In this study, we found that the prevalence of HAIs in the teaching hospital was low (3.31%). It was calculated by episodes of patients with HAIs accounting for episodes of total of patients admitted to the teaching hospital. It was much lower than that in developing countries reported by Allegranzi team in 2010 (15.5%) (3) in a systematic review and meta-analysis. It was even much lower than that in developed countries reported by WHO in 2011 (7.6 per 100 patients) (20). Compared with the prevalence of HAIs on point prevalence survey days of five public tertiary hospitals gotten in our team’s previous research in Hubei Province, China (2013-2015: 2.69%) (6), it is slightly higher. It is mainly because of the different methods to conduct the HAIs and AMR prevalence survey. In this teaching hospital, there is a department named Infection Control Centre (ICC). However, it is not a routine job for the department to carry out inspection of HAIs and AMR. This was the first time to undertake such a survey by cooperating with the health professionals of the teaching hospital. Based on the experience on our previous research in China, a new survey table was designed but the identification of HAIs and AMR was defined by European Centre for Disease Control and Prevention (ECDC). Therefore, the number of patients diagnosed as HAIs and AMR may be lower than the actual number thereby a low prevalence. It may be also because of the limited health resources in the teaching hospital. The main investigators were nurses and staff from the microbiology lab in this study. It means a lack of support was available from clinical doctors. This could result in a low number of patients with HAIs and AMR. Because when a patient should be diagnosed as HAIs, the patient was assigned to the Non-HAIs group in our practice.
Usually, HAIs and AMR are related to a weak healthcare system. Poor infection control is the key driver of HAIs. However, there is no establishment of HAIs and AMR surveillance systems in Nepal, which could help the hospitals to monitor, alert and analyse HAIs and AMR cases according to the evidence from the developed countries, like the United Sates (21), European Countries (22-24) and the United Kingdom (25-27). Health professionals might not be willing to report HAIs without incentives. Such low reporting might lead to even more serious and broader infections, deteriorate the infection control, and make the situations complex. Given these factors, hospital management rules might likely restrain active reporting of HAIs.
This study showed that the extra total medical expenditure, medicines expenditure, out-of-pocket expenditure and length of hospitalization caused by HAIs were 17,224.93 Rupees, 11,947.49 Rupees, 15,776.57 Rupees and 7 days. The conclusion that HAIs can increase the direct economic burden from the patient perspective is consistent with other international studies. With a foreign currency exchange by using the rate (109.70) in 25th August 2019 published by Nepal Bank Limited, the respective extra total medical expenditure, medicines expenditure, and out-of-pocket expenditure caused by HAIs were US$ 157.02, US$ 108.91 and US$ 143.82. Compared with the results calculated in Hubei province, China (the respective values were 6,173.02 US$, 2,257.98 US$ and 1,958.25 US$), the direct economic burden caused by HAIs was much lower. It cannot be said that the issues of HAIs should not be set priority when it comes to talk about the gross domestic product (GDP) and health expenditure in Nepal. By the end of 2018, Nepal's GDP was US$ 28.81 billion, ranking 107th in the world and its gross domestic product per capita was US$ 812.20 (28). Nepal's total per capita health expenditure in 2014 was US$ 54, and health expenditure accounted for 5.8% of GDP (29). HAIs indeed have increased the financial burden for the patients and their family.
This study also found that the excess total medical expenditure, medicines expenditure, out-of-pocket expenditure and length of hospitalization attributable to HAIs and AMR were 39,879.63 Rupees, 21,173.63 Rupees, 38,770.87 Rupees and 9 days, respectively. Though the direct economic burden attributable to AMR cannot be calculated by comparing the differences between HAIs Group vs. Non-HAIs Group and HAIs-AMR Group vs. Non-HAIs Group, it does indirectly indicate AMR has further increased the direct economic burden for the patients. This is because of irrational use of antibiotics. And the main reason why irrational use of antibiotics existed in this hospital is that clinical doctors lack the awareness of regulation of AMR when giving prescriptions to patients. It is also because patients’ access to buying antibiotics is not limited to hospitals and pharmacies, which further has aggravated the situation, though the government of Nepal has promulgated several policies to regulate antibiotics use since 2014 (30). Therefore, this calls for training for hospital staff and the public to increase their awareness of AMR. In hospitals, clinical staff’s performances should be related to their prescription behaviour.
This study also showed that the percentage of out-of-pocket expenditure accounting for total medical expenditure of HAIs Group was 94.24% while it was 96.75% of HAIs-AMR Group. It means patients have a high economic pressure to pay the medical expenditure. In the teaching hospital, only the staff and their family can get free healthcare due to welfare provided by the hospital. Even if some patients can get some reduction for the expenditure because of charity, the rate is low. The lack of access to health insurance in Nepal is the main reason to result in high financial burden for the patients. Actually, in 2013, Nepal published the National Health Insurance Policy. However, this policy was not carried out properly because of financing (31). This means Nepal needs to take more powerful actions to forward accomplish a universal healthcare insurance to reduce the disease burden for patients.
All above-mentioned problems are associated with an uncompleted hospital information system in the teaching hospital of Nepal. In this teaching hospital, Midas is mainly adopted as the hospital information system. The main function of Midas includes financial system and details of treatment and general information of patients. The main weakness of Midas is that it is not able to synchronize the information among the sub systems though the information from different sub systems can be shared. Specifically, the practice of an electronic medical record has been not achieved. Once there was difference of the information gotten from Midas and the paper medical records, the information of the medical records was more reliable. Another problem was about the financial system. Actually, it was not direct to get the total medical expenditure from Midas. The list of all kinds of expenditure was split into two sub systems. Without synchronization, the total medical expenditure was needed to be calculated again, causing inconvenience for the researchers.
Strengths and Limitations
Compared with the manual matching, this study used a more reasonable approach (PSM) to select the balanced case and control groups to estimate the economic burden attributable to HAIs and AMR. And this is the first time to conduct such a research of HAIs and AMR in this hospital of Nepal by international collaboration. However, there are still some limitations. First, the study period was short, thereby not getting an enough number of patients to estimate the direct economic burden only attributable to AMR. It is better to continue such study in several years to get a more robust result. Second, this study focused on a single-centre hospital. It will be better to extend the research to several hospitals in Nepal to estimate the direct economic burden caused by HAIs and AMR at a national level.