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Impact of Healthcare Acquired Infections on Length of Stay and Treatment costs

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Abstract Healthcare-associated infections (HCAI) are infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting. HCAI are preventable complications occurring with varying but with significant frequency.  HCAI are preventable complications which adversely affect the Length of Stay (LOS), morbidity and mortality of the patients. A review of literature was undertaken to find the magnitude of the reported incidence rate, LOS, morbidity & mortality rates reported in literature. HCAI have been reported to have an average incidence rate of 10.8 % (3.9 % to 34 %.). In high income countries approximately 30% of ICU patients are affected by at least one HCAI. Additional length of stay in HCAI varies from 9.3 days to 23 days in different studies. Patients with HCAI accounted for 20.2% of the total bed days while 79.8 % bed days were accounted for patients without HCAI.  Re-admission rates were also found to be higher in patients with HCAI (26%) as compared to patients without HCAI (19.6%). A 30-day mortality rate in Clostridium difficile infection is estimated to vary from 3%-30% in different countries. 90-day mortality rate in hospitalized older adults rose from 33.2%-49.4% in cases with bloodstream infection. One year mortality was 15.2% in patients without HAI as compared to 24.5% in patients with HAI. The extra mortality due to HCAI was 9.3%. Common HCAI are Catheter Associated Urinary Tract Infections, Central Venous Catheter Associated Blood Stream Infections, Ventilator Associated Pneumonia and Surgical Site Infection. Different infections have a different prevalence rates in different wards related to source of infection. Ventilator Associated Pneumonias are more common in ICUs where patients are on assisted ventilation. Surgical site infections are more frequent in surgical wards. Catheter associated Urinary Tract Infections and Central Venous Catheter related Blood Stream Infections may have high prevalence in both surgical and medical wards. Burns wards also have a high prevalence rate of HCAI. Gynecology & Obstetrics wards have usually a low prevalence of HCAIs. As the infective organisms originate from the hospital flora, they are resistant to many of the commonly used antibiotics, thereby necessitating use of higher drugs and higher cost of treatment. The financial impact of this is seen in terms of increased burden of treatment costs, from increased Length of Stay (LOS) loss of earning due to high and prolonged morbidity due to absenteeism and loss of earning life span of bread earner due to higher mortality. This increased cost of treatment adds to the financial burden to the payers namely, government, insurers as well as patients paying out of pocket. Incidence of HCAI differs from country to country and from hospital to hospital in different studies and hence the financial burden varies accordingly. Cost of treatment can be reduced by controlling HCAI. Payers such as Government, Insurance companies and Hospitals should get together to ensure mitigation of the risks of HCAI and bring down the cost of treatments in hospitals. Key Words: Healthcare Associated Infections, Length of Stay, Re-admission rate, Financial Burden Aim: The aim of this study was to evaluate theimpact of HCAI on LOS, morbidity, mortality andhealth care costs. Methodology: In an attempt to find all relevant information related to the topic an extensive search of literature in English language was performed using online search engines: PubMed, Google Scholar and other digital sources available online. Basis PRISMA guidelines 19 articles providing information on LOS and economic impact in the various types of HCAI were included in this review article. Introduction Health care-associated infection (HCAI), also referred to as “nosocomial” or “hospital” infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility which was neither present nor incubating at the time of admission. HCAI can affect patients in any type of setting where they receive care and can also appear after discharge. Furthermore, they include occupational infections among staff. HCAI represents the most frequent adverse and preventable event during care delivery and no institution or country has ever been able to claim to have solved the problem as yet. Based on a significant amount of data made available from various countries, it is estimated that each year, hundreds of millions of patients around the world are affected by HCAI. The burden of HCAI is several fold higher in low- and middle-income countries than in high-income countries.HCAI results in prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional costs for health systems, high costs for patients and their family, and unnecessary deaths.Although HCAI is the most frequent adverse event in health care, its true global burden remains unknown because of the difficulty in gathering reliable data: most countries lack surveillance systems for HCAI, and those that do have them struggle with the complexity and the lack of uniformity of criteria for diagnosing it.[1] Findings: Health care-associated infection (HCAI), also referred to as “nosocomial” or “hospital” infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission. HCAI can affect patients in any type of setting where they receive care and can also appear after discharge. Furthermore, they include occupational infections among staff.[1, 2, 3, 4, 5]. HCAI can also present as postoperative infection within 30 days from surgery or within 1 year if implantation surgery; device-related infections due to central venous catheters, urinary tract catheters, ventilator treatment, or endotracheal tubes or indwelling cerebral ventricular drainage; drug-related infections defined as C difficile enteritis, infections related to chemotherapy for cancer, or infections due to other immune-modulating drugs or corticosteroids; and other infections occurring after 48 hours of admission. The HAI was categorized according to the suspected anatomic site of the infection origin.[6] Incidence HAIs are known to comprise the largest part of adverse events in health care and cause prolonged hospital length of stay (LOS) and deaths. [2, 3, 4, 5] Different studies on HCAI have reported different incidences varying between 3.9% and 34%. All studies point to the fact that the problem is significant and poses the payer system enormous financial burden. [7]. WHO has reported an incidence of between 5.7 and 19.1% in middle and low income countries.[8] In high income countries approximately 30% of the patients in ICU are affected by at least one HCAI during the stay in the ICU. HCAIs adversely affect the LOS, morbidity, mortality and cost of treatments posing a high financial burden on the payer system.[8, 9] The prevalence rate of HCAI varied significantly between clinical units, ranging from 3.9% to 34.0%, being the highest in ICU and Burns wards and lowest in Gynecology & Obstetrics wards. In a study reported in American Journal of Infection Control,Mikael Rahmqvist et all have reported an average prevalence rate of HCAI to be 10.8% with higher prevalence in males than females and lower in children (4.3%). [10] Mortality: HCAI are known to increase the preventable mortality rates tremendously, thus reducing the earning life span in patients suffering from HCAI.The study reported an in hospital mortality due to HCAI to be 17.4% with 30 day mortality on follow up patients reported to be 15.8%. Both the reported figures were significantly higher as compared to mortality rates in patients without HCAI.[10] In US 20, 00,000 patients are hospitalized every year for treatment. 90,000 of these patients succumb to nosocomial infections every year. [11] One year mortality was 15.2% in patients without HAI as compared to 24.5% in patients with HAI. The extra mortality due to HCAI was 9.3%.  [10, 12, 13]. Klevens et al estimated a US case fatality rate of HAI in hospitalized patients to 5.7% during 1999-2002, with the highest mortality rate in ventilator-associated pneumonia (14.4%) and catheter-associated bloodstream infections (12.3%). [13]. In Europe the 30-day mortality rate for Clostridium difficile infection (CDI) is estimated to be from 3%-30% in different countries. [14] Kaye et al showed that the 90-day mortality rate in hospitalized older adults rises from 33.2%-49.4% in patients with a health care-associated bloodstream infection. [15] LOS& Morbidity: The additional length of stay due to HCAI varies with the site of organ or the body system affected as well as the specialty of admission, ranging from 9.3 days to 23 days in different studies. Plowman et al found that HAIs in general extended the LOS by 14 days, which was almost 3 times longer than the average LOS for patients without an HAI. There was a large variation in extended stay depending on the site of single infection (2-13 days) and admission specialty (1-23 days). [16, 17]. Sheng et al found an additional LOS was around 20 days for patients affected by an HCAI. [18] Bed Days: Patients with HCAI accounted for 20.2% of the total bed days while 79.8 % bed days were accounted for patients without HCAI.Of all days, 9.3% were considered to be excess days for the group with an HAI.The average of excess days were 10.5 per patient with an HAI. The cost for the excess days was, after adjustment, 11.4% of the total costs [10]. Re-admission rates: Mikael Rahmqvistetal reported a 30 days re-admission rate to be 29 % in cases with HCAI as against 16.5% in cases without HCAI. Half of the readmissions (49.6%) were within 10 days of discharge from the hospital. [10] Readmission rates add to treatment costs increasing the financial burden on payer systems. Chopra et al found that it was about twice as common in patients with CDI who had a readmission within 30 days compared with all other patients (30.1% vs 14.4%). [19] Cost of Treatment A study by the Center for Disease Dynamics Economics & Policy has shown the additional cost of treatment due to HCAI in US amounts to 9.8 billion US dollars annually. The healthcare payer system has to meet the additional expenses due to, the additional length of stay, the cost of additional higher drugs that need to be administered due to drug resistance of the infecting organisms and the prolonged morbidity and higher mortality with its accompanying loss of earning for the family. The 11.4 % additional cost was related only to the additional LOS.  There is also additional cost of treatment due to the higher antibiotics administered due to drug resistance to routine drugs. Discussion: Healthcare associated infections (HCAI) and antimicrobial resistance are principal threats to the patients of intensive care units, surgical and burns wards. These remain the major determining factors for determination of patient treatment outcome. They are associated with increased morbidity, mortality, excess& prolonged hospitalization and higher financial costs of medical treatments. The incidence of HCAI varies between 3.9% and 34% of all hospital admissions.[7]. Patients affected by HCAI have a longer hospital stay sometimes in excess of 23 dayswhich is about 4 to 5 times the average LOS of 5 days for their counterparts who have not been infected by HCAI. Also, patients with HCAI discharged from the hospital have a higher readmission rate of 29% (as against readmission rate of 16.5 % for non HCAI patients)for any of the complications of HCAI thereby adding to the cost of a second hospitalization under bed days and medication charges for higher medicines in infections by drug resistant organisms. Patients with HCAI have a higher 30 day mortality of 17.4% as compared to patients without HCAI. This may falsely reduce the cost and LOS findings due to early death following HCAI. Follow up patients with HCAI have a lower mortality of 15.8%. Health care–associated infections are largely preventable, but are associated with considerable health care burden. The causes of HCAI have been fairly well identified. Amongst the important ones are- improper hand hygiene, prolonged and injudicious use of catheters, improper handling of urinary collection systems and airborne transmission of infectious agents caused by less than adequate respiratory precautions. [6] Healthcare associated infections (HCAI) and antimicrobial resistance are two main threats to the morbidity & mortality to patients being treated in intensive care units. HCAI become major determinants of patient treatment outcome. The associated increased morbidity, mortality, and excess LOS have a direct impact on the financial costs of treatment. Healthcare acquired infections rate has been rising in developing countries. This has led to significant increase in LOS and medication costs. Emergence of drug resistant species of common infective agents such as MRSA, VRE, and others add to the burden of medical treatment costs. Patients with HCAI spend higher number of bed days and cost higher than average patients without HCAI. Patients with HAI have a larger proportion of readmissions compared with patients with no HAI (29.0% vs 16.5%). Of the total bed days, 9.3% was considered to be excess days attributed to the group of patients with an HAI. The excess LOS comprised 11.4% of the total costs [10] Increasing healthcare costs affect the economical functioning of healthcare providers and payers. Apart from the direct financial burden on patients it also leads to indirect costs in form of loss of income for the patients and their families. It is imperative for healthcare organizations and payers to make hospitals accountable for the occurrence of HCAI and its related increase in direct and indirect cost of treatment. HCAI also lead to significant morbidity & mortality adding to the sufferings of the patients and their families.It may be argued that an increase in mortality would reduce the LOS and cost of treatment but it may be equally true that the prolonged morbidity period and cost may then convert a morbidity into mortality. Sheng et alfoundan additional LOS was around 20 days for patients affected by an HCAI. They also addressed a difficulty regarding estimating costs for HAIs among inpatients by pointing out a higher mortality rate among patients with an HAI than among uninfected patients. Death reduces the direct medical costs but represents for each patient a unique loss of potential life years. [10, 18] Conclusions HCAI are easily preventable complications of treatments in any healthcare settings. They contribute significantly to increase in healthcare costs by increasing LOS and higher medication costs due to infections by drug resistant organisms. HCAI also increase the morbidity and mortality. Focusing on reduction of HCAI can reduce healthcare cost burden on the payer systems. Healthcare providers need to focus on the prevention of HCAI and Healthcare payer systems should hold healthcare providers accountable for the expenses related to HCAI. Summary HCAI are preventable complications of Healthcare treatments. LOS in hospital is increased due to HCAI and so are the treatment costs related to duration of hospital stay as well as use of higher medications as infective agents are resistant to commonly used medicines. HCAI also increase the morbidity and mortality of patients undergoing treatment. This poses additional financial burden on healthcare payer system which can be controlled by proper control and surveillance of HCAI.  Financial Support & Sponsorship: Nil  Conflict of Interest: There are no conflicts of interests.
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Author Authors: Prof. Dr. Bharat S. Powdwal*, Dr. Tulna Jaiswal, Dr. Sharvari Shukla, Dr. Biranchi Jena *Corresponding Author: Prof. Dr. B. S. Powdwal:[email protected], mobile: 08600031357  

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