Outcome bias

I grew up in Wheaton, Illinois, one of Chicago’s western suburbs, and became a Cubs fan by default. All my friends were Cubs fans, my dad took us to Wrigley for games (never Comiskey!), and the Cubs games were televised on channel 9 while the White Sox were usually on a UHF channel (44) that was hard to tune in (if you remember wiggling a dial to get your grainy local UHF signals, you are old like me). The photo above is from a game I attended in 1969 with my family. That year, and every year since 1945, ended the same way: with the Cubs failing to win the NL pennant. 

So last night’s victory is a gigantic step forward for the Cubs, who will now play Cleveland in the World Series. By now you’re asking, “yes, but that’s a game and this blog is about infection prevention, what’s the connection”?

See Cub manager Joe Maddon’s quote in this piece, about how he approaches challenges:

“When you get to this particular moment, to try to avoid being outcome-biased, just . . . continue to work on the process, which is inning by inning — score first, win the inning. Those are the kind of thoughts that get you beyond this moment.”

I think you can interpret this quote in two ways, each of which applies to infection prevention. 

First, he may have meant to say “avoid being outcome-focused”. In other words, stop wasting energy worrying about your outcomes, instead put your energy into the processes that you know will, eventually, move the outcome in a favorable direction. This is becoming increasingly difficult in infection prevention as CMS PFP programs put more and more pressure on rates. The temptation is to put time and energy into activities that might impact the outcome quickly but without doing anything to improve the safety of patients (gaming the definitions, empiric treatment approaches, changing lab practice). Counterproductive, and in many cases also bad for patients.

Alternatively, he could have been literally referring to “outcome bias”, which is an error in evaluating the quality of a decision, or the effectiveness of a practice, when the outcome is already known. This might lead one to deviate from an effective practice because a bad outcome occurred in the past when the practice was in place, or to institute a dubious practice because prior implementation was coincident with a favorable outcome. This ignores the fact that outcomes are often influenced by a myriad of factors, many of which are not understood or not under the decision-maker’s control.

The infection prevention take-home from either interpretation? Focus on those practices that have been demonstrated to improve outcomes--keep your eye on the process and the outcomes will follow. Avoid gimmicks that might move the outcome needle but for which no evidence exists that patients will benefit.

P.S. I hope to see you at IDWeek in New Orleans!  I'll be joining Debbie Goff on Saturday morning to talk about social media, and Thursday will be facing off with Cliff McDonald about the C. difficile screening issue!  We will also be presenting four-center data on the ongoing M. chimaera outbreak on Saturday afternoon. If I am mysteriously absent from any of the above, it's because I'm on a plane headed to Cleveland or Chicago, to try to sneak in to a World Series game!

Public Reporting - Do we need big brother?

I was fortunate to be an invited speaker at the 2016 ECCMID meeting in Amsterdam last week. My topic was "Monitoring Process of Care: Do We Need Big Brother?" I used the opportunity to take a big picture view of public reporting of HAI and MDRO data in the US and Europe and a closer look at the selection of process versus outcomes measures for reporting. I've posted my slides below and you can also listen to my talk on ECCMID's website. As I believe Dan stated earlier, I hope that all meetings evolve to allow free/open access to presentations like ECCMID has.

C. difficile and Hospital Process Measures: What Works?

One of the more difficult things to cover is a study that you've already written about in an accompanying editorial. It's quite hard to come up with anything "new" to write that you haven't already written. Such is the case with a very nice study examining hospital process measures and C. difficile infections just published in BMJ Quality and Safety by Nick Daneman and colleagues from Sunnybrook Health Sciences Centre in Toronto.

Using results of a mandatory CDI prevention practices survey they compared facility-level processes measures and patient level (via ICD-10 codes) CDI rates in 159 Ontario hospitals. Specifically, they looked at implementation of six hospital-level measures: (1) isolation at diarrhea onset, (2) audit of antibiotic use, (3) audit of environmental cleaning, (4) vancomycin as first line therapy and (5) on-site diagnostic testing and (6) reporting of rates to senior leadership. Somewhat surprisingly, none of the process measures were associated with lower risk of CDI.

In the editorial, Nasia Safdar and I wrote:

"First, the authors identified low self-reported implementation of most CDI prevention practices, with only 27% of facilities reporting isolation of all patients at onset of diarrhoea, and 16% reporting auditing of antibiotic stewardship practices. Low adherence rates for these two practices in particular are concerning because prompt institution of contact precautions is necessary to reduce nosocomial transmission of C. difficile. And antimicrobial stewardship is at least as important as infection prevention practices, if not more so, for reducing CDI."

"This study also highlights the importance of implementation science research to tackle the vexing yet pervasive problem of low and variable adherence to evidence-based interventions for reducing HAI, including CDI. The scope of this study did not extend to exploring barriers to implementation or an in-depth assessment of the self-reported practices that may help inform implementation strategies to increase uptake of proven practices."

and of course my favorite part:

"Last, increasing the evidence base for preventing CDI by undertaking pragmatic randomised controlled trials of novel interventions incorporating efficacy and effectiveness is essential to successfully bridge the quality chasm that currently exists in CDI prevention."

Reference: Daneman N. et al. BMJ Qual Saf. 2015 Apr 24 (open access)