Monitoring

of processes of care: do we need big brother?

Eli Perencevich, MD MS
Professor of Internal Medicine
University of Iowa, Carver College of Medicine

Controversies Blog: stopinfections.org

eli-perencevich@uiowa.edu
Twitter: @eliowa

Outline: Do we need Big Brother?

Maryland and MRSA prevention

Scope and Science of Public Reporting

Process vs Outcomes

Do we need Big Brother?

Preventing MRSA in Maryland in 2008

HAI Technical Advisory

Committee
Distinguished panel from
large tertiary care hospitals
Tasked to develop MRSA
metric for public reporting

FOR MORE INFO...

Passaretti CL et al, Infect Control Hosp Epidemiol, August 2011

6 Criteria for Reporting Measures

1)
2)
3)
4)
5)
6)

Impact (Disability, Mortality, Economic)

Improvability a gap that can be closed
Inclusiveness relevant to many populations
Frequency avoid rare events, improves accuracy
Feasibility easily collected, clear definitions
Functionality helpful in improving quality
*Outcomes measures should be risk-adjusted*

FOR MORE INFO...

Maryland Health Care Commission, 2008, http://mhcc.maryland.gov

Maryland Committee, MRSA Outcome?

Numerator: Number who acquire MRSA infection

or colonization after > 48 hours
Denominator: Patient Days, Admissions,
Discharges, Occupied Beds

MRSA Outcome Deemed Not Functional

Comparison of rates of nosocomial transmission of
MDROs between institutions may be difficult
Certain populations, IVDU or prisoners, have higher
MRSA rates and are common in certain institutions
Appropriate methods of risk-adjustment need to
be determined before this measure can be used
for public reporting

Maryland Selected MRSA Process Measure

Numerator: Number of patients admitted to ICU

who had an anterior nares swab cultured for MRSA
on admission
Denominator: Number of patients admitted to ICU

Active Surveillance Deemed Functional

Compliance with AST as a process measure is
something that is easy to measure and no risk
adjustment is necessary. The goal of 100% of ICU
patients receiving an admission anterior nares
culture for MRSA is clear
Mandatory Reporting: January 2009

2007 SHEA and APIC Position Statement on

Active Surveillance for MRSA and VRE
Do not support legislation to mandate use of active
surveillance cultures to screen for MRSA/VRE
To mandate this strategy as the single infection
control intervention to be applied in all
circumstances would preclude local risk assessment
and implementation of a broad range of
interventions needed to control infections

FOR MORE INFO...

Weber SG et al, Am J Infect Control , March 2007

Inflexibility of legislative mandates

Legislation in general is not sufficiently flexible to
permit rapid response to local epidemiologic trends
or changes in the understanding of the spread and
consequences of antimicrobial resistance
Local experts should be permitted the latitude to
assess the risks of, needs for, and priorities in the
application of guidelines and recommendations to
prevent and control HAI

Best laid plans of MRSA control

MDR-Acinetobacter, > 48 hours in Red

Collecting swabs we no longer need !!

Mandatory gowns/gloves instituted in ICU settings
MRSA swabs no longer needed since all patients
placed on contact precautions

Swabs collected for public reporting added

significant costs without benefits

*Footnote: Maryland discontinued MRSA AST requirement in 2012 and

added facility-wide MRSA bacteremia cases in 2014
FOR MORE INFO...
Wright MO et al. ICHE 2004, Harris AD et al JAMA 2013, Yin J et al Pediatrics 2013

Public Reporting

State of Reporting in the United States

Surveillance from local tool

1970 National Nosocomial Infection Surveillance Network

(NNIS)/National Healthcare Safety Network (NHSN)
Designed to classify internal facility-specific quality metrics

to guide LOCAL prevention efforts

Benchmark local data against deidentified pool of members
Long-standing, field tested track record
Measure HAI burden and prevention effort effectivenes
FOR MORE INFO...
Talbot TR et al, Ann Intern Med 2013

Now with State and National Consequences

Mandatory reporting to state health departments

Pennsylvania and Illinois (2003)

Public access www.hospitalcompared.hhs.gov

Insurers and payers for reimbursement
CMS (Centers for Medicare & Medicaid Services)

Pay for Reporting, Pay for Performance

65% HAC-score is CLABSI, CAUTI

top quartile 1% $ cut

Landscape of Public Reporting

CDCs National Healthcare Safety Network (NHSN) has

migrated from a sentinel surveillance program to a national
performance measurement system, the number of facilities
reporting has surpassed 4,000 for acute care hospitals, and
15,000 when including dialysis facilities, long term care,
inpatient rehabilitation, and long term acute care.1
33 US States mandate reporting into NHSN2

FOR MORE INFO...

1.
2.

Fridkin S. http://haicontroversies.blogspot.com/2016/03/show-me-data.html
http://www.cdc.gov/hai/pdfs/state-progress-landscape.pdf (2 April 2016)

Federal HAI Reporting To NHSN

2011

CLABSI Acute Care ICUs (Jan.)

CAUTI Acute Care ICUs (except NICUs) (Jan.)

CAUTI LTCH, IRF, Cancer Hospitals (Oct)
SSI Colon Surgeries and Abdominal Hyst. Acute Care (Jan)
Dialysis Events ESRD (Jan)
CLABSI LTCH, Cancer Hospitals (Oct)

2013

C. Diff LabID Events Acute Care (Jan.)

MRSA Bacteremia LabID Events Acute Care (Jan.)
HCP Influenza Vaccination Acute Care (Jan.)
HCP Influenza Vaccination LTCH (Jan.)

2014

HCP Influenza Vaccination ASCs (Oct.)

SSI Cancer Hospitals (Jan.)
HCP Influenza Vaccination IRF (Oct.)

2015

CLABSI Acute Care Med, Surg, Med/Surg Units (Jan.)

CAUTI Acute Care Med, Surg, Med/Surg Units (Jan.)
MRSA Bacteremia LabID Events LTCH (Jan.)
C. Diff LabID Events LTCH (Jan.)

2012

Specific MDROs now targeted - CRE

FOR MORE INFO...

http://www.apic.org/ last updated 1 April 2015

Long-term care now included

FOR MORE INFO...

http://www.apic.org/ last updated 30 July 2012

https://www.medicare.gov/hospitalcompare

Europe

Infection Control Experts in 34 European Countries

ECDC National Contacts and expert survey (2010-12)

2010 48% countries HAI reporting, 21% mandatory

70% Questioned public benefit, 50% by 2011

Majority favored structure and process measures

Concerned outcome measures interfere with infection
prevention, create underreporting incentive

FOR MORE INFO...

Martin M et al (PROHIBIT study group), J Hosp Infect 83 (2013) 94-98

England - NINSS

Nosocomial Infection National Surveillance Scheme

1996, voluntary and confidential HA-BSI, SSI

2001, public reporting of all S. aureus/MRSA BSI

Added VRE, orthopaedic SSI, C. difficile infections
MSSA and E. coli bacteremia
No device-related infections, no process measures

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

England Fingertips System

FOR MORE INFO...

http://fingertips.phe.org.uk/profile/amr-local-indicators

France mandated select HAI reporting (2001)

2003 Ministry of Health 4 performance indicators

ICALIN indicator on 31 services, resources, activities
Litres of alcohol hand rub / 1000 in patient days (2005)
Proportion of surgical depts. doing SSI surveillance (2005)
Antibiotic stewardship activities and use (2008)

Global aggregate indicator (2009) 5 classes ranks

3-year average of MRSA in diagnostic specimens (2009)

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Germany mandatory surveillance, not reporting

KISS (Krankenhaus-Infektions-Surveillance-System)
Voluntary (50% participate) and confidential

1997

Surveillance of device-associated HAI, SSI mandated

since 2000; not reported routinely
Neonatal ICU confidential reporting since 2006

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Comparison of Approaches

Majority favor outcome measures

Clinical relevance, simplicity if lab-based

France favors process measures

Uncertain reliability of outcome surveillance

England favors lab-based data

Risk adjustment NHSN, KISS, MRSA target England

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Mandating Unclear Benefits

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Public Increased Commitments, Happy Public

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Disadvantages Skew Priorities and Gaming

FOR MORE INFO...

Haustein T et al. Lancet Infect Dis 2011

Gaming: Clinical Adjudication Panels

Veto power by clinicians external to infection

prevention programs1
Confuse surveillance definitions and clinical care
Not trained, Unconsciously biased if held accountable

70% US CLABSI surveillance with adjudication (i.e.

clinical veto, consensus)2

FOR MORE INFO...

(1) Talbot TR et al, Ann Intern Med 2013, (2) Beekmann et al, ICHE 2012

Do Patient Understand of Hospital Compare?

110 inpatients compared 2 hospitals CAUTI data

Task 1 evaluation better worse than benchmark

Task 2 evaluation + infections, catheter-days, SIR
Task 3 hospitals same ranking (task 1), SIR different
Task 4 data only, no evaluation

FOR MORE INFO...

Masnick M et al. Infect Control Hosp Epidemiol, February 2016

Current public HAI data presentation inadequate

FOR MORE INFO...

Masnick M et al. Infect Control Hosp Epidemiol, February 2016

USA HICPAC Recommendations on Public

Reporting on HAI Surveillance Data
1.
2.
3.
4.
5.
6.

Use NHSN Definitions

Final authority should rest with IC experts
Allow IC experts to maintain integrity of data
Document reason for inclusion/exclusion of HAI
Avoid clinical adjudication of clinician veto
Reported data should be validated by an impartial
external party (state, CMS)

FOR MORE INFO...

(1) Talbot TR et al, Ann Intern Med 2013, (2) McKibbon L. et al. AJIC 2005

This is a tide that will not be turned

MRSA, CDI rose in first three years after mandate, then targets set
It could be argued that it has taken the setting of a target (MRSA, CDI)
to address issues that are organization wide
Infection prevention and control teams now have access and influence
at levels thought unimaginable in the year 2000
Public reportingdoes engage politicians and organizations

FOR MORE INFO...

Kiernan MA, J Hosp Infect. 2013 Feb;83(2):92-3.

Making Sausage: Process vs Outcomes

https://danielnailen.com/2012/07/17/sausage-making-comes-to-utah/making-sausage/

Why are outcomes currently in favor?

Measure what is important infection, death
Reflect all aspects of processes, not just measured ones

Technical expertise, operator skill (not just what but how)

External entities (insurers, public) less concerned with

the cause (process) than avoiding infection
May be easier to capture electronically

FOR MORE INFO...

Mant J. Internation J Qual in Health Care 2001; Vol 13 (6):475-80

Reasons for variations in outcome measures

FOR MORE INFO...

Mant J. Internation J Qual in Health Care 2001; Vol 13 (6):475-80

Is CAUTI objective, preventable harm?

Definition: (foley > 2 days), UCx >105 CFU/ml, UTI

symptoms (80% of time, fever>38C)
48-76% in ICU have foleys; Fever in 26-70%1
Asymptomatic bacteruria -

19% elderly, 50% LTCF1

Not allowed to exclude other causes of fever (68%)2

CAUTI dont extend stay, 0.3% of all HAI $ costs

FOR MORE INFO...

(1) Livorsi DJ, et al. ICHE November 2015 (2) Tedja et al ICHE November 2015

Better CAUTI measures?

Device use denominators cause problems

If intervention targets removal, could increase rates!
Response: Switch to patient day denominators

Better Process? - Foley utilization

Better Outcome? CAUTI treated with antibiotics
Discourages treatment of asymptomatic bacteruria
Could it also lead to under treatment?

FOR MORE INFO...

(1) Livorsi DJ, et al. ICHE November 2015 (2) Tedja et al ICHE November 2015

Hospital-Onset Bacteremia (HOB) vs CLABSI

HOB >48 hours, 80 ICUs, 16 hospitals SHEA Network

After adjusting for blood
cultures obtained - >
1 HOB/1,000 ICU days =
2.5% CLABSI, p<0.01
HOB 75% discriminate
CLABSI 25% discriminate

FOR MORE INFO...

Rock C et al. ICHE February 2016

Embracing Process Measures

Continuous tracking of key metrics needed to

improve outcomes if problem detected (SSI)
Antibiotic selection and timing, glucose control
Dont need to wait for bad outcomes

No need for complicated risk adjustment

More direct measure of quality

No sample size issues unlike rare outcomes

FOR MORE INFO...

(1) Bilimoria KY JAMA October 2015; (2) Mant J. Internation J Qual in Health Care 2001

Conclusion: Do we need big brother?

This is a tide that will not be turned
Favor outcome over process

What public and politicians want

Mandated processes hinders local response
Need to avoid adjudication, subjectivity

New outcome measures

Hospital onset bacteremia, foley utilization

Special thank you!

Martin Kiernan, Jan Kluytmans, Jon Otter, Gabrield

Birgand, Christine Peters, Russell Hope, Didier
Pittet, Claire Kilpatrick, Maaike van Mourik, Joan
Hebden, Marc-Oliver Wright, Stephanie Holley