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Cost of Treatment
Investigation and Prevention Branch, Centers for Disease Control and Prevention, U.S. Public Health Service
Pharmaceutical costs, which approach $40 billion annually, account for about 8% of health care costs. Prescription drugs represent 5% to 20% of the total hospital budget, and antimicrobials account for 20% to 50% of hospital pharmaceutical costs. At one university hospital, the percentage of patients receiving antimicrobials increased from 31.8% in 1988 to 53.1% in 1994. Receipt of vancomycin has been associated with the emergence of resistant enterococci and has resulted in Centers for Disease Control and Prevention (CDC) recommendations for its use. Studies show that vancomycin use is increasing, that dosing is often inappropriate, that certain populations (such as oncology, neurosurgery, and cardiovascular surgery patients) are more likely to receive vancomycin, and that often use is not consistent with CDC recommendations. Few studies have assessed the cost of vancomycin use; those that have show that it is costly
Use of Insurance Claims Data
359 patients who received intravenous vancomycin in the home care setting from January 1998-April 2000.
These patients had uninterrupted insurance coverage for a median of 850 days (range 8-850 days). The 359 patients in the study cohort had a total of 419 episodes of intravenous vancomycin therapy at home during the study period.
Approximately 11% of patients had a second home care episode, and nearly 3% had three or more home care episodes.
The data indicate slightly higher proportion of women (54%), and approximately 96% of all patients were 20-64 years of age. Most patients (66%) were hospitalized before the start of their home care episode.
Forty-two percent of patients with a baseline hospitalization had a discharge diagnosis of gram-positive infection.
The 359 patients were treated with intravenous vancomycin for a total 6123 days.
The median duration and cost of home care intravenous vancomycin therapy/patient and by frequency of home care episodes. The median duration of therapy was slightly higher for the first episode (9 days) compared with subsequent episodes (7 days). Approximately 13% of episodes continued for 30 days or more.
The overall cost of home care directly related to intravenous vancomycin therapy (drug acquisition, management and administration of therapy) for the 359 patients was $698,985.
When examining the cost/patient, we found that the median cost of intravenous vancomycin therapy at home amounted to $1305 (95% CI $1175-$1537), which was approximately 5 times the median acquisition cost of vancomycin/patient ($249; 95% CI $235-$282). Median home care costs for the first and third (or more) episodes of intravenous vancomycin therapy were substantially higher than the second home care episode.
Since the total expenditure for disease management goes beyond the direct cost of handling intravenous treatment, we tried to better estimate these costs. The rate of outpatient visits for gram-positive infection-related events (4.36/patient/month of vancomycin home therapy). The median cost for the 231 patients with these 889 claims was $1150 (95% CI $971-$1299).
The data shows the rate of outpatient visits for complications related to the catheter or intravenous line (0.82/patient/ month). For the 77 patients with these 168 claims, the median cost/patient was $457 (95% CI $251-$909).
Only four patients had outpatient service for an ototoxic reaction.
On closer inspection of pharmacy claim records for these four patients, we confirmed that none received concomitant aminoglycoside therapy over the study period.
The median cost of an ototoxic reaction for these four patients was $121 (95% CI $22-$191).
Thirty-eight of the 168 catheter-related outpatient claims indicated at least one hospitalization within 3 days before or 3 days after the outpatient service. Of the 41 total inpatient claims, 13 were catheter related (37 total hospital days with a total cost of $51,239), 6 were gram-positive infection related (19 total hospital days with a total cost of $31,731), 11 were both catheter and gram-positive infection related (28 total hospital days with a total cost of $138,214), and 11 were neither catheter nor gram-positive infection related (21 total hospital days with a total cost of $72,511). Of the 30 gram-positive infection-and/or catheter-related hospitalizations, 22 occurred within the 3 days preceding the outpatient catheter-related service. Two hospitalizations occurred on the same day as the outpatient catheter-related service, and the remaining six hospitalizations occurred within the 3 days after the outpatient catheter-related service.
Analysis of risk of rehospitalization was restricted to the 94 patients with an index hospitalization for a gram-positive infection before their vancomycin home care episode and 60 days of continuous follow-up.
There were slightly more men in this subcohort (56%), and approximately 96% of the patients were aged 20-64 years. Thirty-two percent and 54% were diagnosed with septicemia and cellulitis, respectively, during the baseline hospitalization. Thirty-eight percent of the patients (36 patients) were rehospitalized during the 60-day follow-up period, 10 of whom had a primary diagnosis of gram-positive infection. Costs associated with rehospitalization during the 60-day follow-up period.The median total cost of vancomycin therapy/patient was $1,568 (not including the baseline hospitalization cost) in year 2000, Whereas the median vancomycin acquisition cost/patient was $287 in 2000 and keep going higher, $389 in 2008.
Direct medical costs associated with using vancomycin in methicillin-resistant Staphylococcus aureus infections:
Typical economic model
Total costs for MRSA admission, including hospital length of stay, were:
Skin and Soft Tissue Infection(SSTI) - $23,616
Bacteremia - $26,446
Infective Endocarditis (IE) - $48,925
Hospital Acquired Pneumonia (HAP) - $22,493.
In univariate analyses varying per diem hospital costs and length of stay had the greatest impact.
Results of the multivariate analysis were comparable to the costs in the baseline scenario for all indications.
Conclusions: This analysis highlights the importance of capturing all costs associated with using a drug and not simply focusing on drug acquisition cost. Future economic analyses should identify and account for the key cost burdens of a particular treatment to calculate its true cost.