Lack of Financial Incentives for Preventive Interventions

One of the barriers to infection control and antimicrobial stewardship is the lack of financial support from third-party payers, such as insurance companies and medicare. For example, wouldn't it be great if we could bill for hand hygiene every time it was practiced correctly? The end result of this lack of support is that society is willing to pay thousands for a CABG surgery, for example, but not willing to spend a penny on preventing a surgical site infection.

There is a new perspective in the NEJM by two physician behavioral economists, Katherine Pryor and Kevin Volpp, that examines barriers to putting preventive services on equal financial footing with treatments. While their comments largely focus on patient-targeted (vs population targeted) preventive services like lifestyle-modification for diabetes prevention or smoking cessation, they highlight many barriers that could apply equally to population-level interventions like infection control. I've highlighted a few:

"...treatments determined by the Food and Drug Administration (FDA) to be safe and effective are usually covered by insurers regardless of their cost, but preventive services have been held to a higher standard: they are often assessed on the basis of whether they generate a positive return on investment and save money in the short term. This disparity leads to overprovision of treatments and underprovision of preventive services"

"Even Medicare — which typically covers beneficiaries for life — holds preventive services to a higher standard, applying cost-effectiveness analyses when making coverage decisions about preventive services but not treatments. This double standard has resulted in coverage of cost-ineffective therapies with prices of up to hundreds of thousands of dollars per quality-adjusted life-year, including treatments of questionable benefit"

The perspetive is worth a careful read. Would also be nice to see a similar commentary describing these barriers from an infection control perspective too.

Recognizing the Value of Infection Control in Addressing the AMR Crisis

One of the challenges that all infection control and QI programs face is obtaining the necessary funding to complete all their required activities such as surveillance, reporting and prevention. Anthony Harris from the University of Maryland spent a great deal of time (e.g. SHEA White Paper on Necessary Infrastructure) as SHEA President pushing for increased resources for hospital epi activities. In a recent BMJ Quality and Safety editorial, Anthony offered suggestions for advancing the recognition and resources for infection control and QI activities, including societies (i.e. SHEA, APIC, ESCMID) partnering with governments to create comprehensive recommendations for infection control programs and funding.

Specifically, he recommends:

(a) guidelines by major organisations outlining the optimal reimbursement and full time employee (FTE) of hospital epidemiologists and infection preventionists for healthcare facilities in various settings. Currently, agencies such as CMS list certain conditions of participation for institutions relative to infection control and soon to be antibiotic stewardship; however, details of these requirements are vague and should be expanded

(b) as reimbursement moves away from fee per service and more towards quality outcomes driving reimbursement and penalties, we need more effective and novel methods of directing resources for day-to-day infection prevention. For example, an infection prevention fee could be imposed on all procedures that require significant infection prevention resources such as surgery or central line insertion and maintenance

(c) funding for state health departments to assist individual hospitals in establishing effective infection prevention programmes

(d) novel reimbursement models such as a fixed fee per surveillance culture reviewed, a fee for each chart reviewed to assess the appropriateness of antibiotic selection or an hourly fee for performing outbreak investigation may be warranted

(e) certification requirements for hospital epidemiology and QI experts that will help recruit and establish more experts to the field.

The full editorial (free full text access) is well worth reading. (COI alert: I'm a co-author)

Is the doctors' white coat evidence of physician economic decline?

We've debated ditching the contaminated white coat many times. In these discussions, I've been struck by responses from colleagues who have clung to the white coat as a symbol of professionalism. I just didn't understand it. There are clearly other, safer ways to identify yourself as a physician, if you feel that is something you need to do. Of course, there are other ways to stay warm or have pockets (cool black vest anyone?) And it's not like the white coat ceremony dates back to Hippocrates or Osler. These modern ceremonies started in 1989 or 1993 depending on your definition.

So why did the modern white coat ceremony emerge and spread across the medical school landscape like...an infectious disease?  I think the answer might be the decline in status of physicians in both healthcare and society. Within healthcare, doctors have been replaced by administrators as primary medical decision makers and in society our salaries pale in comparison to corporate leaders and other professions. Could the white coat (and white coat ceremony) be a vestige of the economic decline of physicians - a psychological defense mechanism?

I was pondering that question, when I came across a fascinating discussion by Malcolm Gladwell on a recent Ezra Klein Show Podcast. In the middle of the interview, around minute 30, they began discussing the decline of journalism. They wondered how members of a profession, who are losing their economic place, respond to this status free-fall. Gladwell was specifically interested in the psychological defense mechanisms that the professional groups adopt when in this free-fall. He says that the group becomes "very particular about who they want to let in or let out, they start to fetishize certain moral stances or positions or codes as a way of enforcing the in-group." Gladwell then discusses a parallel example:

"It is this search for, when you lose one kind of status, one kind of point of differentiation, you have to replace it with something else. A very simple illustration of this is: why are pickup trucks so much larger than they were 25 years ago? Have you ever seen a standard Ford pickup truck of 1975 up against a Ford F-150 of today? The contemporary Ford pickup is literally twice the size...it dwarfs the old one. These are the same people buying those pickup trucks, doing the same jobs, but now their pickup truck is twice as big. And the answer is: in response to the falling economic status of white working class jobs, people have chosen to assert their status in another way. I may not make the kind of money or have the kind economic status that I had 25 years ago, so I'm now going to compensate by having a truck that is twice as big."

It seems that the white coat (ceremony) could be a response to a loss of status of physicians in society. Perhaps this compensatory mechanism would be OK if unwashed, contaminated white coats didn't increase the risk of pathogen transmission in hospital settings. Similarly, large pickups would be OK if they weren't associated with poorer gas mileage and global climate change. Given that physicians have not lost as much power (yet) as journalists or the working class, it might be better to develop strategies to increase our role in medical decision making and maintain our economic status, rather than cling to a cold dirty white coat.

image source: jalopnik.com

$1.2 billion Requested for Antibiotic Resistance!

You don't tug on superman's cape
You don't spit into the wind
You don't pull the mask off the old lone ranger
And you don't mess around with Jim

-Jim Croce

Most days, controlling the spread of antibiotic-resistant bacteria in hospitals feels like fighting with one hand tied behind our backs, or spitting into the wind or...  For example, we have very little control over whether patients are colonized or infected with antibiotic resistant bacteria on admission. It's not like we can move a hospital from the high-prevalence East Coast to the low prevalence Upper Midwest. And once resistant bacteria become endemic in our region/hospitals, we have few reliable evidence-based interventions to prevent patient-to-patient transmission.

So, it's with some trepidation that I began reading the President's proposal to provide extra funds to tackle antibacterial resistance. Would there be any funds for infection prevention? When discussing past initiatives, we've remarked on how little attention is given to infection control programs and research. This time, however, things are looking better.

Here's how the $1.2 billion will be distributed under the current plan:

• $650 million to the NIH and the Biomedical Advanced Research and Development Authority to expand development of antibacterial drugs and diagnostics
• $280 million for CDC-led efforts to curb overprescribing of antibiotics and track outbreaks of drug-resistant infections
• $47 million would go to FDA to evaluate new drugs and monitor livestock antibiotics use
• $77 million to USDA to help develop alternatives to the antibiotics used in farm animals
• $75 million to DoD and $85 million to VHA to focus on reducing antibiotic-resistent infections in health care settings 

This is a well thought-out list and is very close to how I would wish to distribute the resources. I would perhaps request a bit more for CDC to study HAI prevention interventions in addition to stewardship efforts; however, this extra-funding, while long overdue, is on target. I'm also encouraged that the President is asking for increased funds and not reducing other critical research in infectious diseases like HIV, TB and malaria. Let's just hope Congress can approve this request and it's renewed annually. It will be nice to get back to work preventing HAI - this time with two hands and a mask to keep the spit off our faces.

The world will end in 2050 because...resistance

UK Prime Minister David Cameron requested a review of the health and economic burden of antimicrobial resistance in July. Quicker than you can say supercalifragilisticexpialidocious, economist Jim O'Neill has delivered his report and the results are surprising (at least for those who don't follow this blog). Utilizing commissioned studies from KPMG and Rand Europe, the Review estimates that the economic losses attributable to antimicrobial resistance will total $100 trillion and 10 million excess deaths will occur annually by 2050. In fact deaths do to resistance will surpass other major causes of death even the 8.2 million due to cancer. (see figure on right) Of course, cancer deaths might rise due to the fact that we can no longer safely give chemotherapy without effective antibiotics. The report covers these issues in a sobering section titled: "The secondary health effects of AMR: a return to the dark age of medicine?"

Good times.

The independent Review will outline recommendations for an international response by 2016. In the meantime, I leave you with my favorite figure from the report below. Just for reference, $100.2 trillion is 6 times the size of the US GDP (2013). Perhaps this will wake up the world to antimicrobial resistance?

Additional Source: BBC

...at least she didn't die of MRSA

For the past six months our group at Iowa has been collaborating with colleagues at the University of Utah on a project for CDC. We are tasked with measuring the burden of MDRO using systematic reviews to inform economic models that will project MDRO incidence and attributable cost over the next 20 years. We are studying pathogens like C. difficile, VRE, MRSA, ESBL-GNR and CRE. It's a tall order, but we expect that CDC and others will use these estimates to guide funding for research and prevention efforts. Since bacterial pathogen research is so widely underfunded compared to their burden of disease, these new estimates can only help.

But, it has occurred to me that the planned approach of estimating the burden of disease using pathogens typically categorized as MDRO, such as CRE and MRSA will result in serious underestimates of the bacterial pathogen burden and lead to perpetuating the chronic underfunding of our research and prevention efforts. A simple way of demonstrating the impact of neglecting susceptible bacteria is to focus on S. aureus. One widely cited estimate of yearly MRSA mortality burden is 18,650 in-hospital deaths. Ignoring secular trends and community deaths, while assuming 50% of S. aureus infections in the US are MRSA (and thus 50% are MSSA), we might estimate that S. aureus kills 37,300 people annual in the US. This would place S. aureus (one bacteria!) ahead of traffic deaths and rank it as the #11 cause of death in the US (see table below). Imagine if we included "susceptible" (and resistant) bacteria like E coli, Klebsiella and Streptococcus in a total bacterial burden estimate!

For those that will argue that we have effective antibiotics for MSSA, so that it's unimportant, I offer several counterpoints. First, people die of "susceptible" bacteria (18,650 MSSA!) and we don't fund HIV research based on mortality burden for only protease inhibitor resistant strains. Second, even strains we call susceptible are actually resistant to numerous classes of antibiotics - most MSSA is actually PRSA and try treating enterococcus with a cephalosporin. Third, by ignoring susceptible strain burden, we underinvest in strategies that could treat or prevent all infections, not just arbitrarily defined resistant ones. For example, S. aureus vaccines could prevent both MSSA and MRSA infections. If NIH (or CDC or ECDC) uses only MRSA burden to guide funding of S. aureus vaccine research, they would underfund by 50%.

You get my point, but I will leave you with my final reason for recommending inclusion of "susceptible" strains when measuring burden of disease for bacterial pathogens. Imagine if your aunt is very sick with an MSSA prosthetic hip infection in the ICU. And then imagine if the doctor comes to inform your family that she is very sad that your aunt has passed away, but adds... "at least it wasn't MRSA." Does that make you feel any better?

beer image: source

Antibiotic Discovery: Focusing on supply while ignoring demand is doomed to fail

There is an article in today's New York Times (above the fold on page one - see image) that brings the problem of antimicrobial resistance and antibacterial discovery to the public's attention. It's a very important issue and many of the points raised in the article are spot on. Just some things for you to think about when you read the article:

1) Health and Human Services is giving between $40 and $200 million to GlaxoSmithKline over the next 5 years for drug discovery. This amount approximates what NIH spends on all antimicrobial resistance research for ESCKAPE pathogens ($50 million annually).  It's surprising that this amount couldn't be targeted to NIH or CDC funding instead (or ever).

2) Frustratingly, there was not one mention of antibacterial stewardship or infection prevention. Back when I was studying economics under this guy at University of Michigan, I learned about price determination. In principle, the price for a good will tend to settle where demand equals supply. I think of antimicrobial resistance the same way - demand is the need for broad-spectrum antibiotics based on resistance levels in the community and supply is the availability of effective antibiotics to treat resistant infections. If we focus on the supply side by funding pharmaceutical companies, we may end up with more effective antibiotics, but the set point equilibrium with high levels of resistance will remain if we continue to ignore the demand side.  To fix the demand side we need equal investment in stewardship and infection prevention research and implementation. Give $200 million to prevention research and we might actually find ways to scientifically achieve hand hygiene compliance over 50% without just yelling at health care workers! Imagine that...pause...

What did grandma tell me when I was little? - "an ounce of prevention is worth a pound of cure." I think she was spot on and it's is probably why I became a hospital epidemiologist. Thanks grandma.

Why surgical complications may actually hurt profits despite what you've just read.

If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce it?

There's a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and determined that admissions that included a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors concluded that this creates a disincentive for hospitals to prevent surgical complications since they might see reduced profits as a result.  This is a very provocative finding and it's getting a lot of well-placed media attention, as you might expect. However, there is an important caveat with the study that I would like to highlight.

In the study the authors report that admissions with surgical complications result in $39,000 higher "profits" if the care is reimbursed via a private payer and $1800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial, "Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services." His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a US hospital.

This is what the authors assumed (and mentioned as a limitation): "We did not estimate the effect of 3 potential factors that could affect the hospital economics of surgical complications. First, the shorter lengths of stay of procedures without complications could benefit the small percentage of hospitals operating at full capacity because they might be able to admit additional patients with favorable insurance who were “crowded out.”" What this means is that they didn't include any profits that might be generated by an empty bed filled with a second (or third or fourth) patient. In the study, around 5% of patients developed a complication and stayed an excess of 11 days (at the median) - the mean would be higher.

Note: Based on recommendations of Johns Hopkins professor and retired CFO, Bill Ward, we focused on estimating the costs of HAI using return-on-investment calculations from filling empty beds that manifest through HAIs avoided in the Business-Case SHEA Guideline. In discussions he suggested that excess bed capacity is quickly taken off line and therefore doesn't impact economic evaluation to a large degree. If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce length of stay?

The big question: Do you believe that 5% of beds in hospitals with high surgical volumes sit completely empty for almost two weeks? Of course, there is excess capacity in the US system, but the amount of excess capacity is most important here, not that it exists. You can't completely ignore profits from increased admissions. For example, if only one patient was admitted into a bed vacated by a "healthy" patient discharged at day three that would would have otherwise been occupied by a patient with a surgical complication discharged at day 14, the results of the study would be have been negated - i.e., it would have been a negative study. If more than one patient was admitted into an empty bed over 11 days, which seems likely at most high-volume hospitals, admissions with surgical patients with complications would result in reduced profits compared with admissions without complications. It would have been nice to see estimates of the excess capacity at the 12 hospitals under study.

A provocative study and wonderful analysis. However, as Dr. Reinhardt states, the study "provides important data on a pressing clinical and financial problem affecting hospitals" yet "much of this represents a shell game of how costs are allocated." I would add, and which profits are included or excluded.

Image source: wikipedia

Don't Believe the Pennsylvania Hospital-Acquired Infection Report

When reports include claims that are clearly wrong, I wouldn't trust their entirety.  That's the case with the recently released "Impact of Healthcare-associated Infections in Pennsylvania 2010."  Dan and Mike have every reason to be surprised by the very very low infection rates. I too hope that more details concerning the validation of the HAIs will be provided soon.

However, I don't think we have to wait for more details to see that the report is seriously flawed. The error is so obvious (and so frequently repeated in other reports), that it should almost make us laugh.  The serious error is that the Pennsylvania report attempts to estimate the costs and excess length of stay associated with hospital infections by including the outcomes that manifest BEFORE the infection. 

For a better explanation, here is what we said in the methods of a recent Archives of Internal Medicine paper: "Longer hospital stays and higher costs associated with HAI cases may, in part, be due to extended preinfection hospital exposure. Because extended LOS is an independent risk factor for infection, the preinfection LOS of patients with HAIs may be expected to exceed that of similar patients who did not acquire an HAI. Attributing preinfection LOS to HAIs would overstate the true costs of HAIs...A study of 490 nosocomial sepsis cases from 8 tertiary care centers found that the mean preonset LOS was approximately 40% of the total LOS for these hospitalizations." 

To quote from the PA reports methods: "The average payment reported is for the entire length of stay, and not just for the treatment related to the infection."  It's like they are FLAUNTING THEIR ERROR. When the reports states "the estimated average Medicare fee-for-service payment for hospital stays for patients who acquired an HAI was $21,378...(and) the estimated average Medicare fee-for-service payment for those without an HAI was $6,709", we know we can't trust the estimates.  In fact, if we can't trust those, why should we trust any of it?

My copy just went into the trash.

Herd Immunity in the Jet Age

By 2012, I thought we'd already be beyond the jet age. Although, if you go by the GOP debates, determining if a "moon-colony" could apply for U.S. statehood is now our top domestic concern, so maybe we're finally getting beyond the jet age?

An idea central to controlling infectious diseases is herd immunity. This is the idea that vaccinating a proportion of the population (e.g. 80% for mumps or 95% for measles) will protect the entire population, even the unvaccinated. In a paper presented recently at the meeting of the American Mathematical Society and the Mathematical Association of America and discussed in the Economist, Petra Klepac and colleagues wanted to know how increasingly mobile populations with varying vaccination rates would impact optimal vaccination targets for infectious diseases. That is, does it make economic sense to target a herd-immunity threshold? Also, how would high-levels of varicella vaccination in the US vs. low levels in Britain interact to impact chickenpox in both countries?

Dr. Klepac and her team used a susceptible-infected-removed (SIR) mathematical model, which we frequently use in analysis of infection-control interventions. Analysis of their model determined that targeting herd immunity makes sense for an isolated country. However, when international travel was added, she found that a small rate of unvaccinated travelers would reduce the optimal vaccination below the level of herd immunity, so that targeting herd immunity becomes too expensive. Thus, we have to be tolerant of more infections.

There are some other interesting implications of her study, so head on over to the Economist Babbage blog to read more.

#openAccess Costs Less: Think about it.

There are a few good examples as to why we continue to submit papers to non-open access journals. Sure open-access publication costs are high, but many researchers, even the under-funded hospital epidemiologist, should be able to gather up Departmental, Divisional or other resources to pay the publication costs. I think it's a matter of choice. Importantly, even if the research is called "unfunded", it is likely receiving hidden funding through paying of fellows' salaries or the opportunity-costs of less time spent actually doing "infection control." That is to say, someone is paying for the research.

"An implicit although obvious subtheme of Moneyball is that resistance to innovation is driven by job insecurity" - Nate Silver 

There is a new article in the Atlantic by Laura McKenna that further describes the situation, and I think it's worth a close read.  She describes the status quo very accurately:

1) Academic research is funded by national grants and/or subsidized through the university or hospital and the scientist is given "release time" to conduct the research.

2) The paper is then submitted to an academic (non-open access) journal.

3) These journals are housed and subsidized by universities (think ICHE and University of Michigan or AJIC and Columbia).

4) Journals are then edited by faculty members, who spend subsidized time editing the journal for not enough $$ to cover their time.

5) The "home" university provides offices for the editorial faculty and staff.

6) Papers selected for review are sent to faculty at other universities and are thus subsidized by these other universities, who support their peer-review activities.

7) If accepted, the manuscript is further reviewed by the editor and sent to the journal for publication

8) The publisher, to cover printing costs, sells the rights to JSTOR or other services and makes a tidy profit.

9) JSTOR then sells the papers back to university libraries for huge fees; said to be $45,000 initially and $8500/year just for the arts and sciences collection at JSTOR. If the general public (or non-university affiliated ICP) wants to read the article, they have to pay perhaps $38 to read it.

I will directly quote from her conclusion: "Step back and think about this picture. Universities that created this academic content for free must pay to read it. Step back even further. The public -- which has indirectly funded this research with federal and state taxes that support our higher education system -- has virtually no access to this material, since neighborhood libraries cannot afford to pay those subscription costs."

I would say that ALL of these costs, both visible and hidden, dwarf the one-time publication fee and would suggest that the reason we publish is to communicate our important findings with a wide audience.  If universities can't support open-access publication fees to the extent that they already silently fund closed journals, and I would suggest if they did, the pub costs would drastically decline, then I wonder if the research is even worth doing.  We easily spend 10 times more time (and money) collecting and analyzing the data, but can't cover the publication fee?  Hogwash.

Economicks is hard!

I had the privilege of training in hospital epidemiology under Dr. Richard Wenzel, and alongside a number of really smart people (including fellow blogger Mike Edmond). We put a lot of time and energy into estimating the impact of HAIs on costs, lengths of hospital stay (LOS), and mortality…and our approach was simple and intuitive. If our HAI cases had a mean cost/LOS/mortality of x, and matched controls had mean cost/LOS/mortality of y, then the attributable cost/LOS/mortality must be x minus y. Right?

Yes, I’m oversimplifying, and I will give us credit for understanding that it was a little more complicated than that. However, at that time we were still trying to convince people that HAIs actually killed people, and that the damage they did was above and beyond that due to the patient’s underlying illness. So if our estimates were on the high side, it seemed OK (at least to me), since the main purpose was to jar people out of their complacency and increase resources for prevention.

The climate has changed. We know a lot more about the complexity of estimating the costs of HAIs (two excellent sources on this are here and here), and we’ve (at long last) succeeded in attracting needed attention to HAI prevention (from the public, from legislators, from the media, even from our hospital administrators!). So it now behooves us to “take it up a notch”, as advocated by Nicholas Graves and colleagues in a recent letter to the editor at ICHE (with response). You can read these at your leisure, but I want to highlight this section of their CID article, which I think is on target:

"The 'HAI costs a lot' approach to influencing decision making has served the infection control community well…..The time has arrived, however, for the methodological advances that have been achieved in this area to be implemented by researchers. Complete economic evaluations that include changes to all costs and health benefits should be performed...

The information used to update these studies should be of high quality and bias free. Inexorable growth in health care costs is forcing decision makers to respond to scarcity and work toward extracting greater value from health care resources….The time when reliable economic arguments will be paramount for obtaining extra resources—and even retaining existing ones—is close. Those working toward reducing the number of HAIs should craft valid economic arguments on the basis of sound methods and use them to build strong and cost-effective infection control programs"

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." 

Quality, safety, and value

There is an interesting commentary in JAMA this week. The money quote:

“So more than 40 years after the birth of the quality improvement movement, there is still not much known about what has been accomplished.”

The author, Robert Brook, argues for embracing the business case for quality, and for developing a new “epidemiology of value”,

“…which contains both measurement of cost and quality, and is applicable to both the developed and developing world. The results of this work would help to distinguish between a level of quality that is a good value and the best available quality that may produce small improvements in health at enormous cost.”

Eli, as our house economist, has a better grasp of what it takes to build a business case for quality…I should let him take it from here…

Infection Prevention is Customer Service (or Dave Carroll's Guitar)

James Surowiecki has a nice piece in the New Yorker that discusses the angry worker, the angry customer and the reasons behind the decline in customer service.  When reading this, I couldn't help thinking about the parallels between corporate handling of customer service and many hospitals' relationships with their infection control departments.  I've excerpted and highlighted key portions of the article:

For a start, most companies have a split personality when it comes to customers. On the one hand, C.E.O.s routinely describe service as essential to success, and they are well aware that, thanks to the Internet, bad service can now inflict far more damage than before; the old maxim was that someone who had a bad experience in your store would tell ten people, but these days it’s more like thousands or even, as in Carroll’s case, millions. On the other hand, customer service is a classic example of what businessmen call a “cost center”—a division that piles up expenses without bringing in revenue—and most companies see it as tangential to their core business, something they have to do rather than something they want to do. Although some unhappy customers complain, most don’t—one study suggests that only six per cent of dissatisfied customers file a complaint—and it’s tricky to quantify the impact of good service. So when companies are looking for places to cut costs it’s easy to justify trimming service staff, or outsourcing. 

 

The real problem may be that companies have a roving eye: they’re always more interested in the customers they don’t have. So they pour money into sales and marketing to lure new customers while giving their existing ones short shrift, in an effort to minimize costs and maximize revenue. The consultant Lior Arussy calls this the “efficient relationship paradox”: it’s only once you’ve actually become a customer that companies put efficiency ahead of attention, with the result that a company’s current customers are often the ones who experience its worst service.

 

Full New Yorker article

Universal MRSA screening in Newborns

We are all just digging out of our email (and other) piles created while spending a week in Atlanta at the Decennial. In doing so, I just came across this abstract (or here) that I must have missed while there. I found the economic evaluation interesting. Researchers at Loyola University completed a study on 2031 newborn-mother pairs during a 21-month study. The study only detected four positive neonates and 3 positive moms. The testing cost their health system $40,000/MRSA detected. Of note, the authors suggested that this level of cost was not cost-effective but it is pretty clear they didn't using the US Panel for Cost-Effectiveness (1996) criteria to make such a claim.

While this does seem like a lot of money to pay to detect an MRSA colonization, what it really points out is that these types of studies shouldn't be used to make any medical decisions. The main reason is that unless the hospital you work at has the same population prevalence of MRSA colonization, the results can't be applied to your hospital. Even the much talked about cluster-randomized trials are basically useless for informing medical decisions around what is the best method to control transmissible infections in a specific setting. That is of course, unless these trials intervene in 30+ hospitals that are similar to yours, which isn't going to happen. There's just too much variability between hospitals in terms of size, length of stay and MRSA prevalence. The only way to properly analyze MRSA transmission and prevention is through the use of mathematical simulation models which allow for variable hospital characteristics and MRSA prevalence. If these models use the best available data, they could greatly inform medical decision makers.

Hand hygiene compliance >98%, do you believe it?

Stephen Dubner of SuperFreakonomics fame has an interesting post relaying a story by Dr. Jeffrey Starke from Texas Children’s Hospital in Houston. His hospital got their hand hygiene compliance rates to >98% by first making it part of the employee bonus plan and then part of the hospital executives’ performance bonus. Physicians got compliance that high even though they didn't fall under the bonus plans. Few details are given about amount and frequency of the bonus payouts, what the total cost was and what happened to their infection rates. However, I guess people do respond better to carrots than sticks.

New Year's Resolutions, Procrastination and Public Health

I suspect we've all made resolutions at some point, but studies show most of us fail to accomplish our goals. I mean, is Lindsay Lohan really going to stick to this? I give her until St. Patrick's Day, but I digress.

In a recent article, The Economist suggests that a major reason for our failure to accomplish our goals is that we have a tendency to procrastinate; no surprise there. We tend to put off unpleasant or costly things into the future. That would be OK if we would stick to a single delay, but it turns out that we are time-inconsistent or “present-biased” and will always put off tough or costly things to the next day. Tomorrow really is always a day away. They reference a paper by O’Donoghue and Rabin.

I suspect this tendency is at the heart of the public health problems we have in the US. When you build a road you have immediate gratification, but the gratification of a well-funded state health department is uncertain and certainly in the future. Perhaps a better example is one I suspect many of us in infection control will soon face: should we push our administration to restock our N95 mask cache that we used to meet the OSHA/CDC/IOM requirement to care for suspected H1N1 cases? Avian flu is still out there and is just as likely to become a pandemic as it was last year.

This issue really concerns me. Even in this mild pandemic, we all saw how quickly the supply chains dried up for critical supplies. However, I suspect that hospital administrators will assume that the next pandemic will be this mild or forget the supply chain difficulties we had. Even more of a concern for me is procrastination. Will they assume that they can delay purchasing N95s for a cache because we just had a pandemic so the next one won't happen soon? They can "wait 'til next year" just like our favorite Cubs fan. The problem is that next year they will wait until next year.

Fortunately, the Economist and authors Duflo, Kremer and Robinson offer a potential solution using an example of why so few African farmers use fertilizer and how this can be improved. The quick answer is that the tendency to procrastinate can be overcome by small upfront time-limited subsidies. This small investment ends up being far less costly than doing nothing or offering a larger subsidy later in the year. What this suggests is that public officials should offer a grant to hospitals who invest in their pandemic cache (mask, antivirals etc) in the next year, but remove the subsidy quickly. This could overcome the inertia to do nothing because of pandemic fatigue or procrastination. Of course, how can we overcome our public officials' tendency to procrastinate? They do have bridges to fix. Thoughts?