Inter-hospital variation in the utilization of diagnostics and their proportionality in the management of adult community-acquired pneumonia
Stefan M T Vestjens, Esther Wittermans, Simone M C Spoorenberg, Jan C Grutters, Charlotte A van Ruitenbeek, G Paul Voorn, Willem Jan W Bos, Ewoudt M W van de Garde, Stefan M T Vestjens, Esther Wittermans, Simone M C Spoorenberg, Jan C Grutters, Charlotte A van Ruitenbeek, G Paul Voorn, Willem Jan W Bos, Ewoudt M W van de Garde
Abstract
Background: Utilization of diagnostics and biomarkers are the second largest cost drivers in the management of patients hospitalized with community-acquired pneumonia (CAP). The present study aimed to systematically assess the inter-hospital variation in these cost drivers in relation to antibiotic use in CAP.
Methods: Detailed resource utilization data from 300 patients who participated in a multicenter placebo-controlled trial investigating dexamethasone as adjunctive treatment for community-acquired pneumonia was grouped into 3 categories: clinical chemistry testing, radiological exams, and microbiological testing. Based on the identified top 5 items per category, average costs were calculated per category and per hospital. Antibiotic de-escalation at day 3 and secondary ICU admission were assessed as outcomes for proportionality of diagnostics use.
Results: The mean costs for diagnostics varied between hospitals from 350 (SD 31) to 841 (SD 37) euro per patient (p < 0.001). This difference was primarily explained by variation in costs for microbiological testing (mean 195 vs. 726 euro per patient, p < 0.001). There was no difference in number of secondary ICU admissions but there was an inverse association between the costs of microbiological testing and level of antibiotic de-escalation. De-escalation occurred most frequently in the hospital with the lowest cost for microbiological testing (48% vs. 30%; p = 0.018). The latter hospital had an automated physician alert system in place to consider a timely iv-to-oral switch of antibiotics.
Conclusions: Large inter-hospital variation exists in resource utilization, mainly in microbiological diagnostics in the management of adult patients with community-acquired pneumonia. A counterintuitive inverse association between the magnitude of these costs and the amount of antibiotic de-escalation was found. Future studies about the optimal cost-effective set of microbiological testing for antimicrobial stewardship in pneumonia patients should acknowledge the interaction between testing, way of communication of results and triggered physician alert systems.
Trial registration: ClinicalTrials.gov NCT01743755.
Keywords: Antimicrobial stewardship; Choosing wisely; Community-acquired pneumonia; Costs and cost analysis; Microbiological testing.
Conflict of interest statement
The study was approved by the Medical Ethical Committee of the St. Antonius Hospital and all patients provided written informed consent.Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD, et al. Guidelines for the Management of Adults with community-acquired pneumonia. Am J Respir Crit Care Med. 2001;163:1730–1754. doi: 10.1164/ajrccm.163.7.at1010.
- Gibson GJ, Loddenkemper R, Lundbäck B, Sibille Y. Respiratory health and disease in Europe: the new European lung white book. Eur Respir J. 2013;42.
- Spoorenberg SMC, Bos WJW, Heijligenberg R, Voorn PGP, Grutters JC, Rijkers GT, et al. Microbial aetiology, outcomes, and costs of hospitalisation for community-acquired pneumonia; an observational analysis. BMC Infect Dis. 2014; 10.1186/1471-2334-14-335.
- Vissink CE, Huijts SM, de Wit GA, Bonten MJM, Mangen M-JJ. Hospitalization costs for community-acquired pneumonia in Dutch elderly: an observational study. BMC Infect Dis. 2016; 10.1186/s12879-016-1783-9.
- Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012; 10.1001/jama.2012.476.
- Santeon-CAP; Dexamethasone in Community-acquired Pneumonia. . . Accessed 20 Feb 2018.
- Dutch Healthcare Authority (NZA). Medical specialist care rate table. 2016. . Accessed 30 Nov 2016.
- Van de Garde EMW, Plouvier BC, Fleuren HWHA, Haak EAF, Movig KLL, Deenen MJ, et al. Pharmacotherapy within a learning healthcare system: rationale for the Dutch Santeon Farmadatabase. Eur J Hosp Pharm. 2017; 10.1136/ejhpharm-2017-001329.
- Wiersinga WJ, Bonten MJ, Boersma WG, Jonkers RE, Aleva RM, Kullberg BJ, et al. SWAB/NVALT (Dutch working party on antibiotic policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults. Neth J Med. 2012;70:90–101.
- National Institute for Public Health and the Environment (RIVM). Infections of the lower respiratory tract: care use and costs - Public care and health care. . Accessed 20 Feb 2018.
- Leyenaar JK, Lagu T, Shieh M-S, Pekow PS, Lindenauer PK. Variation in resource utilization for the management of uncomplicated community-acquired pneumonia across community and children’s hospitals. J Pediatr. 2014; 10.1016/j.jpeds.2014.04.062.
- Brogan TV, Hall M, Williams DJ, Neuman MI, Grijalva CG, Farris RWD, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Pediatr Infect Dis J. 2012;31:1036–1041. doi: 10.1097/INF.0b013e31825f2b10.
- Berrevoets MAH, Pot JLW, Houterman AE, Dofferhoff ASM, Nabuurs-Franssen MH, Fleuren HWHA, et al. An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study. Antimicrob Resist Infect Control. 2017; 10.1186/s13756-017-0239-3.
Source: PubMed