic resistance, environmental
damage)damage)
Conclusion statistics (mean, median, percent, total)Conclusion statistics (mean, median, percent, total)
Design of analysisDesign of analysis
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4
11. 11
Costs
1. Well described costs associated with
nosocomial infections
2. Poorly described costs associated with
nosocomial infections
12. 12
Well described costsWell described costs
associated with NIassociated with NI
Drug (antibiotics) acquisitionDrug (antibiotics) acquisition
Increased hospital stayIncreased hospital stay
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4
13. 13
Poorly described costs associatedPoorly described costs associated
with NIwith NI
Control measures (isolation facilities,Control measures (isolation facilities,
commitees, policies)commitees, policies)
Impaired hospital activity (ward closing, etc.)Impaired hospital activity (ward closing, etc.)
Confidence, performance of staffConfidence, performance of staff
LitigationLitigation
Effects on communityEffects on community
MorbidityMorbidity
MortalityMortality
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4
14. 14
Excess costs of NIExcess costs of NI
(Adults)-(US Dollars)(Adults)-(US Dollars)
Study Year Country Cost ($$))
Westwood JCN 1974 USA 1,650
Haley RW 1980 USA 1,018
Coello R 1993 England 1,759
Diaz Molina C 1993 Spain 1,909
Yalcin AN 1997 Turkey 1,582
Orrett FA 1998 Trinidad 1,910
Andersen BM 1998 Norway 2,200
Chen YY 2003 Taiwan 3,306
Roberts 2010 USA 1,581-6,824
15. 15
Excess costs of NIExcess costs of NI
(Pediatrics)-(US Dollars)(Pediatrics)-(US Dollars)
Study Year Country Cost ($$))
Leroyer A 1997 France 10,440
Navarette D 1999 Mexico 11,682
Mahieu LM 2001 Belgium 12,399
Yalcin AN.Yalcin AN. Indian J Med SciIndian J Med Sci 2003;57:450-62003;57:450-6
16. 16
Studies on excess costs inStudies on excess costs in
nosocomial infectionsnosocomial infections
Surgical site infectionsSurgical site infections
Bloodstream infectionsBloodstream infections
Catheter-related bloodstream infectionsCatheter-related bloodstream infections
PneumoniasPneumonias
Ventilator-associated pneumoniasVentilator-associated pneumonias
17. 17
Surgical site infections
Songklanagarind Hospital, Chiang Mai University,
Thailand,1998-2003
140 matched pairs of case and control
Procedures:Appendectomy, herniorrhaphy,
mastectomy, cholecystectomy, colostomy and
craniotomy
Mean extra hospital charge………43,658 Baht
(95 % C.l;30,228-57,088 Baht ) (p(p<< 0.001)0.001)
Mean excess postoperative stay…..21,3 days
(95 % C.l;16,6-26,0 days) (p(p<< 0.001)0.001)
Kasatpibal N, et al.Kasatpibal N, et al. J Med Assoc ThaiJ Med Assoc Thai 2005;88:1083-912005;88:1083-91
18. Surgical site infections (1)
Plymouth, England, April 2010-March
2012,
282 operations
Additional length of stay….10 days (7-13
days)
Extra cost…5 239 Pounds (4622-6719)
Total cost…..2 491 424 Pounds
Jenks PR, et al.Jenks PR, et al. J Hosp InfectJ Hosp Infect 2014;86:24-332014;86:24-33
19. Jenks PR, et al.Jenks PR, et al. J Hosp InfectJ Hosp Infect 2014;86:24-332014;86:24-33
Surgical site infections
20. 20
Nosocomial bloodstreamNosocomial bloodstream
infections (ICU)infections (ICU)
Dr BL Kapur Memorial Hospital, New Delhi, India, 2006
24 patients and 48 controls
Excess hospitalization: 11,6 daysExcess hospitalization: 11,6 days (p(p<< 0.0001)0.0001)
Mortality : 54 %Mortality : 54 % (p(p<< 0.0001)0.0001)
Excess cost:Excess cost: $$14,818 (10,663 -18,974), (14,818 (10,663 -18,974), (pp<< 0.0001)0.0001)
Kothari A, et al.Kothari A, et al. J Hosp InfectJ Hosp Infect 2009;71:143-82009;71:143-8
21. Nosocomial bloodstreamNosocomial bloodstream
infections in elderlyinfections in elderly
Cases (n:830) Controls
(n:830)
Mortality 49.4 % 33.2 %
(p(p<< 0.001)0.001)
Excess length
of stay
29.2 days 20.2 days
(p(p<< 0.001)0.001)
Cost $ 102.276 $ 69.690 (p(p<< 0.001)0.001)
Kaye KS, et al. J Am Geriatr Soc 2014 ; 62 : 306-11
22. 22
Central catheter-relatedCentral catheter-related
bloodstream infectionsbloodstream infections
Six ICU, Buenos Aires, Argentina, 1997-2002Six ICU, Buenos Aires, Argentina, 1997-2002
142 patients, 142 controls142 patients, 142 controls
Excess hospitalization: 11,9 daysExcess hospitalization: 11,9 days
Excess mortality: 24,6 %Excess mortality: 24,6 %
Excess cost:Excess cost: $$4,8884,888
Excess antibiotics cost:Excess antibiotics cost: $$1,9131,913
Rosenthal VD, et al.Rosenthal VD, et al. Am J Infect ControlAm J Infect Control 2003;31:475-802003;31:475-80
23. 23
Central venous catheter-associatedCentral venous catheter-associated
bloodstream infections (ICU)bloodstream infections (ICU) General Hospital, Specialties Intituto Mexicano delGeneral Hospital, Specialties Intituto Mexicano del
Seguro Social Hospital, Gabriel Mancera Hospital,Seguro Social Hospital, Gabriel Mancera Hospital,
Mexico City, Mexico, 2002-3Mexico City, Mexico, 2002-3
55 patients, 55 controls55 patients, 55 controls
Excess hospitalization: 6,1 daysExcess hospitalization: 6,1 days
Excess mortality: 20%Excess mortality: 20%
Excess cost (mean):Excess cost (mean): $$11,59111,591
Excess antibiotics cost (mean):Excess antibiotics cost (mean): $$598598
Higuera F, et al.Higuera F, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2007;28:31-52007;28:31-5
24. 24
Nosocomial pneumoniasNosocomial pneumonias
Six ICU, Buenos Aires, Argentina, 2001-2005Six ICU, Buenos Aires, Argentina, 2001-2005
307 n. pneumonias, 307 controls307 n. pneumonias, 307 controls
Excess cost → $ 2,255Excess cost → $ 2,255
Excess antibiotic cost → $ 996Excess antibiotic cost → $ 996
Extra length of stay → 8,95 daysExtra length of stay → 8,95 days
Extra mortality → 30,3 %Extra mortality → 30,3 %
Rosenthal D, et al. Am JRosenthal D, et al. Am J Infect ControlInfect Control 2005;33:157-612005;33:157-61
32. 32
Costs of NI-USACosts of NI-USA (US(US $$))
Infection type Costs
(Mean)
Range
(Minimum-maximum)
CLA-Bloodstream
infections
$ 45,814 30,919-65,245
Ventilator-
associated
pneumonias
$ 40,144 36,286-44,220
Surgical site
infections
$ 20,785 18,902-22,667
Urinary tract
infections
$ 896 603-1,189
Zimlichman E, et al.Zimlichman E, et al. JAMA Intern MedJAMA Intern Med 2013; 173:2039-462013; 173:2039-46
33. 33
Attributable costs of NI (USAttributable costs of NI (US $$))
Infection type Attributable costs
(Mean)
Range
(Minimum-maximum)
Ventilator-
associated
pneumonias
22,875 9,986-54,503
CLA-Bloodstream
infections
18,432 3,592-34,410
Surgical site
infections
17,944 7,874-26,668
Urinary tract
infections
1,257 804-1,710
Yokoe DS, et al.Yokoe DS, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2008; 29 (Suppl. 1):S3-S112008; 29 (Suppl. 1):S3-S11
34. 34
Costs of Nosocomial infectionsCosts of Nosocomial infections
HAIHAI ControlControl
BedBed 464464 214214
LaboratoryLaboratory 417417 249249
AntibioticsAntibiotics 11901190 5454
OthersOthers 209209 181181
TOTALTOTAL $ 2280 $ 698$ 2280 $ 698
Yalcin AN, et al.Yalcin AN, et al. J ChemotherJ Chemother 1997; 9:411-41997; 9:411-4
(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)
35. 35
Distribution of costs inDistribution of costs in
Nosocomial infectionsNosocomial infections
Yalcin AN, et al.Yalcin AN, et al. J ChemotherJ Chemother 1997; 9: 411- 41997; 9: 411- 4
(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)
36. 36
Distribution of cost (VAP)($)
Costs Costs of VAP
Group ± SD (min-
max)
Costs of Control
Group ± SD (min-
max)
P
value
Bed 1193.7±679.8 (176-3140) 381.0±382.2 (154-3320) <0.0001
Antibiotics 837.1±472.9 (40-2140) 8.5±11.0 (0-40) <0.0001
Drugs and medical
materials
2305.0±1347.6 (330-
8143)
816.7±645.9 (125-4125) <0.0001
Laboratory 1647.0±1004.5 (248-
8068)
546.4±442.4 (34-2335) <0.0001
Radiology 269.9±222.1 (36-1683) 156.8±160.9 (16-806) <0.0001
Operation 628.2±1190.1 (0-7280) 302.4±535.3 (0-2523) <0.05
Intervention 1024.6±973.8 (135-7794) 254.3±271.7 (43-1579) <0.0001
Care 696.7±613.1 (72-3753) 155.4±192.8 (23-1524) <0.0001
Total 8602.7±5045.5 2621.9±2053.3 <0.0001
Karaoğlan H,Yalcin AN, et al.Karaoğlan H,Yalcin AN, et al. Infez MedInfez Med 2010;18:248-552010;18:248-55
(Akdeniz University Hospital, Antalya, Turkey, 2006-7)(Akdeniz University Hospital, Antalya, Turkey, 2006-7)
38. 38
Daily antibiotic cost in nosocomialDaily antibiotic cost in nosocomial
infectionsinfections
Yalçın AN, et al.Yalçın AN, et al. Turk J Hosp InfTurk J Hosp Inf 2002;6:41-52002;6:41-5
(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)
39. 39
Daily antibiotic cost inDaily antibiotic cost in
nosocomial infectionsnosocomial infections
MS-KNSMS-KNS $ 44,9$ 44,9
MSMS-S.aureus-S.aureus $$ 46,746,7
E.coliE.coli $ 48,5$ 48,5
EnterobacterEnterobacter spp.spp. $ 63,8$ 63,8
MR-MR-S.aureusS.aureus $ 80,0$ 80,0
P.aeruginosaP.aeruginosa $ 111,7$ 111,7
Yalçın AN, et al.Yalçın AN, et al. Turk J Hosp InfTurk J Hosp Inf 2002;6: 41-52002;6: 41-5
(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)
40. 40
Daily antibiotic cost in nosocomialDaily antibiotic cost in nosocomial
infectionsinfections
Inan D, et al.Inan D, et al. BMC Infect DisBMC Infect Dis 2005; 5 :1-52005; 5 :1-5
(Akdeniz University Hospital, Antalya, Turkey, 2004)(Akdeniz University Hospital, Antalya, Turkey, 2004)
41. 41
Costs of NIs with gramCosts of NIs with gram
negativenegative non-fermentative rodsnon-fermentative rods
Aşık Z,Yalçın AN et al. (Aşık Z,Yalçın AN et al. (Thesis-2011-Akdeniz UniversityThesis-2011-Akdeniz University))
(Akdeniz University Hospital, Antalya, Turkey, 2011)(Akdeniz University Hospital, Antalya, Turkey, 2011)
42. 42
Excess length of stay inExcess length of stay in
nosocomial infectionsnosocomial infections
Study Year Country LOS (days)
Westwood JCN 1974 USA 22,0
Haley RW 1980 USA 13,4
French GL 1991 Hong Kong 23,4
Yalcin AN 1997 Turkey 20,3
Orrett FA 1998 Trinidad 33,5
Sanou J 1999 Burkina Faso 10,0
Roberts R 2010 USA 5,9-9,6
Askarian M 2003 Iran 6,2
Sanchez-V LD 2006 Mexico 10,0
43. 43
Excess length of stay in nosocomialExcess length of stay in nosocomial
infectionsinfections
Infection type Excess length of stay (days)
Urinary tract infection 1-4
Surgical site infection 7-8,2
Bloodstream infection 7-21
Pneumonias 6,8-30
Jarvis WR.Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-71996;17: 552-7
45. Extra mortality in nosocomialExtra mortality in nosocomial
infections (%)infections (%)
Study Year Country Mortality rate
Spengler RF 1978 USA 32,1
French GL 1991 Hong Kong 7,4
Dinkel RH 1994 USA 4,1
Yalcin AN 1997 Turkey 16,7
Martin M 2001 Spain 21,3
Roberts 2010 USA 6,1
47. Methodological limitations in
studies assessing disease burden
attributable to ARI
Failure to adjust for hospital stay prior to
onset of infection
Failure to adjust for severity of underlying
illness and comorbidities
Failure to adjust for effective antibiotic
therapy
Failure to consider exposure as time-
dependent
Gandra S, et al.Gandra S, et al. Clin Microbiol InfectClin Microbiol Infect 20120144;;2020::973-9973-9
48. Reasons for variability in
outcomes of antibiotic-resistant
infections
Heterogeneity in study population
Inadequate sample size
Type of control group
Causative pathogens
Location of infection site
Definitions of resistance
Follow-up time
Gandra S, et al.Gandra S, et al. Clin Microbiol InfectClin Microbiol Infect 20120144;;2020::973-9973-9
49. 49
Economical analysis studies in NIsEconomical analysis studies in NIs
Use of guidelines for authors and editors onUse of guidelines for authors and editors on
conducting an economic analysis,conducting an economic analysis,
Continued development of more sophisticatedContinued development of more sophisticated
mathematical models,mathematical models,
Training of infection control professionals inTraining of infection control professionals in
economic methods ……economic methods ……
Stone PW, et al.Stone PW, et al. Am J Infect ControlAm J Infect Control 2005; 33:501-92005; 33:501-9