September 3, 2004
The Honorable Arnold Schwarzenegger
Governor of California
State Capitol
Sacramento, CA 95814
Re: Request for Signature on SB 1487 (Speier): Hospital-Acquired Infections
Dear Governor Schwarzenegger:
Consumers Union, the nonprofit publisher of Consumer Reports magazine, respectfully requests your signature on SB 1487 (Speier), a bill we are co-sponsoring. This bill would require hospitals to collect and make publicly available data on hospital-acquired infections. Thousands of patients in California die unnecessarily each year. Californians need action on this issue now, not later. We recognize the state’s fiscal situation is not optimal. However, we believe this bill represents a needed incremental step to address a major problem. If needed, future legislation could build on SB 1487’s approach.
The problem
• The Department of Health Services (DHS) estimates 7,200-9,600 preventable deaths occur in the state from hospital-acquired infections. More people die from hospital-acquired infections than from auto accidents and homicides combined. Nationwide, the Centers for Disease Control and Prevention estimate about 90,000 people die each year from hospital-acquired infections.
• An additional 1.9 million people nationwide that get an infection survive but they spend additional days in the hospital getting treated. Five to ten percent of all hospital patients are sickened by a hospital-acquired infection. Hospital-acquired infections add nearly $5 billion per year to our nation’s healthcare costs.
• Studies show that hospitals can reduce infection rates by up to 70 percent through proper implementation of infection control practices, such as hand washing. Despite these facts, one study found hospitals complied with hand washing guidelines less than 50 percent of the time.
• Hospitals do not report infection rate data to any state agency. No data is publicly available. In April 2003, the bipartisan Little Hoover Commission stated that California “should consider mandatory reporting of health-care-setting infection data” to address the problem of hospital-acquired infections (To Protect & Prevent: Rebuilding California’s Public Health System, available at www.lhc.ca.gov).
Current voluntary quality data collection efforts are inadequate
SB 1487 is needed because no current or proposed hospital quality reporting system has both public disclosure and mandatory participation by hospitals. The CDC currently operates a voluntary hospital-acquired infection surveillance system, known as the National Nosocomial Infection Survey (NNIS, see http://www.cdc.gov/ncidod/hip/NNIS/@nnis.htm for more information). But only about 300 hospitals nationwide (out of more than 5,000 total hospitals) participate in NNIS. The NNIS data does not make comparative data among hospitals available to the public. It simply publishes benchmark infection rates for hospitals to use for their own internal purposes.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does not collect infection rate data. JCAHO does not make comparative data between hospitals available to the public. JCAHO recently adopted vague, general “patient safety goals” that include reducing hospital infections. Setting such a goal is meaningless, however, without any kind of data to determine whether hospitals are making progress toward the goal.
In the past year, the California HealthCare Foundation began a project to create a voluntary Hospital Report Card for California hospitals. I sit on the Advisory Committee for that project and have actively participated in its meetings. The hospital representatives object to including hospital infection rate data as part of the report card. Furthermore, because this report card is voluntary, it is not clear how many hospitals will actually participate in the project. Thus, SB 1487 is needed.
Hospitals do not have a good track record of participating in voluntary efforts. For example, only 79 out of 118 hospitals participated in the first California Hospital CABG (coronary artery bypass graft surgery) Mortality Reporting Program (known as CCMRP). CCMRP is a voluntary program jointly operated by the Pacific Business Group on Health and the Office of Statewide Health Planning and Development. In the second CCMRP report, participation actually declined to only 70 hospitals out of 118 (see http://www.pbgh.org/programs/cabg/default.asp for these statistics). Similarly, only 47% of hospitals participated in the first hospital Patient Evaluation of Performance in California (PEP-C), a voluntary survey done by the California HealthCare Foundation (see http://www.chcf.org/documents/consumer/PEPCTechReport.pdf at p. 4). Mandatory reporting such as SB 1487 is needed to ensure complete participation by hospitals.
Other state efforts
Several states have recently established mandatory data collection systems that make hospital-specific quality of care data public. In 2003, Illinois enacted a law (SB 59) requiring public reporting of hospital-acquired infection rates to a state agency. Missouri enacted a similar bill (SB 1279) this year. Pennsylvania is currently implementing infection control reporting pursuant to a previously-enacted statute. Florida also enacted a broad hospital reporting bill this year that includes infection data.
What SB 1487 does
This bill requires hospitals to report hospital-acquired infection rate data to the Office of Statewide Health Planning & Development (OSHPD). OSHPD already collects data on every patient discharged from a hospital (Health & Saf. Code Sec. 128735(g)). The data collected includes such things as patient demographic information, length of stay, diagnosis and procedures, and financial cost information. This data would also be sent to the Department of Health Services, which would use the data as part of its hospital inspection and licensing duties.
The bill adopts an approach suggested by the California Association of Professionals in Infection Control (CAPIC), a professional association for those working in hospitals to reduce hospital-acquired infections. CAPIC supports SB 1487. CAPIC does not believe hospitals will find compliance with this bill costly or difficult. According to CAPIC, many hospitals already collect (or should be collecting) infection rate data for certain types of surgeries and for central-line bloodstream infections in intensive care patients. Therefore, they suggested the bill simply require all hospitals to report this data to OSHPD. The bill requires hospitals to use CDC definitions for hospital-acquired infections, thus ensuring uniformity in data collection. The bill also authorizes OSHPD to determine the format and process for data collection, further ensuring uniformity in data collection.
Rather than mandating in the bill the specific types of surgeries and patients on which data will be collected, the bill sets forth general language in Section 128735.1(b) giving OSHPD authority, in consultation with interested parties, to determine what should be collected. The bill is Medicare Modernization Act ed this way because the science will undoubtedly change over time, thus naming specific surgeries, procedures, or patient types did not seem appropriate. However, the bill gives clear guidance to OSHPD through the intent language of Section 128735.1(c) about how to begin implementation of the bill. Sub (c) reflects discussions between the sponsors and CAPIC about data that is (or should be) collected by many hospitals currently. In the first three years following enactment, the data to be collected shall be infection rates following two types of surgeries, and for central-line bloodstream infections in ICU patients. After those first three years, OSHPD may make changes to what is collected.
How the bill addresses the problem
Public reporting of hospital-acquired infection data will give hospitals a much stronger incentive to reduce the rate of such infections. A study published in Health Affairs last year on state hospital quality reporting programs concluded that “making performance information public stimulates quality improvement.” States that have set up public quality data collection and reporting systems have experienced improved quality of care since the commencement of these systems. Requiring hospitals to track, collect and make public data on hospital-acquired infections is the necessary first step in addressing this hidden problem.
Fiscal issues
SB 1487 will have minor cost implications for OSHPD. However, there will be cost savings to the state from reducing hospital infection rates. Public reporting of this data will strongly encourage hospitals to do a better job of reducing infection rates. Many studies have shown the increased cost of care for patients with hospital infections. One recent study found that hospital infections were associated with 9.58 extra days in the hospital, with $38,656 in excess charges (Zhan & Miller, Journal of American Medical Association (2003)). Another study compared the charges for patients without hospital infections ($7,338) and those that acquired hospital infections ($26,638) (Roberts, Scott II, Solomon, Steele, Kampe, Trick & Weinstein, Clinical Infectious Diseases (2003)).
According to OSHPD data, in 2000, there were 541,161 hospital discharges for patients on Medi-Cal. Estimates of hospital patients acquiring an infection while in the hospital range from 1-10%. Although we obviously cannot provide an exact figure, given the high cost of hospital infections as shown by studies and the number of Medi-Cal recipients treated in hospitals, we believe there would be substantial cost savings to Medi-Cal, and other state health programs, from reducing hospital infection rates by even a small amount.
Other issues
In response to hospital industry concerns, the bill contains language borrowed from the Illinois and Missouri bills mentioned above. This language provides that the infection data shall not be used to establish any kind of standard of care in any civil action. Thus, simply because Hospital A’s infection rate data is above the median, or above Hospital B’s rate, this fact alone could not be used to establish liability for Hospital A. This language would therefore restrict use of this data to establish a “17200” or a malpractice action. In response to issues raised by Kaiser Permanente, the bill provides that infection data for Kaiser-type systems will be reported separately from non-integrated hospital systems.
For all the above reasons, we urge you to sign SB 1487 into law.
Sincerely,
Earl Lui
Senior Attorney
cc: Senator Jackie Speier