How externalities impact an evaluation of strategies to prevent antimicrobial resistance in health care organizations

Background

The rates of antimicrobial-resistant organisms (ARO) continue to increase for both hospitalized and community patients. Few resources have been allocated to reduce the spread of resistance on global, national and local levels, in part because the broader economic impact of antimicrobial resistance (i.e. the externality) is not fully considered when determining how much to invest to prevent AROs, including strategies to contain antimicrobial resistance, such as antimicrobial stewardship programs. To determine how best to measure and incorporate the impact of externalities associated with the antimicrobial resistance when making resource allocation decisions aimed to reduce antimicrobial resistance within healthcare facilities, we reviewed the literature to identify publications which 1) described the externalities of antimicrobial resistance, 2) described approaches to quantifying the externalities associated with antimicrobial resistance or 3) described macro-level policy options to consider the impact of externalities. Medline was reviewed to identify published studies up to September 2016.

Main body

An externality is a cost or a benefit associated with one person’s activity that impacts others who did not choose to incur that cost or benefit. We did not identify a well-accepted method of accurately quantifying the externality associated with antimicrobial resistance. We did identify three main methods that have gained popularity to try to take into account the externalities of antimicrobial resistance, including regulation, charges or taxes on the use of antimicrobials, and the right to trade permits or licenses for antimicrobial use. To our knowledge, regulating use of antimicrobials is the only strategy currently being used by health care systems to reduce antimicrobial use, and thereby reduce AROs. To justify expenditures on programs that reduce AROs (i.e. to formally incorporate the impact of the negative externality of antimicrobial resistance associated with antimicrobial use), we propose an alternative approach that quantifies the externalities of antimicrobial use, combining the attributable cost of AROs with time-series analyses showing the relationship between antimicrobial utilization and incidence of AROs.

Conclusion

Based on the findings of this review, we propose a methodology that healthcare organizations can use to incorporate the impact of negative externalities when making resource allocation decisions on strategies to reduce AROs.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-017-0211-2) contains supplementary material, which is available to authorized users.

Royal Order modifying the Royal Order of 8 October 1981 on access to the territory, residency, establishment, and removal of foreigners, 28 January 1988

This Order sets forth procedural and administrative rules with respect to the right of entry and residence of foreigners who present themselves at the border without the required documents claiming to be refugees. It also contains rules on ordering persons to leave Belgium, urgent requests for re-examination of decisions adverse to foreigners, and legal recourse after an adverse decision. Its major substantive provisions are as follows: 1) persons presenting themselves at the Belgian border without the required documents and claiming to be refugees are authorized to enter and reside in Belgium until a decision has been made on their request for refugee status if they are not refused entry; 2) such persons who are not admitted into Belgium are to be turned back to the country from which they came by border authorities; and 3) urgent requests to re-examine decisions and court appeals operate to suspend the turning back of foreigners and orders to leave Belgium made against those already admitted. The Order is issued in light of the changes made in immigration law by the Act of 14 July 1987 (see Annual Review of Population Law Vol. 14, 1987, Section 810).

Act No. 8/1988 on infractions and sanctions in the social order, 7 April 1988

This Act sets forth infractions and sanctions with respect to labor and social security. Among other things, it classifies the following as very serious offenses: 1) unilateral decisions of employers involving discrimination, either favorable or adverse, in the matter of compensation, hours, training, promotion, and other labor conditions with respect to sex and kinship with other workers; and 2) establishment of conditions through advertising, offers of work, or any other means that constitute discrimination, either favorable or adverse, with respect to access to employment for reasons of sex or kinship with other workers. The following persons will also be considered to have committed very serious infractions: 1) employers who use foreign workers without having first obtained the proper work permit or its renewal; they will incur an infraction for each foreign worker so employed; 2) foreigners who exercise in Spain any lucrative, labor, or professional activity for themselves without having obtained the proper permit or renewed it; and 3) real or legal persons who promote, facilitate, or protect the work of foreigners in Spain without the proper work permit. The Act sets penalties for these infractions ranging from 500,001 pesetas to 15,000,000 pesetas depending on attenuating or aggravating circumstances. In addition, employers committing these infractions are 1) automatically to lose benefits derived from employment programs from the time the infraction was committed and 2) to be excluded from access to such benefits for a maximum period of one year.

Burundi. Ministere du Travail et de la Formation Professionelle. Ministerial Ordinance No. 650/231/88 concerning the regulation of the employment of foreigners in Burundi, 29 July 1988

This Ordinance sets forth rules on the employment of foreigners in Burundi. It requires foreigners working in Burundi to have a work permit, applied for by the foreigner, if the foreigner is a resident of Burundi, and by the foreigner's employer, if the foreigner is not a resident. The permit is valid for one year and may be renewed. Foreigners who have been recognized as refugees or who have resided in Burundi for 15 years may obtain permits valid for five years, and the spouses of Burundi citizens and persons living in Burundi descended from a foreign father married to a Burundi citizen may obtain permanent permits. In addition, an employer desirous of hiring a foreigner must first receive authorization from the relevant Ministry. Such authorization is also valid for one year and renewable. Foreigners may not work in positions higher than those for which they were authorized unless they have acquired higher qualifications than they had when given a work permit and unless no Burundi citizen with the same ability for advancement exists. Foreign investors or their representatives need not receive authorization to work.

Spain. Instituto Espanol de Emigracion. Direccion General. Resolution on procedures for applying for work permits to undertake professional training, 10 October 1988

This Resolution contains procedures for applying for professional training work permits. It provides that those foreigners who wish to come to Spain for a limited period of time in order to become fully qualified in Spanish commercial and professional customs while occupying a training work position are eligible to apply for this permit. The permit is not valid for more than 12 months, although in exceptional cases the permit will be extended for an additional six months. After the period of training has ended, the workers may not remain in Spain in order to exercise another activity. Further provisions of the Resolution deal with when and where applications are to be presented, the form of applications and documentation accompanying applications, and notification of decisions on applications, among other things.

Council of Europe. European Court of Human Rights. Berrehab v. Netherlands, 21 June 1988

The applicants were a citizen of Morocco, divorced from his Dutch wife, and his daughter, who lived with her mother. After the divorce, the Government of the Netherlands refused to renew the father's work permit and eventually expelled him from the country. The applicants argued that the Government's action violated Article 8 of the Convention, which protects family life. The European Court of Human Rights agreed and held that Article 8 had been violated because the refusal to renew the work permit and the expulsion of the father prevented the applicants from maintaining regular contact.