The federal Centers for Disease Control and Prevention collect infection data from several hundred hospitals around the nation, but the CDC also promises hospitals to keep infection rates secret. Government, for the most part, is not helping you choose a safe hospital.
The irony is that it’s easy to get information for the less important decisions you make in life, such as where to have lunch. Most states will help you find out which restaurants and delicatessens have been cited for health violations. But you can’t find out which hospital has the worst infection rate. You can go home to make your own sandwich, but you can’t perform surgery on yourself.
The good news is that twenty-six states have passed laws to provide the public with hospital infection report cards. Publicly comparing hospital performance will motivate hospitals to improve.
New York’s experience with another type of hospital report card proves this. In 1989, New York became the first state to publish each hospital’s risk-adjusted mortality rate for cardiac bypass surgery. The results? Deaths from bypass surgery dropped 40 percent, giving New York the lowest mortality rate in the nation for that procedure. Critics of hospital report cards speculate that deaths went down in New York because hospitals avoided treating the sickest patients, fearing that high-risk operations would bring down the hospital’s grade. However, the evidence proves that’s untrue. Deaths declined for a different reason: hospitals forced their worst-performing surgeons — generally, those with low volume — to stop doing the procedure. Patients of the 27 barred surgeons were more than three times as likely to die during surgery. In technical jargon, the 27 surgeons had an average risk-adjusted mortality rate of 11.9 percent, compared with a statewide average of 3.1 percent. Wisconsin also found that report cards motivate poorly performing hospitals to improve, according to a 2001 study of 24 hospitals there.
Is there a reason not to have infection report cards? The hospital industry argues that publicly comparing hospital infection rates would be unfair to hospitals that treat AIDS, cancer, and organ transplant patients who are especially vulnerable to infection. Fair enough, but reports can be risk-adjusted to reflect these differences. What is unfair is keeping the public uninformed.
Fortunately, several other states are considering legislation to provide the public with the information they need. These states should use the model bill suggested here (Appendix A), because it improves upon the laws already passed in three ways: First, it specifies the method of risk-adjustment for surgical site infections used by the CDC, rather than leaving the risk-adjustment method to be determined by committee. This should assure hospitals that comparisons will be fair and take into account which hospitals treat especially sick and infection-prone patients.
Secondly, the bill imposes civil penalties on hospitals that fail to report or flagrantly underreport their infections. These penalties are needed. For many years, some hospitals have openly ignored data collection laws with impunity. For example, in one recent year, hospitals in New York reported only 16.5 percent of the post-surgical deaths that the law required them to report. In 2005, the first year of Pennsylvania’s hospital infection reporting program, hospitals reported only one tenth as many infections to the new program as they billed. Some Pennsylvania hospitals implausibly claimed they had no infections at all.
Thirdly, the model bill ensures that hospital infection reporting will benefit the public, not enrich trial lawyers. The bill provides that “none of the data collected and reported under this law can be used in litigation against an individual hospital.”
Next time you hear an ad on the radio urging you to use a particular hospital because it has the best doctors or the latest equipment, keep in mind what you’re not being told: how many patients get infections while in that hospital. Hospitals are doing their best to keep that information secret. In contrast, in England hospital infection rates are posted conspicuously on the front door of the hospital. Americans deserve the same information. The legislation proposed here won’t help hospitals save face, but it will help you choose a safe hospital. Let hospitals vie for your business by improving their infection rates.
The following outline is intended to help state lawmakers as they draft legislation to provide the public with hospital infection rates: AN ACT to provide the public with information on infection rates at hospitals in the state of _____________. Section 1. Definitions. (a) The public health law is amended to add a new section (lawmakers here should include the specific title of the public health or health department law to be amended). (b) “Hospital” shall mean (lawmakers here should consider whether to include only acute care hospitals or also free-standing outpatient surgical centers). (c) “Hospital-acquired infection” shall mean, as defined by the federal Centers for Disease Control and Prevention (CDC), “any localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that (a) occurs in a patient in a hospital, (b) and was found not to be present or incubating at the time of admission to the hospital, unless (c) the infection was related to a previous admission to the same hospital.” (d) “Risk adjustment” shall mean a statistical procedure for comparing patient outcomes, taking into account the differences in patient populations, including risk factors such as the number of patients on central line catheters, or the number of patients undergoing specific types of surgery, as a percentage of the overall number of patients treated. For purposes of this bill, risk adjustment shall duplicate the CDC’s NNIS System surgical wound infection risk index or use the number of central-catheter days as a risk-adjustment factor for central line infections. Section 2. (a) Using established public health surveillance methods, each hospital shall maintain a program of identifying and tracking the following types of hospitalacquired infections for the purpose of reporting such data semi-annually to the state health department (lawmakers insert the appropriate state department here): central line-associated, laboratory confirmed primary bloodstream infections contracted by intensive care unit patients, and surgical site infections. (b) The state health department (lawmakers insert the appropriate department name here) shall establish an advisory committee that includes recognized experts in the field of hospital-acquired infection, public reporting of hospital data, and health care quality management to establish data collection and analysis methodologies and risk adjustment procedures. (c) The state health department (lawmakers insert the appropriate department name here) shall establish a state-wide database of all risk-adjusted, hospitals-pecific infection rates and make it available to the public on a website and in printed materials that can be used by consumers, purchasers of healthcare, and advocacy groups to compare the performance of individual hospitals, and the aggregate performance of hospitals in the state with those in other states and nationwide. (d) The first year of data submission under this section shall be considered the “pilot phase” of the reporting system. The pilot phase is to ensure the completeness and accuracy of hospital reporting and the fairness and completeness of the state health department’s report to the public. During this pilot phase, hospital identifiers shall be encrypted, the state health department (lawmakers insert proper department name here) shall provide each hospital with an encryption key for that hospital only, and no public hospital comparisons will be available. Sixty days after the end of the second year of data submission, the state health department (appropriate department name here) will provide its first report to the public with hospital-specific infection rates included. (e) To ensure compliance with this law and the accuracy of self-reporting by the hospitals, the department shall establish an audit process. A civil penalty of $__________ shall be imposed on any hospital that fails to report on time, or is shown to substantially underreport infections, for each semi-annual reporting period. (f) None of the data collected and reported under this law can be used in litigation against an individual hospital.
The following outline is intended to help state lawmakers as they draft legislation to provide the public with hospital infection rates: AN ACT to provide the public with information on infection rates at hospitals in the state of _____________. Section 1. Definitions. (a) The public health law is amended to add a new section (lawmakers here should include the specific title of the public health or health department law to be amended). (b) “Hospital” shall mean (lawmakers here should consider whether to include only acute care hospitals or also free-standing outpatient surgical centers). (c) “Hospital-acquired infection” shall mean, as defined by the federal Centers for Disease Control and Prevention (CDC), “any localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that (a) occurs in a patient in a hospital, (b) and was found not to be present or incubating at the time of admission to the hospital, unless (c) the infection was related to a previous admission to the same hospital.” (d) “Risk adjustment” shall mean a statistical procedure for comparing patient outcomes, taking into account the differences in patient populations, including risk factors such as the number of patients on central line catheters, or the number of patients undergoing specific types of surgery, as a percentage of the overall number of patients treated. For purposes of this bill, risk adjustment shall duplicate the CDC’s NNIS System surgical wound infection risk index or use the number of central-catheter days as a risk-adjustment factor for central line infections. Section 2. (a) Using established public health surveillance methods, each hospital shall maintain a program of identifying and tracking the following types of hospitalacquired infections for the purpose of reporting such data semi-annually to the state health department (lawmakers insert the appropriate state department here): central line-associated, laboratory confirmed primary bloodstream infections contracted by intensive care unit patients, and surgical site infections. (b) The state health department (lawmakers insert the appropriate department name here) shall establish an advisory committee that includes recognized experts in the field of hospital-acquired infection, public reporting of hospital data, and health care quality management to establish data collection and analysis methodologies and risk adjustment procedures. (c) The state health department (lawmakers insert the appropriate department name here) shall establish a state-wide database of all risk-adjusted, hospitals-pecific infection rates and make it available to the public on a website and in printed materials that can be used by consumers, purchasers of healthcare, and advocacy groups to compare the performance of individual hospitals, and the aggregate performance of hospitals in the state with those in other states and nationwide. (d) The first year of data submission under this section shall be considered the “pilot phase” of the reporting system. The pilot phase is to ensure the completeness and accuracy of hospital reporting and the fairness and completeness of the state health department’s report to the public. During this pilot phase, hospital identifiers shall be encrypted, the state health department (lawmakers insert proper department name here) shall provide each hospital with an encryption key for that hospital only, and no public hospital comparisons will be available. Sixty days after the end of the second year of data submission, the state health department (appropriate department name here) will provide its first report to the public with hospital-specific infection rates included. (e) To ensure compliance with this law and the accuracy of self-reporting by the hospitals, the department shall establish an audit process. A civil penalty of $__________ shall be imposed on any hospital that fails to report on time, or is shown to substantially underreport infections, for each semi-annual reporting period. (f) None of the data collected and reported under this law can be used in litigation against an individual hospital.