Making hospital-acquired infection rates transparent
Hospitals have an ethical obligation to release data
The push to make hospital infection rates more transparent is, on its face, an institutional and a patient safety issue. But there also is an ethics component, experts say, and health care has a duty to inform the public on hospital-acquired infections and to put that information in perspective so that it is not misleading.
At a March hearing before a U.S. House Committee on Energy and Commerce sub-committee, members of congress warned the Centers for Disease Control and Prevention (CDC) that cuts in federal funding could loom for hospitals that fail to get their infection rates under control. And more and more states are legislating that hospitals disclose their infection rates — a trend that one ethicist says should be greeted with a mixture of support and caution.
Hospitals do need to be transparent, says Lauris C. Kaldjian, MD, PhD, director of the University of Iowa Carver College of Medicine program in biomedical ethics and medical humanities. However, that transparency needs to render information that is useful to prospective patients, not simply numbers without context.
"How do patients calculate the importance [of the data on infection rates]?" he asks. "If one is going to refer to metrics, they should refer to ones that are the most useful."
Report infection rates same as medical errors?
Pennsylvania was the first state to adopt a law mandating reporting of infection rates, and the director of the Pennsylvania Health Care Cost Containment Council (PHC4) says the state's data show patients who acquire an infection while they are hospitalized are five times more likely to die than patients who avoid hospital-acquired infections.
Letting a community know that about its hospitals is very much an ethical issue, says PHC4's executive director, Marc Volavka.
"I am a strong believer in transparency," says Volavka, who likens reporting infection rates to being truthful in disclosing medical errors.
"In that context, from my perspective and [PHC4's] perspective, it is an ethical issue to some important degree," he suggests. "It is a component to what is right and ethical about letting patients know what is occurring in the hospital setting."
Kaldjian agrees that a community deserves transparency in infection reporting but says that is only part of the equation.
"This has been much discussed, back as far as [New York hospitals] reporting cardiothoracic surgery outcomes," he says. "Where do we draw a line between possible complications and medical error? That implies that [the event being disclosed] was preventable."
Because infections are one of the risks inherent in "puncturing, invading, and treating" a human body, Kaldjian points out, many infections are complications of necessary care and not the result of medical error or careless practices.
"These processes are necessary, but every time you invade the human body, you are creating a transit route," he says. "Through our best practices and standards of care, we try to limit the likelihood that bacteria will travel through those routes and cause infections that result in disease and illness, but we know that's a possibility."
Providing context for the numbers
That is the kind of contextual information that should accompany disclosure of infection rates, for the numbers to mean anything useful to patients, Kaldjian says. Only if a hospital had "all the money in the world and all the resources in the world" could it hope to limit iatrogenic infections, he suggests; but still, simply releasing numbers of cases without educating consumers might suggest that infection rates are completely controllable.
Another question is, how many cases are too many?
"Is there a rate of infection that is the gold standard?" Kaldjian asks. "That line has to be taken very seriously and addressed."
Other points to consider include how many categories of infection should be communicated to patients and how best to help patients calculate the importance of the information, Kaldjian adds.
For example, if the best brain surgeon on the West Coast is at a hospital with only average infection control rates, would patients deprive themselves of the stellar care that a surgeon could provide and opt instead for less-skilled care at a facility that has better infection control numbers?
"How do patients calculate the importance of the information?" Kaldjian asks. "If you are going to refer to metrics, you need to refer to the ones that are most useful."
Infection control — a new advertising tool
With transparency of hospital-acquired infection comes the inevitable ads claiming "best infection control rate in the region."
Kaldjian says the hospitals that choose to be most transparent in their disclosures could be "rewarded" by their transparency being used against them, with competitors using the information as a tool for their own gain.
"When I think about this issue, I think about two principles: transparency and justice," he explains. "In health care, we should not have anything to hide, and if we're inclined to hide things, then we need to question ourselves. And it's a matter of justice in that hospitals that are better about collecting and reporting their data should not be penalized for that."
Volavka says hospitals that are straightforward with their patient populations about infection rates are likely to find that transparency boosts patient confidence rather than undercutting it.
"The Veterans Administration has found this out, because it has been most prominent in taking a different tack than others when it comes to medical error disclosure," he says. "What they have found is that patients want straightforward, honest answers, and that when that happens, they are not as likely to sue."
Volavka recounts being on a radio talk show recently. When he spoke about reporting infection rates, callers vented frustration about the lack of transparency, and those who had had first-hand experience with a hospital-acquired infection simply wanted straightforward answers and a demonstration of what the hospital was planning to do to prevent recurrences.
"I think the provider community, in broad terms, would be better served by being more transparent," he says. "But public reporting still has its skeptics. Our experience has been that public accountability brings focus on providers to improve, and the knowledge of public accountability has spurred the provider community to engage in quality improvement efforts."
Volavka agrees that, often, infections contracted in the hospital are the consequence of necessary procedures, but that simple and effective means of prevention can curb infection rates when rigorously observed.
Kaldjian has this to offer as a starting point for hospital administrators debating whether to support transparency in reporting infection rates:
"If an administrator needed medical care and leaned toward not receiving care from his or her own institution due to insider knowledge about infection or error rates, that would be a pretty straightforward test of whether or not that information should be disclosed to the public."
Sources/Resources
For more information:
- Lauris C. Kaldjian, MD, PhD, department of internal medicine, director, program in biomedical ethics & medical humanities, University of Iowa Carver College of Medicine, Iowa City, IA. E-mail: [email protected].
- Marc P. Volavka, executive director, Pennsylvania Health Care Cost Containment Council (PHC4), Harrisburg, PA. Phone: (717) 232-6787.
- "Ethics in infection control: How to balance the one against the many." Hospital Infection Control June 2005, 65-68.
- "Sea change begins with storm: Feds threatening action to stop infections." Hospital Infection Control, June 2006, 61-66.
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