More states eye reporting infection rates to give scrutiny to hospitals

The movement to require hospitals and other health care organizations to report publicly how well they prevent nosocomial infections is spreading fast. Nine states are looking to join the 16 that have enacted such mandates in the past four years.

Bills in Georgia, Texas and Washington stand the best chance of passing this year, according to Lisa McGiffert, director of Consumers Union's Stop Hospital Infections Campaign. The group has written model legislation on hospital-acquired infections and is leading the push to mandate public reporting. Arkansas, Delaware, Massachusetts, Michigan, Minnesota and New Jersey also are considering legislation. But even as the pressure for more transparency builds, there is debate about whether public reporting is the best way to proceed.

Consumer groups, infection control professionals and many patient safety experts argue that the harsh light of transparency will spur doctors and hospitals to implement system changes that will greatly reduce health care-associated infections. Others worry that current measurement methods allow for too much subjectivity and that transparency could encourage groups to divert attention from improving safety to gaming the numbers.

The hard data that could determine which side has the upper hand in this argument are still trickling in. Three states -- Florida, Missouri and Pennsylvania -- have issued their first public reports of hospital performance on ventilator-associated pneumonia and surgical site, urinary tract and bloodstream infections. Most other states with mandated reporting are still in the two-year window between legislative enactment and the beginning of public disclosure established so state agencies have time to set out compliance rules and test reporting systems.

Experts acknowledge that it is too early to say whether the new public reporting mandates have driven down infection rates. Nearly 2 million patients a year acquire an infection while being treated for another disease or illness and nearly 90,000 die, according to the Centers for Disease Control and Prevention. Nosocomial infections add nearly $5 billion in health costs each year, the CDC estimates.

But proponents point to previous success with state requirements for coronary artery bypass graft outcomes and improvements on Medicare's Hospital Compare measures as evidence that transparency works.

"The general question is do these reports stimulate hospitals to improve quality, and I think the answer is yes," said David B. Nash, MD, editor of the American Journal of Medical Quality and chair of the technical advisory group for the Pennsylvania Health Care Cost Containment Council, or PHC4, which issued the state's nosocomial infection performance reports.

Mark Piasio, MD, president of the Pennsylvania Medical Society -- which supports the infection-reporting mandate -- agreed with Dr. Nash. "If you want to be honest about quality, then transparency is absolutely required," said Dr. Piasio, a Dubois, Pa., orthopedic surgeon.

But the Hospital & Healthsystem Assn. of Pennsylvania has assailed PHC4's reports, saying estimates of mortality, extended hospital stays and added costs are inaccurate because they don't differentiate between infections acquired in the hospital and those that weren't. PHC4 defends its claims data-based estimates, which other mandated reporting laws don't include.

Rob Schaaf, MD, is a family physician and Missouri state representative who helped enact a 2004 infection-reporting law with the support of the state medical society and hospital association. Getting the law passed was one of the principal reasons he ran for public office. "As a family physician who has been in practice for 20-some years, I believe I did a lot of good, but with this one bill I feel like the benefits and the number of lives saved eclipses all the other work I did in my whole career," Dr. Schaaf said.

Questioning what is collected

Peter J. Pronovost, MD, PhD, said transparency is valuable but that the current means of measuring many types of nosocomial infections are subpar. He said public reporting could distract physicians and hospitals from the focus on saving lives.

To tally infections, many state reporting laws rely on the CDC's longstanding measures, and those are often surveillance definitions rather than clinical ones, Dr. Pronovost said.

"The surveillance definitions have a subjectivity to them," said Dr. Pronovost, director of adult critical care at the Johns Hopkins University's Schools of Medicine and Nursing in Baltimore. "The CDC developed these definitions in a low-stakes environment with no pay-for-performance and no public reporting."

Dr. Pronovost said confidential reporting can work just as well, pointing to his own work with Michigan hospitals accounting for 85% of the state's intensive-care unit beds. The ICU project, the results of which were published in the Dec. 28, 2006, New England Journal of Medicine, reduced rates of catheter-related central-line bloodstream infections by 66% and achieved median rates of zero infections per 1,000 catheter days compared to the 5.2 national average.

Working with a hospital in another state that was considering a public reporting law, the leadership's focus suddenly "shifted from doing good to looking good," Dr. Pronovost said. "The CEO was debating with staff whether a certain infection really was a true infection."

Denise Cardo, MD, director of the CDC's Division of Healthcare Quality Promotion, said concerns about clinical wiggle room in the definitions were legitimate but added that the agency is working with the National Quality Forum to develop broadly accepted process measures to alleviate the problem. The American Hospital Assn. said states requiring public infection reporting should use NQF-endorsed measures, expected to be presented to the standard-setting group's stakeholder members in May or June.

"We don't have any perfect system for doing [public infection reporting], but I think the good thing that is coming out of the different states is we are learning how to do better," Dr. Cardo said.

Eight of the 16 states that mandate public nosocomial infection reporting will require hospitals to use the CDC's National Healthcare Safety Network, which replaced the National Nosocomial Infections Surveillance System in October 2005. At press time, 534 health care organizations -- 511 of them hospitals -- were enrolled and participating in the new system.