Surgical site infection rates within the nation's hospitals are largely a secret, with public reporting required by only eight states, says a new Johns Hopkins University report, which calls for federal disclosure mandates so problem hospitals are better motivated to reduce preventable harm.
"There's a huge transparency problem within the entire industry of modern medicine," says Martin Makary, MD, a gastroenterology surgeon at Johns Hopkins University School of Medicine and the paper's lead author. "Patients by and large are still left with no useful information to make healthcare choices about which hospital to go to, and because of that fact, they don't have access to metrics that are being collected and they're forced to walk in blind."
The eight states that require public reporting are South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont and Oregon.
Of those eight, only South Carolina and Missouri require reporting on seven and five types of procedures, respectively, while the rest require reporting on four procedures or fewer. Although legislatures in 21 states require monitoring and reporting of infections, that data is not publicly available for the remaining 13. Twenty-nine states have no state reporting laws at all as of the date of the report, September of 2010, Makary says, and not much has changed since.
Makary adds that professional societies maintain risk-adjusted databases to collect hospital surgical infection rates, but they're listed without the hospital's name.
"Nothing motivates hospitals to improve quality and listen to their front line staff like public reporting," he says. "In order for the consumer to interpret publicly reported SSI rates, it is imperative that the data be collected and reported in a standardized manner," he and his co-authors wrote.
The report by Makary and colleagues is published in the current issue of the Journal for Healthcare Quality. It points to other studies showing that surgical site infections not only result in 8,000 deaths a year in the U.S., they occur in 4% to 25% of patients who undergo major surgical procedures, and their cost to the healthcare system is about $10 billion annually.
Asked why states have not been more forceful in requiring consistent, uniform reporting of surgical site infection rates, Makary blames state hospital associations, which "are actively lobbying against public reporting.
"Many states have come up with public reporting mechanisms, and they've been shot down a lot of times," he says. "I don't think there's an incentive for a hospital business manager, a CEO with a business background who is running the business, to say 'I'm going to put out stats that could hurt my business if we perform poorly in a year.' "An administrator for a hospital with a surgical infection rate that is five times higher in one hospital than its competitor would worry that it "could potentially kill the hospital," he says.
There are some indications that change is coming, however. As of Jan. 1, 2012, the Centers for Medicare & Medicaid Services instituted pay-for-reporting measures for any infection related to colon surgery or abdominal hysterectomy. This will affect payment with discharges in fiscal year 2014. Any surgeries and infections that ensue must now be reported quarterly to the Centers for Disease Control and Prevention's National Healthcare Safety Network, and shared with CMS, which will include them on HospitalCompare.
That's good, but not good enough, says Makary, because those two procedures don't capture the hospitals' real rates of surgical site infections. "Those are just two operations, out of hundreds that are commonly done," he says. At Johns Hopkins, of the 250 operations done each day, only about one is a colon surgery and only about two are abdominal hysterectomies.
Makary is emphatic that national standards requiring hospital reporting are the only way to achieve consistency for fair comparison and for meaningful efforts toward improvement.
"Our study highlights the need for the Federal Government to set the rules for how hospitals define, monitor and report SSIs," he adds.
"Though SSI process measures have received tremendous attention from CMS, the public, and the media, studies have failed to demonstrate that adherence to these measures reduce SSIs...In fact, focusing on process measures rather than outcomes may divert important resources that could improve quality," he wrote.
Emphasizing that he was not commenting on or responding to Makary's report per se, Dan Pollock, MD, CDC Surveillance Branch Chief for the Division of Healthcare Quality Promotion, explained that over time, the agencies intend that the types of procedures will be expanded for payment. "But colon (surgery) is one of the worst for infections, and we think it's really important. And abdominal hysterectomies are frequently performed." He added, "this is just a start."
Makary, a well-known advocate of expanded transparency in healthcare, is the author of an upcoming book entitled, "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care." He says public display of provider outcomes, by name as well as by facility, has the greatest impact on improving quality of care and points to New York state as a prime example.
Two decades ago, the state required mortality outcomes reporting for coronary artery bypass graft (CABG) procedures by name, he says. When the numbers were published, he says he interviewed CEOs, and heard their stories of how they came into cardiac intensive care units to ask the nurses and doctors what was going on.
"They told the CEOs: we need a dedicated cardiac anesthesiologist, we need cardiac nurse practitioners, we need to get a better cardiac ICU. And in the course of the pressure of public reporting, (these CEOs) gave them what they needed... (in some cases) resulting in a dramatic 40% reduction in (CABG) mortality almost overnight."
Additionally, the CEO was able to "look at individual physician profiles and found out there was a guy who should have retired, who had a mortality rate so high he was bringing the whole average up."
The same should happen now across the country with surgical site infection rates, he says.
But Makary's recent paper points to other problems within the emerging state reporting system, and that is the enormous variation that exists from state to state that prevents fair comparisons among hospitals.
In addition to the fact that only eight states publicly report on infections occurring in at least one type of surgery, which procedures they choose to report on varies widely. For example, only South Carolina requires reporting on spinal fusion procedures, only Ohio mandates reports on C-sections, and only Missouri requires reports on breast surgery infections. And colon surgery, which has the highest rates of surgical site infections, was only reported by two states.
"The motivation to monitor and report certain procedures over others is unclear, and further highlights the variability between states," Makary and his co-authors wrote.