3.1. Need for economic evaluation
Several choices are usually available to endeavour to deal with health problems. These choices are often referred to as interventions. Identification of interventions is usually based on whether they lead to the desired outcomes or not i.e. does the chosen intervention reduce death or disability, or improve the quality of life to the desired extent? This simplistic approach is often adequate as the first step. However, when more than one intervention is available, which may be often the case, it is necessary to choose the one that provides a greater return on “investment”. In particular, when resources are limited, a choice has to be made in favour of the one that provides the most output (reduction in disease, death or disability) at the lowest cost.
Economic evaluation refers to “the comparative analysis of alternative courses of action in terms of both costs and consequences. The basic task of any economic evaluation is to identify, measure, value, and compare the costs and consequences of the alternatives being considered”.1044 Thus, two features always characterize any economic analysis. The first deals with obtaining information on inputs and outputs (often called costs and consequences) of the interventions. The linkage between costs and consequences usually facilitates the reaching of a rational decision. The second feature concerns available choices. An inherent assumption underlying this characteristic is that resources are scarce and only the most efficacious ones should be deployed. A full economic evaluation thus means measuring the costs and consequences of two or more interventions or between an intervention and the status quo at the least.
In addition to hand hygiene, several infection control interventions are available. According to Graves and colleagues,1045 “those who set budgets for infection control in hospitals and decide how those budgets should be allocated between infection control programmes must address two questions. First, should current rates of HCAI be reduced, and if so, by how much? Second, which infection control strategies are cost effective and/or productively efficient?” Answers to these questions can be found by studying how economic costs and health benefits change with different infection control strategies.1046 The framework below provides basic information on how two of the more common types of economic evaluation are carried out to select health interventions ().
Basic types of economic evaluation.
3.2. Cost–benefit and cost–effectiveness analyses
illustrates two competing interventions, A and B. Intervention A is the intervention of interest, e.g. hand hygiene using alcohol-based handrub, and intervention B is the comparator, e.g. hand hygiene using soap and water. Intervention B does not necessarily have to be an “active programme”; a second option of maintaining the status quo could even be considered, i.e. doing nothing. The consequences of both interventions would be reduction of HCAIs. While the identification of various types of cost are similar across most economic evaluations, the overall process of economic evaluation can be of two types: cost–benefit analysis or cost–effectiveness analysis.
3.2.1. Cost–benefit analyses
Cost-benefit analyses (CBA) measure both the costs and the consequences of alternatives.1044 The results of these analyses may be presented in the form of a ratio of monetary costs to monetary benefits or as a simple sum. A typical example of a CBA would be to compare the costs and benefits of performing hand hygiene using soap with that of an alcohol-based handrub. While there is extensive evidence on the added advantages of alcohol-based handrubbing as part of a multimodal promotion strategy in reducing the transmission and disease rates, few studies have compared costs of alternative interventions using a CBA approach. Haddix and colleagues1047 state that “CBA is often the most appropriate approach when a policy-maker has a broad perspective and is faced with one or more of the following situations: (1) must decide whether to implement a specific programme; (2) required to choose among competing options; (3) has a set budget and must choose and set priorities from a group of potential projects; or (4) the interventions under consideration could produce a number of widely differing outcomes.”
3.2.2. Cost–effectiveness analyses
Analyses in which costs are related to a single common effect or consequence which may differ in magnitude between alternative programmes are referred to as cost–effectiveness analyses (CEA). Compared with CBA, in a typical CEA the consequence or summary measure is expressed in costs per unit of health outcome, e.g. costs per quality-adjusted life year (QALY) saved, per life saved or per life year gained.1047 A typical example may be extension of life after renal failure. Two interventions that could be compared may be renal dialysis and kidney transplantation. The outcome of interest for both these interventions is common, i.e. life years gained. Normally, we would compute the differential costs and consequences and then lean towards the intervention with the least cost. This measure is called an incremental cost–effectiveness ratio (ICER). If kidney transplantation costs US$ 50 000 and extends life by 10 years, this would generate an ICER of US$ 5000 for each life year gained. Similarly, we could compute the costs of dialysis and compare the ICERs of the two interventions in order to make a decision.
Cost utility analysis is one form of CEA that uses QALYs instead of merely looking at costs per life year gained. The QALY concept attempts to place values (derived from population-based exercises) on different states of health. QALYs allow for the comparison of different health outcomes as health positions or “utility” value placed by society. To do this, any state of health or disability is assigned a utility value on a scale ranging from 0 (immediate death) to 1 (state of perfect health). QALYs thus measure health positions and are a linear measure. There are perhaps some issues with their use, as they discount health gains among the elderly more severely and treat each movement as of equal value. Such movements are probably non-linear, however, with people valuing slight improvements when they are ill more than they value similar improvement increments from gains in fitness at the top end of their recovery.
The ability to compare directly the dollar cost of different health outcomes is sometimes attractive to the decision-maker. For the policy-maker, the health intervention that produces the greatest QALYs at the least cost is often seen to be more attractive.
Cost utility is a difficult but interesting area to explore. This is because most health infections are transient states and assigning health utility states over a long term may be less meaningful. Using QALYs, which are rather static instruments, may be less applicable to infection-related illnesses, as these may come and go, thereby making assessments difficult. The DALY (disability-adjusted life year) is another outcome measure used in CEA that combines life years gained in full health and life years gained in less than perfect health (seen as a disability) in one combined measure. The DALY has been used when examining health deficiencies or the burden of disease in the international literature – particularly that relating to less developed countries. Thus one might estimate the DALYs lost related to various illnesses, e.g. eye disease, or infections, e.g. pneumonia.
3.2.3. Analyses perspective
Regardless of whether a CBA or CEA is performed, the analyses perspective is a crucial element in decision-making. Perspectives available for either analysis include societal, payer, hospital or individual. Costs and consequences within the analyses will differ based on the perspective chosen; the results will thus also vary based on the perspective chosen. Most studies to date have focused mainly on the hospital or institution and have not captured costs and consequences from a broader perspective.1048 A societal perspective is more useful for policymakers and governments who need to allocate budgets and choose between different health programmes or interventions.
3.3. Review of the economic literature
Despite the availability of established methods of economic evaluation, few prospective studies have been conducted to establish the cost–benefit or cost–effectiveness of hand hygiene in health-care settings. The Agency for Health Care Research and Quality in their recent review of quality improvement prevention strategies for HCAI concluded that “the evidence for quality improvement strategies to improve adherence to preventive interventions for HCAI is generally of suboptimal quality, consisting primarily of single-centre, simple before–after studies of limited internal and external validity. Thus, we were unable to reach any firm conclusions regarding actionable quality improvement strategies to prevent HCAIs”.1049
In general, studies have compared the costs of hand hygiene promotion programmes versus the potential cost savings from preventing HCAIs using a business case analytic approach. Unlike a CBA or CEA, a business case analysis usually provides an explanation of a provider’s expenditures for a programme over a short period (often1–3 years), including the effects of any offsetting savings.1050 Ritchie and colleagues reviewed all economic studies relating to the overall impact of alcohol-based hand hygiene products in health care1025 and concluded that, while further research is required to measure the direct impact of improved hand hygiene on infection rates, the potential benefit of providing alcohol-based handrubs is likely to outweigh costs, and their wide-scale promotion should continue. The review also recommended that those planning local improvements should note that multimodal interventions are more likely to be effective and sustainable than single-component interventions and, although these are more resource-intensive, they have a greater potential to save costs over the long term.
Examples of typical costs incurred and cost savings associated with implementing hand hygiene programmes in institutions are provided below. Furthermore, evidence is provided on the costs and cost savings from a hospital/institutional perspective through the use of a business case approach. While some studies presented here have shown cost savings, it should be noted that business cases usually fail to deliver projected cost savings in the short or near term.1051 This is mainly because hospitals are known to have high fixed costs (up to 85%).1052 This leaves the administration with limited scope to demonstrate savings from a small percentage of remaining variable costs.
3.4. Capturing the costs of hand hygiene at institutional level
The costs of hand hygiene promotion programmes include costs of hand hygiene installations and products, plus costs associated with HCW time and the educational and promotional materials required by the programme. These can be categorized into fixed and variable costs. Examples of fixed costs include those associated with buildings, equipment and new installations, salaried staff, and overhead costs such as heating, air conditioning, and water. Examples of variable costs include products needed for handwashing, including soap, water, and materials used for drying hands (e.g. towels), while the costs of hand antisepsis using an alcohol-based handrub include the cost of the handrub product plus dispensers and pocketsized bottles, if made available. In general, non-antimicrobial soaps are often less expensive than antimicrobial soaps. In health-care settings, mainly in resource-poor countries, basic handwashing equipment such as sinks and running water is often not available or of limited quality. In calculating costs for hand hygiene, these substantial construction costs need also to be taken into account. In addition, overhead costs for used water and maintenance need to be added to the calculation.
The cost per litre of commercially prepared alcohol-based handrubs varies considerably, depending on the formulation, the vendor, and the dispensing system. Products purchased in 1.0–1.2 litre bags for use in wall-mounted dispensers are the least expensive; pump bottles and small pocket-sized bottles are more expensive; and foam products that come in pressurized cans are the most expensive. Presumably, a locally-produced solution composed of only ethanol or isopropanol plus 1% or 2% glycerol would be less expensive than commercially produced formulations. Boyce estimated that a 450-bed community teaching hospital in the USA spent US$ 22 000 (US$ 0.72 per patient-day) on 2% chlorhexidine-containing preparations, plain soap, and an alcohol-based hand rinse.1053 When hand hygiene supplies for clinics and non-patient care areas were included, the total annual budget for soaps and hand antiseptic agents was US$ 30 000 (about US$ 1 per patient-day).
Annual hand hygiene product budgets at other institutions vary considerably because of differences in usage patterns and varying product prices. Countries/states/regions/localities with centralized purchasing can achieve economies on a scale that can result in considerable cost reduction of products. A recent cost comparison of surgical scrubbing with an antimicrobial soap versus brushless scrubbing with an alcohol-based handrub revealed that costs and time required for pre-operative scrubbing were less with the alcohol-based product.328 In a trial conducted in two ICUs, Larson and colleagues329 found that the cost of using an alcohol-based handrub was half that of using an antimicrobial soap for handwashing (US$ 0.025 vs US$ 0.05 per application, respectively). In another study conducted in two neonatal ICUs, investigators looked at the costs of a traditional handwashing regimen using soap, use of an alcohol-based handrub supplemented by a non-antimicrobial soap, use of hand lotion, and nursing time required for hand hygiene.646 Although product costs were higher when the alcohol-based handrub was used, the overall cost of hand hygiene was lower with the handrub because it required less nursing time.
3.5. Typical cost-savings from hand hygiene promotion programmes
To assess the cost savings of hand hygiene promotion programmes, it is necessary to consider the potential savings that can be achieved by reducing the incidence of HCAIs. One of the easiest ways to assess the cost savings is to estimate the excess hospital costs associated with the excess patient days caused by HCAIs. In a recent study by Stone and colleagues, costs of catheter-related bloodstream infection (CR-BSI), surgical site infection (SSI), ventilator-associated pneumonia (VAP), and hip SSIs were estimated and found to be a minimum of US$ 5500 per episode. The authors further reported that CR-BSI caused by MRSA may cost as much as US$ 38 000 per episode.1054
provides a summary of the costs of the four most common HCAIs based on a systematic review of literature published by Stone and colleagues for periods 1990–2000 and 2001–2004.15,1055
Costs of the most common health care-associated infections in the USA.
In addition to the costs reported above, there are several hidden costs that are not included in the calculation of these figures. These costs could instead be referred to as lost “opportunities for saving”. Stone and colleagues provide several examples. An unscheduled revisit to the operating room for incision and drainage after an SSI can limit the number of procedures that can be performed in a day. Hold-ups often cause delays and postponement of scheduled procedures. Another example of a hidden cost includes the dissatisfaction of the patient and the referring doctor. Research suggests that dissatisfied customers often have the tendency to tell more people about the deficiencies in their care. Hence, the loss of existing customers (patients) means higher replacement costs associated with attracting and receiving new patients. These include costs for marketing and registering new patients into the medical records system and the costs of countering any negative publicity and building renewed trust.
Thus, it is not surprising that the excess hospital costs associated with only four or five HCAIs of average severity may equal the entire annual budget for hand hygiene products used in inpatient care areas. Just one severe SSI, lower respiratory infection, or BSI may cost the hospital more than the entire annual budget for antiseptic agents used for hand hygiene.1053 For example, in a study conducted in a Russian neonatal ICU, the authors estimated that the excess cost of one health care-associated BSI (US$ 1100) would cover 3265 patient-days of hand antiseptic use (US$ 0.34 per patient-day).687 The authors estimated that the alcohol-based handrub would be cost saving if its use prevented approximately 3.5 BSIs per year or 8.5 pneumonias per year. In another study, it was estimated that cost savings achieved by reducing the incidence of C. difficile-associated disease and MRSA infections far exceeded the additional cost of using an alcohol-based handrub.429
Several studies provided some quantitative estimates of the cost savings from hand hygiene promotion programmes.60,181 Webster and colleagues181 reported a cost saving of approximately US$ 17 000 resulting from the reduced use of vancomycin following the observed decrease in MRSA incidence over a 7-month period. Similarly, MacDonald and colleagues reported that the use of an alcohol-based hand gel combined with education sessions and performance feedback to HCWs reduced the incidence of MRSA infections and expenditures for teicoplanin (used to treat such infections).489 For every UK£ 1 spent on alcohol-based gel, UK£ 9–20 were saved on teicoplanin expenditure.
Including both direct costs associated with the intervention (increased use of handrub solution, poster reproduction, and implementation) and indirect costs associated with HCW time, Pittet and colleagues60 estimated the costs of the programme to be less than US$ 57 000 per year for a 2600-bed hospital, an average of US$ 1.42 per patient admitted. Supplementary costs associated with the increased use of alcohol-based handrub solution averaged US$ 6.07 per 100 patient-days. Based on conservative estimates of US$ 100 saved per infection averted, and assuming that only 25% of the observed reduction in the infection rate has been associated with improved hand hygiene practice, the programme was largely cost effective. A subsequent follow-up study performed in the same institution determined the direct costs of the alcohol-based handrub used, other direct costs, indirect costs for hand hygiene promotion, and the annual prevalence of HCAI for 1994–2001.490 Total costs for the hand hygiene programme averaged Swiss francs (CHF) 131 988 between 1995 and 2001, or about CHF 3.29 per admission. The prevalence of HCAI decreased from 16.9 per 100 admissions in 1994 to 9.5 per 100 admissions in 2001. Total costs of HCAIs were estimated to be CHF 132.6 million for the entire study period.
The authors concluded that the hand hygiene programme was cost saving if less than 1% of the reduction in HCAIs observed was attributable to improved hand hygiene practices. An economic analysis of the “cleanyourhands” hand hygiene promotional campaign conducted in England and Wales concluded that the programme would be cost beneficial if HCAI rates were decreased by as little as 0.1%. The impact of the “cleanyourhands” campaign is the subject of a 4-year research programme which will look at the effectiveness of the various components of the multimodal approach.
A quasi-experimental study in Viet Nam to assess the impact of the introduction of an alcohol- and chlorhedixine-based hand santizer for hand antisepsis on SSI rates among neurosurgical patients revealed a reduction in the infection rate by 54% and a reduction in post-operative length of stay and antimicrobial use from 8 days to 6 days (P<=0.001).717 Although no costs were provided in this study, it is reasonable to assume that the reduction in hospital stay allowed the hospital to generate additional revenue by filling beds with new admissions (increased volume). Antibiotic costs were also reduced because of earlier discharge for these patients.
Despite the fact that the above-mentioned studies strongly suggest a clear benefit of hand hygiene promotion, budget constraints are a fact, particularly in developing countries, and cost–effectiveness analysis might be used to identify the most efficient strategies. To achieve this goal, data on the incidence of HCAI and the resulting opportunity costs, as well as on the cost and effectiveness of competing infection control strategies, are required.1045 Because these variables may vary by and large according to the region and institution, local studies may be necessary to help choose the best strategies.1045 Well-conducted local studies may suggest other infection control interventions of even greater cost benefit, depending on the socioeconomic and cultural environments of the health-care system. Although a business case approach may be beneficial to the hospital management in determining the cost of the infection control programmes, it is necessary to conduct economic evaluation from a broader perspective, i.e. societal, so as to reflect the values of all members of society and not just the preferences of select individuals who manage hospital services. This approach will allow policy-makers and payers to choose between infection control interventions that offer the greatest quality output per unit of cost. Clearly, hand hygiene would be an intervention of interest for many developing nations that are often faced with several competing priorities compounded with limited resources.
3.6. Financial strategies to support national programmes
Interventions designed to improve hand hygiene across a country may require significant financial and human resources, particularly multifaceted campaigns. Costs must be balanced in terms of anticipated reduction in HCAI. The economies of scale achieved by centralized design and production of supporting materials will logically result in less cost to the overall health economy. This approach was used in the “cleanyourhands” campaign conducted in England and Wales (described in the box below). Countries without centralized distribution networks might not achieve sufficient economies of scale to make such an approach feasible without additional massive investment from the commercial sector. Similar approaches have been used by some other countries and have met with success. For instance, according to the WHO recommendations, Hong Kong SAR has adopted a centralized system for the production and distribution of alcohol-based hand rub to all its hospitals. This strategy has not only resulted in economies of scale by lowering the cost of the product, i.e. alcohol-based hand rub (see Part I, Section 12), it has also fostered a spirit of campaign and competition, achieved standardization across health entities, and provided a foundation for evaluation of its success in the future.
England and Wales national programme, a programme with potential benefits. National programmes can achieve economies of scale in terms of the production and distribution of materials. In England and Wales, the NPSA “cleanyourhands” campaign (more...)
Taking into account the many financial constraints in resource-poor countries and the considerably high cost investment required (e.g. secure water supply and sinks), the investment in programmes using alcohol-based handrubs as the primary or sole means of hand hygiene seems to be an obvious solution. It should nevertheless be taken into account that investment in the infrastructure of health-care facilities, such as secure water supply and sinks, is necessary in the long run to improve the quality of health-care delivery as a whole. This investment can show benefits other than an improvement in hand hygiene practices.
