Comparative Effectiveness and Cost of Surgical Prophylaxis Regimens

描述(由申请人提供)： 项目摘要/摘要近年来，卫生保健获得性感染(HAIs)受到了极大的关注。在联邦和州一级颁布了越来越多的任务，以强制实施HAI预防战略，目前大量资源用于支持这些战略，但没有一个明确的模板来评估其临床和经济影响。手术部位感染(SSI)是最常见的HAI之一，导致显著的发病率、死亡率和医疗费用。针对皮肤微生物使用预防性抗生素是预防SSI的标准护理程序。甲氧西林耐药金黄色葡萄球菌(MRSA)携带率的增加使使用头孢菌素(如头孢菌素)进行抗菌预防的传统方法变得复杂起来，因为它对MRSA无效。在已知有MRSA定植或感染的患者中，万古霉素被推荐用于外科预防。然而，目前还不清楚万古霉素应该单独使用还是与内酰胺类药物一起使用。单独使用万古霉素作为外科预防有显著的缺点，包括不能预防革兰氏阴性(如大肠杆菌)感染和选择万古霉素耐药性。MRSA筛查导向的万古霉素手术预防与通用万古霉素在高危手术中的比较和成本效益也尚未确定。因此，在充分了解预防SSI的政策和最佳做法方面存在严重的知识差距。这项建议的主要目的包括：1)开展一项回顾性队列研究，以确定接受手术的MRSA阳性和MRSA阴性患者SSI的风险，按手术预防方案和其他危险因素(如年龄、手术类型和ASA分类)进行分层，以检验术前鼻腔MRSA状况是接受万古霉素手术预防和SSI风险之间关系的有效修饰者的假设；2)评估万古霉素单独和万古霉素加内酰胺作为手术预防SSI的比较有效性，以验证联合方案在预防SSI方面比单用万古霉素更有效的假设；3)评估高危手术的术前筛查、定向万古霉素手术预防与普通万古霉素手术预防的比较和成本-效果，以检验以下假设 筛查指导的手术预防与万古霉素手术预防的比较取决于筛查人群中MRSA的流行率。我们将利用现有的国家VA数据库对接受手术的患者进行回顾性队列研究，外科护理改善项目的外部同行审查计划(EPRP)对这些患者的具体表现指标进行了评估。我们将使用回归和马尔可夫模型来评估MRSA筛查指导的外科预防方法和方案的比较有效性和成本效益。调查结果将与耐甲氧西林金黄色葡萄球菌预防计划办公室协调实施。

DESCRIPTION (provided by applicant): Project Summary/Abstract Healthcare-acquired infections (HAIs) have received significant attention in recent years. An increasing number of mandates have been enacted at the federal and state levels to force the implementation of HAI-prevention strategies, and considerable resources are now devoted to supporting them without a clear template for how to evaluate their clinical and economic ramifications. Surgical site infections (SSI) are among the most common HAIs and result in significant morbidity, mortality, and health care costs. Use of prophylactic antibiotics directed against skin organisms is a standard of care process for preventing SSI. An increasing prevalence of methicillin-resistant S. aureus (MRSA) carriage has complicated the traditional approach of using a ¿-lactam (e.g. cephalosporin) for antimicrobial prophylaxis because it does not work against MRSA. In patients known to have MRSA colonization or infection, vancomycin is recommended for surgical prophylaxis. However, it is not clear whether vancomycin should be used alone or in addition to a ¿-lactam drug. The use of vancomycin alone as surgical prophylaxis has significant downsides, including inability to prevent Gram-negative (e.g. E. coli) infections and selecting for vancomycin resistance. The comparative and cost effectiveness of MRSA screening-directed vancomycin surgical prophylaxis vs. universal vancomycin for high- risk surgeries has also not been established. Thus, there are critical gaps in knowledge to fully inform policies and best practices for SSI prevention. The main aims of this proposal include: 1) Conduct a retrospective cohort study to determine the risk of SSI in MRSA positive and MRSA negative patients undergoing surgical procedures, stratified by surgical prophylaxis regimen and other risk factors such as age, type of surgery, and ASA classification to test the hypothesis that pre-operative nasal MRSA status is an effect modifier of the association between receipt of vancomycin surgical prophylaxis and SSI risk; 2) Evaluate the comparative effectiveness of vancomycin alone vs. vancomycin plus a ¿-lactam as surgical prophylaxis in prevention of SSI to test the hypothesis that the combination regimen is more effective in preventing SSI than vancomycin alone; and 3) Evaluate the comparative and cost-effectiveness of pre-operative screening followed by directed vancomycin surgical prophylaxis vs. universal vancomycin for high-risk surgeries to test the hypothesis that the cost efficiency of screening-directed surgical prophylaxis compared to universal vancomycin surgical prophylaxis depends on the MRSA prevalence in the screened population. We will utilize existing national VA databases to conduct a retrospective cohort study of patients undergoing surgeries that are assessed for specific performance measures by the Surgical Care Improvement Project's External Peer Review Program (EPRP). We will use regression and Markov modeling to evaluate comparative effectiveness and cost-effectiveness of MRSA- screening directed surgical prophylaxis approaches and regimens. The findings will be implemented in coordination with the MRSA Prevention Initiative Program Office.