policy implications of healthcare associated infections
DESCRIPTION
On February 19, 2014 at the Ateneo School of Medicine and Public Health in Pasig City, Dr. Albert Domingo presented an introduction to the economic impact of healthcare associated infections (HAIs) as well as related concepts in health policy and management. The speaker discussed common approaches taken to ascertain the economic impact of HAIs, followed by factors/considerations in Philippine health policy and management that must be understood and adjusted in order to minimize HAIs.TRANSCRIPT
Policy Implications ofHealthcare Associated
Infections
Outline
1. Introduction / Overview2. Economic Impact3. Policy and Management Implications4. Some Curious Questions5. Open Forum / Q&A
INTRODUCTION/OVERVIEW
What is health care?
• In caring for patients, the good physician dispenses time, sympathy, and understanding to his patients
• The physician also scientifically applies principles of diagnosis and treatment
• Medical care has become a mosaic of many health and non-health professionals executing the necessary skills
Reference: Larson et al., 2001
Quality of Care and Health Systems
• In any country, one of the factors affecting the health and well-being of individuals and populations is the quality of care provided within the health service.
• In turn, the performance of any health system (including provider quality) is determined by the way in which it is designed, managed, and financed.
Reference: Gray, 2004 (p. 288), modified
Reference: Berman, 2012
Three Fundamental Goals
• Improve the health of the population served;• Respond to people’s expectations;• Provide financial protection against the costs
of ill-health
*These are irrespective of the level of resources available and the organization of the health system
Reference: Gray, 2004 (p. 289)
What are healthcare associated infections?
Health care-associated infections, or “nosocomial” and “hospital” infections, affect patients in a hospital or other health-care facility, and are not present or incubating at the time of admission. They also include infections acquired by patients in the hospital or facility but appearing after discharge, and occupational infections among staff.
(WHO HAI Fact Sheet)
ECONOMIC IMPACT
Using Economics to Set Priorities
• Economic approach is to set priorities based on costs and benefits of health services: to do more of some things, we have to take resources from elsewhere
• Economists should also consider practical and ethical challenges that managers and doctors face in making rational priority setting decisions
Reference: Peacock, 2006
Estimating the Cost of HAIs (1)
1. Why measure the cost of an HAI?2. What outcome should be used to
measure the cost of an HAI?3. What is the best method for making
this measurement?
Reference: Graves et al., 2010
Estimating the Cost of HAIs (2)
• Why measure: “biggest bang for the buck” argument– “bang” = health benefits; “buck” = costs
– ΔC/ΔE < λ (cost-effectiveness approach)
• What outcome: bed-days– C = (bed-days lost x price of a bed-day) + cost of consumables + professional fees– public policy economist vs. cost accountant
Reference: Graves et al., 2010
Estimating the Cost of HAIs (3)
• Bed-days saved by infection control can increase productivity (e.g., treat more patients)
• As long as demand for >> supply of health services, then bed-days will be valuable– In decentralized systems (e.g., US, PH?), the
purchasers will be willing to pay a certain price to access
– In centrally-managed systems owned by government (e.g., UK), it can be a political issue
– Note: The Philippines is a hybrid of both systems Reference: Graves et al., 2010
Estimating the Cost of HAIs (4)
Perspectives vary.• Political: promises of improving health care
services need for more hospital capacity and shorter waiting lists; hence, need to save bed-days
• Operational: bed-days saved more patients, hence more workload; will there be adequate compensation for the higher stress of staff?
Reference: Graves et al., 2010
Estimating the Cost of HAIs (5)
• What is the best method: use of a statistical model to describe the relationship between a cost outcome (e.g., length of stay) and predictors of that outcomeEconometrics modeling, statistical analysis, etc.– Matched cohort studies have severe limitations
(e.g., biases in selection, timing issues, logistical considerations, etc.) and tend to overestimate costs
Reference: Graves et al., 2010
Easier said than done…
POLICY AND MANAGEMENT IMPLICATIONS
Health Policy:Scope, Scale, and Stakeholders
Point of Care
Service Delivery
Networks
National and Local
Governments
Private Sector Dynamics
International/Global Health
“Pharmacology” of Health Policy
• DYNAMICS and the mechanism of action:– Will an intervention reduce the risk?
• KINETICS and the response of the system:– Will the intervention for the main concern
increase other risks? (i.e., adverse effects)• THERAPEUTICS and delivery:– Is it operationally possible to introduce the
intervention?
Reference: Gray, 2004 (p. 296), with modification
Purchasers vs. Providers
• In health services world-wide, there is a trend to separate the function of purchasing healthcare from that of providing healthcare– Purchasers decide which health services to buy– Providers deliver healthcare to individual patients within the
resources available• Purchasers aim to maximize the value obtained from
the resources available• Purchasers are not usually asked to reallocate resources
on the basis of specific diseases, but for particular patient groups
Reference: Gray, 2004 (pp. 269; 272)
Healthcare Financing
• Health systems are not just concerned with improving people’s health, but also with protecting them against the financial cost of illness (by reducing out-of-pocket expenses).
• The sources of financing usually dictates the system of healthcare provision. Two main sources are:– Insurance (risk-pooling) “pay as you go”; common in
low income countries – Taxation (subsidies)
Reference: Gray, 2004 (p. 278)
The Policy Cycle
Agenda Setting
Policy Formulation
AdoptionImplementation
Evaluation
Factors in Health Policy Change
OLD POLICY
NEW POLICY
Ideologicalinspirations
Change in circumstances
Evidence
Common sense
From researchFrom experience
Reference: Gray, 2004 (Fig 7.8, p. 291; p. 292)
NOTE: Policy makers operate on a timescale that does not generally admit of delays that research will take.
Agenda for Clinical Governance (1)
1. Are we doing the right things?2. Are we doing things right?3. Do the right people have the right
knowledge, skills and attitude?4. What further evidence do we need?
Reference: Department of Health (UK), 2001 – The epic project
Agenda for Clinical Governance (2)
The right things• Guidelines = statements of good practice• Standard principles = a consistent approach• National/central guidelines have to be
adapted for local use• Local adaptations must follow a recognized
protocol (i.e., backed by evidence)
Reference: Department of Health (UK), 2001 – The epic project
Agenda for Clinical Governance (3)
Doing them right• Clear guidelines allow for
monitoring/measurement• Audit should focus on dissemination
strategies, management support, and practitioner adherence
Reference: Department of Health (UK), 2001 – The epic project
Agenda for Clinical Governance (4)
The right people• Guidelines can identify areas where staff
training and professional development are required
• Practitioners must receive appropriate training, supervision, and support to adhere
• Adherence is a complicated issue (individual behavior + organizational factors like resources available)
Reference: Department of Health (UK), 2001 – The epic project
Agenda for Clinical Governance (5)
Further evidence requirements• Adherence/behavior change• Staffing• Surveillance• Clinical technologies (e.g., needle safety
devices, indwelling urethral catheters, central venous catheters, etc.)
Reference: Department of Health (UK), 2001 – The epic project
Examples of Strategies / Guidelines
• US: National Plan to Prevent Health Care-Associated Infections: Road Map to Elimination
• UK: National Evidence-based Guidelines for Preventing Healthcare-associated Infections in NHS hospitals in England (epic project)
• PH: Standards in Infection Control for Healthcare Facilities
Ensuring Performance
Reference: Gray, 2004 (p. 327; 367)
P =
Where:P = performanceM = motivationC = competence
B = barriers
Options to achieve change:
• Incentives (carrots)• Disincentives (sticks) hit people with carrots
Quality Improvement throughPay for Performance (P4P)?
Quality Improvement Demonstration Study (QIDS)• A large policy experiment that followed the
impact of two interventions on physician practices, health behaviors, and health status of children 5 years and under in the Philippines
• Took place at 30 district hospitals in 11 provinces of the Visayas; started in 2004, ended in 2008
• Cluster randomized controlled trial
Reference: Peabody et al., 2013
The P4P Intervention
Quality Improvement Demonstration Study (QIDS)• For doctors randomized into the intervention P4P
scheme, those who met pre-determined quality standards were eligible for bonus payments
• Doctors were told that they have been randomly assigned to the P4P scheme, and that they could earn a bonus based on their clinical practice vignette (CPV) score
• Those who met the cut-off score were paid a bonus of P100 per patient seen per quarter (representing 5% of total salary, on average)
Reference: Peabody et al., 2013
Did P4P Work?
Quality Improvement Demonstration Study (QIDS)The number of children who were wasted
increased by 9 percentage points from baseline for the control group, compared with children in the P4P group where doctors received bonuses where there was no change (P<0.001)
Parents reported an improvement in General Self-Reported Health (GSRH) of 7 percentage points in P4P sites compared to control sites (P<0.001)
Reference: Peabody et al., 2013
P4P for Infection Control?
• Performance-based incentives are thought to be one of the best ways to improve health, particularly in the developing world where MDs are not adequately incentivized to provide quality care
• Measurement of outcomes can be done via CPVsMaybe a CPV on infection control practices can be
designed, then providers who meet a certain quality score cut-off will get bonus payments?
Reference: Peabody et al., 2013
SOME CURIOUS QUESTIONS
(Dis)incentives via the Purchaser
• In the US, HAIs are not reimbursable via insurance. Can this be done in the Philippines?– Yes, it can be done. BUT…– Who exactly is our dominant purchaser?– How much influence does our dominant purchaser
have?– Will the providers be affected by decisions of our
dominant purchaser?– So, what can we do?
Sue someone so soon?
• In the Philippines, can a patient who gets a healthcare-associated infection sue the hospital?– Because of fault, or negligence? (proximate cause)– What kind of suit – criminal (reckless imprudence),
administrative (PRC license), civil (damage$)?– Who could be liable: the hospital, the doctor, the
nurses, the other paramedicals, or all of the above?– What evidence – res ipsa loquitur?– Any case precedents?
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Open Forum / Q&A