Appendix

Full title
Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions

Appendix A. PubMed Search Criteria

Common Search Criteria for Cost

Common Search Criteria for Cost

("Costs and Cost Analysis"[mh] OR "Cost of Illness"[mh] OR "Economics"[mh] OR "Health Care Costs"[mh] OR "Direct Service Costs"[mh] OR "Hospital Costs"[mh] OR "Health Expenditures"[mh] OR cost[tiab] OR costs[tiab] OR expenditure*[tiab] OR expense[tiab] OR spend*[tiab] OR "financial outcome"[tiab] OR "financial outcomes"[tiab] OR "financial impact"[tiab] OR "financial impacts"[tiab] OR "economic impact"[tiab] OR "economic impacts"[tiab] OR "economic outcome"[tiab] OR "economic outcomes"[tiab]) AND (incremental[tiab] OR additional[tiab] OR extra[tiab] OR attribut*[tiab] OR excess[tiab] OR "compared to"[tiab] OR "compared with"[tiab] OR "associated with"[tiab] OR "because of"[tiab] OR "due to"[tiab] OR "caused by"[tiab]) AND (hospital*[tiab] OR inpatient[tiab] OR "Hospital Costs"[mh] OR "intensive care unit"[tiab]) NOT "cost effectiveness"[ti]

 

Common Search Criteria for Mortality

"Mortality"[mh] OR "Hospital mortality"[mh] OR mortalit*[tiab] OR death*[tiab] OR fatalit*[tiab]) AND (additional[tiab] OR extra[tiab] OR attribut*[tiab] OR excess[tiab] OR "compared to"[tiab] OR "compared with"[tiab] OR "associated with"[tiab] OR "because of"[tiab] OR "due to"[tiab] OR "caused by"[tiab]

 

Common Exclusions

English[lang] AND United States[pl] AND (2000:2017[dp]

 

Adverse Drug Events

(("Drug therapy/adverse effects"[mh] OR "drug interactions"[mh] OR "anaphylaxis"[mh] OR "drug overdose"[mh] OR "Drug-related side effects and adverse reactions"[mh] OR "adverse drug event"[tiab] OR "adverse drug events"[tiab] OR "adverse drug reaction"[tiab] OR "adverse drug reactions"[tiab] OR "medication errors"[mh] OR "medication error"[tiab] OR "medication errors"[tiab] OR adverse [tiab] OR "allergic reaction"[tiab] OR "allergic reactions"[tiab] OR "anaphylaxis"[tiab] OR overdose[tiab] OR ((drug[tiab] OR medication[tiab]) AND (harm[tiab] OR injury[tiab])))

AND

(("anticoagulants"[mh] OR "anticoagulation"[tiab] OR "anticoagulant"[tiab] OR "4- Hydroxycoumarins"[mh] OR "Acenocoumarol"[mh] OR "Ancrod"[mh] OR "Antithrombin III"[mh] OR "Antithrombin Proteins"[mh] OR "Beta 2-Glycoprotein I"[mh] OR "Blood Coagulation Factor Inhibitors"[mh] OR "Citric Acid"[mh] OR "Dabigatran"[mh] OR "Dalteparin"[mh] OR "Dermatan Sulfate"[mh] OR "Dextrans"[mh] OR "Dicumarol"[mh] OR "Edetic Acid"[mh] OR "Enoxaparin"[mh] OR "Ethyl Biscoumacetate"[mh] OR "Fibrin Fibrinogen Degradation Products"[mh] OR "Gabexate"[mh] OR "Heparin"[mh] OR "Heparin Cofactor II"[mh] OR "Heparin, Low-Molecular-Weight"[mh] OR "Heparinoids"[mh] OR "Hirudins"[mh] OR "Nadroparin"[mh] OR "Pentosan Sulfuric Polyester"[mh] OR "Phenindione"[mh] OR "Phenprocoumon"[mh] OR "Protein C"[mh] OR "Protein S"[mh] OR "Rivaroxaban"[mh] OR "Warfarin"[mh] OR "Hirudin Therapy"[mh])

OR

("analgesics, opioid"[mh] OR opioid*[tiab] OR "Alfentanil"[mh] OR "Alphaprodine"[mh] OR "Buprenorphine"[mh] OR "Buprenorphine, Naloxone Drug Combination"[mh] OR "Butorphanol"[mh] OR "Codeine"[mh] OR "Dextromoramide"[mh] OR "Dextropropoxyphene"[mh] OR "Dihydromorphine"[mh] OR "Diphenoxylate"[mh] OR "Enkephalin, Ala(2)-MePhe(4)-Gly(5)- "[mh] OR "Enkephalin, D- Penicillamine (2,5)- "[mh] OR "Ethylketocyclazocine"[mh] OR "Ethylmorphine"[mh] OR "Etorphine"[mh] OR "Fentanyl"[mh] OR "Heroin"[mh] OR "Hydrocodone"[mh] OR "Hydromorphone"[mh] OR "Levorphanol"[mh] OR "Meperidine"[mh] OR "Meptazinol"[mh] OR "Methadone"[mh] OR "Methadyl Acetate"[mh] OR "Morphine"[mh] OR "Nalbuphine"[mh] OR "Opiate Alkaloids"[mh] OR "Opium"[mh] OR "Oxycodone"[mh] OR "Oxymorphone"[mh] OR "Pentazocine"[mh] OR "Phenazocine"[mh] OR "Phenoperidine"[mh] OR "Pirinitramide"[mh] OR "Promedol"[mh] OR "Sufentanil"[mh] OR "Tilidine"[mh] OR "Tramadol"[mh]))

AND

("iatrogenic disease"[mh] OR "nosocomial"[tiab] OR "healthcare associated"[tiab] OR "health care associated"[tiab] OR "hospital acquired"[tiab] OR "inpatient"[tiab] OR "hospitalized"[tiab] OR "hospital related"[tiab] OR "in hospital"[tiab] OR "in hospitals"[tiab] OR "within hospitals"[tiab]))

 

CAUTI

((("urinary tract infections"[mh] OR "urinary tract infection*"[tiab]) AND (Urinary catheterization[mh] OR urinary catheter*[tiab] OR "catheter associated"[tiab])) OR ("catheter-related infections"[mh] AND "urinary"[tiab]) OR (Urinary Catheterization/adverse effects*[mh) OR "CAUTI"[tiab] OR (("cross infection"[mh] OR "iatrogenic disease"[mh] OR "nosocomial"[tiab] OR "hospital infection"[tiab] OR "hospital infections"[tiab] OR "healthcare associated"[tiab] OR "health care associated"[tiab] OR "hospital acquired"[tiab] OR "hospital related"[tiab]) AND "urinary"[tiab]))

 

CLABSI

((("catheter-related"[tiab] OR "catheter-associated"[tiab] OR "Catheterization, Central Venous/adverse effects"[Mesh] OR "Central Venous Catheters/adverse effects"[mh] OR "Catheters, Indwelling/adverse effects"[mh] OR "umbilical catheter"[tiab] OR central line*[tiab] OR central venous catheter*[tiab]) AND ("bloodstream infection"[tiab] OR "bloodstream infections"[tiab] OR "blood stream infection"[tiab] OR "blood stream infections"[tiab] OR "bacteremia"[tiab] OR "bacteremia"[mh] OR ((Cross infection[mh] OR "cross infection"[tiab] OR "cross infections"[tiab] OR nosocomial[tiab] OR "hospital-acquired infection"[tiab] OR "hospital-acquired infections"[tiab] OR "healthcare-associated infection"[tiab] OR "healthcare-associated infections"[tiab] OR "health care-associated infection"[tiab] OR "health care-associated infections"[tiab]) AND ("bloodstream"[tiab] OR "blood stream"[tiab])))) OR CLABSI[tiab] OR CRBSI[tiab] OR CABSI[tiab] OR CLAB[tiab] OR ("catheter-related infections"[mh] AND ("blood stream"[tiab] OR "bloodstream"[tiab])))

 

Falls

("Accidental Falls" [mh] OR Falls [tiab] OR Falling [tiab] OR Fall [tiab] OR "Accidental Falls" [tiab] OR "Accidental Fall" [tiab] OR Slip [tiab] OR Faller [tiab])

AND

(hospital*[tiab] OR inpatient*[tiab] OR "Hospital Costs"[mh] OR "intensive care unit"[tiab] OR "acute care setting"[tiab] OR "hospitalization"[mh] OR "inpatients"[mh] OR "Intensive Care Units"[Mesh])

 

Obstetric Adverse Events

("Inferior Wall Myocardial Infarction"[Mesh] OR "Anterior Wall Myocardial Infarction"[Mesh] OR "Acute Kidney Injury"[Mesh] OR "Respiratory Distress Syndrome, Adult"[Mesh] OR "Embolism, Amniotic Fluid"[Mesh] OR "Aneurysm"[Mesh] OR "Heart Arrest"[Mesh] OR "Ventricular Fibrillation"[Mesh] OR "Disseminated Intravascular Coagulation"[Mesh] OR "Heart Failure"[Mesh] OR "Head Injuries, Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular Disorders"[Mesh] OR "Pulmonary Edema"[Mesh] OR "Anesthesia, Obstetrical/adverse effects"[Mesh] OR "Anesthesia, Obstetrical/complications"[Mesh] OR "Sepsis"[Mesh] OR "Shock"[Mesh] OR "Anemia, Sickle Cell/complications"[Mesh] OR "Thrombosis/complications"[Mesh] OR "Blood Transfusion"[Mesh] OR "Defibrillators"[Mesh] OR "Interactive Ventilatory Support"[Mesh])

 

Pressure Ulcers

(("Pressure Ulcer" [MeSH] OR "Pressure Ulcer" [tiab] OR "Bedsore" [tiab] OR "Bed Sores" [tiab] OR "Decubitus Ulcer" [tiab] OR "Pressure Sore" [MeSH] OR "Pressure Sore" [tiab] OR "Suspected Deep Tissue Injury" [tiab] OR "Pressure Ulcer" [MeSH] OR "Pressure Ulcer" [tiab] OR "osteomyelitis" [MeSH] OR "osteomyelitis" [tiab] OR "tunneling" [tiab] OR "fissure" [tiab])

AND

("hospital acquired" [tiab] OR "healthcare acquired" [tiab] OR "nosocomial" [tiab] OR "hospitalization" [MeSH] OR "hospitalized"[tiab] OR "healthcare associated"[tiab] OR "health care associated"[tiab] OR "health care acquired"[tiab] OR "hospital related"[tiab] OR "inpatient"[tiab] OR "in hospital"[tiab] OR "in hospitals"[tiab] OR "within hospitals"[tiab))

 

Venous Thromboembolism

(("pulmonary embolism/economics"[MeSH Terms]) OR ("Upper Extremity Deep Vein Thrombosis"[MeSH Terms]) OR ("venous thromboembolism/economics"[MeSH Terms]) OR ("venous thrombosis/economics"[MeSH Terms]) OR ("Pulmonary Infarction"[Mesh]) OR (("deep venous"[tiab] OR "deep vein"[tiab] OR "pulmonary"[tiab]) AND (thrombos*[tiab] OR embolism*[tiab] OR thromboembolism*[tiab])))

AND

("iatrogenic disease"[mh] OR "nosocomial"[tiab] OR "healthcare associated"[tiab] OR "health care associated"[tiab] OR "hospital acquired"[tiab] OR "inpatient"[tiab] OR "hospitalized patients"[tiab] OR "hospital related"[tiab] OR "in hospital"[tiab] OR "in hospitals"[tiab] OR "within hospitals"[tiab])

 

Surgical Site Infections

("cross infection"[mh] OR "hospital acquired" [tiab] OR "healthcare acquired" [tiab] OR "nosocomial" [tiab] OR "hospitalized"[tiab] OR "healthcare associated"[tiab] OR "hospital associated"[tiab] OR "health care associated"[tiab] OR "health care acquired"[tiab] OR "hospital related"[tiab] OR "inpatient"[tiab] OR "in hospital"[tiab] OR "in hospitals"[tiab] OR "within hospitals"[tiab])

AND

("surgical wound infection/economics"[mh] OR "surgical procedures, operative/adverse effects"[mh] OR ("surgical wound infection"[mh] AND prognosis[mh]) OR (("surgical wound infection*"[tiab] OR "surgical site infection*"[tiab]) AND outcome*[tiab]))

 

Ventilator Associated Pneumonia

(("Pneumonia, Ventilator-Associated/economics"[mh]) OR ("Ventilator Associated Pneumonia"[tiab] OR "Ventilator-Associated Pneumonia"[tiab] OR "Ventilators, Mechanical/adverse effects"[mh]) OR (("Respiration, Artificial/economics"[mh] OR "Artifical respiration"[tiab]) AND (mechanically ventilat*[tiab] OR mechanical ventilat*[tiab] OR intubat*[tiab] OR ventilator associated*[tiab]))

AND

("cross infection"[mh] OR "iatrogenic disease"[mh] OR "hospital acquired" [tiab] OR "healthcare acquired" [tiab] OR "nosocomial" [tiab] OR "healthcare associated"[tiab] OR "hospital associated"[tiab] OR "health care associated"[tiab] OR "health care acquired"[tiab] OR "hospital related"[tiab] OR "inpatient"[tiab] OR "in hospital"[tiab] OR "in hospitals"[tiab]))

 

Clostridium difficile Infections

(("Clostridium difficile" [Mesh] OR "Clostridium difficile*" [tiab] OR "C diff"[tiab] OR "Colitis" [Mesh] OR "Colitis" [tiab] OR CDAD[tiab]) AND("cross infection" [Mesh] OR "bacteremia" [Mesh] OR "iatrogenic disease"[MeSH] OR "nosocomial"[tiab] OR "healthcare associated"[tiab] OR "health care associated"[tiab] OR "hospital acquired"[tiab] OR "hospital infection*"[tiab] OR "inpatient"[tiab]))

Appendix B. Excess Mortality Calculations

We define excess mortality as an estimate of additional deaths due to the hospital-acquired condition (HAC). These are expressed as the percentage of HAC cases who die as a result of the HAC.

Calculation:        Formula

Where P(D|E) indicates the probability of death in those with HAC and P(D|not E) indicates the  probability of death in those at risk for, but do not acquire, the HAC.

  Died Alive
HAC group a b
Non-HAC group c d

Meta-analysis Method for Estimating Excess Mortality

We calculate the pooled relative risk using meta-analysis and then calculate excess mortality using the pooled RR and an estimate of the underlying mortality rate:

Formula

where RR = Formula represents the underlying mortality in patients at risk for the HAC.

When the underlying mortality was not available from other literature, we used an estimate of the general inpatient mortality rate. This rate, 2 percent, can be thought of as the overall mortality rate among all hospitalized patients, HAC and non-HAC patients. This rate was used for falls and VTE. For all other HACs, the underlying mortality rate was drawn from the published literature. Exhibit B1 shows the underlying mortality rates and a description of the underlying population alongside the meta-analysis-based estimates of excess mortality.

Exhibit B1. Underlying Mortality Rates

HAC Underlying Population Description Underlying Mortality Rate RR (range) Pooled RR (95% CI) Excess Mortality Estimate (95% CI)
ADE Hospitalized patients who are given anticoagulants, hypoglycemic agents, and opioids during hospitalization 0.02a 0.68–3.09 1.61 (1.14, 2.27) 0.012 (0.003–0.025)
CAUTI Hospitalized patients with urinary catheters 0.071b 1.28–1.97 1.50 (1.06, 2.11) 0.036 (0.004–0.079)
CLABSI Hospitalized patients with central lines 0.086b 1.86–4.88 2.72 (1.81, 4.10) 0.15 (0.070–0.27)
Falls All hospitalized patients who are at risk to fall in the hospital 0.02a 3.50 3.50 (2.73, 4.48) 0.050 (0.035–0.070)
OBAE Estimate was not based on RR and underlying mortality; please see report for details 0.0049 (0.0030–0.013)
Pressure Ulcer All hospitalized patients who are at risk to have pressure ulcer 0.018c 2.42–5.06 3.26 (1.71, 6.17) 0.041 (0.013–0.093)
SSI All hospitalized postsurgical patients 0.0114d 1.75–5.70 3.32 (1.79, 6.18) 0.026 (0.009–0.059)
VAP Hospitalized patients with ventilator 0.3e 0.52–4.90 1.48 (0.64, 3.42) 0.14 (-0.11–0.73)
VTE All hospitalized patients who are at risk to get VTE 0.02a 1.01–13.63 3.15 (2.02, 4.91) 0.043 (0.040–0.078)
CDI All hospitalized patients who are at risk to get CDI 0.073f 1.17–9.60 1.60 (1.38, 1.87) 0.044 (0.028–0.064)

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Warren DK, Quadir WW, Hollenbeak CS, et al. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med. 2006 Aug;34(8):2084-9.

Wilson MZ, Rafferty C, Deeter D, et al. Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population. Am J Infect Control. 2014 Nov;42(11):1157-60.

Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Joint Com J Qual Patiet Saf. 2011 Feb 28;37(2):81-7.

Wu H, Nguyen GC. Liver cirrhosis is associated with venous thromboembolism among hospitalized patients in a nationwide U.S. study. Clin Gastroenterol Hepatol. 2010 Sep;8(9):800-5.

Yi SH, Baggs J, Gould CV, et al. Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis. Med Care. 2014 Jun;52(6):469-78.

Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003 Oct;290(14):1868-74.

Appendix D. Key Study Characteristics

Exhibit D1. Adverse Drug Events

    Kessler (2013) Oderda (2007) Suh (2000) Classen (2010) Alexander (2005) LaPointe (2007) Seigerman (2014)
Study Study Year 2009-2010 1990-1999 1998 2004 2004 2005 2009-2010
Population Patients with a primary surgical procedure Adult surgical patients
( >17 y) in a single Utah hospital
All patient (≥2 y) admissions to a single New York hospital Medicare beneficiaries Patients with NSTE ACS Patients with NSTE ACS Patients with cardiac surgery
Study Design Retrospective cohort Matched cohort Retrospective matched control Retrospective cohort Prospective observational Prospective observational Retrospective cohort
Data Source(s) Hospital administrative data Hospital clinical and surveillance data Hospital pharmacy and medical record reporting systems MPSMS CRUSADE National Quality Improvement Initiative Registry CRUSADE National Quality Improvement Initiative Registry HCUP-NIS
Number of Cases 4,537 1,586 131 172 22,480g 13,803 560
Definition of HAC ICD-9 Hospital surveillance criteria and Noranjo criteria WHO Medication-specific algorithms Recommended dosing categories Recommended dosing categories Non-specified diagnosis
Cost Cost or Charges Reported Cost Cost Cost        
Attributable Y Y Y        
Year of Cost Data Not specified Not specified Not specified        
Mean Attributable Cost Calculated $6,721.00 $786.00 $5,483.00        
Standard Error $347.54 $151.79 $1,959.00        
Mortality Matched Control Sample Y Y   N N N N
Adjusted RR/OR 3.39 (2.42–4.74) Not reported   Not used in analysis 1.50 (1.03-2.17) 1.31 (0.99-1.73) 1.47 (1.30-1.67)
SE(logRR)/SE(logOR) 0.161 0.321   0.314 0.190 0.142 0.064

g Represents the number of instances of a major bleed in the presence of drug therapy administration; some patients received more than one drug therapy.

Exhibit D2. Catheter-Associated Urinary Tract Infection

    Glied (2016) Yi (2014) Byrn (2015) Dasenbrock (2016) Goudie (2015) Sammon (2013) Murthy (2016)

Study

Study Year 2006-2012 2009 2006-2012 2008-2011 2009-2011 1999-2009 2002-2011
Population All patients, New York City hospital network Medicare beneficiaries with ESRD Patients with colorectal resection Patients with aneurysmal subarachnoid hemorrhage Patients 1-17 years of age Patients with any of 8 surgical oncology procedures Patients with nontraumatic intracerebral hemorrhage
Study Design Matched retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Matched retrospective cohort Retrospective Retrospective cohort
Data Source(s) Hospital clinical and administrative data MedPAR, Beneficiary Annual Summary File University hospital database HCUP-NIS HCUP-NIS HCUP-NIS HCUP-NIS
Number of Cases 8,048 884 18 1,793 1,513 105,113 40,018
Definition of HAC Lab results and ICD-9 CDC-NHSN NHSN; NSQIP; ICD-9 ICD-9 ICD-9 ICD-9 ICD-9
Cost Cost or Charges Reported Charges Payment Cost Charges Cost    
Attributable Y Y N N Y    
Year of Cost Data 2012 2009 2012 2011h 2011    
Mean Attributable Cost Calculated $20,857.50 $5,877.13 $11,587.10 $27,858.50 $7,200.00    
Standard Error $2,365.07 $1,644.05 $5,531.84 $2,164.43 $2,538.82    
Mortality Matched Control Sample Y Y       N N
Adjusted RR/OR 1.28 1.37 (1.04-1.80) ICU;
1.17 (0.62-2.23) non-ICU
      1.97 (1.85-2.10) 1.42 (1.10-1.94)
SE(logRR)/SE(logOR) 0.054 0.311       0.032 0.145

h The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

Exhibit D2. Catheter-Associated Urinary Tract Infection continued

    Kilgore (2008)
Study Study Year 2001-2006
Population All hospitalized patients
Study Design Retrospective cohort
Data Source(s) Cardinal Health MedMined database
Number of Cases 18,930
Definition of HAC Lab results

Cost

Cost or Charges Reported Cost
Attributable Y
Year of Cost Data 2007
Mean Attributable Cost Calculated $3,936.00
Standard Error $1,961.26

Mortality

Matched Control Sample  
Adjusted RR/OR  
SE(logRR)/SE(logOR)  

Exhibit D3. Central-Line Associated Bloodstream Infections

 

 

Dimick (2001) Glied (2016) Warren (2006) Cohen (2010) Dasenbrock (2016) Goudie (2014) Wilson (2014)
Study Study Year 1998-1999 2006-2012 1998-2000 2006-2007 2008-2011 2008-2011 2008-2011
Population Surgical ICU patients in single Maryland hospital All patients, New York City hospital network All ICU patients, suburban St. Louis Missouri hospital All ICU patients,single Chicago-area hospital Patients with aneurysmal subarachnoid hemorrhage Patients under 18 years of age Pediatric hematology and oncology patients in Mid-Atlantic hospital
Study Design Prospective cohort Matched retrospective cohort Prospective cohort Case-control Retrospective cohort Matched case-control Matched prospective cohort
Data Source(s) Hospital administrative data Patients’ electronic medical record and other digital sources Hospital clinical and administrative data Hospital administrative data HCUP-NIS HCUP-NIS Hospital clinical and administrative data
Number of Cases 9 3,603 41 12 77 1,339 60
Definition of HAC Catheter colonization Lab results and ICD-9 CDC-NHSN ICD-9 ICD-9 AHRQ PQI Lab results

Cost

Cost or Charges Reported Cost Charges Cost Cost Charges Cost Cost
Attributable Y Y Y Y N Y Y
Year of Cost Data 1998 2012 2000 2008 2011i 2011 2011j
Mean Attributable Cost Calculated $56,167.00 $17,197.00 $11,971.00 $82,005.00 $40,983.42 $55,646.00 $69,332.00
Standard Error $39,340.52 $4,425.38 $2,964.34 $15,687.02 $7,366.13 $8,602.71 $17,443.43
Mortality Matched Control Sample N Y N      

 

Adjusted RR/OR 4.3 (0.9-19.9) 2.49 Not reported      

 

SE(logRR)/SE(logOR) 0.322 0.063 0.160        

i The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

j The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

Exhibit D3. Central-Line Associated Bloodstream Infections continued

    Mendizabal (2016) Sammon (2013) Stevens (2014)
Study Study Year 2000-2010 1999-2009 2008-2010
Population Adult patients with epilepsy Patients with any of 8 surgical oncology procedures All patients, single tertiary-care hospital
Study Design Retrospective cohort Retrospective Retrospective cohort
Data Source(s) HCUP-NIS HCUP-NIS Hospital clinical and administrative data
Number of Cases Not reported 47,551 197
Definition of HAC AHRQ PSI ICD-9 CDC-NHSN

Cost

Cost or Charges Reported      
Attributable      
Year of Cost Data      
Mean Attributable Cost Calculated      
Standard Error      

Mortality

Matched Control Sample N N N
Adjusted RR/OR 4.88 (4.02-5.93) 17.29 (16.33-18.31) 2.27 (1.15-4.46)
SE(logRR)/SE(logOR) 0.099 0.015 0.346

Exhibit D4. Falls

    Memtsoudis (2012) Bates (1995) Wong (2011)
Study Study Year 1998-2007 1987-1991 2004-2006
Population Postoperative hip and knee surgery patients All patients in a single Massachusetts hospital Adult inpatients in 3 Midwest hospitals
Study Design Retrospective cohort Retrospective case-control Retrospective case-control
Data Source(s) HCUP-NIS Hospital clinical data Hospital incident reporting system
Number of Cases 9,198 62 57
Definition of HAC ICD-9 Patient reported as having fallen Serious fall-related injury

Cost

Cost or Charges Reported Cost Charges Cost
Attributable N Y Y
Year of Cost Data 2007k 1991l 2009
Mean Attributable Cost Calculated $2,247 $3,802 $13,806
Standard Error $90.57 $2,262.97 $6,031.23

Mortality

Matched Control Sample N    
Adjusted RR/OR Not reported    
SE(logRR)/SE(logOR) 0.126    

k The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

l The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

Exhibit D5. Obstetric Adverse Events

    Zhan (2003) Hunt (2016) Callaghan (2008) Callaghan (2012) Creanga (2014) Grobman (2014)
Study Study Year 2000 2010 1991-2003 1998-2009 2008-2010 2008-2011
Population Women with delivery-related discharge Women with delivery-related discharge in New York Women with delivery-related discharges Women with delivery-related discharges Women with delivery-related discharges in 7-state sample Women who delivered ≥23 weeks gestations in any of 25 cohort hospitals
Study Design Retrospective cohort Retrospective cohort Retrospective Retrospective Retrospective Retrospective cohort
Data Source(s) HCUP-NIS State-level inpatient database National Hospital Discharge Survey HCUP-NIS HCUP-NIS Eunice Kennedy Shriver National Institute of Child Health & Human Development Maternal-Fetal Medicine Units Network cohort
Number of Cases 64,879 1,053 257,000 597,920 74,720 332
Definition of HAC AHRQ PSI ICD-9 ICD-9 ICD-9 ICD-9 Geller et al. (2004) morbidity scoring system
Cost Cost or Charges Reported Charges Cost        
Attributable Y Y        
Year of Cost Data 2000 2010        
Mean Attributable Cost Calculated $8.35 $1,091.34        
Standard Error $28.344 $30.20        
Mortality Matched Control Sample     N N N N
Adjusted RR/OR     Alternative estimation method used Alternative estimation method used Alternative estimation method used Alternative estimation method used
SE(logRR)/SE(logOR)     - - - -

Exhibit D6. Pressure Ulcers

    Bauer (2016) Spector (2016) Goudie (2015) Zhan (2003) Mendizabal (2016) Lyder (2012)
Study

Study Year

2008-2012 2011–2012 2009-2011 2000 2000-2010 2006-2007
Population General hospitalized patients Adult patients with surgery Patients 1-17 years of age General hospitalized patients Adult patients with epilepsy Medicare beneficiary FFS sample
Study Design Retrospective Matched retrospective cohort Matched retrospective cohort Retrospective cohort Retrospective cohort Retrospective
Data Source(s) HCUP-NIS HCUP-SID and MPSMS HCUP-NIS HCUP-NIS HCUP-NIS MPSMS
Number of Cases 676,435 534 120 843 Not reported 2,313
Definition of HAC ICD-9 MPSMS chart review ICD-9 ICD-9 AHRQ PSI ICD-9
Cost Cost or Charges Reported Charges Cost Cost Charges    
Attributable N Y Y Y    
Year of Cost Data Not specified 2011 2011 2000  

 

Mean Attributable Cost Calculated $19,900.00 $8,251.00 $19,740.00

$5,422.50

 

 
Standard Error

$149.72

$11,553.78

$11,553.78

$184.00

 

 
Mortality Matched Control Sample N       N N
Adjusted RR/OR Not reported      

2.42 (2.20-2.66)

2.81 (2.44-3.23)
SE(logRR)/SE(logOR) 0.004      

0.048

0.072

Exhibit D7. Surgical Site Infections

    Glied (2016) Kim (2012) Boltz (2011) de Lissovoy (2009) Eagye (2009) Sammon (2013)
Study Study Year 2006-2012 2001-2008 2007-2009 2005 2005-2007 1999-2009
Population All patients, New York City hospital network Adults undergoing radical cystectomy for bladder cancer Adult general and vascular surgical patients in single hospital Surgical patients Patients with ECS procedures in single Connecticut hospital Patients with any of 8 surgical oncology procedures
Study Design Matched retrospective cohort Retrospective cohort Retrospective cohort Matched retrospective cohort Prospective cohort and case-control Retrospective
Data Source(s) Patients’ electronic medical record and other digital sources HCUP-NIS Hospital clinical data HCUP-NIS Hospital administrative data HCUP-NIS
Number of Cases 1,292 381 186 6,891 46 80,086
Definition of HAC Lab results and ICD-9 ICD-9 NSQIP; CDC NNIS ICD-9 ICD-9 ICD-9
Cost Cost or Charges Reported Charges Cost Cost Cost Cost  
Attributable Y N Y Y N  
Year of Cost Data 2012 2008 Not specified 2005 Not specified  
Mean Attributable Cost Calculated $34,813.00 $36,454.00 $10,497.00 $20,842.00 $21,228.07  
Standard Error $7,274.19 $2,530.06 $3,532.46 $971.19 $3,844.11  
Mortality Matched Control Sample Y N       N
Adjusted RR/OR Not reported 5.70 (3.94–8.24)       3.78 (3.56-4.02)
SE(logRR)/SE(logOR) 0.129 0.188       0.031

Exhibit D8. Venous Thromboembolism

    Hennessey (2012) Kim (2012) Goudie (2015) Ali (2011) Gephart (2012) Mendizabal (2016) Nguyen (2008)

Study

Study Year 2003-2008 2001-2008 2009-2011 2005 2002-2008 2000-2010 1998-2004
Population Patients with head or neck cancers Adults undergoing radical  cystectomy for bladder cancer Patients 1-17 years of age Patients with cirrhosis Adult patients with thoracic/thoraco-lumbar spinal fusion Adult patients with epilepsy Patients with inflammatory bowel disease
Study Design Retrospective cohort Retrospective case control Matched retrospective cohort Retrospective cross sectional Retrospective cohort Retrospective cohort Retrospective cohort
Data Source(s) HCUP-NIS HCUP-NIS HCUP-NIS HCUP-NIS HCUP-NIS HCUP-NIS HCUP-NIS
Number of Cases 1,860 219 1,563 8,231 162 Not reported 1,934
Definition of HAC ICD-9 ICD-9 ICD-9 ICD-9 ICD-9 AHRQ PSI ICD-9
Cost Cost or Charges Reported Cost Cost Cost        
Attributable Y N Y        
Year of Cost Data 2011 2008 2011        
Mean Attributable Cost Calculated $10,313.28 $27,387 $27,686.00        
Standard Error $1,159.73 $3,024.31 $8,443.52        
Mortality Matched Control Sample N N   N N N N
Adjusted RR/OR 3.08 (1.56 – 6.12) 5.85 (3.61 – 9.48)   1.01 (0.83, 1.23) 13.63 (6.37-29.16) 3.09 (2.64-3.62) 2.50 (1.83 – 3.43)
SE(logRR)/SE(logOR) 0.349 0.246   0.100 0.388 0.081 0.160

Exhibit D8. Venous Thromboembolism continued

    Satahoo (2015) Trinh (2014) Wu (2010)
Study Study Year 2005-2009 1999-2009 1998-2006
Population Patients with burn injuries Patients with major cancer surgery Patients with liver cirrhosis
Study Design Retrospective cohort Retrospective cohort Retrospective cohort
Data Source(s) HCUP-NIS HCUP-NIS HCUP-NIS
Number of Cases 297 33,409 Not reported
Definition of HAC ICD-9 ICD-9 ICD-9

Cost

Cost or Charges Reported      
Attributable      
Year of Cost Data      
Mean Attributable Cost Calculated      
Standard Error      
Mortality Matched Control Sample N N N
Adjusted RR/OR 1.88 (1.147 – 3.075) 5.30 (4.88 – 5.76) 2.30 (2.06 – 2.57)
SE(logRR)/SE(logOR) 0.252 0.042 0.056

Exhibit D9. Ventilator-Associated Pneumonia

    Cocanour (2005) Kollef (2012) Rello (2002) Restrepo (2010) Warren (2003) Apisarnthanarak (2003) Gupta (2015)
Study Study Year 2002-2003 2008-2009 1998-1999 2002-2006 1998-1999 2000-2001 2009
Population ICU patients with shock trauma in a single Texas tertiary-care hospital Adults ICU patents, ≥1 day in ICU with mechanical ventilation ≥2 days All patients admitted to ICU who received mechanical ventilation for >24h Hospitalized patients in 54 medical centers, nationwide All patients admitted to ICU in a single Missouri medical center Extremely pre-term neonates in Missouri hospital Mechanically ventilated patients <18 y across 16 geographically diverse PICUs
Study Design Matched retrospective cohort Matched retrospective cohort Matched retrospective cohort Matched retrospective cohort Prospective cohort Prospective and nested cohort Prospective cohort
Data Source(s) Hospital administrative data Premier Healthcare Informatics Database MediQual Profile database NASCENT study Hospital clinical and administrative data Hospital clinical data Hospital CXR
Number of Cases 93 2,144 816 30 127 19 108
Definition of HAC NNIS guideline ICD-9 ICD-9 ICD-9 and lab results NNIS criteria CDC-NNIS CDC-NHSN
Cost Cost or Charges Reported Cost Cost Charges Cost Cost    
Attributable Y Y N N Y    
Year of Cost Data 2003 2009 1999 2005 1999    
Mean Attributable Cost Calculated $57,158.00 $39,828.00 $20,647.00 $44,331.50 $11,897.00    
Standard Error $1,045.59 $2,250.00 $1,730.21 $6,731.00 $5,344.23    

Mortality

Matched Control Sample Y Y Y Y   Y N
Adjusted RR/OR Not reported Not reported Not reported Not reported   3.4 (1.2, 12.3) 3.07 (1.36 – 6.90)
SE(logRR)/SE(logOR) 0.414 0.052 0.062 0.435   0.594 0.414

Exhibit D9. Ventilator-Associated Pneumonia continued

    Josephson (2010) Klompas (2011) Klompas (2012) Sammon (2013)
Study Study Year 2006-2007 2006-2007 Not specified 1999-2009
Population Patients with neurovascular disease in a California hospital Mechanically ventilated patients >18 y in 3 geographically diverse hospitals 8 U.S. hospital ICUs Patients with any of 8 surgical oncology procedures
Study Design Retrospective Retrospective matched control Retrospective Retrospective cohort
Data Source(s) Hospital clinical and administrative Hospital clinical data Hospital clinical data HCUP-NIS
Number of Cases 24 55 Not reported 87,594
Definition of HAC CDC-NHSN CDC-NHS Candidate surveillance definitions ICD-9
Cost Cost or Charges Reported        
Attributable        
Year of Cost Data        
Mean Attributable Cost Calculated        
Standard Error        

Mortality

Matched Control Sample N Y Y N
Adjusted RR/OR 1.11 (0.37 – 3.30) 1.1 (0.5 – 2.4) 2.1 (1.3 – 3.3) 4.90 (4.64 – 5.17)
SE(logRR)/SE(logOR) 0.558 0.395 0.238 0.02

Exhibit D10. Clostridium difficile Infections

    Donnelly (2015) Glance (2011) Kim (2012) Lagu (2014) Pakyz (2011) Sundaram (2014) Tabak (2013)
Study Study Year 2012-2014 2005-2006 2001-2008 2004-2010 2002-2007 2008-2011 2007-2008
Population Patients with solid organ transplant Trauma patients LOS >3 days Adults undergoing radical  cystectomy for bladder cancer Adult, non-surgical patients with sepsis Adult patients Adult patients with primary diagnosis of alcoholic hepatitis Adult patients in six Pennsylvania hospitals
Study Design Retrospective cohort Retrospective Retrospective cohort Retrospective cohort Retrospective Retrospective Retrospective
Data Source(s) University Health System Consortium Clinical Database HCUP-NIS HCUP-NIS Premier Healthcare Informatics Database University Health System Consortium Clinical Database HCUP-NIS Clinical research database
Number of Cases 1,109 768 73 2,368 10,857 177 282
Definition of HAC ICD-9 ICD-9 ICD-9 ICD-9, lab results, and treatment codes ICD-9 and treatment codes ICD-9 Toxin Assay

Cost

Cost or Charges Reported Cost Cost Cost Cost Cost Charges Cost
Attributable Y Y (ratio) N Y N N Y
Year of Cost Data 2014 2011m 2008 2010 2007 2011 2013n
Mean Attributable Cost Calculated

$27,890.65

$14,905.00

$22,634.00

$4,924.00

$27,160.00

$3,894.00

$6,117.00

Standard Error

$1,617.07

$1,147.00

$3,346.00

$1,244.00

$249.00

$1,382.00

$2,274.00

Mortality

Matched Control Sample N N N Y Y N Y
Adjusted RR/OR 1.22 (0.9-1.65) 1.87 (1.31-2.66) 2.11 (1.04-4.28) Not reported Not reported 1.75 (1.01-3.03) 1.61
SE(logRR)/SE(logOR)

0.155

0.181

0.361

0.060

0.037

0.280

0.214

m The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

n The year of cost data is not specified; the last year of the study period was used for the purpose of this analysis.

Exhibit D10. Clostridium difficile Infections continued

    Damle (2014) O’Brien (2007) Flagg (2014) Keshavamurthy (2014) Lemaire (2015) Lesperance (2011) Luo (2015)
Study Study Year 2008-2012 1999-2003 2004-2008 2005-2011 2002-2009 2004-2006 2005-2011
Population Adult patients with colorectal resection and malignancy All hospitalizations in a single Massachusetts hospital database with primary or secondary diagnosis of CDAD Patients who underwent cardiac surgery Patients who underwent cardiac surgery in a single Ohio hospital Patients who underwent coronary artery bypass grafting and valvular surgery Patients who underwent colonic resection during hospital admission Adult patients with leukemia
Study Design Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort
Data Source(s) University Health System Consortium Database Hospital database HCUP-NIS Hospital clinical data and REDCap database HCUP-NIS HCUP-NIS HCUP-NIS
Number of Cases 1,266 3,692 2,581 145 Not reported 10,077 42,438
Definition of HAC ICD-9 ICD-9 ICD-9 Lab testing ICD-9 ICD-9 ICD-9
Cost Cost or Charges Reported Cost Cost          
Attributable Y Y          
Year of Cost Data 2008 2005          
Mean Attributable Cost Calculated $14,130.00 $13,675.00          
Standard Error $465.00 $583.00          
Mortality Matched Control Sample     Y Y N N N
Adjusted RR/OR     Not reported Not reported 2.0 (1.65-2.35) (CABG)
1.9 (1.51-2.39) VS
1.19 (1.11-1.29) 1.17 (1.13-1.22)
SE(logRR)/SE(logOR)     0.089 0.276 0.095 0.038 0.02

Exhibit D10. Clostridium difficile Infections Ccontinued

    Skovrlj (2014)
Study Study Year 2002-2011
Population Patients with lumbar spine surgery for degenerative diagnoses
Study Design Retrospective
Data Source(s) HCUP-NIS
Number of Cases 2,867
Definition of HAC ICD-9
Cost Cost or Charges Reported  
Attributable  
Year of Cost Data  
Mean Attributable Cost Calculated  
Standard Error  

Mortality

Matched Control Sample N
Adjusted RR/OR 9.6 (5.17-17.83)
SE(logRR)/SE(logOR) 0.316

Appendix E. Forest Plots

Adverse Drug Events

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (5) respectively.  Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (5) respectively.

Catheter-Associated Urinary Tract Infection 

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (6) and mortality (4) respectively.  Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (6) and mortality (4) respectively.

Central-Line Associated Bloodstream Infections

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (7) and mortality (5) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (7) and mortality (5) respectively.

Falls

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (1) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (1) respectively.

Obstetric Adverse Events

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (2) and mortality (4) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (2) and mortality (4) respectively.

Pressure Ulcers

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (3) respectively.  Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (3) and mortality (3) respectively.

Surgical Site Infections

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (5) and mortality (3) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (5) and mortality (3) respectively.

Venous Thromboembolism

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (4) and mortality (9) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (4) and mortality (9) respectively.

Ventilator-Associated Pneumonia

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (5) and mortality (10) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (5) and mortality (10) respectively.

Clostridium difficile Infections

Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (9) and mortality (13) respectively.   Two forest plots – additional costs and excess mortality – of the studies included in the adverse drug events meta-analysis for cost (9) and mortality (13) respectively.

Page last reviewed November 2017
Page originally created November 2017
Internet Citation: Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions. Content last reviewed November 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/pfp/haccost2017-appendix.html