The
researchers
point to a
decade-long
U.S. study of
investment
in infection-
prevention
measures that
produced an
ICER of US
$23,278
per QALY
based on
reductions in
central line-
associated
bloodstream
infections and
ventilator-
associated
pneumonia.
22
in a net cost saving of AUD$375,000. They note,
“Because extra length-of-stay estimates for VRE
were not available separately for the general ward
and the ICU, our analysis assumed cost savings for
this infection based on general ward values only.
There was strong evidence that the intervention
was cost-effective; however, outcomes were
affected by the approach taken for valuing bed
days. Under the conservative CEO WTP approach,
the NMB of the cleaning bundle was approximately
AUD $1.02 million, with an expected ICER of
AUD$4,684 per QALY. In contrast, higher dollar
values assigned to general ward and ICU bed
days under the accounting approach returned
an NMB of AUD $1.6 million and an expected
savings of AUD$8,685 per QALY. Despite these
differences, the probability that the intervention
was cost-effective was consistently high, with
86 percent and 88 percent of model simulations
returning a positive NMB under CEO WTP and
accounting approaches, respectively.”
The researchers provide evidence for allocating
hospital resources to improving cleaning, and
Mitchell notes that making the business case
for cleaning and disinfection requires a realistic
approach to institutional economics: “My view
is that intervention in healthcare cost money to
deliver. The costs and return on this investment
varies. There would be many healthcare inter-
ventions that cost more per QALY than cleaning.
One controversial option is to ‘disinvest’ in more
costly interventions and use that money to invest
in cleaning.”
White concurs, adding, “The incremental
cost of implementing the bundle per QALY was
favorable when compared with our chosen
willingness-to-pay threshold ($28,000/QALY).
Given the trial was implemented in real-world
hospital settings, this evidence reflects the
incremental value of improved cleaning compared
with infection control measures that were already
in place at participating hospitals. For hospitals
working within fixed budgets, investment in
the bundle is likely to redirect resources away
from other programs. In making this decision,
hospitals should therefore consider the costs
and effectiveness of current measures, against
the additional costs involved with establishing
and maintaining implementation of the bundle.”
The researchers acknowledge the study’s lim-
itation, including the complications of ascertaining
real-world implementation costs: “Low-quality
data on detergent use led to their exclusion from
analysis; however, the effect of this was likely
to be small as practice changes predominantly
involved increased disinfectant use for frequent
touch-point cleaning. Furthermore, costs were
not attributed to improving cleaning technique as
this would have required time-in-motion studies.
Instead, we assumed that the number of cleaning
staff within a hospital did not change, and that
staff would be cleaning more effectively due to
improved product use and cleaning technique.
No major changes to staffing were reported as
part of routine monitoring throughout the study.
Cost savings relied on secondary data sources for
extra length of stay and infection-related mortality.
Outcomes from multistate modeling studies were
used for SAB to minimize the risk of time-de-
pendent bias; however, similar studies for VRE
infection were unavailable. Vancomycin-resistant
enterococci estimates were sourced from studies
with comparable patient infection case mix and
were comparable with other HAI studies. Future
studies of VRE outcomes should prioritize the use
of multistate modeling to address this limitation
and the differential effects of bloodstream versus
urinary tract infection.”
White, et al. (2019) add that treatment
costs per infection are a potential limitation of
the model because they were based on expert
opinion; however, the resulting cost savings were
conservative compared with other studies, they
add: “For example, a retrospective cohort anal-
ysis on the costs of SAB-related hospitalizations
between 2010 and 2014 reported estimates of
US$15,578 to $40,725 for methicillin-susceptible
Staphylococcus aureus and US$14,792 to $34,526
for MRSA. Attributable costs per VRE infection of
US$6,565 to $14,850 have also been published. It
is possible that a Hawthorne effect contributed to
bundle-effectiveness outcomes, as hospital staff
were likely to change behavior because they were
being monitored. Given the inclusion of monthly
audits as a fixed element of the bundle, such an
effect can be considered as part of the bundle as
staff were likely to change their behavior precisely
because they were being monitored. Findings from
this study compare favorably against other HAI
prevention strategies and provide evidence for al-
locating hospital resources to improving cleaning.”
The researchers point to a decade-long U.S.
study of investment in infection-prevention
measures that produced an ICER of US$23,278
per QALY based on reductions in central
line-associated bloodstream infections and ven-
tilator-associated pneumonia. A retrospective
evaluation of the Australian National Hand
Hygiene Initiative reported similar outcomes
for SAB, with an incremental program cost of
february 2020 • www.healthcarehygienemagazine.com