Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review

Correspondence to Sara G McCleskey, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; [email protected]

Introduction

Healthcare-associated infections (HCAIs) are the most frequently reported patient safety issue in healthcare delivery worldwide, occurring in 7 out of every 100 hospitalised patients in high-income countries.^{1 2} The financial burden of HCAI is also high at approximately €7 billion in Europe and about $6.5 billion in the USA annually.² In Europe and the USA, urinary tract infections (UTIs) are the most common type of HCAI (36% and 27%, respectively), with approximately 75% of these infections occurring in association with a urinary catheter.^{1 3} More than 19 000 catheter-associated UTIs (CAUTIs) occurred nationwide in the USA in 2019 with attributable costs well over $1000 per CAUTI.^4–6

To address this problem in the USA, the Centers for Medicare & Medicaid Services (CMS), a federal agency within the US Department of Health and Human Services that administers the Medicare federal health insurance programme and works with state governments to administer Medicaid,⁷ implemented several policies that created financial incentives for hospitals to reduce rates of CAUTI. In 2008, CMS implemented the Hospital-Acquired Conditions policy, which requires hospitals to absorb the costs associated with CAUTI and seven other hospital-acquired conditions.⁸ The Hospital Value-Based Purchasing Program, implemented in 2012, increases or decreases Medicare payments, the largest payer for healthcare in the USA, to hospitals based on performance relative to other hospitals on several quality measures, including CAUTI.⁹ Most recently, in 2015, CMS implemented the Hospital-Acquired Condition Reduction Program, which also adjusts payments to hospitals based on quality measures for CAUTI and other hospital-associated infections.¹⁰

In response to these policies, US hospitals have implemented various CAUTI-prevention practices, including purchasing antimicrobial catheters and/or changing hospital policies and practices, such as reducing the frequency of catheter placement, assuring proper catheter insertion and maintenance, employing automated reminder and stop order systems, and promptly removing catheters.^11–14 CAUTI rates have subsequently decreased over time.¹⁵ However, little is known about the economic value of quality improvement (QI) interventions for CAUTI, meaning the associated changes in clinical outcomes relative to the net cost.¹⁶ QI initiatives require substantial investments of staff time, supplies and other economic resources, which together comprise QI programme costs.