Prevention of Back Injuries in Health Care Organizations: Defining Cost and Benefit Variables

DEFINING COST AND BENEFIT VARIABLES”

Bilodeau, Henriette

École des sciences de la gestion / Département Organisation et ressources humaines / Université du Québec à Montréal / 315, rue Sainte-Catherine Est, 3ième étage, local 3490 / Montréal, (Québec) / Canada, H3C 4R2 / (514) 987-3000 poste 8390#/ bilodeau.henriette@uqam.ca

Berthelette, Diane

École des sciences de la gestion / Département Organisation et ressources humaines / Université du Québec à Montréal / 315, rue Sainte-Catherine Est, 3ième étage, local 3490 / Montréal, (Québec) / Canada, H3C 4R2 / (514)987-3000 poste 3955# / berthelette.diane@uqam.ca

Leduc, Nicole

Groupe de recherche interdisciplinaire en santé / Faculté de médecine / Université de Montréal / C.P. 6128, succursale Centre- Ville / Montréal, (Québec) / Canada, H3C 3J7 / (514) 343-6185 / nicole.leduc@umontreal.ca

Loignon, Christine

Groupe de recherche interdisciplinaire en santé / Faculté de médecine / Université de Montréal

Lagacé, Marie-Claude

École des sciences de la gestion / Département Organisation et ressources humaines / Université du Québec à Montréal

Durand, Marie-Josée

Université de Sherbrooke / Département des sciences de la santé communautaire/ 1111, rue Saint-Charles Ouest , bureau 101/ Longueuil (Québec) / Canada, J4K 5G4/ (450)674-5908 /marie- jose.durand@usherbrooke.ca

ABSTRACT                                                                                                            

ABSTRACT                                                                                                            

The objective of this article is to present the first part of a broader ergonomic training program evaluative research: The Safe Patients’ Transfer Program. Proceeding with the intended cost-benefit analysis, required identifying cost and benefit variables from the perspective of various stakeholders. A case study design was used for the exploratory study. In hospitals, members of the following stakeholder categories were interviewed: Human Resources or Administrative Services Managers, Occupational Health and Safety Intervention Managers, SPTP trainers and Health Care workers. Program designers and coordinators also participated in the interview process.

Keywords

cost-benefit variables, ergonomic program, stakeholders’ perspectives, social affairs sector.

INTRODUCTION

The objective of this project is to identify variables that will be used to approximate the costs and benefits of a program aimed at preventing back injuries, The Safe Patients’ Transfer Program (SPTP). This program is offered in hospital environments to health care providers who are employed in long-term residential and care facilities as well as in general and specialized hospital centers in the Canadian province of Québec. It was designed by the ASSTSAS, the Association for Health and Safety in the Workplace, social affairs sector (Association pour la santé et la sécurité du travail du secteur des affaires socials) a sector-based association as defined in the Loi sur la santé et la sécurité du travail (Occupational Health and Safety Law) adopted in 1979 by the Government of Québec. In accordance with this Act, sector-based associations are deemed to represent workers and employers of a given economic industrial sector and to provide information, training and research services on occupational injury prevention to institutions within that sector.

The training program assessed herein was implemented by the ASSTSAS in 1985. It focuses on basic health and safety ergonomic principles with regard to body mechanics and the task of transferring patients. Within their respective health care facility, health care providers, mainly nursing staff and care attendants, are trained by instructors who themselves undergo training by ASSTSAS master instructors. The program boasts two objectives: on the one hand, it aims to modify care providers’ behaviors when transferring patients by enabling them to analyze each situation and determine the risk of back injury and by having them adopt safe transferring practices. On the other hand, instructors are called upon to become agents of change within their respective institutions by contributing to the process of identifying occupational injury risk factors and to the implementation of appropriate primary prevention measures. The program’s ultimate objective is to reduce the incidence and severity of back injuries resulting from the transfer of patients by health care providers.

In Québec, as in all industrialized nations, costs associated with musculo-skeletal impairments are significant. According to the most recent data, such injuries have resulted in Income Replacement Indemnities (IRI) totaling CAD $95.9 million. Vertebrae impairments still represent the majority of back injuries (back 77%), followed by upper limbs (20.1%) and lower limbs (2.4%) (IRSST, 1999).

The most recent social affairs occupational injury statistics reveal that in 1996, 11,703 injuries were compensated by the Commission de la santé et de la sécurité du travail (CSST) (Workmen’s Compensation Board) and that such injuries resulted in 434,441 days of absence, an average of 37.1 days per injury. The most frequent injuries are back injuries, which account for 46.2% of all injuries, followed by upper limbs (26.7%) and lower limbs (11.9%). Residential and long-term care facilities,

as well as general and specialized hospital centers, report the highest number of injuries, i.e. 66% of those requiring compensation. The highest incident rate is found in long-term care facilities where it stands at 14.5 injuries for every 100 equivalent full time employees.

Since 1995, more than 1,000 health care workers have been trained as SPTP instructors by ASSTSAS master trainers. According to the agency’s estimates, the cost of training a new instructor for a health care facility stands at some CAD$2,390 while renewing an instructor’s accreditation costs CAD $624. Based on this information, we feel that the total training cost (initial cost plus accreditation renewal) for health care facility instructors in Québec has reached more than one and a half million Canadian dollars since 1995. Added to this initial cost is the cost of training provided by such instructors to caregivers within their own institutions. The ASSTSAS estimates that the unit cost for training health care attendants stands at CAD $485. However, the total number of people trained in health care facilities remains unknown.

The ASSTSAS estimates its program’s cost given that not all data on expenditure sources are available. Furthermore, it does not have access to information on the program’s global potential benefits, or on their monetary value, (such as a decrease in the number and severity of back injuries). Finally, the Association is unaware of the SPTP competitive benefits compared to alternative measures used by other organizations in their attempt to reduce back injuries caused by transferring patients. Such measures include equipment to lessen physical workloads, work reorganization to promote teamwork, adapting patients’ rooms to reduce the number of risk factors, and other training programs.

Few economic evaluations have compared the costs and benefits of such alternative measures. In their review of the literature, Jacobs and Fassbender (1998) state that only 57 of the 163 articles published between 1994 and 1996 are effectiveness analyses comparing at least two alternative measures. Supporting the process we have undertaken are the prevalence of back injuries among care attendants in health care institutions, as well as the lack of scientific knowledge with regard to the costs and benefits of various measures used to prevent such injuries.

We have documented cost-benefit variables from the perspective of the three following stakeholders – the Association of Health and Safety in the Workplace, social affairs sector (ASSTSAS), employers’ representatives (Hospital managers) and care attendants (nursing staff, and patient attendants). Having identified variables that characterize the program’s costs and benefits, we then sought out the available sources of financial data on such variables in order to assess validity and reliability and in the absence of such data, to identify those variables requiring the establishment of evaluation techniques.

The following briefly summarizes the scientific knowledge resulting from evaluative research on training programs that target the primary prevention of back injuries. We will then define efficiency analyses as research findings will be used to develop this very type of analysis. This remains an essential preliminary phase. Research methodologies will then be outlined, followed by our findings.

KNOWLEDGE SUMMARY

All material on each page should fit within a rectangle of 15 x 25.7 cm, centered on The SPTP is a primary back injury prevention program that focuses mainly on acquiring workplace analytical skills, and modifying motor and communication behaviors in dealings with patients and colleagues. The majority of studies published in the field of primary prevention of back injuries program evaluations

deal with the direct outcomes of such programs, i.e. knowledge acquisition by workers, adoption of safe behaviors when transferring loads and frequency or incidence rate of back injuries. Two groups of researchers have identified publications dealing with the evaluation of back injury prevention programs (Lahad et al., 1994; Karas and Conrad, 1996) for the period from 1966 to 1994. The first group agreed that only three of the studies of superior scientific value examined training programs, i.e. Walsh and Schwartz (1990), Daltroy (1993) and McCauley (1990). As for Karas and Conrad (1996) they identified 3 relevant studies dealing with training for the primary prevention of back injuries. These were Feldstein et al. (1993), Scopa (1993) and Wood, (1987) who had already been mentioned by Lahad et al. (1994). Most of these studies identified increased knowledge about body mechanics and safe behaviors. However, results also revealed that very little use is being made of the patient transfer principles that are being taught. Indeed, the only study dealing specifically with the SPTP (St-Vincent and Tellier, 1989) also stressed that principles of safe patient transfers taught during training sessions are rarely used. These studies focused mainly on knowledge acquisition and adoption of safe behaviors. These findings deal with intermediate outcomes while the ultimate goal of such programs is to decrease the incidence of back injuries. This being the case, none of the studies measured the program’s outcomes in terms of number and incidence of back injuries, nor did they demonstrate any significant difference between experimental groups and control groups. (Lynch and Freund (2000), Fanello et al. (2002), Gatty et al. (2003), Morken et al. (2002), Yassi et al. (2001) and Linton et al. (2001)). Moreover, none of these studies attempted to establish or assess the cost benefit ratio of such prevention programs.

ECONOMIC EVALUATION: EFFICIENCY ANALYSIS

Drummond et al. define economic evaluation as: “…the comparative analysis of alternative courses of action in terms of both their cost and consequences (1997: 9)”. An efficiency analysis, a type of economic assessment, compares the relationship between the resources used for, and the outcomes of, a given intervention. The main task is therefore to identify, measure and assess costs and benefits of applied interventions and to compare them. There are three types of efficiency analyses: 1) cost-effectiveness analysis; 2) cost-utility analysis and 3) cost-benefit analysis. Each type of efficiency analysis is defined mainly by how outcomes are defined and assessed. Each presents advantages and various application limits depending on the situation and on the type of intervention being evaluated. This issue is addressed more specifically below.

Cost-Effectiveness Analysis

This type of analysis compares the financial costs and the physical or natural outcomes of the intervention. Results are expressed through tangible indicators of intervention outcomes such as decreased pain or frequency of disease, etc. The advantage of this type of analysis is that it provides a comparison between very different interventions, the only condition being that intervention consequences or outcomes must be measured with the same measuring unit. However, this type of analysis only applies when interventions have one, clearly defined objective (for example – decreasing the incidence rate of an injury). This being said, such situations rarely occur. Furthermore, interventions usually have concurrent objectives, which significantly reduce the appropriateness of this approach in this situation. As a result, this type of analysis cannot be adopted here as the SPTP has a number of the intermediate concurrent objectives as mentioned above.

Cost-Utility Analysis

This form of analysis compares costs expressed in monetary units and estimated outcomes in terms of their utility as perceived by individual end users. Utility is a theoretical mean of measuring how valuable various goods and services are to

individuals. It consolidates an intervention’s various outcome measurement methods into one single subjective measure of the utility of or preferences for a given outcome. In the health care sector, the most frequently used measure is the “quality adjusted life year” (QUALY). A cost-utility analysis provides the opportunity to compare interventions that have very different “natural or physical” effects. Among the limits associated with this approach, Clyne and Edwards (2002) point out the subjective nature of the utility measure. They declare that individual’s preferences tend to change over time. Moreover, they mention disagreements on the means of evaluating quality of life as well as the fragile nature of findings given the weighting techniques used. Because of the nature of the SPTP and the potential intervention comparisons, this approach is less relevant here.

Cost-Benefit Analysis

A cost-benefit analysis is the type of effectiveness analysis that offers fewer restrictions in terms measured outcome selection. Like other types of analyses, it combines costs expressed in monetary units. However, the intervention outcomes are estimated in monetary values. This transformation provides a comparison of interventions with different outcomes and a direct cost-benefit comparison of interventions with very different objectives. On the other hand, the main limit of this approach is the fact that there is no standardized method to transform the outcomes of an intervention into monetary units. As a general rule, the methods used to implement such a transformation (human capital, willingness-to-pay) present methodological and ethical issues that are often difficult to resolve. More specifically, such difficulties stem from certain categories of intangible benefits such as decreasing pain or attributing value to human life. We have adopted a cost- benefit approach because of the flexibility it affords and given that, at the outset, we were unaware of the type of alternative interventions implemented in health care institutions. Once costs and benefits had been established from the selected perspectives, a method of attributing monetary values that best serve the variables representing intangible effects such as employee motivation, musculo-skeletal injury related pain and improvements in the workplace will be developed.

Analysis Perspective

An intervention can be evaluated using a diversity of analysis perspectives such as that of individuals, organizations, industrial sectors, government or society (collectives). Costs and benefits considered in the analysis will depend on the approach used. For example a company-sponsored intervention implies direct corporate expenditures and no direct cost to employees. On the other hand, employees may have to assume the costs or expenses (baby-sitter, traveling costs, etc.) associated with their participation in the intervention. Costs and benefits of a given intervention vary depending on the parties involved, each being faced with their own personal issues. As a result, an intervention may often benefit one party but be detrimental to others. That is why, prior to making any decision on the future of an intervention (should it be maintained, abolished or modified?) based on the results of an efficiency analysis, it is essential to know from what perspective researcher conducted the analysis. Within the framework of this project, three perspectives where taken into account, the ASSTSAS, employer representatives (hospital managers) whose employees have been exposed to the program, and the health-care personnel.

Identifying Cost-Benefit Variables

A number of studies identified cost-benefit variables associated with occupational injuries and interventions designed to prevent them. (Leigh, P. et al. 2001; Maetzel and Li, 2002; Loisel et al., 2002; Oxenburgh, 1997; Brody et al., 1990). Mossink et al. (2002) re-examined such variables in an inventory of the socio-economic costs of occupational accidents. This inventory brings to light that the main cost-benefit variables identified in the literature depend on the adopted analysis perspective (employer, employee, society). Consequently, from the employer’s perspective,

costs relating to preventive measures can be included in the following categories 1) investing in personal protective equipment; 2) modifying equipment and work environment set-up and consulting experts in the field; 3) modifying work procedures; 4) providing time-off for employees (meetings, training, etc.); 5) in- house promotional activities and 6) other expenditures. Cost variables associated with occupational accidents are: 1) absenteeism; 2) staff turnover due to poor working environment or early retirement; 3) non-medical rehabilitation; 4) administration (investigation, sickness, absence, injuries, etc.); 5) insurance premium penalties; 6) production losses and 7) other expenditures. For the employer, the benefits of prevention are: 1) decreased insurance premiums associated with a decrease in injuries; 2) improvement in employee morale; 3) production increase and 4) improvement in service quality. Workers’ perspective is basically examined in terms of occupational injuries. This signifies that cost variables address: 1) decreased health and well-being; 2) reduced income and 3) medical costs, while benefit variables are employability, employee health and well- being. The workers’ perspective is based on the benefits provided to them by preventive interventions, a fact that would appear to confirm the importance of this undertaking.

While conceptualizing various types of effectiveness analyses is relatively simple, delivery can be difficult. We have noted that this type of study can be conducted from various perspectives and that it is important to select a number of methodologies for the variables under review and for the ways of measuring costs and benefits. It was therefore essential that the main parameters adopted for this analysis be identified early on (comparative interventions, cost and benefit variables based on analysis perspective).

METHODOLOGY

This exploratory descriptive study uses a case study design. Cases are composed of a purposive sample of 5 out of the 260 hospitals that did implement the SPTP and the ASSTSAS. In hospitals, members of the following stakeholder categories were interviewed: human resources or administrative services managers, occupational health and safety intervention managers, SPTP trainers, and health care workers. Selected hospitals are all publicly funded and are representative of the various characteristics found throughout the hospital system with regard to mission (general, specialized, ultra specialized), size and type of care provided (acute and long term). Within the ASSTSAS, program’s designers and coordinators were interviewed. Semi-directed interviews were used to collect information on SPTP cost and benefit variables from each stakeholder category. On average, interviews lasted one hour. Each respondent was asked to identify the perceived costs and advantages of the SPTP according to his or her own perspective (ASSTSAS, hospital and worker).

Investigated cost variables relate to program design and implementation both by the ASSTSAS and by trained instructors when they provide in-hospital training and also relate to staff members affected by the program. Data was collected on resources used to dispense or to receive training, whether these originated from the ASSTSAS or from the hospital in which the program was offered (e.g. meeting room) or other sources (e. g. transportation costs if training held outside regular business hours). The benefits that were taken into account include SPTP outcomes that could translate into prevention of occupational injuries or savings in terms of resources.

The interview form is divided into two sections. The first is used to identify the overall SPTP cost-related variables such as direct costs of instructor training, institutional expenditures, and fees paid by individuals to be trained by SPTP instructors and cost of setting-up the program within the hospital. The second part

is used to seek out SPTP benefit-related variables such as “resources saved” by employers and employees with regard to musculo-skeletal injuries following the adoption of a given intervention; efficiency gains in work organization and task execution; changes in workers’ musculo-skeletal health; saved resources with regard to employee replacements or transfers to light task and other created values. At the end of the interview, the respondent was provided the opportunity to add any information he or she considered relevant.

FINDINGS                                                                                                            

Table 1 presents the provenance of those who participated in this study. A total of27 respondents were interviewed, including three master instructors who had participated in program design and implementation.

Table 1: Respondent Category per Type of Institution

Interview findings are presented on the basis of the three outlined perspectives (ASSTSAS, hospitals, workers) in table form and include costs and benefits as identified by respondents.

ASSTSAS Perspective

For this specific perspective, the data were collected among three master instructors interviewed at ASSTSAS headquarters. These individuals participated in the design of the SPTP program and are currently coordinating the SPTP program within the ASSTSAS.

Table 2: List of SPTP cost variables from ASSTSAS perspective

Travel expenses for master instructors Invoices Classes (location) Market price Teaching materials (computer, film,) Invoices

Participants’ registration(Mailings…)

Total wages for timespent,Invoices

Advertising Invoices

Certification cards (issuing, production and renewal)

Invoices, Total wages for time spent

Technical support staff Total wages for time spent

Up-dating program

Training master instructors and updating knowledge

Program revision

Revision of teaching materials Meetings (time)

Professional fees; total wages for time spent

Assessment SPTP quality control by ASSTSAS coordinators

Professional fees, Total wages for time spent

Other expenses

Time lost designing a non-completed video; abandoning a project for producing support documents

Professional fees, Total wages for time spent

Table 3: List of SPTP benefit variables from ASSTSAS perspective

The Hospital Perspective

Data presented on the basis of this perspective were collected among SPTP instructors, administrative services managers, Human Resources managers and occupational health and security program managers.

Table 4: List of SPTP cost variables from a hospital perspective

Table 5: List of SPTP benefit variables from a hospital perspective

Productivity Improved task planning

Improved staff skills Improved efficacy as workers skills increase

Work climate Improved partnership between union/ management

Improved relationship of trust among workers, union and employer Employee satisfaction

Increased employee involvement Prevention culture Setting up special events(occupational injury prevention week, conferences…)

No directmeasure

No directmeasure

Invoice, total wages of time spent

Worker’s Perspective

Data was collected on the basis of this perspective among SPTP instructors and workers.

Table 6: List of SPTP cost variables from workers’ perspective

Variable Description Example of monetary value

Up-date, follow-up Lunch time To be determined

Table 7: List of SPTP benefit variables from workers’ perspective

Work satisfaction

At the outset, this process revealed that cost and benefit variables vary significantly depending on the analysis perspective. Respondents identified a number of prevention program cost and benefit variables inventoried by Mossink et al. (2002). Secondly, the process confirmed that many of the advantages attributed to a prevention program like the SPTP are more than simply reducing the number of accidents or illness-related absenteeism. A large part of the benefits identified from both the hospital and the workers’ perspectives remain intangible and bear no direct cost measure. There is no current consensus as to the means of applying a monetary value to this type of benefit (Mossink et al., 2002; Maetzel et Li, 2002). Initially, variables must be validated among a broader group in order to retain the most relevant and to determine how long it would take for them to become apparent (occurrence of such benefits in the short, mid or long terms). Concomitantly, an outcome analysis estimate must be designed to measure the retained variables as a tangible unit of measure, as well as a price measurement for such variables, based on a “willingness-to-pay” approach. These stages of the analysis will be conducted in collaboration with representatives of the main stakeholders involved (ASSTSAS, hospitals, workers’ representatives) to provide them the opportunity to understand methodological decisions and their impact on findings and results’ interpretation.

CONCLUSION

Attempting to obtain an economic evaluation of an SPTP-like intervention is a complex undertaking that requires making series of choices during the design and implementation stages of the study. The perspective used within the framework of such an analysis is one choice that has to be made and it will provide an assessment guide in establishing the cost and benefit variables that should be considered. In-depth knowledge of such variables, based on the various stakeholders’ perspectives, is the first step to establishing an economic evaluation of the SPTP that is both valid and credible for the potential users of applicable findings.

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