An economic - quality business case for infection control & prevention @VandijckD Prof. dr. Dominique Vandijck
What you/we all know, (hopefully) but do our healthcare executives, and politicians know this?
Some essential facts about HAIs Infections contracted in hospitals are one of the largest killers We have the knowledge to prevent HAIs still a lot of work to be done They add an enormous economic burden to hospitals (and the larger economy) Patients, insures and taxpayers pay part of that, but hospitals have to absord a large amount too HAIs erode hospital profits Move towards a new legal situation
To know the business case for IPC The impact of HAIs ( make the best case!) Clinical impact Cost of infections and exposures The cost-benefit of IPC Cost-effectiveness of IPC interventions How to quantify the ROI
Making the business case for preventing HAIs Demonstrate the value for money of IPC Most important aspect of a business case for prevention is to show the reduction of (associated) harm and loss of life However, from a financial health perspective boards, healthcare executives, managers are (mostly) only interested in cutting costs and getting maximum value for expenditures they may not see the benefit of IPC if the ROI is not realized within a certain time frame
Patient harm, an unavoidable price we pay?
Patient harm, an unavoidable price we pay?
Patient harm, an unavoidable price we pay?
Common misconceptions about HAIs 1) The fallacy that the incidence of HAI is insignificant 2) The erroneous belief that the additional costs of HAIs are largely offset by reimbursements, and that the potential cost savings associated with reducing HAIs are not worth the investment 3) The misperception that HAI are an expected outcome of modern healthcare
Economic burden of HAI What? HAIs consume resources Prolong patients hospital stays = primary cost Only partially reimbursed at best
Economic burden of HAI Highlights Cost of HAI per patient approximately 20,000 25,000 DRG-based reimbursement is NOT increased when a patient develops a HAI No specific DRG codes available for HAIs In most cases, fixed amounts are reimbursed based on diagnosis Hospitals then have to absorb the additional costs associated with HAIs! simultaneously prevent the hospital from taking new admissions with reimbursable conditions Graves, Emerg Infect Dis 2004
To keep in mind Striving towards optimal prevention will involve extra costs costs of more intensive follow-up (surveillance) cost of training/motivation of HC professionals (and patients) It will also lead to savings in the mid/long run (less subsequent events) It will lead to additional QALYs
What is cost? Perspective Depends upon perspective patient hospital / provider (e.g. healthcare executive - infectious diseases specialist) insurer / payer society
What is cost? Components of total costs Direct costs direct payment for healthcare goods and services Indirect costs lost of work, productivity Intangible costs cannot easily assign a monetary value Opportunity costs what you give up when you (chose) use a (alternative) resource
What is cost? Other dimensions of costs Fixed costs costs incurred for fixed inputs cannot easily be eliminated at the short term (eg. buildings) Variable costs costs incurred for variable inputs can easily be eliminated at the short term (eg. labor)
Where can you start? Select a type of (HA)infection to estimate (eg. SSI) Obtain individual costs and LOS for patients undergoing specific surgical procedure List patients who developed SSI Calculate additional costs (eg. readmission, return to OR, ICU stay, antibiotics, etc.) Compare costs of patients without SSI with patients with SSI who had the same procedure during the same time period
Comparison of endemic vs. epidemic SSI rates Variables Hospital X Period of increased SSI Surgical procedure Number of procedures performed in 20XX Reported benchmark SSI rate / 100 procedures Operating unit endemic rate / 100 procedures Operating unit epidemic rate /100 procedures Average LOS for uninfected vs. infected cases Mean excess LOS per SSI Average cost for uninfected vs. infected cases Mean excess cost per SSI Rate reduced to baseline / benchmark (date) Projected number of procedures 20XX+2 Expected number of SSI based on endemic rate (3.0%) Expected number of SSI based on epidemic rate (22.6%) Number of SSI avoided (based on reduced rate) Estimated cost avoidance 20XX+1 20XX+2 June 20XX December 20XX Gastric bypass 70 2.7 5.1 2.86% (2 SSI / 70 procedures) 22.6% (7 SSI / 31 procedures) 4 days vs. 22 days 18 days 7,816 vs. 44,963 37,147 3.0% (April 20XX+1 April 20XX+2) 70 cases 2 SSI 16 SSI 14 SSI annually 520,0589 ( 37,147 * 14)
Comparison of endemic vs. epidemic SSI rates (2) Lost opportunity costs fewer HAIs results in fewer infected/contaminated cases in the OR opportunity for more primay surgery cases with often higher reimbursement than secondary/follow-up procedures higher volumes Intangible costs risk for negative PR (~ impact on referrals) impact on societal trust changes in insurance premiums due to high cost of HAIs impact on status with accreditation and regulatory agencies
VAP Cost of NI perspectives for prevention
Cost analysis simulation of a preventive (ET) measure 15-bed MICU 5 MV pts / week 250 MV pts / year mean MV-duration ~ ± 5 days 1,250 MV days / year no problem of VAP in MICU (15 VAP / 1,000 MV days) 19 VAP / year 19 * 30,000 = 570,000 / year
Cost analysis simulation of a preventive (ET) measure Conventional ET ( 1.00) Micro-cuff ET ( 15.00) Subglottic ET ( 25.00) Coated ET ( 50.00) Cost of ET / year 1.00 * 250 pts = 250 15.00 * 250 pts = 3,750 25.00 * 250 pts = 6,250 50.00 * 250 pts = 12,500 Cost of attributable ICU LOS (7 days) (~ 3,000 / day) 19 VAP * 21,000 = 399,000 12 VAP * 21,000 = 252,000 9 VAP * 21,000 = 189,000 12 VAP * 21,000 = 252,000 Cost of additional interventions (~ 1,285 / day) 19 * 9,000 = 171,000 12 * 9,000 = 108,000 9 * 9,000 = 81,000 12 * 9,000 = 108,000 Total costs 570,250 363,750 276,250 372,500 Cost savings 206,500 294,000 197,750-87,500 (vs. SG-ET) 8750 (vs. C-ET) 87,500 (vs. MC-ET) 96,250 (vs. C-ET) - 8,750 (vs. MC-ET) - 96,250 (vs. SG-ET)
VAP Cost of NI Belgian perspective
Belgian perspective 21,000 7 days attributable ICU LOS 3,000/day 8,244 9 days attributable hosp LOS 916/day 2,024,194 admissions/yr/belgium = 125,000 pts = 6,638 pts = 1,195 pts 6.2% develop a NI UTI (CR)BSI SSI 5.3% develop nos. pneumonia in ICU 18% with VAP 8,365 days 10,755 days = 478 pts 40% attributable mortality = 25.1 million = 9.9 million = 35 million Cost of VAP for Belgium / year ± 30 50 % preventable
Demonstrating the ROI of infection prevention and control
Return on investment Greatest opportunity to demonstrate a positive ROI in IPC hospital LOS decreasing patients releasing those beds to new patients volumes revenues reimbursements Reinforces the evidence that financial investments in IPC programs offer good value (for money), and that resources to implement best practice strategies at the bedside should be made available
Return on investment (2) Components of a high-quality IPC program Sufficient staff and time to conduct risk-adjusted surveillance Staff education Isolation and outbreak management Report review and development Employee health activities Tasks intented to meet regulatory requirements (incl. public reporting tasks) Implementation of evidence-based best practices Process improvement activities
Return on investment (3) Program resource needs Trained infection prevention specialists Administrative support Epidemiologists (at least part-time) Physician Supplies Data-mining support, ICT Education (patient) safety culture!
Return on investment (4) Show the value of IPC (~ functional and strategic level) Examples of cost savings associated with a well-resourced, quality IPC program eliminate supply waste appropriate selection, application of (expensive) products and technology avoiding lack of progress in decreasing infection rates creating effective / better collaboration between HC professionals / administration enhancement of the hospitals image / maintain reputation for service excellence minimizing the threat of outbreaks, resistant pathogens, employee injuries from blood-borne pathogens, HAI disclosures, sentinel events, malpractice claims, etc.
Return on investment (5) Show the value of IPC (~ functional and strategic level) creating a safer environment for patients and staff, increasing satisfaction to grow volumes (eg. empty out ICU beds more quickly, less need for surgery, increase OR performance) to hit target on 100% of quality scorecards
Success stories highlight the opportunities for all organizations to make zero HAIs a target
The business case for IPC from an executives perspective
Business case for IPC from an executives perspective Key question Administrators want to know what comprises an effective IPC program the costs and (potential) savings to the hospital how much to invest what else could be done with the resources released through HAI prevention + they want this information in a timely fashion for budget considerations
Business case for IPC from an executives perspective Survey of senior hospital executives (US) found that: focus on patient safety is a key component of an organization vision IPC identified as one of the top five categories with the highest budget growth potential However, only 1/3 are willing to increase spending to reduce errors and infection rates L.E.K. consulting, 2010
Many hospital administrators worry that they can t afford to implement these IPC precautions the truth is, they can t afford not to
In conclusion Do know and share the impact of HAIs and all benefits of IPC Don t do your own cost-benefit studies; but use estimates from the literature, and adjust for inflation Do understand the caveats (economics of IPC) and what is most important to your hospital and governmental leaders Don t base your case on solely reducing costs of HAIs avoided Do focus on interventions to reduce HAIs and demonstrate, market your value Don t forget infection prevention is the right thing to do!
Executive summary for dummies
Executive summary for dummies
If you want to go fast, go alone If you want to go far, go together
Patient safety is a never ending effort! @VandijckD dominique.vandijck@zorgneticuro.be