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New Data May Strengthen Push for Mandatory Reporting of Infection Rates at Hospitals

By John Reichard, CQ HealthBeat Editor

November 20, 2006 -- It's a myth that Medicare pays the added care costs associated with infections acquired in the hospital, according to research findings released at news conference Monday. Hospitals lose an average of $26,839 per case in which patients develop a "central line infection" in which a catheter is pushed through a vein into the heart, according to the data.

And the data show that infection is largely the result of the processes of care followed by a hospital in treating patients, rather than the medical condition of the patients themselves when they are admitted to the hospital, researchers said at the briefing.

The findings demonstrate that thousands of lives and billions of dollars could be saved each year through mandatory public reporting by individual hospitals of their infection rates, the researchers said. The issue is ripe for congressional action that would slash national health spending, said Marc P. Volavka, executive director of the state agency that last week became the first in the nation to publicly post data on surgical infection rates at individual facilities.

"This one is here for the taking—and it's billions and billions of dollars," said Volavka of the Pennsylvania Health Care Cost Containment Council. But the hospital industry and the Bush administration have shied away from endorsing a program along the lines of the one in Pennsylvania that reports the actual number of infections at a hospital.

The data released Monday, published in the American Journal of Medical Quality, "will do much to help explode the myth that infections . . . cannot be prevented," said Dr. David B. Nash at the press briefing. Nash is chairman of the Department of Health Policy at Philadelphia's Thomas Jefferson University and the editor of the medical journal.

Many in health care believe that infections acquired in the hospital are "almost an expected outcome from the care of seriously ill patients, especially those in our high-technology settings, such as the operating room, intensive care unit or renal dialysis center," Nash said in an editorial accompanying the studies.

But a study by Richard P. Shannon, professor of medicine at the University of Pennsylvania, "found that there was no link between the severity of illness on admission and the risk" of central line-associated bloodstream infections, Nash said. Although a second study did find that factors associated with patients themselves—their age, for example, or whether they had diabetes—helped predict their risk of developing infections from surgical incisions, factors associated with the hospital's care itself were much more important in predicting that risk. Christopher S. Hollenbeak, a professor at Pennsylvania State University's College of Medicine, led the second study.

The study led by Shannon examined 54 cases of patients at Allegheny General Hospital who developed central-line associated bloodstream infections. On average, the hospital received a payment of $64,894 for treating the patient. The actual costs of care, however, were $91,733, resulting in a net loss per patient of $26,839.

The Pennsylvania data released Nov. 14 on numbers of infections at individual hospitals in the state also showed large outlays for treatment. A total of 19,154 cases of hospital-acquired infection occurred in the state in 2005, according to the data. Hospital charges for treating the patients totaled $3.5 billion. The death rate for patients with a hospital-acquired infection was 12.9 percent, compared with 2.3 percent for patients without an infection.

The rates of infection in Pennsylvania , if applied to other states, suggest that nationally 400,000 cases of hospital-acquired infection occur each year, resulting in 50,000 deaths and $20 billion in payments for treatment, Volavka said Monday.

Nash and Volavka said that requiring hospitals around the country to publicly post their infection rates would spur their executives to quickly take steps to improve care. Shannon attributed high infection rates to the complex and variable processes that go into treating patients. But if those processes were standardized and routinely followed, infection rates would plummet, he said.

Shannon said his team observed many different ways in which operating room personnel put on gowns and gloves to guard against infection. In many instances, nurses didn't have everything they needed to prepare for surgery and had to run in and out of the operating room to get equipment, trips that added to the risk of infection, he said.

"If you eliminate the variation, I think you can eliminate 85 percent of cases" of infection, Shannon said.

Volavka said that if Congress were to deny Medicare payments for cases of hospital-acquired infection, hospital executives would start scrambling today to figure out how to eliminate them. Nash said Medicare could begin by refusing to pay for "sentinel events"—cases that should never occur, such as treating the wrong limb, or incorrectly identifying a patient, for example. The researchers also urged increased federal funding to help states gather data on numbers of infections and to study improved processes of care.

William Vaughan, a senior policy analyst at Consumers Union, said the issue is ripe for congressional action. Sixteen states have laws requiring some form of disclosure, three others have laws requiring studies of disclosure and two more have laws requiring gathering of infection data without public reporting, he said.

"With 20-plus state laws that vary, . . . we're rapidly reaching a point and getting enough provider experience that national legislation should occur fairly soon," he said. "It's time to complete the circle. We are going to keep pounding it state by state, but we are going to seek a national solution."

The Centers for Disease Control and Prevention (CDC) has offered states pursuing mandatory reporting advice on how to conduct those programs but has not endorsed them. A spokesman referred a reporter to a Feb. 28, 2005 statement on the issue by Dr. Denise Cardo, director of CDC's Division of Healthcare Quality Promotion.

"The goal of mandatory reporting is to provide consumers with information they can use to make informed health care choices," Cardo said. "We don't know yet if public reporting will reduce the number of infections, but we do support collecting information that can lead to improvements in patient safety."

An official with the American Hospital Association said the lobby is focusing its efforts on disclosure on data hospitals are reporting for Medicare's Hospital Compare Web site. "We are not reporting the same [data] yet" as Pennsylvania, said the official, Nancy Foster, vice president for quality and patient safety quality.

Hospitals are reporting data for the site—which allows the public to compare individual hospitals on a variety of measures—on three measures relating to preventing surgical infections, Foster said. One measure assesses the extent to which a hospital gives patients antibiotics within an hour before surgery, another examines whether the right antibiotic was administered, and a third looks at whether the antibiotic was properly discontinued within 24 hours after surgery.

But Volavka said reliance on those "process" measures by hospitals and the Medicare program is "disappointing." There are many elements that go into whether or not a patient develops a surgical infection, and those processes are just one of many steps along the way to preventing infection, Volavka said. "Outcome" measures should be used instead of process measures, he said.

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