Story first appeared on US News -
Simple swab-based cleansing cut rates of some drug-resistant bacteria by 23 percent, study found
A daily swabbing with a simple antiseptic greatly decreases the number of life-threatening bloodstream infections and drug-resistant bacteria lurking among patients in acute-care hospital units, a new study suggests.
Researchers found that bathing patients with washcloths soaked with chlorhexidine -- a cheap, broad-spectrum antiseptic -- lowered the rate of hospital-acquired bloodstream infections by 28 percent.
Highly feared multidrug-resistant organisms such as MRSA (methicillin-resistant staphylococcus aureus) and VRE (vancomycin-resistant enterococcus) were reduced by 23 percent.
"We're talking about an intervention that's very simple to implement and minimal in cost," said study author Dr. Edward Wong, chief of infectious disease at Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Va. "This can be laid on top of all the other things [experts recommend] to decrease the spread of these organisms."
The study is published in the Feb. 7 issue of the New England Journal of Medicine.
About 5 percent of hospitalized patients acquire healthcare-associated infections, often from bacteria entering the bloodstream through surgical incisions or catheters, according to the U.S. Centers for Disease Control and Prevention (CDC). The per-patient cost of treating such infections is enormous -- approximately $40,000, Wong said.
Wong and his colleagues analyzed more than 7,700 patients in nine intensive-care and bone-marrow-transplantation units in six hospitals. Health providers were randomly assigned to bathe patients with either no-rinse chlorhexidine-soaked washcloths or non-antimicrobial washcloths for six months, then alternate with the other product for an additional six months. Chlorhexidine wipes, when sold in bulk, cost less than 20 cents apiece on Internet sites.
The dramatically lowered rates of bloodstream infections and MRSA and VRE acquisition -- which can mean a patient is either a carrier or infected with the bacteria -- didn't surprise Wong, whose previous research yielded similar results.
"At least based on preliminary studies we've done, we knew we'd have some benefit but we wanted to make sure we could generalize," he said. Chlorhexidine wipes "are clearly going to cost much less than the cost of antibiotics or the cost of health care."
Dr. Philip Tierno, director of clinical microbiology and immunology at NYU Langone Medical Center in New York City, said his institution has been using chlorhexidine for years on patients about to have surgery.
"It's very good because it has residual effectiveness on the skin for a day or two," he said. "So when the surgeon cuts through flesh, it's less likely to impregnate the skin with organisms."
"If you get a very serious infection ... it may lead to significant problems," Tierno added. "This has a very good benefit and it's worthwhile to pursue."
Showing posts with label Infection. Show all posts
Showing posts with label Infection. Show all posts
07 February 2013
05 June 2012
Hospitals Gear Up on Cleaning
Story first appeared in The Wall Street Journal.
An environmental services director at Hunterdon Medical Center, uses a swab to swipe a bedside tray table in a freshly cleaned patient room. She then dips the swab into a hand-held device that can detect bacterial contamination in less than a minute.
The reading is in the safe zone by most industry standards. But at Hunterdon, it will trigger a repeat visit from the cleaning crew to wipe out lingering bacteria.
The environmental services director and her colleague Hunterdon's infection-prevention director, are on the front lines of one of the most critical battles in health care—keeping virulent hospital infections at bay. Nationwide, about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs, according to the federal Department of Health and Human Services. Dangers lurk not only in vulnerable places like operating rooms. Recent studies have shown that some of the most common surfaces, from sink faucets to TV remote controls, can harbor the most deadly bacteria.
Besides increased diligence, the Hunterdon team is mobilizing new technologies, including bathing patient rooms with germ-killing ultraviolet light. Specialized computer software tracks new outbreaks of infection. And a new generation of powerful disinfectant products are used to kill even some of the most potent germs, especially Clostridium difficile, or C. diff, which is linked to some 14,000 U.S. deaths a year.
Many hospitals have succeeded in driving down the rates of some once-common infections, including MRSA, a type of staph bacteria that doesn't respond to some antibiotics. Changed medical practices have helped, including keeping patients in intensive care hooked up to ventilators only for as long as is necessary. Helping to spur action: The government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels. The Center for Medicare and Medicaid Services has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.
Hunterdon cut its rate of C. diff infections by 79% and reduced MRSA by 66% between 2006 and 2011. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. The hospital's successes led the Association for Professionals in Infection Control and Epidemiology, an industry group, to ask the Hunterdon team to help launch "Clean Spaces, Healthy Patients," a national program that includes Web-based seminars aimed at infection-control officials and cleaning staff.
Hunterdon Medical Center, which has 178 beds, has many of the same hygiene challenges that face numerous other U.S. hospitals that are large and aging. And most of Hunterdon's rooms are semiprivate, shared by two patients, making them more difficult to keep clean. Prompting Hunterdon to overhaul its methods was a growing threat from a strong strain of C. diff in 2004. At highest risk for C. diff are patients, especially older adults, who are on antibiotics for other infections. The drugs destroy good germs that protect against infection for several months, during which time patients can get sick from C. diff picked up from contaminated surfaces or spread from a health-care provider's hands.
The hospital began isolating patients who had contracted C. diff and asked doctors to restrict the use of the antibiotic Cipro. But it was becoming clear that spores could survive for weeks, even on a doorknob. Alcohol-based hand sanitizers didn't kill C. diff, and hand-washing wasn't sufficient.
So the hospital adopted new, stronger soaps containing the antiseptic chlorhexidine for staffers and patients. Cleaning crews began using bleach and a more potent form of hydrogen peroxide. Rooms were scrubbed as never before: In rooms where C. diff patients had been treated, even the curtains were taken down and cleaned.
The environmental director coaches cleaning staff on the importance of disinfecting "high-touch" surfaces on which germs can linger. One current focus: the remote control devices whose buttons allow patients to watch TV or call a nurse. Cleaning staff are encouraged to speak up if they feel they are being rushed to clean a room.
The visual checks traditionally done to confirm a room was clean are no longer sufficient.
The Hunterdon team conducts random audits with the swabbing device on about 300 surfaces a month. Some 95% to 100% of checks get a passing grade, up from 75% when the hospital acquired the device in 2009.
There are costs involved. Besides hiring additional staff, including more cleaners, Hunterdon administrators invested about $81,500 in rapid-testing equipment for the microbiology lab to detect C. diff and MRSA from patient samples. New, washable computer keyboards for nursing stations—to eliminate the problem of bacteria on standard models—cost about $15,000. The hand-held device to test surfaces for contamination using a special light assay cost about $3,000 to purchase and up to $1,500 monthly to operate.
Many hospital administrators still don't understand they have to spend money if they want to cut costs related to infection, such as isolating patients with c. diff. and readmitting patients to hospitals if infections worsen.
Hunterdon also pays $100,000 in annual fees for its computerized surveillance system for its lab. This uses patient samples to determine when organisms are present that show unusual resistance or a particular pattern of spreading—a task that was previously impossible with stacks of paper reports.
To motivate staff, Hunterdon uses a government video-training program called "Partnering to Heal." It includes a dramatic film of a young patient who dies from a MRSA infection after multiple failures of hospital staff to follow preventive steps. The hospital also produces a newsletter, "BugBytes," that celebrates successes and passes along infection-prevention tips. And doctors who adhere closely to the guidelines are awarded a model stethoscope made of chocolate.
An environmental services director at Hunterdon Medical Center, uses a swab to swipe a bedside tray table in a freshly cleaned patient room. She then dips the swab into a hand-held device that can detect bacterial contamination in less than a minute.
The reading is in the safe zone by most industry standards. But at Hunterdon, it will trigger a repeat visit from the cleaning crew to wipe out lingering bacteria.
The environmental services director and her colleague Hunterdon's infection-prevention director, are on the front lines of one of the most critical battles in health care—keeping virulent hospital infections at bay. Nationwide, about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs, according to the federal Department of Health and Human Services. Dangers lurk not only in vulnerable places like operating rooms. Recent studies have shown that some of the most common surfaces, from sink faucets to TV remote controls, can harbor the most deadly bacteria.
Besides increased diligence, the Hunterdon team is mobilizing new technologies, including bathing patient rooms with germ-killing ultraviolet light. Specialized computer software tracks new outbreaks of infection. And a new generation of powerful disinfectant products are used to kill even some of the most potent germs, especially Clostridium difficile, or C. diff, which is linked to some 14,000 U.S. deaths a year.
Many hospitals have succeeded in driving down the rates of some once-common infections, including MRSA, a type of staph bacteria that doesn't respond to some antibiotics. Changed medical practices have helped, including keeping patients in intensive care hooked up to ventilators only for as long as is necessary. Helping to spur action: The government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels. The Center for Medicare and Medicaid Services has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.
Hunterdon cut its rate of C. diff infections by 79% and reduced MRSA by 66% between 2006 and 2011. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. The hospital's successes led the Association for Professionals in Infection Control and Epidemiology, an industry group, to ask the Hunterdon team to help launch "Clean Spaces, Healthy Patients," a national program that includes Web-based seminars aimed at infection-control officials and cleaning staff.
Hunterdon Medical Center, which has 178 beds, has many of the same hygiene challenges that face numerous other U.S. hospitals that are large and aging. And most of Hunterdon's rooms are semiprivate, shared by two patients, making them more difficult to keep clean. Prompting Hunterdon to overhaul its methods was a growing threat from a strong strain of C. diff in 2004. At highest risk for C. diff are patients, especially older adults, who are on antibiotics for other infections. The drugs destroy good germs that protect against infection for several months, during which time patients can get sick from C. diff picked up from contaminated surfaces or spread from a health-care provider's hands.
The hospital began isolating patients who had contracted C. diff and asked doctors to restrict the use of the antibiotic Cipro. But it was becoming clear that spores could survive for weeks, even on a doorknob. Alcohol-based hand sanitizers didn't kill C. diff, and hand-washing wasn't sufficient.
So the hospital adopted new, stronger soaps containing the antiseptic chlorhexidine for staffers and patients. Cleaning crews began using bleach and a more potent form of hydrogen peroxide. Rooms were scrubbed as never before: In rooms where C. diff patients had been treated, even the curtains were taken down and cleaned.
The environmental director coaches cleaning staff on the importance of disinfecting "high-touch" surfaces on which germs can linger. One current focus: the remote control devices whose buttons allow patients to watch TV or call a nurse. Cleaning staff are encouraged to speak up if they feel they are being rushed to clean a room.
The visual checks traditionally done to confirm a room was clean are no longer sufficient.
The Hunterdon team conducts random audits with the swabbing device on about 300 surfaces a month. Some 95% to 100% of checks get a passing grade, up from 75% when the hospital acquired the device in 2009.
There are costs involved. Besides hiring additional staff, including more cleaners, Hunterdon administrators invested about $81,500 in rapid-testing equipment for the microbiology lab to detect C. diff and MRSA from patient samples. New, washable computer keyboards for nursing stations—to eliminate the problem of bacteria on standard models—cost about $15,000. The hand-held device to test surfaces for contamination using a special light assay cost about $3,000 to purchase and up to $1,500 monthly to operate.
Many hospital administrators still don't understand they have to spend money if they want to cut costs related to infection, such as isolating patients with c. diff. and readmitting patients to hospitals if infections worsen.
Hunterdon also pays $100,000 in annual fees for its computerized surveillance system for its lab. This uses patient samples to determine when organisms are present that show unusual resistance or a particular pattern of spreading—a task that was previously impossible with stacks of paper reports.
To motivate staff, Hunterdon uses a government video-training program called "Partnering to Heal." It includes a dramatic film of a young patient who dies from a MRSA infection after multiple failures of hospital staff to follow preventive steps. The hospital also produces a newsletter, "BugBytes," that celebrates successes and passes along infection-prevention tips. And doctors who adhere closely to the guidelines are awarded a model stethoscope made of chocolate.
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23 April 2010
Troubling Increase in Serious Hospital Infections
Associated Press
WASHINGTON — The nation's hospitals are failing to protect patients from potentially fatal infections despite years of prevention campaigns, the government said Tuesday.
The Health and Human Services department's 2009 quality report to Congress found "very little progress" on eliminating hospital-acquired infections and called for "urgent attention" to address the shortcomings — first brought to light a decade ago.
Of five major types of serious hospital-related infections, rates of illnesses increased for three, one showed no progress, and one showed a decline. As many as 98,000 people a year die from medical errors, and preventable infections — along with medication mixups_ are a significant part of the problem.
Such medical missteps will have financial consequences under President Barack Obama's new health care overhaul law. Starting in a few years, Medicare payments to hospitals will be reduced for preventable readmissions and for certain infections that can usually be staved off with good nursing care.
HHS Secretary Kathleen Sebelius called the report "a pretty clear diagnosis of some of the gaps and shortcomings in our nation's health care system."
Although the U.S. spends about $2.5 trillion a year on medical care, patients often don't receive the care recommended for their particular condition. Generally, patients are more likely to receive optimal care in a hospital as compared to an outpatient facility. The quality report was accompanied by a second study that found continuing shortfalls in quality of care for minorities and low-income people, particularly the uninsured.
The bleak statistics on hospital infections were a disappointment for officials. It's been more than 10 years since the Institute of Medicine launched a crusade to raise awareness about medical errors and encourage providers to systematically reduce and, if possible, eliminate them.
"We know that focused attention to eliminating health care acquired infections can reduce them dramatically," said Dr. Carolyn Clancy, head of the Agency for Healthcare Research and Quality, which conducted the studies. It marked the first time her agency attempted a comprehensive assessment of progress on hospital infections. The statistics for 2007 were the latest available.
According to the report:
_ Rates of bloodstream infections following surgery increased by 8 percent.
_ Urinary infections from the use of a catheter following surgery increased by 3.6 percent.
_ The overall incidence for a series of common infections due to medical care increased by 1.6 percent.
_ There was no change in the number of bloodstream infections due to central venous catheters — tubes placed in the neck, chest or groin to administer medications, drain fluids or collect blood samples.
_ Rates of pneumonia following surgery dropped by 12 percent, the one bright spot.
The bloodstream infections are the most serious, said Clancy, because they can be fatal. Recovery from hospital-acquired pneumonia usually depends on the overall health of the patient. Urinary tract infections are painful, but they usually respond to treatment with antibiotics. But any complication for patients in the hospital is of concern.
"If you are looking at patients who are hospitalized, you are looking at people with multiple underlying conditions, who are already fighting for their health on several fronts," Clancy said.
The hospital industry said it was disappointed by the findings, but hopes the next round of studies will show improvement. Some recent efforts to reduce infections may not yet be reflected in the data.
"We're doing that which we know how to do, and it's not having the intended effect," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We need to identify other things we can do to drive down that rate of infections."
It is possible to turn the tide — and radically. Some 100 hospital emergency rooms in Michigan have reduced the rate of central catheter infections to near zero, said Clancy. It's accomplished by painstaking attention to procedure.
The Health and Human Services department's 2009 quality report to Congress found "very little progress" on eliminating hospital-acquired infections and called for "urgent attention" to address the shortcomings — first brought to light a decade ago.
Of five major types of serious hospital-related infections, rates of illnesses increased for three, one showed no progress, and one showed a decline. As many as 98,000 people a year die from medical errors, and preventable infections — along with medication mixups_ are a significant part of the problem.
Such medical missteps will have financial consequences under President Barack Obama's new health care overhaul law. Starting in a few years, Medicare payments to hospitals will be reduced for preventable readmissions and for certain infections that can usually be staved off with good nursing care.
HHS Secretary Kathleen Sebelius called the report "a pretty clear diagnosis of some of the gaps and shortcomings in our nation's health care system."
Although the U.S. spends about $2.5 trillion a year on medical care, patients often don't receive the care recommended for their particular condition. Generally, patients are more likely to receive optimal care in a hospital as compared to an outpatient facility. The quality report was accompanied by a second study that found continuing shortfalls in quality of care for minorities and low-income people, particularly the uninsured.
The bleak statistics on hospital infections were a disappointment for officials. It's been more than 10 years since the Institute of Medicine launched a crusade to raise awareness about medical errors and encourage providers to systematically reduce and, if possible, eliminate them.
"We know that focused attention to eliminating health care acquired infections can reduce them dramatically," said Dr. Carolyn Clancy, head of the Agency for Healthcare Research and Quality, which conducted the studies. It marked the first time her agency attempted a comprehensive assessment of progress on hospital infections. The statistics for 2007 were the latest available.
According to the report:
_ Rates of bloodstream infections following surgery increased by 8 percent.
_ Urinary infections from the use of a catheter following surgery increased by 3.6 percent.
_ The overall incidence for a series of common infections due to medical care increased by 1.6 percent.
_ There was no change in the number of bloodstream infections due to central venous catheters — tubes placed in the neck, chest or groin to administer medications, drain fluids or collect blood samples.
_ Rates of pneumonia following surgery dropped by 12 percent, the one bright spot.
The bloodstream infections are the most serious, said Clancy, because they can be fatal. Recovery from hospital-acquired pneumonia usually depends on the overall health of the patient. Urinary tract infections are painful, but they usually respond to treatment with antibiotics. But any complication for patients in the hospital is of concern.
"If you are looking at patients who are hospitalized, you are looking at people with multiple underlying conditions, who are already fighting for their health on several fronts," Clancy said.
The hospital industry said it was disappointed by the findings, but hopes the next round of studies will show improvement. Some recent efforts to reduce infections may not yet be reflected in the data.
"We're doing that which we know how to do, and it's not having the intended effect," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We need to identify other things we can do to drive down that rate of infections."
It is possible to turn the tide — and radically. Some 100 hospital emergency rooms in Michigan have reduced the rate of central catheter infections to near zero, said Clancy. It's accomplished by painstaking attention to procedure.
07 October 2009
Hospitals Learning: Better Care Is Cheaper Care
Story from the Wall Street Journal
Be it cereal or cars, buyers usually have an idea of how good the products are and how much they cost before they buy them.
That's not how U.S. health care works. Patients rarely know which hospitals offer top-quality lung or aortic surgery, and which are more likely to harm them. Hospitals don't compete on price and rarely publish measurements of their quality, if they measure it at all.
Except in Pennsylvania. For two decades, a state agency has published "medical outcomes" -- death and complication rates -- from more than 50 types of treatments and surgery at hospitals. The state has found that publishing results can prompt hospitals to improve, and that good medical treatment is often less expensive than bad care.
One reason is that high-quality treatment usually results in shorter hospital stays and fewer readmissions. The state has had less success in publishing hospital prices and has drawn criticism from hospitals that disagree with its reporting methods. But companies or unions in Pennsylvania that have agreed to work only with the best-performing hospitals say they have been able to drive down medical costs.
"High-quality care costs less -- always," says David B. Nash, a medical-quality expert and dean at Thomas Jefferson University's School of Population Health in Philadelphia. "If the federal government could behave like a savvy shopper, that would change the health-cost game overnight. But the government is a bill payer, not a savvy shopper."
Walter McClure, who helped spark Pennsylvania's efforts, was an early advocate of publicizing medical outcomes and fostering competition among hospitals.
The Senate Finance Committee could vote late this week on its sweeping health bill, seen as the backbone for any final legislation. That bill would make available $75 million annually for the U.S. Department of Health and Human Services to develop methods of improving quality, including potentially publishing outcomes.
Although at times premium care can be exorbitant, there's evidence some in Pennsylvania saved money using top-rated hospitals. Hershey Co. offered workers medical coverage based on the state agency's reported outcomes, and cut the company's expenses by 50% over several years. The Philadelphia police union's benefits-management company says it uses the state reports to steer officers to the best hospitals; as a result, it say its costs fall about 17% below those of comparable plans.
Tom Lamb, administrator of Philadelphia police health benefits, says he frequently explains to members why they should go to hospitals with better outcomes. "If an officer's 7-year-old daughter has to go in for surgery," he says, "I'll sit down with the father and say, 'Are you just going to shake your head yes when your pediatrician wants to send her to his golfing buddy?' "
Quality Ratings
The Delaware Valley Health Care Coalition, a group of union and municipal health funds covering 1.3 million people, is beginning the process of picking about 20 hospitals based on the state's quality ratings. Capital BlueCross in Harrisburg has designed a plan that selects hospitals based on the reports. Mark Dever, benefits manager at Duquesne Light in Pittsburgh, says his company recently got an offer from a hospital chain to treat the company's workers. But after reviewing state quality data and comparing prices, he rejected it.
An August 2008 study in the American Journal of Medical Quality reported that Pennsylvania in-hospital odds of death were 21% to 41% lower than those in other states. The research focused on heart attacks, congestive heart failure, brain hemorrhage, stroke, pneumonia and septic infections.
The Obama administration is allotting $1 billion for research to compare effectiveness of medical treatments. Some hope comparing hospital outcomes will be part of that. "As a patient," says Michael Pine, who runs a medical quality-measuring business in Chicago, "I would generally be more interested in whether Hospital A or Hospital B gets better results, more than whether drug A is more effective than surgery."
The theory underlying the Pennsylvania program is that, to create a truly competitive health-care market, consumers need hard information showing which hospitals perform better.
Curbing Infections
For example, Pennsylvania three years ago published its first report on hospitals' infection rates that arise largely from intravenous catheters and tubes left in too long. Infection numbers the following year fell 7.8%, as hospitals responded with steps designed to lower infections.
The average payment in 2006 for hospitalization where a patient acquired an infection was $53,915; with no infection, the average payment was $8,311, according to state reports.
By simply getting rid of preventable infections, Pennsylvania estimates its hospitals could lower expenses by nearly $1 billion.
The White House is looking at publishing information possibly including medical outcomes as part of overhaul efforts, officials say. Quality data could also be used in existing programs. "There is a clear understanding from the Obama administration that both Medicare and Medicaid need to move in the direction of what's happening in Pennsylvania," says Jonathan Blum, director of the government's Center for Medicare Management.
The Philadelphia police health fund benefit-management company, covering 26,000 people, adopted a plan pegged to the state's hospital-quality results seven years ago. Mr. Lamb says the police fund has saved as much as $5 million a year using the information.
Sent Home
One retired Philadelphia police officer benefited from the state reports in an unusual way -- by learning he didn't need the coronary angioplasty he had been prescribed. Ed Gillespie, of Cape May, N.J., says he was told by his doctor six years ago that he needed angioplasty to clear out heart arteries. After consulting with Mr. Lamb, he learned state reports showed good results at Jefferson Medical College in Philadelphia. He decided to go there.
While he was on the gurney awaiting angioplasty, his cardiologist asked colleagues to study the films more carefully -- and concluded he could go home without treatment, Mr. Gillespie recalls. "I get checked every year, and I've been OK," he says.
Pennsylvania's agency -- called the Pennsylvania Health Care Cost Containment Council, or PHC4 -- has its critics. Hospitals have complained its data are imprecise or unnecessary.
P.J. Brennan, chief medical officer of the University of Pennsylvania Health System, says that PHC4 reports -- even though they are adjusted for certain risk factors -- still aren't comprehensive enough to take into account the very sickest patients, the sort treated at academic medical centers. "These reports are very important for transparency, but I don't think you can look at a PHC4 report and conclude you should not go to that hospital," he says.
In the state's most recent report, the Hospital of the University of Pennsylvania performed well in many categories but had worse-than-expected death rates in treating septicemia, or blood infections.
State legislators have tentatively cut the PHC4's budget to $2.8 million this year from $5.4 million in 2008, largely because of a state deficit.
The program got its start in the 1980s. Alarmed by health-cost inflation, business and labor leaders sought out Walter McClure, a Minnesotan who had pioneered a medical-quality program. Dr. McClure, who has a Ph.D. in physics, made a presentation to the Pennsylvania Business Roundtable in 1985.
Dr. McClure called on the executives to foment competition among hospitals. "We used to say to a patient, 'Go anywhere, regardless of cost, and we will pay the bill,' " he said in his speech. "Quality was assumed. That was dumb."
In 1986, Pennsylvania legislators created the PHC4. Three years later, the agency published its first report comparing death rates at about 180 hospitals.
Hahnemann University Hospital in Philadelphia fared poorly at first on several quality measures. Its ratings were significantly "worse than expected" on eight of 55 procedures in the first PHC4 "Hospital Effectiveness Report." The report included data for July 1, 1989, to June 30, 1990.
John Russell, then president of the Hospital Association of Pennsylvania, says Hahnemann and others complained, but "within about six weeks, they cleaned up their act." In the second Hospital Effectiveness Report, Hahnemann improved its ratings on seven of the eight procedures. The hospital declined to comment.
PHC4's first report on infections in 2006 showed Hamot Medical Center in Erie with a relatively high infection rate, in part because the hospital was early to use computers to track such rates. Emily McCracken, the hospital's epidemiologist, says the report "put a spotlight on something that needed a spotlight."
The hospital has since lowered the infection rate by about 20% by cleaning IV catheters more often and removing them earlier.
Care Disparities
Over the years, PHC4 sought a wider variety of data and started producing reports on infection rates, readmissions and lengths of stay due to complications. The reports revealed startling disparities among hospitals and even individual doctors.
The hospital-performance reports use data compiled from medical records. Results are "risk adjusted," meaning the agency collects laboratory and medical-chart information about the age and overall health of patients so hospitals taking on difficult cases won't be unduly penalized.
The agency estimates the cost to the state's 172 acute-care hospitals of collecting the data annually is $7 million. The state's hospital association says it is $10 million or more.
The state agency hasn't been as successful in obtaining the prices that insurers pay to hospitals, information that would be important because it would allow patients and payers to factor in prices when choosing hospitals. The agency has legal power to get that information from insurers and publish it, but it has done so only for heart surgery. An agency spokesman says insurers didn't refuse, and that lack of manpower at the agency explains this omission. One person familiar with the events says many insurers wouldn't divulge prices.
Hershey came to rely on the state's hospital reports. In the early 1990s, medical costs for its 15,000 workers and dependents were soaring. "I told the human-resources department we needed to do something," says then-Chief Executive Richard Zimmerman.
Richard C. Dreyfuss, compensation and benefits manager, and his boss, William Lehr Jr., scrutinized the state's data for 23 hospitals. Mr. Dreyfuss ranked hospitals based 70% on medical outcomes and 30% on hospital prices, which the company obtained from insurers on its own. He focused on 21 costly procedures such as heart bypass and diabetes care.
Cost Correlation
Results shocked him. "The correlation between cost and quality was zero," he says. "You go in thinking that all hospitals are pretty much equal, but this was eye-opening. Generally, higher-cost hospitals had poorer outcomes."
Mr. Dreyfuss devised a plan called Health Styles in which only 10 hospitals would be included -- and 13 left out. Employees had other plans to choose from, but Health Styles was cheaper than the relatively inexpensive health maintenance organizations Hershey offered, Mr. Dreyfuss says.
The 13 excluded hospitals weren't happy -- especially the highly regarded Penn State University's Milton S. Hershey Medical Center, founded by the family that created the chocolate company.
C. McCollister Evarts, dean of the hospital's medical school, told Messrs. Dreyfuss and Lehr that the state agency's information was wrong and "you don't understand what an academic medical center does," Messrs. Dreyfuss and Lehr recall.
Dr. Evarts confirms his remark and says he believes such measurements have become far more precise over the years. In recent years, Hershey Medical was reinstated under the company's plans. The hospital declined to comment.
The Health Styles plan took effect in 1994. About 40% of employees in central Pennsylvania signed up. The company, which was self-insured, was able to hold its medical-care cost increases annually to 4%, about half the national rate, saving about $10 million in the first five years. "This thing was a real winner," says Mr. Dreyfuss. He and other former Hershey executives say the company cut its annual medical expense by 50% for several years.
Dennis Bomberger, business manager of Chocolate Workers Local 464, says Hershey's Health Styles "was an excellent plan" that "employees liked the best."
The plan was discarded two years ago, however, when a new Hershey management team changed health coverage, Mr. Bomberger says. A Hershey spokesman declined to comment.
Former Hershey vice president Mr. Lehr is now chairman and chief executive of Capital BlueCross, where he has installed a plan for customers that would use PHC4 data to select hospitals. He would like to see hospital-quality information available across the country. "I would ask officials in Washington to push for mandatory compiling of medical data."
Be it cereal or cars, buyers usually have an idea of how good the products are and how much they cost before they buy them.
That's not how U.S. health care works. Patients rarely know which hospitals offer top-quality lung or aortic surgery, and which are more likely to harm them. Hospitals don't compete on price and rarely publish measurements of their quality, if they measure it at all.
Except in Pennsylvania. For two decades, a state agency has published "medical outcomes" -- death and complication rates -- from more than 50 types of treatments and surgery at hospitals. The state has found that publishing results can prompt hospitals to improve, and that good medical treatment is often less expensive than bad care.
One reason is that high-quality treatment usually results in shorter hospital stays and fewer readmissions. The state has had less success in publishing hospital prices and has drawn criticism from hospitals that disagree with its reporting methods. But companies or unions in Pennsylvania that have agreed to work only with the best-performing hospitals say they have been able to drive down medical costs.
"High-quality care costs less -- always," says David B. Nash, a medical-quality expert and dean at Thomas Jefferson University's School of Population Health in Philadelphia. "If the federal government could behave like a savvy shopper, that would change the health-cost game overnight. But the government is a bill payer, not a savvy shopper."
Walter McClure, who helped spark Pennsylvania's efforts, was an early advocate of publicizing medical outcomes and fostering competition among hospitals.The Senate Finance Committee could vote late this week on its sweeping health bill, seen as the backbone for any final legislation. That bill would make available $75 million annually for the U.S. Department of Health and Human Services to develop methods of improving quality, including potentially publishing outcomes.
Although at times premium care can be exorbitant, there's evidence some in Pennsylvania saved money using top-rated hospitals. Hershey Co. offered workers medical coverage based on the state agency's reported outcomes, and cut the company's expenses by 50% over several years. The Philadelphia police union's benefits-management company says it uses the state reports to steer officers to the best hospitals; as a result, it say its costs fall about 17% below those of comparable plans.
Tom Lamb, administrator of Philadelphia police health benefits, says he frequently explains to members why they should go to hospitals with better outcomes. "If an officer's 7-year-old daughter has to go in for surgery," he says, "I'll sit down with the father and say, 'Are you just going to shake your head yes when your pediatrician wants to send her to his golfing buddy?' "
Quality Ratings
The Delaware Valley Health Care Coalition, a group of union and municipal health funds covering 1.3 million people, is beginning the process of picking about 20 hospitals based on the state's quality ratings. Capital BlueCross in Harrisburg has designed a plan that selects hospitals based on the reports. Mark Dever, benefits manager at Duquesne Light in Pittsburgh, says his company recently got an offer from a hospital chain to treat the company's workers. But after reviewing state quality data and comparing prices, he rejected it.
An August 2008 study in the American Journal of Medical Quality reported that Pennsylvania in-hospital odds of death were 21% to 41% lower than those in other states. The research focused on heart attacks, congestive heart failure, brain hemorrhage, stroke, pneumonia and septic infections.
The Obama administration is allotting $1 billion for research to compare effectiveness of medical treatments. Some hope comparing hospital outcomes will be part of that. "As a patient," says Michael Pine, who runs a medical quality-measuring business in Chicago, "I would generally be more interested in whether Hospital A or Hospital B gets better results, more than whether drug A is more effective than surgery."
The theory underlying the Pennsylvania program is that, to create a truly competitive health-care market, consumers need hard information showing which hospitals perform better.
Curbing Infections
For example, Pennsylvania three years ago published its first report on hospitals' infection rates that arise largely from intravenous catheters and tubes left in too long. Infection numbers the following year fell 7.8%, as hospitals responded with steps designed to lower infections.
The average payment in 2006 for hospitalization where a patient acquired an infection was $53,915; with no infection, the average payment was $8,311, according to state reports.
By simply getting rid of preventable infections, Pennsylvania estimates its hospitals could lower expenses by nearly $1 billion.
Where are the insurance companies? They are the major payers. They should be driving this data collection and management of the system.
The White House is looking at publishing information possibly including medical outcomes as part of overhaul efforts, officials say. Quality data could also be used in existing programs. "There is a clear understanding from the Obama administration that both Medicare and Medicaid need to move in the direction of what's happening in Pennsylvania," says Jonathan Blum, director of the government's Center for Medicare Management.
The Philadelphia police health fund benefit-management company, covering 26,000 people, adopted a plan pegged to the state's hospital-quality results seven years ago. Mr. Lamb says the police fund has saved as much as $5 million a year using the information.
Sent Home
One retired Philadelphia police officer benefited from the state reports in an unusual way -- by learning he didn't need the coronary angioplasty he had been prescribed. Ed Gillespie, of Cape May, N.J., says he was told by his doctor six years ago that he needed angioplasty to clear out heart arteries. After consulting with Mr. Lamb, he learned state reports showed good results at Jefferson Medical College in Philadelphia. He decided to go there.
While he was on the gurney awaiting angioplasty, his cardiologist asked colleagues to study the films more carefully -- and concluded he could go home without treatment, Mr. Gillespie recalls. "I get checked every year, and I've been OK," he says.
Pennsylvania's agency -- called the Pennsylvania Health Care Cost Containment Council, or PHC4 -- has its critics. Hospitals have complained its data are imprecise or unnecessary.
P.J. Brennan, chief medical officer of the University of Pennsylvania Health System, says that PHC4 reports -- even though they are adjusted for certain risk factors -- still aren't comprehensive enough to take into account the very sickest patients, the sort treated at academic medical centers. "These reports are very important for transparency, but I don't think you can look at a PHC4 report and conclude you should not go to that hospital," he says.
In the state's most recent report, the Hospital of the University of Pennsylvania performed well in many categories but had worse-than-expected death rates in treating septicemia, or blood infections.
State legislators have tentatively cut the PHC4's budget to $2.8 million this year from $5.4 million in 2008, largely because of a state deficit.
The program got its start in the 1980s. Alarmed by health-cost inflation, business and labor leaders sought out Walter McClure, a Minnesotan who had pioneered a medical-quality program. Dr. McClure, who has a Ph.D. in physics, made a presentation to the Pennsylvania Business Roundtable in 1985.
Dr. McClure called on the executives to foment competition among hospitals. "We used to say to a patient, 'Go anywhere, regardless of cost, and we will pay the bill,' " he said in his speech. "Quality was assumed. That was dumb."
In 1986, Pennsylvania legislators created the PHC4. Three years later, the agency published its first report comparing death rates at about 180 hospitals.
Hahnemann University Hospital in Philadelphia fared poorly at first on several quality measures. Its ratings were significantly "worse than expected" on eight of 55 procedures in the first PHC4 "Hospital Effectiveness Report." The report included data for July 1, 1989, to June 30, 1990.
John Russell, then president of the Hospital Association of Pennsylvania, says Hahnemann and others complained, but "within about six weeks, they cleaned up their act." In the second Hospital Effectiveness Report, Hahnemann improved its ratings on seven of the eight procedures. The hospital declined to comment.
PHC4's first report on infections in 2006 showed Hamot Medical Center in Erie with a relatively high infection rate, in part because the hospital was early to use computers to track such rates. Emily McCracken, the hospital's epidemiologist, says the report "put a spotlight on something that needed a spotlight."The hospital has since lowered the infection rate by about 20% by cleaning IV catheters more often and removing them earlier.
Care Disparities
Over the years, PHC4 sought a wider variety of data and started producing reports on infection rates, readmissions and lengths of stay due to complications. The reports revealed startling disparities among hospitals and even individual doctors.
The hospital-performance reports use data compiled from medical records. Results are "risk adjusted," meaning the agency collects laboratory and medical-chart information about the age and overall health of patients so hospitals taking on difficult cases won't be unduly penalized.
The agency estimates the cost to the state's 172 acute-care hospitals of collecting the data annually is $7 million. The state's hospital association says it is $10 million or more.
The state agency hasn't been as successful in obtaining the prices that insurers pay to hospitals, information that would be important because it would allow patients and payers to factor in prices when choosing hospitals. The agency has legal power to get that information from insurers and publish it, but it has done so only for heart surgery. An agency spokesman says insurers didn't refuse, and that lack of manpower at the agency explains this omission. One person familiar with the events says many insurers wouldn't divulge prices.
Hershey came to rely on the state's hospital reports. In the early 1990s, medical costs for its 15,000 workers and dependents were soaring. "I told the human-resources department we needed to do something," says then-Chief Executive Richard Zimmerman.
Richard C. Dreyfuss, compensation and benefits manager, and his boss, William Lehr Jr., scrutinized the state's data for 23 hospitals. Mr. Dreyfuss ranked hospitals based 70% on medical outcomes and 30% on hospital prices, which the company obtained from insurers on its own. He focused on 21 costly procedures such as heart bypass and diabetes care.
Cost Correlation
Results shocked him. "The correlation between cost and quality was zero," he says. "You go in thinking that all hospitals are pretty much equal, but this was eye-opening. Generally, higher-cost hospitals had poorer outcomes."
Mr. Dreyfuss devised a plan called Health Styles in which only 10 hospitals would be included -- and 13 left out. Employees had other plans to choose from, but Health Styles was cheaper than the relatively inexpensive health maintenance organizations Hershey offered, Mr. Dreyfuss says.
The 13 excluded hospitals weren't happy -- especially the highly regarded Penn State University's Milton S. Hershey Medical Center, founded by the family that created the chocolate company.
C. McCollister Evarts, dean of the hospital's medical school, told Messrs. Dreyfuss and Lehr that the state agency's information was wrong and "you don't understand what an academic medical center does," Messrs. Dreyfuss and Lehr recall.
Dr. Evarts confirms his remark and says he believes such measurements have become far more precise over the years. In recent years, Hershey Medical was reinstated under the company's plans. The hospital declined to comment.
The Health Styles plan took effect in 1994. About 40% of employees in central Pennsylvania signed up. The company, which was self-insured, was able to hold its medical-care cost increases annually to 4%, about half the national rate, saving about $10 million in the first five years. "This thing was a real winner," says Mr. Dreyfuss. He and other former Hershey executives say the company cut its annual medical expense by 50% for several years.
Dennis Bomberger, business manager of Chocolate Workers Local 464, says Hershey's Health Styles "was an excellent plan" that "employees liked the best."
The plan was discarded two years ago, however, when a new Hershey management team changed health coverage, Mr. Bomberger says. A Hershey spokesman declined to comment.
Former Hershey vice president Mr. Lehr is now chairman and chief executive of Capital BlueCross, where he has installed a plan for customers that would use PHC4 data to select hospitals. He would like to see hospital-quality information available across the country. "I would ask officials in Washington to push for mandatory compiling of medical data."
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