ISQUA16-2548WHAT WOULD IT TAKE FOR ACCREDITATION TO BE COST-EFFECTIVE? A THRESHOLD ANALYSIS CASE STUDY

Abstract

Objectives: Accreditation is designed to improve patient safety and quality of care through assessing whether hospitals have appropriate clinical governance systems and training programs in place. Despite widespread adoption, there is little evidence that accreditation programs are cost effective in achieving their stated aims. Hospital infection control standards are common across accreditation programs and hospital acquired infection rates are routinely promoted as a quality indicator of acute care. We hypothesised that hospitals with higher accreditation scores would have reduced infection rates through a co-ordinated governance approach to infection control. Our aim was to assess the change in hospital acquired infection rates needed to meet the costs of accreditation in Australian public hospitals. Methods: We used threshold analysis to estimate the minimum impact of the infection control standard in order for it to be considered cost-effective. We used published incremental costs of accreditation in Australian hospitals, and analysed hospital acquired Staphylococcus aureus bacteraemia (SAB) rates as an outcome indicator accreditation. We calculated the benefits of reducing SAB rates through reduced length of stay, [1] and Quality Adjusted Life Year (QALY) measures from the literature to capture the value a life lost from a SAB infection and patient inconvenience from non-fatal infections. Results: The evidence that accreditation is associated with infection rates is mixed. One study showed that smaller hospitals with higher accreditation scores had lower infection rates, but this effect was reversed in larger hospitals [2]. Our analysis illustrates the magnitude of SAB rate changes that are needed to match accreditation costs. The incremental costs of accreditation for public hospitals have been reported at 0.097% of annual recurring revenue, equivalent to AUD42.68 million in 2013-14 (1AUD = 0.72USD). This equates to AUD3.05 million per standard when apportioned across the 14 standards in the accreditation surveys conducted by the Australian Council on Health Care Standards during 2012-13. Accreditation benefits can be described by the number of infections averted. Based on an extended length of stay of 12.1 days and an average bed day cost of AUD2,337.5 in 2013-14, the extra cost per SAB infection is AUD28,283.00. The accreditation costs per standard are equivalent to reducing SAB rates by 107.8, or 6.7% of all SAB infections in 2013-14. Using a conservative estimate of AUD46,100.00 per QALY gained, the patient impact of 0.007 QALYs per non-fatal infection, reduces this figure to 6.6% of non-fatal infections, or 0.11 fatal infections per year. Accreditation standards cover a wide range of hospital activities. We estimate a bed day reduction of bed days by 0.097% would meet total accreditation costs, although a sensitivity analysis would be required to complement this analysis. Conclusion: The lack of clear outcomes and causal relationship between accreditation and patient safety and quality outcomes creates a challenge in determining whether accreditation is cost effective. However only a small reduction in bed days would be required for a positive return on the investment made in an accreditation program. The approach illustrated in this study demonstrates the complex nature of the analysis required to assess accreditation costs and benefits.