Infection Control & Hospital Epidemiology (2019), 40, 242–244 doi:10.1017/ice.2018.300
Research Brief
Cost Analysis of Computerized Clinical Decision Support and Trainee Financial Incentive for Clostridioides difficile Testing
Gregory R. Madden MD1, Heather L. Cox PharmD, BCPS-AQID1,2, Melinda D. Poulter PhD, D(ABMM)3, Jason A. Lyman MD4, Kyle B. Enfield MD, MS (Epi)5 and Costi D. Sifri MD1,6 1Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, 2Department of
Pharmacy Services, University of Virginia Health System, Charlottesville, Virginia, 3Clinical Microbiology Laboratory, Department of Pathology, University of Virginia Health System, Charlottesville, Virginia, 4Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia, 5Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia and 6Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia Health System, Charlottesville, Virginia
(Received 29 May 2018; accepted 2 September 2018; electronically published 23 November 2018)
Clostridioides (formerly Clostridium) difficile infection (CDI) is the most common cause of healthcare-associated infections, leading to increased morbidity, mortality, length of hospital stay, and costs.1,2 CDI contributes an estimated $5.4 billion to US healthcare annually.2 In an era of highly sensitive molecular testing, over- diagnosis of CDI is also suspected to be common, and up to half of inpatients with a positive C. difficile nucleic acid amplification test (NAAT) may not require treatment.3 Overdiagnosis may be due to testing patients with low pretest probability for disease. Improving test utilization through diag- nostic stewardship has the potential to reduce unnecessary testing and diagnostic error.4 Various strategies have been proposed for C. difficile testing, including computerized clinical decision sup- port (CCDS).4 We previously reported implementation of a CCDS tool (as part of a multifaceted bundle of interventions to reduce National Healthcare Safety Network (NSHN)–defined hospital-onset CDI [HO-CDI])5 in our institution that led to significantly reduced testing and fewer HO-CDI events.6 Here, we present a cost analysis of this intervention.
Methods
The CCDS tool was implemented after internal auditing sug- gested that testing for C. difficile might not have been indicated in up to 67% of HO-CDI cases in our institution.6 A detailed description of the decision support algorithm, including a video demonstration of the CCDS tool, has previously been published.6 House staff were involved with an educational campaign that preceded CCDS implementation and offered a 0.8% salary bonus at the end of the academic year if testing fell by≥25%.
Author for correspondence: Costi D. Sifri, Division of Infectious Diseases & Inter-
national Health, University of Virginia Health System, PO Box 800473, Charlottesville, VA 22908–0473. E-mail:
csifri@virginia.edu PREVIOUS PRESENTATION: Data from this study were presented in part as an
abstract at the 2018 Society for Healthcare Epidemiology of America meeting on April 19, 2018, in Portland, Oregon (abstract #327).
Cite this article: Madden GR, et al. (2019). Cost analysis of computerized clinical
decision support and trainee financial incentive for Clostridioides difficile testing. Infection Control & Hospital Epidemiology 2019, 40, 242–244. doi: 10.1017/ice.2018.300
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. The financial incentive, funded jointly by the UVA Office of
Graduate Medical Education and UVA Health System, was part of a recurring incentivized annual quality improvement project led by trainees, for which C. difficile testing was chosen as the subject for the 2016–2017 academic year. Real-time monitoring of test utili- zation, with unit and service attributions, was available through an electronic portal as feedback during the intervention period. A retrospective cost analysis was performed that included cost
savings from reduced test utilization and fewer HO-CDI events (based on estimated attributable costs for hospitalized patients with CDI),1,7,8 in addition to costs of building the CCDS tool and house staff financial incentives.
Results
Hospital census remained relatively constant during the study period, with 156,154 and 159,094 patient days during the pre- intervention (December 2015 – November 2016) and post- intervention (December 2016 – November 2017) periods, respectively. Total laboratory cost (materials and labor) was estimated at $31.36 per test (Table 1). Based on the literature, the estimated attributable cost per hospitalized CDI case was between $3,6691 and $9,197;7 the median, $6,326,8 was chosen for purposes of our analysis. The 0.8% house-staff financial incentive was based on house staff salaries (median, $61,669; range $54,107–$71,167). The technology-associated cost involved with creating the CCDS tool (ie, developing question algorithm, software building, testing, migration through envir- onments, etc) was estimated to be $1,000. In total, the CCDS tool was associated with a net $61,524
annual cost savings, largely attributable to estimated reductions in unnecessary inpatient CDI treatment and laboratory diagnostics (Table 2).
Discussion
Diagnostic stewardship was successfully applied to C. difficile testing through implementation of a CCDS tool coupled with a financial incentive. The intervention not only reduced testing and
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