A significant share of health spending is at best ineffective and at worst, wasteful. One-fifth of health spending could be channelled towards better use.’ Organization for Economic Cooperation and Development (OECD), 2018.
Health Economics is not about money, it concerns the most effective and efficient allocation of scarce resources to meet a specified goal. Our goal in healthcare is the cure or mitigation of disease, but we cannot afford to fix everything so our goal as clinicians and as administrators is also to obtain the maximum cost-benefit from the treatments and strategies we employ for patient care. In this we would also be following Hippocrates’s dictum, primum non nocere, ‘first, do no harm’.
Patient harm is estimated to be the 14th leading cause of global disease burden. This is comparable to the impact of diseases such as tuberculosis, while OECD evidence suggests that 15 per cent of hospital expenditure treats safety failures. The annual cost of common adverse events in England was calculated to be worth the equivalent of the yearly salary of 3,500 hospital nurses.
Patient harm also impacts the broader economy through partial or total incapacitation of workers and productivity losses. This is a difficult figure to calculate but we can be sure that it is significant, and some work has been done on the human capital and an individual’s contribution to Gross Domestic Product (GDP) lost through medical error. A human life is priceless, but in terms of economic contribution to GDP an American study found that whilst US$19.5 billion was the direct cost of treating medical error, a further US$20 billion was lost in productivity, and in long-term disability costs.
A strong economic case at a national level can, therefore, be made for investment in patient safety, as unintended patient harm exerts a burden on society and investing in the prevention of harm can create long term value. ‘Value’ is defined here in classical economic terms, as the net impact or effect in reducing patient harm per dollar invested, expressed mathematically as: Value = Patient Outcome / Cost.
Well-constructed studies from as long ago as 1998 identified medication error (50 per cent) as the most common type of unintended harm. The word unintended is important in this context and serves to distinguish between adverse events and complications. No healthcare intervention is completely devoid of risk. Another key concept is preventability, a medication error is not easy to prevent, but investments in smart pumps, Dose Error Reduction Systems (DERS), automated dispensing cabinets, and barcode medication administration systems have all been shown to make a difference to reduce error rates.
Below we take a very simple example of how health economics can be applied to intravenous infusions given by gravity and via smart pumps with DERS. Whilst we recognise that much of the Gulf Region operates at extremely high levels of integration, well beyond a simple DERS, this is a useful exercise as around 80 per cent of all patients admitted to hospital will have an IV infusion of some sort during their stay. Furthermore, WHO data indicates that two-thirds of all adverse events occur in low-to-middle-income countries, where highly integrated solutions may not attainable.
In Health Economics Cost-Effectiveness Analysis (CEA) we commonly use a comparator to rate the introduced technology against. In this case we have gravity delivery of IV infusions as the comparator to a smart pump with DERS, (we might call this the ‘do-nothing’ option, as it employs no technology in terms of rate/dose control, warning for empty or near empty infusions or pressure limiting / vein protection alarms).
Such comparisons take place through head-to-head studies, randomised controlled trials, or literature reviews. Gravity infusions and smart pumps are such long-established technologies that we can turn to the literature to compare their efficacy and efficiency; efficacy being how well a technology performs under ‘ideal conditions’, and efficiency being how well it performs in the ‘real world’.
A summary of the documented evidence for both technologies in terms of accuracy from the literature is given below:
For the appraisal of the value impact of gravity versus DERS smart pumps, we need to know how many times the procedure is undertaken. An average Adult Day Medicine Unit (DMU) would perform about 150,000 gravity infusions per annum. We cost the resources used by both techniques, and apply costs to some of the complications, if the evidence exists. We have followed the conventions of Health Economics by applying Monetary Units (MU) to all costs in ratios that are common to the healthcare market in our region. The smart pump cost reflects staff training time in new technology, initial capital investment, disposables costs, etc. Classically the capital investment for medical technology should be discounted over time as the initial, one time, the investment gives benefits over its lifecycle but in our model, we have included all costs in a disposables cost (5.5 MU) to make comparison simpler.
Above, we have taken very basic performance figures for the smart pump and DERS, ignored fixed costs such as cannula and dressing replacements, and chosen the very lowest costs for serious IV medication error and extravasation injury from the available literature.
An OECD Cost-Effective Incremental Factor of 5:1 is in-line with expectations of such programmes in terms of investment made and return. Furthermore, extravasation injuries have been estimated to cost up to £45,500 (56,000 MU) per incident in the UK NHS, and medication errors in Europe have been estimated at €6,700 per incident. (7200 MU). Using these numbers (35X56,000) + (840 X7200) would make the Cost-Effective Incremental Factor of the programme 12:1. The OECD has saluted programmes to reduce central line infections with cost-effective incremental factors of 3:1!
Medication error causes suffering, and for that reason alone we cannot afford to ignore it but given that active medication safety initiatives and technology bring cost-benefits, there are also compelling hard-headed financial reasons for embracing it.