Economics and Preventing Healthcare Acquired Infection

173 Pages·2009·3.22 MB·English

by  Nicholas Graves

Economics and Preventing
Healthcare Acquired Infection
Nicholas Graves Kate Halton
(cid:129)
William Jarvis
Economics and Preventing
Healthcare Acquired Infection
Nicholas Graves Kate Halton
Queensland University of Technology Queensland University of Technology
Institute of Health & Biomedical Innovation Institute of Health & Biomedical Innovation
Musk Avenue & Blamey Street Musk Avenue & Blamey Street
Kelvin Grove QLD 4059 Kelvin Grove QLD 4059
Australia Australia
William Jarvis
135 Dunn Ln
Hilton Head SC 29928-6527
USA
ISBN: 978-0-387-72649-6 e-ISBN: 978-0-387-72651-9
DOI: 10.1007/978-0-387-72651-9
Library of Congress Control Number: 2009926696
© Springer Science+Business Media, LLC 2009
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Acknowledgments
We are grateful to the following individuals who gave up their valuable time to
read large sections of this book as it was being prepared; they provided excel-
lent comments: Richard Cookson from the University of York; Sonja Firth from
Queensland University of Technology; and Jim Zhao from Queensland University
of Technology. Linda Robertus worked hard providing supporting material for
this project. Our colleagues in Brisbane have supported this project: Michael
Whitby and David Cook from the Princess Alexandra Hospital; Dolly Olesen from
the Centre for Healthcare Related Infection Surveillance and Prevention; David
Paterson from the Royal Brisbane Hospital; Malcolm Faddy, Tony Pettitt, and
Adrian Barnett from Queensland University of Technology. We also enjoyed the
excellent support of our University managers MaryLou Fleming, Lynne Daniels,
and Ross Young.
The preparation of this book was supported by the Queensland Health Quality
Improvement and Enhancement Program through the Center for Healthcare Related
Infection Surveillance and Prevention.
v
Contents
Introduction ...................................................................................................... 1
Reasons for Writing This Book .................................................................... 1
Audiences for the Book ................................................................................ 5
Organization of the Book ............................................................................. 6
1 Economics ................................................................................................... 9
1.1 A Broad View of Economics ............................................................... 9
1.2 The Building Blocks of Economics ..................................................... 11
1.2.1 The Concept of Scarcity .......................................................... 11
1.2.2 The Concept of Opportunity Cost ........................................... 13
1.2.3 The Concept of Effi ciency ....................................................... 17
1.2.4 The Concept of Competitive Markets ..................................... 18
1.2.5 The Concept of Market Failure ............................................... 22
1.2.6 The Concept of Economic Appraisal ....................................... 24
1.3 Conclusions ......................................................................................... 25
2 Health Economics ....................................................................................... 27
2.1 Origins and Content of Health Economics .......................................... 27
2.2 The Parts of Health Economics Most Useful
for Infection-Control ........................................................................... 30
2.3 Competing Approaches to Economic Appraisal .................................. 32
2.3.1 Welfarism ................................................................................. 33
2.3.2 Extra-Welfarism ....................................................................... 35
2.4 Advantages and Disadvantages of Each Type
of Economic Appraisal ........................................................................ 36
2.5 Conclusions ......................................................................................... 37
3 Economic Appraisal: A General Framework .......................................... 39
3.1 What an Economic Appraisal Looks Like ........................................... 39
3.2 Incremental Analysis ........................................................................... 43
3.3 Ceiling Ratios and Choosing Healthcare Programs ............................ 46
3.4 Conclusions ......................................................................................... 48
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viii Contents
4 Economic Appraisal: The Nuts and Bolts ................................................ 49
4.1 Using a Clinical Trial vs. a Modeling Study ....................................... 49
4.1.1 Economic Appraisal Alongside Clinical Trials........................ 49
4.1.2 Economic Appraisal by Modeling Study ................................. 50
4.2 Building a Model ................................................................................. 52
4.2.1 Objective One: Defi ne the Structure of the Model .................. 53
4.2.2 Objective Two: Find the Evidence Required
to Make the Decision .............................................................. 54
4.2.3 Objective Three: Evaluate the Model
that has been Designed ............................................................ 56
4.2.4 Objective Four: Account for Heterogeneity
and Uncertainty ....................................................................... 59
4.2.5 Objective Five: Value Future Research ................................... 63
4.3 Important Features of an Economic Appraisal .................................... 63
4.4 Conclusions ......................................................................................... 65
5 Changes Arising from the Adoption of Infection
Control Programs ...................................................................................... 67
5.1 Overview of the Major Changes ......................................................... 67
5.2 Changes to the Number of Infections .................................................. 70
5.2.1 Epidemiological Studies .......................................................... 70
5.2.2 Synthesizing Existing Evidence .............................................. 71
5.3 Conclusions ......................................................................................... 75
6 Measuring the Cost of Healthcare Acquired Infections ......................... 77
6.1 Why Data on the Cost of HAI are Useful ........................................... 77
6.2 Defi ning and Measuring Costs of HAI ................................................ 78
6.2.1 The Cost Accountant’s Method ............................................... 78
6.2.2 The Economist’s Method ......................................................... 83
6.2.3 Differences Between the Cost Accounting
and Economics Methods ......................................................... 87
6.3 Estimating the Increase in Length of Stay due to HAI........................ 88
6.3.1 Design Approaches .................................................................. 90
6.3.2 Statistical Approaches ............................................................. 92
6.4 Conclusions ......................................................................................... 96
7 Measuring the Cost of Implementing Infection Control Programs ...... 97
7.1 Estimating the Costs of Infection Control Programs .......................... 97
7.2 Two Case Studies for Estimating the Cost of Infection Control ......... 98
7.2.1 A Case Study of the Costs of Adopting
Antimicrobial Catheters .......................................................... 98
7.2.2 A Case Study of the Costs of a Staff Education Program ........ 100
Contents ix
7.3 Analyzing Costs, Inputs, and Outputs ............................................. 101
7.3.1 Incremental Costs .............................................................. 103
7.3.2 Average Costs .................................................................... 105
7.3.3 Cost Data and Decision Making ........................................ 105
7.4 Capital Costs .................................................................................... 106
7.5 Conclusions ..................................................................................... 107
8 Preventing HAI and the Health Benefi ts that Result ............................ 109
8.1 Health Benefi ts ................................................................................ 109
8.2 What QALYs are and How they are Estimated ............................... 109
8.3 Information Required to Estimate QALYs ...................................... 116
8.3.1 The Risk of Death due to Infection ................................... 116
8.3.2 The Nature of the Health States and the Methods
for Finding Utility Scores that Describe Them ................. 117
8.4 Conclusions ..................................................................................... 122
9 Dissecting a Published Economic Appraisal .......................................... 123
9.1 Economic Evaluation in the Infection Control Literature ............... 123
9.2 Case Study of a Decision to Adopt Antimicrobial
Central Venous Catheters ................................................................. 124
9.3 Structuring the Evaluation ............................................................... 124
9.4 Evidence Required for the Evaluation ............................................. 128
9.4.1 Epidemiological Parameters .............................................. 129
9.4.2 Effectiveness of Antimicrobial CVCs ............................... 129
9.4.3 Costs .................................................................................. 130
9.4.4 Health Outcomes ............................................................... 132
9.5 Evaluating the Decision ................................................................... 132
9.6 Handling Uncertainty in the Decision ............................................. 133
9.6.1 Parameter Uncertainty ....................................................... 134
9.6.2 Data Quality ....................................................................... 135
9.6.3 Generalizability ................................................................. 136
9.7 Interpreting the Results for Decision Making ................................. 136
9.8 Conclusions ..................................................................................... 137
10 Economic Facts and the Infection Control Environment ..................... 139
10.1 The Changing Infection Control Environment ................................ 139
10.2 The Economic Facts ........................................................................ 141
10.2.1 Diminishing Returns .......................................................... 141
10.2.2 Cost Structures ................................................................... 144
10.2.3 Lack of Good Information ................................................. 147
10.3 Incentives for Bad Behavior ............................................................ 148
10.4 Good Decision Making for Infection Control ................................. 149
10.5 Conclusions ..................................................................................... 152
x Contents
Appendix ........................................................................................................... 153
References ......................................................................................................... 155
Index ................................................................................................................ 161
List of Figures
Figure 1 Two ways to crack a nut, one better than the other ........................ 10
Figure 2 The Saturn rocket used for the space program
that put man on the moon ............................................................... 15
Figure 3 Three types of effi ciency ................................................................ 18
Figure 4 How the price system works .......................................................... 21
Figure 5 Alan Williams’ description of health economics ............................ 28
Figure 6 Welfaist and extra-welfarist approaches to economic appraisal .... 32
Figure 7 The cost-effectiveness plane .......................................................... 40
Figure 8 Quadrant I of the cost-effectiveness plane
with new program ........................................................................... 41
Figure 9 Quadrant I of the cost-effectiveness plane
with new program and alternate data ............................................. 42
Figure 10 The cost and QALY outcomes of fi ve competing decisions .......... 44
Figure 11 Average cost-effectiveness ratios for fi ve decisions:
these are misleading ....................................................................... 46
Figure 12 The costs and health benefi ts of competing strategies
for colorectal cancer screening. ...................................................... 51
Figure 13 The possible outcomes for patients at risk of infection
following hip replacement .............................................................. 53
Figure 14 A choice between two competing infection control
alternatives (no data) ...................................................................... 54
Figure 15 A choice between two competing infection control
alternatives (data included) ............................................................ 55
Figure 16 A choice between two competing infection control
alternatives (data included and model evaluated) .......................... 58
Figure 17 Costs and QALYs of existing vs. Novel infection control ............. 58
Figure 18 Costs and QALYs of existing vs. fi ve novel infection
control programs – graphed. ........................................................... 59
Figure 19 The results of a probabilistic sensitivity analysis ........................... 61
Figure 20 The results of a probabilistic sensitivity analysis
presented as a cost-effectiveness acceptability curve ..................... 62
Figure 21 How costs might change with more infection control
(decrease overall) ........................................................................... 68
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