Analyzing Published Research
Using these two articles please complete the following assignment. I included an outline of what the paper needs to include.
NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines
NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2
1
Purpose
The purpose of this paper is to interpret the two articles identified as most important to the group topic.
Course outcomes: This assignment enables the student to meet the following course outcomes.
CO 2: Apply research principles to the interpretation of the content of published research studies.
(POs 4 and 8)
CO 4: Evaluate published nursing research for credibility and clinical significance related to evidence-based practice.
(POs 4 and 8)
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.
Total points possible: 200 points
Preparing the assignment
1. Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
2. Please make sure you do not duplicate articles within your group.
3. The paper will include the following:
a. Clinical Question (30 points/15%)
1. Describe the problem: What is the focus of your group’s work?
2. Significance of problem: What health outcomes result from your problem? Or what statistics document this
is a problem? You may find support on websites for government or professional organizations.
3. Purpose of the paper: What will your paper do or describe?
***Please note that although most of these questions are the same as you addressed in paper 1, the purpose of
this paper is different. You can use your paper 1 for items 1 & 2 above, including any faculty suggestions for
improvement provided as feedback.
b. Evidence Matrix Table: Data Summary (Appendix A) – (60 points/30%)
Categorize items in the Matrix Table, including proper intext citations and reference list entries for each article.
1. References (recent publication within the last 5 years)
2. Purpose/Hypothesis/
Study Question(s)
3. Variables: Independent (I) and Dependent (D)
4. Study Design
5. Sample Size and
Selection
6. Data Collection Methods
7. Major Findings (Evidence)
c. Description of Findings (60 points/30%)
Describe the data in the Matrix Table, including proper intext citations and reference list entries for each article.
1. Compare and contrast variables within each study.
2. What are the study design and procedures used in each study; qualitative, quantitative, or mixed method
study, levels of confidence in each study, etc.?
3. Participant demographics and information.
4. Instruments used, including reliability and validity.
5. How do the research findings provide evidence to support your clinical problem, or what further evidence
is needed to answer your question?
6. Next steps: Identify two questions that can help guide the group’s work.
d. Conclusion (20 points/10%)
Review major findings in a summary paragraph.
1. Evidence to address your clinical problem.
2. Make a connection back to all the included sections.
2
NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines
NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 2
3. Wrap up the assignment and give the reader something to think
about.
e. Format (30 points/15%)
1. Correct grammar and spelling
2. Include a title and reference page
3. Use of headings for each section:
o Problem
o Synthesis of the Literature
− Variables
− Methods
− Participants
− Instruments
− Implications for Future Work
4. Conclusion
5. Adheres to current APA formatting and guidelines
6. Include at least two (2) scholarly, current (within 5 years) primary sources other than the textbook
7. 3-4 pages in length, excluding appendices, title and reference pages
For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned.
https://library.chamberlain.edu/APA
NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines
NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 3
Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
Clinical Question
(30 points/15%)
30 points 26 points 24 points 11 points 0 points
Required criteria
1. Describe the problem: What is the focus of your group’s work?
2. Significance of problem: What health outcomes result from your
problem? Or what statistics document this is a problem? You may
find support on websites for government or professional
organizations.
3. Purpose of the paper: What will your paper do or describe?
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
Present, yet
includes no
required criteria.
No requirements
for this section
presented.
Evidence Matrix Table: Data Summary (Appendix A)
(60 points/30%)
60 points 56 points 47 points 25 points 0 points
Required criteria
Categorize items in the Matrix Table, including proper intext citations and
reference list entries for each article.
1. References (recent publication within the last 5 years)
2. Purpose/Hypothesis/Study Question(s)
3. Variables: Independent (I) and Dependent (D)
4. Study Design
5. Sample Size and Selection
6. Data Collection Methods
7. Major Findings (Evidence)
Includes 7
requirements for
section.
Includes 6
requirements for
section.
Includes 5
requirements for
section.
Includes 4 or less
requirements for
section.
No requirements
for this section
presented.
Description of Findings
(60 points/30%)
60 points 53 points 47 points 23 points 0 points
Required criteria
Describe the data in the Matrix Table, including proper intext citations
and reference list entries for each article.
1. Compare and contrast variables within each study.
2. What are the study design and procedures used in each study;
qualitative, quantitative, or mixed method study, levels of confidence
in each study, etc.?
3. Participant demographics and information.
Includes 6
requirements for
section.
Includes 5
requirements for
section.
Includes 4
requirements for
section.
Includes 3 or less
requirements for
section.
No requirements
for this section
presented.
NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines
NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 4
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
4. Instruments used, including reliability and validity.
5. How do the research findings provide evidence to support your
clinical problem, or what further evidence is needed to answer your
question?
6. Next steps: Identify two questions that can help guide the group’s
work.
Conclusion
(20 points/10%)
20 points 18 points 15 points 8 points 0 points
Required criteria
Review major findings in a summary paragraph.
1. Evidence to address your clinical problem.
2. Make a connection back to all the included sections.
3. Wrap up the assignment and give the reader something to think
about.
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
Present, yet
includes no
required criteria.
No requirements
for this section
presented.
Format
(30 points/15%)
30 points 26 points 23 points 11 points 0 points
Required criteria
1. Correct grammar and spelling
2. Include a title and reference page
3. Use of headings for each section:
o Problem
o Synthesis of the Literature
▪ Variables
▪ Methods
▪ Participants
▪ Instruments
▪ Implications for Future Work
4. Conclusion
5. Adheres to current APA formatting and guidelines
6. Includes at least two (2) scholarly, current (within 5 years) primary
sources other than the textbook
7. 3-4 pages in length excluding appendices, title and reference pages
Includes 8
requirements for
section.
Includes 7
requirements for
section.
Includes 6
requirements for
section.
Includes 5 or less
requirements for
section.
No requirements
for this section
presented.
Total Points Possible = 200 points
NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines
NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 5
Appendix A
EVIDENCE MATRIX TABLE
Article
References
Purpose
Hypothesis
Study Question(s)
Variables
Independent(I)
Dependent(D)
Study Design
Sample
Size &
Selection
Data
Collection
Methods
Major Finding(s)
1
(SAMPLE
ARTICLE)
Smith, L. (2013). What
should I eat? A focus for
those living with diabetes.
Journal of Nursing
Education, 1(4), 111-112.
How do educational support
groups effect dietary modifications
in patients with diabetes?
D-Dietary
modifications
I-Education
Quantitative N- 18
Convenience
sample-selected
from local support
group in Pittsburgh,
PA
Focus Groups Support and education
improved compliance with
dietary modifications.
1
2
3
4
5
i n fec ti on c o nt rol a n d h o spi ta l e p idem i olo gy f eb ru a ry 2 011, v o
l.
3 2, n o . 2
o r i g i n a l a r t i c l
e
Estimating the Proportion of Healthcare-Associated Infections That
Are Reasonably Preventable and the Related Mortality and Cost
s
Craig A. Umscheid, MD, MSCE;1,2,3 Matthew D. Mitchell, PhD;1 Jalpa A. Doshi, PhD;1,3
Rajender Agarwal, MD, MPH;1 Kendal Williams, MD, MPH;1,3 Patrick J. Brennan, MD2,3,4
objective. To estimate the proportion of healthcare-associated infections (HAIs) in US hospitals that are “reasonably preventable,”
along with their related mortality and costs.
methods. To estimate preventability of catheter-associated bloodstream infections (CABSIs), catheter-associated urinary tract infections
(CAUTIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), we used a federally sponsored systematic review of
interventions to reduce HAIs. Ranges of preventability included the lowest and highest risk reductions reported by US studies of “moderate”
to “good” quality published in the last 10 years. We used the most recently published national data to determine the annual incidence of
HAIs and associated mortality. To estimate incremental cost of HAIs, we performed a systematic review, which included costs from studies
in general US patient populations. To calculate ranges for the annual number of preventable infections and deaths and annual costs, we
multiplied our infection, mortality, and cost figures with our ranges of preventability for each HAI.
results. As many as 65
%
–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current
evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed b
y
VAP. CABSI also has the highest cost impact; costs due to preventable cases of VAP, CAUTI, and SSI are likely less.
conclusions. Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based preventio
n
strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of
thousands of lives and billions of dollars.
Infect Control Hosp Epidemiol 2011;32(2):101-114
Affiliations: 1. Center for Evidence-Based Practice, University of Pennsylvania, Philadelphia, Pennsylvania; 2. Center for Clinical Epidemiology and
Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania; 3. Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
4. Office of the Chief Medical Officer, University of Pennsylvania, Philadelphia, Pennsylvania.
Received May 12, 2010; accepted August 10, 2010; electronically published January 14, 2011.
� 2011 by the Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3202-0001$15.00. DOI: 10.1086/657912
In 1999, the Institute of Medicine released its groundbreaking
report “To Err Is Human.”1 The report acknowledged the
overwhelming incidence and cost of medical errors that occur
in our healthcare system and identified healthcare-associat
ed
infections (HAIs) as an important patient safety challenge.
Subsequent studies have further documented the extent of
HAIs in the United States.2
Numerous studies have examined interventions to reduce
the most common HAIs: catheter-associated bloodstream in-
fection (CABSI), ventilator-associated pneumonia (VAP),
catheter-associated urinary tract infection (CAUTI), and sur-
gical site infection (SSI).3,4 These strategies have demonstrated
some success, and payers have responded by using financial
incentives to encourage hospitals to adopt them. In Octob
er
2008, Medicare stopped providing reimbursement for treat-
ment of 8 largely preventable conditions, 3 of which it deemed
“never events” and 5 “reasonably preventable.”5 Three of the
5 “reasonably preventable” conditions are HAIs; namely,
CABSI, CAUTI, and SSI. VAP is being considered for inclu-
sion in an expanded list scheduled for release in 2011.
6
Although nonpayment for treatment of HAIs may be an
effective incentive for hospitals and physicians to reduce the
incidence of HAIs, some have asserted that not all HAIs are
preventable and that this new incentive may be a challen
ge
for hospitals that care for patients at high risk for HAIs.5,6 T
o
inform discussions regarding the preventability of HAIs, we
estimated the proportion of HAIs that are reasonably pre-
ventable in US hospitals, as well as their associated mortality
rates and costs.
m e t h o d s
HAI Incidence, Associated Mortality, and Risk Reduction
An accurate estimation of the annual number of preventable
HAIs requires accurate estimates of 2 underlying values: the
current total annual number of HAIs and the proportion of
1 0 2 i n f e c t i o n c o n t r o l a n d h o s p i t a l e p i d e m i o l o g y f e b ru a ry 2 0 1 1 , v o l . 3 2 , n o . 2
these that are “reasonably preventable.” Likewise, an accurate
estimation of the number of preventable HAI-associated
deaths requires accurate estimates of the current total annual
number of deaths from HAIs and the proportion of the
se
deaths that are “reasonably preventable.” We obtained data
for CABSI, VAP, CAUTI, and SSI.
To estimate the number of HAIs and their associated mor-
tality rates, we used figures assembled by Klevens et al2 from
the National Nosocomial Infections Surveillance (NNIS) sys-
tem, the National Hospital Discharge Survey, and the Amer-
ican Hospital Association. These estimates include HAIs in
infants, children, and adults in and outside of the intensive
care unit (ICU) setting. HAIs were defined as infections that
occurred during a hospitalization and that were not present
prior to hospital admission. Infections had to meet body site–
specific criteria. Death was considered associated with an HA
I
if an infection preventionist determined that the HAI direct
ly
contributed to or caused the death.
To estimate the proportion of HAIs that could be pre-
vented, we used the estimates of HAI risk reductions resulting
from quality improvement strategies reported in an Agency
for Healthcare Research and Quality (AHRQ) Evidence-Based
Practice Center (EPC) report,3 a systematic review of the
published literature on HAI prevention. We used only HAI
risk reductions reported in US studies published in the past
10 years that had a controlled or time-series design or were
graded as “good” quality by the AHRQ EPC report.3 When
there were fewer than 3 studies that met these criteria, we
included studies graded as “moderate” quality. Quality ratings
were based on answers to questions that pertained to the
internal and external validity of the studies.3
We obtained the full text of all studies cited in our report
for further detailed analysis. For studies with a simple before-
after design, we calculated risk reductions from the reported
infection rates before and after the study intervention. For
studies with a controlled before-after design, we estimated
the risk reduction of the intervention by calculating the dif-
ference between the risk reductions in the control arm and
the intervention arm. For studies using an interrupted time-
series design, we used the risk reductions estimated by mod-
eling, if that was available; if modeling was not available, we
estimated risk reductions using data from the first and last
time periods.
Because the patient populations and interventions tested
in the published studies of HAI reduction varied, it was not
appropriate to combine the risk reductions into a single sum-
mary estimate using meta-analysis. Thus, we used the highest
and lowest infection reduction values from US studies for
each type of HAI to generate a range of possible risk reduc-
tions for each type of HAI. The ranges were multiplied by
the estimated number of infections, as reported by Klevens
et al,2 to yield an estimated range of the number of reasonably
preventable infections for each type of HAI. The ranges were
also multiplied by the estimated number of deaths as reported
by Klevens et al,2 to yield an estimated range of the number
of reasonably preventable deaths for each type of HAI.2 To
estimate the costs associated with each type of HAI, we mul-
tiplied the number of potentially preventable infections by
the estimated incremental cost for that type of infection.
HAI Cost
Estimating the cost of preventable HAIs requires knowledge
of the total incidence of HAIs, the proportion of HAIs that
are “reasonably preventable,” and the cost of each type of
HAI. The costs of CABSI, VAP, CAUTI, and SSI were obtained
from studies identified by a MEDLINE search. Search strat-
egies for HAIs were based on those used in the AHRQ EPC
report.3 Search strategies for economic impact were based on
those used by the Canadian Agency for Drugs and Technol-
ogies in Health.7 The 2 search elements were combined, and
results were limited to English-language studies published in
the 10 years prior to the search; searches were completed in
May 2008.
The titles and abstracts of all articles found by the searches
were reviewed by a research analyst (M.D.M.), and potentially
relevant articles were retrieved. Studies were included in the
analysis if they reported original calculations of costs for one
of the selected HAIs, were conducted at US hospitals, and
included 10 or more patients with infection. Studies from
outside the United States were excluded because their cost
estimates may not be reflective of those in the United States.
Studies of highly specialized or narrow patient populations
were also excluded, since our aim was to estimate costs for
the general population.
Cost results from each study were reported as the incre-
mental cost to the hospital per case patient with an HAI. We
calculated confidence intervals for the mean cost per case if
these intervals were not reported by study authors and if
sufficient information was available to do so. All results were
converted to 2009 dollars using the Consumer Price Index
(CPI) for Hospital Services (US Bureau of Labor Statistics),
except for one study of CABSI,8 which included data from
before 1997; for this study, the CPI for Medical Services was
used as the inflator, because the CPI for Hospital Services
was not published until 1997. Where possible, summary es-
timates of cost were based only on studies that used regression
models to isolate the costs of the infection from costs that
may have been coincident with the infection. Where multiple
studies for a particular infection measured costs the same
way, we took their range of estimates.
r e s u l t s
Number of HAIs and Associated Mortality
A comprehensive estimate of annual incidence of the mor-
tality rates associated with HAIs in US hospitals was reported
in 2007 (Appendix Table A1).2 These data suggest that CAB
SI
and VAP cause more than two-thirds of the deaths resulting
from HAIs and that they are 5 times as deadly as the other
HAIs.
re a s on ab l y p re ve n t a b le h a i s 1 03
Proportion of HAIs and HAI-Associated Deaths That Are
Reasonably Preventable
From a total of 4,847 potentially relevant articles identified
in the AHRQ EPC report,3 434 articles were retrieved, and
64 ultimately met the inclusion criteria (Appendix Table A2).3
However, the quality of the studies was generally poor. Few
were controlled or time-series analyses, and most of the sim-
ple before-after studies were categorized by the AHRQ EPC
report3 as “moderate” or “poor” quality. They did not grade
the quality of controlled and interrupted time-series trials,
assuming they were of higher quality than the simple before-
after studies. Because there was little consistency among pa-
tient groups studied or interventions tested, the AHRQ in-
vestigators could not perform any quantitative synthesis of
the data, and they did not attempt to make a summary es-
timate of the proportion of infections or deaths that could
be considered preventable.3 Appendix Table A2 shows the
number of studies excluded on quality grounds and for other
reasons.
The characteristics of the included studies are summarized
in Table 1. All of the good-quality CABSI prevention studies
reported in the AHRQ EPC report3 focused on ICU patients.
The interventions tested varied from study to study, as did
absolute infection rates both before and after the interven-
tions, suggesting that either patient populations varied across
studies or some centers already had effective infection pre-
vention measures in place before their studies commenced.
With respect to VAP prevention studies, there were only 2
good-quality before-after studies and no studies utilizing
other designs, so we broadened our inclusion criteria to in-
clude 3 additional moderate-quality studies. As with CABSI
rates, VAP rates also varied from study to study, both before
and after implementation of infection prevention programs.
In the case of CAUTI prevention studies, there were no avail-
able good-quality studies and only 2 studies of moderate
quality. The SSI studies tested a variety of interventions, and
their results showed more heterogeneity than those seen in
studies of any other type of HAI.
Costs of HAIs
The HAI-related costs to hospitals in the included studies are
summarized for each type of HAI in Tables 2, 3, 4, and 5.
Four studies of the cost of CABSI in ICU patients met our
inclusion criteria (Table 2). One study10 identified costs as-
sociated with CABSIs by reviewing charts and each line item
in patient bills to ascertain whether the cost was attributable
to infection. Costs determined by this method were consistent
with those from the other studies. Two studies11,12 used re-
gression models to isolate incremental costs of CABSI; how-
ever, the mean incremental cost was $21,400 in 2009 dollars
in one11 and $110,800 in the other.12 The first of these 2 studies
was hampered by an extremely wide confidence interval.
For VAP, of the 4 included cost studies (Table 3), 3 reported
similar results in unadjusted mean incremental costs per case,
but the other study13 reported a much higher figure. Only
the study of Warren and colleagues14 used regression to cal-
culate a mean adjusted incremental cost per infection
($23,000).
All 3 studies of CAUTI (Table 4) estimated costs by sum-
ming the costs of specific line items associated with CAUTI.
One study15 considered only the cost of laboratory tests used
to diagnose CAUTI and medications used to treat it. The
other 2 studies16,17 counted those costs plus an assumed 0.5-
day increase and a 1-day increase in hospital length of stay,
respectively. Our summary cost calculation ($1,200–$4,700
)
is based on the range of estimates in the included studies.
The 4 studies of SSI costs (Table 5) differed considerably
in methods. Unadjusted mean or median costs per infection
fell in the range of $5,600–$12,900. One study18 also reported
adjusted mean incremental costs, which were much lower, at
$2,200 per SSI.
To arrive at a national total cost of HAIs, we selected a
summary estimate of incremental costs per infection case for
each type of infection. To do this, we first used adjusted
estimates on the basis of regression models to account for
confounding variables. Regression models were available for
all infections except CAUTI, for which cost estimates were
necessarily based on studies that simply summed line-item
costs presumed to be associated with the infection, so we
took the range of those estimates as our summary estimate.
There were 2 estimates of CABSI costs based on regression
models, but they differed widely from each other; therefore,
we used their range as the basis for calculating our range of
the estimated total cost of CABSI. Only 1 adjusted incre-
mental cost estimate was available for VAP and for SSI to be
used in our total cost calculations.
Estimates of the Total Impact of HAIs
The literature suggests that as many as 65%–70% of cases of
CABSI and CAUTI and 55% of cases of VAP and SSI are
preventable with current evidence-based strategies. CAUTI
may be the most preventable HAI; the number of avoidable
infections ranges from 95,483 to 387,550 per year. This
is
followed by CABSI, with 44,762–164,127 preventable infec-
tions; VAP, with 95,078–137,613 preventable infections; and
SSI, with 75,526–156,862 preventable infections.
Our calculations demonstrate that CABSI is associated with
the highest number of preventable deaths, followed by VAP.
If best practices in infection control were applied at all US
hospitals, the reduction in the number of cases of CABSI
could save as many as 5,520–20,239 lives, and for VAP 13,667–
19,782 lives could be saved. The potential to save lives by
reducing the number of cases of CAUTI and SSI is smaller:
2,225–9,031 lives annually for CAUTI and 2,133–4,431 lives
annually for SSI.
Of the HAIs we examined, preventable cases of CABSI are
likely to have the highest associated costs, ranging anywhere
from $960 million to $18.2 billion annually. The hospital costs
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y
;
IC
U
p
at
ie
n
ts
In
te
rv
en
ti
o
n
p
er
io
d
:
P
re
ve
n
ti
ve
:
H
an
d
h
y-
gi
en
e;
m
ax
im
u
m
st
er
il
e
b
ar
ri
er
p
re
ca
u
–
ti
o
n
s;
in
se
rt
io
n
si
te
se
le
ct
io
n
;
ch
lo
rh
ex
i-
d
in
e
d
is
in
fe
ct
io
n
;
re
m
o
va
l
o
f
u
n
n
ec
es
sa
ry
ca
th
et
er
s
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
au
d
it
,
an
d
fe
ed
b
ac
k
C
o
n
tr
o
l
p
er
io
d
:
C
li
n
ic
ia
n
e
d
u
ca
ti
o
n
o
n
ly
In
te
rv
en
ti
o
n
p
er
io
d
:
1
1
.3
ca
se
s
p
er
1
,0
00
C
D
s;
co
n
tr
o
l
p
er
io
d
:
5
.7
ca
se
s
p
er
1
,0
0
0
C
D
s
In
te
rv
en
ti
o
n
p
er
io
d
:
0
ca
se
s
p
er
1
,0
0
0
C
D
s;
co
n
tr
o
l
p
er
io
d
:
1
.6
ca
se
s
p
er
1
,0
0
0
C
D
s
2
8
%
b
C
o
o
p
er
sm
it
h
et
al
2
8
(2
0
0
4
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
an
d
h
yg
ie
n
e;
m
ax
im
u
m
st
er
il
e
b
ar
ri
er
p
re
ca
u
ti
o
n
s;
in
se
rt
io
n
si
te
se
le
ct
io
n
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
3
.4
ca
se
s
p
er
1
,0
0
0
C
D
s
2
.8
ca
se
s
p
er
1
,0
0
0
C
D
s
1
8
%
W
ar
re
n
et
al
2
9
(
2
00
4
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
an
d
h
yg
ie
n
e;
m
ax
im
u
m
st
er
il
e
b
ar
ri
er
p
re
ca
u
ti
o
n
s;
in
se
rt
io
n
si
te
se
le
ct
io
n
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
au
d
it
,
an
d
fe
e
d
b
ac
k
9
.4
ca
se
s
p
er
1
,0
0
0
C
D
s
5
.5
ca
se
s
p
er
1
,0
0
0
C
D
s
4
2
%
W
ar
re
n
et
al
3
0
(2
00
3
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
M
ax
im
u
m
st
er
il
e
b
ar
ri
er
p
re
–
ca
u
ti
o
n
s;
in
se
rt
io
n
si
te
se
le
ct
io
n
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
au
d
it
,
an
d
fe
ed
b
ac
k
4
.9
ca
se
s
p
er
1
,0
0
0
C
D
s
2
.1
ca
se
s
p
er
1
,0
0
0
C
D
s
5
7
%
C
o
o
p
er
sm
it
h
et
al
3
1
(2
0
02
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
an
d
h
yg
ie
n
e
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
au
d
it
,
an
d
fe
ed
b
ac
k
1
0
.8
ca
se
s
p
er
1
,0
00
C
D
s
3
.7
ca
se
s
p
er
1
,0
0
0
C
D
s
6
6
%
Sh
er
er
tz
et
al
3
2
(2
00
0
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
an
d
h
yg
ie
n
e;
m
ax
im
u
m
st
er
il
e
b
ar
ri
er
p
re
ca
u
ti
o
n
s
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
4
.5
1
ca
se
s
p
er
1
,0
00
C
D
s
2
.9
2
ca
se
s
p
er
1
,0
00
C
D
s
3
5
%
V
A
P
(g
o
o
d
-q
u
al
it
y
st
u
d
ie
s)
B
ab
co
c
k
et
al
3
3
(2
0
04
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
an
d
h
yg
ie
n
e;
h
ea
d
o
f
b
ed
an
–
gl
e
1
3
0�
;
d
ai
ly
in
te
rr
u
p
ti
o
n
o
f
s
e
d
at
io
n
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
8
.7
5
ca
se
s
p
er
1
,0
0
0
V
D
s
4
.7
4
ca
se
s
p
er
1
,0
00
V
D
s
4
6
%
Z
ac
k
et
al
3
4
(2
00
2)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
ea
d
o
f
b
ed
an
gl
e
1
3
0�
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
1
2
.6
ca
se
s
p
er
1
,0
00
V
D
s
5
.7
ca
se
s
p
er
1
,0
0
0
V
D
s
5
5
%
V
A
P
(m
o
d
er
at
e-
q
u
al
it
y
st
u
d
ie
s)
L
ai
et
al
3
5
(2
0
03
)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
H
ea
d
o
f
b
ed
an
gl
e
1
3
0�
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
au
d
it
,
an
d
fe
ed
b
ac
k
SI
C
U
:
4
5
.1
ca
se
s
p
er
1
,0
00
V
D
s;
M
IC
U
:
2
2
.4
ca
se
s
p
er
1
,0
00
V
D
s
SI
C
U
:
2
7
.9
ca
se
s
p
er
1
,0
00
V
D
s;
M
IC
U
:
1
1
.6
ca
se
s
p
er
1
,0
00
V
D
s
SI
C
U
:
3
8
%
;
M
IC
U
:
4
8
%
C
A
U
T
I
(m
o
d
er
at
e-
q
u
al
it
y
st
u
d
ie
s)
T
o
p
al
et
al
3
6
(2
0
05
)
B
ef
o
re
-a
ft
er
st
u
d
y;
w
ar
d
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
R
ed
u
ct
io
n
in
p
la
ce
m
e
n
t
o
f
ca
th
et
er
s
;
re
m
o
va
l
o
f
u
n
n
ec
es
sa
ry
ca
t
h
et
er
s
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
;
cl
in
ic
ia
n
re
–
m
in
d
er
;
o
r
g
an
iz
at
io
n
al
ch
a
n
ge
3
6
ca
se
s
p
er
1
,0
0
0
C
D
s
1
1
ca
se
s
p
er
1
,0
0
0
C
D
s
6
9
%
D
u
m
ig
a
n
et
al
3
7
(1
99
8)
B
ef
o
re
-a
ft
er
st
u
d
y;
IC
U
p
at
ie
n
ts
P
re
ve
n
ti
ve
:
A
se
p
ti
c
in
se
rt
io
n
an
d
ca
th
et
er
ca
re
;
re
m
o
va
l
o
f
u
n
n
ec
es
sa
ry
ca
th
et
er
s
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
;
o
rg
an
iz
at
io
n
al
ch
an
ge
SI
C
U
:
1
0
.3
ca
se
s
p
er
1
,0
00
C
D
s;
M
IC
U
:
1
5
.8
ca
se
s
p
er
1
,0
00
C
D
s;
C
IC
U
:
1
5
.1
ca
se
s
p
er
1
,0
0
0
C
D
s
SI
C
U
:
8
.6
ca
se
s
p
er
1
,0
00
C
D
s
;
M
IC
U
:
1
1
.2
ca
se
s
p
er
1
,0
00
C
D
s
;
C
IC
U
:
8
.3
ca
se
s
p
er
1
,0
0
0
C
D
s
SI
C
U
:
1
7
%
;
M
IC
U
:
2
9
%
;
C
IC
U
:
4
5
%
SS
I
(m
o
d
er
at
e
q
u
al
it
y
st
u
d
ie
s)
D
el
li
n
ge
r
et
al
3
8
(2
00
5
)
B
ef
o
re
-a
ft
er
st
u
d
y;
ty
p
e
o
f
p
at
ie
n
t
s
n
o
t
re
p
o
rt
ed
P
re
ve
n
ti
ve
:
A
p
p
ro
p
ri
at
e
u
se
o
f
p
er
io
p
er
a-
ti
v
e
an
ti
b
io
ti
cs
;
d
ec
re
as
ed
u
se
o
f
p
re
o
p
–
er
at
iv
e
sh
av
in
g;
i
m
p
r
o
ve
m
en
t
in
p
er
io
p
–
er
at
iv
e
gl
u
co
s
e
co
n
tr
o
l
Q
I:
A
u
d
it
an
d
fe
ed
b
ac
k
;
cl
in
ic
ia
n
ed
u
ca
–
ti
o
n
;
cl
in
ic
ia
n
re
m
in
d
er
2
.3
%
1
.7
%
2
6
%
L
u
ta
re
w
yc
h
et
al
3
9
(2
0
04
)
B
ef
o
re
-a
ft
er
st
u
d
y;
ty
p
e
o
f
p
at
ie
n
ts
n
o
t
re
p
o
rt
ed
P
re
ve
n
ti
ve
:
Im
p
ro
ve
m
en
t
in
p
er
io
p
er
at
iv
e
gl
u
co
se
co
n
tr
o
l
Q
I:
A
u
d
it
an
d
fe
ed
b
ac
k
;
cl
in
ic
ia
n
ed
u
ca
–
ti
o
n
;
p
at
ie
n
t
ed
u
ca
ti
o
n
7
.5
8%
3
.4
7%
5
4
%
R
ao
et
al
4
0
(2
00
4)
B
ef
o
re
-a
ft
er
st
u
d
y;
ty
p
e
o
f
p
at
ie
n
ts
n
o
t
re
p
o
rt
ed
P
re
ve
n
ti
ve
:
A
p
p
ro
p
ri
at
e
u
se
o
f
p
er
io
p
er
a-
ti
ve
an
ti
b
io
ti
cs
;
d
ec
re
as
ed
u
se
o
f
p
re
o
p
–
er
at
iv
e
sh
av
in
g;
im
p
ro
ve
m
en
t
in
p
er
io
p
–
er
at
iv
e
gl
u
co
se
co
n
tr
o
l
Q
I:
C
li
n
ic
ia
n
ed
u
ca
ti
o
n
,
cl
in
ic
ia
n
re
m
in
d
er
2
.1
%
1
.
5
%
2
9
%
n
o
t
e.
C
A
B
SI
,
ca
th
et
er
-a
ss
o
ci
at
ed
b
lo
o
d
st
re
am
in
fe
ct
io
n
;
C
A
U
T
I,
ca
th
et
er
-a
ss
o
ci
at
ed
u
ri
n
ar
y
tr
ac
t
in
fe
ct
io
n
;
C
D
,
ca
th
et
er
–
d
ay
;
IC
U
,
in
te
n
si
ve
ca
re
u
n
it
;
C
IC
U
,
ca
rd
io
lo
gy
IC
U
;
M
IC
U
,
m
e
d
ic
a
l
IC
U
;
Q
I,
q
u
al
it
y
in
it
ia
ti
ve
;
SI
C
U
,
su
rg
ic
al
IC
U
;
SS
I,
su
rg
ic
al
si
te
in
fe
ct
io
n
;
V
A
P
,
ve
n
ti
la
to
r-
as
so
ci
at
ed
p
n
eu
m
o
n
ia
;
V
D
,
ve
n
ti
la
to
r-
d
ay
.
a
R
ep
o
rt
ed
ri
sk
re
d
u
ct
io
n
re
su
lt
in
g
fr
o
m
in
te
rr
u
p
te
d
ti
m
e-
se
ri
e
s
m
o
d
el
in
g.
b
R
is
k
re
d
u
ct
io
n
ca
lc
u
la
te
d
b
y
ta
k
in
g
th
e
d
if
fe
re
n
ce
b
e
t
w
ee
n
th
e
ri
sk
re
d
u
ct
io
n
s
o
f
th
e
in
te
rv
en
ti
o
n
ar
m
an
d
th
e
co
n
tr
o
l
ar
m
.
t
a
b
l
e
2
.
Su
m
m
ar
y
o
f
4
St
u
d
ie
s
o
f
th
e
C
o
st
s
A
ss
o
ci
at
ed
w
it
h
C
at
h
et
er
-A
ss
o
ci
at
ed
B
lo
o
d
st
re
am
In
fe
ct
io
n
(C
A
B
SI
)
V
ar
ia
b
le
Sh
an
n
o
n
et
al
1
0
W
ar
re
n
et
al
1
1
D
im
ic
k
et
al
1
2
D
iG
io
vi
n
e
et
al
8
C
it
y
P
it
ts
b
u
rg
h
,
PA
St
.
L
o
u
is
,
M
O
B
al
ti
m
o
re
,
M
D
A
n
n
A
r
b
o
r,
M
I
T
yp
e
o
f
p
at
ie
n
ts
,
b
y
h
o
sp
it
al
si
t
e
M
ed
ic
a
l
an
d
co
ro
n
ar
y
IC
U
Su
rg
ic
al
an
d
m
ed
ic
al
IC
U
Su
rg
ic
al
IC
U
M
ed
ic
al
IC
U
N
o
.
o
f
p
at
ie
n
ts
a
5
4
4
1
8
6
6
8
C
o
st
an
al
ys
is
p
ri
m
ar
y
o
r
se
co
n
d
ar
y
ai
m
?
P
ri
m
ar
y
P
ri
m
ar
y
P
ri
m
ar
y
Se
co
n
d
ar
y
P
u
rp
o
se
o
f
ec
o
n
o
m
ic
an
al
ys
i
s
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
M
et
h
o
d
o
f
d
efi
n
in
g
in
fe
ct
io
n
N
o
t
re
p
o
rt
ed
B
y
in
fe
ct
io
n
co
n
tr
o
l
te
am
u
si
n
g
C
D
C
cr
it
er
ia
C
o
lo
n
iz
at
io
n
o
f
ca
th
et
er
( 1
1
5
C
F
U
)
w
it
h
o
rg
an
is
m
f
o
u
n
d
in
p
er
ip
h
–
e
r
al
b
lo
o
d
sp
ec
im
en
B
y
in
fe
ct
io
n
co
n
tr
o
l
te
am
u
si
n
g
C
D
C
cr
it
er
ia
C
o
n
tr
o
l
gr
o
u
p
N
o
n
e
IC
U
p
at
ie
n
t
s
w
it
h
o
u
t
in
fe
ct
io
n
IC
U
p
at
ie
n
ts
w
it
h
o
u
t
in
fe
ct
io
n
M
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s;
m
at
c
h
in
g
b
as
ed
o
n
p
re
d
ic
te
d
m
o
rt
al
it
y,
se
x,
ag
e,
ra
ce
,
ad
m
it
ti
n
g
d
ia
gn
o
–
si
s,
an
d
c
h
ro
n
ic
h
ea
lt
h
M
et
h
o
d
o
f
d
et
er
m
in
in
g
co
st
C
li
n
ic
ia
n
s’
re
tr
o
sp
ec
ti
ve
re
vi
e
w
o
f
ch
ar
ts
,
b
il
ls
,
an
d
p
ay
m
en
ts
M
u
lt
ip
le
li
n
ea
r
re
gr
es
si
o
n
m
o
d
e
l
M
u
lt
ip
le
li
n
ea
r
re
gr
es
si
o
n
m
o
d
el
B
y
L
O
S
an
d
b
y
to
ta
l
d
ir
ec
t
co
st
s;
w
h
ic
h
co
st
s
w
er
e
re
p
o
rt
ed
is
n
o
t
st
at
ed
So
u
rc
e
o
f
co
s
t
d
at
a
(
b
as
el
in
e
ye
ar
)
H
o
sp
it
a
l
co
st
re
p
o
rt
s,
2
00
2
–
20
0
5
d
o
ll
ar
s
H
o
sp
it
al
co
st
ac
co
u
n
ti
n
g
d
at
ab
as
e,
2
00
0
d
o
ll
ar
s
H
o
sp
it
al
c
h
ar
ge
s
co
n
ve
rt
e
d
to
co
st
s,
1
9
98
d
o
ll
ar
s
H
o
sp
it
al
co
st
ac
co
u
n
ti
n
g
d
at
ab
as
e,
1
9
94
–
1
99
6
d
o
ll
ar
s
C
o
st
s
m
ea
s
u
re
d
L
in
e
it
em
co
st
s
o
f
ca
re
at
tr
ib
u
ta
b
le
to
C
A
B
SI
(e
g,
ad
d
it
io
n
a
l
h
o
sp
it
al
d
ay
s,
an
ti
b
io
ti
cs
,
an
d
te
st
s)
an
d
/o
r
it
s
co
m
p
li
ca
ti
o
n
s
(e
g,
ex
p
lo
ra
to
ry
la
p
ar
o
to
m
y
,
h
em
o
d
ia
ly
si
s)
A
ll
co
st
s
in
h
o
sp
it
al
ac
co
u
n
ti
n
g
d
at
ab
as
e
,
in
cl
u
d
in
g
o
ve
rh
ea
d
co
st
s
A
ll
co
st
s
in
h
o
sp
it
al
b
il
li
n
g
d
at
ab
as
e;
o
ve
rh
ea
d
co
st
s
n
o
t
re
p
o
rt
ed
C
o
st
an
al
ys
is
m
et
h
o
d
s
am
b
ig
u
o
u
s;
it
ap
p
ea
rs
th
a
t
o
n
ly
d
ir
ec
t
co
st
s
fo
r
IC
U
ca
re
w
er
e
co
n
si
d
er
ed
P
er
sp
ec
ti
ve
H
o
sp
it
al
H
o
sp
it
al
H
o
sp
it
al
H
o
sp
it
al
T
im
e
h
o
ri
zo
n
In
p
at
ie
n
t
st
ay
In
p
at
ie
n
t
st
ay
In
p
at
ie
n
t
st
ay
IC
U
co
m
p
o
n
en
t
o
f
st
a
y
M
ai
n
ec
o
n
o
m
ic
o
u
tc
o
m
e
M
ea
n
in
cr
em
e
n
ta
l
d
ir
ec
t
co
s
t
p
er
h
o
sp
it
al
i-
za
ti
o
n
at
tr
ib
u
ta
b
le
t
o
th
e
C
A
B
SI
A
d
ju
st
ed
m
ea
n
in
cr
em
en
ta
l
to
ta
l
co
st
p
er
h
o
sp
it
al
iz
at
io
n
at
tr
ib
u
ta
b
le
to
th
e
C
A
B
SI
A
d
j
u
st
e
d
m
ea
n
in
cr
em
en
ta
l
t
o
ta
l
co
st
p
er
h
o
sp
it
al
iz
at
io
n
at
tr
ib
u
ta
–
b
le
to
th
e
C
A
B
SI
M
ea
n
in
cr
em
en
ta
l
IC
U
co
st
at
tr
ib
–
u
ta
b
l
e
to
th
e
C
A
B
SI
M
u
lt
iv
ar
ia
te
ad
ju
st
m
en
t
m
ad
e
t
o
co
st
es
ti
m
at
es
N
o
Y
es
;
re
gr
es
si
o
n
m
o
d
el
co
n
tr
o
ll
ed
fo
r
A
PA
C
H
E
II
sc
o
re
,
h
ea
rt
fa
il
u
re
,
h
e-
m
o
d
ia
ly
si
s,
ve
n
ti
la
to
r-
d
ay
s,
an
d
co
rt
i-
co
st
er
o
id
u
se
Y
es
;
re
gr
es
si
o
n
m
o
d
el
co
n
tr
o
ll
ed
fo
r
A
PA
C
H
E
II
I
sc
o
re
an
d
ag
e
N
o
U
n
ad
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
M
ea
n
,
$
40
,1
79
(S
D
n
o
t
re
p
o
rt
ed
)
M
ed
ia
n
,
$
63
,5
72
(7
5
th
–
9
5t
h
q
u
ar
ti
le
ra
n
ge
,
$
39
,3
14
–
$
84
,8
71
)
M
ed
ia
n
,
$
62
,6
52
(
7
5
t
h
–
9
5t
h
q
u
ar
ti
le
ra
n
ge
,
$
17
,4
39
–
$
17
0,
79
9
)
A
ll
p
at
ie
n
ts
:
m
ea
n
,
$
23
,7
51
;
su
rv
iv
o
rs
:
m
ea
n
,
$
34
,5
08
(S
D
s
n
o
t
re
p
o
rt
ed
)
A
d
ju
st
e
d
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$1
1,
97
1
(9
5
%
C
I,
$
6,
73
2–
$
1
8,
3
52
)
M
ea
n
,
$
56
,1
67
(9
5
%
C
I,
$
11
,
5
2
3–
$
1
65
,7
35
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
U
n
ad
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
M
ea
n
,
$
56
,0
00
(S
D
n
o
t
re
p
o
rt
ed
)
M
ed
ia
n
,
$
11
3,
70
0
(7
5t
h
–
9
5
th
q
u
ar
ti
le
ra
n
ge
,
$
70
,3
00
–
$
15
1,
70
0
)
M
ed
ia
n
,
$
12
3,
60
0
(7
5t
h
–
9
5
th
q
u
ar
–
ti
le
ra
n
ge
,
$
34
,4
00
–
$
3
37
,0
00
)
A
ll
p
at
ie
n
ts
:
m
ea
n
,
$
41
,
9
00
;
su
rv
iv
o
rs
:
m
ea
n
,
$
60
,9
00
(S
D
s
n
o
t
re
p
o
rt
ed
)
A
d
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$2
1,
40
0
(9
5%
C
I,
$
12
,0
00
–
$
3
2,
8
00
)
M
ea
n
,
$
11
0,
80
0
(9
5%
C
I,
$
2
2,
7
00
–
$
3
27
,0
00
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
C
o
m
m
en
ts
T
h
re
e
cl
in
ic
ia
n
re
vi
ew
er
s
h
ad
to
ag
re
e
co
st
s
w
er
e
at
tr
ib
u
ta
b
le
to
th
e
C
A
B
SI
o
r
it
s
co
m
p
li
ca
ti
o
n
s
fo
r
co
st
s
t
o
b
e
in
cl
u
d
ed
;
av
er
ag
e
lo
ss
to
h
o
sp
it
al
,
$
26
,8
8
5
Se
p
ar
at
e
an
al
ys
e
s
d
o
n
e
fo
r
al
l
p
a-
ti
en
ts
an
d
fo
r
p
at
ie
n
ts
w
h
o
su
r-
vi
ve
d
to
d
is
ch
ar
ge
n
o
t
e.
C
o
st
s
w
er
e
co
n
ve
rt
ed
to
2
0
0
9
d
o
ll
ar
s
u
si
n
g
th
e
C
o
n
su
m
er
P
ri
ce
In
d
ex
(
C
P
I)
fo
r
H
o
sp
it
al
Se
rv
ic
es
(U
S
B
u
re
au
o
f
L
ab
o
r
St
at
is
ti
cs
),
ex
ce
p
t
fo
r
D
iG
io
vi
n
e
et
al
,8
fo
r
w
h
ic
h
co
st
s
w
er
e
co
n
ve
rt
ed
u
si
n
g
th
e
C
P
I
fo
r
M
ed
ic
al
Se
rv
ic
es
,
si
n
ce
th
e
h
o
sp
it
al
in
d
ex
w
as
n
o
t
ca
lc
u
la
te
d
b
ef
o
re
1
9
9
7
.
A
PA
C
H
E
II
,
A
cu
te
P
h
ys
io
lo
gy
an
d
C
h
ro
n
ic
H
ea
lt
h
E
va
lu
at
io
n
II
;
C
D
,
ca
th
et
er
-d
ay
;
C
D
C
,
C
en
te
rs
fo
r
D
is
ea
se
C
o
n
tr
o
l
an
d
P
re
ve
n
ti
o
n
;
C
F
U
,
co
lo
n
y-
fo
rm
in
g
u
n
it
;
C
I,
co
n
fi
d
e
n
ce
in
te
rv
al
;
IC
U
,
in
te
n
si
ve
ca
re
u
n
it
;
L
O
S,
le
n
gt
h
o
f
st
ay
;
SD
,
st
an
d
a
r
d
d
ev
ia
ti
o
n
;
V
D
,
ve
n
ti
la
to
r-
d
ay
.
a
N
o
.
o
f
p
at
ie
n
ts
w
it
h
in
fe
ct
io
n
;
ex
cl
u
d
es
m
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s.
t
a
b
l
e
3.
Su
m
m
ar
y
o
f
4
St
u
d
ie
s
o
f
th
e
C
o
st
s
A
ss
o
ci
at
ed
w
it
h
V
en
ti
la
to
r-
A
ss
o
ci
at
ed
P
n
eu
m
o
n
ia
(V
A
P
)
V
ar
ia
b
le
L
an
sf
o
rd
et
al
1
3
C
o
ca
n
o
u
r
et
al
4
1
W
ar
re
n
et
al
1
4
R
el
lo
et
al
4
2
C
it
y
K
an
sa
s
C
it
y,
M
O
H
o
u
st
o
n
,
T
X
St
.
L
o
u
is
,
M
O
N
at
io
n
w
id
e
T
yp
e
o
f
p
at
ie
n
ts
,
b
y
h
o
sp
it
al
si
te
T
ra
u
m
a
IC
U
T
ra
u
m
a
IC
U
Su
rg
ic
al
an
d
m
ed
ic
al
IC
U
s
IC
U
N
o
.
o
f
p
at
ie
n
ts
a
1
3
7
0
1
2
7
8
1
6
C
o
st
an
al
ys
is
p
ri
m
ar
y
o
r
se
co
n
d
ar
y
ai
m
?
Se
co
n
d
ar
y
P
ri
m
ar
y
P
ri
m
ar
y
Se
co
n
d
ar
y
P
u
rp
o
se
o
f
ec
o
n
o
m
ic
an
al
ys
is
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
M
et
h
o
d
o
f
d
efi
n
in
g
in
fe
ct
io
n
B
y
in
fe
ct
io
n
co
n
tr
o
l
te
am
u
si
n
g
N
N
IS
cr
it
er
ia
B
y
in
fe
ct
io
n
co
n
tr
o
l
te
am
u
si
n
g
N
N
IS
cr
it
er
ia
B
y
in
fe
ct
io
n
co
n
tr
o
l
te
am
u
si
n
g
N
N
IS
cr
it
er
ia
N
o
t
re
p
o
rt
ed
C
o
n
tr
o
l
gr
o
u
p
P
at
ie
n
ts
in
sa
m
e
IC
U
w
it
h
o
u
t
in
fe
ct
io
n
M
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s:
m
at
ch
in
g
b
as
ed
o
n
ag
e
an
d
In
ju
ry
Se
ve
ri
ty
Sc
o
re
P
at
ie
n
ts
in
sa
m
e
IC
U
w
it
h
o
u
t
in
fe
ct
io
n
M
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s:
m
at
ch
in
g
b
as
ed
o
n
ty
p
e
o
f
ad
m
is
si
o
n
,
p
re
d
ic
te
d
m
o
rt
al
–
it
y,
d
u
ra
ti
o
n
o
f
ve
n
ti
la
ti
o
n
,
an
d
ag
e
M
et
h
o
d
o
f
d
et
er
m
in
in
g
co
st
A
ve
ra
ge
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
V
A
P
vs
p
at
ie
n
ts
w
it
h
o
u
t
V
A
P
A
ve
ra
ge
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
V
A
P
vs
p
at
ie
n
ts
w
it
h
o
u
t
V
A
P
A
ve
ra
ge
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
V
A
P
vs
p
at
ie
n
ts
w
it
h
o
u
t
V
A
P
A
ve
ra
ge
to
ta
l
ch
ar
ge
s
fo
r
p
at
ie
n
ts
w
it
h
V
A
P
vs
p
at
ie
n
ts
w
it
h
o
u
t
V
A
P
So
u
rc
e
o
f
co
st
d
at
a
(b
as
el
in
e
ye
ar
)
N
o
t
re
p
o
rt
ed
,
20
03
–
20
04
d
o
ll
ar
s
H
o
sp
it
al
co
st
ac
co
u
n
ti
n
g
d
at
ab
as
e,
2
0
02
–
2
00
3
d
o
ll
ar
s
H
o
sp
it
al
co
st
ac
co
u
n
ti
n
g
d
at
ab
as
e,
1
9
98
–
1
99
9
d
o
ll
ar
s
H
o
sp
it
al
b
il
le
d
ch
ar
ge
s
d
at
ab
as
e,
1
9
98
–
1
99
9
d
o
ll
ar
s
C
o
st
s
m
ea
su
re
d
T
o
ta
l
h
o
sp
it
al
co
st
s
an
d
ch
ar
ge
s;
d
et
ai
ls
an
d
o
ve
rh
ea
d
co
st
s
n
o
t
re
p
o
rt
ed
T
o
ta
l
IC
U
co
st
s;
d
et
ai
ls
an
d
o
ve
rh
ea
d
co
st
s
n
o
t
re
p
o
rt
ed
A
ll
co
st
s
in
d
at
ab
as
e,
in
cl
u
d
in
g
o
ve
rh
ea
d
A
ll
ch
ar
ge
s
in
d
at
ab
as
e,
o
ve
rh
ea
d
co
st
s
n
o
t
re
p
o
rt
ed
P
er
sp
ec
ti
ve
H
o
sp
it
al
H
o
sp
it
al
H
o
sp
it
al
H
o
sp
it
al
T
im
e
h
o
ri
zo
n
N
o
t
re
p
o
rt
ed
IC
U
st
ay
In
p
at
ie
n
t
st
ay
N
o
t
re
p
o
rt
ed
M
ai
n
ec
o
n
o
m
ic
o
u
tc
o
m
e
M
ea
n
in
cr
em
en
ta
l
ch
ar
ge
s
p
er
h
o
sp
i-
ta
li
za
ti
o
n
at
tr
ib
u
ta
b
le
to
V
A
P
M
ea
n
in
cr
em
en
ta
l
IC
U
co
st
s
p
er
st
ay
at
tr
ib
u
ta
b
le
to
V
A
P
A
d
ju
st
ed
m
ea
n
in
cr
em
en
ta
l
co
st
s
p
er
h
o
sp
it
al
iz
at
io
n
at
tr
ib
u
ta
b
le
to
V
A
P
M
ea
n
in
cr
em
en
ta
l
ch
ar
ge
s
p
er
h
o
sp
it
al
iz
at
io
n
at
tr
ib
u
ta
b
le
to
V
A
P
M
u
lt
iv
ar
ia
te
ad
ju
st
m
en
t
m
ad
e
to
co
st
es
ti
m
at
es
N
o
N
o
Y
es
;
re
gr
es
si
o
n
m
o
d
el
co
n
tr
o
ll
ed
fo
r
A
PA
C
H
E
II
sc
o
re
,
h
ea
rt
fa
il
u
re
,
C
A
B
SI
,
h
em
o
d
ia
ly
si
s,
tr
ac
h
eo
st
o
m
y,
n
u
m
b
er
o
f
C
V
C
s,
H
2
b
lo
ck
er
u
se
,
co
rt
ic
o
st
er
o
id
u
se
N
o
U
n
ad
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
M
ea
n
,
$
23
3,
09
9
(9
5%
C
I,
$
1
06
,2
00
–
$
3
60
,0
00
)
M
ea
n
,
$
57
,1
58
(9
5
%
C
I,
$
39
,3
0
0–
$
7
5,
0
00
)
M
ea
n
,
$
48
,9
48
(9
5
%
C
I,
$
38
,6
1
7–
$
5
9,
2
78
)
M
ea
n
,
$
41
,2
94
(9
5
%
C
I,
$
3
4,
9
00
–
$
47
,7
0
0)
A
d
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
i
s
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$1
1,
89
7
(9
5%
C
I,
$
5,
26
5–
$
2
6,
2
14
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
U
n
ad
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
M
ea
n
,
$
32
4,
00
0
(9
5%
C
I,
$
1
48
,0
00
–
$
5
00
,0
00
)
M
ea
n
,
$
84
,7
00
(9
5
%
C
I,
$
58
,2
0
0–
$
1
11
,0
00
)
M
ea
n
,
$
94
,6
00
(9
5
%
C
I,
$
75
,6
0
0–
$
1
14
,0
00
)
M
ea
n
,
$
80
,2
00
(9
5
%
C
I,
$
6
7,
5
00
–
$
92
,2
0
0)
A
d
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$2
3,
00
0
(9
5%
C
I,
$
10
,
1
00
–
5
0
,7
0
0)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
C
o
m
m
en
ts
A
rt
ic
le
m
et
h
o
d
re
p
o
rt
s
co
st
s,
re
su
lt
s
re
p
o
r
t
ch
ar
ge
s
n
o
t
e.
C
o
st
s
w
er
e
co
n
ve
rt
ed
to
2
0
0
9
d
o
ll
ar
s
u
si
n
g
th
e
C
o
n
su
m
er
P
ri
ce
In
d
ex
fo
r
H
o
sp
it
al
Se
rv
ic
es
(U
S
B
u
re
au
o
f
L
ab
o
r
St
at
is
ti
cs
)
.
C
D
C
,
C
en
te
rs
fo
r
D
is
ea
se
C
o
n
tr
o
l
an
d
P
re
ve
n
ti
o
n
;
C
F
U
,
co
lo
n
y-
fo
rm
in
g
u
n
it
;
C
I,
co
n
fi
d
en
ce
in
te
rv
al
;
IC
U
,
in
te
n
si
ve
ca
re
u
n
it
;
N
N
IS
,
N
at
io
n
a
l
N
o
so
co
m
ia
l
In
fe
ct
io
n
s
Su
rv
ei
ll
an
ce
.
a
N
o
.
o
f
p
at
ie
n
ts
w
it
h
in
fe
ct
io
n
;
ex
cl
u
d
es
m
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s.
t
a
b
l
e
4
.
Su
m
m
ar
y
o
f
3
St
u
d
ie
s
o
f
th
e
C
o
st
s
A
ss
o
ci
at
ed
w
it
h
C
at
h
et
er
-A
ss
o
ci
at
ed
U
ri
n
ar
y
T
ra
ct
In
fe
ct
io
n
(C
A
U
T
I)
V
ar
ia
b
le
T
am
b
ya
h
et
al
1
5
Sa
in
t
et
al
1
6
B
o
lo
gn
a
et
al
1
7
C
it
y
M
ad
is
o
n
,
W
I
Se
at
tl
e,
W
A
P
h
il
ad
el
p
h
ia
,
P
A
T
yp
e
o
f
p
at
ie
n
ts
,
b
y
h
o
sp
it
al
si
te
In
p
at
ie
n
ts
In
p
at
ie
n
ts
IC
U
N
o
.
o
f
p
at
ie
n
ts
a
1
2
3
N
o
ca
se
s
N
o
ca
se
s
C
o
st
an
al
ys
is
p
ri
m
ar
y
o
r
se
co
n
d
ar
y
ai
m
?
Se
co
n
d
ar
y
Se
co
n
d
ar
y
Se
co
n
d
ar
y
P
u
rp
o
se
o
f
ec
o
n
o
m
ic
an
al
ys
is
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
es
ti
m
at
io
n
C
o
st
es
ti
m
at
io
n
M
et
h
o
d
o
f
d
e
fi
n
in
g
in
fe
ct
io
n
B
ac
te
ri
a
o
r
fu
n
gi
at
co
n
ce
n
tr
at
io
n
o
f
1
1
,0
0
0
C
F
U
/m
L
N
o
ca
se
s
N
o
ca
se
s
C
o
n
tr
o
l
gr
o
u
p
N
o
co
n
tr
o
l
N
o
co
n
tr
o
l
N
o
co
n
tr
o
l
M
et
h
o
d
o
f
d
et
er
m
in
in
g
co
st
C
li
n
ic
ia
n
s’
re
tr
o
sp
ec
ti
ve
re
vi
ew
o
f
ch
ar
ts
an
d
b
il
ls
In
ve
st
ig
at
o
rs
’
es
ti
m
at
e
o
f
ad
d
it
io
n
al
le
n
gt
h
o
f
st
ay
,
te
st
in
g,
an
d
tr
ea
tm
en
t
n
ee
d
ed
In
ve
st
ig
at
o
rs
’
es
ti
m
at
e
o
f
ad
d
it
io
n
al
le
n
gt
h
o
f
st
ay
an
d
te
st
in
g
n
ee
d
ed
So
u
rc
e
o
f
co
st
d
at
a
(b
as
el
in
e
ye
ar
)
N
o
t
re
p
o
rt
ed
;
1
9
98
d
o
ll
ar
s
St
an
d
ar
d
h
o
sp
it
al
ch
ar
ge
m
u
lt
ip
li
ed
b
y
co
st
/c
h
ar
ge
ra
ti
o
;
1
99
8
d
o
ll
ar
s
N
o
t
re
p
o
rt
ed
,
b
as
el
in
e
ye
a
r
n
o
t
re
p
o
rt
ed
C
o
st
s
m
ea
su
re
d
L
a
b
te
st
co
st
s
an
d
m
ed
ic
at
io
n
co
st
s
0
.5
-d
ay
in
p
at
ie
n
t
st
ay
,
u
ri
n
e
an
al
ys
is
,
u
ri
n
e
cu
lt
u
re
,
an
d
se
n
si
ti
vi
ty
te
st
in
g;
an
ti
m
ic
ro
b
ia
l
th
er
ap
y
1
-d
ay
IC
U
st
ay
,
fe
ve
r
ev
al
u
at
io
n
P
er
sp
ec
ti
ve
H
o
sp
it
al
H
o
sp
it
al
H
o
sp
it
al
T
im
e
h
o
ri
zo
n
D
ia
gn
o
st
ic
an
d
tr
ea
tm
en
t
p
er
io
d
F
ix
ed
as
0
.5
a
d
d
it
io
n
al
in
p
at
ie
n
t
d
ay
F
ix
ed
as
1
ad
d
it
io
n
al
in
p
at
ie
n
t
d
ay
M
ai
n
ec
o
n
o
m
ic
o
u
tc
o
m
e
C
o
st
o
f
la
b
te
st
s
an
d
m
ed
ic
at
io
n
s
u
se
d
in
m
an
ag
em
en
t
o
f
C
A
U
T
I
C
o
st
o
f
h
o
sp
it
al
st
ay
,
la
b
o
ra
to
ry
te
st
s,
an
d
m
ed
ic
at
io
n
s
u
se
d
in
m
an
ag
em
en
t
o
f
C
A
U
T
I
C
o
st
o
f
IC
U
st
ay
an
d
d
ia
gn
o
st
ic
w
o
rk
u
p
u
se
d
in
m
an
ag
em
en
t
o
f
C
A
U
T
I
M
u
lt
iv
ar
ia
te
ad
ju
st
m
en
t
m
ad
e
to
co
st
es
ti
m
at
es
N
o
N
o
N
o
U
n
ad
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
M
ea
n
,
$5
89
E
st
im
at
e,
$2
,0
41
E
st
im
at
e,
$2
,4
71
A
d
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
U
n
ad
ju
st
ed
re
su
lt
s
(2
0
0
9
d
o
ll
ar
s)
E
st
im
at
e,
$
1
,2
0
0
E
st
im
at
e,
$
4
,0
0
0
E
st
im
at
e,
$
4
,7
0
0
A
d
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
C
o
m
m
en
ts
Ig
n
o
re
d
ad
d
it
io
n
al
p
h
ys
ic
ia
n
an
d
n
u
rs
in
g
co
st
s
an
d
co
st
o
f
b
lo
o
d
–
st
re
am
in
fe
ct
io
n
s
Ig
n
o
re
d
al
l
o
th
er
co
st
s,
su
ch
as
n
u
rs
in
g
an
d
p
h
ys
ic
ia
n
co
st
s;
se
le
ct
ed
lo
w
es
ti
m
at
es
o
f
co
st
s
P
ar
t
o
f
a
m
u
lt
ic
en
te
r
st
u
d
y;
co
st
an
al
ys
is
fo
r
ju
st
1
h
o
sp
it
al
;
ig
n
o
re
d
tr
ea
tm
en
t,
o
th
er
co
st
s;
se
–
le
ct
ed
lo
w
es
ti
m
at
e
so
as
n
o
t
to
o
ve
re
st
im
at
e
im
p
ac
t
o
f
p
re
ve
n
ti
o
n
m
ea
su
re
s
n
o
t
e.
C
o
st
s
w
er
e
co
n
ve
rt
ed
to
2
0
0
9
d
o
ll
ar
s
u
si
n
g
th
e
C
o
n
su
m
er
P
ri
ce
In
d
ex
fo
r
H
o
sp
it
al
Se
rv
ic
es
(U
S
B
u
re
au
o
f
L
ab
o
r
St
at
is
ti
cs
).
C
F
U
,
co
lo
n
y-
fo
rm
in
g
u
n
it
;
IC
U
,
in
te
n
si
ve
ca
re
u
n
it
.
a
N
o
.
o
f
p
at
ie
n
ts
w
it
h
in
fe
ct
io
n
;
ex
cl
u
d
es
m
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s.
t
a
b
l
e
5.
Su
m
m
ar
y
o
f
4
St
u
d
ie
s
o
f
th
e
C
o
st
s
A
ss
o
ci
at
ed
w
it
h
Su
rg
ic
al
Si
te
In
fe
ct
io
n
(S
SI
)
V
ar
ia
b
le
H
er
w
al
d
t
et
al
4
3
K
ir
k
la
n
d
et
al
4
4
P
er
en
ce
vi
ch
et
al
4
5
D
im
ic
k
et
al
4
6
C
it
y
Io
w
a
C
it
y,
IA
D
u
rh
am
,
N
C
B
o
st
o
n
,
M
A
A
n
n
A
rb
o
r,
M
I
T
yp
e
o
f
p
at
ie
n
ts
,
b
y
h
o
sp
it
al
si
te
G
en
er
al
,
ca
rd
io
th
o
ra
ci
c
su
rg
er
y
,
o
r
n
eu
ro
su
rg
er
y
A
ll
su
rg
er
y
A
ll
su
rg
er
y
G
en
er
al
o
r
va
sc
u
la
r
su
rg
er
y
N
o
.
o
f
p
at
ie
n
ts
a
3
1
6
2
5
5
2
6
7
7
5
C
o
st
an
al
ys
is
p
ri
m
ar
y
o
r
se
co
n
d
ar
y
ai
m
?
Se
co
n
d
ar
y
P
ri
m
ar
y
P
ri
m
ar
y
P
ri
m
ar
y
P
u
rp
o
se
o
f
ec
o
n
o
m
ic
an
al
ys
is
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
C
o
st
id
en
ti
fi
ca
ti
o
n
M
et
h
o
d
o
f
d
efi
n
in
g
in
fe
ct
io
n
B
y
in
d
ep
en
d
en
t
p
h
ys
ic
ia
n
s,
u
si
n
g
C
D
C
cr
it
er
ia
B
y
in
fe
ct
io
n
co
n
tr
o
l
n
u
rs
e,
u
si
n
g
N
N
IS
cr
it
er
ia
B
y
in
ve
st
ig
at
o
r,
u
si
n
g
N
N
IS
cr
it
er
ia
U
si
n
g
N
SQ
IP
cr
it
er
ia
C
o
n
tr
o
l
gr
o
u
p
P
at
ie
n
ts
in
sa
m
e
h
o
sp
it
al
w
it
h
o
u
t
in
fe
ct
io
n
M
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s:
m
at
ch
in
g
b
as
ed
o
n
N
N
IS
ri
sk
in
d
ex
,
ty
p
e
o
f
p
ro
ce
d
u
re
,
ag
e,
d
at
e
o
f
su
rg
er
y,
an
d
su
rg
eo
n
M
at
ch
ed
co
n
tr
o
l
su
b
je
ct
s:
m
at
ch
in
g
b
as
ed
o
n
ty
p
e
o
f
p
ro
ce
d
u
re
,
ag
e,
an
d
d
u
ra
ti
o
n
o
f
p
ro
ce
d
u
re
P
at
ie
n
ts
in
sa
m
e
h
o
sp
it
al
w
it
h
o
u
t
in
fe
ct
io
n
M
et
h
o
d
o
f
d
et
er
m
in
in
g
co
st
M
ed
ia
n
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
SS
I
vs
p
at
ie
n
ts
w
it
h
o
u
t
SS
I
M
ea
n
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
SS
I
vs
p
at
ie
n
ts
w
it
h
o
u
t
SS
I
M
ea
n
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
SS
I
vs
p
at
ie
n
ts
w
it
h
o
u
t
SS
I
M
ed
ia
n
to
ta
l
co
st
s
fo
r
p
at
ie
n
ts
w
it
h
SS
I
vs
p
at
ie
n
ts
w
it
h
o
u
t
SS
I
So
u
rc
e
o
f
co
st
d
at
a
(b
as
el
in
e
ye
ar
)
H
o
sp
it
al
fi
n
an
ci
al
d
e
p
ar
tm
en
t,
d
et
ai
ls
n
o
t
re
p
o
rt
ed
;
1
99
5–
1
9
98
d
o
ll
ar
s
C
o
st
ac
co
u
n
ti
n
g
d
at
ab
as
e;
1
99
1
–
1
99
5
d
o
ll
ar
s
H
o
sp
it
al
ch
ar
ge
s
m
u
lt
ip
li
ed
b
y
co
st
/
ch
ar
ge
ra
ti
o
;
1
99
8
d
o
ll
ar
s
C
o
st
ac
co
u
n
ti
n
g
d
at
ab
as
e;
2
00
1
–
2
00
2
d
o
ll
ar
s
C
o
st
s
m
ea
su
re
d
A
ll
h
o
sp
it
al
co
st
s
ex
cl
u
d
in
g
p
h
ys
ic
ia
n
s’
fe
es
,
o
ve
rh
ea
d
n
o
t
re
p
o
rt
ed
D
ir
ec
t
co
st
s:
o
ve
rh
ea
d
ex
cl
u
d
ed
,
d
e-
ta
il
s
n
o
t
re
p
o
rt
ed
A
ll
h
o
sp
it
al
an
d
o
u
tp
at
ie
n
t
ch
ar
ge
s,
o
ve
rh
ea
d
n
o
t
re
p
o
rt
ed
L
ab
o
r
an
d
su
p
p
ly
co
st
s,
d
et
ai
ls
n
o
t
re
–
p
o
rt
ed
,
o
ve
rh
ea
d
n
o
t
re
p
o
rt
ed
P
er
sp
ec
ti
ve
H
o
sp
it
al
H
o
sp
it
al
H
ea
lt
h
sy
st
em
H
o
sp
it
al
T
im
e
h
o
ri
zo
n
3
0
d
ay
s
af
te
r
o
p
er
at
io
n
3
0
d
ay
s
af
te
r
o
p
er
at
io
n
8
w
ee
k
s
af
te
r
d
is
ch
ar
ge
N
o
t
re
p
o
rt
ed
M
ai
n
ec
o
n
o
m
ic
o
u
tc
o
m
e
T
o
ta
l
p
o
st
o
p
er
at
iv
e
co
st
s
at
tr
ib
u
ta
b
le
to
th
e
SS
I
M
ea
n
in
cr
em
en
ta
l
d
ir
ec
t
co
st
p
er
h
o
sp
it
al
iz
at
io
n
as
so
ci
at
ed
w
it
h
th
e
SS
I
M
ea
n
in
cr
em
en
ta
l
co
st
p
er
ca
se
as
so
–
ci
at
ed
w
it
h
th
e
SS
I
M
ea
n
in
cr
em
en
ta
l
co
st
p
er
h
o
sp
it
al
iz
a-
ti
o
n
as
so
ci
at
ed
w
it
h
in
fe
ct
io
u
s
co
m
p
li
ca
ti
o
n
M
u
lt
iv
ar
ia
te
ad
ju
st
m
en
t
m
ad
e
to
co
st
es
ti
m
at
es
Y
es
,
b
u
t
re
su
lt
s
re
p
o
rt
ed
o
n
ly
as
p
er
–
ce
n
ta
ge
s;
re
gr
es
si
o
n
m
o
d
el
co
n
tr
o
ll
ed
fo
r
K
ar
n
o
fs
k
y
sc
o
re
,
N
N
IS
ri
sk
in
–
d
ex
,
n
u
m
b
er
o
f
co
m
o
rb
id
it
ie
s,
o
b
e-
si
ty
,
p
re
o
p
er
at
iv
e
L
O
S,
an
d
ag
e
N
o
N
o
Y
es
;
re
gr
es
si
o
n
m
o
d
el
co
n
tr
o
ll
ed
fo
r
p
ro
ce
d
u
re
co
m
p
le
xi
ty
,
p
at
ie
n
t
ch
ar
–
ac
te
ri
st
ic
s
(d
et
ai
ls
n
o
t
re
p
o
rt
ed
),
an
d
o
th
er
co
m
p
li
ca
ti
o
n
s
U
n
ad
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
M
ed
ia
n
,
$
3,
3
43
In
it
ia
l
st
ay
:
m
ea
n
,
$
3,
08
9
(9
5%
C
I,
$
2
,1
3
9–
$
4,
1
63
);
w
it
h
re
ad
m
is
si
o
n
:
m
ea
n
,
$
5,
0
38
(9
5
%
C
I,
$
4,
0
20
–
$
6
,2
8
9)
M
ea
n
,
$
3,
3
82
(9
5%
C
I,
$
1,
3
14
–
$
5
,4
5
0)
M
ed
ia
n
,
$
8,
0
39
A
d
ju
st
ed
re
su
lt
s
(a
s
p
u
b
li
sh
ed
)
In
cr
ea
se
o
f
25
%
–
10
6%
b
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$
1,
3
98
(9
5%
C
I,
$
37
7
–
$
2,
4
18
)
U
n
ad
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
M
ed
ia
n
,
$
5,
6
00
In
it
ia
l
st
ay
:
m
ea
n
,
$
6,
00
0
(9
5%
C
I,
$
4
,2
0
0–
$
8,
1
00
);
w
it
h
re
ad
m
is
si
o
n
:
m
ea
n
,
$
9,
8
00
(9
5
%
C
I,
$
7,
9
00
–
$
1
2,
3
00
)
M
ea
n
,
$
6,
7
00
(9
5%
C
I,
$
2,
6
00
–
$
1
0,
8
00
)
M
ed
ia
n
,
$
12
,9
00
A
d
ju
st
ed
re
su
lt
s
(2
00
9
d
o
ll
ar
s)
In
cr
ea
se
o
f
25
%
–
10
6%
b
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
N
o
m
u
lt
iv
ar
ia
te
an
al
ys
is
M
ea
n
,
$
2,
2
00
(9
5%
C
I,
$
60
0
–
$
3,
9
00
)
C
o
m
m
en
ts
C
o
st
m
et
h
o
d
s
gi
ve
n
in
se
p
ar
at
e
re
p
o
rt
4
7
M
o
st
ca
se
s
o
f
SS
I
ar
e
d
ia
gn
o
se
d
af
te
r
d
is
ch
ar
ge
In
fe
ct
io
u
s
co
m
p
li
ca
ti
o
n
s
in
cl
u
d
ed
4
1
w
o
u
n
d
in
fe
ct
io
n
s,
1
0
ca
se
s
o
f
se
p
si
s,
2
4
ca
se
s
o
f
w
o
u
n
d
d
eh
is
ce
n
ce
n
o
t
e.
C
o
st
s
w
er
e
co
n
ve
rt
ed
to
2
0
0
9
d
o
ll
ar
s
u
si
n
g
th
e
C
o
n
su
m
er
P
ri
ce
In
d
ex
(C
P
I)
fo
r
H
o
sp
it
al
Se
rv
ic
es
(U
S
B
u
re
au
o
f
L
ab
o
r
St
at
is
ti
cs
),
ex
ce
p
t
fo
r
K
ir
k
la
n
d
et
al
,4
4
fo
r
w
h
ic
h
co
st
s
w
er
e
co
n
ve
rt
ed
u
si
n
g
th
e
C
P
I
fo
r
H
ea
lt
h
ca
re
Se
rv
ic
es
,
b
ec
au
se
th
e
h
o
sp
it
al
se
rv
ic
es
co
m
p
o
n
en
t
w
as
n
o
t
ca
lc
u
la
te
d
b
ef
o
re
1
9
9
7
.
C
D
C
,
C
en
te
rs
fo
r
D
is
ea
se
C
o
n
tr
o
l
an
d
P
re
ve
n
ti
o
n
;
C
F
U
,
co
lo
n
y-
fo
rm
in
g
u
n
it
;
C
I,
co
n
fi
d
en
ce
in
te
rv
al
;
IC
U
,
in
te
n
si
ve
ca
re
u
n
it
;
L
O
S,
le
n
gt
h
o
f
st
ay
;
N
N
IS
,
N
at
io
n
al
N
o
so
co
m
ia
l
In
fe
ct
io
n
s
Su
rv
ei
ll
an
ce
;
N
SQ
IP
,
N
at
io
n
al
Su
rg
ic
al
Q
u
al
it
y
Im
p
ro
ve
m
en
t
P
ro
gr
am
.
a
N
o
.
o
f
p
at
ie
n
ts
w
it
h
in
fe
ct
io
n
;
ex
cl
u
d
es
m
at
ch
ed
co
n
tr
o
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1 1 0 i nf ec ti on c ont ro l a n d h osp ita l e p ide mi ol ogy f eb ru ary 2 0 11, v ol . 3 2, n o. 2
of preventable VAP are estimated to be $2.19 billion to 3.17
billion dollars annually. Costs of preventable CAUTIs are es-
timated to be $115 million to $1.82 billion annually, and the
costs of preventable SSIs are estimated to be $166 million to
$345 million.
d i s c u s s i o n
Past studies have estimated the number of infections pre-
vented or lives saved if hospitals followed best practices in
infection prevention and control. The Centers for Disease
Control and Prevention’s Study on the Efficacy of Nosocomial
Infection Control (SENIC) project made such an estimate in
1975.19 Its estimate considered that 30%–35% of most HAIs
were preventable with effective surveillance and control pro-
grams, including 22% of cases of pneumonia. In a 1985 fol-
low-up survey,20 the SENIC project found that only a fraction
of those infections were actually being prevented, because
many hospitals still had not implemented recommended in-
fection control measures. This was still the case in the present
decade.21 Our estimated ranges of potential reductions in
HAIs are in line with the most recent estimates by Kaye et al.22
The considerable uncertainty in our estimates of prevent-
able HAIs and the associated mortality and costs stems from
both the component numbers and the calculations them-
selves. First, while our estimates of the annual numbers of
HAIs and associated deaths are based on broad national sur-
veillance systems,2 those data are more than 5 years old and
do not capture the possibly lower infection and mortality
rates resulting from improved care practices implemented
since 2002. If care has improved since that time, the current
number of infections and deaths would be lower than those
observed in 2002. That would continue the trend observed
since 1975–1976, when the total number of HAIs estimated
by the SENIC project was 2.15 million.19 Second, there is no
definite way to attribute a death to an HAI, because patient
deaths frequently have multiple causes, and the role of in-
fection may not always be clear. Klevens et al2 attempted to
address this by only including deaths for which an infection
preventionist determined that the HAI caused or directly con-
tributed to the death, but this may overstate the number of
deaths of patients with HAI who may have actually died of
other causes. However, for some infections—specifically,
CABSI—other investigators have provided higher estimates
of attributable mortality than Klevens et al.2 Pittet and col-
leagues23 estimated an attributable mortality of 35% in sur-
gical ICU patients. For other HAIs, such as VAP, recent sys-
tematic reviews of the literature have highlighted difficulty of
quantifying the attributable mortality.24 Therefore, for most
HAIs additional studies are needed to determine the attrib-
utable mortality.
Certainty in the estimate of the proportion of HAIs that
are “reasonably preventable” is limited by the quality of the
HAI reduction studies. None of the studies was randomized,
and few were controlled, limiting the validity of reported risk
reductions. Most utilized a simple before-after design, com-
paring outcomes before and after an intervention to reduce
the incidence of HAIs, a design that cannot control for other
changes in patient care between the control period and the
intervention period and makes it difficult to attribute the
results to the intervention rather than to random variation,
patient selection, or other uncontrolled variables. To address
this limitation, we only included studies of good or moderate
quality in which causality could reasonably be attributed to
the intervention. In addition, some of the published studies
included in the AHRQ EPC report3 date back a decade or
more; infection prevention and control practices examined
in these older studies may be standard practice currently,
making large HAI reductions resulting from these interven-
tions less likely in modern hospitals. To address this limita-
tion, our analyses only included studies published in the past
decade.
Another source of uncertainty is generalizing from the re-
sults of studies in specialized populations, such as ICU pa-
tients, to patients on general hospital wards. In our review,
all but one of the CABSI, VAP, and CAUTI studies were
carried out in an ICU. The one study not performed in an
ICU examined CAUTI on a general medical ward.36 If that
study were discounted, the upper limit for the percentage of
HAIs that were reasonably preventable would fall from 69%
to 45%, which corresponds to 134,800 fewer preventable in-
fections, 3,100 fewer preventable deaths, and $160 million to
$630 million less in costs.
The key uncertainty in estimating “reasonably preventable”
HAI deaths is the fact that the studies we reviewed did not
directly measure death as an outcome. Instead, we extrapo-
lated reductions in death rates from the estimates of reduc-
tions in the number of HAIs, which have their own limita-
tions. In addition, in multiplying the estimated fraction of
HAIs that are preventable by the estimated number of HAI-
related deaths, we assume that the proportion of deaths that
are preventable is the same as the proportion of infections
that are preventable. The true effect on deaths could be larger
or smaller, depending on the extent to which preventive mea-
sures affect the severity of HAIs and the extent to which
preventive measures work for the kinds of patients who are
more susceptible to fatal HAIs. In addition, this review fo-
cused on HAIs associated with invasive devices and surgical
procedures but did not capture data on morbidity and mor-
tality associated with other infections, such as Clostridium
difficile infection.
Cost estimates are also limited, mostly by the poor design
of the available studies. In general, 2 types of cost analyses
were available in the published literature. The first was a raw
comparison of costs between patients with the HAI in ques-
tion and patients without an infection (unadjusted results).
Some of these studies attempted to control for confounding
variables, such as patient age and disease severity, by selecting
uninfected matched control patients for each infected case
patient. Others simply compared mean or median costs for
re a s on ab l y p re ve n t a b le h a i s 1 11
all infected patients and uninfected patients, an approach that
likely overestimates HAI costs because some of the variables
predicting increased risk of infection also predict increased
cost irrespective of infection. This limitation on the precision
of true cost estimates has been reviewed elsewhere.25 The
second type of cost analysis in the literature used regression
modeling to account for the effect of multiple variables, in-
cluding HAIs, on hospital costs (adjusted results). In all in-
stances, adjusted analyses yielded lower incremental costs per
infection than did the unadjusted analyses in the same study.
We used adjusted estimates if they were available, but in some
instances, such as for CAUTI, only a range of unadjusted
estimates was available, which increased the risk that we over-
estimated incremental costs.
Importantly, the cost objective of our study was to estimate
the incremental costs of HAIs to hospitals, not the cost-ef-
fectiveness of various interventions or “bundles” of practices
to prevent or decrease the incidence of HAIs. Hence, our cost
estimates do not factor in the costs of those interventions
required to prevent or reduce HAIs, such as those described
in the AHRQ EPC report (eg, use of chlorhexidine).3
Our study suggests that, in the patients and settings ex-
amined, HAIs have never been 100% preventable, even with
the implementation of comprehensive evidence-based infec-
tion control strategies. Instead, risk reductions may be limited
to 65%–70% for CABSI and CAUTI and approximately 55%
for VAP and SSI—reductions that may actually be overesti-
mated given the limitations cited above. The magnitude of
risk reductions did not appear to be associated with study
design or study quality. However, for all HAIs the studies of
patients with the highest risk of infection prior to the inter-
vention were often the studies that showed the greatest risk
reductions, and the studies of patients with the lowest risk
were the ones that demonstrated the smallest reductions; this
suggests regression to the mean.
Given the difficulty of preventing 100% of HAIs even with
comprehensive evidence-based interventions, it may be ap-
propriate to consider reimbursement strategies that encour-
age hospitals to reduce the incidence of HAIs while also ac-
counting for hospitals’ case mix indices. For example,
reimbursement based on a percentage reduction in the in-
cidence of an HAI or a reduction of the number of cases of
an HAI below a threshold set according to the case mix.
In conclusion, our findings suggest that the goal of pre-
venting 100% of HAIs may not be attainable even with use
of current evidence-based HAI prevention strategies; how-
ever, comprehensive implementation of such strategies could
prevent hundreds of thousands of HAIs and save tens of
thousands of lives and billions of dollars. Given their limi-
tations, the figures in our study should not be used as a basis
for policy decisions but should prompt future studies with
robust designs to measure accurately the impact of HAI re-
duction strategies and the incremental cost of HAIs.
acknowledgments
We thank our colleague David Goldmann, MD, at the University of Penn-
sylvania, for reviewing the manuscript and for his many thoughtful
suggestions.
Potential conflicts of interest. P.J.B. reports that he is chair of the Health-
care Infection Control Practices Advisory Committee of the Centers for
Disease Control and Prevention and past president of SHEA. The authors
report no other potential conflicts of interest.
Address reprint requests to Craig A. Umscheid, MD, MSCE, Assistant
Professor of Medicine and Epidemiology, Director, Center for Evidence-Based
Practice, University of Pennsylvania, 3535 Market Street, Mezzanine, Suite
50, Philadelphia, PA 19104 (craig.umscheid@uphs.upenn.edu
This study was originally performed for the Society for Healthcare Epi-
demiology of America (SHEA) and was included in its written testimony to
the Committee on Oversight and Government Reform in its “Hearing on
Healthcare-Associated Infections: A Preventable Epidemic,” chaired by Henry
A. Waxman on April 16, 2008, in Washington, DC. Findings from the man-
uscript were subsequently presented at the 19th Annual Scientific Meeting
of SHEA in San Diego, California, in 2009.
1 1 2 i nf ec ti on c ont ro l a n d h o sp ita l e p ide mi ol ogy f eb ru ary 2 01 1, v o l . 3 2 , n o. 2
a p p e n d i x a
table a1. Reported Rates of Healthcare-Associated Infections in US Hospitals in 2002
Type of infection
No. of
infections
No. of deaths
from infection
Case fatality
rate, %
Catheter-associated bloodstream infection 248,678 30,665 12.3
Ventilator-associated pneumonia 250,205 35,967 14.4
Catheter-associated urinary tract infection 561,667 13,088 2.3
Surgical site infection 290,485 8,205 2.8
Other 386,090 11,062 2.9
Total 1,737,125 98,987 5.7
note. Data are from Klevens et al.2
table a2. Evaluation of Studies of Prevention of Healthcare-Associated Infections
in US Hospitals Reported in the Agency for Healthcare Research and Quality (AHRQ)
Report and in the Present Report
No. of studies included,
by type of HAI
Variable CABSI VAP CAUTI SSI
EPC report
Controlled studies 2 0 3 4
Time-series studies 1 0 0 2
“Good” pre-post studies 6 3 0 1
“Moderate” pre-post studies 2 4 6 6
“Poor” pre-post studies 8 5 1 15
Total 19 12 10 28
Present report
Excluded from analysis
Because quality was low 10 5 1 15
Because more than 10 years old 0 1 3 3
Because only reported process outcomes 0 1 2 2
Because from outside US 2 2 2 5
Included in analysis 7 3 2 3
note. Data are from the AHRQ report by Ranji et al.3 CABSI, catheter-associated
bloodstream infection; CAUTI, catheter-associated urinary tract infection; EPC, evi-
dence-based practice center; SSI, surgical site infection; VAP, ventilator-associated pneu-
monia; US, United States.
re a s on ab l y p re ve n t a b le h a i s 1 13
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Healthcare-Associated Infections
Healthcare-Associated InfectionsNew
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Healthcare-Associated Infections
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Are In!
Check out our interactive infographic
to see progress toward the Healthcare Associated Infections objectives and other Healthy People topic areas.
Goal
Prevent, reduce, and ultimately eliminate healthcare-associated infections (HAIs).
Overview
HAIs are infections that patients get while receiving treatment for medical or surgical conditions, and many HAIs are preventable. Modern healthcare employs many types of invasive devices and procedures to treat patients and to help them recover. Infections can be associated with procedures (like surgery) and the devices used in medical procedures, such as catheters or ventilators. HAIs are important causes of morbidity and mortality in the United States and are associated with a substantial increase in health care costs each year. At any one time in the United States, 1 out of every 2
5
hospitalized patients are affected by an HAI.
1
HAIs occur in all types of care settings, including:
- Acute care hospitals
- Ambulatory surgical centers
- Dialysis facilities
- Outpatient care (e.g., physicians’ offices and health care clinics)
- Long-term care facilities (e.g., nursing homes and rehabilitation facilities)
The establishment of the Healthcare-Associated Infections objectives for Healthy People 2020 reflects the commitment of the U.S. Department of Health and Human Services (HHS) to preventing HAIs. These high-priority objectives address central line-associated bloodstream infections (CLABSI) and methicillin-resistant Staphylococcus aureus (MRSA) infections.
Besides these sources of HAIs, several other sources have been identified as major contributors to HAI-related illness and deaths in the
National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination
.
Common types of HAIs include:
- Catheter-associated urinary tract infections
- Surgical site infections
- Bloodstream infections
- Pneumonia
- Clostridium difficile
Why Are Healthcare-Associated Infections Important?
HAIs are a significant source of complications across the continuum of care and can be transmitted between different health care facilities. However, recent studies suggest that implementing existing prevention practices can lead to up to a
7
0 percent reduction in certain HAIs.2 Likewise, recent modeling data suggests that substantial reductions in resistant bacteria, like MRSA, can be achieved through coordinated activities between health care facilities in a given region.3 The financial benefit of using these prevention practices is estimated to be $25 billion to $31.5 billion in medical cost savings.4
Risk factors for HAIs can be grouped into three general categories: medical procedures and antibiotic use, organizational factors, and patient characteristics.5 The behaviors of health care providers and their interactions with the health care system also influence the rate of HAIs.
Studies have shown that proper education and training of health care workers increases compliance with and adoption of best practices (e.g., infection control, hand hygiene, attention to safety culture, and antibiotic stewardship) to prevent HAIs.5,
6
Examples of best practices by a health care provider include careful insertion, maintenance, and prompt removal of catheters, as well as the careful use of antibiotics. Another example of a best practice is decolonization of patients with an evidence-based method to reduce transmission of MRSA in hospitals.7
Back to Top
Related Topic Areas
Immunization and Infectious Diseases
Medical Product Safety
Social Determinants of Health
Emerging Issues in Healthcare-Associated Infections
Healthy People 2020 objectives measure progress toward reducing the incidence of CLABSI and invasive MRSA infections. However, more work needs to be done. In addition, there are other major types of HAIs that HHS is working to prevent, including those caused by antibiotic-resistant pathologens:
- Catheter-associated urinary tract infections
- Surgical site infections
- Ventilator-associated events/ventilator-associated pneumonia
- Clostridium difficile infections
Research suggests that many of these infections are preventable. Efforts are under way to expand implementation of strategies known to prevent HAIs, advance development of effective prevention tools, and explore new prevention approaches.
8
Many efforts to prevent HAIs have focused on acute care settings. Increasingly, health care delivery, including complex procedures, is being shifted to outpatient settings, such as ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities. These settings often have limited capacity for oversight and infection control compared to hospital-based settings. Because patients with HAIs, including HAIs caused by antibiotic resistance organisms, often move between various types of health care facilities, prevention efforts must also expand across the continuum of care. Moreover, the challenges posed by antibiotic-resistant organisms and C. difficile are best addressed through coordinated action among health care facilities in a given region.
The National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination contains strategies on preventing HAIs in non-acute care hospital settings and supports further research on how to identify and control HAIs in these settings and apply evidence-based approaches for reducing HAIs.
Learn More
National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination
AHRQ Healthcare-Associated Infections Program
AHRQ Comprehensive Unit Based Safety Program (CUSP)
CDC Infection Control in Healthcare
Healthcare Infection Control Practices Advisory Committee (HICPAC)
CMS Quality Initiatives
AHRQ Patient Safety Primer on Healthcare-Associated Infections
AHRQ CUSP for CLABSI Final Report
AHRQ Tools for Reducing CLABSI
Universal ICU Decolonization: An Enhanced Protocol
AHRQ Tools for Reducing Clostridium difficile Through Antibiotic Stewardship
CDC Vital Signs
Combating Antibiotic Resistant Bacteria
More
References
1Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. New England Journal of Medicine 2014; 370:1198-208.
2Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32.
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