THE VALUE OF QUALITY IMPROVEMENT INTERVENTIONS FOR CATHETER-ASSOCIATED URINARY AND BLOOD STREAM INFECTIONS: A SYSTEMATIC REVIEW

Purpose: To systematically review economic evaluations addressing quality improvement (QI) interventions related to central-line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).

Method: We searched MEDLINE, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, Greylit, and Worldcat from January 1, 2004 to May 15, 2015; examined lists of references; and contacted experts. We selected English-language original research studies that described QI interventions related to CLABSI or CAUTI, measured or modeled the cost of the QI intervention, included both program costs and downstream financial effects, and were from developed countries. Dual reviewers extracted information related to the design, implementation, and reporting of the QI interventions and the economic analysis; extracted results related to clinical effectiveness and costs (program costs, downstream financial effects, net costs); and assessed the quality of the economic analyses using a modified version of the Quality of Health Economics Studies (QHES) Checklist (range 0 to 115).

Result: Of 311 unique titles in the CLABSI search, 11 studies were eligible. Of 518 titles in the CAUTI search, 4 were eligible. The types of QI interventions for CLABSI and CAUTI included standardizing care (5 and 3 studies, respectively), case management (4 and 2), provider decision support (3 and 0), enhancing efficiency (3 and 1), audit/feedback (2 and 1), reminders (0 and 2), tailoring care for patient subgroups (2 and 0), team changes (1 and 0), electronic patient registry (1 and 0), changes to facilities (0 and 1), and other (6 and 2). For CLABSI, 7 studies were cost-effectiveness/cost-benefit analyses while 4 were business-case analyses; 10 studies used the hospital perspective and 1 used multiple perspectives. For CAUTI, all four were cost-effectiveness/cost-benefit analyses; all used the hospital perspective. For CLABSI, 8 studies reported net cost savings, two reported increased costs, and one reported a range around zero costs. For CAUTI, three studies reported net cost savings and one reported increased cost. Scores on the modified QHES Checklist ranged from 85 to 113 for CLABSI, and 77 to 109 for CAUTI.

Conclusion: : Economic evaluations exist for diverse QI interventions targeting CLABSI and CAUTI, involved varied methods, and are of variable quality. Nonetheless, a majority of studies have reported net cost savings from the hospital perspective.