Policy responses and statements

Name of organisation:

NHS Quality Improvement Scotland

Name of policy document:

Clinical and cost effectiveness of screening for MRSA

Deadline for response:

24 July 2006

Background: NHS QIS has published a consultation HTA report on the clinical and cost effectiveness of screening for MRSA. This report considers evidence indicating the possible clinical and cost effectiveness benefits associated with MRSA screening programmes, and assesses the potential impact of the findings in terms of patient management procedures, the patients themselves and NHSScotland.

NHS QIS requested views on the report.

COMMENTS ON
NHS QUALITY IMPROVEMENT SCOTLAND CLINICAL AND COST EFFECTIVENESS OF SCREENING FOR MRSA

The Royal College of Physicians of Edinburgh is pleased to respond to NHS Quality Improvement Scotland on its consultation on the Clinical and cost effectiveness of screening for MRSA.  

The College welcomes this consultation document, clearly the result of much painstaking effort and running to over 200 pages when one includes references and appendices.  Our comments are as follows:

• The document is clear and readable.

• The scale and cost of the proposed intervention is high, perhaps £12 million per year for a region like Lothian, £50 million for Scotland.

• There is doubtful evidence base for some of the proposals due to the inadequacy of recent literature in terms of quantity and quality.

• Not all would agree that screening all patients on arrival to hospital is realistic or necessary.  Screening of all such patients pragmatically is not achievable with current resources and using risk assessment to target at risk admissions would involve screening less than 20% of admissions and misses only 10-15% of carriers.

• Much is made of isolation of MRSA positive patients in single room accommodation.  Capacity for up to 3 beds in a 25 bedded ward is just not there at present, and the report might have considered the alternative use of cohort nursing in isolation wards instead.

• Isolation per se is not 100% effective.

• Some assumptions such as the efficacy of Mupirocin eradication are doubtful and do not consider the risk of Mupirocin resistance developing. 

• There are concerns about the estimated costs in this document, for instance that the laboratory costs for re-agents, PCR tests, skill mix costs and general labour costs are too high.

• Also the projected number of increased nursing staff may be exaggerated.

• The use of alternative strategies might be emphasised such as improved care of intravascular devices, improved management of antimicrobial agent use in hospitals and improved staff/patient ratios leading to better general hand hygiene compliance.

• It is possible that the document grossly over estimates the benefit of the proposed intervention but on the other hand the disbenefit of not dealing with the threat of MRSA should be stressed.

• For instance, MRSA infection levels will probably increase rather than stay as they are if there is no control strategy: they may even double and there is certain to be more antibiotic resistance.

• It should be stressed that after 5 years of such a screening programme, benefits will continue to accrue and costs should fall. 

• Some assumptions made in the report are probably erroneous e.g. that the MRSA rate on admission is as high as 7%, whereas most would estimate it as considerably less, say 2-3%.

• It is the use of such assumptions, doubtful estimates of cost and predictions based on lack of evidence which lead to concerns that these interventions driven by major media and political interest might distort perception of cost benefit attached to MRSA control strategies and lead to inappropriate targeting of healthcare expenditure.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324    ext 608
Fax: 0131 220 3939

[18 July 2006]