Guest Post: The National Hand Hygiene Initiative in Australia

This is a guest post by Nicholas Graves, Professor of Health Economics at Institute of Biomedical and Health Innovation, School of Public Health, Queensland University of Technology Queensland Health, Australia. Nick is currently the Academic Director for The Australian Centre for Health Services Innovation (AusHSI) and the Academic Director for the Centre of Research Excellence in Reducing Healthcare Associated Infections (CRE-RHAI), Queensland University of Technology / Institute of Health and Biomedical Innovation.

Between 2009 and 2012 Hand Hygiene Australia implemented an initiative to improve hand hygiene compliance in all Australian hospitals. Federal and state governments provided the funding and there was political support for this high profile patient safety program. My research group at QUT obtained funding of almost $1M in 2012 to evaluate whether it was cost-effective and here are the results just published in PLoS ONE.

We found the annual maintenance costs to be $2.9M per year. This investment of scarce resources prevented 67 cases of S. aureus bloodstream infection and 96 years of life were gained. The cost per one life year gained was $29,700. Hand Hygiene Australia have indicated the program is today likely to be less costly, due to a 50% reduction in their own running costs and that compliance auditors now spend 50% less time on their tasks. Testing these scenarios in our cost-effectiveness model suggest the cost per one life year gained falls to $25,094 and then $18,960.

The only outcome measure for which reliable data were available was S. aureus bloodstream infection. Because SAB is very expensive to treat and has large mortality risk it is a good outcome measure to demonstrate cost-effectiveness. We did evaluate other infection outcomes in a separate paper and found a statistically significant reduction in 11/23 rates, no change for 9/23 and increases for 3/23. Whether we underestimated the health benefits of the initiative by only including SAB outcomes is uncertain.

This was a challenging and difficult study, but that made it interesting. Now that the project has finished, what do I think?

Estimating the value for money of infection prevention programmes is important. Particularly in today's climate where health funding is tight, and there are multiple competing demands on scarce resources. If this Hand Hygiene initiative displaced other infection prevention programmes that deliver larger health benefits for the same or less money, then has been an opportunity cost measurable in health benefits lost.

Rolling out a national program of this complexity requires massive energy. Hand Hygiene Australia did a remarkable job achieving improvements in hand hygiene compliance. They were successful by being single minded and building momentum for the initiative. They did not let obstacles get in the way. Hand Hygiene Australia achieved the task they set themselves.

The timing of our evaluation was wrong. If it were done during a pilot phase then the results might have been useful to change the national initiative. Presenting the study and results after the programme had gained momentum and had political support reduced the usefulness of the findings. 

Doing this project has been interesting and I learned a lot, and I hope the papers and talks I have given are valuable for others interested in estimating the cost-effectiveness of infection prevention programs.

This blog presents my views alone.

“The scandal isn't what's illegal, the scandal is what's legal”

This quote, attributed to Michael Kinsley, is applicable to a very disturbing trend that is having an increasing impact on antimicrobial availability: the acquisition of exclusive marketing rights (usually by small private firms) to inexpensive generic drugs in order to jack up their prices astronomically. The antimicrobials pyrimethamine, albendazole, cycloserine, flucytosine, and doxycycline have all experienced price increases of up to 5000%, and there have been several recent posts on the Emerging Infections Network about how this is limiting availability of these agents for those who desperately need them. 

I hope this NY Times story about the pyrimethamine saga draws more attention to this trend, and leads to some regulatory reforms to prevent this obvious price gouging. Because you-guessed-it, there is nothing illegal about this under U.S. law.

Fortunately, because it engenders bad press when people suffer and/or die due to unavailability of an essential drug, some of these “pharmaceutical companies”* will immediately send out the drug at a reduced price (or even without charge) if contacted by the treating physician. Such saints, these folks are….

*I put that term in quotes, because the company that owns marketing rights to pyrimethamine is founded and run by a hedge fund manager

$35 a day

A new paper in the American Journal of Infection Control takes a look at the cost of contact precautions. The investigators determined that on average 48 gowns and pairs of gloves are used daily for each isolated patient, and donning and removing the personal protective equipment consumed 43 minutes of time per isolated patient per day. This resulted in a cost of $35 per isolated patient day. In the ICU setting the cost was higher at $42. Of course, this represents a fraction of the true cost since there are many other indirect costs. But it's nice to have at least a ball park figure. I quickly calculated that de-escalating contact precautions at my hospital (i.e., no longer isolating patients with MRSA or VRE unless they have uncontrolled drainage or secretions) results in a cost savings of over $700,000 annually. I need to let my CFO know about that!

Photo: TimesUnion.com

Quote of the Day

Ezekiel Emanual (U Penn) wrote an Editorial in this weeks JAMA titled "Where are the Health Care Cost Savings?" where he suggests that there are not enough aggregate savings in targeting malpractice costs, insurance profits, drug costs, and the "million dollar babies" to make a significant impact in US medical expenditures.

Where does he think the savings are:

"One estimate suggested that as much as 22% of all health care expenditures is related to potentially avoidable complications...reducing avoidable complications by 10% could save more than $40 billion per year."

The reference for the 22% estimate is a 2009 article by François de Brantes et al in the NEJM. What was the preventable complication example in the 2009 article? A readmission for a harvest site SSI post-CABG.

Holy Superlatives, Batman! Hospital-acquired infections have significant economic costs!

1935 Dollar

There is a well done study out in Medical Care by Rebecca Roberts et al. from Stroger/Cook County that assesses the attributable costs of HAIs in a cohort of patients from 2000.  What sets this paper apart is the careful attention they paid to design and analysis methodology.  Just to paste from the abstract, they used "ordinary least squares linear regression and median quantile regression, Winsorizing, propensity score case matching, attributable LOS multiplied by mean daily cost, semi-log transformation, and generalized linear modeling. Three-state proportional hazards modeling was also used for LOS estimation. Attributable mortality was estimated using logistic regression." 

The bean counters are missing some beans

There is a recently released report from the Society of Actuaries entitled the Economic Measurement of Medical Errors. It's nearly 300 pages long and includes data on catheter-associated UTI, central line associated bloodstream infection, and surgical site infections. It is based entirely on administrative claims data, which are notoriously inaccurate for healthcare-associated infections. See Kurt Stevenson's paper on this topic here.

As I looked through the report, I noted that the numbers looked quite odd based on my familiarity with the literature. So I compared the SOA report data to CDC's estimates on the burden of HAIs in the US (Klevens et al) and Eli's review of the literature on attributable cost in the table below.

	Estimated annual number of cases		Attributable cost/case
	SOA Report	CDC	SOA Report	Perencevich
CA-UTI	9,080	561,667	$32,820	$1,257
CLABSI	3,679	248,678	$110,462	$18,462

Now there a number of caveats to point out:

• The SOA reports the estimated number of cases due to error; to convert from number of cases to cases due to error they multiplied the number of cases by 0.95. Therefore, I divided the "error" cases by 0.95 to convert back to number of cases (Does anyone believe that 95% of CA-UTI cases are due to error, that is, preventable???)
• Eli used 2005 dollars for cost data, and SOA used 2008
• SOA used 2008 claims data, and CDC (Klevens et al) used 1990-2002 NNIS data and National Hospital Discharge Survey 2002 data
• CDC data appear to included non-device associated infections, though we know that the vast majority of UTIs and BSIs are device related

However, despite the differences I note, the SOA data seem hugely flawed. They appear to vastly underestimate the frequency of HAIs, while substantially overestimating the attributable costs. I suspect the SOA report will be widely quoted, so take a look at it and be prepared!