Don't Believe the Pennsylvania Hospital-Acquired Infection Report

When reports include claims that are clearly wrong, I wouldn't trust their entirety.  That's the case with the recently released "Impact of Healthcare-associated Infections in Pennsylvania 2010."  Dan and Mike have every reason to be surprised by the very very low infection rates. I too hope that more details concerning the validation of the HAIs will be provided soon.

However, I don't think we have to wait for more details to see that the report is seriously flawed. The error is so obvious (and so frequently repeated in other reports), that it should almost make us laugh.  The serious error is that the Pennsylvania report attempts to estimate the costs and excess length of stay associated with hospital infections by including the outcomes that manifest BEFORE the infection. 

For a better explanation, here is what we said in the methods of a recent Archives of Internal Medicine paper: "Longer hospital stays and higher costs associated with HAI cases may, in part, be due to extended preinfection hospital exposure. Because extended LOS is an independent risk factor for infection, the preinfection LOS of patients with HAIs may be expected to exceed that of similar patients who did not acquire an HAI. Attributing preinfection LOS to HAIs would overstate the true costs of HAIs...A study of 490 nosocomial sepsis cases from 8 tertiary care centers found that the mean preonset LOS was approximately 40% of the total LOS for these hospitalizations." 

To quote from the PA reports methods: "The average payment reported is for the entire length of stay, and not just for the treatment related to the infection."  It's like they are FLAUNTING THEIR ERROR. When the reports states "the estimated average Medicare fee-for-service payment for hospital stays for patients who acquired an HAI was $21,378...(and) the estimated average Medicare fee-for-service payment for those without an HAI was $6,709", we know we can't trust the estimates.  In fact, if we can't trust those, why should we trust any of it?

My copy just went into the trash.

Attention, Pennsylvania IPs and hospital epidemiologists!

I share Mike’s amazement at the low overall prevalence of healthcare-associated infections (HAIs) in recent reports from Pennsylvania (1% of all admitted patients for the years 2009 and 2010). Especially since the 5-10% estimates aren’t just from older studies. Recent studies-- in fact, virtually every study performed outside of high-stakes public reporting mandates--report similar estimates (see this WHO summary, pages 12-15, from which the I pasted part of a Figure to the right, with PA added in red). As Mike points out, an amazing achievement.

But I have to stay true to the name of this blog, so for the sake of argument I will now assume a highly impolite and cynical stance regarding this report. Here goes: I don’t believe it.

I think we have reason to assume that a healthy proportion of CLABSIs are “adjudicated away” by many centers, and lord only knows how many other HAIs (VAP, anyone?) vanish into the ether of consensus review, clinician veto, administrative adjustment, or just plain old bad surveillance. Recall also the SHEA 2011 presentation reporting evidence for gaming in the earlier PA data (using methods that can also be criticized, but the “difference-in-differences” analysis was persuasive enough for me to accept that there was both a real reduction in HAI rates, and evidence for gaming, since the PA public reporting mandate).

Now that I’ve thrown down the gauntlet, Pennsylvania, please convince me that these data are accurate. The report references validation—how was it done? Was your own hospital subject to audit of HAI rates? How many records were reviewed, if chart review was performed? What were the credentials of the auditors? As a “consumer” of health care, would you base your decisions about where to receive care on facility level data from your state reporting program?

Pretty damn good!

The 2010 report on healthcare associated infections in Pennsylvania was recently released. Since Pennsylvania mandates the reporting of all HAIs, this probably represents the most robust data that currently exist. The most important statistic in the report, I think, is that 1.1% of patients admitted to acute care hospitals developed an infection. That shows tremendous progress since previous studies estimated that 5-10% of patients developed nosocomial infections. Of the infections reported in Pennsylvania, over half were surgical site infections, 20% were urinary tract infections, and bloodstream infections accounted for approximately 10%.

Graphic:  Leica News

Hand over your money or I'll give you #MRSA

From the truth is stranger than fiction department: A man walked into Lucky's Internet Cafe in Sharon, Pennsylvania on Monday and began touching everything in the place before walking up to the cashier.  He then threatened to give the cashier MRSA if he didn't hand over the money.

The cashier refused, the man left and was later arrested at a Rite Aid Pharmacy across the street - no doubt attempting to fill his clindamycin script. I suspect the cashier was armed with bottle of alcohol hand rub under the counter, but this is just a guess.

Washington Post 1/19/2012

Sharon Herald 1/18/2012

More than you'll ever want to know.....

For those of you interested in public reporting of healthcare associated infections, Pennsylvania has just released its 2009 report on HAIs. You can view it here. Since every HAI in every hospital is reported by mandate, this report represents the closest thing to a registry of HAIs that has ever been produced, and this report represents the first full year of reporting. There are 128 pages of slicing and dicing the data. In the 250 hospitals there were 26,000 HAIs across 11 million patient-days for an overall crude rate of 2.4 HAIs per 1,000 patient days. Surgical site infections accounted for 24%, UTIs accounted for 23%, BSIs accounted for 13%, and pneumonia cases accounted for 11% of the HAIs. Note that PA requires non-device related infections to be reported as well. Rates of infections were highest in academic medical centers and long-term acute care hospitals, as would be expected considering the patient populations served. Of note, MSRA accounted for 8% of all HAIs. Of the CLABSIs reported, 16% were due to Staph. aureus, 16% were due to coag-negative staph, and 14% were due to enterococci. One caveat: there has been no true validation of the surveillance at the hospitals though on-site audits are reported to begin this summer.