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