Financial incentives help control MRSA infections in NHS hospitals

Improved levels of risk management standards in NHS hospitals would reduce MRSA infections by between 11% and 20%, according to new research by Professor Neil Rickman of the University of Surrey and colleagues.

Their study also finds that:

• Larger hospitals are more at risk of MRSA infections and that hospitals of a given size are more at risk of MRSA the closer they are to full capacity.
• The likelihood of infections is highest for hospitals with more bed days devoted to ‘riskier’ treatments, surgery and gynaecology in particular.
• If financial incentives can play an important role in the control of MRSA infections, they may also help to control other hospital infections (such as C-difficile) and, in general, to encourage high quality hospital care.

The incidence of MRSA infections in NHS hospitals has increased markedly over the last 15 years: deaths from MRSA alone rose from 51 in 1993 to 955 in 2003 while deaths involving MRSA have increased by 39% (to 1,629) since 2004/05.

Such statistics have resulted in the introduction of a mandatory surveillance system in England in 2001, vapour treatments in some hospitals, the specific employment of a hygiene company by the NHS and several ward closures.

These costs, along with well-documented compensation payouts to a number of MRSA sufferers, additional treatment costs of approximately £1bn per year and reputation costs to the NHS make the control of MRSA a particularly important objective for the NHS. Despite this, reports from the Department of Health in 2006 suggest that the NHS is set to miss targets set for MRSA outbreaks by April 2008.

The study by Professor Rickman and his colleagues asks whether financial incentives can play a role in controlling MRSA infection rates (and, indeed, in encouraging high quality care more generally).

All NHS hospitals carry insurance to cover them against claims for illness and injuries caused by medical treatment. As in many familiar insurance settings, a common problem caused by such insurance is that the cover it provides reduces the need to try to minimise exposure to claims, because the insurer (not the hospital) will be paying the claim.

In the NHS, the insurer (the NHS Litigation Authority) seeks to overcome this problem by specifying risk management standards. The standards are increasingly demanding and, if they can demonstrate compliance with them, hospitals are granted increasing discounts on the premiums they pay the NHSLA for their cover.

If the financial incentives implicit in these arrangements are effective, the researchers hypothesise that hospitals attaining higher risk management levels should face lower MRSA infection rates (all else equal).

The researchers have assembled a unique panel data set for each NHS hospital to examine this hypothesis. This contains MRSA infection rates for 2001-05, hospital size (measured by the total number of bed days), bed utilisation rates (i.e. bed days relative to bed capacity), casemix variables (i.e. the proportion of bed days allocated to the main treatment specialities) and the risk management levels achieved by the hospitals over the 2001-05 period.

The results show that larger hospitals appear to be more at risk of MRSA infections and that hospitals of a given size are more at risk of MRSA the closer they are to full capacity. (This is consistent with evidence of a link between hospital capacity pressures and infection rates reported in Northern Ireland.)

Furthermore, the likelihood of infections is highest for hospitals with more bed days devoted to ‘riskier’ treatments (surgery and gynaecology in particular).

The main finding is that attaining higher levels of risk management standard reduce MRSA infections by between 11% and 20%.

These results suggest that financial incentives may be able to play an important role in the control of MRSA infections. The researchers also conjecture that they may also help to control other hospital infections (such as C-difficile) and, in general, to encourage high quality hospital care.

These results are important in the context of MRSA control but, also, at a time when reforms to the way that ‘medical injuries’ are compensated are being debated and receiving Royal Assent.