Here is the headline, "Trump administration rule could stop public reporting of hospital infections despite death toll," taken from the online version of USA today. The article goes on to report that CMS is proposing to remove six measures of “patient safety” from its ratings of hospitals. Those measures are all hospital-acquired conditions so that they do reflect in part how hospitals perform and they include:
- Infections related to placement of urinary catheters
- Infections related to placement of central intravenous lines
- Wound infections after colon surgery or abdominal hysterectomy
- Blood-borne Infections due to Methicillin Resistant Staph Aureus
- Infections due to Clostridium dificile [1]
On the face of it, it seems like a real loss of transparency, what are the hospitals hiding? But a closer examination of the proposal, and it is at this time a proposal open for public comment, reveals a more complicated issue.
CMS states that continuing to collect this information to be reported by the Hospital Compare program is a greater cost than benefit. And while you may be skeptical about that view, the truth is the information will continue to be reported but to a different program, the Hospital Associated Condition Reduction Program. ( You have to love those government names). More importantly, the financial penalties for being in the bottom 25% of hospitals, losing 1% of your Medicare payments, remain in place. So this will, in fact, be less burdensome for hospitals in not having to duplicate reporting and perhaps the money and time saved will allow them more resources to fix the problem.
Safety measures would then no longer be part of the Hospital Compare rating system. The current measures of patient satisfaction and outcomes would be maintained, and safety would be replaced by a measure showing the cost of care for Medicare patients. But all of this shuffling of the deckchairs misses a fundamental question, how valuable and how often are these metrics used by patients, after all, that is the intended audience. Here, data is sparse, opinions plentiful.
The biggest argument about these measures of safety is that they do not reflect the entirety of clinical conditions present, they lack context. Certainly, if you are not having these abdominal operations or having a central line or urinary catheter placed the information is not directly pertinent to your care. MRSA bloodstream infections are closely related to those central lines so again it might not be directly relevant. Finally, C. dificile infections are more closely associated with long courses of antibiotics, so for a majority of patients, it does not pertain directly to them.
A less mentioned problem is that medical care changes faster than the metrics. For example, there has been a legitimate push to improve the results for placement of central lines and the associated bloodstream infections. These lines are placed to allow easier access to a patient's blood, to take samples and to give medications that might injure small, more delicate veins. They are very useful when patients are ill. The improvement in infections associated with these lines has come through checklists, more standardized care in placing and caring for the lines and by not using so many of them. Physicians have substituted another type of access, a peripherally inserted central catheter (PICC) in its place that significantly lessens the risk of infection, it also greatly increases the risk of a clot in the vein, thrombophlebitis. The incidence of these types of clots has gone from occasional to about 10% of all hospital-related clots - but this is not a reported safety measure.
Finally, there is the question of how useful safety ratings are to the public. More and more care is provided in outpatient settings, not reported by Hospital Compare. And most hospital choice is governed by insurance or physician choice, ask yourself, when was the last time you sought care based primarily on where it would be provided rather than who was providing the care?
As is often the case in healthcare, safety is a nuanced issue that requires more than a soundbite or pull quote. It is difficult to capture all the details and concerns in 500 words, this article included.
[1] This is taken verbatim from the 500 page Proposed Rule Changes for 2019 that CMS has published.
