Breaking down the cost-benefit equation
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Pertussis vaccines for health care workers?
What the guidelines say: The Centers for Disease Control and Prevention in Atlanta recommends vaccinating health care workers with direct patient contact with a pertussis booster to reduce the risk of nosocomial spread. CDC estimated that hospitals would save $2.38 for every dollar spent on vaccination because of the reduction in pertussis exposures. However, because of a lack of studies on the effectiveness of the pertussis booster (Tdap), the CDC still recommends prophylaxis for exposed health care workers. (Daily monitoring of exposed health care workers for symptoms could be a "reasonable strategy" as an alternative, CDC said.)1
Cost implications: The pertussis vaccine is combined with a tetanus and diphtheria vaccine. The two licensed versions, Boostrix and Adacel, cost about $37 per dose.2
How one health system saves money: At the Marshfield (WI) Clinic, health care workers who care for pediatric patients are encouraged to receive the vaccine - free of charge. This includes pediatrics, urgent care, family practice, radiology, and OB/GYN. Other health care workers are informed about the new vaccine and encouraged to ask their private providers to give them Tdap when they are due for a tetanus booster. Tdap is covered by the clinic's medical plan.
QuantiFERON-TB Gold instead of skin tests for tuberculosis screening?
What the guidelines say: CDC recommends using the blood assay test, QuantiFERON-TB Gold (QFT-G), in place of but not in addition to the tuberculin skin test (TST). In the case of an exposure, a negative QFT-G should be followed up with a repeat test in eight to 10 weeks. QFT-G is more specific than the TST and is not affected by previous BCG vaccination. Although it avoids the reader bias of the TST, errors in collecting or transporting the specimens or lab errors can affect the accuracy of QFT-G. It would be "prudent" to follow an indeterminant QFT-G with another QFT-G or a TST.3
Cost implications: One study estimated the cost, including laboratory and phlebotomy costs, to be $37.39 per test.4 However, this may vary based on lab costs and volume. Tampa (FL) General Hospital estimated their per-test cost to be $14. Because QuantiFERON is more specific, it is expected to produce fewer false positive results than skin testing. False positive results could lead to unnecessary treatment for latent tuberculosis infection.
How hospitals save money: Tampa General began using the QFT-G only in pre-placement exams, instead of the two-step TST. Of 130 health care workers who reported having had a previous positive skin test, 86 (66%) were negative with the QFT-G. Last year, the hospital began QFT-G screening of employees who had previous positive TSTs; 74% of them had a negative QFT-G. The hospital now uses the QFT-G for all pre-placement tests and for annual screening of employees with previous positive TSTs. (Employees with a history of negative skin tests continue to receive annual skin tests due to the lower cost.) The QFT-G program costs the hospital about $20,000, but it saves the expense of chest X-rays and other medical evaluation of employees with a positive TST, says JoAnn Shea, MSN, ARNP, director of employee health and wellness. The hospital may convert all tuberculosis screening to the QFT-G because of its greater specificity and sensitivity, she says. The advantages extend beyond the cost comparison, she says. "Seventy-four percent of these employees [with a previous positive skin test] now feel relieved that they don't have latent tuberculosis," she says.
Many hospitals in communities that have very few cases of TB have been able to reduce or even eliminate annual screening of employees due to the "low-risk" status. In some cases, the money and time saved from the hospitalwide skin testing program can be used on QFT-G for a limited number of higher-risk employees.
Still, the cost and lab requirements for QFT-G remain a barrier, especially for smaller, rural hospitals. April Tainter, RN, employee health nurse at Shawano (WI) Medical Center, sent two employees for QFT-G testing after questionable TST results in their pre-employment screens. The lab in Green Bay charges $76 for the test and $17 for the blood draw, and it is 40 miles away. "We will do it very infrequently," says Tainter. "Until they come up with a different testing method that we'll be able to do in our own lab, we won't [use it for screening]."
Powered air-purifying respirators instead of N95s?
What the guidelines say: The U.S. Occupational Safety and Health Administration requires respiratory protection of an N95 filtering facepiece respirator or greater for employees who are exposed to airborne infectious diseases such as tuberculosis. If employees cannot wear an N95 due to a beard or other reasons, they must wear a full-face elastomeric or powered air-purifying respirator (PAPR). When performing aerosol-generating procedures (such as bronchoscopy) with a patient who has tuberculosis or pandemic influenza, CDC recommends use of "at least an N95" or greater protection. The CDC states that "use of N95 respirators for other direct care activities involving patients with confirmed or suspected pandemic influenza also is prudent.5
Cost implications: Cost may vary based on the model and quantity ordered, but PAPRs cost about $500, including the hood, battery pack unit, and air flow tubing.
How a hospital saved money: Time is money, and Prince William Health System in Manassas, VA, was spending too much time on a program to fit-test hundreds of employees for N95s. The hospital system hired an outside consultant who brought two Portacount machines for the fit-testing. When the tests took longer than expected, nurses and other health care workers were kept waiting as long as two hours for their test, says Kathy Moss, RN, CPHQ, CPUR, Lead Clinical Nurse for Employee Health/Occupational Health Services.
That debacle influenced the health system to purchase PAPRs, which do not require fit-testing. They started with 50 battery packs and 200 hood sets of the 3M Air Mate PAPR. Employees who need to enter the room of a suspected tuberculosis patient receive their own hood, which they disinfect and keep for future use. The health system also purchased chargers that can charge up to five battery-pack units. For example, a department such as radiology would receive five battery-pack units and 20 hoods. More could then be purchased out of the department's budget, if necessary. The initial investment came to about $15,000.
Moss found nurse "champions" in the departments who agreed to train their co-workers. New employees receive their medical clearance for respiratory protection during their pre-placement screening, and additional training takes place during annual "skills" days.
While the initial investment is costly, the hospital saves money by eliminating the fit-testing and the need to purchase the disposable N95s, notes Moss. About 800 of the hospital's 1,300 employees, including housekeepers, are trained to use the PAPRs, if necessary. (Prince William is considered "low risk" for TB, but because the hospital is near the higher-risk metro area of Washington, DC, the hospital has numerous patients that must be assessed for tuberculosis.)
Employees have embraced the change. "N95s are very constricting, but these have air blowing constantly, so they're nice and cool to work in," Moss says.
References
1. Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2006; 55(RR-17):1-37. Available at www.cdc.gov/mmwr/PDF/rr/rr5517.pdf. Accessed Feb. 19, 2009.
2. Centers for Disease Control and Prevention. CDC Vaccine Price List. February 5, 2009. Available at www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm. Accessed on Feb. 19, 2009.
3. Centers for Disease Control and Prevention. Guidelines for Using the QuantiFERON®-TB Gold Test for Detecting Mycobacterium tuberculosis Infection, United States. MMWR 2005; 54(RR15):49-55.
4. Dewan PK, Grinsdale J, Liska S, et al. Feasibility, acceptability, and cost of tuberculosis testing by whole-blood interferon-gamma assay. BMC Infect Dis 2006; 6:47. Available at www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1434750. Accessed on Feb. 11, 2009.
5. U.S. Department of Health and Human Services. Interim guidance on planning for the use of surgical masks and respirators in health care settings during an influenza pandemic. October 2006. Available at www.pandemicflu.gov/plan/healthcare/maskguidancehc.html#aerosol. Accessed Feb. 17, 2009.
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