Mandatory public reporting of hospital acquired infections

True

There is a strong healthcare consumer movement in the US, driven in part by advocacy organizations (e.g., Consumers’ Union)

True

Many, but not all, HAIs are preventable

The Keystone Project, implemented in >100 Michigan ICUs, demonstrated that with a standardized approach to central line insertion, central line associated bloodstream infections (CLABSI) were reduced by approximately 2/3

A systematic review of the literature determined that the proportion of reasonably preventable HAIs were:

CLABSI 65 to 70%

Catheter-associated UTI 65 to 70%

Ventilator-associated pneumonia 55%

Surgical site infection 55%

At the present time, there are concerns that the data reported publicly are in many cases not valid; however, many states have not performed validity studies to assess this.

A retrospective cohort study at 4 medical centers comparing the performance of CLABSI surveillance by IPs to a computer algorithm found significant variation in IP surveillance

A validation study done in Connecticut found that IPs surveillance for CLABSI was only 48% sensitive

A retrospective review of 50 ventilated patients found application of the CDC definition for ventilator-associated pneumonia by IPs to be highly variable

A study of three different VAP definitions found that all definitions performed poorly when compared to autopsy evidence of VAP

For elective procedures, consumers may or may not make informed choices about their healthcare

Patients rely on the recommendations of their physicians, family members and friends.

President Bill Clinton underwent coronary artery bypass graft (CABG) surgery at the hospital in the state of New York with the highest mortality rate for that procedure

It is not clear if consumers either understand HAI data or if these data are consistently applied to informed, medical decision making

Patients 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

Consumers likely will not use indicators which they do not understand

Two recent reviews concluded that consumers rarely seek out this information and that it has a modest impact on medical decision-making

Many patients are unable to choose their site of care due to their health insurance plan

A significant proportion of the population has little choice in healthcare venue or may have some choice that comes with financial penalty.

24% of Americans are enrolled in health maintenance organizations (HMOs) and 95% of covered workers are enrolled in a managed care plan (HMO, preferred provider organization or point-of-service plan)

This assumption is valid only if the following underlying assumptions are correct:

Comparative data on hospital HAI rates are valid

Healthcare consumers can and will change their site of care in response to the reported data

The theoretical argument for the improvement of quality stems from the following potential responses to public reporting:

Remediation (hospitals make a concerted effort to improve quality)

Restriction (licensing and accreditation organizations use the data to restrict provision of care by poor performers)

Removal (poor performers discontinue providing services)

Stimulation of competition between providers on the basis of improving quality in order to improve market share.

Data to support these claims are sparse and come from observational studies

Following mandatory public reporting of CABG surgery in New York State, a 21% reduction in CABG mortality was reported.

The decline in mortality may have been due to other factors, such as the avoidance of surgery on high risk patients

Unintended consequences of mandatory public reporting exist.

Some low volume surgeons with high mortality rates stopped performing CABGs after mortality rates were published

Uncertain

Marshall et al., have described seven potential unintended consequences of public reporting on the quality of medical care:

Tunnel vision. This occurs when quality improvement efforts are concentrated on areas being measured to the detriment of other important areas.

Sub-optimization. This is pursuing narrow organizational objectives at the expense of strategic coordination.

Myopia. Hospitals may concentrate on short-term issues and lose sight of the long-term outcomes.

Convergence. Convergence is defined as placing more emphasis on being exposed as an outlier than on efforts to perform in an outstanding fashion.

Ossification. This occurs when organizations avoid experimentation with new approaches out of fear of poor performance. .

Gaming. Hospitals game the system when they alter behavior to gain strategic advantage. For example, quality indicators that are measured via administrative data can be affected by coached changes in the coding of diagnoses, since risk adjustment is dependent on the coding of co-morbid conditions.

Misrepresentation. Public reporting may incentivize surveillance systems with suboptimal sensitivity.

In the United States, unlike many other countries, health care is treated as a commodity rather than as a basic human right

A large segment of the U.S. population is unable to purchase healthcare due to lack of resources.

Public reporting of quality indicators stems from and reinforces the commodity concept.

Persons unable to purchase healthcare will not benefit from mandatory public reporting of hospital acquired infections