Economic evaluations of maintaining patient safety systems in teaching hospitals
Introduction
In spite of momentum gained by designing and requiring patient safety goals, such as from Committee on Quality Health Care in America [1] and from The Joint Commission [2], discussions of cost, imperative to assessing the feasibility and logistics of these goals, are still lacking. In response to the report by the Institute of Medicine (IOM) on medical errors in hospitals in the United States [3], stakeholders in healthcare have recommended actions to reduce the occurrence of preventable medical errors [4], the public has expressed support for a range of programs aimed at reducing medical errors [5], regulation authorities have exerted new efforts to reduce the incidence of medical errors [6], [7], [8], [9], [10], and researchers have accelerated patient safety researches and publications [11]. This phenomenon is similar to the state of patient safety systems in Japan. Although the importance of research that estimates costs of patient safety systems has been recognized in recent years [12], [13], few estimates have been conducted [14].
Studies that estimate the costs of implementing resources for patient safety in hospitals should include hospital-wide activities, because the most important strategy for improving patient safety is to develop systems that will reduce the probability of error and improve the probability of safety [1], [3], [15]. Whereas the necessity of a system approach has been emphasized, the cost issue has received scant attention. According to our preliminary cost study focused on hospital-wide activities for patient safety and infection control in seven teaching hospitals [16], an increase of an average of US$ 9.68 per patient-day was required to implement patient safety programs between 1999 and 2004. Since a system approach requires participation in patient safety programs by all healthcare staff with a high opportunity cost, healthcare organizations must expend considerable resources for a system approach of patient safety.
In addition, little to no attention has been paid to the issue of patient safety from the perspective of national healthcare delivery systems on a macroscale. In general, patients have few chances to select a hospital themselves. Even if free access to healthcare institutions is assured, such as in Japan, it is common for family doctors to judge institutions based on the patient's medical necessity, emergency, or relationship among institutions. Due to the difficulty of measuring safety [17], it is nearly impossible to select safer hospitals even when patients can choose institutions on their own. This leads hospital administrators to find little incentive to implement patient safety measures. Moreover, most of costs associated with adverse events in hospital fall on injured patients, their family and their health insures [10]. Therefore, policy-makers are required to develop safer healthcare delivery systems; wherever patients visit, they will receive safe medical care because all hospitals will have effective patient safety programs.
Considering these points, important economic issues arise. If all hospitals were to implement measures typical for patient safety among teaching hospitals, the degree of financial impact on the government would be essential information for policy-makers. While it remains difficult to evaluate the impact of patient safety programs [17], if all hospitals were to improve upon previously insufficient quantities of measures compared to current investment in safety, cumulative financial resources will be required at a national level. Hence, from the viewpoint of health policy-makers who need to assure a safe environment for the public, quantifying the necessary costs for widespread adoption is essential. Past estimates of the costs associated with activities for patient safety have had serious limitations; they either have not been hospital-wide or have mainly focused on material intervention [14].
To estimate the costs associated with hospital-wide systems for hospital-level patient safety measures (including infection control), we conducted a national questionnaire survey. We placed particular focus on three aims. First, we assessed the status of hospital patient safety systems in Japan's teaching hospitals. Second, according to the status of the systems, we estimated unit cost (e.g. per 100 bed-months, per inpatient-day, and ratio of cost to revenue) to maintain patient safety systems. Finally, based on the cost calculations, we estimated additional costs for providing patient safety resources at the average level for all the 1039 teaching hospitals in Japan.
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Data and sampling
Between December 2006 and May 2007, we conducted a national questionnaire survey. We sent questionnaire surveys to patient safety managers and infection control practitioners of all 1039 teaching hospitals in Japan. We requested that information regarding activity status of patient safety and infection control be provided by the patient safety managers and the infection control practitioners, respectively. To ensure participant anonymity, we also requested respondents to use the enclosed
Results
Of the 1039 questionnaires sent, we received 418 replies (response rate of 40.2%). Table 2 shows the distribution of bed-size categories and hospital ownership type, which is similar to that of hospitals nationally. We chose these variables for comparison because they are considered to be factors associated with volume of prevention activities for patient safety. As such, they provide an indication of similarity between respondent hospitals and all the 1039 teaching hospitals nationally.
Discussion
To our knowledge, this is the first nation-wide study to show the costs to maintain patient safety systems. The mean total cost of hospital-wide activities for patient safety including infection control was US$ 8.52 per inpatient-day. Based on our cost estimates and hospital bed-size data across all the 1039 teaching hospitals in Japan, we estimated that US$ 259.7 million per year is needed to make hospitals where spending on patient safety systems is currently below average attain the mean
Conclusion
Our results clearly show that hospital-wide activities for patient safety and infection control pose significant costs to hospitals and national healthcare systems. Economic evaluations may provide policy-makers with financial information for designing and improving patient safety systems, as well as for discussing strategies to assure sustainability of health care delivery systems.
Acknowledgments
The authors thank all the hospitals that participated in this research. The work described in this article was funded in part by the Health Sciences Research Grants for the Research on Policy Planning and Evaluation from the Ministry of Health, Labor and Welfare of Japan and the Grant-in-aid for Scientific Research A from the Ministry of Education, Culture, Sports, Science and Technology of Japan.
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