October 1, 2007

Public Reporting of HAIs May Have Unintended Consequences

Everyone agrees that hospitals must be made safer for patients, but not everyone agrees on the best way to make this happen. Public reporting of HAIs has been offered as a possible solution, but it could in fact have unintended consequences. That was the consensus of panel members at a symposium on public reporting at IDSA’s 45th Annual Meeting this month in San Diego. Public reporting, they said, could encourage hospitals and physicians to avoid sicker patients, use intervention targets that may not be appropriate for all patients, and diminish the role of patient preferences and clinical judgment.

There has been significant legislative and regulatory activity around HAIs, according to Denise M. Cardo, MD, FIDSA, of the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion. At least 40 states have introduced or passed HAI legislation and eight states have considered additional legislation specific to methicillin-resistant Staphylococcus aureus.

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There’s wide variation in the complexity of bills in various states, Dr. Cardo said, with little focus on the validation of reported data. In most states, the reporting systems are an unfunded mandate.

At the federal level, the “Healthy Hospitals Act” has been proposed that would mandate reporting of HAIs. In addition, the federal Deficit Reduction Act of 2005 requires Medicare to stop paying for certain health care-associated conditions (see IDSA News, September 2007). One important bill has been introduced to address antimicrobial resistance (see http://www.idsociety.org/STAARact.htm).

Neil Fishman 220Neil Fishman, MD, of the University of Pennsylvania, described his home state’s new public reporting mandate, which was signed into law in July 2007. Among other things, the new law requires all hospitals to become members of the National Healthcare Safety Network, compile monthly reports on multiple measures, report HAIs to the state, and disclose a new HAI to the patient in writing within 24 hours of detection. The law will provide financial rewards for hospitals that see a 10 percent or more reduction in HAIs. Hospitals that fail to comply with the law will be fined $1,000 a day.

The speakers questioned some of the basic assumptions of advocates of public reporting—for example, although hospitals that report their infection rates generally will work to lower them, it is not yet proven that hospitals that report lower rates are safer or that informed patients will obtain safer care. Some assumptions inherent in public reporting need to be tested, said Robert A. Weinstein, MD, FIDSA, of Stroger (Cook County) Hospital and Rush Medical College.

Public reporting is not a new idea, Dr. Weinstein noted. In the 1980s and 1990s, New York and Pennsylvania reported on cardiac surgery outcomes. However, according to one study, most patients did not actually use the data—either because they were not aware of the data, did not trust it, or did not understand it. Physicians did not use it, either—62 percent reported that the data had no influence on them, and 82 percent cited inadequate risk adjustment. The same study found that cardiac surgeons were turning away the most severely ill patients, with a 31 percent increase in transfers. The study also found an increase in racial disparities. (Werner RM, Asche DA. JAMA 2005;293:1239-44).

According to Dr. Weinstein, certain lessons emerged from the cardiac surgery experience. Outcomes data needs to be risk-adjusted so that providers who see sicker patients aren’t unfairly penalized. The choice of denominators in quality measures is important, so it’s clear what’s being compared. Sophisticated information technology is needed. Benchmarks need to be established (for example, it’s challenging to come up with a fair rate to report in a small hospital that sees few patients). And trends in a given hospital’s rates over time may be more useful than hospital-to-hospital comparisons, he said.

For public reporting to succeed, Dr. Weinstein said, research is needed to identify meaningful metrics, determine the best ways to report them, and assess whether the reports actually improve patient care and safety.

Several speakers noted a cautionary tale of unintended consequences: In 2003, IDSA’s community-acquired pneumonia (CAP) guidelines recommended antibiotics within four hours of emergency department registration. The Centers for Medicare and Medicaid Services adopted this recommendation as a quality measure. Antibiotic use went up—because more patients were being misdiagnosed with CAP. There was no change in mortality. The guidelines have since been revised, but the lesson remains: Rigid adherence to a “quality measure” actually lowered the quality of care. 

Until now, public reporting has not been demonstrated to decrease infection rates or improve quality of care, said Dr. Fishman. Thus far, it’s a case of legislation outpacing science.

Slides from this session and many others from IDSA 2007 are available online.

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.

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