Researchers: Shmuel Benenson¹, Phillip Levin², Matan J Cohen³, Carmella Schwartz¹, Michael Raveh¹

Background: According to US data, acquired infection is associated with increased health care costs reaching tens of thousands of dollars per case. The Israeli medical system is significantly different from the US system, and to date, no assessment has been made of health-care costs associated with infections acquired in Israeli hospitals.

Objectives: To assess the attributable-costs of acquired infections in an Israeli hospital.

Method: We performed a prospective cohort study with matched controls. Patients were identified with either (a) Central Line Associated Blood Stream Infections (CLABSI), (b) Surgical Site Infections (SSI), or (c) Clostridium difficile infection (CDI). Three control patients were matched to each case according to age, sex, illness severity and department or type of surgery. Hospital costs were measured in terms of equipment used, procedures, drugs given, and tests performed, while hospital reimbursement was calculated on a fee per day basis for CLABSI and CDI, and a per procedure fee (DRG) for SSI. Costs per admission day for the hospital were compared for patients vs. controls for CLABSI and CDI, while absolute attributable costs were compared for SSI. Secondary outcome measures included length of hospital admission, proportion of patients discharged to long term care facilities (LTCF), total extra costs per case to the insurer and mortality.

Findings: The attributable direct cost (min, max) associated with infection were respectively: CLABSI: NIS 15743 (7387, 21976; p<0.001), CDI: NIS 2441 (-270, 4514; p=0.047) and SSI: NIS 3525 (2700, 4146; P<0.001). The attributable additional length of stay (min, max) was respectively: CLABSI: 20 days (9, 30; p<0.001), CDI: 7.8 (2.2, 12.4; p=0.02), and SSI: 2.8 (1.9, 3.6; p=0.002). Differential costs per day of admission (min, max) were similar for CLABSI and CDI (-460 (-3962, 1738; p=0.6) and 33 (-286, 271; p=0.5)). There was an indirect cost of NIS 96,000 per case of CLABSI due to lower remuneration for extra days in the ICU. Considering SSI (reimbursed per case and not per day) total losses per infection were estimated at NIS 19,374. For the insurer, there was an extra cost for CLABSI and SSI (NIS 52,465 and 41,949 respectively) due to extra admission days and readmissions and for SSI 9,372 due to readmissions. The proportion of patients discharged to LTCF was significantly higher for all case-patients vs controls, while mortality was higher for CLABSI and CDI patients only.

Conclusions: SSI and CLABSI incur additional costs on Israeli hospitals while CDI does not. Insurers spend more on CLABSI and CDI and are protected from most SSI losses though the DRG reimbursement.

Recommendations: Rearrangement of hospital reimbursement and transparent publication of HAIs rates will pressure the hospital to prevent HAIs. Allocating dedicated infection prevention specialists to SSI prevention is a potentially profitable course of action.

Research end date: 11/2017