Mandatory HAI Reporting in
Pennsylvania: One Year and
Counting
Stephen Ostroff, MD
PA Department of Health
Disclosure: Nothing to disclose
“An optimist is one who makes
opportunities of his difficulties
while a pessimist is one who makes
difficulties of his opportunities.”
Harry Truman
“The nice thing about being a pessimist
is that you are constantly either being
proven right or are pleasantly
surprised.”
George Will
70% of states/DC
have reporting
requirements in
place
California and Pennsylvania are
currently the only states that have
legislatively mandated reporting
from both hospitals & LCTFs along
with MRSA screening.
Outline
• Background
• PA legislation
• Implementation
– Resources
– Status
• Data
• Benefit & value
Pittsburgh Regional Health
Initiative
32 hospitals in SW Pennsylvania
68% reduction in CLABSI
PA Legislation
• In 2004, PA became 2nd state (IL 1st) to
mandating HAI reporting & public
disclosure
• Through PA Healthcare Cost Containment
Council (PHC4)
• Publish annual report
PA Healthcare Cost Containment Council
2006 Report
Healthcarerelated
infection
Yes
www.phc4.org
No
No.
30,237
1.5 m
Fatal
12.3%
2.1%
LoS (days) 19.3
4.4
Charge
$176k
$33k
Healthcare Associated Infections
in Pennsylvania
• Fueled perception that HAIs
were/are:
– Out of control
– Expensive
– Easy to prevent
Rx for PA (Jan 2007)
Governor’s Office of Healthcare Reform
Quality Component:
- Hospitals must implement
procedures
to eliminate virtually all HAIs
- Require reporting via uniform
electronic surveillance system
- Fund regional best practice
training
- Eliminate perverse incentives for
paying
added costs of HAIs
- Nursing facilities to report HAIs
Act 52 (Aug 2007)
(Implement Rx for PA)
• All facilities submit inf. control plan
– 255 Acute Care Facilities
– 722 Long term Care Facilities
– Include MRSA/MDRO screening
• “Qualified” electronic surveillance
system
– Incentives for implementation
• Facility-wide reporting of HAIs
– For hospitals, use all modules in CDC’s NHSN
patient safety component
– 180 days post-enactment (Feb 14, 2008)*
– Nursing home dates/system not specified
*Only 33 hospitals used NHSN at time of
enactment
Act 52 of 2007 (2)
• All HAIs reported as serious events to
Patient Safety Authority (PSA)
• PADOH to report:
– Facility-specific time trends
– Compare rates among like facilities
– Compare Pennsylvania to national data
• Annual benchmark reduction targets
– 10% reduction in 1st year
– Subsequent annual targets set by DOH
• Corrective action plan/fines if target unmet
Implementation
• 1200+ facilities (ACHs, LCTFs, ASCs)
submitted Infection Control Plans
– Only 3 fined for late submission
• 100% compliance with Feb 08 deadline
• 14 Electronic systems “qualified”
– 79% of eligible hospitals now using a QES
Benchmarking Conditions
for Hospitals
• Catheter-associated urinary tract
infection
• Central line-associated bloodstream
infections
• Surgical site infections
• Abdominal hysterectomies
• Hip & knee replacements
• Cardiac surgeries
HAI Reporting
Long term care facilities
• Developed reporting criteria based on
modified McGeer criteria
• Stand-alone electronic system for
reporting
• Phased implementation began two weeks
ago
Data
Reports into NHSN
from 255 Pennsylvania facilities
Category
Total
Mean/month
2/08-12/08
36,819
3,506
1/09-4/09
5,738
1,435
Represents approx 10% of all
facilities and reports in NHSN
Healthcare-associated Infections
Pennsylvania, (n = 42,617)
All others
2358, 6%
Resp
4994, 12%
UTIs
16491, 39%
BSIs
4816, 11%
SSIs
6940, 16%
7018, 16%
GI
HAIs
Benchmarking Conditions
• Catheter Assoc UTIs
• Central line BSIs
• Surgical site infections
12,120
3,224
– Cardiac surgery
– Hip replacement
– Knee replacement
– Abdominal hysterectomy
All others
495
350
358
278
25,792
Data Analysis & Reporting
• Use of Standardized Infection Ratios
• Maximizes potential for risk
adjustment
• Reported no. of infections
• Complex determination of no. expected
• Ratio of observed to expected
• Statistical significance
Example: CAUTIs
Medical ICUs
Statewide
Facility A
Facility B
Catheter
days
250,000
1,000
23,500
No.
infections
1,200
4
200
Rate per
1,000
4.8
4.0
8.5
Expected
x
4.8
112.8
SIR
1.00
0.83
1.77
Estimated Cost/Time
for Acute Care Facilities
Assumptions
• Personnel cost of $50/hr
• Enrollment & training on NHSN
– 2 persons/facility x 2 weeks
• Non-benchmark conditions
– 30 minutes to gather data & enter
• Benchmark conditions (incl denominators)
– 60 minutes to gather data & enter
Data collection
costs & person-hours
• Training
– $1,020,000
– 40,800 person/hrs
• Non-benchmark (25,792 reports)
– $644,800
– 12,896 person/hrs
• Benchmark (16,825)
– $841,250
– 16,825 person/hrs
Totals (15 months):
$2.5 million 70,500 person/hours
Cost/Personnel Estimates
• Does not include
– DOH/PSA/HC4 costs
– Data quality monitoring efforts
– Long term care facilities
– Added modules in NHSN
– Required MRSA/MDRO screening
costs
• Lab testing costs
• Isolation and care costs
Questions
• Does mandatory reporting add value?
– Does this motivate facilities to implement practices they
otherwise would not implement?
– Examples in PA of reductions independent of reporting
requirement
– CMS Deficit Reduction/never events approach
– More targeted/efficient reporting approaches
•
•
•
•
•
Can consumers understand the data?
Will consumers/others use these data?
Cost effectiveness of approach?
Ability of institutions to further HAI reductions?
How to evaluate impact of mandatory reporting?