How do we evaluate the cost of nosocomial infection? The ECONI protocol: an incidence study with nested case-control evaluating cost and quality of life

Introduction Healthcare-associated or nosocomial infection (HAI) is distressing to patients and costly for the National Health Service (NHS). With increasing pressure to demonstrate cost-effectiveness of interventions to control HAI and notwithstanding the risk from antimicrobial-resistant infections, there is a need to understand the incidence rates of HAI and costs incurred by the health system and for patients themselves. Methods and analysis The Evaluation of Cost of Nosocomial Infection study (ECONI) is an observational incidence survey with record linkage and a nested case-control study that will include postdischarge longitudinal follow-up and qualitative interviews. ECONI will be conducted in one large teaching hospital and one district general hospital in NHS Scotland. The case mix of these hospitals reflects the majority of overnight admissions within Scotland. An incidence survey will record all HAI cases using standard case definitions. Subsequent linkage to routine data sets will provide information on an admission cohort which will be grouped into HAI and non-HAI cases. The case-control study will recruit eligible patients who develop HAI and twice that number without HAI as controls. Patients will be asked to complete five questionnaires: the first during their stay, and four others during the year following discharge from their recruitment admission (1, 3, 6 and 12 months). Multiple data collection methods will include clinical case note review; patient-reported outcome; linkage to electronic health records and qualitative interviews. Outcomes collected encompass infection types; morbidity and mortality; length of stay; quality of life; healthcare utilisation; repeat admissions and postdischarge prescribing. Ethics and dissemination The study has received a favourable ethical opinion from the Scotland A Research Ethics Committee (reference 16/SS/0199). All publications arising from this study will be published in open-access peer-reviewed journal. Lay-person summaries will be published on the ECONI website. Trial registration number NCT03253640; Pre-results

Impact of surgical-site infection on health utility values: a meta-analysis

Background: SSI are recognised as negatively affecting patient quality of life. Currently, no meta-analysis of SSI utility values is available in the literature to inform estimates of this burden and investment decisions in prevention. Method: A systematic search of PubMed, Medline, CINAHL and the NHS Economic Evaluation Database was performed in April 2022 as per PROSPERO registration CRD 42021262633. Studies were included where quality of life data was gathered from adults undergoing surgery whereby quality of life data was presented as those with infection and those without at similar time points. Two researchers performed data extraction and quality appraisal independently, with a third as arbiter. Utility values were converted to EQ-5D. Meta-analyses were conducted using a random effects model across all relevant studies with subgroup analyses on SSI type and timing since surgery. Results: 15 studies met the inclusion criteria with 2817 patients; six studies across seven time points were used for meta-analysis. The pooled mean difference in EQ-5D utility in all studies combined was – 0.08 (95% CI -0.11 - -0.05, I2 = 40%, prediction interval -0.16 to -0.01.). The mean difference in EQ-5D utility associated with Deep SSI was -0.10 (95%CI -0.14 - -0.06, I2 = 0.00%) and the mean difference in EQ-5D persisted over time. Conclusion: The first synthesised estimate of SSI burden over the short and long term is provided. EQ-5D utility estimates for a range of SSI are essential for infection prevention planning and future economic modelling.I am uploading the PDF of the accepted manuscript and will update it with the PDF proof once availabl

Exploring the gender gap in young adult mental health during COVID-19: Evidence from the UK

AimsTo explore the prevalence of a mental health gender gap within a young adult sample during the COVID-19 pandemic, and to identify the impact of loneliness and domestic time use on young people’s, and particularly young women’s mental health.MethodUsing data from the UK Longitudinal Household Survey (UKHLS), this research examines mental health prior to the pandemic (2019) and during the pandemic (April 2020 until September 2021). A random-effects regression analysis was conducted to examine the effects of loneliness, and domestic factors across age and gender to ascertain their contribution to the mental health gender gap in a young adult population.ResultsAverage mental health decline was consistently higher for women compared to men, and young people (ages 16–24) saw a reduction in mental health twice as much as those in the oldest age category (over 65). Loneliness accounted for a share of the mental health gender gap, and a more decrease in mental health was recorded for young women experiencing loneliness, compared to older age groups. Domestic and familial factors did not have a significant impact on young people’s mental health.ConclusionsAlthough across all ages and genders, mental health had returned to near pre-pandemic levels by September 2021, young people and especially women continue to have worse mental health compared to other age groups, which is consistent with pre-COVID age and gender inequalities. Loneliness is a key driver in gendered mental health inequalities during the pandemic in a young adult population

Estimating excess length of stay due to healthcare-associated infections : a systematic review and meta-analysis of statistical methodology

BACKGROUND: Healthcare-associated infection (HAI) affects millions of patients worldwide. HAI is associated with increased healthcare costs, owing primarily to increased hospital length of stay (LOS) but calculating these costs is complicated due to time-dependent bias. Accurate estimation of excess LOS due to HAI is essential to ensure we invest in cost-effective infection prevention and control (IPC) measures. AIM: To identify and review the main statistical methods that have been employed to estimate differential LOS between patients with, and without, HAI; to highlight and discuss potential biases of all statistical approaches. METHODS: A systematic review from 1997 to April 2017 was conducted in PUBMED, CINAHL, PROQUEST and ECONLIT databases. Studies were quality assessed using an adapted Newcastle-Ottawa Scale (NOS). Methods were categorised into time-fixed or time-varying with the former exhibiting time-dependent bias. We use two examples of meta-analysis to illustrate how estimates of excess LOS differ between different studies. FINDINGS: Ninety-two studies with estimates on excess LOS were identified. The majority of articles employed time-fixed methods (75%). Studies using time-varying methods are of higher quality according to NOS. Studies using time-fixed methods overestimate additional LOS attributable to HAI. Undertaking meta-analysis is challenging due to a variety of study designs and reporting styles. Study differences are further magnified by heterogeneous populations, case definitions, causative organisms and susceptibilities. CONCLUSIONS: Methodologies have evolved over the last 20 years but there is still a significant body of evidence reliant upon time-fixed methods. Robust estimates are required to inform investment in cost-effective IPC interventions

Comparison of multistate model, survival regression, and matched case–control methods for estimating excess length of stay due to healthcare-associated infections

Background: A recent systematic review recommended time-varying methods for minimizing bias when estimating the excess length of stay (LOS) for healthcare-associated infections (HAIs); however, little evidence exists concerning which time-varying method is best used for HAI incidence studies. Aim: To undertake a retrospective analysis of data from a one-year prospective incidence study of HAIs, in one teaching hospital and one general hospital in NHS Scotland. Methods: Three time-varying methods – multistate model, multivariable adjusted survival regression, and matched case–control approach – were applied to the data to estimate excess LOS and compared. Findings: The unadjusted excess LOS estimated from the multistate model was 7.8 (95% confidence interval: 5.7–9.9) days, being shorter than the excess LOS estimated from survival regression adjusting for the admission characteristics (9.9; 8.4–11.7) days, and the adjusted estimates from matched case–control approach (10; 8.5–11.5) days. All estimates from the time-varying methods were much lower than the crude time-fixed estimates of 27 days. Conclusion: Studies examining LOS associated with HAI should consider a design which addresses time-dependent bias as a minimum. If there is an imbalance in patient characteristics between the HAI and non-HAI groups, then adjustment for patient characteristics is also important, where survival regression with time-dependent covariates is likely to provide the most flexible approach. Matched design is more likely to result in data loss, whereas a multistate model is limited by the challenge in adjusting for covariates. These findings have important implications for future cost-effectiveness studies of infection prevention and control programmes

Abdominal massage plus advice, compared with advice only, for neurogenic bowel dysfunction in MS:a RCT

Background: Between 50% and 80% of people with multiple sclerosis (PwMS) experience neurogenic bowel dysfunction (NBD) (i.e. constipation and faecal incontinence) that affects quality of life and can lead to hospitalisation.Objectives: To determine the clinical effectiveness and cost-effectiveness of abdominal massage plus advice on bowel symptoms on PwMS compared with advice only. A process evaluation investigated the factors that affected the clinical effectiveness and possible implementation of the different treatments.Design: A randomised controlled trial with process evaluation and health economic components. Outcome analysis was undertaken blind.Setting: The trial took place in 12 UK hospitals.Participants: PwMS who had 'bothersome' NBD.Intervention: Following individualised training, abdominal massage was undertaken daily for 6 weeks (intervention group). Advice on good bowel management as per the Multiple Sclerosis Society advice booklet was provided to both groups. All participants received weekly telephone calls from the research nurse.Main outcome measures: The primary outcome was the difference between the intervention and control groups in change in the NBD score from baseline to week 24. Secondary outcomes were measured via a bowel diary, adherence diary, the Constipation Scoring System, patient resource questionnaire and the EuroQol-5 Dimensions, five-level version (EQ-5D-5L).Results: A total of 191 participants were finalised, 189 of whom were randomised (two participants were finalised in error) (control group, n = 99; intervention group, n = 90) and an intention-to-treat analysis was performed. The mean age was 52 years (standard deviation 10.83 years), 81% (n = 154) were female and 11% (n = 21) were wheelchair dependent. Fifteen participants from the intervention group and five from the control group were lost to follow-up. The change in NBD score by week 24 demonstrated no significant difference between groups [mean difference total score -1.64, 95% confidence interval (CI) -3.32 to 0.04; p = 0.0558]; there was a significant difference between groups in the change in the frequency of stool evacuation per week (mean difference 0.62, 95% CI 0.03 to 1.21; p = 0.039) and in the number of times per week that participants felt that they emptied their bowels completely (mean difference 1.08, 95% CI 0.41 to 1.76; p = 0.002), in favour of the intervention group. Of participant interviewees, 75% reported benefits, for example less difficulty passing stool, more complete evacuations, less bloated, improved appetite, and 85% continued with the massage. A cost-utility analysis conducted from a NHS and patient cost perspective found in the imputed sample with bootstrapping a mean incremental outcome effect of the intervention relative to usual care of -0.002 quality-adjusted life-years (QALYs) (95% CI -0.029 to 0.027 QALYs). In the same imputed sample with bootstrapping, the mean incremental cost effect of the intervention relative to usual care was £56.50 (95% CI -£372.62 to £415.68). No adverse events were reported. Limitations include unequal randomisation, dropout and the possibility of ineffective massage technique.Conclusion: The increment in the primary outcome favoured the intervention group, but it was small and not statistically significant. The economic analysis identified that the intervention was dominated by the control group. Given the small improvement in the primary outcome, but not in terms of QALYs, a low-cost version of the intervention might be considered worthwhile by some patients.Future work: Research is required to establish possible mechanisms of action and modes of massage delivery.Trial registration: Current Controlled Trials ISRCTN85007023 and NCT03166007.</p

How do we evaluate the cost of nosocomial infection? The ECONI protocol: an incidence study with nested case-control evaluating cost and quality of life

Introduction: Healthcare-associated or nosocomial infection (HAI) is distressing to patients and costly for the National Health Service (NHS). With increasing pressure to demonstrate cost-effectiveness of interventions to control HAI and notwithstanding the risk from antimicrobial-resistant infections, there is a need to understand the incidence rates of HAI and costs incurred by the health system and for patients themselves. Methods and analysis: The Evaluation of Cost of Nosocomial Infection study (ECONI) is an observational incidence survey with record linkage and a nested case-control study that will include postdischarge longitudinal follow-up and qualitative interviews. ECONI will be conducted in one large teaching hospital and one district general hospital in NHS Scotland. The case mix of these hospitals reflects the majority of overnight admissions within Scotland. An incidence survey will record all HAI cases using standard case definitions. Subsequent linkage to routine data sets will provide information on an admission cohort which will be grouped into HAI and non-HAI cases. The case-control study will recruit eligible patients who develop HAI and twice that number without HAI as controls. Patients will be asked to complete five questionnaires: the first during their stay, and four others during the year following discharge from their recruitment admission (1, 3, 6 and 12 months). Multiple data collection methods will include clinical case note review; patient-reported outcome; linkage to electronic health records and qualitative interviews. Outcomes collected encompass infection types; morbidity and mortality; length of stay; quality of life; healthcare utilisation; repeat admissions and postdischarge prescribing. Ethics and dissemination: The study has received a favourable ethical opinion from the Scotland A Research Ethics Committee (reference 16/SS/0199). All publications arising from this study will be published in open-access peer-reviewed journal. Lay-person summaries will be published on the ECONI website

Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom

BackgroundAntimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients.ObjectiveWe assess the relative cost-effectiveness of screening programmes compared with no- screening.MethodsA microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective.ResultsIn the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs.ConclusionThe specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters