By Lambert Strether of Corrente
Spoiler alert: No. In this post, I want to continue my investigation of our enormous health system, adopting as ever the position of a citizen/patient — and not the “bending the cost curve wonk,” but no longer from the outside, as a single payer advocate, but from the inside, imagining what it would like inside the system, receiving treatment. Last time, I looked at overtreatment; this time, I’ll look at Hospital-Acquired Infections (HAIs), which also have the fancier moniker “nosocomial infections.” Readers will have noticed a tendency to focus on the worst that can happen, rather than the best; but that’s just who I am. And our system provides so many opportunities for the worst to happen!
So I will ask four questions:
1) Are Hospital-Acquired Infections (HAIs) significant?
2) Have measures been taken against HAIs?
3) Has HAI been eradicated?
4) Can you avoid HAI by being a “smart shopper”?
Let’s take these questions in order. (Note that I’m not taking about other bad things that can happen in hospitals, like mistakes by doctors, or overdoses, or Kafka-esque bureaucratic nightmares. I’m only talking about infection. Nor am I talking about other medical institutions, like nursing homes; only hospitals.)
Is Hospital-Acquired Infection (HAI) Significant?
In a word, yes. From the Center for Disease Control (CDC):
On any given day, about hospital patients has at least one healthcare-associated infection.
Those odds seem uncomfortably high to me, all the more because they are unlikely to be evenly distributed. More:
In 2014, results of a project known as the HAI Prevalence Survey were published. The Survey described the burden of HAIs in U.S. hospitals, and reported that, in 2011, there were an estimated 722,000 HAIs in U.S. acute care hospitals…. Additionally, about during their hospitalizations. More than half of all HAIs occurred outside of the intensive care unit.
Have Measures Been Taken Against HAI?
They have. The CDC once more:
Among national acute care hospitals, the most recent report (2014 data, published 2016) found:
- 50 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2014
- No change in overall catheter-associated urinary tract infections (CAUTI) between 2009 and 2014
- However, there was progress in non-ICU settings between 2009 and 2014, progress in all settings between 2013 and 2014, and even more progress in all settings towards the end of 2014
- 17 percent decrease in surgical site infections (SSI) related to the 10 select procedures tracked in previous reports
- 17 percent decrease in abdominal hysterectomy SSI between 2008 and 2014
- 2 percent decrease in colon surgery SSI between 2008 and 2014
- 8 percent decrease in hospital-onset Clostridium difficile (C. difficile) infections between 2011 and 2014
- 13 percent decrease in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections) between 2011 and 2014
So it’s not like the powers-that-be aren’t working the problem; but you’ll note that all the dates listed have significant overlap with 2014’s 75K figure.
Institutional factors that encourage HAIs seem common-sense enough. Science Direct:
Risk factors determining nosocomial infections depends upon the environment in which care is delivered, the susceptibility and condition of the patient, and the lack of awareness of such prevailing infections among staff and health care providers.
Poor hygienic conditions and inadequate waste disposal from health care settings.
Immunosupression in the patients, prolonged stay in intensive care unit, and prolonged use of antibiotics.
Improper use of injection techniques, poor knowledge of basic infection control measures, inappropriate use of invasive devices (catheters) and lack of control policies. In these risk factors are associated with poverty, lack of financial support, understaffed health care settings and inadequate supply of equipment.
Low income “countries,” and not low income counties? From this list, it also looks to me like a lot of HAI prevention is tasked to what MBAs would call “cost centers,” as opposed to “profit centers.” You can bill for surgery, but not for handwashing, or training for handwashing. Hence the notion that HAI’s are profitable, hence incentivized:
While the exorbitant costs of health care associated infections (HAIs) have been repeatedly cited as a prime reason for prevention — second only to the higher calling of patient safety [thank you for that]— a somewhat shocking finding came out in a 2013 study by the respected Peter Pronovost, MD, and colleagues.
As previously reported in Hospital Infection Control & Prevention, they found that hospitals actually profit from infections in certain circumstances due to that reward higher payments for complications and outlier cases.
So, much depends on reimbursement. Who eats the excess costs? From a study in the Journal of the American Medical Association:
If all 547 [Surgical Site Infections (SSIs)] were eliminated, the data suggest that The Johns Hopkins Health System would experience a cost increase of $9,124,029 ($2,606,865.43 annually) and a billable capacity increase of 362 admissions (103 annually), equating to a revenue increase of $11,392,618 ($3,255,034 annually). Additionally, for 30-day readmissions related to SSIs, then the elimination of SSIs would provide The Johns Hopkins Health System an increase in revenue of approximately $21,288,486 ($6,082,425 annually) over the study period by increasing their available billable capacity by 922 admissions (264 annually). The data suggest that the total change in profit over the period for the health system, if they eliminated all SSIs, would be $2,268,589, $12,164,457 if it is assumed 30-day readmissions would not be reimbursed
Note that Medicare has been penalizing hospitals for re-admissions (a proxy for HAIs) and this has had some effect.)
Has HAI Been Eradicated?
Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates .
Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.
It is true that Medicare is now measuring for and penalizing the presence of superbugs, it’s not clear that such regulation as we have can outrun the abiity of superbugs to adapt. From an excellent series in 2016 by Reuters:
Yet the United States lacks a unified nationwide system for reporting and tracking outbreaks. Instead, a patchwork of state laws and guidelines, inconsistently applied, tracks clusters of the deadly infections that the federal government 15 years ago labeled a grave threat to public health.
Imagine if our IT systems were coding for outbreaks instead of for billing…
Can You Avoid HAI by Being a “Smart Shopper”?
Of course, if you live in a rural area with zero or one hospitals, you’re going to take what you can get. For those with more than one hospital to choose from, it’s hard to see on what basis — besides local reputation — comparison shopping might be done, even if your insurance network (if any) permits it. Medicare publishes tables of hospitals that it penalizes, at least, but it gives no details on what the penalties were for! And the CMS has an online “hospital compare” service that gives star ratings. But there are problems with it. Health Affairs:
A single summary score that describes overall quality at one hospital is probably not very useful for consumers. [sic] . Given that the quality for different types of care can vary widely within a single institution, it is unlikely that a single summary score would accurately represent the quality of care for all conditions or procedures at one hospital.
The stars are also fitted to a bell curve, which is the wrong sort of curve:
To construct the summary star scores, some fairly complex statistical calculations are performed, which essentially use rank order performance on individual measures, weighted by importance to come up with a summary score. The end result is a distribution of summary scores that approximates a bell-shaped curve with 48 percent of hospitals assigned 3-stars; about 3 percent assigned each 1- and 5-stars, and the rest 2- or 4-stars. There are several problems with using a curve. First, it implies a meaningful difference in performance when there might not be one. For many of the individual measures from which the summary score is derived most hospitals are no different than the national average. Second, it implies that many stars equal high quality and few stars low. . Consider the measures reported in the “effectiveness of care” domain. The average national score is over 92 percent for most of the measures; for several it approaches 100 percent. There is little clinically meaningful difference in scores across hospitals and the performance is uniformly high. For some measures, most hospitals would achieve the threshold; for others few. Whether or not a hospital reaches a quality standard for an individual measure is more important to patients and policymakers than the relative performance on individual measures, especially when performance is uniformly high or low.
I hate to say that picking a hospital is a crapshoot. But absent personal contact with hospital personnel who have “clinically meaningful” knowledge of you, your condition, and the procedure you may need, I don’t see an alternative. Reader comments on this topic, as always, are welcome.