cost of antimicrobial therapy 1243
table 1. Cost and Days of Therapy (DOT) by Antimicrobial Category Among 357,522 Patients Cost
Antimicrobial drug class Antibacterials
Antifungals Antivirals
Antimycobacterial Antiparasitic
Anti-infective, not categorizable US $
139,908,848 38,269,369 13,600,154 773,279 356,284 4,902
192,912,836 %
72.5% 19.8% 7.0% 0.4% 0.2%
<0.1% 100.0%
aCost-to-DOT ratio is proportion of total cost divided by proportion of total DOT. (a)
Pneumonia 300
Among antimicrobials used for at least 10,000 DOT (43 drugs 3 200 2 100 1 0 Hospitals (b)
Appendectomy 300
0
accounting for 93.3% of all DOT), 4 of the 5most expensive drugs by cost-to-DOT ratio were antifungals: amphotericin B-lipid (8.6), caspofungin (6.5),micafungin (3.3), and voriconazole (2.9). Children with bone marrow transplant and cystic fibrosis exacerbation accounted for the largest share of antimicrobial spending (10.7% and 7.3%, respectively) and had the third and fifth highest cost-to-DOT ratios among conditions with at least 10,000 DOT (1.8 and 1.7, respectively). Neonatal admissions accounted for the third highest total expenditures (6.8%) but nearly the lowest cost-to-DOT ratio (0.5). Across hospitals, the median (range) proportion of the
3
total pharmacy budget spent on antimicrobials was 17.1% (11.7%-33.7%). After standardizing for patient characteristics, the median (range) antimicrobial cost per patient-day at each hospital was $48 ($9-$139) (interquartile range, $38-$66). After standardizing for patient demographic characteristics
200 2 100 1
and severity of illness, the median (range) antimicrobial cost per patient-day at each hospital was $47 ($5-$186) (inter- quartile range, $31-$69) for pneumonia and $80 ($8-$248) (interquartile range, $62-$119) for appendectomy, and the variation in cost was not strongly correlated with DOT (Figure 1A and 1B; r = 0.3 and 0.4, respectively).
0 Hospitals
figure 1. Standardized cost in US dollars (USD) and days of therapy (DOT) of antimicrobial treatment per patient-day by hospital. Black bars are cost and associated with the left y-axis. The dashed line is median cost. Gray dots are DOT and associated with the right y-axis. Patients with pneumonia (n=11,826) and appendectomy (n=13,214) were identified using All Patient Refined Diagnosis Related Groups. Analyses excluded patients with complex chronic conditions or who received critical care and were standardized for age, sex, surgical procedure, and All Patient Refined Diagnosis Related Groups severity of illness.
Among antifungals, amphotericin B-lipid and the echino-
candins (micafungin/caspofungin) each accounted for $11.5 million (ie, each accounted for more than 6% of antimicrobial costs), followed by voriconazole at $7.8 million (4%).
0 discussion
We examined the cost of antimicrobial prescribing by drug, therapeutic class, and clinical condition at 36 freestanding children’s hospitals. We found that (1) antimicrobial drugs made up a sizable proportion of each hospital’s total medica- tion expenditures, (2) a few specific drugs accounted for a large proportion of antimicrobial cost, (3) some drugs that accounted for a large proportion of cost did not account for a similar amount of use (eg, antifungals), and (4) anti- microbial costs for common pediatric infections varied across hospitals. These findings highlight cost as an important metric
to identify antimicrobial stewardship targets. First, anti- microbials accounted for 17.1%of pharmacy drug costs. Thus, promoting judicious antimicrobial use could substantially impact a hospital’s budget. This finding is consistent with
No.
2,518,344 377,352 147,470 20,247 16,224 762
3,080,399
DOT %
81.8% 12.3% 4.8% 0.7% 0.5%
<0.1% 100.0%
Cost-to-DOT ratioa 0.9
1.6 1.5 0.6 0.4 0.1
Standardized cost per patient day (USD)
Standardized cost per patient day (USD)
Standardized DOT per patient day (•)
Standardized DOT per patient day (•)
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