The Growing Temptation to Underreport Healthcare-associated Infections

Over the past decade, there has been much written about the rise of antibiotic resistant pathogens and the growing numbers of serious healthcare-associated infections. Some statistics have put the total cost of healthcare-associated infections at around $35-$45 billion dollars1. Infections associated with MRSA have been estimated to cost about $3-$4 billion2 and ventilator-associated pneumonia costs another $3 billion3. The truth is that we really do not know the extent of the problem or the associated costs, and this in itself is a problem. Whatever the number, we can all agree that the costs of healthcare-associated infections are an enormous drain on the economy, and this is prior to factoring in any of the socio-economic multiplier effects of HAIs due to death, loss of employment, impact on families/companies etc.

Statistics, indicating that more people die of MRSA infections in the US than from HIV/AIDS4, have generated public policy responses in a number of jurisdictions. Due largely to the impact of public outcry, hospitals in the UK and in several US states are now required  to report on, and publicly disclose, their annual HAI numbers. The American states which have mandated that annual HAI occurrences are to be tracked and published as a matter of public record are5:  Alabama, California, Colorado, Florida, Illinois,  Minnesota, Missouri, Maine,  New Hampshire , New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Vermont, Virginia, and West Virginia.  More states are expected to follow this lead in the coming years, to see the full list, visit www.hospitalinfection.org/legislation.

In Canada, there is no mandate yet to publicize the extent of the HAI problem or cost, or any incentive to disclose these given that Canada has a provincially-run medical system. Indeed, publicly available healthcare-associated infection data in Canada is sorely lacking and outdated at best, causing, in my view, gross underfunding of appropriate HAI prevention protocols and a lack of economic support for new technologies to combat them.

One of the responses of hospitals in North America has been to increase the use of powerful prophylactic antibiotics to prevent healthcare-associated infections, especially surgical site infections (SSIs). As one can imagine, this behaviour leads to short term HAI reductions at the expense of long term antibiotic resistance setbacks. With few, if any, new antibiotics currently under development, this dependency on greater use of last resort antibiotics to address an antibiotic resistant problem must be seen to be short-sighted and flawed.

Some of the public policies and new HAI protocols that were introduced by the early adopters over the past 5-10 months have begun to demonstrate successes and these results are leading to greater pressures on other jurisdictions to also adopt new HAI control protocols.  Indeed, on October 20, 2011, the CDC  announced data that demonstrated declines in healthcare-associated infection rates.6 The public at large, having been sensitized to the risks of superbugs and other healthcare-associated infections, are now alert to HAI prevention progress being made locally. Many people, after all, have heard about patients going in for routine medical operations only to experience loss of life or limb. Each one of us is now aware of a person that has suffered from a serious infection; a phenomenon that is new to our generation. The fact that antibiotic resistant infections have become one of the world’s top ten health issues is well understood.

The first step to fixing any serious problem is to fully understand the extent of the issue and the rate of any changes. Collection of accurate data is critical and key to determining appropriate solutions and resources that may be required.  Once problems and solutions are fully identified, the next challenge is  implementing  the solution plans as well as ongoing systems for monitoring progress against targeted objectives.  Every effort must be made to ensure accuracy and timeliness of data collection throughout this process if we are to optimize results.  Anything to undermine the accuracy of data throughout this process can only compromise infection control successes in the long run.

Successfully introducing new protocols to the healthcare industry often requires both a system of rewards and penalties. Indeed, even the simple necessity of hand washing between patients is well known but still often ignored due to time and convenience considerations.  Additional monitoring and access points are being implemented throughout hospitals globally just to encourage a well-known HAI intervention strategy.

When trying to implement change, however, it is never useful to simultaneously implement a system of data collection and a system of penalties because it can encourage underreporting and therefore the generation of compromised data. When asking hospital facilities to report and publicize HAI incidence rates across various wards, there is a natural system-wide incentive to underreport due to the negative publicity which could potentially impact reputational capital, revenues and margins as well as provide ammunition for undesirable and costly lawsuits. After all, which of us would willingly choose a hospital that is known for higher-than-average superbug infection rates? Reputational damage, once done, is very difficult to fix.  Public admission of significantly higher than average HAI occurrences will likely lead to patient flow to other facilities for high margin elective and major surgeries. Any loss of patient flow, of course, will have the effect of reducing both revenues and overall profit margins.

Complicating, and potentially undermining the emerging HAI data collection process, the US and UK Government have recently begun to simultaneously adopt tough penalties to discourage HAI.

Two year MRSA trends in UK after implementation of universal screening and decolonization.

In the UK, the Government is adopting a system of withholding budgetary funds for hospitals which exceed infection quotas.  In an effort to curb rising costs of the Medicare and Medicaid programs, the US Government is attempting to adopt a stance that it will no longer reimburse hospitals and other healthcare facilities for the costs of treating the HAIs incurred within their facilities. The premise is that if the costs of patient care related to HAIs are borne entirely by the hospital facility instead of by the Government, the hospital facility will quickly adopt the necessary measures to ensure that infection control procedures are implemented and properly executed.  Without such penalties, it is argued that the hospital facilities in the US have little economic incentive to reduce HAI rates as they are currently being reimbursed (generating additional revenues) for HAI related costs by the Government.

This growing disclosure requirement combined with reduced HAI cost reimbursements and other economic penalties related to HAIs (including lawsuits and budget cuts), has created a growing temptation to disguise the number and scope of healthcare-associated infections.  This potential conspiracy is made more likely because healthcare personnel have a tendency to protect their personal interests and patient results.

When combining the simultaneous phenomena of publicizing HAI data with the transference of HAI cost burdens to hospitals in a weak economy, there are enough incentives and opportunities to ‘reclassify’ and underreport HAI occurrences.   Any deliberate misclassification, of course, would represent a tremendous step backwards in the global fight to reduce healthcare-associated infections, as it would obscure the magnitude of the problem and funds relating to HAI prevention.

My first exposure to this concept of underreporting came about during discussions with an experienced Venture Capitalist when pursuing their financial support. This VC lost interest in our HAI technology during due diligence, when he learned from his contacts that the medical community was not ready to embrace, at its own cost, new HAI prevention technology. Instead, the VC advised me that the medical community would simply resort to reclassifying and underreporting the number and scope of infections to minimize their financial consequences in the short term.  With millions of dollars at stake, I was told, that this kind of initial response in the marketplace was to be expected.

If this temptation to underreport HAIs is indeed to be expected as suggested by this VC, we should therefore also then expect compromised outcomes, fewer real successes, and reduced patient benefits from the public policy initiatives that are being introduced.  With widespread underreporting, there is reduced economic justification to invest in the future HAI solutions and worse, little justification for the people within the medical, insurance and policy communities to embrace the changes needed. Without their support, small innovative companies cannot raise the funds required to commercialize the innovations needed to treat and prevent HAIs. Under this scenario, the whole world suffers.

My goal is to shed light on this temptation and ability to manipulate the HAI data to prevent the critical global health issue from being marginalized. My hope is that we can alert policy makers to the importance of accurate data and encourage them not to introduce policies which will inhibit the collection and communication of the very data needed by all constituents.

We need to encourage accurate HAI readings to understand the real trends as they arise. Accurate data collection is critical to ensure the appropriate policy decisions are being made, appropriate HAI control protocols are being supported universally, adequate resources are being allocated and properly implemented, and most importantly, that HAI reductions continue to be made until they are eliminated. Any concurrent policy changes/requirements that will stand in the way of accurate HAI data reporting as is currently being considered, in my view, must take a backseat. With antibiotic resistance reaching new heights, the HAI crisis is too important to allow for underreporting temptations to stand in the way of real solutions and real commitment. Above all, we must be made aware of the current temptation to underreport HAIs and understand that any underreporting of HAIs is an impediment to global long term HAI reduction.

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