Economic implications of optimal diagnosis and treatment of sepsis - Work in progress: Marginal penalties, antibiotic alterations, and outcome hypotheses

Gerald J Kost, Zuping Tang, Nam Tran, Emily E. Curd, Richard F. Louie, Timothy E Albertson, Robert W. Derlet, Rahman Azari

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Our goals: (a) to design value strategies for optimal diagnosis and treatment of sepsis; (b) to assess theoretical marginal penalties of inadequate antimicrobial treatment of intensive care patients with infections (case study) ; and (c) to analyse physician antibiotic alterations in patients with blood culture-proven bloodstream infections. Marginal penalties, which reflect extra procedures and excess costs arising from uninformed treatment decisions, were transformed to subject group-distributed opportunity costs. Value analysis revealed substantial marginal penalties associated with adverse factors, such as increased ICU length of stay, procedures (catheterisation, mechanical ventilation, tracheostomy) and ultimately, higher mortality, in critically ill patients. Investigation of 66 septicaemica patients (International Classification of Disease [ICD-9] code 038 and related derivatives) hospitalised over 17 months revealed that physicians altered antibiotics extensively during three time intervals: TI1 - collection of blood for culture to qualitative positive blood culture notification, TI2 - notification to final MIC result, and TI3 - final MIC result to 72 hours afterward. Empirical antibiotic alterations during TI1 may have adversely affected survival. Alterations peaked after blood collection and after notification of qualitative positive blood culture results. Based on patterns of alterations and 28-day mortality, we hypothesize that nucleic acid testing, if used to identify organisms and rule in bloodstream infections early (4-6 h) following admission, will help facilitate diagnosis, focus antibiotic therapy, and avert dysfunctional sepsis cascades. Reduced "alteration debt" and marginal penalties should offset the costs of nucleic acid testing. The potential for enhanced survival and improved outcomes warrants clinical trials of rapid nucleic acid testing to decrease indiscriminate antibiotic alterations, evaluate proposed value strategies, and test outcome hypotheses.

Original languageEnglish (US)
Pages (from-to)16-26
Number of pages11
JournalScandinavian Journal of Clinical and Laboratory Investigation, Supplement
Volume63
Issue number239
StatePublished - 2003

Fingerprint

Sepsis
Blood
Economics
Anti-Bacterial Agents
International Classification of Diseases
Nucleic Acids
Costs and Cost Analysis
Testing
Infection
Physicians
Therapeutics
Costs
Intensive care units
Value engineering
Survival
Mortality
Tracheostomy
Critical Care
Artificial Respiration
Critical Illness

Keywords

  • Alteration debt
  • Cost effectiveness
  • Frame shift
  • Length of stay (LOS)
  • Multiple organ dysfunction syndrome (MODS)
  • Nucleic acid testing
  • Pathogen
  • Systemic inflammatory response syndrome (SIRS)
  • Value analysis
  • Value proposition
  • Value strategy

ASJC Scopus subject areas

  • Clinical Biochemistry

Cite this

@article{29ef093d6bd841738280340ce2cfb6ff,
title = "Economic implications of optimal diagnosis and treatment of sepsis - Work in progress: Marginal penalties, antibiotic alterations, and outcome hypotheses",
abstract = "Our goals: (a) to design value strategies for optimal diagnosis and treatment of sepsis; (b) to assess theoretical marginal penalties of inadequate antimicrobial treatment of intensive care patients with infections (case study) ; and (c) to analyse physician antibiotic alterations in patients with blood culture-proven bloodstream infections. Marginal penalties, which reflect extra procedures and excess costs arising from uninformed treatment decisions, were transformed to subject group-distributed opportunity costs. Value analysis revealed substantial marginal penalties associated with adverse factors, such as increased ICU length of stay, procedures (catheterisation, mechanical ventilation, tracheostomy) and ultimately, higher mortality, in critically ill patients. Investigation of 66 septicaemica patients (International Classification of Disease [ICD-9] code 038 and related derivatives) hospitalised over 17 months revealed that physicians altered antibiotics extensively during three time intervals: TI1 - collection of blood for culture to qualitative positive blood culture notification, TI2 - notification to final MIC result, and TI3 - final MIC result to 72 hours afterward. Empirical antibiotic alterations during TI1 may have adversely affected survival. Alterations peaked after blood collection and after notification of qualitative positive blood culture results. Based on patterns of alterations and 28-day mortality, we hypothesize that nucleic acid testing, if used to identify organisms and rule in bloodstream infections early (4-6 h) following admission, will help facilitate diagnosis, focus antibiotic therapy, and avert dysfunctional sepsis cascades. Reduced {"}alteration debt{"} and marginal penalties should offset the costs of nucleic acid testing. The potential for enhanced survival and improved outcomes warrants clinical trials of rapid nucleic acid testing to decrease indiscriminate antibiotic alterations, evaluate proposed value strategies, and test outcome hypotheses.",
keywords = "Alteration debt, Cost effectiveness, Frame shift, Length of stay (LOS), Multiple organ dysfunction syndrome (MODS), Nucleic acid testing, Pathogen, Systemic inflammatory response syndrome (SIRS), Value analysis, Value proposition, Value strategy",
author = "Kost, {Gerald J} and Zuping Tang and Nam Tran and Curd, {Emily E.} and Louie, {Richard F.} and Albertson, {Timothy E} and Derlet, {Robert W.} and Rahman Azari",
year = "2003",
language = "English (US)",
volume = "63",
pages = "16--26",
journal = "Scandinavian Journal of Clinical and Laboratory Investigation, Supplement",
issn = "0085-591X",
publisher = "Taylor and Francis Ltd.",
number = "239",

}

TY - JOUR

T1 - Economic implications of optimal diagnosis and treatment of sepsis - Work in progress

T2 - Marginal penalties, antibiotic alterations, and outcome hypotheses

AU - Kost, Gerald J

AU - Tang, Zuping

AU - Tran, Nam

AU - Curd, Emily E.

AU - Louie, Richard F.

AU - Albertson, Timothy E

AU - Derlet, Robert W.

AU - Azari, Rahman

PY - 2003

Y1 - 2003

N2 - Our goals: (a) to design value strategies for optimal diagnosis and treatment of sepsis; (b) to assess theoretical marginal penalties of inadequate antimicrobial treatment of intensive care patients with infections (case study) ; and (c) to analyse physician antibiotic alterations in patients with blood culture-proven bloodstream infections. Marginal penalties, which reflect extra procedures and excess costs arising from uninformed treatment decisions, were transformed to subject group-distributed opportunity costs. Value analysis revealed substantial marginal penalties associated with adverse factors, such as increased ICU length of stay, procedures (catheterisation, mechanical ventilation, tracheostomy) and ultimately, higher mortality, in critically ill patients. Investigation of 66 septicaemica patients (International Classification of Disease [ICD-9] code 038 and related derivatives) hospitalised over 17 months revealed that physicians altered antibiotics extensively during three time intervals: TI1 - collection of blood for culture to qualitative positive blood culture notification, TI2 - notification to final MIC result, and TI3 - final MIC result to 72 hours afterward. Empirical antibiotic alterations during TI1 may have adversely affected survival. Alterations peaked after blood collection and after notification of qualitative positive blood culture results. Based on patterns of alterations and 28-day mortality, we hypothesize that nucleic acid testing, if used to identify organisms and rule in bloodstream infections early (4-6 h) following admission, will help facilitate diagnosis, focus antibiotic therapy, and avert dysfunctional sepsis cascades. Reduced "alteration debt" and marginal penalties should offset the costs of nucleic acid testing. The potential for enhanced survival and improved outcomes warrants clinical trials of rapid nucleic acid testing to decrease indiscriminate antibiotic alterations, evaluate proposed value strategies, and test outcome hypotheses.

AB - Our goals: (a) to design value strategies for optimal diagnosis and treatment of sepsis; (b) to assess theoretical marginal penalties of inadequate antimicrobial treatment of intensive care patients with infections (case study) ; and (c) to analyse physician antibiotic alterations in patients with blood culture-proven bloodstream infections. Marginal penalties, which reflect extra procedures and excess costs arising from uninformed treatment decisions, were transformed to subject group-distributed opportunity costs. Value analysis revealed substantial marginal penalties associated with adverse factors, such as increased ICU length of stay, procedures (catheterisation, mechanical ventilation, tracheostomy) and ultimately, higher mortality, in critically ill patients. Investigation of 66 septicaemica patients (International Classification of Disease [ICD-9] code 038 and related derivatives) hospitalised over 17 months revealed that physicians altered antibiotics extensively during three time intervals: TI1 - collection of blood for culture to qualitative positive blood culture notification, TI2 - notification to final MIC result, and TI3 - final MIC result to 72 hours afterward. Empirical antibiotic alterations during TI1 may have adversely affected survival. Alterations peaked after blood collection and after notification of qualitative positive blood culture results. Based on patterns of alterations and 28-day mortality, we hypothesize that nucleic acid testing, if used to identify organisms and rule in bloodstream infections early (4-6 h) following admission, will help facilitate diagnosis, focus antibiotic therapy, and avert dysfunctional sepsis cascades. Reduced "alteration debt" and marginal penalties should offset the costs of nucleic acid testing. The potential for enhanced survival and improved outcomes warrants clinical trials of rapid nucleic acid testing to decrease indiscriminate antibiotic alterations, evaluate proposed value strategies, and test outcome hypotheses.

KW - Alteration debt

KW - Cost effectiveness

KW - Frame shift

KW - Length of stay (LOS)

KW - Multiple organ dysfunction syndrome (MODS)

KW - Nucleic acid testing

KW - Pathogen

KW - Systemic inflammatory response syndrome (SIRS)

KW - Value analysis

KW - Value proposition

KW - Value strategy

UR - http://www.scopus.com/inward/record.url?scp=0043234608&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0043234608&partnerID=8YFLogxK

M3 - Article

AN - SCOPUS:0043234608

VL - 63

SP - 16

EP - 26

JO - Scandinavian Journal of Clinical and Laboratory Investigation, Supplement

JF - Scandinavian Journal of Clinical and Laboratory Investigation, Supplement

SN - 0085-591X

IS - 239

ER -