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Turning point: CDC cites IP impact in opening new era of transparency in healthcare infection data
HAI drop linked to 'improved practices at local level'
By Gary Evans, Senior Managing Editor
In a report that may prove to be the cornerstone of a long-anticipated national surveillance system for healthcare associated infections (HAIs), the Centers for Disease Control and Prevention recently reported an 18% decline in the national incidence of central line-associated bloodstream infections (CLABSIs).
Gleaning data from the CDC's National Healthcare Safety Network (NHSN), the report includes national numbers as well as state-specific information from 17 states. With additional reports on CLABSIs and other infections slated to follow, a national reporting system may emerge as more and more hospitals report their infection data to the NHSN to comply with state laws. The rudimentary system could eventually be transformed into a full blown national HAI reporting network given the increasing interest in HAI prevention at the federal level. Though they didn't survive the final cuts, there were federal HAI reporting requirements in some versions of the health care reform legislation.
While there are caveats like the issue of data validation or perceived pressures to "under report" HAIs, the overall 18% drop reflects in part the dramatic reduction in CLABSIs reported by hospitals who have implemented infection prevention measures like a checklist for aseptic insertion of central venous catheters. The ultimate benefactors of such efforts are the patients and families spared the fear and grief of infections. In that regard, one of the principals behind the checklist viewed the CDC report in the stark light of human loss.
"Thirty-one-thousand people die annually from bloodstream infections in the U.S. and most [of these] can be prevented," Peter Pronovost, MD, PhD, medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins Hospital in Baltimore, said at a CDC press conference on the report. "Today marks a turning point in transparency and accountability for healthcare. We now must begin to be responsible for our outcomes and no doubt these data will make some uncomfortable. In the end, it's clinicians who must use the best practices and healthcare leaders who must be accountable for their infections."
The CDC report and the larger trend toward a CDC national reporting system for HAIs represents a critical victory for infection preventionists fighting for resources in the nation's hospitals. If there is to be a system of HAI accountability, then IPs and health care epidemiologists must be empowered as its prime agents.
"We are ultimately advocates for the patients in our hospitals," said Stephen Streed, MS, CIC, a member of the national board of directors of the Association for Professionals in Infection Control and Epidemiology (APIC), and system director of epidemiology at Lee Memorial Healthcare System at Fort Meyers, FL. "Patient safety means we are unbiased in finding and reporting these [infections] and using those findings to drive down the infection rates. That's what we get paid to do."
Indeed, the reported reduction in central line-associated bloodstream infections stands as a testimony to "the return on investment" that dedicated infection prevention teams can have, said Neil Fishman, MD, president of the Society for Healthcare Epidemiology of America (SHEA). "I think this is a game changer," he told Hospital Infection Control & Prevention. "We are headed toward national reporting. We are moving in that direction, though not all states mandate public reporting and not all states mandate the public reporting of the same information."
The report also was framed as part of the ambitious federal plan to reduce central line-associated bloodstream infections by 50% by the end of 2013. HAI rate reporting has clearly emerged as one of the drivers toward such goals to reduce a variety of HAIs.
"There is an increasing trend towards public [HAI] reporting," Don Wright, MD, MPH, principal deputy assistant secretary for health at the HHS said at the press conference. "Over the last two years, we've seen the number of states requiring mandatory reporting move from 13 to 20 to 27 states. Not all states require the use of National Healthcare Safety Network, but certainly there is an increasing trend and we expect that trend will continue to encourage public reporting at the state level."
One of the original ideas behind all of this HAI reporting and transparency was to let informed consumers select their health care settings. The somewhat inconvenient truth remains that many patients are limited in their health care options regardless of the reported infection rates at any given facility. "The big disconnect is can the consumer really use this data?" Fishman asks. "And the answer [for many of them] is no they can't. Because most often they are not making their own choices about where they receive care. They are being made by the insurers for them."
Still, even with health care reform something of a work in progress, one can make a fairly compelling argument that opening infection rates to public and press scrutiny will drive outlier institutions toward quality improvement with all due haste. In addition, federal agencies like the Centers for Medicare & Medicaid Services are cutting off reimbursements for preventable adverse outcomes.
"Today we have stronger momentum than ever in the form of political will, funding, use of existing prevention tools, public engagement, and surveillance to perform this work," Arjun Srinivasan, MD, director of HAI Prevention in the CDCs division of healthcare quality promotion said at the press briefing.
The political will apparently goes to the very top, with Secretary of Health Kathleen Sebelius issuing a statement on the report underscoring that "the administration is firmly committed to promoting transparency in our healthcare system so that we can know what's working, what's not, and how we can do better."
Such political momentum should translate to increased clout for infection prevention programs. "I don't think there is a downside to it," Streed told HIC. "This [CDC reporting] is going to even the playing field and drive our profession of infection prevention to have better standardization of our training [and] more leverage toward making sure that we are better resourced. It puts us squarely in the spotlight."
The report is only a first step, a baseline of sorts to measure future progress. "The real test will be comparing the data [with] the data in future reports, which will be published every six months," Srinivasan said. "At that point we can judge progress over time and determine whether or not central line-associated bloodstream infection prevention efforts are driving infections down."
Contrasting federal reports
The CDC data reveal that important inroads are being made against a major infection, in contrast to another recent federal report that cited little progress against HAIs. However, that report by the Agency for Healthcare Research and Quality (AHRQ) was widely criticized for using discharge data, which are considered a faulty measure of HAIS by epidemiologists. Patient advocacy groups like Consumers Union have also generated HAI rate reports based on the available data, putting increasing pressure on the CDC to take a lead role and validate the process so that infection rate data and subsequent comparisons are valid.
"I think every expert in the field of infection prevention is going to agree that [CDC data] are much more accurate and should be the basis that we use for a comparison, whether it is between hospitals within a state or between states," Streed said. "Certainly administrative data were never designed for surveillance purposes such as this. I think it would be our hope that [APIC] could move in that direction with them. There's no question of that."
The CDC report compares national and state data from January to June 2009 with national data from 2006 to 2008. (The CDC's First State-Specific Healthcare-Associated Infections Summary Data Report is available at http://www.cdc.gov/hai/statesummary.html.)
"This report gives us a snapshot of where the country stands in our efforts to prevent central line-associated bloodstream infections," Srinivasan said. Using a metric called "the national standardized infection ratio" the CDC found an 18% decrease in central line-associated bloodstream infections during the first six months of 2009, compared to the previous three years. "We believe this decrease reflects broader implementation of CDC guidelines, enhanced tracking and measurement and improved practices at the local level by thousands of dedicated healthcare professionals," he said.
The standardized infection ratio is the number of central line-associated bloodstream infections observed in any group, compared to the "predicted number" of central line-associated bloodstream infections, he added. The predicted number is based on the number of central line-associated bloodstream infections reported by healthcare facilities to the NSHN from 2006 through 2008. A standardized infection ratio of greater than one means that there were more infections observed than predicted, whereas a standardized infection ratio of less than one means that there were fewer infections observed than predicted, Srinivasan explained. Though there was broad agreement that the system is striving more for eradication than benchmarks, the CDC metric does give the consumer a basic tool to assess HAIs in their health care system.
"It presents the data in a way that consumers can understand," Fishman says. "It's a relatively easy explanation to say if it's `one' then it's where it's expected to be, if it's less than one that's good, and if it's greater than one that's bad. That can be done with circles and dots too."
Trust, but verify
Beyond the immediate numbers and comparisons are the broader implications, the first steps toward a standardized, national reporting system that could eventually supersede the current patchwork of state laws requiring reporting a variety of infections. But as more individual states report data to CDC there must be assurances that the figures are validated to ensure meaningful comparisons.
"The advantage is they are standard [NHSN] definitions and the data are collected using standard methodologies," Fishman said. "More and more states will be validating the data as time goes on. Right now there are only four states that validate the data, but a lot of states got [federal ] money to validate the data that is being submitted to NHSN."
Srinivasan noted that the CDC is "seeing an expansion of efforts to validate data being submitted to the NHSN." In fact, a number of states submitted requests for and were provided funding through the American Recovery and Reinvestment Act specifically to enhance their ability to validate data they're submitting to the NHSN, he added.
In New York, for example, validating the reported HAI data is a rigorous process that was mandated in the state's reporting law from the onset, said Rachel Stricof, MPH, an epidemiologist in the New York State Department of Health in Albany.
"The department of health was given not only the responsibility but the resources to ensure the completeness and accuracy of self-reported hospital data," she said. "Experienced infection preventionists were hired and dedicated to monitor compliance, to audit the hospital data, but also to evaluate risk factors for infection, and to conduct surveys for prevention activities."
Given such rigor, "it would not be surprising to find that states with strong auditing and validation programs have higher reported infection rates, at least in the short term," Stricoff said. However, such validation efforts are necessary in part to address concerns that HAI surveillance for public disclosure may lead to under-reporting of infections.
"I don't think [that's an issue] – not from the infection preventionists standpoint," Streed said. "And I've been in this business for 34 years. My experience is that physicians want what we want – the best outcomes for their patients."