Public reporting of health care-associated infection data in Australia: time to refine

In December 2011, the Australian Institute of Health and Welfare (AIHW) launched the MyHospitals website, allowing national reporting of safety and quality indices for Australian hospitals, including health care-associated infection (HAI) indicators.1 Unlike approaches taken in the United States and United Kingdom, public reporting initiatives have lagged in Australia, with challenges being identified in the design and implementation of reporting strategies.2 Specific avenues for improving HAI indicators are now emerging.

The MyHospitals website contains data reported by individual hospitals.1 While all public hospitals submit data, participation by private hospitals is voluntary. Safety and quality indicators include compliance with hand-hygiene practices and rates of Staphylococcus aureus bacteraemia (SAB). Each is compared with a national benchmark — greater than 70% compliance for hand hygiene, and less than 2 days per 10 000 days of patient care for SAB events.

Infection control performance indicators can be broadly categorised as “outcome” or “process” indicators. Outcomes refer to measurable end points, such as hospital length of stay or mortality. SAB events are outcome indicators reported by the MyHospitals website. Currently, all hospitals are compared with a single target rate, and jurisdictional performance is gauged on the aggregate for the relevant state or territory. However, many hospitals (eg, specialist paediatric or cancer hospitals, tertiary referral centres and small rural hospitals) have patient populations that are different from those of most general hospitals. For rational comparisons to be possible, data should be risk-adjusted or stratified to correct for differences in patient casemix across the wide range of health care facilities. This sometimes requires collection of additional data. Determining whether an infection is (i) present and (ii) health care-associated is not always straightforward, as definitions can be complex and are updated over time.

In contrast to outcome indicators, process indicators encompass a broad range of risk-reduction measures and accepted best practice, such as the use of appropriate antibiotics before surgery and ensuring health care workers’ vaccinations (eg, influenza, hepatitis B) are up to date. Compliance with hand-hygiene practices is a process indicator reported by the MyHospitals website. Process measures generally do not require risk adjustment3 as they are often not patient-specific, but should be applied across the board. However, consistent data collection methods are essential for fair comparison. Process indicators allow unfair comparisons of disparate health care facilities to be more easily avoided and unambiguous targets to be applied.3

The benefits of public reporting in health care include the ability to drive change in practice and reduce risk to admitted patients. Hospital administrators may opt to support and actively resource areas of need, with the aim of maintaining standards and achieving public confidence in their hospital. In the UK, a considerable reduction in S. aureus infections has been ascribed, in part, to public release of data,4 together with strong and frequent media exposure. The potential pitfalls of public reporting of HAI indicators include the provision of misleading data,5 unfair comparisons between dissimilar health care facilities,6 the application of unfounded target thresholds,7 and an undue focus by health care facilities on a “rate” rather than on prevention of HAIs,7 ultimately diverting a disproportionate amount of infection-control consultant time from prevention to surveillance activities. Expectations must also be realistic. To date, although quality improvement activity has been enhanced at the hospital level,8 improvement in health care performance or any reduction in HAIs have not been demonstrated.9 Further, public reporting has not been shown to influence consumers’ choice of hospital.

The measures that are currently reported have limitations. For example, a hospital may choose to perform regular hand-hygiene surveillance of high-risk wards with rotation of surveillance in other wards, or surveillance of high-risk wards with auditing of all other wards, or surveillance in the intensive care unit with auditing of all other wards.1 Ideally, the process should be uniform across all health care facilities to enable valid comparison. However, as the sizes of health care facilities in Australia vary widely, this is unlikely to be achieved, and stratification of centres would therefore be a sensible way to compare similar data. Another limitation is that non-standardised data are also used to calculate SAB rates. For instance, the denominator (patient-days) includes psychiatry admissions, which are generally associated with a very low risk of developing SAB. Hospitals have large differences in their number of psychiatry beds, so this can affect calculated SAB rates. Also, no adjustment is made for different rates of use of intravenous catheter or haemodialysis access devices between facilities, despite these devices being associated with an increased risk of health care-associated SAB.

A number of factors are necessary for a valid and beneficial strategy for public reporting of infection control indices.3 First, the choice of a reportable outcome or process must be based on burden of illness, preventability and feasibility of monitoring. Second, the target for surveillance and the audience must be defined, together with the intended objectives of reporting.3 Third, valid methods of data collection, analysis and reporting must be applied.10 This includes consistency with widely accepted case definitions and applying appropriate methods for risk adjustment.3 In the absence of methods for hospital-level risk adjustment, the US Centers for Disease Control and Prevention recommends reporting of HAI data according to specific hospital units (eg, intensive care unit, transplant unit, surgical wards) rather than reporting hospital-wide data.11 Hospitals have also previously been stratified according to casemix or size to enable meaningful comparison of SAB rates.12 To reduce the burden of manual data collection, electronic data sources may be considered to optimise case detection.3 Any targets that are set must be: (i) justifiable in terms of available evidence; (ii) reviewed in a timely fashion; and (iii) revised if any improvement in outcome is achieved. For example, SAB rates below the stipulated target (2 days per 10 000 days of patient care) are now reported by many centres,13 and it could be argued that a lower threshold should now be applied. Finally, feedback about the reporting strategy must be sought from stakeholders. Potential incentives or penalties for participating in a system of public reporting must be communicated, ideally with strategies in place for when targets are not met.

Given the limited time frame since the launch of the MyHospitals website, some of these criteria have not yet been addressed. Interestingly, it has been suggested that bloodstream infections associated with central venous catheters, surgical antibiotic prophylaxis, and influenza vaccination rates among health care workers should be the priority and the minimum data that are publicly reported,3,14 rather than the indices selected by the AIHW (SAB and hand hygiene). The scope of the current strategy does not fully represent the Australian health care system, as participation by private facilities is not mandatory. It is assumed that the target audience is the Australian general public. However, it is not clear how data are to be analysed over time or if tests of statistical significance ought to be applied. In small hospitals, a small number of infections may lead to very high rates, interpretable only with the understanding of sample size effects and accompanying confidence intervals. Reporting on the MyHospitals website takes this into consideration by reporting the number of events, rather than a rate of infection, for hospitals with fewer than 5000 days of patient care per year. Quality-assurance measures to ensure submission of valid data from all surveyed health care facilities have not been formally defined. To improve the quality of captured data, implementation guidelines for surveillance of SAB have been released by the Australian Commission on Safety and Quality in Healthcare, and concerted efforts have been made at a national level to train hand-hygiene auditors by standardised methods.13 However, jurisdictions are ultimately responsible for the quality of submitted data. Published threshold rates represent consensus or expert opinion, rather than evidence-based targets for improved quality of care. It is also unclear if public opinion on the relevance of content, terminology, and educational value has or will be canvassed,15 or if the availability of data is likely to or is intended to influence patient perceptions and decisions about the choice of facility before hospital admission.

While it would be optimal to investigate each of these factors, a formal review may not be practical. As a minimum requirement, measures to ensure the validity of data capture, analysis and reporting are paramount. This has also been identified as a priority after a review of reporting by the English National Health Service.16 If methods are not well founded, the value of data will diminish, stakeholders will not support findings, and the resources hospitals need to collate data may be regarded as unjustified. Hospital care and HAIs are complex, and stakeholders with expertise in public health, infectious diseases, infection control, informatics and epidemiology must all be engaged to ensure that valid data are released.

We welcome public reporting of infection control indicators in Australia, and applaud the efforts taken to date to accomplish the release of data and jurisdictional agreement. However, to improve quality, the strategy requires further development. The focus must now be on validating and enhancing reported indices according to local epidemiology, stakeholder opinion and the needs of the Australian public. Other reportable processes (such as rates of influenza vaccination among health care workers) and outcomes (such as rates of central-line-associated bloodstream infections) may be considered as quality measures, but not before the current reporting strategy for hand-hygiene compliance and SAB events is refined.