Resource Utilization of Intravenous Drug Associated Endocarditis: What Can Be Done?

E. Tham, T. D'etcheverry, L. Lagazzi, L. Wei, J. Juskowich, A. Sarwari, V. Badhwar, J. Hunter. Mehaffey
West Virginia University, Morgantown, West Virginia

Purpose: Infective endocarditis continues to inflict significant burden on healthcare costs and resource utilization. Intravenous drug associated (IVDA) endocarditis has been a particularly widespread challenge to surgeons and health systems to provide high quality and efficient care. We sought to quantify the impact of IVDA endocarditis on a regional health system.

Methods: To assess clinical outcomes, resource utilization, and cost of IVDA endocarditis, we combined a regional multidisciplinary infectious disease and surgical endocarditis database, our Society of Thoracic Surgeons Adult Cardiac Surgery Database, and detailed hospital-specific financial records. Patients were stratified by etiology (IVDA vs non-IVDA) to identify targets for quality improvement and resource optimization. Descriptive statistics compared variables by IVDA status. Our outcomes of interest include intensive care unit (ICU) and total length of stay (LOS), total costs, and reimbursement. Multivariable linear regression assessed risk-adjusted hospital costs. Subgroup analysis further stratified IVDA patients by repair vs replacement.

Results: A total of 244 consecutive patients were identified (194 IVDA, 50 non-IVDA). IVDA patients were younger, more likely male, with lower BMI, higher proportion of Medicaid, and more frequently isolated tricuspid valve endocarditis. Staphylococcus species were the most common microbe in both populations however, compared to non-IVDA patients, methicillin-resistant Staphylococcus aureus was more prevalent in IVDA patients (44.5% vs. 12.0%, p< 0.001). IVDA patients compared to non-IVDA had shorter intensive-care-unit (ICU) length of stay (LOS) (53 vs 109 hours, p< 0.0001) but much longer total LOS (49 vs 21 days, p< 0.0001, Table), largely due to inpatient intravenous antimicrobial therapy requirements. The percent of total cost recuperated by the hospital was significantly lower in the IVDA versus non-IVDA patients (42% vs 70%, p= < 0.0001). Subgroup analysis demonstrated IVDA patients undergoing valve repair versus replacement had lower rates of postoperative pacemaker implantation (1% vs 12%, p=0.01), shorter ICU LOS (47 vs. 72 hours, p=0.007) and shorter hospital LOS (45 vs 49 days, p=0.017), and lower total costs ($118,564.15 vs. $142,634.46, p=0.0001). After risk-adjustment, IVDA endocarditis was associated with a significant additional premium to total hospital cost ($26,409, p< 0.001) and ICU cost ($297/hour, p< 0.001) over non-IVDA patients.

Conclusion: IVDA endocarditis remains a significant burden to healthcare with longer hospitalizations and low reimbursement. Despite an increased technical demand, valve repair over replacement improves outcomes and costs. Given the added surgical complexity and resource utilization of IVDA endocarditis, a reappraisal of reimbursement weighting for both surgeons and hospitals appears warranted.

Identify the source of the funding for this research project: N/A