WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART III. PROCESS AND OUTCOME MEASUREMENT
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 alcoholbased
hand hygiene products in health care 1025 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 singlecomponent
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
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