National infection rate reporting standard is coming for hospitals
National infection rate reporting standard is coming for hospitals
NQF action would codify CDC guidelines, standardize laws
A leading health care quality group is moving to set national standards for infection rate disclosure laws that essentially would codify recently released guidance by the Centers for Disease Control and Prevention (CDC), Hospital Infection Control has learned.
The National Quality Forum (NQF) in Washington, DC, is seeking funding to establish a national standard for hospital infection rate reporting, an issue that is sweeping the country in the form of individual and often varying state laws. Many infection control professionals — who will be largely responsible for gathering and reporting the rates — want to head off the nightmarish scenario of different reporting laws in every state, preferring instead a national standard based on the template created by the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).1
"I think the great fear among the folks who are going to have to deal with this is — if there are 50 different ways of doing it — it is just going to be total chaos," Kenneth W. Kizer, MD, MPH, president and chief executive officer of the NQF, tells HIC.
Four states (Pennsylvania, Illinois, Florida, and Missouri) have passed infection-rate disclosure laws, and some 30 other states are discussing legislation. As a result, HICPAC recently released a template for such laws, which recommends reporting three process measures and two outcome measures. The HICPAC process measures selected for rate disclosure laws are central line insertion practices in intensive care units; appropriate timing of surgical antimicrobial prophylaxis; and influenza vaccination coverage rates for health care personnel and patients. The outcomes indicators are surgical-site infection (SSI) rates and central line- associated laboratory-confirmed bloodstream infections. (See HIC March 2005 under archives at www.HIConline.com.)
While the HICPAC document was released with no recommendation in favor or against state disclosure laws, the issue has taken on an air of inevitability as state after state takes up discussions. Infection rate disclosure continues to gather momentum despite criticism from ICPs and others who question the value of such laws.
"There is a strong feeling that consumers, purchasers, and others want this information," Kizer says. Even though critics point out there is no evidence such laws will actually improve patient safety, he says he is convinced infection rate disclosure will drive quality improvement.
"There is no question. Have there been randomized controlled, double-blind studies that have shown it? No, nor will there ever be. But when you start reporting stuff about hospitals, it’s amazing how much attention suddenly gets focused on these things," Kizer explains. "Who wants to have their hospital known as the one where you go to get infected? Having this information out there basically increases the competition to drive the rates as low as possible, which has a beneficial effect of improving the quality and making it better for patients."
The NQF, a private, nonprofit organization, is seeking funding to go forward with the national standard. "Before we start on something like this, we would have to make sure we could finish it," he adds. "That funding basically goes to pay for the meetings where the different groups and experts would come together and to pay for mailing, reviewing, and other expenses of putting one of these standards into effect."
A funding proposal is under creation, but an obvious source, the CDC, is considered a doubtful benefactor for the NQF. "We have talked to the CDC, but we are all cognizant of what its budget looks like for next year, and it’s not very pretty," Kizer notes.
The NQF strives to improve health care through endorsement of consensus-based national standards for measurement and public reporting of health care performance data. The organization can endorse something such as the HICPAC guidance as a "voluntary consensus standard," a kind of precursor to actual regulation.
"What comes out of our process actually does have a legal status," he says. "That legal status relates to the federal entities, so that if Medicare were to require reporting of [health care infections], it is obligated to use a consensus standard or justify that something government-specific is better. The latter is not likely to happen. If the standard is good enough for the industry, then it is probably good enough for Medicare."
How would an NQF national standard affect current state laws and ongoing state discussions? "If the states know we are working on a national template, some of them might say, "Let’s wait a few months and see what comes out of that process," Kizer continues. "The states could also take the position that they will put something in place for now; but when there is, in fact, a national consensus standard, they will move to that. My sense is that most states [that have adopted laws] would want to come into compliance with a national standard."
Wasps in the ointment
Considerable controversy still dogs the issue, not the least of which is that it was somewhat forced upon health care by the Consumers Union — a group known primarily for evaluating cars and other products. Initial resistance has turned more conciliatory, as evidenced by the "Realizing the Benefits of Mandatory Reporting" subtitle of a recent conference by the Association for Profes-sionals in Infection Control and Epidemiology (APIC).
Still, even with appropriate attitude adjustment, there are daunting logistical problems to make such laws translate into meaningful comparisons between hospitals. For example, HICPAC recommended risk adjustment of any reported infection rate data, but there is considerable question about the accuracy of such efforts.
"Unfortunately, there is currently no widely agreed-upon, scientifically validated method for risk adjusting health care-associated infection (HAI) indicators," according to a position paper recently released by the Society for Healthcare Epidemiology of America (SHEA).2
Available systems for assessing severity of illness, such as the Acute Physiology and Chronic Health Evaluation (APACHE) score or systems using discharge diagnoses, were designed to predict the risk of death rather than the risk of HAI acquisition and, therefore, are useful tools to adjust for differences in expected mortality among comparison groups, SHEA noted.
These systems, however, have not been validated to predict a patient’s risk for developing a HAI, it added.
"Objections [to rate disclosure laws] by SHEA or anyone else likely will not be productive and, in fact, may be perceived by consumers as attempts by health care providers to stonewall, foot-drag, or obfuscate," SHEA conceded.
Nevertheless, such rate reporting laws — and the very fear of poor public perception implicit in them — could create disincentives to track and report every infection. For example, some hospitals might be tempted to use "adverse selection" of patients, that is tracking patients who have fewer risk factors and are therefore less likely to develop infection.
"The possibility exists that there could be adverse selection of patients as a result of public disclosure," Patrick J. Brennan, MD, HICPAC chairman said at a press conference.
"We would certainly hope that that would not happen and that there would be appropriate prohibitions and consequences for such actions. But I think that this process is no different than any other public disclosure process in that regard. Adverse selection could be a consequence of report cards on heart bypass surgery, for example," he added.
The HICPAC guidelines warned about such unintended consequences, but also cite two studies that suggest participation in a private, organized, ongoing system for monitoring and reporting of HAIs may reduce HAI rates.3,4
"This same beneficial consequence may apply to mandatory public reporting systems," HICPAC stated. "Conversely, as with voluntary private reporting, mandatory public reporting that doesn’t incorporate sound surveillance principles and reasonable goals may divert resources to reporting infections and collecting data for risk adjustment and away from patient care and prevention; such reporting also could result in unintended disincentives to treat patients at higher risk for HAI."
Show us the money
Another major unresolved issue is assurance that ICPs will be given the necessary resources to comply with such laws, added Kathleen Meehan Arias, MS, CIC, president-elect of APIC.
"Some of the states have actually conducted studies of infection control programs in hospitals, specifically, and they have found that some of the hospitals are going to have a hard time collecting some of the data that are currently proposed, just because the resources may be not there," she said at the press conference. "The resources aren’t necessarily just personnel resources; some of the resources that we need are technology, hardware, and software programs that allow the data to be collected and accurately reported to the public."
The HICPAC template document emphasizes that "a reporting system can not produce quality data without adequate resources. At the institution level, trained personnel with dedicated time are required, e.g., infection control professionals to conduct HAI surveillance." At the system level, infrastructure needs include instruction manuals, training materials, data collection forms, methods for data entry and submission, databases to receive and aggregate the data, appropriate quality checks, computer programs for data analysis, and standardized reports for dissemination of results, the guidelines stated. Computer resources must be able to collect detailed data on factors such as use of invasive devises (e.g., central lines), patient care location within the facility, and type of operation, the committee noted.
"The right resources need to be in place if public disclosure is to be carried out properly, but the resources may include additional full-time equivalent employees in the infection control professional category or the proper information system resources," Brennan said. "But resources are essential, and in fact, I think the states that have implemented [laws] so far have really done this with the intention of raising the profile of this issue, raising the profile of infection control and prevention in hospitals, and are really sending a challenge out to organizations and to their leadership to step forward and meet this challenge."
References
1. Centers for Disease Control and Prevention. Guidance on Public Reporting of Health Care-Associated Infections. Recommendations of the Healthcare Infection Control Practices Advisory Committee. Web: www.cdc.gov/ncidod/hip/PublicReportingGuide.pdf.
2. Society for Healthcare Epidemiology of America. Public disclosure of health care-associated infections: The role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212.
3. McCall JL, Macchiaroli S, Brown RB, et al. A method to track surgical site infections. Quality Management in Health Care 1998; 6(3):52-62.
4. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety — United States, 1990-1999. MMWR 2000; 49(8):149-53.