Medical Device Daily Washington Editor

WASHINGTON — Modern healthcare has its share of problems and does not lack for initiatives to cut costs by boosting the value of care. A briefing on hospital-acquired infections (HAI) offered another potential avenue for savings, but any such movement will have to compete with the panoply of pilot programs and Medicare incentives already vying for the attention of hospital administrators.

And if proponents have their way, hospitals won’t get paid to treat infections acquired at the hospital.

The prime mover of this event at the National Press Club in downtown DC was the announcement last week that the state of Pennsylvania has commenced with annual reports on HAIs. The Pennsylvania Health Care Cost Containment Council (PHC4) looked at roughly 1.6 million patient records for calendar year 2005 and concluded that more than 19,000 patients picked up an infection in the state’s 168 hospitals. Those patients spent almost 400,000 additional days in the hospital as a consequence, running up a tab of nearly $1 billion.

The moderator for the five-member panel, David Nash, MD, the editor-in-chief of the American Journal of Medical Quality said that the Pennsylvania report consisted of “a one-two knockout punch against hospital-acquired infection.”

Nash said that “[r]egrettably, many in healthcare think that hospital-acquired infections are expected outcomes from the care of seriously ill patients,” but promised the audience that the studies to be presented at the briefing would “do much to explode the myth that infections cannot be prevented.”

Richard Shannon, MD, vice chair of clinical affairs at the University of Pennsylvania (Philadelphia), remarked that he learned a lot about safety from former Treasury secretary Paul O’Neill, who ran the Aluminum Company of America (Alcoa; Pittsburgh) for a time and re-engineered safety procedures at the company’s operations.

Shannon struck a now-familiar note when he insisted that as matters currently stand, “there are perverse incentives in the reimbursement system,” which “pays for activity and not outcomes.” There is currently “no relationship between what hospitals expenses [are] and what they get paid,” he added.

Shannon discussed a recent study of central line catheter-associated bloodstream infections that occurred over two years at Allegheny General Hospital (Pittsburgh). The data suggest that of the 54 cases reviewed, the average payment was slightly less than $65,000, but the average expense was slightly less than $92,000, yielding a net per-case loss of more than $26,000 for Allegheny.

The condition of the patient played a role in susceptibility, Shannon admitted, but he argued that the data also showed that “the severity-of-illness scores and principal diagnoses, together with the average age of the patients, suggests that process defects rather than illness were more important predictors” of central line catheter-associated bloodstream infections. He concluded that this class of infections represented a “lose-lose scenario” because hospitals spend more than they can bill for to treat such patients.

Marc Volavka, the executive director of PHC4, opened by pointing out that “sometimes, one can learn a lot from one’s critics,” a reference to the 1999 report by the Institute of Medicine titled “To Err is Human.”

He said that one of the prevailing ideas that the Pennsylvania hospital study has to fight through is that “meaningful public reporting can’t be done.” Volavka observed that many believe that the information is too complicated for the typical legislator or layperson to grasp, but that the PHC4 results prove that “it can be done.”

Volavka stated that since the PHC4 report was posted at the site provided by the state of Pennsylvania, visitors to the site have downloaded part or all of the report 123,000 times.

“I don’t think they had any trouble understanding the report,” Volavka quipped.

The second prevailing idea that he seeks to debunk is that hospital infections are inevitable, an idea that he said “lacks credence” because the problem has not been attacked in a serious fashion up to now.

“Every patient who enters a hospital” is at risk due to the “flawed processes and the chaos” in the modern hospital environment, Volavka averred, adding that an extrapolation of the Pennsylvania data to the entire U.S. population suggests that as many as 400,000 Americans pick up an HAI each year and that 50,000 of them die, incurring a cost to society of more than $20 billion (by some estimates, healthcare spending in the U.S. in 2002 was $1.6 trillion).

“If it was bird flu, we would call it an epidemic,” Volavka commented.

He advocated a different approach at hospitals to such problems, stating that “the classic way to identify [and track] infections is not time-productive.” E-surveillance software could do a better job than the current approach and that it would free up vital resources, such as a nurse’s time, to see to the needs of the patient.

Volavka said that “we’ve had some back and forth” with the Centers for Medicare & Medicaid Services (CMS), but that despite the communication, surgical site infections had disappeared as an item on the slate for public reporting initiatives at CMS. Premier (Charlotte, North Carolina) is handling the pay-for-performance contract with CMS that evaluates best practices for community-acquired pneumonia, but not any hospital-based infections.

Volavka said that in testimony before the House Energy and Commerce committee in March, he recommended that Congress disallow Medicare payments for treatment of acquired infections. Volavka told yesterday’s audience that “if Congress simply said that this was going to happen, CEOs would scramble” to deal with infections.

Nash told Medical Device Daily that in terms of overall improvement of hospital quality, infection control “could be [low-hanging fruit], but there is not a measurement set available now” to evaluate its potential impact. He said that “if a statistician looked at this work, they would give it a B+ or an A-,” but insisted that hospital could respond rapidly to a dictum from payers.

“To deny payment for a ‘never’ event” would move things along rapidly. “We’re in favor of” denial of payment, Nash said.