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OBJECTIVE To create a national policy model to evaluate the projected cost-effectiveness of multiple hospital-based strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. DESIGN Cost-effectiveness analysis using a Markov microsimulation model that simulates the natural history of MRSA acquisition and infection. PATIENTS AND SETTING Hypothetical cohort of 10,000 adult patients admitted to a US intensive care unit. METHODS We compared 7 strategies to standard precautions using a hospital perspective: (1) active surveillance cultures; (2) active surveillance cultures plus selective decolonization; (3) universal contact precautions (UCP); (4) universal chlorhexidine gluconate baths; (5) universal decolonization; (6) UCP + chlorhexidine gluconate baths; and (7) UCP+decolonization. For each strategy, both efficacy and compliance were considered. Outcomes of interest were: (1) MRSA colonization averted; (2) MRSA infection averted; (3) incremental cost per colonization averted; (4) incremental cost per infection averted. RESULTS A total of 1989 cases of colonization and 544 MRSA invasive infections occurred under standard precautions per 10,000 patients. Universal decolonization was the least expensive strategy and was more effective compared with all strategies except UCP+decolonization and UCP+chlorhexidine gluconate. UCP+decolonization was more effective than universal decolonization but would cost $2469 per colonization averted and $9007 per infection averted. If MRSA colonization prevalence decreases from 12% to 5%, active surveillance cultures plus selective decolonization becomes the least expensive strategy. CONCLUSIONS Universal decolonization is cost-saving, preventing 44% of cases of MRSA colonization and 45% of cases of MRSA infection. Our model provides useful guidance for decision makers choosing between multiple available hospital-based strategies to prevent MRSA transmission.

Surgical site infection (SSI) surveillance is performed using a variety of methods with unclear performance characteristics. We used claims data to identify records for review following hysterectomy and colorectal surgery. Claims-enhanced screening identified SSIs missed by routine surveillance and could be used for targeted chart review to improve SSI detection.

ObjectiveWe sought to identify hospital characteristics associated with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) carriage among inpatients.Design Prospective cohort study.Setting Orange County, California.Participants Thirty hospitals in a single county.Methods We collected clinical MRSA isolates from inpatients in 30 of 31 hospitals in Orange County, California, from October 2008 through April 2010. We characterized isolates by spa typing to identify CA-MRSA strains. Using California's mandatory hospitalization data set, we identified hospital-level predictors of CA-MRSA isolation.Results CA-MRSA strains represented 1,033 (46%) of 2,246 of MRSA isolates. By hospital, the median percentage of CA-MRSA isolates was 46% (range, 14%-81%). In multivariate models, CA-MRSA isolation was associated with smaller hospitals (odds ratio [OR], 0.97, or 3% decreased odds of CA-MRSA isolation per 1,000 annual admissions; P < .001, hospitals with more Medicaid-insured patients (OR, 1.2; P = .002), and hospitals with more patients with low comorbidity scores (OR, 1.3; P < .001). Results were similar when restricted to isolates from patients with hospital-onset infection.Conclusions Among 30 hospitals, CA-MRSA comprised nearly half of MRSA isolates. There was substantial variability in CA-MRSA penetration across hospitals, with more CA-MRSA in smaller hospitals with healthier but socially disadvantaged patient populations. Additional research is needed to determine whether infection control strategies can be successful in targeting CA-MRSA influx.

BackgroundCentral line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures.ObjectiveEvaluate consistency and reasons for discordance among chart review and claims-based CLABSI events.MethodsWe conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). All events had full-text medical record reviews and were identified as concordant or discordant with the other metric.ResultsIn the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source.ConclusionSubstantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

ObjectiveTo assess the ability of Medicare claims to identify US hospitals with high rates of surgical site infection (SSI) after hip arthroplasty.DesignRetrospective cohort study.SettingAcute care US hospitals.ParticipantsFee-for-service Medicare patients 65 years of age and older who underwent hip arthroplasty in US hospitals from 2005 through 2007.MethodsHospital rankings were derived from claims codes suggestive of SSI, adjusted for age, sex, and comorbidities, while using generalized linear mixed models to account for hospital volume. Medical records were obtained for validation of infection on a random sample of patients from hospitals ranked in the best and worst deciles of performance. We then calculated the risk-adjusted odds of developing a chart-confirmed SSI after hip arthroplasty in hospitals ranked by claims into worst- versus best-performing deciles.ResultsAmong 524,892 eligible Medicare patients who underwent hip arthroplasty at 3,296 US hospitals, a patient who underwent surgery in a hospital ranked in the worst-performing decile based on claims-based evidence of SSI had 2.9-fold higher odds of developing a chart-confirmed SSI relative to a patient with the same age, sex, and comorbidities in a hospital ranked in the best-performing decile (95% confidence interval, 2.2-3.7).ConclusionsMedicare claims successfully distinguished between hospitals with high and low SSI rates following hip arthroplasty. These claims can identify potential outlier hospitals that merit further evaluation. This strategy can also be used to validate the completeness of public reporting of SSI.

BackgroundHospitalized patients are at increased risk for acquisition of methicillin-resistant Staphylococcus aureus (MRSA). As hospital length of stay shortens, hospital-acquired MRSA events may be more likely to be detected after discharge.ObjectiveWe assessed the impact of attributing MRSA cases discovered within 30 days after discharge to the most recent hospitalization and identified patient characteristics associated with MRSA detection after discharge.DesignRetrospective cohort study.SettingTwenty-seven acute care hospitals in Orange County, California.ParticipantsAdult acute care admissions (2002-2007).MethodsUsing a countywide hospital data set containing diagnostic codes with present-on-admission (POA) indicators, we identified the first admission with a MRSA code for each patient. This incident MRSA admission was defined as predischarge-detected (pre-DD) hospital-onset MRSA (HO-MRSA) when MRSA was not POA. If MRSA was POA and a prior admission occurred within 30 days, this prior admission was assigned postdischarge-detected (post-DD) HO-MRSA. We evaluated the impact of including post-DD HO-MRSA in the calculation of hospital HO-MRSA incidence using signed-rank tests and reviewed changes in hospital rankings. We conducted multivariate comparisons of patient characteristics of pre-DD versus post-DD HO-MRSA patients.ResultsAmong 1,217,253 at-risk hospitalizations, the inclusion of post-DD HO-MRSA tripled the median hospital HO-MRSA incidence, from 12.2 to 35.7 cases per 10,000 at-risk admissions (P < .0001). Hospital ranking changed substantially when including post-DD HO-MRSA. Patients with shorter stays were more likely to have post-DD MRSA.ConclusionsOn the basis of administrative claims data, the inclusion of post-DD HO-MRSA significantly increased the estimated HO-MRSA incidence and altered hospital rankings. This finding underscores the limitations of single-facility data when deriving HO-MRSA incidence and rank.

BackgroundAssessing the relative success of serial strategies for increasing healthcare personnel (HCP) influenza vaccination rates is important to guide hospital policies to increase vaccine uptake.ObjectiveTo evaluate serial campaigns that include a mandatory HCP vaccination policy and to describe HCP attitudes toward vaccination and reasons for declination.DesignRetrospective cohort study.MethodsWe assessed the impact of serial vaccination campaigns on the proportions of HCP who received influenza vaccination during the 2006-2011 influenza seasons. In addition, declination data over these 5 seasons and a 2007 survey of HCP attitudes toward vaccination were collected.ResultsHCP influenza vaccination rates increased from 44.0% (2,863 of 6,510 HCP) to 62.9% (4,037 of 6,414 HCP) after institution of mobile carts, mandatory declination, and peer-to-peer vaccination efforts. Despite maximal attempts to improve accessibility and convenience, 27.2% (66 of 243) of the surveyed HCP were unwilling to wait more than 10 minutes for a free influenza vaccination, and 23.3% (55 of 236) would be indifferent if they were unable to be vaccinated. In this context, institution of a mandatory vaccination campaign requiring unvaccinated HCP to mask during the influenza season increased rates of compliance to over 90% and markedly reduced the proportion of HCP who declined vaccination as a result of preference.ConclusionsA mandatory influenza vaccination program for HCP was essential to achieving high vaccination rates, despite years of intensive vaccination campaigns focused on increasing accessibility and convenience. Mandatory vaccination policies appear to successfully capture a large portion of HCP who are not opposed to receipt of the vaccine but who have not made vaccination a priority.

ObjectiveTo evaluate whether longitudinal insurer claims data allow reliable identification of elevated hospital surgical site infection (SSI) rates.DesignWe conducted a retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) in US hospitals performing at least 80 procedures in 2005. Hospitals were assigned to deciles by using case mix-adjusted probabilities of having an SSI-related inpatient or outpatient claim code within 60 days of surgery. We then reviewed medical records of randomly selected patients to assess whether chart-confirmed SSI risk was higher in hospitals in the worst deciles compared with the best deciles.ParticipantsFee-for-service Medicare beneficiaries who underwent CABG in these hospitals in 2005.ResultsWe evaluated 114,673 patients who underwent CABG in 671 hospitals. In the best decile, 7.8% (958/12,307) of patients had an SSI-related code, compared with 24.8% (2,747/11,068) in the worst decile ([Formula: see text]). Medical record review confirmed SSI in 40% (388/980) of those with SSI-related codes. In the best decile, the chart-confirmed annual SSI rate was 3.2%, compared with 9.4% in the worst decile, with an adjusted odds ratio of SSI of 2.7 (confidence interval, 2.2-3.3; [Formula: see text]) for CABG performed in a worst-decile hospital compared with a best-decile hospital.ConclusionsClaims data can identify groups of hospitals with unusually high or low post-CABG SSI rates. Assessment of claims is more reproducible and efficient than current surveillance methods. This example of secondary use of routinely recorded electronic health information to assess quality of care can identify hospitals that may benefit from prevention programs.

BackgroundSince hospitals in a region often share patients, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in one hospital could affect other hospitals.MethodsUsing extensive data collected from Orange County (OC), California, we developed a detailed agent-based model to represent patient movement among all OC hospitals. Experiments simulated MRSA outbreaks in various wards, institutions, and regions. Sensitivity analysis varied lengths of stay, intraward transmission coefficients (β), MRSA loss rate, probability of patient transfer or readmission, and time to readmission.ResultsEach simulated outbreak eventually affected all of the hospitals in the network, with effects depending on the outbreak size and location. Increasing MRSA prevalence at a single hospital (from 5% to 15%) resulted in a 2.9% average increase in relative prevalence at all other hospitals (ranging from no effect to 46.4%). Single-hospital intensive care unit outbreaks (modeled increase from 5% to 15%) caused a 1.4% average relative increase in all other OC hospitals (ranging from no effect to 12.7%).ConclusionMRSA outbreaks may rarely be confined to a single hospital but instead may affect all of the hospitals in a region. This suggests that prevention and control strategies and policies should account for the interconnectedness of health care facilities.

Postdischarge risks of vancomycin-resistant Enterococcus (VRE) infection among carriers are unknown. We conducted a retrospective cohort study of 199 patients newly detected as VRE carriers. Fifteen patients (8%) developed 27 VRE infections in the 18 months after detection. Among 10 postdischarge infections, 2 involved bacteremia and 3 resulted in readmission.

BackgroundAssessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier states.MethodsWe quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered "direct" transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered "indirect" patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection.ResultsIn 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals "exposed" more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers.ConclusionsIn a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.