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Cost Utility of Competing Strategies to Prevent Endoscopic Transmission of Carbapenem-Resistant Enterobacteriaceae

Almario, Christopher V MD, MSHPM1,2,3; May, Folasade P MD, PhD1,3,4; Shaheen, Nicholas J MD, MPH5; Murthy, Rekha MD6; Gupta, Kapil MD, MPH2; Jamil, Laith H MD2; Lo, Simon K MD2; Spiegel, Brennan M R MD, MSHS1,2,4

American Journal of Gastroenterology: December 2015 - Volume 110 - Issue 12 - p 1666–1674
doi: 10.1038/ajg.2015.358
ORIGINAL CONTRIBUTIONS: ENDOSCOPY
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OBJECTIVES: Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or “superbug”) to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management.

METHODS: We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by “endoscope culture and hold”; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained.

RESULTS: In the base–case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%.

CONCLUSIONS: In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.

1Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA

2Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA

3Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA

4Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA

5Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA

6Department of Hospital Epidemiology, Division of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA

Correspondence: Brennan M R Spiegel, MD, MSHS, Cedars-Sinai Medical Center, Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Health Services Research, Cedars-Sinai Health System, Pacific Theatres Building, 116 North Robertson Boulevard, 4th Floor, Los Angeles, California 90048, USA. E-mail: Brennan.Spiegel@cshs.org

SUPPLEMENTARY MATERIAL accompanies this paper at http://links.lww.com/AJG/B152

Received 01 June 2015; accepted 02 September 2015

Guarantor of the article: Brennan M.R. Spiegel, MD, MSHS.

Specific author contributions: Christopher V. Almario: planning and conducting the study, collecting and interpreting data, drafting the manuscript, and approval of final draft submitted. Folasade P. May: planning and conducting the study, collecting and interpreting data, drafting the manuscript, and approval of final draft submitted. Nicholas J. Shaheen: planning and conducting the study, interpreting data, drafting the manuscript, and approval of final draft submitted. Rekha Murthy: planning and conducting the study, interpreting data, drafting the manuscript, and approval of final draft submitted. Kapil Gupta: planning and conducting the study, interpreting data, and approval of final draft submitted. Laith H. Jamil: planning and conducting the study, interpreting data, and approval of final draft submitted. Simon K. Lo: planning and conducting the study, interpreting data, and approval of final draft submitted. Brennan M.R. Spiegel: planning and conducting the study, interpreting data, drafting the manuscript, and approval of final draft submitted.

Financial support: Almario and May were supported by a National Institutes of Health T32 training grant (NIH T32DK07180-40) during their gastroenterology and health services research training at UCLA.

Potential competing interests: None.

© The American College of Gastroenterology 2015. All Rights Reserved.
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