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Doing the easy things in health care reform

Health care reform is never easy, in Australia or the United States, but too often politicians and bureaucrats are so concerned with big issues that require substantial resources, time and political maneuvering to implement that they allow small issues that could really make a difference to go unaddressed.

15 Mar 2010






 By Dr Lesley Russell

Health care reform is never easy, in Australia orthe United States, but too often politicians and bureaucrats are so concernedwith big issues that require substantial resources, time and politicalmaneuvering to implement that they allow small issues that could really make adifference to go unaddressed. A case in point is hospital-acquired infections(HAIs) which are shockingly costly in terms of lives and health care dollarsand yet so easily preventable.

A paper published this month in Archives ofInternal Medicineshows that sepsis and pneumonia caused in the US by HAIs cost the Australian equivalent of about $7.5 billion to treat and killed 48,000 patients in2006.  The total toll and cost of HAIsis actually much higher; the US Centers for Disease Control and Preventionestimates that HAIs are associated with 99,000 deaths every year.

Suchfindings immediately lead us to wonder about the Australian situation. Afterall, there is no evidence to show that Australian doctors are better at washingtheir hands before seeing each patient or wearing a sterile gown, mask andgloves before placing a central line than their American counterparts. Theseare both time-tested ways to prevent infections, but compliance with thesimple, cheap and obvious is far from 100%.

Thisis clearly highlighted by an intervention study done in NSW in 2006, whichaimed to improve the hand hygiene compliance rate of hospital staff. Theintervention appeared to be successful, raising compliance rates from 47% to61% over a year, but much of this improvement was a result of the better practicesof nursing staff; compliance among medical staff soon reverted topre-intervention rates.

We are in the dark about how many Australianpatients get HAIs each year, how many die and what the additional costs are.The first and last national survey of the prevalence of hospital- andcommunity-acquired infections in Australian hospitals was carried out in July1984. The over-all adjusted prevalence of hospital-acquired infections then was6.3%. 

The Productivity Commission recently quoted anestimate that Australia has 180,000 HAIs annually. Frankly, on the basis ofsome 7.5 million public and private hospital admissions a year, that looks likea pretty low estimate. The cost impost of preventable infections on strainedhospital budgets can only be guessed at. 

One Australian study,conducted in 2001, reported that an infection after coronary artery bypassgraft surgery added an average $12,419 to the cost of the hospital stay. If itwas a deep sternal wound infection, then the extra cost was $31,597.

Surveillance programs, and public reporting of theresults, have been shown to reduce hospital-acquired infections significantlyin the US and Europe. So why is Australia so laggardly in this regard? 

Currently,there is no systematic Australia-wide approach to the measurement of patientharm caused by or associated with HAIs. That doesn't mean that there isn'tconsiderable discussion, report writing and activity, but this work is done bydifferent jurisdictions and specialist groups. I hope that foreshadowed developments suchas performance reporting under the National Healthcare Agreements will move Australia closer to a robust nationally-consistent datacollection on HAIs.

TheAustralian Commission on Safety and Quality in Health Care (ACSQHC), which wasset up to focus on areas of the health system that could benefit from urgentnational consideration and action, recognises that a coordinated approach tothe prevention and control of HAIs is essential to improving patient safety.

ThoughHAIs are also an important indicator of quality, they must be compiled,assessed and publicly reported carefully to provide an accurate picture of thesituation and progress in addressing it. For example, it is important todistinguish between deaths caused by HAIs and deaths associated with theseinfections. And with many patients leaving the hospital quickly, often stillhaving therapy and treatment involving cannulas and catheters in out-patientsettings, it is important to include the infection rates for dischargedpatients as well as those of hospitalised patients.

Furthermore,approximately 45% of hospital services are now provided in the private sectorand there is a significant crossover of the patient population. Therefore, anynational surveillance system will be incomplete without private sector data.

Finally,it is increasingly the case that many HAIs, including those that are multi-drugresistant, are brought into the hospital from the community, either by thepatients, their carers or their visitors. For many procedures, it would makesense to test patients for infections before surgery, so that appropriateprophylactic measures can be implemented.

Checklisttype initiatives such as those driven by Harvard paediatrician Donald Berwick,anaesthesiologist Peter Provonost at Johns Hopkins Hospital and Atul Gawande, asurgeon at Harvard, have shown how quickly - and cheaply - dramatic progresscan be made in reducing HAIs, saving lives and money. It's time for anation-wide Australian commitment to a comprehensive approach to reduce therisk posed by these deadly infections.

Dr Lesley Russell is the Menzies Foundation Fellow at theMenzies Centre for Health Policy, The University of Sydney/Australian NationalUniversity, and a Research Associate at the US Studies Centre at The Universityof Sydney.  She is currently a VisitingFellow at the Center for American Progress in Washington, DC.

Published: 15 Mar 2010