Re: Hand Hygiene Aistralia - Cost effectiveness publication - ACIPC - Australasian College for Infection Prevention and Control

21/03/2016 at 3:04 pm #72908 Quote

Michael Wishart

Participant

Author:
Michael Wishart

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Organisation:

State:
NSW

[Posted on behalf of the original authors – Moderator}

As the University based authors of this paper, we also welcome this discussion. It was a challenging and difficult study but that made it interesting. With almost $1M of funding from the NHMRC and ACSQHC we felt a large responsibility to do the best possible study. We have no prior position or biases about the value of the NHHI.

In response to the specific points raised by Lindsay and Andrew:

o When we halved the costs of running Hand Hygiene Australia (HHA) the main result changed from $29,700 per life year gained to $25,094 per life year gained

o When we additionally reduced the estimated time spent on audits by hand hygiene auditors by 50% the main result changed from $25,094 per life year gained to $18,960 per life year gained.

o S. aureus bloodstream infections were chosen as the outcome measure by the steering committee for the project, and the reasoning was sound. The data are reliable for the states and territories, SAB is very expensive to treat and has large mortality risk. It is likely the best outcome measure to demonstrate the cost-effectiveness of the NHHI.

o We did an analysis of other infection outcomes that showed a statistically significant reduction in 11/23 infection rates, no change for 9/23 and increases for 3/23. Here is the paper http://www.publish.csiro.au/?paperHI14033

o Including quality of life changes had a negligible impact on the results.

o We responded to Lindsay’s letter in JHI here http://www.ncbi.nlm.nih.gov/pubmed/25555834

Estimating the value for money of infection prevention programmes is important, particularly in today’s climate where funding is tight. This situation of scarce resources is likely to be the new ‘normal’ for health services.

Our study, and the interest in it, highlights the need for evaluations to inform policy decisions. As a community we should take every opportunity to build a culture of evidence-based policy. We are obliged to prefer health programmes that deliver good value for money.

Prof Nick Graves, on behalf of the authors

[This post added for continuity – Moderator}

[Posted on behalf of HHA – Moderator]

We welcome discussion regarding this paper, and more broadly of the National Hand Hygiene Initiative. The QUT study was a large and complex project with many issues that warrant discussion and comment. Some of our comments have been previously published (see Grayson ML. J Hosp Infect 89: 137). We’d like to contribute the following points to today’s discussion on this list:

* The annual cost of the NHHI as assessed by this study reflects ‘start-up’ rather than ‘maintenance’ costs. The cost information used in this study is taken from the 2011-2012 financial year (Page et al. J Hosp Infect, 2014;88:141). HHA’s budget, which represented 20% of the NHHI costs, was halved in the subsequent financial year of 2012-13 (on schedule) and has since remained at this lower level.

* Other changes have been made as this program matured. For example, the costing study pre-dates introduction of the ‘HHCApp mobile’ tool. This was developed to reduce total auditing time requirements (by elimination of data entry), while also facilitating immediate feedback and minimising data entry errors. Surveyed hand hygiene auditors that have moved to mobile devices have estimated that this can reduce time spent on audits by up to 50% (we aim to publish). So the cost-effectiveness study no longer reflects current practice.

* The benefits of the NHHI are almost certainly under-estimated. This study only considered health and cost benefits of preventing one type of HAI: S. aureus bloodstream infections. This is because no national measures were available for other infection types or pathogens. But appropriate hand hygiene should have broader benefits, not only for other healthcare-associated infections but also to reduce the transmission of antimicrobial resistance. No assessment of patient suffering was included.

Despite these points, the summary finding of this QUT study was that the NHHI is cost-effective according to Australian standards: “This is the first cost-effectiveness evaluation of a National Hand Hygiene Initiative and shows that overall the programme was cost effective with a cost per life year gained of $29,700.”

The NHHI is unique both in Australia and globally. We believe that its successes have been the result of combining evidence-based interventions and strong collaboration between infection control professionals, jurisdictional authorities, HHA, the Australian Commission on Safety and Quality in Health Care, and other groups. But just as the program has evolved since the 2012 snapshot provided by this study, it should also continue to do so into the future. This discussion is one part of that process.

Andrew Stewardson, National Project Manager, Hand Hygiene Australia
Lindsay Grayson, Director, Hand Hygiene Australia

Thank you Mary-Louise for your response re Graves et al study and the variances.

The concerns of biased data reported for hand hygiene compliance is worth noting and I too agree with your comments here.

Costs associated with the efforts to report HH data as required which detracts from some of the critical day to day requirements of the IC nurse need further review.

Thank you
Michelle

Michelle Bibby
Infection Prevention Australia
Michelle@infectionprevention.com.au
+429071165

Dear Ramon and Glenys

Graves et al study relies on the accuracy of the 2 pivotal variables: SAB and hand hygiene compliance. The accuracy of the latter is serious limited. Our report in the Medical Journal of Australia (Med J Aust 2014; 200 (9):534-537. http://dx.doi.org/10.5694/mja13.11203) concluded the HHA program reports rates that have been biased upwards by very few high performers.

The conclusion from our findings and Graves et al is:

(1) SAB respond to multiple interventions and hand hygiene is only one of these.
(2) hygiene compliance rates have not reached a tipping point to reduce SAB and this tipping point is a long way off because
(3) the hand hygiene compliance rates are inaccurate.

It is important to have a national HH program. But the expense of the current program is too high when the cost of audits provides flawed data that reinforces a misguided belief that our hospitals are performing HH well.

Mary-Louise

Professor Mary-Louise McLaws

Professor of Epidemiology in Healthcare Infection and Infectious Diseases Control

http://research.unsw.edu.au/people/professor-marylouise-mclaws

SPHCM SAMUELS BUILDING

UNSW AUSTRALIA, SYDNEY NSW 2052 AUSTRALIA

CRICOS Provider Code 00098G

________________________________
Colleagues

The study by Graves et al. reports a range of interesting findings, and raises many issues regarding hand hygiene for broader consideration. The College is examining the paper and is preparing a media release for release in the coming days.

Kind regards,
Ramon

Professor Ramon Z Shaban
PRESIDENT

Australasian College for Infection Prevention and Control

GPO Box 3254, Brisbane Qld 4001

On 25 February 2016 at 21:16, Glenys Harrington <infexion@ozemail.com.au> wrote:
Dear All,

Find attached the following publication (February 9, 2016).

* Graves et al. Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia. PLoS ONE 11(2): e0148190. doi:10.1371/journal.

The analysis was undertaken on data from 6 Australian states:

* In 2/6 states there was a 1% chance it was cost effective

* In 1/6 states there was a 26% chance it was cost effective

* In 1/6 states there was a 80% chance it was cost effective and

* In 2/6 a 100% chance it was cost effective.

Interesting figure showing cost increases and cost savings by state (fig 2).

Also some interesting points in the discussion.

Shame there was “No useable pre-implementation” data available for Victoria and hence was not able to be analysed.

Given the findings of the analysis it raises the following questions for governments:

* Shouldn’t the program be scaled back and some of the money be spent on other initiatives to reduce hospitals associated infections(HAIs)?

* Shouldn’t the program be scaled back to reduce the infection control workload associated with the program which is currently overwhelming and taking ICPs away from other core infection control activities?

A press release by the College about the findings of this study and the views of the college in terms of the allocation of limited resources would be timely.

regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
PO Box 5202
Middle Park
Victoria, 3206
Australia
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

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