Q&A with author of provocative new book
'Medical mistakes and preventable infections constitute the number three cause of death in the U.S.'
Martin A. Makary, MD, MPH, an associate professor of surgery and health policy at the Johns Hopkins Hospital in Baltimore, MD is the author of the recently published book "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care." We talked to him recently about health care associated infections (HAIs) and other patient safety issues raised in his provocative book.
"I talk about infections a fair bit and about the progress that has been made in measuring infections, and how increased measurement results in improvement in infection rates," Makary tells Hospital Infection Control & Prevention. "When infection rates are available to the public, hospitals place more resources into the effort to prevent them."
Our interview with Makary continues as follows:
HIC: The old recommendation to calculate and feedback surgeon-specific surgical site infection (SSI) rates seems to have fallen out of favor. Why isn't that being done more?
Makary: "The problem with surgeon specific infection rates is that they are often not statistically valid because if you look at the case mix of an individual surgeon many times they have a broad range of operations that they do with high and low risk of infections. I believe that the best level to evaluate infection rates is at the hospital level. When the hospital infection rate is public the administration will scramble to tap their local wisdom, to talk to their infection control personnel and their doctors to find out how to fix the problem. The public disclosure of infection rates is what creates accountability at the hospital level, and accountability is what drives resources to be dedicated to fix the problem on a local level."
Regarding SSIs, are many post-discharge infections still going undocumented for lack of follow-up? Historically, that has been a problem.
"It's still an issue; we still lack standardized measures nationwide. For example, the American College of Surgeons (ACS) has a program called NSQIP — the National Surgical Quality Improvement Program — that has highly standardized independent definitions of what constitutes an infection. Yet only 500 hospitals in the United States participate in their measurement program. Historically, we have a problem with hospitals that do a poor job of measuring infections coming out looking good, but those that do a very good job of tracking down their infections come out looking bad. Without standardized definitions we end up punishing people that are doing a good job."
What about the Centers for Disease Control and Preventions rapidly expanding surveillance system – the National Healthcare Safety Network?
"It definitely moves to more standardized definitions for infections. The best way to measure surgical infections is actually the one authored by the surgeons — the standardized definitions by the American College of Surgeons. There are so many types of surgical infections, there are deep infections within the abdomen or you could have a superficial infection of the skin. There are so many different types, and of course, certain types of operations are more likely to have higher rates versus the others. But I applaud the CDC's NSHN as a force to try standardize the definitions."
Such systems are still only as good as the data they receive, of course, and we hear anecdotal stories of pressure to narrowly define infections in an age of "zero tolerance" for HAIs.
"There are flaws to self-reported data that is not independently collected. The American College of Surgeons tries to use independent clinical reviewers. In business we have the Sarbanes-Oxley Act, which means if a CEO misreports their earnings they can go to jail. In health care, a hospital can misreport their performance on infections and there is really no accountability for it. That is a problem, and unfortunately with self-reported data that means again we reward those who do a sloppy job of closely following their patients while penalizing those that do a very aggressive job tracking their patients."
We are certainly hearing calls for increased transparency regarding HAIs and other patient outcomes, but how does that really translate to improved quality?
"We have seen this before in states that reported mortality rates for heart bypass surgery. When the hospital average is a bad outlier — I don't want to say 'high' or 'low' because that can confuse people — with respect to the national average, [administrators] put more resources into fixing the problem. Many times the local doctors and nurses on the front lines say that they know how to improve quality of care and reduce infections, but they often describe feeling disempowered. They describe feeling like their management isn't interested in their input. So you have the sense of frontline workers feeling like tenants and the hospitals are their landlords. When frontline providers don't own the entire delivery of care their performance [suffers]."
You give accounts in your book of impaired surgeons, who clearly pose a risk to patients, but you also point out that the risk of infections and other adverse events is highly dependent on the procedures practiced by a particular surgeon or at a given facility.
"Take for example the minimally invasive option for surgery. Surgeons who don't do the minimally invasive approach — who don't offer it — have patients in their practice that will have a disproportionate high rate of 'open' operations, which are known to have higher surgical infection rates. Other hospitals — such as the University of Pittsburgh that do most of their GI surgery as minimally invasive — will have lower infection rates.
The decision as to who gets minimally invasive surgery and who gets an 'open' operation among those that are candidates [is often arbitrary]. If hospitals were accountable for their infection rates in a meaningful way they would be more incentivized to encourage [minimally invasive] operations for their patients. There are some hospitals that do 90% of a procedure through the open surgical methods, whereas another similar hospital will perform that same procedure in a more minimally invasive method."
Are you hopeful that ongoing efforts to improve transparency will improve outcomes?
"Well, anytime there is a valid measurement of health care outcomes, outcomes globally seem to improve. Transparency is a great way to empower the public, because right now we have a free market that is dysfunctional. Patients choose hospitals based on the ease of parking and other factors which essentially leave them walking in blind when it comes to quality. Measurement is a dangerous business when the measures are not scientifically valid. We have suffered with invalid or inaccurate measures for a long time, which is why now there is an exciting revolution in health care where doctors have endorsed valid ways to measure complications like infections fairly. The question we have to ask as a society now is do we believe the public has a right to know about the quality of their hospitals? The information is now collected, for example by the ACS program. It is being housed in a data base where you have valid ways to measure infection rates in hospitals in a way that is endorsed by surgeons. But the information is not available to the public — yet. It is becoming available and that is the revolution I talk about in the book."
Did you write the book as a sort of call to action?
"Exactly. There are massive disparities in the quality of health care in the United States. And in observing disparities and participating in the revolution in these quality improvement efforts it became clear to me that there is a dilemma in society right now. We have good valid information about hospital outcomes that the public have a right to know about. Medical mistakes and preventable infections constitute the number three cause of death in the U.S. One of the reasons why that statistic is a shock to people — even doctors — is that we have not been a culture that openly talked about this problem in the past. It is only now that doctors' groups are talking about trying to improve this problem. [We are talking about] transparency with valid and fair ways to measure outcomes, with physician endorsed measures — the right measures.
There will be the inevitable questions and comments about the additional cost of adopting these better metrics and other improvements.
"Absolutely, hospitals have to pay for this. But I think increasingly Medicare is realizing that hospitals shouldn't be losing money by trying to improve quality. We saw that with the readmission reimbursement provision that went into effect [recently]. Hospitals are going to be docked, 1% based on whether or not they are an outlier in readmissions. Right now it is just [readmissions] for heart disease, heart attacks and pneumonias but that will likely expand. Even though it's 1% this year, it is going to be 2% next year and 2% the following year. It is all part of the Affordable Care Act. I think it is already making a difference with readmissions. In the past, hospitals that reduced readmissions would earn less money because they wouldn't be able to profit from the readmission. Now it is a more even playing field."