NUR 8250 Module 3 Cost-Effectiveness Paper: Universal Decolonization, QALY Thresholds and the Second Panel's Rules Example

One Infection Prevented per 54 Patients: A Cost-Benefit Analysis of Universal Decolonization in Four ICUs at a Neptune Hospital

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8250: Health Economics and Finance

Mentor Name

Month Day, Year

One Infection Prevented per 54 Patients: A Cost-Benefit Analysis of Universal Decolonization in Four ICUs at a Neptune Hospital

The Decision

The setting is fictional: the hospital is a 520-bed regional hospital in Neptune with four adult intensive care units and about 6,800 ICU admissions a year. Its ICUs currently screen patients for MRSA and isolate carriers. Last year the units had 41 bloodstream infections, 14 of them central line infections. The infection prevention committee asks whether to switch to universal decolonization: daily chlorhexidine bathing and nasal mupirocin for every ICU patient, without screening. The pharmacy and supply costs worry the finance office. The DNP-prepared director of quality is asked to analyze the decision.

The committee's question has a history. Two years ago the hospital tried chlorhexidine bathing on one unit without nasal mupirocin and without training, and compliance fell below half within months. Nurses reported that the cloths were cold, patients disliked them and night shifts skipped baths when busy. The finance office remembers paying for supplies that went unused. Any new proposal must therefore show not only that the intervention works in trials but that the hospital can deliver it, which affects the effect size the analysis assumes.

The Clinical Evidence

Huang et al. (2013) conducted a cluster-randomized trial in 43 hospitals with 74 ICUs and 74,256 patients during the intervention period. Hospitals were randomized to one of three strategies: screen and isolate, decolonize only the MRSA carriers found, or universal decolonization of every patient without screening. Universal decolonization produced the largest reductions: MRSA clinical isolates fell with a hazard ratio of 0.63, and bloodstream infections from any organism fell with a hazard ratio of 0.56, dropping to 3.6 per 1,000 patient-days from a baseline of 6.1. Decolonizing 54 patients averted one bloodstream infection, and the effect was significantly greater than with screening or targeted approaches.

The Methods

Sanders et al. (2016) set out what the Second Panel, the expert group that updated cost-effectiveness standards for U.S. health and medicine, recommended. They recommended that every cost-effectiveness analysis report two reference cases, one taking the view of the health care sector and the other the view of society, and use an impact inventory, a structured table that lists consequences both inside and outside health care, letting readers check what each viewpoint counts. They emphasized transparency about assumptions and analysis of uncertainty.

Neumann et al. (2014) asked why a $50,000 line for each quality-adjusted life year has lasted for decades as a benchmark for good value, though it has no firm empirical basis and has not been adjusted for inflation. They argued that a line at $100,000, or even $150,000, for each QALY better reflects current values and that a range is more honest than a single number.

The Analysis

The primary analysis takes the hospital's perspective, since the hospital bears the cost, and reports it as a cost-benefit analysis in dollars. A health care sector perspective adds costs to payers, and an impact inventory lists societal effects, such as lost work, that are not quantified.

Each input is sourced. Supply costs come from the hospital's purchasing contracts for chlorhexidine cloths and mupirocin. Nursing time is measured by timing ten baths on two units and comparing them with current basin bathing; the difference is small, about four minutes per patient per day. The cost of a bloodstream infection to the hospital, about $40,000, comes from its own finance department's analysis of added days and services for infected patients over two years, and the paper labels it an internal estimate.

Costs of universal decolonization include chlorhexidine cloths, mupirocin, nursing time for bathing beyond current care and staff education. Savings include avoided MRSA screening tests and isolation supplies, and avoided bloodstream infections. Using the trial's number needed to treat, the hospital's 6,800 ICU admissions would prevent about 126 infections if the full effect were achieved; the analysis uses a more conservative 40 percent of that effect, about 50 infections, because the hospital's baseline infection rate is lower than in the trial.

The net result is a saving of about $1.8 million a year, which makes the decision dominant: better outcomes at lower cost, so no QALY threshold is needed. The paper still estimates QALYs from published mortality and quality-of-life effects of bloodstream infection to show that, even if savings were much smaller, the intervention would remain well under a threshold of $50,000 per QALY.

Testing the Assumptions

One-way sensitivity analysis varies each input. If the cost of an infection is $20,000 rather than $40,000, savings fall but remain. If only 15 infections are prevented, the program costs about $212,000 more than it saves but still costs well under $50,000 per QALY gained. If chlorhexidine resistance rises, the benefit may shrink over time, so the plan includes monitoring. Mupirocin resistance is tracked through laboratory sampling.

A break-even analysis makes the result easier for the committee to grasp. Dividing the program's net annual cost before infection savings, about $212,000, by the hospital's cost per infection gives roughly five or six infections that must be prevented each year for the program to pay for itself. Since the hospital had 41 bloodstream infections last year, preventing even one in seven would cover the cost, a figure the committee can weigh against the trial's much larger effect.

Recommendation and Measures

The paper recommends adopting universal decolonization in all four ICUs, with monthly measures of bloodstream infections, MRSA clinical isolates, chlorhexidine bathing compliance, skin reactions and mupirocin and chlorhexidine resistance. The finance office will compare actual supply costs and infection counts with the projections after one year.

Conclusion

A large cluster-randomized trial showed that decolonizing every ICU patient prevents more bloodstream infections than screening and isolation. Following reference case standards, the analysis finds that universal decolonization would likely save this hospital money while improving outcomes, a dominant choice, and sensitivity analysis shows it would remain good value even under pessimistic assumptions. The decision is recommended with monitoring for resistance and a one-year check of costs and results.

References

Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T. R., Lankiewicz, J., Gombosev, A., Terpstra, L., Hartford, F., Hayden, M. K., Jernigan, J. A., Weinstein, R. A., Fraser, V. J., Haffenreffer, K., Cui, E., Kaganov, R. E., Lolans, K., Perlin, J. B., & Platt, R. (2013). Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine, 368(24), 2255-2265. https://doi.org/10.1056/NEJMoa1207290

Neumann, P. J., Cohen, J. T., & Weinstein, M. C. (2014). Updating cost-effectiveness: The curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine, 371(9), 796-797. https://doi.org/10.1056/NEJMp1405158

Sanders, G. D., Neumann, P. J., Basu, A., Brock, D. W., Feeny, D., Krahn, M., Kuntz, K. M., Meltzer, D. O., Owens, D. K., Prosser, L. A., Salomon, J. A., Sculpher, M. J., Trikalinos, T. A., Russell, L. B., Siegel, J. E., & Ganiats, T. G. (2016). Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA, 316(10), 1093-1103. https://doi.org/10.1001/jama.2016.12195