1Infectious Diseases Division, Rhode Island Hospital, Providence, RI. 2Warren Alpert Medical School of Brown University, Providence, RI.
Crit Care Med. 2015 Feb;43(2):382-93. doi: 10.1097/CCM.0000000000000711.
ICUs are a major reservoir of methicillin-resistant Staphylococcus aureus. Our aim was to estimate costs and effectiveness of methicillin-resistant Staphylococcus aureus prevention policies.
We evaluated three up-to-date methicillin-resistant Staphylococcus aureus prevention policies, namely, 1) nasal screening and contact precautions of methicillin-resistant Staphylococcus aureus-positive patients; 2) nasal screening, contact precautions, and decolonization (targeted decolonization) of methicillin-resistant Staphylococcus aureus carriers; and 3) universal decolonization without screening. We implemented a decision-analytic model with deterministic and probabilistic analyses. Methicillin-resistant Staphylococcus aureus infections averted, quality-adjusted life years gained, and incremental cost-effectiveness ratios were calculated. Cost-effectiveness planes and acceptability curves were plotted for various willingness-to-pay thresholds to address uncertainty.
At base-case scenario, universal decolonization was the dominant strategy; it averted 1.31% and 1.59% of methicillin-resistant Staphylococcus aureus infections over targeted decolonization and screening and contact precautions, respectively, and saved $16,203/quality-adjusted life year over targeted decolonization and 14,562/quality-adjusted life year over screening and contact precautions. Results were robust in sensitivity analysis for a wide range of input variables. In probabilistic analysis, universal decolonization increased quality-adjusted life years by 1.06% (95% CI, 1.02-1.09) over targeted decolonization and by 1.29% (95% CI, 1.24-1.33) over screening and contact precautions; universal decolonization resulted in average savings of $172 (95% CI, $168-$175) and $189 (95% CI, $185-$193) over targeted decolonization and screening and contact precautions, respectively. With willingness-to-pay threshold per quality-adjusted life year gained ranging from $0 to $50,000, universal decolonization was dominant over targeted decolonization in 67.5-75.4% and dominant over screening and contact precautions in 66.0-75.4%.
In the ICU setting, universal decolonization outperforms the other two strategies and is likely to be cost-effective even at low willingness-to-pay thresholds. Assuming 700 annual ICU admissions in an average 12-bed ICU, the projected annual savings reach $129,500 to $135,100.
重症监护病房（ICU）是耐甲氧西林金黄色葡萄球菌（MRSA）的主要储存库。我们的目的是评估 MRSA 预防策略的成本和效果。
我们评估了三种最新的 MRSA 预防策略，即 1）对 MRSA 阳性患者进行鼻腔筛查和接触预防；2）对 MRSA 携带者进行鼻腔筛查、接触预防和去定植（靶向去定植）；3）不进行筛查的普遍去定植。我们实施了一个具有确定性和概率性分析的决策分析模型。计算了避免的 MRSA 感染、获得的质量调整生命年以及增量成本效益比。绘制了各种支付意愿阈值的成本效益平面和可接受性曲线，以解决不确定性问题。
在基本情况下，普遍去定植是主导策略；与靶向去定植和筛查接触预防相比，它分别避免了 1.31%和 1.59%的 MRSA 感染，与靶向去定植相比，每获得一个质量调整生命年节省 16,203 美元，与筛查接触预防相比，节省 14,562 美元。在输入变量的广泛范围内进行敏感性分析后，结果仍然可靠。在概率分析中，与靶向去定植相比，普遍去定植使质量调整生命年增加了 1.06%（95%置信区间，1.02-1.09），与筛查接触预防相比，增加了 1.29%（95%置信区间，1.24-1.33）；与靶向去定植和筛查接触预防相比，普遍去定植分别平均节省 172 美元（95%置信区间，168-175 美元）和 189 美元（95%置信区间，185-193 美元）。如果每获得一个质量调整生命年的支付意愿阈值从 0 美元到 50,000 美元不等，那么与靶向去定植相比，普遍去定植在 67.5-75.4%的情况下具有优势，与筛查接触预防相比，在 66.0-75.4%的情况下具有优势。
在 ICU 环境中，普遍去定植优于其他两种策略，即使在较低的支付意愿阈值下，也可能具有成本效益。假设在一个平均有 12 张床位的 ICU 中每年有 700 名 ICU 入院患者，预计每年可节省 129,500 至 135,100 美元。
