infection control & hospital epidemiology october 2015, vol. 36, no. 10 concise communication
Cost of Antimicrobial Therapy Across US Children’s Hospitals
Rachael K. Ross, MPH;1 Adam L. Hersh, MD, PhD;2 Matthew P. Kronman, MD, MSCE;3 Jason G. Newland,MD;4 Jeffrey S. Gerber, MD, PhD1,5
We analyzed the cost of antimicrobial prescribing across freestanding children’s hospitals. A few specific antimicrobials accounted for a large proportion of expenditures, and antimicrobial spending varied substantially across hospitals, even within specificclinicalconditions. Antimicrobial stewardship programs should consider these data to incor- porate high-value antimicrobial prescribing when clinically appropriate.
Infect.ControlHosp.Epidemiol. 2015;36(10):1242–1244
Diagnosis Related Groups, version 25, codes.9 To examine variation across hospitals, we chose 2 clinical conditions, pneumonia and appendectomy, that (1) have previously been identified as stewardship targets,4 (2) had high antimicrobial use in both cost and DOT, and (3) do not vary greatly in clinical presentation across hospitals. Antimicrobial use was summarized by the proportion of
Medications account for more than 10% of healthcare spending, and antimicrobials are consistently among the medication classes with the most expenditures in US hospitals.1,2 Both the volume and choice of antimicrobials used, however, vary substantially across centers.3,4 Antimicrobial stewardship programs (ASPs) are patient
safety and quality improvement initiatives shown to reduce antimicrobial overuse while improving clinical outcomes.5-7 Although the primary target of ASPs should be improving patient outcomes, secondary measures include the impact on healthcare costs. Recent studies have estimated antimicrobial expenditures in hospitalized patients but have not compared antimicrobial spending across hospitals.1,8 Identifying the impact of different antimicrobial use patterns across children’s hospitals could yield potential targets for pediatric ASPs.
methods
We performed a cross-sectional analysis to examine the volume and cost of antimicrobial use for hospitalized children. Data were obtained from the Pediatric Health Information System, an administrative database of freestanding US children’s
hospitals.Analyses were restricted to 36 hospitals after excluding institutions with data quality issues, with incomplete data, or without an available cost-to-charge ratio. We included all inpatient and observation patients discharged in 2012. Billed charges were obtained for all antimicrobials by any
route of administration. To assess volume, the number of days of therapy (DOT) was calculated.3 For cost, presented in US dollars, the hospital- and department-specific cost-to-charge ratio was used to calculate cost from charges. Antibiotic use was summarized by condition using All Patient Refined
overall medication costs and of total DOT contributed by anti- microbials. The cost-to-DOT ratio, the proportion of total anti- microbial cost divided by the proportion of total DOT, was calculated to identify antimicrobials that were disproportionately costly relative to utilization (ie, ratio >1.0). For variability ana- lyses, log-gamma (cost) and Poisson (DOT) models were fit overall and for individual conditions, with hospitals as fixed effects. Using marginal standardization, we estimated the stan- dardized cost and DOT per patient-day. Correlation between DOTand cost was assessed by the Pearson correlation coefficient. Overall analyses standardized for the following patient covariates: age (<1 year, 1-4 years, 5-11 years, ≥12 years), sex, complex chronic conditions,10 surgical procedure, and need for critical care (≥2 consecutive days with mechanical ventilation or vasoactive medications, or a single day of extracorporeal membrane oxygenation). Analysis by condition excluded patients with complex chronic conditions and those who required critical care (mechanical ventilation or vasoac- tive medications for children with pneumonia; vasoactive medications for children with appendectomy) and standar- dized for age, sex, surgical procedure, and All Patient Refined Diagnosis Related Groups severity of illness. SAS, version 9.3 (SAS Institute), and Stata, version 13.1 (StataCorp), were used.
results
In 2012, there were 599,518 patients discharged from 36 hos- pitals, ofwhom357,522 (59.6%) received antimicrobial therapy. Overall, $192.9 million was spent on antimicrobials, accounting for 17.1% of the total pharmacy budget ($1.13 billion). Table 1 describes use by antimicrobial category. Of all antimicrobial use, antibacterials accounted for 72.5% of cost and 81.8% of DOT. Cost-to-DOT ratio was greater than 1 for both antifungals and antivirals. The top 5 drugs contributing to cost—vancomycin ($15.9 million), meropenem ($15.4 million), piperacillin-tazobactam ($14.7 million), amphoter- icin B-lipid ($12.2 million), and ceftriaxone ($10.1 million)— accounted for more than 35% of total antimicrobial expendi- tures and 22% of DOT. Meropenem accounted for 8.0% of total antimicrobial costs
but only 2.8% of antimicrobial DOT (cost-to-DOT ratio, 2.8). Linezolid also had a disproportionately large proportion of cost relative to DOT (ratio, 3.8), whereas vancomycin con- tributed equally in cost and DOT (ratio, 1.0). Cefazolin had one of the lowest ratios (0.6) among commonly used antibacterials.
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