A wise colleague, Dr. Michael Gardam, who works at the University Health Network in Toronto, taught us a very valuable lesson about infection prevention and control. In a public forum, he asked people to take a contrarian view and to describe the ideal environment that could be built to spread infections.
The audience answered with insights such as: putting a significant number of sick people in one building, not ensuring a clean/hygienic environment, moving patients around, using a judicious amount of antibiotics for a significant period, complying poorly with best practices, breaking the skin with incisions, frequently touching others with our hands, allowing visitors to come inside without rigorous cleaning/disinfecting, or even putting a coffee shop in the lobby to encourage more outside traffic in for lunch … the list goes on and on.
And as you go through that exercise, you start to realize that we have just built a very typical Canadian hospital!
It is a simple, yet incredible teaching moment that never fails to open eyes. We have created a great environment to spread infections, and our best defense comes down to rigorous compliance with established infection prevention and control best practices – which in many cases we don’t do very well.
Given that we have created this ideal environment for the spread of infections, and are generally poor at addressing the risks, what is the path forward?
Investment in new healthcare technologies that target infection control is one area that can quickly and positively contribute to much better infection prevention, safety, and quality. Amazing solutions continue to be developed in Canada (one of the legacies from the SARS epidemic), and to be introduced from other countries where they have very successful track records.
However, despite a strong evidence base of effective outcomes from many of these technologies, adoption in Canada continues to be weak. For many reasons, the ability of Canadian healthcare institutions to become early adopters of infection prevention and control solutions is extremely limited.
So, let’s examine the financial impact of nosocomial infections on healthcare systems, and identify a path forward when making the case for the adoption of infection prevention and control technology.
The challenge of ROI: While there is an administrative, policy-driven and moral responsibility to ensure that patient and workplace safety related to nosocomial infections is improved – the economic incentive is unclear. There remains a lack of clarity regarding the financial return on investment in infection prevention and control among Canadian hospitals.
If we accept that the financial realities of the Canadian healthcare system discourage adoption of innovations that will make a significant difference in the quality of care and safety of patients and healthcare workers, what are the steps that can be taken that will better make the case for these investments by the healthcare system?
The current Canadian healthcare fiscal environment involves providing care with limited resources. Lack of financial clarity – and who benefits from these investments – contributes to the slow pace of infection prevention and control technology adoption.
While nosocomial infections can place additional financial and operational burdens on a hospital or healthcare institution, these are not well-accepted or quantified. Additionally, many of the healthcare costs associated with infections impact provincial healthcare systems post-discharge – in many cases, over a number of years.
As an example, Levy et al.1 (2015) looked carefully at the incidence and cost of Clostridium Difficile Infections (CDI or C. difficile) in Canada and concluded that extra days of hospitalization accounted for the largest proportion of costs (estimated to be $281 million in 2012). The authors believed that the largest absolute effect on medical costs resulted from interventions that reduced the severity of infection, and/or relapses leading to re-hospitalizations. Part of the challenge results from decentralized budgets and responsibilities that create silos of care, which are exacerbated by uncertainty over the benefits of infection control.
As well, the Canadian healthcare system is continually challenged by inadequate staffing levels, low standards of hygiene in healthcare facilities, privatization of some clinical services, as well as pervasive overcrowding in hospitals (Levy et al.).
The cost of infections: Using the example of C. difficile, Levy et al. concluded that 64% of all cases are hospital associated. In 2012, they found 37,900 episodes of which 7,980 (21%) were relapses and 10,900 (27%) were recurrences. The total cost of C. difficile alone was approximately C$281 million, including C$260 million in direct hospital costs, C$12 million in direct community medical costs, and $10 million in costs due to lost productivity.
From these and other studies, we know that the annual burden is increasing, due to an aging North American demographic that significantly increases the number of potential patients at higher risk. North American studies reviewed by Kwon, Olsen, and Dubberke2 (2015), confirmed that C. difficile mortality before 2000 was 1.5% or less. From 2000 onward, the mortality rate rose between 4.5%-5.7%, with attributable costs per episode between $3,427 and $9,960 (Kwon, Olsen, & Dubberke).
As a comparison, starting in 2008 the US healthcare system developed a number of financial penalties associated with infection rates – essentially reducing or eliminating reimbursement for conditions they consider a hospital ‘mistake’, such as certain nosocomial infections.
In 2015, a compelling US study by Dick et al.3 examined the cost-effectiveness of ongoing investments in preventing hospital acquired infections (HAI) in intensive care units (ICU). Using five years of Medicare data combined with HAI rates and cost and quality of life estimates, they saw gains per ICU of 15.55 Life Years (LY) and 9.61 Quality Adjusted Life Years (QALY) for ventilator associated pneumonia (Dick et al.).
The authors noted a reduction in index admission ICU costs of US$174,713 for central-line associated bloodstream infections (CLABSI) and US$163,091 for ventilator-associated pneumonia (VAP). In addition, their modeling of incremental cost effectiveness ratios (ICERS) of multifaceted HAI prevention programs suggested costs of US$14,251 per LY gained and US$23,278 per QALY gained (Dick et al.). The authors concluded that multifaceted HAI prevention programs are cost effective and require ongoing investment.
Who benefits from increased investment? This is more difficult to answer than you might immediately think.
The obvious beneficiary is, first and foremost, patients and their families. The shock and health impacts of a nosocomial infection can linger far longer than an extended stay period in a hospital – should the patient survive. Infections that are acquired in hospitals or healthcare facilities can result in patients with significant post-discharge special care requirements related to medications, primary care follow-up, lab work, rehabilitation and home care.
In some cases, this is drawn out over the course of years – depending on the infection, severity and patient health status.
About half of all healthcare worker (HCW) absences can be attributed to gastrointestinal and/or respiratory illness, two sets of conditions that could be caught from patients. HCWs likely experience infection-related illness one and a half more times than comparable non-HCWs.
The overall burden of short-term, infection-related absence is difficult to assess because of the possibility that having sick HCWs attend work could be more expensive if infections are then passed on to the patient – and of course, their families.
Health systems can lower direct costs through infection reduction, and avoid ‘extraordinary events’ that are unplanned and the response that can eat away at budgets (terminal cleaning/lawsuits etc.). Better service to the community can also be seen as administration self-preservation. There are few instances that will cause senior management to be placed under review – or be replaced – but losing the trust of the community they serve is one.
It is paramount for healthcare systems and provincial governments to properly understand their financial burden from HAIs, so they are better prepared to understand their baseline costs and the potential impacts of the interventions and innovations they alone can drive.
Patient cohorts can be isolated and compared (i.e. comparing those who acquired an infection while in a healthcare/hospital setting – HAI cohort – versus the general population – regular cohort.) By comparing the cost using financial metrics that are more common in the US (i.e. dollar per member per month) between the two cohorts for a period of three years post-discharge, the increased cost to governments can be established.
Evaluation of infection prevention: While there are many considerations that must be given when evaluating new technologies that offer the promise of better and more efficient infection prevention and control, there are common themes that healthcare systems typically consider and that vendors must address.
An evaluation framework designed to address the main questions and concerns of health administrators and quality and safety managers – with input from clinical leadership, surgeons, and critical care nurses – allows for a common review of new infection prevention and control innovations.
Too often purchasers are presented with innovation opportunities that promise a considerable cost saving that is calculated by assuming a reduction in infection cases. The challenge is that these are sometimes fanciful and wildly optimistic, or do not consider the complexity of, and processes that lead to, acquiring an infection.
The following considerations can assist when presenting comparative analysis to a hospital’s value-based purchasing committees, or other internal groups that review new clinical innovations.
• Does the proposed innovation provide a sufficient evidence base for improvement of clinical outcomes that are recognized challenges? Does it apply to an increased eligible patient population, reduce clinical complications, and/or reduce risk to patients and HCWs?
• Does the solution align with current strategies and initiatives to improve patient safety, and reduce infection transmission risks to patients, their families, and HCWs? After all, healthcare systems are not able to address all pressing issues and are guided by priorities from government, strategic plans, and their local initiatives.
• What is the financial impact for the innovation and is it able to provide a cost-saving or cost-neutral outcome to the health system? ROI can be measured in: Cost comparison with existing devices or services; reduction of staff time – while increasing quality and safety; and potential reduced direct costs associated with a reduction in infection cases. This final point is usually discounted using a value-analysis approach – but can be helpful as a separately calculated financial outcome and setting targets.
• Following a service assessment, does the innovation represent a solution that will be adopted as the preferred clinical choice? Note that without the support of clinicians for adoption, the initiative is likely to fail.
• Is there the benefit of improvement in population health, reduction in longer-term costs, and improved healthcare system stewardship to ensure ongoing viability? This point is key for provincial governments and other payers.
Conclusion: Even though the threat of disease, infections and antibiotic resistance is a very real and present danger, Canadian healthcare system uptake and adoption of innovation and new solutions are poor and slow. Unfortunately, the system favors the status quo. The case for innovation adoption has to start with financial reasons, given the current fiscal environment that involves providing care with limited resources. We know that infection avoidance in healthcare has a very significant return on investment – it is just that the various stakeholders, systems, and silos are not yet aligned to these potential savings.
Realizing the financial benefit is a final step in the process of evaluating and adopting new infection prevention and control technologies – innovations and solutions that will result in a safer and higher quality of healthcare, and help save lives.
Niall Wallace is the co-founder of Infonaut, author and an international speaker on topics focused on infection prevention and control innovation. Frank Naus is a consultant and leader in the pharmaceutical, clinical research, and healthcare sectors. He holds a Doctorate in Business Administration, along with an MBA and MSc.