Public Reporting of Healthcare-Associated Infection Rates
Michael Edmond
Michael P. Stevens
The movement to mandate that hospitals publicly disclose information on rates of healthcare-associated infections (HAIs) has gained momentum rapidly. In 2003, Illinois and Pennsylvania became the first states to enact legislation that mandated reporting. Since then, 30 additional states have enacted legislation (1). With the passage of the Patient Protection and Affordable Care Act in 2010, there is now a de facto federal mandate for HAI reporting, as Centers for Medicare and Medicaid Services (CMS) payment will now be linked with this process (2).
The incidence and impact of HAIs are primarily driven by progress in medical care. The development of invasive diagnostic and therapeutic modalities, which have revolutionized medical care, bypass anatomic and physiologic barriers and markedly increase the risk of HAIs. This is compounded by the increase in severity of illness in inpatients along with an increased proportion of these patients who are immunosuppressed via their underlying diseases or transplantation, or cytotoxic therapies. Problems in the healthcare delivery system have contributed to the problem as well. The decreasing profitability of hospitals has caused some to decrease funding for infection control programs. Thus, for a myriad of reasons, the incidence of HAIs remains problematic.
Over the past few years, the once hidden magnitude of HAIs has been exposed by the popular press. In response to this and a grassroots campaign by Consumers Union, the organization that publishes Consumer Reports (3), states are enacting legislation mandating the reporting of HAIs and disclosure of infection rates to the public.
The concept of mandatory reporting of HAIs and other healthcare quality issues converges well with the emergence of consumer-driven healthcare and value-based purchasing, paradigms designed to control healthcare costs. Unlike managed care that controls costs by limiting the supply of healthcare, consumer-driven healthcare attempts to control costs by limiting the demand for healthcare. This is accomplished through the use of health savings accounts and the provision of incentives for healthcare consumers to seek involvement in decisions about their health and their healthcare (4). Thus, the well-informed consumer is an integral feature of consumer-driven healthcare. More recently, the concept of value-based purchasing has emerged. In this paradigm, purchasers of care (i.e., employers) are attempting to hold providers of care accountable for cost and quality (5).
Whether public reporting of healthcare quality data is effective remains unknown. In a systematic review of the literature performed by the Centers for Disease Control and Prevention (CDC), the authors found that few rigorous studies adequately addressed the issue of effectiveness and no conclusions could be drawn (6). A systematic Cochrane review published in 2011 also found no consistent evidence that consumer behavior or care is improved by the public release of performance data (7).
HEALTHCARE-ASSOCIATED INFECTIONS: THE SCOPE OF THE PROBLEM
With any public policy issue, it is important to estimate the impact of the problem for which legislation is intended to address. It is estimated that 2 million persons (8), or 5% to 10% of hospitalized patients in the United States, develop HAIs each year (9,10). These infections account for an estimated 90,000 deaths and have an attributable cost of $4.5 billion (11).
From the standpoint of public policy, it is important to point out that the focus should be on HAIs that are preventable because interventions and policies will have no impact on infections that cannot be prevented—but what fraction of HAIs can be prevented? In a study designed to answer this question, Harbarth et al. performed a systematic review of 25 multimodal intervention studies to decrease HAIs reported in the medical literature from 1991 to 2002. They determined that the preventable proportion of HAIs ranges from 10% to 70%, with the best overall estimate at 20% to 30% (12). More recently, Umscheid and colleagues performed a systematic review wherein they estimated that ~65% to 70% of catheter-associated urinary tract infections (CA-UTIs) and central line-associated bloodstream infections (CLA-BSIs) may be preventable, as well as 55% of cases of ventilator-associated pneumonia (VAP) (13). Unfortunately, when HAIs are discussed in the popular press, it is seldom pointed out that many of these infections cannot be prevented, leading to unrealistic expectations on the part of healthcare consumers.
Table 47.1 illustrates the potential impact of mandatory reporting of HAIs. Each year, 8% of Americans are hospitalized (14). If 5% to 10% of inpatients develop HAIs and 10% to 70% of these HAIs are preventable, the annual incidence of preventable HAIs is 0.04% to 0.56%. Applied to 2010 census data (U.S. population ~309 million) (15), we can estimate that the number of persons affected by preventable HAIs in the United States ranges from ~124,000 to 1.7 million yearly. Finally, by estimating the effect of a mandatory reporting and disclosure program at a range of 10% to 50% reduction in HAIs, we can determine that the estimated number of persons who will be affected ranges from ~12,000 to 860,000 annually.
TABLE 47.1 Potential Annual, National Impact of Mandatory Reporting and Disclosure of HAIs | |||||||||||||||||
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ASSUMPTIONS UNDERLYING THE POLICY OF MANDATORY REPORTING AND DISCLOSURE
The mandatory reporting movement is predicated on 10 assumptions (Table 47.2), all of which must be true for a completely successful outcome. However, at the present time there is little reason to believe that all of these assumptions are true, as discussed, and for some, data are not currently available to either confirm or refute.
Transparency, open exchange of information, and accountability are important societal values. At the heart of the consumer movement is the desire to diminish information asymmetry so that consumers are able to select providers of high-quality care. Consumer advocates argue that consumers currently do not have the data necessary to make decisions regarding their healthcare. Thus, release of HAI rates by all hospitals should empower consumers. When hospitals attempt to block disclosure, they risk the loss of trust by their patients because of the assumption made by many that the hospital must have something to hide. Conversely, when hospitals disclose their quality data, they pursue a transparent approach that demonstrates accountability to the public and honors the public’s right to know.
TABLE 47.2 Assumptions Underlying Mandatory Reporting and Public Disclosure of HAI Rates
1. Transparency, open exchange of information, and accountability are important societal values.
2. HAIs are preventable.
3. Valid data on HAI rates will be produced.
4. Consumers make rational decisions about choices in healthcare.
5. Consumers will understand and use data on HAI rates.
6. Consumers are able to choose their site of medical care and are willing to change their site of care.
7. Consumers who use HAI rate data will make decisions that will improve the quality of their care.
8. Market forces will provide incentive for hospitals to lower HAI rates.
9. Positive outcomes will outweigh negative unintended consequences.
10. Healthcare is a commodity.
HAIs are preventable. While the medical literature is replete with examples of how to prevent HAIs through best practices and technologic advances, the proportion of HAIs that can be prevented remains unknown. In the aforementioned systematic review by Umscheid and colleagues, it was estimated that ~65% to 70% of CA-UTI and CLA-BSI may be preventable, as well as 55% of cases of VAP (13); it is important to note that these are estimates and the true proportion of preventable HAIs is unknown.
Valid HAI data will be produced. Given the complexities of surveillance and the difficulties in risk adjustment, delivering valid data to consumers is not easy. Careful attention must be directed to surveillance methodology. This will require standardization of HAI case definitions, surveillance strategies, and data sources. Moreover, the data must be risk-adjusted to account for the severity of illness and the complexity of care offered at each hospital. Without risk adjustment, hospitals with the sickest patients will appear to be providing lower-quality care simply on the basis of higher crude HAI rates. Standardization and risk adjustment are imperative to produce meaningful interhospital comparisons. While this can be addressed in mandatory reporting legislation, arriving at valid risk adjustment remains extraordinarily difficult.
Consumers make rational decisions about choices in healthcare. In other words, do consumers make decisions regarding their healthcare that maximize their welfare? There has been little research focused on how patients reach such decisions; however, it seems likely that the more urgent the required treatment, the less likely that the patient will proceed with a rational, well-planned investigation of the options with regard to where to seek treatment. In the setting of a major health crisis, patients rely on the recommendations of their physicians, family members, and friends, and often need to reach decisions relatively quickly. A well-publicized, illustrative anecdote is the decision by former President Bill Clinton to have coronary artery bypass graft (CABG) surgery at the hospital in the State of New York with the highest mortality rate for that procedure (16).
Abraham and colleagues performed a survey of 467 patients from four Minnesota clinics that examined the factors of importance to healthcare consumers in choosing providers. They found that physician and healthcare organization reputation were of greatest importance, with logistic and contractual issues also being important. They found few survey respondents who indicated formal quality information sources to be important (17).
Consumers will understand and use reported data on HAI rates. It is important to realize that reports on healthcare quality are designed by experts and policy makers whose understanding of the healthcare system informs their decision on the specific indicators that should be used to measure quality. However, the end user of the data, the consumer, may not be able to work backward from the indicator to the bigger picture of quality (18). Overall, consumers have a poor understanding of quality of care indicators, and this is worse in patients with low socioeconomic status. A significant proportion of the population does not have the reading proficiency to understand quality report cards (19). Moreover, consumers do not use indicators that they do not understand (20).
Given that HAI rates are among the newest metrics to be released to consumers, it is unknown at this point how frequently these specific data are used by consumers. However, two reviews concluded that consumers rarely seek out this information and that it has a modest impact on medical decision making (21,22).
A recent Cochrane review by Ketelaar and colleagues examined the effect of publicly releasing performance data. These authors performed a systematic literature review that included four studies encompassing 1,560 hospitals and over 35,000 consumers. They found that there is “no consistent evidence that the public release of performance data changes consumer behavior or improves care” (7).
Although the public’s desire to access healthcare quality data may change as consumers become more educated, more data become available, and more individuals have access to and are more comfortable with online information sources, at the present time it appears that a minority of individuals are interested in these data and prefer the recommendations of their healthcare providers, family, and friends.
Consumers are able to choose their site of care and are willing to change their site of care. Many patients are unable to choose their site of care owing to their health insurance plan. Twenty-four percent of Americans are enrolled in health maintenance organizations (HMOs), and 95% of covered workers are enrolled in a managed care plan (i.e., HMO, preferred provider organization, or point-of-service plan) (23). Thus, a significant proportion of the population has little choice in healthcare venue or may have some choice that comes with financial penalty.
A recent analysis of New York CABG quality data from 1989 to 2002 showed that public reporting of hospital performance had no impact on changes in market share for hospitals (24). However, it could be argued that even if patients are unwilling to use healthcare quality reports or change their site of care, third-party payers will use the data to direct their members to hospitals that demonstrate higher quality. There is also little evidence to date, however, to support that argument (24,25,26,27). It also could be argued that if public reporting is effective in improving the overall quality of care in a given state, even patients who are unwilling to change their site of care may experience a benefit (28).
Consumers who use data reported on HAIs will make decisions that will improve their care. This assumption depends on two other assumptions: that comparative data on hospital HAI rates are valid and that healthcare consumers can and will change their site of care in response to the reported data.Related posts:
Occupational Health Services
The Role of the Laboratory in Prevention of Healthcare-Associated Infections
Economic Evaluation of Healthcare-Associated Infections and Infection-Control and Antimicrobial-Stewardship Interventions
Dialysis-Associated Complications and Their Control
Incidence and Nature of Endemic and Epidemic Healthcare-Associated Infections
Surgical Site Infections
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