title: Cost Utility of Competing Strategies to Prevent Endoscopic Transmission of Carbapenem-Resistant Enterobacteriaceae.
abstract: OBJECTIVE
  Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or "superbug") to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management.
  
  
  METHODS
  We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by "endoscope culture and hold"; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained.
  
  
  RESULTS
  In the base-case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%.
  
  
  CONCLUSIONS
  In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.
authors.affiliation: Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA.|Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.|Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: Almario
authors.affiliation: Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA.|Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.|Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA.
authors.forename: Folasade P
authors.initials: FP
authors.lastname: May
authors.affiliation: Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Shaheen
authors.affiliation: Department of Hospital Epidemiology, Division of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA.
authors.forename: Rekha
authors.initials: R
authors.lastname: Murthy
authors.affiliation: Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
authors.forename: Kapil
authors.initials: K
authors.lastname: Gupta
authors.affiliation: Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
authors.forename: Laith H
authors.initials: LH
authors.lastname: Jamil
authors.affiliation: Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
authors.forename: Simon K
authors.initials: SK
authors.lastname: Lo
authors.affiliation: Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California, USA.|Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA.|Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA.
authors.forename: Brennan M R
authors.initials: BM
authors.lastname: Spiegel
mesh_terms: D015780:Carbapenems / Q000494:pharmacology*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D017081:Cholecystectomy, Laparoscopic / Q000191:economics; D042883:Choledocholithiasis / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018562:Disease Transmission, Infectious / Q000191:economics* / Q000517:prevention & control*; D024881:Drug Resistance, Bacterial; D020698:Duodenoscopes / Q000382:microbiology*; D004755:Enterobacteriaceae / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000635:transmission*; D006801:Humans; D009010:Monte Carlo Method; D011322:Primary Prevention / Q000191:economics* / Q000379:methods*; D019057:Quality-Adjusted Life Years; D013242:Sterilization / Q000191:economics* / Q000379:methods; D014481:United States
chemical_list: D015780:Carbapenems