Assessing the economic value of avoiding hospital admissions by shifting the management of gram+ acute bacterial skin and skin-structure infections to an outpatient care setting

Figures & data

Figure 1. Decision-tree for the economic analysis of gram positive ABSSSI.

Table 1. Medical resource use cost inputs.

Resource	Cost per unit (US)	Assumptions and reference
Treatment and care unit costs
Hospital Day Inpatient	$2090.00	Expenses per inpatient day, Kaiser State Health Facts
Outpatient Infusion Visit	$165.23	CPT code: 96365
Injection Costs	$8.19	Tice et al.26; injection and administration costs per dose based on meta-analysis of 9 time and motion studies; $6.00 in 2005, inflated to January 2015 using medical component of Consumer Price Index (CPI) from BLS27
Nurse Visit at Home	$101.98	Tice et al.28; $66 average cost for fee for service (FFS) in 2002; inflated to January 2015 with medical component of CPI from BLS27
Physician Visit	$261.12	CPT code: 99215
Per diem IV Home Care Costs	$220.03	Tice et al.28. FFS outpatient cost with medication costs removed ($198 − $55.60) = $142.40, then inflated to January 2015 using BLS Inflation Calculator27
PICC for outpatient administration of IV antibiotic	$632.82 + $240.20 + $204.64	CPT 36569, for PICC placement plus CPT 76000, for fluoroscopy placement plus $205 complications summary (see below average cost per patient)
Lab work	$118.07	CPT 80069 renal function panel $66.99 and CPT 80202 drug trough level $51.08

Note: All CPT codes are from Ingenix25, 2015 National Fee Analyzer and costs are 50th percentile.

Table 2. Cost calculations of PICC complications.

Resource use	Cost	Source	Base case incidence	Source	Sensitivity analysis incidence	Source	Final cost (sensitivity analysis range)
Physician visit	$261	CPT 99215	17%	Tice et al.13	8–50%	Chapman et al.16, Seckold et al.17	$44 ($21–$131)
CathFlo (Alteplase)	$121	2 mg vial Red Book WAC 2015	7%	Tice et al.13	7.6–10.3%	Seckold et al.17	$8 ($8–$12)
Declotting procedure	$215	CPT 36593	7%	Tice et al.13	7.6–10.3%	Seckold et al.17	$15 ($15–$22)
ER visit (CPT 99284  + facility fee)	$717	CPT 99284 ($470) plus facility fee of $224 for APC adjusted by 3.3% for 2012 per CMS to $232, then inflated to January 2015 to $247	2%	Moureau et al.12	—		$14
Re-hospitalization for management	$8167	DRG 920, DRG Expert 2012, national average payment, inflated to January 2015	1%	Moureau et al.12	1–2%	Chapman et al.16	$82 ($82–$163)
PICC replacement	$574	CPT 36584	5%	Moureau et al.12	6%	Leroyer et al.18	$29 ($29–$34)
Fluoroscopy for placement	$240	CPT 76000	5%	Moureau et al.12	—		$12
Total average complication cost per patient with PICC line							$205 ($181–$388)

All CPT codes are from 2015 National Fee Analyzer and costs are 50th percentile25. Other costs inflated to 2015 US dollars.

Tice et al.13 found ∼17% of PICCs for outpatient treatment with thrombotic and phlebitis complications; assumption derived that these patients would incur a physician visit and some would receive a declotting agent/procedure.

Moureau et al.12 found most complications < 7 days are thrombotic occlusion and provided breakdown of outcomes from complications (assumptions derived from this article for ER, hospitalization, PICC replacement).

Figure 2. Costs for four hospital LOS scenarios followed by outpatient IV treatment.

Table 3. Detailed cost outcomes for model scenarios.

Resource use categories	Twice daily IV antibiotic*	Once daily IV antibiotic
0 days inpatient/14 days outpatient (Avoidable Admissions Scenario)
Inpatient Costs
Hospital LOS	$0	$0
Adverse Events	$387	$387
Outpatient Costs
Daily Home Care/Infusion Center Visit	$3081	$2313
Physician Visit	$261	$261
Lab Tests	$118	–
PICC Line	$1078	$1078
3 days inpatient/11 days outpatient
Inpatient Costs
Hospital LOS	$6270	$6270
Adverse Events	$387	$387
Outpatient Costs
Daily Home Care/ Infusion Center Visit	$2420	$1818
Physician Visit	$261	$261
Lab Tests	$118	–
PICC Line	$1078	$1078
5 days inpatient/9 days outpatient
Inpatient Costs
Hospital LOS	$10,450	$10,450
Adverse Events	$387	$387
Outpatient Costs
Daily Home Care/ Infusion Center Visit	$1980	$1487
Physician Visit	$261	$261
Lab Tests	$118	–
PICC Line	$1078	$1078
7 days inpatient/7 days outpatient
Inpatient Costs
Hospital LOS	$14,630	$14,630
Adverse Events	$387	$387
Outpatient Costs
Daily Home Care/Infusion Center Visit	$1540	$1157
Physician Visit	$261	$261
Lab Tests	$118	–
PICC Line	$1078	$1078

*For example, a traditional glycopeptide.

Table 4. Cost savings associated with shifting ABSSSI care to the outpatient setting.

	Total cost (range for once and twice daily IV treatments)	Cost savings compared to 7 days inpatient/7 days outpatient scenario
0 days inpatient/14 days outpatient (Avoidable admission scenario)	$4039–$4924	$13,090–$13,473
3 days inpatient/11 days outpatient	$9813–$10,534	$7480–$7699
5 days inpatient/9 days outpatient	$13,663–$14,274	$3740–$3849
7 days inpatient/7 days outpatient	$17,512–$18,014	NA

Figure 3. Breakdown of costs related to PICC line complications.

Table 5. Top drivers of total cost of ABSSSI treatment.

Drivers of total costs	Baseline value of total cost drivers	Impact on total costs in $ (using ± 30% from baseline value)
Hospital bed day cost	$2090	±$3135 (Once Daily)/±$4389 (Twice Daily)
Hospital LOS	5 days (Once daily)/7 days (Twice daily)	±$2887 (Once Daily)/±$3927 (Twice Daily)
Length of treatment	14 days	±$694 (Once Daily)/±$924 (Twice Daily)

Table 6. Top drivers of outpatient cost of ABSSSI treatment.

Drivers of outpatient costs	Baseline value of outpatient cost drivers	Impact on outpatient costs in $ (using ± 30% from baseline value)
Outpatient infusion visit cost	$165 (Once Daily)/$220 (Twice Daily)	± $694 (Once Daily)/ ±$924 (Twice Daily)
PICC cost	$1078	± $323
Physician visit cost	$261	± $78

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