Are financial disincentives and the underreporting of healthcare-associated infections (HAIs) more than speculation? The answer to this question would appear to be a resounding yes based on two recent publications: a recent commentary entitled “Infection control: Public reporting, disincentives, and bad behavior”1 and a communique alert2 written jointly by the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) emphasizing the importance of adhering to the CDC’s infection definitions and criteria for HAI reporting.
In his commentary, Dr. Horowitz (Professor, Division of Infectious Diseases and Immunology at NYU School of Medicine) notes that the surveillance definitions used by infection preventionists (IPs) are necessary to ensure standardized and consistent case-finding for valid intra- and inter-hospital comparisons but that the ignorance of clinical factors used by clinicians to define an infection and inform treatment decisions is not well accepted. He describes a “destructive triangulation” that has risen between hospital administrators, clinicians and IPs primarily fueled by publicly reported HAI rankings and pay-for-performance reimbursement.
High HAI rates derived from an IP’s use of surveillance definitions without clinician agreement has led to pressure on the IP to revise reporting and has led to “an atmosphere of distrust” that undermines the policy development and educational initiatives of the IP. Further, he feels that this distrust has promoted questionable clinician practices or “bad behavior.” He appears to be right as CDC and CMS released their communique alert on the reporting of accurate HAI data not long after Dr. Horowitz’s commentary was published, which calls out two of these behaviors:
- Ordering diagnostic tests in the absence of clinical symptoms upon admission in order to attribute positive cultures, which occur later in the hospitalization as present on admission and avoid HAI reporting.
- Discouraging the ordering of diagnostic tests in the presence of clinical symptoms. An example would be eliminating urine cultures from fever protocol and only performing urine cultures in the presence of pyuria, which is not a criteria of the urinary tract surveillance (UTI) definition. No culture, no UTI.
I would offer that the subjective bias that is inherent in the use of the surveillance definitions by IPs, coupled with the pressure to “game” the data from hospital administrators and clinicians, are two very good reasons to accelerate the adoption of fully electronic surveillance for HAI reporting.
1 Horowitz HW. Infection control: Public reporting, disincentives, and bad behavior. Am J Infect Control 2015 (43):989-91.
2 Adherence to the Centers for Disease Control and Prevention’s (CDC’s) Infection Definitions and Criteria is Needed to Ensure Accuracy, Completeness, and Comparability of Infection Information. CDC Division of Healthcare Quality Promotion Policy Office: October 2015.