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CDA 11-210
Using Economics and Epidemiology to Evaluate MRSA Decolonization in the VA
Richard E Nelson PhD
VA Salt Lake City Health Care System, Salt Lake City, UT
Salt Lake City, UT
Funding Period: March 2013 - February 2018

BACKGROUND/RATIONALE:
Treatments for infectious diseases are unique in that they produce externalities, spillover effects that are felt by individuals who are currently not infected. While these externalities are recognized, their magnitude is not well measured. Similarly, the impact of nosocomial infections on health care cost and utilization has not been quantified accurately. These two elements (externalities and costs) are important inputs to an economic analysis of any infectious disease treatment strategy.

OBJECTIVE(S):
The goal of this research is to apply cutting edge empirical methods of estimating the costs and benefits of prevention efforts for infectious disease transmission to the specific case of decolonization of MRSA within the VA. This research has 3 aims: (1) quantify the positive externalities associated with decolonization of MRSA positive veterans, (2) estimate the cost and healthcare use associated with hospital-acquired MRSA infections in the VA, and (3) perform economic analyses of a MRSA strategy that adds decolonization to the VA's current VA strategy of contact isolation.

METHODS:
In Aim (1), we will use a nationwide database of VA patient data obtained from Patient Care Services (PCS) to estimate the association between hospital-level decolonization use and resistance to this decolonization and the risk of hospital-acquired MRSA infection using multi-level logistic regressions. Next we will link this PCS data to VA Decision Support System (DSS) data to estimate the impact of MRSA infection on inpatient length of stay using inverse probability weights in a longitudinal logistic regression and on post-discharge health care costs and utilization using generalized linear models that are appropriate for skewed data, in Aim (2). In addition, we will link this PCS and DSS data to Medicare and VA Fee Basis data to capture post-discharge health care costs from outside the VA. Finally, in Aim (3), we will use the results for Aims (1) and (2) as inputs to an agent-based model of MRSA transmission to conduct dynamic economic analyses.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
By examining the associations between facility-level decolonization usage and MRSA infection rates, as well as the impact of MRSA infections on length of inpatient stay and post-discharge costs, we will provide valuable insight into the specific question of whether to add decolonization to the VA-wide initiative aimed at controlling Methicillin-resistant Staphylococcus aureus (MRSA) infections within VA hospitals. In addition, estimates of the cost of hospital-acquired MRSA infections can be used to determine the budget impact to the VA of the successful reduction in such infections resulting from the national VA MRSA Prevention Initiative.

Through this research and training experience, I will be prepared to conduct similar research in other healthcare-acquired and community-acquired infections that could impact infection control practice throughout the VA healthcare system.

Many of the methods that I am developing while conducting these analyses can be applied to non-infectious disease-related healthcare-associated events as well, such as venous thromboembolism. In addition, I am applying these methods to estimate the causal effect of a time-varying exposure on patient outcomes within the context of homelessness programs in the VA. This exercise is part of an IIR that was recently selected for funding by HSR&D.

The methods utilized in these analyses can be extended to identify variation in the effect of healthcare-associated infections by facility and by type of infection. In addition, variation in the process measures of the VA MRSA Prevention Initiative can be measured and combined with these other estimates in order to decompose the effect of the initiative. A better understanding of the MRSA Prevention Initiative can inform the ongoing efforts to reduce healthcare-associated infections due to other organisms in the VA such as Clostridium difficile and Gram-negative bacteria.

PUBLICATIONS:

Journal Articles

  1. Nelson RE, Evans ME, Simbartl L, Jones M, Samore MH, Kralovic SM, Roselle GA, Rubin MA. Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019 Feb 1; 68(4):545-553.
  2. Nelson RE, Suo Y, Pettey W, Vanneman M, Montgomery AE, Byrne T, Fargo JD, Gundlapalli AV. Costs Associated with Health Care Services Accessed through VA and in the Community through Medicare for Veterans Experiencing Homelessness. Health services research. 2018 Dec 1; 53 Suppl 3:5352-5374.
  3. Bress AP, Dodson JA, King JB, Sauer BC, Reese T, Crook J, Radwanski P, Knippenberg K, Greene T, Nelson RE, Munger MA, Weintraub WS, LaFleur J. Clinical and Economic Outcomes of Ranolazine Versus Conventional Antianginals Users Among Veterans With Chronic Stable Angina Pectoris. The American journal of cardiology. 2018 Dec 1; 122(11):1809-1816.
  4. Nelson RE, Hicken B, Vanneman M, Liu CF, Rupper R. The Impact of a Change in the Price of VA Health Care on Utilization of VA and Medicare Services. Medical care. 2018 Jul 1; 56(7):569-576.
  5. Livorsi DJ, Chorazy ML, Schweizer ML, Balkenende EC, Blevins AE, Nair R, Samore MH, Nelson RE, Khader K, Perencevich EN. A systematic review of the epidemiology of carbapenem-resistant Enterobacteriaceae in the United States. Antimicrobial resistance and infection control. 2018 Apr 24; 7:55.
  6. McDanel J, Schweizer M, Crabb V, Nelson R, Samore M, Khader K, Blevins AE, Diekema D, Chiang HY, Nair R, Perencevich E. Incidence of Extended-Spectrum -Lactamase (ESBL)-Producing Escherichia coli and Klebsiella Infections in the United States: A Systematic Literature Review. Infection control and hospital epidemiology. 2017 Oct 1; 38(10):1209-1215.
  7. Williams ST, Lawrence PT, Miller KL, Crook JL, LaFleur J, Cannon GW, Nelson RE. A comparison of electronic and manual fracture risk assessment tools in screening elderly male US veterans at risk for osteoporosis. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2017 Nov 1; 28(11):3107-3111.
  8. Nelson RE, Slayton RB, Stevens VW, Jones MM, Khader K, Rubin MA, Jernigan JA, Samore MH. Attributable Mortality of Healthcare-Associated Infections Due to Multidrug-Resistant Gram-Negative Bacteria and Methicillin-Resistant Staphylococcus Aureus. Infection control and hospital epidemiology. 2017 Jul 1; 38(7):848-856.
  9. Kamal MA, Smith PF, Chaiyakunapruk N, Wu DBC, Pratoomsoot C, Lee KKC, Chong HY, Nelson RE, Nieforth K, Dall G, Toovey S, Kong DCM, Kamauu A, Kirkpatrick CM, Rayner CR. Interdisciplinary pharmacometrics linking oseltamivir pharmacology, influenza epidemiology and health economics to inform antiviral use in pandemics. British journal of clinical pharmacology. 2017 Jul 1; 83(7):1580-1594.
  10. Pinto NM, Nelson R, Botto L, Puchalski MD, Krikov S, Kim J, Waitzman NJ. Costs, mortality, and hospital usage in relation to prenatal diagnosis in d-transposition of the great arteries. Birth defects research. 2017 Mar 1; 109(4):262-270.
  11. Lawrence PT, Grotzke MP, Rosenblum Y, Nelson RE, LaFleur J, Miller KL, Ma J, Cannon GW. The Bone Health Team: A Team-Based Approach to Improving Osteoporosis Care for Primary Care Patients. Journal of primary care & community health. 2017 Jul 1; 8(3):135-140.
  12. Chiang HY, Perencevich EN, Nair R, Nelson RE, Samore M, Khader K, Chorazy ML, Herwaldt LA, Blevins A, Ward MA, Schweizer ML. Incidence and Outcomes Associated With Infections Caused by Vancomycin-Resistant Enterococci in the United States: Systematic Literature Review and Meta-Analysis. Infection control and hospital epidemiology. 2017 Feb 1; 38(2):203-215.
  13. Nelson RE, Stevens VW, Khader K, Jones M, Samore MH, Evans ME, Douglas Scott R, Slayton RB, Schweizer ML, Perencevich EL, Rubin MA. Economic Analysis of Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. American journal of preventive medicine. 2016 May 1; 50(5 Suppl 1):S58-65.
  14. Nelson RE, Jones M, Leecaster M, Samore MH, Ray W, Huttner A, Huttner B, Khader K, Stevens VW, Gerding D, Schweizer ML, Rubin MA. An Economic Analysis of Strategies to Control Clostridium Difficile Transmission and Infection Using an Agent-Based Simulation Model. PLoS ONE. 2016 Mar 31; 11(3):e0152248.
  15. Nair R, Perencevich EN, Blevins AE, Goto M, Nelson RE, Schweizer ML. Clinical Effectiveness of Mupirocin for Preventing Staphylococcus aureus Infections in Nonsurgical Settings: A Meta-analysis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Mar 1; 62(5):618-30.
  16. Nelson RE, Nelson SD, Khader K, Perencevich EL, Schweizer ML, Rubin MA, Graves N, Harbarth S, Stevens VW, Samore MH. The Magnitude of Time-Dependent Bias in the Estimation of Excess Length of Stay Attributable to Healthcare-Associated Infections. Infection control and hospital epidemiology. 2015 Sep 1; 36(9):1089-94.
  17. Nelson RE, Samore MH, Jones M, Greene T, Stevens VW, Liu CF, Graves N, Evans MF, Rubin MA. Reducing Time-dependent Bias in Estimates of the Attributable Cost of Health Care-associated Methicillin-resistant Staphylococcus aureus Infections: A Comparison of Three Estimation Strategies. Medical care. 2015 Sep 1; 53(9):827-34.
  18. Stevens VW, Khader K, Nelson RE, Jones M, Rubin MA, Brown KA, Evans ME, Greene T, Slade E, Samore MH. Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model. Infection control and hospital epidemiology. 2015 Sep 1; 36(9):1024-30.
  19. Nelson RE, Khader K, Jones MM, Samore MH, Evans MF, Scott II, Slayton RB, Schweizer ML, Perencevich EL, Rubin MA. Economic Analysis of Veterans Affairs Initiative to prevent methicillin resistance Staphylococcus aureus infections. Antimicrobial resistance and infection control. 2015 Jun 16; 4(Suppl 1):doi: 10.1186/2047-2994-4-S1-O56.
  20. Nelson RE, Angelovic AW, Nelson SD, Gleed JR, Drews FA. An economic analysis of adherence engineering to improve use of best practices during central line maintenance procedures. Infection control and hospital epidemiology. 2015 May 1; 36(5):550-6.
  21. Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Graves N, Lee B, Rubin MA. The impact of healthcare-associated methicillin-resistant Staphylococcus aureus infections on post-discharge healthcare costs and utilization. Infection control and hospital epidemiology. 2015 May 1; 36(5):534-42.
  22. Varier RU, Biltaji E, Smith KJ, Roberts MS, Kyle Jensen M, LaFleur J, Nelson RE. Cost-effectiveness analysis of fecal microbiota transplantation for recurrent Clostridium difficile infection. Infection control and hospital epidemiology. 2015 Apr 1; 36(4):438-44.
  23. Nelson RE, Stevens VW, Jones M, Samore MH, Rubin MA. Health care-associated methicillin-resistant Staphylococcus aureus infections increases the risk of postdischarge mortality. American journal of infection control. 2015 Jan 1; 43(1):38-43.
  24. Nelson RE, Hoop R, Korner E, DuVall S, Hayden CL, Knippenberg K, Morgan T, Pandya P, Han J, LaFleur J. Predicting Discontinuation of Pegylated Interferon as a Result of Lack of Efficacy in United States Veterans With Chronic Hepatitis C on Dual Therapy. The Annals of pharmacotherapy. 2014 Jul 1; 48(7):826-836.
  25. Stevens V, Geiger K, Concannon C, Nelson RE, Brown J, Dumyati G. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clinical Microbiology and Infection : The Official Publication of The European Society of Clinical Microbiology and Infectious Diseases. 2014 May 1; 20(5):O318-24.
  26. LaFleur J, Hoop R, Morgan T, DuVall SL, Pandya P, Korner E, Knippenberg K, Hayden C, Nelson RE. High rates of early treatment discontinuation in hepatitis C-infected US veterans. BMC research notes. 2014 Apr 24; 7:266.
  27. Nelson RE, Battistone MJ, Ashworth WD, Barker AM, Grotzke M, Huhtala TA, Lafleur J, Tashjian RZ, Cannon GW. Cost effectiveness of training rural providers to perform joint injections. Arthritis care & research. 2014 Apr 1; 66(4):559-66.
  28. Nelson RE, Stenehjem D, Akerley W. A comparison of individualized treatment guided by VeriStrat with standard of care treatment strategies in patients receiving second-line treatment for advanced non-small cell lung cancer: A cost-utility analysis. Lung cancer (Amsterdam, Netherlands). 2013 Dec 1; 82(3):461-8.
  29. Nelson RE, Hicken B, Cai B, Dahal A, West A, Rupper R. Utilization of travel reimbursement in the Veterans Health Administration. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2013 Jul 29; 30(2):128-38.
  30. Akerley WL, Nelson RE, Cowie RH, Spinella DG, Hornberger J. The impact of a serum based proteomic mass spectrometry test on treatment recommendations in advanced non-small-cell lung cancer. Current Medical Research and Opinion. 2013 May 1; 29(5):517-25.
  31. Nelson RE, Nebeker JR, Hayden C, Reimer L, Kone K, LaFleur J. Comparing adherence to two different HIV antiretroviral regimens: an instrumental variable analysis. AIDS and behavior. 2013 Jan 1; 17(1):160-7.
  32. Nelson RE, Jones M, Rubin MA. Decolonization with Mupirocin and Subsequent Risk of Methicillin-Resistant Staphylococcus aureus Carriage in Veterans Affairs Hospitals. Infectious Diseases and Therapy. 2012 Dec 1; 1(1):1.
  33. Nelson RE, Hicken B, West A, Rupper R. The effect of increased travel reimbursement rates on health care utilization in the VA. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2012 Jul 31; 28(2):192-201.
  34. Byington CL, Reynolds CC, Korgenski K, Sheng X, Valentine KJ, Nelson RE, Daly JA, Osguthorpe RJ, James B, Savitz L, Pavia AT, Clark EB. Costs and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012 Jul 1; 130(1):e16-24.
Journal Other

  1. Jones MM, Nelson RE, Rubin MA. Cumulative Attributable Difference: An Infection Metric That Reflects a Value System. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2015 Dec 1; 36(12):1385-7.
Center Product

  1. Nelson RE. Cost Effective Analysis on VA Interventions to inform VA Decision Makers. 2017 Jul 1.
Conference Presentations

  1. Nelson RE, Slayton RB, Stevens V, Jones MM, Khader K, Jerigan J, Rubin MA, Samore MH. The risk of mortality following healthcare associated infections due to Gram negative bacteria. Poster session presented at: Infectious Diseases Week; 2015 Oct 7; San Diego, CA.
  2. Nelson RE, Jones MM, Rubin MA, Samore MH. Avoiding time-dependent bias in estimating the attributable cost of healthcare-associated methicillin-resistant Staphylococcus aureus infections. Poster session presented at: ID Week: A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2014 Oct 8; Philadelphia, PA.
  3. Nelson RE, Butler J, DuVall SL, LaFleur J, Xie Y, Shuerch M, Foskett N. Multiple sclerosis subtypes and serious infections resulting in a hospitalization in the Veterans Health Administration. Poster session presented at: Pharmacoepidemiology and Therapeutic Risk Management Annual International Conference; 2013 Nov 25; Montreal, Canada.
  4. Nelson RE, Battistone MJ, Ashworth WD, Barker A, Grotzke M, Huhtala TA, Tashjian RZ, Cannon GW. Cost-effectiveness of Training Rural Providers to Perform Joint Injections. Paper presented at: American College of Rheumatology Annual Scientific Meeting; 2013 Nov 9; Washington, DC.
  5. Nelson RE, Blaschke AJ. Economic Analysis of Rapid and Highly Sensitive PCR Testing for Viral Respiratory Infections in Children with Influenza Like Illness. Paper presented at: ID Week: A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2013 Oct 2; San Francisco, CA.
  6. DuVall SL, Butler J, LaFleur J, Nelson RE, Kamauu A, Shuerch M, Foskett N. Determining multiple sclerosis subtype from electronic medical records. Poster session presented at: Pharmacoepidemiology and Therapeutic Risk Management Annual International Conference; 2013 Aug 25; Montreal, Canada.
  7. Nelson RE, LaFleur J, Xie Y, Kamauu A, Shuerch M, Foskett N. Multiple sclerosis subtypes and serious infections resulting in a hospitalization in the Veterans Health Administration. Poster session presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2013 May 20; New Orleans, LA.
  8. Nelson RE, Xie Y, Kamauu A, LaFleur J, Schuerch M, Foskett N. Multiple sclerosis early treatment rates in U.S. Veterans. Poster session presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2013 May 18; New Orleans, LA.


DRA: Health Systems, Infectious Diseases
DRE: Prevention, Epidemiology
Keywords: none
MeSH Terms: none

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