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Cost-Benet Analysis from the Hospital Perspective of

Universal Active Screening Followed by Contact
Precautions for Methicillin-Resistant Staphylococcus aureus
Carriers

James A. McKinnell, Sarah M. Bartsch, Bruce Y. Lee, Susan S. Huang and Loren G. Miller
Infection Control & Hospital Epidemiology / Volume 36 / Issue 01 / January 2015, pp 2 - 13
DOI: 10.1017/ice.2014.1, Published online: 05 January 2015
Link to this article: http://journals.cambridge.org/abstract_S0899823X14000014
How to cite this article:
James A. McKinnell, Sarah M. Bartsch, Bruce Y. Lee, Susan S. Huang and Loren G. Miller (2015). Cost-Benet
Analysis
from the Hospital Perspective of Universal Active Screening Followed by Contact Precautions for Methicillin-
Resistant
Staphylococcus aureus Carriers. Infection Control & Hospital Epidemiology, 36, pp 2-13 doi:10.1017/ice.2014.1

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 i n fe ctio n c ontr ol & h osp ita l e pid e miol ogy j anua ry 2015, v ol. 3 6, no. 1

original article

Cost-Benefit Analysis from the Hospital Perspective of Universal

Active Screening Followed by Contact Precautions for Methicillin-
Resistant Staphylococcus aureus Carriers

1,2 3,4 3 5
James A. McKinnell, MD; Sarah M. Bartsch, MPH; Bruce Y. Lee, MD, MBA; Susan S. Huang, MD, MPH;
Loren G. Miller, MD, MPH1

objectiv e. To explore the economic impact to a hospital of universal methicillin-resistant Staphylococcus aureus (MRSA)
screening.
met h o d s . We used a decision tree model to estimate the direct economic impact to an individual hospital of starting universal
MRSA screening and contact precautions. Projected costs and benefits were based on literature-derived data. Our model examined outcomes
of several strategies including non-nares MRSA screening and comparison of culture versus polymerase chain reaction–based screening.
results. Under baseline conditions, the costs of universal MRSA screening and contact precautions outweighed the projected benefits
generated by preventing MRSA-related infections, resulting in economic costs of $104,000 per 10,000 admissions (95% CI, $83,000–
$126,000). Cost-savings occurred only when the model used estimates at the extremes of our key parameters. Non-nares screening and
polymerase chain reaction–based testing, both of which identified more MRSA-colonized persons, resulted in more MRSA infections
averted but increased economic costs of the screening program.
co nclusion s. We found that universal MRSA screening, although providing potential benefit in preventing MRSA infection, is
relatively costly and may be economically burdensome for a hospital. Policy makers should consider the economic burden of MRSA screening
and contact precautions in relation to other interventions when choosing programs to improve patient safety and outcomes.
Infect Control Hosp Epidemiol 2 01 5 ; 3 6 ( 1 ): 2 –
13
Methicillin-resistant Staphylococcus aureus (MRSA) is a major
cause of healthcare-associated infections, with particularly
high incidence in the United States, Asia, and parts of
1,2
Europe.
MRSA infections amongst hospitalized patients can result in
passing laws mandating that hospitals perform active
surveillance for MRSA in selected populations, particularly for
intensive care units, regardless of underlying MRSA
14
prevalence. Others have advocated for even broader, hospital-
wide programs of universal surveillance and isolation.
15,16

devastating morbidity and significant mortality. Support for broader screening has come from investigators
Preventing spread of MRSA amongst hospitalized patients is a suggesting that hospital-wide, universal surveillance may be a
priority for hospitals, public health officials, and policy cost-effective strategy when considered from a societal
makers. perspective.
16,17

Amongst hospital-based strategies to prevent MRSA
infections, MRSA screening followed by subsequent contact
3–5
precautions is a common strategy used by US hospitals.
MRSA screening and contact precautions in populations with
high MRSA prevalence has demonstrated effectiveness in
reducing transmission and the number of newly acquired
6–12
infections. Guidelines from SHEA recommend active
5
surveillance for MRSA, but this recommen- dation has been
challenged and is not universally adopted as a gold standard
13
across the United States. Public concern about MRSA
infections has led to a number of US state legislatures
Although universal surveillance may be cost-effective from
a societal perspective, hospitals considering
implementation of universal surveillance must consider the
additional costs incurred from surveillance, isolation, and
contact precautions that are not reimbursed. The economic
impact to an individual hospital may represent an important
barrier to implementation. To examine the potential economic
barriers to implementation of universal MRSA surveillance,
we developed a decision tree model to quantify the costs
and benefits of implementing

Affiliations: 1. Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-
UCLA Medical Center, Torrance, California; 2. Torrance Memorial Medical Center, Torrance, California; 3. Public Health Computational and Operations
Research Group (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; 4. Department of Industrial Engineering, University
of Pittsburgh, Pittsburgh, Pennsylvania; 5. Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of
Medi- cine, Irvine, California.
Received April 3, 2014; accepted August 13, 2014
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3601-0002. DOI: 10.1017/ice.2014.1
 co st-be n e fi t a n a l y sis f ro m t h e h o spital per s pe ctive o f u ni ve rsal ac tive scr e e
n in g 3

Patient Admission (Patient is Screened for MRSA)

4 i nfectio n co ntr o l & hospital epidemiology j a nuar y 2 015, vo l. 36, n
o. 1 no yes
Is Patient Colonized with MRSA?

Does Patient Test Positive? Does Patient have MRSA at Site Screened?

no yes yes
no
CP Applied

True Negative False Positive

Patient Positive for MRSA at Another Site Does Patient Test Positive?
Cost: screening Cost: screening + CP
no yes
CP Applied
Does Patient Test Positive?

no yes False Negative True Positive

CP Applied
Cost: screening Cost: screening + CP

“False” Negative* False Positive

Cost: screening Cost: screening + CP

CP = contact isolation precautions

* A ‘”false” negative is correct in terms of colonization, but is also “true” negative in terms of testing
(i.e., not colonized at screening site and should therefore result in a negative test)

fi gur e 1. Flow of admitted patients through the model. CP, contact precautions; MRSA, methicillin-resistant Staphylococcus aureus; false
negative, an MRSA carrier is not detected because the wrong site was chosen for surveillance, e.g., a patient colonized in the groin only who
undergoes nares-only surveillance, or the MRSA testing is falsely negative at an MRSA-colonized body site.

universal MRSA surveillance in a hospital. We believe that
results of our model may help hospitals, state, and national
policy makers understand the economic impact of universal
surveil- lance on a hospital.
me t h potential benefits of contact precautions were extracted from
o ds
We developed a decision tree model to estimate the economic
impact of adopting a hospital-wide, universal active surveil-
lance program for MRSA with subsequent contact precautions
for all MRSA carriers. Specifically, we compared the costs of
the surveillance and contact precaution program against the
projected economic benefits of preventing secondary MRSA
infections. The cost-benefit analysis was conducted from the
individual hospital perspective and compared against no
screening. We report results for 10,000 inpatient admissions,
which can readily be converted to any number of admissions
(e.g., a 500-admission hospital would divide 10,000 by 20).
Based on a recently completed systematic literature
18
review, our baseline conditions assume an MRSA nares
colonization prevalence of 7.3% in US hospitals. Based
18
on the same review, our baseline conditions assume a
ratio of nasal carriage to total body MRSA colonization.
the model was categorized as either MRSA colonized or not
colonized. Each patient was defined as carrying MRSA at
each prespecified body site, on the basis of our previous
systematic review of the literature.
18,19
Input parameters for
costs, MRSA epidemiology, MRSA testing characteristics, and
the literature and summarized in Table 1. Several key para-
meters were the focus of additional sensitivity analysis as
described below.
All patients underwent MRSA screening on admission
using one of the following screening strategies: (1) nares only,
(2) nares and oropharynx, or (3) multisite swabbing. In our
model, patients test either positive or negative for MRSA
depending on their colonization status and the sensitivity and
specificity of the test (Table 1). In our model, patients testing
positive, regardless of their true colonization status (i.e., both
true and false positives) were placed in contact precautions for
the remainder of their hospitalization. (Contact precautions
were not used preemptively pending test results.) Separate
analyses were conducted to compare screening with chroma-
gar methods and polymerase chain reaction (PCR)–based
methods. We used each of these models to test the hypothesis
that better screening, either by swabbing more body sites or
by using more sensitive diagnostic testing, would improve
the benefit of screening and contact precautions.

Development of the Decision Analysis Model

We used TreeAge Pro 2013 (TreeAge) to build a cost-benefit
model to examine the implementation of a hospital-wide,
universal MRSA screening program from the hospital per-
spective (Figure 1, Appendix 1). Briefly, each patient entering
Determination of Estimated Costs
The costs of the screening and contact precaution program are
based on the material and labor costs to the hospital of both
ta b l e 1 . Model Input Parameters, Values, and Sources
Parameter Distribution Mean or mediana Range or SD Source
Costs (2014 $US)
Swab 1 (10)
PCR materials 25 (10)
Chromogenic agar materials 3.5 (10)
Gloves gamma 0.10 0.007 (10,32)
Gown 1.01 (10)
RN hourly wage triangular 33.40a 27.37–40.14 (33)
Technician hourly wage triangular 18.99a 12.65–29.44 (33)
Cost of hospital bed-dayb,c gamma 1507.92 205.71 (34)
Probabilities
PCR sensitivity beta 0.87 0.075 (35–39)
PCR specificity beta 0.96 0.022 (35–39)
Chromogenic agar sensitivity beta 0.82 0.007 (35–39)
Chromogenic agar specificity beta 0.99 0.0007 (35–39)
MRSA prevalence on admission triangular 0.095a 0.06–0.20 (18)
Carriers detectable by nares triangular 0.72a 0.63–0.73 (18)
Carriers detectable by oropharynx uniform 0.15–0.20 (18)
Durations
Hospital length of stay for admitted patients, daysb,d gamma 5.0 0.42 (34)
Nurse time don/doff, min 1 (10,32,40)
Contacts per day triangular 35a 25–50 (9,41)
Technician time to process PCR sample, min 7.5 (10,32,40)
Technician time to process chromogenic agar sample, min 3.5 Expert opinion
Sensitivity Analysis
Parameter Base Case Scenario Range of Values Tested Sources
No. of MRSA infections averted per isolated MRSA carrier 0.005 0.005, 0.015, 0.03 (8–
11,15,23) MRSA-attributable length of stay 6 2–16
(24–28) MRSA prevalence of admitted patients Distribution listed above 0.095–0.30
(18)
NOTE. Carriers detectible by multisite is the remainder of the total body colonization minus that detectable in the nares and oropharynx (this is
not presented in the table). MRSA, methicillin-resistant Staphylococcus aureus; PCR, polymerase chain reaction; RN, registered nurse; SD,
standard deviation.
a
Denotes median values.
b
Values are mean and standard error.
c
Calculated from the mean cost of hospitalization divided by the mean length of stay for ICD-9 code 041.12 in Healthcare Cost and Utilization
Project (HCUP) for 2011 and discounted to 2014 $US.
d
Length of stay for all admissions in HCUP.
the screening procedures
and the contact
precautions (Table 1). For
each simulation, the cost
for each screening strategy
was calculated as:
ðCost of Contact
Precautions + Cost of
ScreeningÞ
The screening costs
included the cost of
swab(s), which assumed
each body site was tested
with its own swab. The costs
of routine culture were
based on chromogenic
agar plates where each
patient required 1 plate. For
multiple body site testing,
we allowed for split plate
testing, maintaining 1 chro-
mogenic agar plate per
patient. For PCR-based
testing, we included the cost
of PCR materials. For
multisite PCR testing, we
assumed that the multiple
body site samples could be
bat- ched for 1 PCR test.
For both culture and PCR
testing, we included the cost
of technicians’ time to
process the sample.
The cost of contact
precautions included the
material costs of additional
gloves and gowns used and
additional nursing time to
don and doff gloves and
gowns before each entry
into patient rooms for the
duration of their hospital
stay. The cost of nursing
time was estimated from
the average hourly nurse
wage from the US Bureau
of Labor and Statistics
(national statistics for
20
2012). We did not
include additional support
for infection control
personnel to manage the
program, nor did we
include start-up costs—for
example, staff training.
Costs were converted from
previous years to 2014 US
dollars using a 3% discount
rate.
Determination of Projected
Benefits
The potential benefit to a
hospital of a screening and
contact precaution program
is averting secondary
MRSA infections
through the appropriate
implementation of contact
precautions. The cost of an
MRSA infection to the
hospital was calculated from
the MRSA-attributable
length of stay and the cost
of a hospital bed-day,
following a method
described by Graves.
21
each screening strategy was were performed for each
calculated as: simulation, varying each
ðNo: of Infections parameter throughout its
range (Table 1). The
Averted ´ MRSA distributions varied in the
Attributable Length Monte Carlo simulations
of Stay ´ Cost of account for variability in
known parameters and
Lost Bed-DayÞ
were created on the basis of
ðCost of Contact the available data (e.g.,
7.3% nares colonization
prevalence, and a 6-day
attributable length of stay.
We estimated the number
of MRSA infections averted
per MRSA carrier placed in
contact precautions as
0.005, on the basis of
currently available estimates
from the literature.
8–11,16

These additional days Precautions + Cost variability across studies or However, we recognize that
represent the opportunity of ScreeningÞ ranges/CIs from 1 source). the literature on MRSA
cost of a lost bed-day, contact precautions efficacy
The optimal strategy is mixed and based largely
where a bed could have been Sensitivity
was defined as the on select popu- lations or
used by another patient to Analyses of
strategy with the best cost- 22
generate revenue. Key Model higher prevalence settings.
benefit to the hospital—
For each simulation, the Estimates We therefore used data from
that is, cost-neutral (costs
benefit for each screening a randomized trial of
= benefit) or cost-saving Additional 1- and 2-way
strategy was calculated as: hospital-wide, universal
(cost < benefit). sensitivity analysis varied
ðNo: of Infections screening and contact
key para- meters in the precautions combined with
Averted ´ M model to determine their chlorhexidine bathing as an
MRSA o impact on the projected extreme estimate for the
Attributable d cost-benefit of each efficacy of universal active
e strategy. These parameters screening followed by
Length of Stay include the number of
l contact precautions—that
´ Cost of Lost MRSA infections averted is, 0.05
Bed-DayÞ S per isolated MRSA carrier, MRSA cases per patient
i MRSA-attributable length placed in contact
C m of stay, and MRSA precautions and
o u prevalence among admitted decolonized.
23
Using this
s l patients. Our baseline data, we varied contact
t a conditions assumed 0.005 precaution efficacy in
- t infections averted per reducing MRSA infection
B i isolated MRSA carrier, a from 0.005 (base-case
e o estimate), to 0.015
n n (optimistic estimate), to
e s 0.03 (extreme estimate)
fi Each simulation sent 1000 MRSA cases averted per
t hospital admissions through MRSA carrier placed in
the model 1000 times for a contact precautions.
A total of 1 million trials. Our We estimated the
n model results are expressed additional hospital length of
a as outcomes per 10,000 stay attributed to MRSA was
l hospital admis- sions and 6 days. However, as the
y include total number of attributable length of stay
s colonized patients identified due to MRSA depends on
i by the surveillance program, the type of acquired
s total number of patients infection (e.g., skin and soft-
The economic impact of placed in contact tissue infection vs.
adopting a universal precautions, number of bacteremia vs. endocarditis),
surveillance and contact secondary infections averted we ranged this from 2 to
precautions program was by the intervention, and 16 additional hospital days
based on the difference the cost-benefit (costs (based on estimates of
averted by preventing attributable length of stay
between the benefits (i.e.,
MRSA infections – for different types of
cost-savings from averting
intervention costs) of the infection available from the
MRSA infections) and 24–28
intervention costs. For each intervention. Probabilistic literature ).
simulation, the economic sensitivity analyses (i.e., We designed our base-case
impact to the hospital for Monte Carlo simulations) scenario with MRSA nares
coloni- zation prevalence of estimate of contact
7.3% and the total body precaution efficacy (0.03
MRSA colonization infections averted per
prevalence was 9.5% on the carrier isolated). Results
basis of a recent systematic were similar to less
literature review on MRSA efficacious scenarios,
18
colonization. On the basis resulting in economic losses
of this review, we varied greater than $104,000. Our
total body MRSA results can be used to
colonization to range from estimate the associated
9.5% to 30% and nares costs and cost-benefit for a
colonization ranging from hospital with any number
7.3% to 22% to determine of admissions. For
whether hospitals with a example, a hospital with
higher burden of MRSA 2500 admissions
may benefit from universal implementing nares-only
active surveillance.

r
e
s
u
l

s
Table 2 shows results for
our baseline conditions for
both chromagar and PCR
methods. A program of
nares screening for all
patients admitted to a
hospital using chromogenic
agar identified 545 MRSA-
colonized patients/10,000
admissions (95% CI, 420–
683 colonized
patients/10,000 admissions)
and averted 3 cases of
invasive MRSA disease
(95% CI, 2–3.4),
preventing 18 additional
hospitalization days and
saving
$24,740 (95% CI,
$18,920–$30,960) (Table
2). The nares surveillance
program improperly placed
79 patients in contact
precautions. The overall
economic impact to the
hospital was a $237,494
loss (95% CI, $199,867–
$283,610) for 10,000
admissions (Table 2).
Table 3 shows results
assuming an extreme
tab l e 2 . Costs and Benefit (mean [95% CI]) per 10,000 Admissions under Baseline Conditions (Contact Precautions Avert 0.005 Methicillin-Resistant Staphylococcus aureus
[MRSA] Infections per Carrier Isolated and a 6-Day Attributable Length of Stay for MRSA Infection)
Variable Chromogenic agar screening Polymerase chain reaction screening

Total number of MRSA colonized

patients 954 (770–1106) 955 (780–1150)

Body site(s) tested Nares Nares/oropharynx Multisite swab Nares Nares/oropharynx Multisite swab
Patients correctly identified as 545 (420–684) 683 (540–863) 786 (630–943) 577 (440–720) 723 (560–890) 832 (670–1010)
colonized
Patients placed in contact precautions 625 (490–766) 761 (600–950) 864 (700–1020) 921 (740–1110) 1,060 (870–1260) 1,164 (980–1370)
 36, no. 1
6 i nfec tio n c o n t ro l & h o s p ita l epidemio lo gy
Intervention cost $252,234 $304,977 $347,253 $573,179 $626,601 $669,420
($209,295–$299,142) ($254,186–$359,529) ($293,332–$397,025) ($514,179–$641,748) ($565,180–$701,205) ($608,348–$732,835)
Swabs $10,000 $20,000 $30,000 $10,000 $20,000 $30,000
a
Testing $46,879 $46,879 ($46,747– $46,879 ($46,747– $275,451 ($275,201– $275,451 ($275,201– $275,451 ($275,201–
($46,747–$47,062) $64,062) $47,062) $285,451) $285,451) $285,451)
Gloves $11,618 $14,163 ($11,185– $16,087 ($12,915– $17,117 ($13,680– $19,716 ($16,035– $21,657 ($18,014–
($9,074–$14,308) $17,533) $19,224) $20,625) $23,655) $25,502)
Gowns $118,046 $143,880 ($113,479– $163,414 ($131,081– $173,878 ($138,931– $209,645 ($162,818– $219,971 ($183,116–
($92,456–$145,878) $176,394) $192,441) $209,645) $239,539) $257,964)
Nursing time $65,691 $80,054 $90,873 $96,733 $111,416 $122,341
($51,017–$ ($62,774–$ ($72,574– ($76,587– ($90,620– ($102,017–$
−81,893) − 98,540) −$1 08,297) −$1 16,027) −$1 32,810) − 143,661)
MRSA infections avoided − 2. 7 (2.1–3.4) −3. 4 (2.7–4.3) −3. 9 (3.2–4.7) − 2. 9 (2.2–3.8) − 3. 6 (2.8–4.6) − 4. 2 (3.4–
5.1) − − − − − −
Cost averted $24,740 $30,904 $35,552 $26,596 $32,914 $37,630
($18,930–$30,963) ($24,162–$38,740) ($28,137–$42,757) ($20,184–$33,422) ($25,779–$40,879) ($30,311–$45,562)
Cost-benefitb $227,494 $274,072 $311,701 $546,583 $593,937 $631,790
( $189,867 to $273,610) ( $233,858 to $322,300) ( $279,386 to $360,541) ( $493,450 to $599,579) ( $536,988 to $651,979) ( $577,609 to $689,002)
Gain vs. loss Loss Loss Loss Loss Loss Loss
a
Includes test materials and technician labor to process sample; multiple samples were tested by splitting chromogenic agar plates and combining samples for PCR runs.
b
Negative values indicate a economic loss to hospital given a $0 break-even threshold.

jan u a r y 2 015 , v o l .
tab le 3 . Costs and Benefit (mean [95% CI]) per 10,000 Admissions with Baseline Methicillin-Resistant Staphylococcus aureus (MRSA) Prevalence on Admission, a 6-day
Attributable MRSA Length of Stay, and an Extreme Contact Precaution Efficacy Estimate (0.03 Infections Averted per MRSA-Colonized Patient Isolated)
Variable Chromogenic Agar Screening Polymerase chain reaction (PCR) Screening

Total no. of MRSA colonized patients 953 (780–1140) 946 (770–1140)

Body site(s) tested Nares Nares/Oropharynx Multi Site Swab Nares Nares/Oropharynx Multi Site Swab
Patients correctly identified as 542 (410–680) 680 (530–820) 786 (630–950) 575 (430–730) 720 (560–890) 824 (660–1,000)
colonized
Patients placed in contact precautions 622 (470–760) 758 (590–920) 863 (690–1040) 915 (740–1110) 1,054 (870–1250) 1,155 (960–1370)
Intervention cost $251,555 $304,142 $346,774 $571,564 $625,012 $666,295
($205,554–$299,868) ($250,214–$353,933) ($292,645–$402,702) ($515,439–$632,775) ($566,246–$690,416) ($601,959–$733,215)
Swabs $10,000 $20,000 $30,000 $10,000 $20,000 $30,000
Testinga $46,876 $46,876 $46,876 $275,455 $275,455 $275,455
($46,740–$47,006) ($46,740–$47,006) ($46,740–$47,006) ($275,165–$275,715) ($275,165–$275,715) ($275,165–$275,715)
Gloves $11,583 $14,119 $16,061 $17,025 $19,610 $21,475
($8841–$14,452) ($10,941–$17,159) ($12,867–$19,366) ($13,750–$20,763) ($16,127–$23,420) ($17,658–$25,422)
Gowns $117,659 $143,386 $163,125 $172,913 $199,178 $218,074
($90,020–$146,384) ($110,867–$173,361) ($130,381–$196,500) ($139,405–$209,892) ($164,097–$238,282) ($179,641–$258,298)
Nursing time $65,437 $79,762 $90,713 $96,171 $110,768 $121,293
−
($49,952–$ 82,027) −
($61,666–$ 96,407) −
($72,656–$1 09,830) −
($77,118–$1 16,404) −
($90,856–$1 33,000) −
($99,495–$1 43,780)
MRSA infections avoided − −
16 (12–20) − −
20 (16–25) − −
24 (19–29) − −
18 (13–22) − −
22 (17–27) − −
25 (20–30)
Cost averted $147,777 $143,386 $163,125 $158,993 $196,630 $223,685
($110,142–$186,002) ($110,867–$173,361) ($130,381–$196,830) ($121,130–$199,233) ($152,043–$243,162) ($176,000–$272,216)
 b
Cost-benefit $103,778 $119,474 $133,349 $412,571 $428,381 $442,609
( $83,491 to $126,252) ( $97,905 to $143,518) ( $110,865 to $157,160) ( $376,833 to $452,963) ( $392,508 to $469,522) ( $405,763 to $481,495)
Gain vs. loss Loss Loss Loss Loss Loss Loss
a
Includes test materials and technician labor to process sample; multiple samples were tested by splitting chromogenic agar plates and combining samples for PCR runs.
b
Negative values indicate a economic loss to hospital given a $0 break-even threshold.

ning 7
co st-ben e fi t a nal y sis f r o m t h e h o spital per s p e cti v e o f u ni ve rsal ac tive scr e e
88 i n fe ctio n c ontr ol & h ospital e pid e miol ogy j anua ry 2015, v ol. 3 6,
no. 1
 cost-be n e fi t a n a ly sis f rom t he ho spi t al pe rspe ctive o f u nive rsa l acti ve scre en
Colonization Prevalence: Baseline in g 9 Colonization Prevalence: 20% Colonization Prevalence: 30% High/Very High Complexity
16 16 16 MRSA Infections
(mediastinitis; PJI;
14 disseminated BSI)
14 14
MRSA attributable LOS

12 12 12 Moderate/High Complexity
MRSA Infections
10 10 10
(BSI; pneumonia)

8 8 8

6 6 6 Mild/Moderate Complexity
MRSA Infections (SST)
4 4 4

2 2 2
0.005 0.010 0.015 0.020 0.025 0.030 0.005 0.010 0.015 0.020 0.025 0.030 0.005 0.010 0.015 0.020 0.025 0.030
Number of Infections Averted Number of Infections Averted Number of Infections Averted

Optimal Surveillance Strategy

No Screening Nares Screening Nares/Oropharynx Screening Three Site Swab Screening

fi gure 2. Two-way sensitivity analysis of methicillin-resistant Staphylococcus aureus (MRSA)–attributable length of stay (LOS [y-axis])
and efficacy of contact precaution efficacy (number of infections averted [x-axis]). The shaded area represents the optimal surveillance
strategy, i.e., cost = benefits or costs < benefits. Units of number of infections averted are per MRSA carrier placed in contact isolation.
Nares screening and nares/oropharynx screening were never the optimal strategy. BSI, bloodstream infection; PJI, Prosthetic Joint Infection;
SST, skin and soft-tissue.

screening (under the baseline conditions) would isolate 156
patients (625/4) resulting in losses of $56,874 ($227,494/4).
Multisite Testing for MRSA
Under the baseline conditions, both the nares/oropharynx and
3-site surveillance improved the number of correctly identified
carriers and improved the number of infections avoided. The
multisite swabbing approaches resulted in modest increases
in prevention of infection but resulted in more substantial
economic losses to the hospital (Tables 2 and 3). Multisite
screening was cost minimizing with relatively high estimates
of attributable length of stay for MRSA infection (10 days)
and optimistic estimates of contact precaution efficacy (0.03
infections per MRSA carrier isolated). Nares alone or nares/
oropharynx screening were never cost-minimizing when
MRSA colonization prevalence was 30% or less (Figure 2).
PCR versus Chromogenic Agar
Under the baseline conditions, PCR-based surveillance
improved the number of correctly identified carriers and
improved the number of infections avoided (Tables 2 and
3). PCR-based nares surveillance resulted in modest
improvements in infection prevention but resulted in an
economic loss of $546,583 (95% CI, $493,459–$599,579) for
10,000 admissions (Table 2). PCR screening was never cost-
minimizing under any of the conditions tested.
Sensitivity Analyses
Figure 2 displays 2-way sensitivity analyses for the MRSA attri-
butable length of stay (2–16 days) and number of infections
averted (0.005–0.03 per carrier placed in contact precautions)
by MRSA admission prevalence (9.5%–30%). The graphs
display the screening strategy that results in the best cost-
benefit to the hospital (i.e., optimal strategy). Under most
model assumptions, no screening resulted in the best cost-
benefit to the hospital. Under baseline conditions, the only
time that universal screening was cost-saving occurred with
extreme estimates for contact precaution efficacy (0.03 cases
averted per patient placed in contact precautions) and when
MRSA attributable length of stay was greater than 10. With
MRSA admission prevalence of 30%, the time that universal
screening became cost-saving occurred with extreme contact
precaution efficacy (0.03 cases averted per MRSA carrier
placed in contact precautions) and when MRSA attributable
length of stay was greater than 8 days.
d i s cu ss io n
We found that even though MRSA screening and contact
precaution programs may prevent MRSA infections, these
programs have substantial cost (≥$103,000) per 10,000
admissions. These results demonstrate that there may be sub-
stantial economic cost to the adoption of an expanded MRSA
surveillance and contact precautions program to include
hospital-wide, universal surveillance. Our findings were robust
under a wide range of MRSA prevalence, contract precaution
efficacy, and attributable length of stay values. Universal active
screening followed by contact precautions was never cost-
saving even when the number of sites and type of screening
was modified. Even using extreme estimates for contact
precaution efficacy (0.03 infections averted per carrier iso-
lated) and prolonged attributable length of stay for acquired
MRSA infections (up to 16 days), universal surveillance would
likely incur significant costs reimbursement to the or even cost-saving. For prevented by application of
for hospitals, even if only hospital and financial incen- example, recent the intervention. The
nares surveillance was tives may need to be investigations of number of infections
adopted. Our results are for changed a good deal in order chlorhexidine and prevented per intervention is
general bench- marking and to overcome the economic mupirocin-based MRSA mathematically related to
hospitals of any size can barriers to dissemination. decolonization have shown the number needed to treat
29,30
estimate the impact to their We note that the results efficacy and may not and can be calculated for
own facility on the basis of of our analysis were face such a large economic other interventions, such as
their own local sensitive to the impact of barrier to implementation. MRSA decolonization. The
epidemiology. Thus our MRSA invasive disease. One of the benefits of our cost and benefits of
results can help inform Therefore, although a method is that our model universal screening and
various decision makers program of hospital-wide, estimates efficacy of the contact precautions should
(i.e., infection control universal surveillance may intervention on the basis of be weighed against other
specialists, hospital not be economically the number of infections infection control strategies,
administrators, and even feasible, there are likely such as decolonization, and
insurance companies) about subpopulations for which other quality improvement
the cost-benefits and how screening and contact initiatives. More work is
much they can invest in precautions may result in needed to understand the
MRSA prevention and sizeable savings for the relative benefits and costs
control. hospital. For example, the of infection prevention
Our results are important impact of MRSA infection strategies with respect to
in the context of on burn patients or patients one another in reducing
understanding following cardiothoracic MRSA or other infections.
the economic barriers to surgery is substantial and There are limitations to
dissemination of potentially may surpass the range of our analysis. Importantly,
effective infection control attributable length of stay our analysis was limited
practices across US analyzed in our by the data we used in
16
hospitals. Lee et al. investigation. Within these our model to establish
demonstrated that universal specific high-risk MRSA contact precaution
MRSA surveillance is cost- populations, invasive efficacy in terms of the
effective for a wide range MRSA infection can have number of infections
of MRSA prevalence and disastrous and costly prevented. Our model did
reproductive rates. However, implications. Similarly, the not specifi- cally analyze
the investigation by Lee et impact of invasive MRSA preemptive isolation
16 strategies. However, our
al. and a similar disease in intensive care
investigation by Hubben units can be large. results remained robust even
17
and colleagues analyzed Therefore, universal when using extreme
the cost- effectiveness of screening and contact estimates for contact
universal surveillance from precautions within high-risk precaution efficacy that
the societal or third- party patients and intensive care far exceed estimates for
perspective. Although units may be less eco- potential benefits of
8
universal MRSA screening nomically burdensome for preemptive isolation. Our
may be beneficial to society a hospital, but further model did not model
(as previously analysis is required before potential unintended costs
16,17
described ), our analysis specific suggestions can be of contact precautions,
demonstrates that the made about specific including falls or reduced
expanded screening program subpopulations. 31
patient contact. Including
is econom- ically burdensome Another key observation these impacts would have
for a hospital and that the from our study is that our made screening more
benefits of screening may be results were sensitive to economically burdensome.
reaped only by later or the efficacy of the MRSA That said, there are
external beneficiaries (e.g., intervention. Although conflicting estimates for the
other hospitals or non– screening and contact unintended impact of
hospital-based care entities). precautions may not result 9
contact precautions, so lack
To achieve the population in sufficient benefit to of model- ing this
benefits of improved patient overcome the costs of the consequence may be
quality and improved patient intervention, more appropriate. We did not
safety for the strategy of efficacious strategies that include physician time to
universal surveillance and result in greater projected don/doff contact precautions
contact precautions, benefits may be cost-neutral (although their visits are
counted) because we o
assumed independent w
medical staff reimbursed by
physician billing. Inclusion
l
of physician time to e
don/doff contact d
precautions may be g
appropriate for some m
systems—that is, employed e
hospitalists would see
larger costs. Lastly, our
n
model did not attempt to t
measure the cumulative s
impact of universal
surveillance and contact J.A.M. reports that he received
precautions. It is likely that support from the National
as population benefit Institutes of Health/ National
increases (MRSA declines), Center for Research Resources
the cost-benefit of the /National Center for Advancing
Translational Sciences University
program would continue to of California, Los Angeles
degrade. Clinical and Translational Science
Overall, our results Institute (grant KL2TR000122).
estimate the economic J.A.M., S.M.B., B.Y.L., S. S.H., and
burden that expanded L.G.M. report that they received
support from the Agency for
MRSA surveillance and Healthcare Research and Quality
contact precautions will (grant RC4AI092327). S.S.H.
create for a hospital. If reports that she
health policy experts,
legislators, or patient safety
advocates hope to
implement universal MRSA
surveillance on a large
scale, they must be aware
of the economic barriers to
implementation and the
potential economic impact
from these programs.
Without significant
improvement in financial
reim- bursement to
hospitals, it seems unlikely
that hospital adminis- trators
can responsibly adopt
expanded MRSA surveillance
for the entire hospital
population. Finally, many
costly interventions may
improve patient outcomes,
but given that money is a
limited resource, policy
makers should consider our
findings in light of other
hospital-based interventions
to prevent patient harm.

a
c
k
n
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3 6, no. 1

appendi x 1

appendix fi gu re 1. Decision tree model comparing MRSA screening strategies, including No Screening, Nares Screen, Nares/
Oropharynx, and Three-Site Swab.
*“False Negative” is correct in terms of colonization, but is also a “true” negative in terms of testing. (i.e. not colonized at screening site and
should therefore result in a negative test, but actually carries MRSA elsewhere).
 cost-be n e fi t a na ly sis f rom t he ho spi t al pe rspe ctive o f u n i ve rsal active scre en
in g 1515

appendix table 1 . Cost-Benefit (mean [95% CI]) per 10,000 Admissions When Technician Time to Process Sample Was 1 Min
Given the Baseline Methicillin-Resistant Staphylococcus aureus (MRSA) Prevalence Rate and a 6-Day MRSA Attributable Length of Stay
1616 infe ction c o n tr ol & h o s pi ta l e pide miol ogy j a n uar y 2015, v o l .
3 6, no. 1

Nares

− − −

Body site(s) tested

− −
− Nares/oropharynx Three-site swab
− −

No. of infections Averted per

MRSA carrier isolated − −
Chromogenic agar screening −
−

0.005 (baseline estimate) $218,377 ($174,780 to $262,917) $264,571 ($217,530 to $312,442) $303,198 ($255,592 to $350,888)
0.03 (extreme estimate) $94,606 ($74,236 to $115,606) $110,081 ($88,595 to $132,170) $124,506 ($103,047 to $149,188)
PCR screening
0.005 (baseline estimate) $522,985 ($472,473 to $578,678) $569,819 ($517,700 to $627,807) $607,160 ($551,245 to $668,317)
0.03 (extreme estimate) $391,216 ($356,927 to $426,624) $406,936 ($371,740 to $443,610) $421,272 ($382,652 to $459,816)
NOTE. Negative values indicate an economic loss to hospital given a $0 break-even threshold.

appendix fi gur e 2 . Two-Way Sensitivity Analysis Using Chromogenic Agar Screening with the Baseline Methicillin-Resistant
Staphylococcus aureus (MRSA) Colonization Prevalence