Hospital Infection Control

Measuring cost-benefit in infection control

How does measuring cost-benefit currently impact infection control?

Cost and benefit play an integral role in all infection control programs. Cost-benefit analyses measure benefits in terms of money. Simply put, cost-benefit analyses determine the net savings or net cost associated with an intervention. Cost-benefit analysis is often confused with cost-effectiveness analysis. In cost-effectiveness, the outcome is measured in non-monetary terms such as cases of infection prevented or number of life-years saved.

There are several reasons why a cost-benefit analysis might be performed. Funds for infection control are limited and infection control programs should understand how resources relate to benefits. Policy makers may use information to determine whether a proposed or existing policy is a sound investment of public money. Finally, cost-benefit analyses are useful when infection control programs are defending their funding as healthcare organizations seek to cut costs.

For example, an infection control program might note that a pilot intervention was associated with a decrease in ventilator-associated pneumonia (VAP). A cost-benefit analysis might be done to compare the cost of the intervention with the money saved by averting cases of VAP. The cost of the intervention could be measured in terms of the cost of supplies and the wages of personnel. The cost of a case of VAP might be drawn from the literature or might be estimated using the expected reimbursement from third-party payers. The result could be used to argue for funding to make the pilot program permanent.

What elements are necessary for cost-benefit analysis in infection prevention and control?

There are several key principles underlying cost-benefit analysis. It is important to use data that are relevant to the intended audience. If the audience is a healthcare administrator, then relevant costs will be those that are paid by the hospital rather than the patient. Thus, out-of-pocket costs to the patient would not be included in this example. For a national perspective, broader costs would be considered. The audience determines the perspective of the analysis.

All cost-benefit analyses require assumptions about variables: the cost of an intervention, the likelihood that an infection is prevented, the cost of a prevented infection, etc. Although it is important to use the best data for these variables, it is impossible to pick a single point-estimate that is perfectly accurate. Thus, an important element is the ‘sensitivity analysis’, which examines how cost-benefit is affected by changes in assumptions. The conclusions of the analysis are considered more robust if they are sustained when variables are changed over reasonable ranges. More sophisticated analyses use computer modeling to simulate a theoretical population of patients undergoing the intervention, using a range of assumptions.

What conclusions from cost-benefit analyses guide infection control practices and policies?

Many infection control activities have favorable cost-benefit profiles. This is especially true for serious infections in high-risk populations such as intensive care units. For example, the Institute for Healthcare Improvement VAP Prevention Bundle is cost-beneficial, and is less expensive to a healthcare organization than a strategy of suctioning alone. Coupled with the increasing reluctance of third-party payers to pay for nosocomial infections, a favorable cost-benefit profile has significant weight in hospitals’ decisions to fund or expand infection control programs.

What are the consequences of ignoring cost-benefit?

Ignoring cost-benefit may lead to impractical actions. A costly intervention may reduce nosocomial infections, but if it is less cost-beneficial than alternatives the result may be wasted resources or resources that are inappropriately drained from other interventions. Ignoring the financial impact of infection control may also put the team at a disadvantage with administrators who are tasked with balancing a budget.

What other information supports measuring cost-benefit?

Several key factors have brought infection control to the forefront of modern medicine. These include the drive to make infection rates public, the increasing focus on infections by regulators, reduced or absent reimbursement for nosocomial infections, and reports by bodies such as the Institute of Medicine. Unfortunately, interest in infection control has expanded faster than financial resources. Thus, it is critical to spend existing resources in a way that maximizes cost-benefit ratios and to make the financial benefits clear to hospital administrators.

Summary of current controversies.

Cost-benefit analysis sometimes makes clinical providers uncomfortable, because they feel that the emphasis should be on patient outcome rather than economics. A more pragmatic approach would be to say that we should use limited financial resources to maximize patient outcome.

Other controversies arise when people disagree on the type or quality of input data used for cost-benefit analysis. In these cases, the analysis can be run using a range of variables to see if it affects the results.

One additional example is the problem of unit-based accounting. Although the costs of infection control are directly accounted to the infection control department, the savings due to averted infections may be accounted to another area. This is especially problematic if the reporting relationship of the infection control program is in a lower stratum of the organizational chart, far from the chief financial officers of the institution. Cutting infection control clearly has downstream consequences on hospital costs, but individual units may not have the full perspective that a cost-benefit analysis could bring and thus may make short-sighted decisions to cut budgets.

What is the role of measuring cost-benefit relative to the impact of other infection control methods?

Cost-benefit analysis is a valuable tool in infection control, although it does not directly reduce infections. Unfortunately, cost-benefit analysis is not routinely taught to infection control practitioners or epidemiologists. Yet, it is an integral part of medical economics and a powerful tool that can allow programs to prioritize activities or analyze the value of their programs.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to cost-benefit.

There have been several examples of cost-benefit analysis in the recent literature. A study by Slayton, et al. found that a national, multi-faceted approach to reducing infection with Clostridium difficile would save $2.5 billion. An analysis by McKinnell, et al. found that the cost of universal screening for methicillin-resistant Staphylococcus aureus (MRSA) outweighed the financial benefit using a hospital-based perspective. A systematic review by Farbman, et al. of MRSA screening studies including those from other countries identified broad heterogeneity in study methodology. Table 1 lists a few recent studies.

Table I.

Examples of cost-benefit studies in infection control
Reference Intervention Favorable/Unfavorable
Branch-Elliman, et al. 2015 Strategies to reduce VAP Favorable (selected strategies)
Halton, et al. 2010 Bundle to prevent CABSI Favorable under some conditions
Hong, et al. 2010 Effect of infection control on BSI in hemodialysis Favorable
Leonhardt K, 2011 Universal screening of inpatients for MRSA Unfavorable compared to targeted screening
McKinnell, et al. 2015 Universal screening for MRSA Unfavorable
Schwebel C, et al. 2012 Chlorhexidine sponges for preventing line infections Favorable
Slayton, et al. 2015 Strategies to reduce C. difficile Favorable
Waters H, et al. 2011 Keystone Patient Safety Project Favorable

Controversies in detail

Before relying on the results of a published cost-benefit analysis, it is important to assess whether the setting of the analysis is relevant to the local infection control setting. Some studies model societal costs including costs that would not normally be borne by a hospital. Some are done in high-risk populations and others are done in a special population, often leading to different conclusions.

The benefit of any intervention hinges on the ability to prevent infections and realize the attributable savings. Sometimes, interventions are performed in sequence or layered on top of other interventions. For example, an infection control program that already has an effective bundle in place to prevent catheter-associated bloodstream infections (CABSI) may obtain only marginal benefit from adding impregnated catheters, whereas a program with no bundle in place might see a larger impact.

The savings attributable to prevented infections is sometimes controversial because seriously ill patients consume large amounts of resources with or without a hospital-acquired infection. It is often difficult to tease out the contribution of the infection to the overall cost of stay. Techniques to address this include case-control studies and other methods. Again, a sensitivity analysis can determine whether reasonable variation in the estimate has an effect on the results.

An examination of the table shows that most published interventions had a favorable cost-benefit ratio. This is likely due in part to publication bias, meaning that negative studies are more difficult to publish than positive studies. It is also possible that industry-funded studies are less likely to be published if they portray a product negatively. As discussed by Zilberberg, et al., there are many challenges in applying general cost-benefit studies to real-life infection control programs.

What are the national and international guidelines on alternatives for measuring cost-benefit?

National guidelines for cost-benefit analysis do not exist, and this is an important limitation. As a result, studies use varied methodologies and are of variable quality.

What other consensus group statements exist, and what do key leaders advise?

An article by Stone et al highlighted additional important issues of cost-benefit analysis that are specific to the area of infection control, many of which are detailed above.

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