90,000 Americans die from hospital-acquired infections every year, more than from auto accidents and homicides combined.
Public Disclosure of Hospital Infections
Consumers Union, publisher of Consumer Reports, supports four bills (S1308, HB 2729, HB 2743, and HB 2745), which require Massachusetts hospitals to submit data on hospital-acquired infections for the purpose of reporting hospital-specific infection rates to the public.
In July, 2005, the Pennsylvania Health Care Cost Containment Council published the first report in the U.S. on incidences of hospital-acquired infections in that state. Although the agency found that hospitals underreported the infections occurring at their facilities, the hospitals identified almost 12,000 infections that caused over 1700 deaths in 2004. The estimated charges for these 12,000 infections totaled $2 billion. The agency also asked third party payers about the average cost to treat a patient with an infection – the cost was more than $29,000, compared to the average cost of $8300 for a patient without an infection.
We strongly support this legislation which will give consumers important patient safety information. The following points address many of the issues that are raised as similar legislation has been debated in the 34 other states this year. Transparency around something as basic as the ability of a hospital to prevent and control the spread of infection will save lives and reduce health care costs.
Hospital-acquired (“nosocomial”) infections are a major health care problem.
They are most common among patients using invasive devices like intravenous tubes (IVs), catheters, and ventilators – and among surgical patients, elderly patients, infants, and ICU patients.
• 90,000 Americans die from hospital-acquired infections every year, more than from auto accidents and homicides combined.
• An additional 1.9 million people get an infection that does not cause death, but leads to weeks, months and years of rehabilitation and treatment; permanent disability; and loss of jobs.
• Depending on the type of infection, these patients spend from one to 30 extra days in the hospital.
• Hospital infections add billions of dollars to the cost of health care, paid for by individual consumers, employers, state/federal government programs, and health plans.
Hospital infections add significantly to state and national health care costs
• The CDC estimates that hospital infections add $5 billion every year to our national health care costs.
• Serious infections acquired during surgery add approximately $57,000 to these patients’ hospital bills due to extended stays (almost 11 more days of care).
• A 2000 study found that targeted infection control intervention was cost effective in reducing the rate of respiratory nosocomial infections in a large pediatric hospital – for every dollar spent on the program, approximately six dollars were saved.
• Based on the findings of the first state report on hospital-acquired infections in Pennsylvania, the Wall Street Journal reported: “There is no reason to think that Pennsylvania hospials are any better or worse at controlling infections than those inother staes. Extrapolating from the Pennsylvania data to the rest of the country suggests that morethan 125 people a day are dying from hospital-acquired infections with an associated $50 billion of related hospital charges every year, [the agency] estimates.”
Mandatory reporting is needed to make information available on all Massachusetts hospitals
• To provide for accurate comparisons. Voluntary systems leave individual consumers and employers with incomplete information about the hospitals in their area.
• Hospitals with good infection control programs have an incentive to participate in voluntary systems, while hospitals with poor programs have no incentive to risk sanction.
• Hospitals choose when to report in a voluntary system, so information may be available one year, but not the next.
• Information should be publicly available on a timely basis so it is an accurate reflection of the hospital’s quality of care.
• Existing national reporting efforts are voluntary and secret.
• The CDC’s National Nosocomial Infection Surveillance System has collected hospital infection data for 30 years from 315 US hospitals. Participating hospitals collectively reduced their infection rates during the 1990s, but there is no information for patients or employers to distinguish the best from the worst.
• The CDC has now converted this to a National Healthcare Safety Network that will allow more hospitals to participate, but will remain voluntary and confidential.
• The Joint Commission on Accreditation of Health care Organizations (JCAHO), which accredits hospitals for participation in the Medicare program, asks hospitals to voluntarily send hospital infection incidents to them but admits that hospitals are not doing so. Since 1996, only 57 infection-related adverse events have been reported to JCAHO. JCAHO has recently “toughened” their infection control monitoring, but hospital-specific results will not be public.
• Since September 2003, Consumers Union has received over 800 reports of infections from consumers – not all resulted in death but most occurred in the past 5 years.
• Pennsylvania has two reporting systems – the voluntary confidential adverse events system reported 747 hospital-acquired infections while hospitals identified almost 11,668 infections under the mandatory reporting system and billing records indicate there may have been as many as 115,000 hospital-acquired infections.
Reasons to support public disclosure of hospital-acquired infection rates.
• Reporting of performance can drive quality.
• For the first time, hospitals will be required to look for infections that are spread within the facility and this will cause more of them to address the problem.
• Hospitals will be able to see how they compare to their competitors, and when this information is publicized, they will have an incentive to improve their performance.
• When New York published hospital mortality rates for heart bypass surgery (CABG), mortality declined by 28% while nationally, mortality for this surgery declined by 13%. The NY decline was partly related to public dissemination of information.
• A recent Wisconsin study found that making hospital performance information public “stimulated quality improvement activities in the areas where performance was reported to be low.” The study found added value in publicly disclosing such information versus reporting privately back to the hospital.
• Disclosure gives individual consumers and large health care purchasers like employers, information that will help them make wiser health care choices and drive competition in health care based on quality of care.
Hospital-acquired infections are preventable.
• Hospital infections can be reduced significantly by adherence to well-organized infection control programs, including simple practices like hand-washing.
• The CDC recommends for health care workers to use alcohol-based hand products to clean between patients. Even though improved hand-washing reduces infection rates significantly, hand-washing compliance rates are generally less than 50 percent. Hand hygiene adherence rates are lowest in the areas where it is most needed: ICU, surgery, anesthesia and emergency medicine.
And much can be done to reduce infections, yet most hospitals are not using these scientifically proven methods 100% of the time:
• A study of neonatal ICU infection found that a campaign of aggressive monitoring and education dropped the infection rate from 42 percent to 12 percent in five years.
• Studies indicate that the use of catheters coated with antimicrobial or antiseptic agents can reduce infections, although they cost slightly more.
• Surgical site infections, the second most common type of hospital-acquired infection, can be reduced through timely administration of antibiotics before surgery and timely discontinuation following surgery.
• Simple reminder systems to remove catheters can prevent urinary tract infections.
• Raising the head of the bed for patients who are on ventilators can prevent ventilator associated pneumonia, one of the deadliest hospital-acquired infections.
Hospital infections are on the rise because our health care system does not have a culture of prevention; rather it has a culture of reacting after the infection occurs. Other reasons why the rate of infection is rising:
• Hospitals use more invasive procedures than ever before.
• People in hospitals are sicker, which requires more diligence in infection control.
• While the rate of infection per patient has remained stable (1 in 20 patients get an infection), because of shorter hospital stays over the last 20 years, the rate per patient days has increased (Weinstein, 1998)
• The incidence (number per 1000 patient days) in 1975 was 7.2; in 1995 was 9.8 (Burke, NEJM, Feb 2003)
• The rise of antibiotic-resistant superbugs:
• Most antibiotics are not effective in treating these infections, so they often cannot be cured.
• A recent surgical site infection (SSI) analysis presented at a conference of epidemiologists found (using CDC data from 1993-2003) the rate of SSI following knee and hip replacement surgery is increasing, and the rise is due primarily to an increase in the rate of SSI caused by MRSA, an antibiotic resistant infection.
• These superbugs have walked out of the hospital doors into our communities and we are now seeing MRSA infections coming from high school locker rooms, day care centers, and jails/prisons. Ten years ago, MRSA was rarely seen outside of a health care facility.
Centers for Disease Control and Prevention (CDC)
• In February 2005, the CDC issued guidance to states considering public reporting bills; these bills should include:
• An advisory committee with infection control experts, consumers, public health officials, and health care providers, should be created to assist the state agency in the planning and oversight of the reporting process.
• Collection techniques should be standardized, data should be risk-adjusted, and provide for feedback to health care providers.
• Measures to be initially reported:
• Three “process” measures, rates of adherence to:
- Central line (IV) insertion practices,
- Proper antibiotic timing before and after surgery, and
- Flu vaccines for health care personnel and patients.
• Outcome measures, rates of:
- Central-line-associated blood stream infections in the ICU that are laboratory confirmed, and
- Surgical site infections following selected operations.
• The CDC intends to continue to review this issue and to recommend additional measures in the future.
Activities in other states
• 35 states debated public reporting of hospital-acquired infections this year.
• Six states (Missouri, Illinois, Pennsylvania, Florida, Virginia, and New York) now have laws in place requiring hospital infection information to be available to the public.
• Pennsylvania is the only state that has collected a full year of information and issued their first report in July, 2005, as indicated in the introduction of this testimony. The report was a statewide report, without hospital specific rates, because the agency believes the data was seriously underreported and does not accurately reflect the infection rates of the majority of hospitals. The agency is working with hospitals to improve reporting and will be conducting audits when necessary. They intend to publish hospital specific rates in future reports.
Other states estimate the cost to their Medicaid and other state programs
• New York estimates local and state Medicaid expenses to treat hospital infections: $100-200 million; estimated cost statewide $1.9 billion (using the CDC estimate of infection of one in 20 patients and an average cost per infection of $15,000).
• Colorado: Estimated additional cost (for the limited reporting in their bill) $3 million state funds.
• Pennsylvania: $125 million state funds spent on hospital infections for Medicaid enrollees and state employees. In the first report, the Pennsylvania Health Care Cost Containment Council estimates third party payments (distinct from hospital charges) for 12,000 infections was $350 million. The average cost to treat a patient with an infection was more than $29,000, compared to the average payment of $8300 for a patient without an infection.
• Texas: $32 million for 2/3 of the Medicaid population (for a limited list of infections).
For more information contact: Lsa McGiffert, www.StopHospitalInfections.org, 512-477-4431 ext. 115.