On February 19, 2014 at the Ateneo School of Medicine and Public Health in Pasig City, Dr. Albert Domingo presented an introduction to the economic impact of healthcare associated infections (HAIs) as well as related concepts in health policy and management. The speaker discussed common approaches taken to ascertain the economic impact of HAIs, followed by factors/considerations in Philippine health policy and management that must be understood and adjusted in order to minimize HAIs.

1. Policy Implications of
Healthcare Associated
Infections

2. Outline
1.
2.
3.
4.
5.
Introduction / Overview
Economic Impact
Policy and Management Implications
Some Curious Questions
Open Forum / Q&A

3. INTRODUCTION/OVERVIEW

4. What is health care?
• In caring for patients, the good physician
dispenses time, sympathy, and understanding
to his patients
• The physician also scientifically applies
principles of diagnosis and treatment
• Medical care has become a mosaic of many
health and non-health professionals executing
the necessary skills
Reference: Larson et al., 2001

6. Quality of Care and Health Systems
• In any country, one of the factors affecting the
health and well-being of individuals and
populations is the quality of care provided
within the health service.
• In turn, the performance of any health system
(including provider quality) is determined by
the way in which it is designed, managed, and
financed.
Reference: Gray, 2004 (p. 288), modified

7. Reference: Berman, 2012

8. Three Fundamental Goals
• Improve the health of the population served;
• Respond to people’s expectations;
• Provide financial protection against the costs
of ill-health
*These are irrespective of the level of resources
available and the organization of the health
system
Reference: Gray, 2004 (p. 289)

9. What are healthcare associated infections?
Health care-associated infections, or
“nosocomial” and “hospital” infections, affect
patients in a hospital or other health-care
facility, and are not present or incubating at the
time of admission. They also include infections
acquired by patients in the hospital or facility
but appearing after discharge, and occupational
infections among staff.
(WHO HAI Fact Sheet)

10. ECONOMIC IMPACT

11. Using Economics to Set Priorities
• Economic approach is to set priorities based
on costs and benefits of health services: to do
more of some things, we have to take
resources from elsewhere
• Economists should also consider practical and
ethical challenges that managers and doctors
face in making rational priority setting
decisions
Reference: Peacock, 2006

12. Estimating the Cost of HAIs (1)
1. Why measure the cost of an HAI?
2. What outcome should be used to
measure the cost of an HAI?
3. What is the best method for making
this measurement?
Reference: Graves et al., 2010

13. Estimating the Cost of HAIs (2)
• Why measure: “biggest bang for the buck”
argument
– “bang” = health benefits; “buck” = costs
–
ΔC/ΔE < λ
(cost-effectiveness approach)
• What outcome: bed-days
–
C = (bed-days lost x price of a bed-day)
+ cost of consumables + professional fees
– public policy economist vs. cost accountant
Reference: Graves et al., 2010

14. Estimating the Cost of HAIs (3)
• Bed-days saved by infection control can increase
productivity (e.g., treat more patients)
• As long as demand for >> supply of health
services, then bed-days will be valuable
– In decentralized systems (e.g., US, PH?), the
purchasers will be willing to pay a certain price to
access
– In centrally-managed systems owned by government
(e.g., UK), it can be a political issue
– Note: The Philippines is a hybrid of both systems
Reference: Graves et al., 2010

15. Estimating the Cost of HAIs (4)
Perspectives vary.
• Political: promises of improving health care
services  need for more hospital capacity
and shorter waiting lists; hence, need to save
bed-days
• Operational: bed-days saved  more
patients, hence more workload; will there be
adequate compensation for the higher stress
of staff?
Reference: Graves et al., 2010

16. Estimating the Cost of HAIs (5)
• What is the best method: use of a statistical
model to describe the relationship between a
cost outcome (e.g., length of stay) and
predictors of that outcome
Econometrics  modeling, statistical analysis, etc.
– Matched cohort studies have severe limitations
(e.g., biases in selection, timing issues, logistical
considerations, etc.) and tend to overestimate
costs
Reference: Graves et al., 2010

17. Easier said than done…

18. POLICY AND MANAGEMENT
IMPLICATIONS

19. Health Policy:
Scope, Scale, and Stakeholders
National and Local
Governments
Service Delivery
Networks
Private Sector
Dynamics
Point
of Care
International/Global
Health

20. “Pharmacology” of Health Policy
• DYNAMICS and the mechanism of action:
– Will an intervention reduce the risk?
• KINETICS and the response of the system:
– Will the intervention for the main concern
increase other risks? (i.e., adverse effects)
• THERAPEUTICS and delivery:
– Is it operationally possible to introduce the
intervention?
Reference: Gray, 2004 (p. 296), with modification

21. Purchasers vs. Providers
• In health services world-wide, there is a trend to
separate the function of purchasing healthcare
from that of providing healthcare
– Purchasers decide which health services to buy
– Providers deliver healthcare to individual patients
within the resources available
• Purchasers aim to maximize the value obtained
from the resources available
• Purchasers are not usually asked to reallocate
resources on the basis of specific diseases, but for
particular patient groups
Reference: Gray, 2004 (pp. 269; 272)

22. Healthcare Financing
• Health systems are not just concerned with
improving people’s health, but also with
protecting them against the financial cost of
illness (by reducing out-of-pocket expenses).
• The sources of financing usually dictates the
system of healthcare provision. Two main sources
are:
– Insurance (risk-pooling)  “pay as you go”; common
in low income countries
– Taxation (subsidies)
Reference: Gray, 2004 (p. 278)

23. The Policy Cycle
Agenda Setting
Evaluation
Implementation
Policy
Formulation
Adoption

24. Factors in Health Policy Change
Ideological
inspirations
Evidence
From experience
From research
OLD
POLICY
NEW
POLICY
Common sense
Change in
circumstances
NOTE: Policy makers operate on a
timescale that does not generally admit
of delays that research will take.
Reference: Gray, 2004 (Fig 7.8, p. 291; p. 292)

25. Agenda for Clinical Governance (1)
1. Are we doing the right things?
2. Are we doing things right?
3. Do the right people have the right
knowledge, skills and attitude?
4. What further evidence do we need?
Reference: Department of Health (UK), 2001 – The epic project

26. Agenda for Clinical Governance (2)
•
•
•
•
The right things
Guidelines = statements of good practice
Standard principles = a consistent approach
National/central guidelines have to be
adapted for local use
Local adaptations must follow a recognized
protocol (i.e., backed by evidence)
Reference: Department of Health (UK), 2001 – The epic project

27. Agenda for Clinical Governance (3)
Doing them right
• Clear guidelines allow for
monitoring/measurement
• Audit should focus on dissemination
strategies, management support, and
practitioner adherence
Reference: Department of Health (UK), 2001 – The epic project

28. Agenda for Clinical Governance (4)
The right people
• Guidelines can identify areas where staff
training and professional development are
required
• Practitioners must receive appropriate
training, supervision, and support to adhere
• Adherence is a complicated issue (individual
behavior + organizational factors like
resources available)
Reference: Department of Health (UK), 2001 – The epic project

29. Agenda for Clinical Governance (5)
•
•
•
•
Further evidence requirements
Adherence/behavior change
Staffing
Surveillance
Clinical technologies (e.g., needle safety
devices, indwelling urethral catheters, central
venous catheters, etc.)
Reference: Department of Health (UK), 2001 – The epic project

30. Examples of Strategies / Guidelines
• US: National Plan to Prevent Health CareAssociated Infections: Road Map to
Elimination
• UK: National Evidence-based Guidelines for
Preventing Healthcare-associated Infections in
NHS hospitals in England (epic project)
• PH: Standards in Infection Control for
Healthcare Facilities

31. Ensuring Performance
MxC
P=
B
Where:
P = performance
M = motivation
C = competence
B = barriers
Reference: Gray, 2004 (p. 327; 367)
Options to achieve change:
• Incentives (carrots)
• Disincentives (sticks)
 hit people with carrots

32. Quality Improvement through
Pay for Performance (P4P)?
Quality Improvement Demonstration Study (QIDS)
• A large policy experiment that followed the
impact of two interventions on physician
practices, health behaviors, and health status of
children 5 years and under in the Philippines
• Took place at 30 district hospitals in 11 provinces
of the Visayas; started in 2004, ended in 2008
• Cluster randomized controlled trial
Reference: Peabody et al., 2013

33. The P4P Intervention
Quality Improvement Demonstration Study (QIDS)
• For doctors randomized into the intervention P4P
scheme, those who met pre-determined quality
standards were eligible for bonus payments
• Doctors were told that they have been randomly
assigned to the P4P scheme, and that they could
earn a bonus based on their clinical practice
vignette (CPV) score
• Those who met the cut-off score were paid a
bonus of P100 per patient seen per quarter
(representing 5% of total salary, on average)
Reference: Peabody et al., 2013

34. Did P4P Work?
Quality Improvement Demonstration Study (QIDS)
 The number of children who were wasted
increased by 9 percentage points from baseline
for the control group, compared with children in
the P4P group where doctors received bonuses
where there was no change (P<0.001)
 Parents reported an improvement in General SelfReported Health (GSRH) of 7 percentage points in
P4P sites compared to control sites (P<0.001)
Reference: Peabody et al., 2013

35. P4P for Infection Control?
• Performance-based incentives are thought to be
one of the best ways to improve health,
particularly in the developing world where MDs
are not adequately incentivized to provide quality
care
• Measurement of outcomes can be done via CPVs
 Maybe a CPV on infection control practices can
be designed, then providers who meet a certain
quality score cut-off will get bonus payments?
Reference: Peabody et al., 2013

36. SOME CURIOUS QUESTIONS

37. (Dis)incentives via the Purchaser
• In the US, HAIs are not reimbursable via
insurance. Can this be done in the Philippines?
– Yes, it can be done. BUT…
– Who exactly is our dominant purchaser?
– How much influence does our dominant
purchaser have?
– Will the providers be affected by decisions of our
dominant purchaser?
– So, what can we do?

38. Sue someone so soon?
• In the Philippines, can a patient who gets a
healthcare-associated infection sue the
hospital?
– Because of fault, or negligence? (proximate cause)
– What kind of suit – criminal (reckless
imprudence), administrative (PRC license), civil
(damage$)?
– Who could be liable: the hospital, the doctor, the
nurses, the other paramedicals, or all of the
above?
– What evidence – res ipsa loquitur?
– Any case precedents?

39. Open Forum / Q&A
AlbertDomingo.com
facebook.com/aedomingo
twitter.com/AlbertDomingo