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closeResponse to Graves et al., Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia
Posted by astewardson on 05 Jul 2016 at 05:31 GMT
This cost-effectiveness study was a large and complex project with many issues that warrant discussion and comment. In conjunction with previously published comments (see Grayson ML. J Hosp Infect 89: 137. doi: 10.1016/j.jhin.2014.10.009), the following points should be considered while interpreting the results:
First, 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. doi: 10.1016/j.jhin.2014.06.005). HHA’s budget, which represented 20% of the NHHI costs, was halved in the subsequent financial year of 2012-13 (on schedule) as the program moved into maintenance and has since remained at this lower level.
Second, other changes have been made as this program matured. For example, the costing study pre-dates introduction of the ‘HHCApp mobile’ tool for conducting hand hygiene audits on mobile devices rather than paper. 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%. So the cost-effectiveness study no longer reflects current practice.
Finally, the benefits of the NHHI are almost certainly under-estimated. This study only considered health and cost benefits of preventing one type of healthcare associated infection: Staphylococcus aureus bloodstream infections. This is because no national measures were available for other infection types or pathogens. But appropriate hand hygiene has broader potential benefits, not only for other healthcare-associated infections but also to reduce the transmission of antimicrobial resistance. No assessment of patient suffering was included in the study.
Despite these points, the summary finding of this 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.” (Graves et al. PLoS One, 2016:11(2):e0148190. doi: 10.1371/journal.pone.0148190)
The NHHI is unique both in Australia and globally. 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.
Dr Andrew Stewardson, National Project Manager, Hand Hygiene Australia
Professor Lindsay Grayson, Director, Hand Hygiene Australia
RE: Response to Graves et al., Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia
Nicholas_Graves replied to astewardson on 05 Jul 2016 at 09:21 GMT
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....
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.g...
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