A health system perspective on patient safety

THE ECONOMICS OF PATIENT SAFETY STRENGTHENING A VALUE BASED APPROACH TO REDUCING PATIENT HARM AT NATIONAL LEVEL Most research on the cost of patient harm has focused on the acute care setting in the developed world where the disease burden can be compared to chronic conditions such as multiple sclerosis and some types of cancer. Luke Slawomirski and Niek Klazinga ISQua London, October 1th 217 sepsis; pressure ulcers; inpatient hip fractures due to falls; VTE; central line infections; deaths in lowmortality conditions A health system perspective on patient safety The financial impact of safety failure is considerable. Approximately 15% of total hospital activity and expenditure is a direct result of adverse events. The most burdensome adverse event types include venous thromboembolism, pressure ulcers, and infections The burden and cost of patient harm and balancing prevention and failure costs (based on literature reviews) Impact and costs of patient safety interventions; rating and choosing the best buys (based on literature and a survey amongst a panel of 8 expert and policy makers from 15 countries) Patient harm is the 14th leading cause of the global disease burden. This can be compared to tuberculosis and malaria. The majority of this burden falls on the developing countries. Related costs outside the hospital Less is known about harm in primary and ambulatory care. Research indicates that wrong or delayed diagnosis is a considerable problem. Some studies suggest that every adult in the United States can expect to be harmed as a result of diagnostic error at some point in their lifetime. The flow on and indirect costs of harm include loss of productivity and diminished trust in the healthcare system. In 28, the economic cost of medical error in the US was estimated to be almost USD 1 trillion. 1

Many adverse events are preventable. For example improving patient safety in US Medicare hospitals is estimated to have saved USD 28 Billion between 21 and 215. Foreign body left in during procedure, 215 (or nearest year) 16 14 12 Per 1 surgical discharges Confidence interval 1 12.3 8 6 7.2 7.5 8.1 8.8 7.7 9. 4 2 Poland.2 1.6 Belgium 2.2 Ireland Slovenia OECD13 Germany United Kingdom United States 2.7 3.3 Australia 4.2 Switzerland 5.2 Italy 5.4 New Zealand 6.4 1.6 1.9 Spain 2.1 Slovenia 2.2 OECD1 3.5 Norway 4.1 4.2 4.4 Canada 5.5 Surgical admission method All admission method Note: Given very low incidence of events, 95% confidence intervals have been calculated for all countries as represented by grey areas. Source: OECD Health Statistics 217. Furthermore the costs of prevention are dwarfed by the cost of failure. Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) in hip and knee surgeries, 215 (or nearest year). 18 16 14 12 1 8 6 4 2 Per 1 hip and knee surgical discharges DVT PE Poland 33 56 69 46 166 9 17 184 294 29 22 316 237 339 233 35 357 31 293 397 3 411 419 34 29 51 1328 267 1113 549 Belgium 84 69 97 58 183 99 152 153 185 344 289 United States United Kingdom Switzerland 312 443 358 Ireland OECD14 Germany Slovenia France Australia 657 311 69 14 572 574 Spain Norway New Zealand OECD9 Canada Italy Surgical admission method Source: OECD Health Statistics 217. All admission method OECD Activities on Patient Safety Patient Safety Indicators (PSI s) based on administrative data bases (since 1 years) and published in Health at a Glance Report on the implementation and use of PSI s in OECD countries (217) Patient Safety Indicators based on Patient Reporting (PRIMS) (since 216) Safety indicators in PHC and LTC based on prescription data and point prevalence measurements (since 216). The Economics of Patient Safety (OECD report for the ministerial conference on safety, Bonn, March 217) 4 35 3 25 2 15 1 5 259 Postoperative sepsis in abdominal surgeries, 215 (or nearest year) Per 1 abdominal surgical discharges 1352 1717 1862 1989 2117 2129 221 2269 2316 2371 2386 2453 Source: OECD Health Statistics 217. This document, as w ell as any data and any map included herein, are w ithout prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area Information on data for : http://oe.cd/israel-disclaimer 2658 Poland Belgium Germany OECD14 United States Slovenia Denmark Switzerland United Kingdom Australia Ireland Surgical admission method 3673 381 421 552 618 784 992 996 14 1218 1365 1395 2224 Korea New Zealand Denmark OECD11 Italy Canada Norway Spain All admission method 9 2

Obstetric trauma, vaginal delivery with instrument, 21 and 215 (or nearest year) 18 Crude rates per 1 instrument-assisted vaginal deliveries 21 215 16 16.9 14 12 1 8 6 4 2 11.3 9.6 1.9 8.5 7.4 7.2 6.8 6.4 5.7 4.8 4.2 3.7 3.4 3.2 2.5 2.1 1.9 1.9 3.9.7 2.5 REPORT ON THE IMPLEMENTATION AND USE OF PSI S IN OECD COUNTRIES (217) 1. Based on registry data. Source: OECD Health Statistics 217. 16 Obstetric trauma, vaginal delivery without instrument, 21 and 215 (or nearest year) Participation 4. Crude rates per 1 vaginal deliveries w ithout instrument assistance 21 215 3.5 3.1 3. 2.5 2. 2.8 2.5 2.5 2.6 2.4 2.4 2.1 1.6 1.5 1. 1.5 1.4 1.2 1.6 1.4.9.7.7.5.5.5.1.5..5 1. Based on registry data. 1. Based on registry data This document, as w ell as any data and any map included herein, are w ithout prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area Information on data for : http://oe.cd/israel-disclaimer 17 Prescription of sedatives (benzodiazepines) among elderly people also varies widely National measurement programs Elderly people prescribed long term benzodiazepines or related drugs, 215 (or latest year) 8 7 6 5 4 3 2 1 Per 1 persons aged 65 years and over 67 54 52 44 34 27 26 18 18 18 18 17 11 1 5 3 25 2 15 1 Source: OECD Health Statistics 217 5 Elderly people prescribed long acting benzodiazepines or related drugs, 215 (or latest year) Per 1 persons aged 65 years and over 192 How much of these prescriptions are inappropriate? Need to be able to link prescription data to diagnosis 15 113 12 95 82 85 67 57 55 36 31 24 2 18 13 9 About 9% of countries have national and hospital level programs HOWEVER only a third of countries indicated there was good alignment. Countries with national coverage: 1% hospital 5% primary care and long term care Purpose of indicators Mainly improvement and learning (formative function) 5% national 7% clinical level Accountability (summative function) 25% national % clinical level. 18 3

1. Improve availability and quality of data Access to mature data systems is holding back the availability of indicators in some countries Estonia has an administrative data system (Health Information System) that most hospitals contribute to but coverage is not complete and the data quality is variable, it has only been in full operation for two years and extending coverage and completeness of the data is the principal priority at this time. A national system of data does not currently exist in Poland. The Centre for Medical Information has been implementing a national project but it has not been successful. It has not been able to create and collect national data, largely because of the need to access data from variety organisations, each of which have quite different data holdings. 3. Facilitate calculation of the indicators OECD PSIs are complex to calculate and data demanding (e.g. SDx coding depth) Major change required to bring about improved availability of indicators: Need to strengthen expertise and resources Some countries are just embarking on calculations: Cyprus, Italy, Latvia, Lithuania, Mexico, Peru Broader application of approach used in hospital performance project is proposed. 19 22 1. Improve availability and quality of data National data availability remains the predominant issue for primary care safety indicators 4. Bundle process & outcome indicators Actionability can be strengthened by linking outcome indicators to process indicators The US does not a have nationally representative prescribed drug reporting platform. This prohibits the US from reporting and using the OECD primary care prescribing indicators at the national level. Calculation of the OECD prescribing indicators can be achieved through a 1% sample of prescribing data that is available in Spain at the national level Poland does not currently have access to a national prescription drug database and therefore can t calculate and use the OECD primary care indicators. At this time, Chile does not collect and have access to prescribed drugs data at the national level, nor does it have plans to develop this capacity in the future. In Belgium... A greater focus is now on the use of process indicators. Rather than measuring DVT/PE rates, anticoagulant therapy and bed stocking utilisation measures are now being considered given they are sensitive to changes in clinical practice and more actionable. Chile considers these indicators [OECD PSIs] will be useful in assessing whether its prevention strategies are working at a national level. For example, process indicators around embolism prevention can be confronted with outcome measures on the incidence of DVT or PE after hip and knee surgery. 2 23 2. Establish stable indicator specifications 5. Hospital acquired infection indicators Further refinement and clarification of existing indicators will improve actionability. Nearly all countries have well established databases on healthcare acquired infections would encourage the development of publicly available specifications of the indicators by the OECD that identify PSIs that are stable in specification. The Ministry and districts require clear guidance and assurance of stability and a more formal official release with clear specification of the PSIs by the OECD would help. The issues they [OECD PSIs] pertain to are important but has developed more specific (and with specific denominators) and (in their view) better defined indicators that align with the priority conditions and quality registries that exist in In the US CDC has been adding more measures of health care associated infections, not just in the ICU but also on general wards, including surgical site infections, MRSA, C difficile, central infections and catheter associated infections in line with the introduction of more sophisticated ICD code sets In Canada Hospitalized Surgical Site Infections (SSIs): the rate of hospitalized SSIs occurring within 3 or 9 days after specific surgical procedures. This indicator picks up 29 procedures, relies on data linkage and is currently being validated. 21 24 4

6. Retrospective record review Patient safety interventions included in the snapshot survey (scoring of perceived impact and costs by 8 experts and policy makers in 15 countries) Emerging interest in the use of retrospective record review to monitor patient safety In the last 2 3 years, there has been a focus on safety related deaths In NHS England. The Learning from Deaths Program uses a structured judgement method of case note review to identify and consider the causes of avoidable deaths. That is, deaths where the balance of probability suggests they were due to problems in care. The program encouraged the use of the Global Trigger Tool (GTT) and from 1 January 213 the Tool was implemented across all 6 acute care hospitals in. The GTT program involves continuous monthly random audit of records. This data is then available to each hospital for regular internal and review and consideration to improve care and reported to a national registry. 25 Value based selection of patient safety strategies Highest and lowest impact and cost ratings for individual interventions, all respondents (n=23) Reducing failure costs and increasing investments in prevention Alignment of strategies on National, Hospital and Clinical level Broadening to PHC and LTC Importance data infrastructure Selection of best buys safety strategies niek.klazinga@oecd.org Average impact and cost ratings for all 42 interventions (n=23) 5

Most and least favourable impact/cost Frequency of interventions included in LMIC context best buys bundles (n=19) 3.18 Patient identification and procedure matching protocols 3.17 Patient hydration and nutrition standards 3.16 Response to clinical deterioration 3.15 Acute delirium & cognitive impairment management programs 3.14 Falls prevention protocols 3.13 Pressure injury (ulcer) prevention protocols 3.12 Clinical care standards 3.11 VTE prevention protocols 3.1 Peri operative medication protocols 3.9 Operating room integration and display checklists 3.8 Procedural / surgical checklists 3.7 Ventilator associated pneumonia minimisation protocols 3.6 Central line catheter insertion protocols 3.5 Urinary catheter use and insertion protocols 3.4 Aseptic technique protocols and barrier precautions 3.3 Smart infusion pumps and drug administration systems 3.2 Transcribing error minimisation protocols 3.1 Medication management / reconciliation 2.14 Medical equipment sterilisation protocols 2.13 Blood and blood management protocols 2.12 Antimicrobial stewardship 2.11 Hand hygiene initiatives 2.1 Infection detection, reporting and surveillance systems 2.9 Building a positive safety culture 2.8 Human resources interventions 2.7 Digital technology solutions for safety 2.6 Clinical communication protocols and training 2.5 Person and patient engagement initiatives 2.4 Monitoring and feedback of patient safety indicators 2.3 Integrated patient complaints reporting system 2.2 Clinical incident reporting and management system 2.1 Clinical governance systems and frameworks related to safety 1.1 A national agency responsible for patient safety 1.9 National interventions based on specific safety themes 1.8 System level public engagement and health literacy initiatives 1.7 No fault medical negligence legislation 1.6 Electronic Health Record (EHR) systems 1.5 Professional education and training 1.4 Pay for performance schemes for patient safety 1.3 Mandatory reporting of specified adverse events 1.2 Public reporting of patient safety indicators 1.1 Safety Standards linked to accreditation and certification 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 Frequency of interventions included in OECD context best buys bundles (n=22) 3.18 Patient identification and procedure matching protocols 3.17 Patient hydration and nutrition standards 3.16 Response to clinical deterioration 3.15 Acute delirium & cognitive impairment management programs 3.14 Falls prevention protocols 3.13 Pressure injury (ulcer) prevention protocols 3.12 Clinical care standards 3.11 VTE prevention protocols 3.1 Peri operative medication protocols 3.9 Operating room integration and display checklists 3.8 Procedural / surgical checklists 3.7 Ventilator associated pneumonia minimisation protocols 3.6 Central line catheter insertion protocols 3.5 Urinary catheter use and insertion protocols 3.4 Aseptic technique protocols and barrier precautions 3.3 Smart infusion pumps and drug administration systems 3.2 Transcribing error minimisation protocols 3.1 Medication management / reconciliation 2.14 Medical equipment sterilisation protocols 2.13 Blood and blood management protocols 2.12 Antimicrobial stewardship 2.11 Hand hygiene initiatives 2.1 Infection detection, reporting and surveillance systems 2.9 Building a positive safety culture 2.8 Human resources interventions 2.7 Digital technology solutions for safety 2.6 Clinical communication protocols and training 2.5 Person and patient engagement initiatives 2.4 Monitoring and feedback of patient safety indicators 2.3 Integrated patient complaints reporting system 2.2 Clinical incident reporting and management system 2.1 Clinical governance systems and frameworks related to safety 1.1 A national agency responsible for patient safety 1.9 National interventions based on specific safety themes 1.8 System level public engagement and health literacy initiatives 1.7 No fault medical negligence legislation 1.6 Electronic Health Record (EHR) systems 1.5 Professional education and training 1.4 Pay for performance schemes for patient safety 1.3 Mandatory reporting of specified adverse events 1.2 Public reporting of patient safety indicators 1.1 Safety Standards linked to accreditation and certification The most frequently selected interventions for the LMIC context across all respondents 1.5 professional education and training (16 times) 2.1 Infection detection and surveillance systems (9 times) 2.11 Hand hygiene initiatives (8 times) 1.9 National interventions based on specific safety themes (8 times) 1.1 Safety standards linked to accreditation and certification (8 times) 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 Most frequently selected for OECD countries Let s not forget: First - do no harm 1.5 Professional education and training (14 times) 2.1 Clinical governance systems and frameworks (13 times) 1.1 Safety standards linked to accreditation and certification (11 times) 2.5 Person and patient engagement strategies (9 times) 1.6 EHR systems (9 times) 1.9 National interventions based on specific safety themes (9 times) 1.7 No fault medical negligence legislation (8 times) 1.1 A national agency responsible for patient safety (8 times). 6

A systems approach to improving safety at national level Strong associations in the network of OECD countries 1.5 Professional education and training, 2.1 Clinical governance systems and frameworks related to safety, 2.5 Person and patientengagement, 2.9 Building a positive safety culture and 1.1 A national agency responsible for patient safety. 1.1 Safety Standards linked to accreditation and certification, 1.9 National interventions based on specific safety themes, 1.2 Public reporting of safety indicators and 2.2 Clinical incident reporting and management system. Key Messages Economics Patient Safety Patient safety is a critical policy issue. The cost to patients, healthcare systems and societies is considerable Most of the burden is associated with a few common adverse events. Greater investment in prevention is justified Solid foundations for patient safety need to be in place Active engagement of providers and patients is critical. Innovation at the clinical level is enhanced through national leadership, vision & prioritisation Practical approaches exist to identify national priorities for action References AHRQ (215), National Healthcare Quality and Disparities Report and 5 th Anniversary Update on the National Quality Strategy. Agency for Healthcare Research and Quality. AHRQ Pub. No. 16 15. Brown, PM et al (22). Cost of Medical Injury in New Zealand: A retrospective cohort study. Journal of Health Services Research and Policy, 7(Suppl. 1), S29 S34. Ehsani J et al (26). The incidence and cost of adverse events in Victorian hospitals 23 4. Medical Journal of Australia 5;184(11):551 5. Etchells et al (212), The Economics of Patient Safety in Acute Care. The Canadian Patient Safety Institute. Hauck, K et. al. (217). Healthy Life Years Lost and Excess Bed Days Due to 6 Patient Safety Incidents: Empirical Evidence from English Hospitals. Medical Care 55(2):125 13. Health Policy Analysis (213), Analysis of hospital acquired diagnoses and their effect on case complexity and resource use Final report, Australian Commission on Safety and Quality in Health Care, Sydney. Hoonhout L. et al (29), Direct medical costs of adverse events in Dutch hospitals. BMC Health Services Research, 9:27. doi: 1.1186/1472 6963 9 27. Jackson, T. (29), One dollar in seven: Scoping the Economics of Patient Safety. The Canadian Safety Institute. Levinson, D.R. (214), Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. The Department of Health and Human Services, United States of America, OEI 6 11 37 Mahan, C. et al (211), Deep vein thrombosis: A United States cost model for a preventable and costly adverse event. Thromb Haelost; 16:45 415. doi:1. 116/TH11 2 132. Rafter, N. et al (216), The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals a retrospective record review study. BMJ Qual Saf;:1 9. doi:1.1136/bmjqs 215 4828 Zsifkovits, J. et al (216), Costs of unsafe care and cost effectiveness of patient safety programmes. European Commission, Health and Food Safety. 7

. Thank you www.oecd.org/health Niek.KLAZINGA@oecd.org Luke.SLAWOMIRSKI@oecd.org 8