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Keywords:

  • legislation;
  • public reporting;
  • surgical site infection

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies

Objective

Surgical site infections (SSIs) are common, costly, and often preventable. There are no national requirements for measuring or reporting hospital SSI rates and state-level monitoring occurs with little coordination between states. We designed a study to describe the current status of SSI reporting in the United States.

Methods

We reviewed SSI monitoring and reporting legislation in all 50 states in September 2010. Data collected included whether SSI monitoring and reporting legislation exists, if public reporting is required, how the data are accessible, and for which procedures SSI data are reported.

Results

Twenty-one (42%) states have legislation for SSI monitoring and reporting. All 21 of these states require public release of findings. Of the states with legislation, eight (38%) currently have SSI data available publicly. A range of two to seven procedures were reported for SSI measurement by individual states. Eighteen (86%) states use state agency websites to make their data publicly available.

Conclusion

There is wide variation in state monitoring and reporting of SSI rates. Standardized reporting may be needed so that consumers can make informed health choices based on quality metrics.

Surgical site infections (SSI) occur 4–25% of patients after major surgical procedures and are estimated to cause over 8,000 deaths annually (Klevens et al., 2007). The occurrence of an SSI is increasingly being recognized to be a preventable harm and, as a result, SSI rates are being used as a surrogate measure healthcare quality. SSIs are also costly. The associated increased length of hospital stay, wound care supplies, and home care needs are estimated to cost $10.07 billion annually (Scott, 2009). Despite many efforts to reduce these events and associated harm and costs, sustained reductions in SSI rates have not been achieved.

One strategy that has been highly effective in improving quality on a large scale is public reporting (Fung, Lim, Mattke, Damberg, & Shekelle, 2008; Jha, Orav, Li, & Epstein, 2007). Benchmarking outcomes has been demonstrated to have a global improvement effect with surgical outcomes (Hall et al., 2009) and public reporting has been shown to improve cardiac surgery outcomes in New York State. In the 4 years after implementation of public reporting, the State of New York saw mortality from coronary artery bypass surgery decrease by 41% (Hannan, Kilburn, Racz, Shields, & Chassin, 1994). However, despite the evidence supporting the dramatic benefits of benchmarking and public reporting in surgical outcomes, there is no national standard for SSI. We designed a study to review current state legislation on SSI monitoring and public reporting.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies

Data Collection

The laws, administrative regulations, and state plans of 50 U.S. states and one U.S. territory (District of Columbia) were reviewed. We began by conducting a search of relevant Hospital Associated Infection (HAI) keywords in the Lexis-Nexis legal research database to identify state HAI-related statutory laws, regulations on state administrative databases. We also recorded each state's regulation or plan to report SSI as reported by the CDC website (Centers for Disease Control, 2010) and we accessed department of health websites for published reports on SSI. If a report was not found by indicators such as healthcare quality, data, and/or statistical reports, we conducted a page search for the following terms: “SSI,” “HAI,” “health care associated infection,” “hospital acquired infection,” “nosocomial infection,” and “mandatory reporting.” We accessed all online data in September 2010.

Data Analysis

After locating each state's laws, HAI plans, and SSI or HAI reports if available, we abstracted information relevant to monitoring and reporting practices, public disclosure mechanisms, and content of currently available reports. We assessed the data to determine if the state requires SSI monitoring, whether the law specifies if monitoring and/or reporting is mandatory or voluntary. We also collected data on the public reporting mechanism, the type of procedures in each report currently available and the time lag between collecting and reporting. Finally, we assessed toward which agency the data are reported.

Results are provided using descriptive data and percentages; state monitoring and reporting practices are listed in table form.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies

Twenty-one states (42%) have legislation regarding monitoring and reporting of SSIs. All 21 states have legislation that requires monitoring of SSIs. Twenty (40%) of the states require SSI reporting and one state (Arkansas) has legislation encouraging voluntary reporting. The District of Columbia does not have any monitoring regulations. The remaining 29 states (58%) had no laws specifying SSI monitoring and reporting.

Data are disseminated in 15 states by Annual Reports, 18 states use their State Agency Websites, and 12 states use both. Additionally, three states also provide quarterly or semiannual reports (see Table 1).

Table 1. Data Collection, Reporting, and Availability by State of Surgical Site Infections
  Data Reporting Mechanism 
 Data CollectionAnnualPosting to Is Data Currently
StateEntityreportstate websiteOtherPublicly Available?
  1. NHSN, Center for Disease Control's National Healthcare Safety Network.

ALNHSN  No
ARNHSN No
CANHSN  No
CONHSNSemiannual bulletinsYes
ILNHSNQuarterly bulletinsNo
MANHSN  Yes
MENHSN No
MONHSN Yes
NVNHSN No
NHNHSN  No
NJNHSN  No
NYNHSN Yes
OHNHSN  Yes
OKNHSN  No
ORNHSN Quarterly reportYes
PANHSN No
RIState agency No
SCNHSN Yes
TNNHSN No
VTNHSN  Yes
WANHSN No

Of the eight states with SSI public data currently available, a total of 10 procedures are reported. Seven (88%) states report coronary artery bypass graft procedures, six (75%) states report on hip replacement procedures, and six (75%) report on knee replacement procedures. Four states (50%) report hysterectomy, two states (25%) report colon surgery, and two states (25%) report herniorrhaphy. One state (13%) reports on breast surgery procedures, one state (13%) reported on gallbladder procedures, one state (13%) reports on cesarean section procedures, and one state (14%) reports on spinal fusion (see Table 2).

Table 2. Procedures Publicly Reported by States of Surgical Site Infections
 States
Procedure (Number of States Reporting, %)SCMOCOMANYOHVTOR
Coronary artery bypass graft (n = 7, 88%) 
Hip replacement (n = 6, 75%)  
Knee replacement (n = 6, 75%)  
Hysterectomy (n = 4, 50%)    
Herniorrhaphy (n = 2, 25%)      
Colon surgery (n = 2, 25%)      
Breast surgery (n = 1, 13%)       
Gallbladder (n = 1, 13%)       
Cesarean section (n = 1, 13%)       
Spinal fusion (n = 1, 13%)       

Among the eight states with currently available data, a range of two to seven procedures are reported. South Carolina reports seven procedures, Missouri reports five procedures, Colorado and Massachusetts report four procedures, New York, Ohio, and Vermont report three procedures, and Oregon reports two procedures. The average time lag between collection and publication was 6 months, with a range of 2–11 months.

Of the 21 states with legislation, 20 (95%) report using the Center for Disease Control's National Healthcare Safety Network (NHSN) and one state reports to its own state agency. Public SSI data reports are required in all 21 states with SSI legislation; eight (38%) of these states currently have public data available (see Figure 1).

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Figure 1. United States Map of States with Surgical Site Infection Legislation that Requires Public Reporting

Download figure to PowerPoint

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies

This study describes the variation in state reporting of SSI rates. We found legislation in 21 of 50 states requiring reporting of SSI rates and currently public data available for eight states. The type of data available was varied with states reporting anywhere from two to seven procedures. Interestingly, colon surgery that has the highest rates of SSIs nationally was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures a patient undergoes, was only reported by one state. The motivation to monitor and report certain procedures over others is unclear, and further highlights the variability between states. Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care (Pronovost, Miller, & Wachter, 2007).

While the most striking variation in reporting is in whether or not a state reports at all, even within the reporting variation exists. In order for the consumer to interpret publicly reported SSI rates, it is imperative that the data be collected and reported in a standardized manner. For example, for colorectal SSIs, in-hospital monitoring versus monitoring with 30-day follow-up results in nearly a 40% discrepancy in SSI rates as many infections are diagnosed postdischarge (Smith et al., 2004). Furthermore, certain patient factors not amenable to change are associated with significantly increased risk of SSIs (Wick, Vogel, Church, Remzi, & Fazio, 2009). Thus, hospital patient mix will impact SSI rates and risk adjustment will be needed to make meaningful comparisons. Two of the most prevalent programs to calculate risk adjusted SSI rates are the CDC-NHSN and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Although they use the same definitions for SSIs, the risk-adjustment techniques are markedly different and can consequently result in different expected rates for SSIs. In addition, numerous private sector groups have developed programs (e.g., ArborMix, Ann Arbor, Michigan) that will provide yet another set of metrics to follow surgical quality. Thus, as we move to mandated public reporting, it will be important to use a common program or at least ensure common parameters, inputs, and definitions that are used.

Measuring SSI rates is labor intensive but benchmarking these data represent one common-sense strategy to quality improvement in healthcare (Edwards et al., 2009). In New York State, legislating mandatory public reporting of cardiac surgery mortality rates resulted in an overall reduction in mortality rates. There was continued improvement with each subsequent year of public reporting. One explanation is that the public was more empowered with the data to make informed decisions, pressuring hospitals to focus on improving quality. Similarly, participation in benchmarking of hospital data within a large collaborative has been shown to improve surgical outcomes (Hall et al., 2009). Despite the dramatic impact of these monitoring practices, hospitals remain reluctant to publicly disclose their outcome data when it is not required. Legislation requiring reporting would motivate hospitals to re-evaluate their practices in SSI prevention and address internal outliers.

While we believe national standards would best facilitate improved reporting practices, other alternatives exist. At the very least, agreed upon definitions for a surgical site infection would be helpful so that the term is being used with universal understanding as it relates to policy and quality improvement. This could be facilitated, in part, by soliciting input from physician groups and societies. Payment incentives from payers with appropriate definitions and expectations may also be helpful to motivate accurate and timely reporting. Finally, if these efforts cannot be coordinated at a national level, multistate collaboratives may be a useful stepping stone.

Our study highlights the need for the Federal Government to set the rules for how hospitals define, monitor, and report SSIs. Though SSI process measures have received tremendous attention from the Centers of Medicare and Medicaid Services (CMS), the public, and the media, studies have failed to demonstrate that adherence to these measures reduce SSIs (Hawn et al., 2008; Nguyen, Yegiyants, Kaloostian, Abbas, & Difronzo, 2008; Stulberg et al., 2010). In fact, focusing on process measures rather than outcomes may divert important resources that could improve quality (Makary & Ibrahim, 2010). Accordingly, CMS recently announced that hospitals will have to begin reporting SSIs rates for select procedures beginning in January 2012 to impact payment for fiscal year 2014 (Hanshaw, Olson, & Gillespie, 2010). It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme.

This study has some important limitations. First, we searched only state health department websites, thus data may be publicly available that we did not consider (such as on individual hospital websites). We recognize that not all publicly available SSI data are present in this manuscript; however, a component to consumer-friendly data is easy access. Nevertheless, the few number of states that have publicly available data further advance our thesis that data are not readily accessible. Second, we conducted our review during a single month, and we do not know what legislation might be forthcoming. It is likely that states are preparing for SSI reporting in light of recent CMS announcements (Hanshaw, Olson, & Gillespie, 2010), however national guidelines and definitions for collection and reporting are not in place. Third, we did not validate the accuracy of the web reporting. Yet, the intent of making SSI data publicly available is so consumers may use it when selecting a provider or assessing improvement efforts within a hospital, thus we assumed accuracy of the data.

We applaud efforts to promote SSI public reporting. We believe that there is potential to mitigate this form of preventable harm through these standardized efforts. At minimum it represents a novel strategy to decrease SSI in the context of many other previously unsuccessful efforts. Yet these policy provisions do not go far enough. We encourage CMS to build a rigorous process to validate SSI data or for CMS to require participation in the ACS-NSQIP or the CDC-NHSN so that appropriate definitions and risk adjustment can be used for monitoring. Only when SSI data are uniformly collected, reported, clinically validated, and made transparent will such a choice be possible. SSI can provide a model for monitoring and reducing other types of preventable harm.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies
  • Centers for Disease Control. (2010). State Plans to Address Healthcare-Associated Infections, May 27, 2010. Retrieved August 7, 2010, from http://www.cdc.gov/HAI/HAIstatePlans.html.
  • Edwards, J. R., Peterson, K. D., Mu, Y., Banerjee, S., Allen-Bridson, K., Morrell, G., et al. (2009). National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued December 2009. American Journal of Infection Control, 37, 783805.
  • Fung, C. H., Lim, Y. W., Mattke, S., Damberg, C., & Shekelle, P. G. (2008). Systematic review: The evidence that publishing patient care performance data improves quality of care. Annals Internal Medicine, 148, 111123.
  • Hall, B. L., Hamilton, B. H., Richards, K., Bilimoria, K. Y., Cohen, M. E., & Ko, C. Y. (2009). Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: An evaluation of all participating hospitals. Annals Surgery, 250, 363376.
  • Hannan, E. L., Kilburn, H., Jr., Racz, M., Shields, E., & Chassin, M. R. (1994). Improving the outcomes of coronary artery bypass surgery in New York State. Journal of the American Medical Association, 271, 761766.
  • Hanshaw, J., Olson, T., & Gillespie, S. (2010). “Healthcare Associated Infections Reporting Requirements”: A presentation given for the Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
  • Hawn, M. T., Itani, K. M., Gray, S. H., Vick, C. C., Henderson, W., & Houston, T. K. (2008). Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection. Journal of the American College of Surgeons, 206, 814819.
  • Jha, A. K., Orav, E. J., Li, Z., & Epstein, A. M. (2007). The inverse relationship between mortality rates and performance in the Hospital Quality Alliance measures. Health Affairs (Millwood), 26, 11041110.
  • Klevens, R. M., Edwards, J. R., Richards, C. L., Jr., Horan, T. C., Gaynes, R. P., & Pollock, D. A., et al. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports, 122, 160166.
  • Makary, M. A., & Ibrahim, A. M. (2010). Surgical care improvement project adherence and postoperative infections. Journal of the American Medical Association, 304, 16701671.
  • Nguyen, N., Yegiyants, S., Kaloostian, C., Abbas, M. A., & Difronzo, L. A. (2008). The Surgical Care Improvement Project (SCIP) initiative to reduce infection in elective colorectal surgery: Which performance measures affect outcome? The American Surgeon, 74, 10121016.
  • Pronovost, P. J., Miller, M., & Wachter, R. M. (2007). The GAAP in quality measurement and reporting. Journal of the American Medical Association, 298, 18001802.
  • Scott, R. D., II. (2009). The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention.
  • Smith, R. L., Bohl, J. K., McElearney, S. T., Friel, C. M., Barclay, M. M., Sawyer, R. G., et al. (2004). Wound infection after elective colorectal resection. Annals of Surgery, 239, 599605.
  • Stulberg, J. J., Delaney, C. P., Neuhauser, D. V., Aron, D. C., Fu, P., & Koroukian, S. M. (2010). Adherence to surgical care improvement project measures and the association with postoperative infections. Journal of the American Medical Association, 303, 24792485.
  • Wick, E. C., Vogel, J. D., Church, J. M., Remzi, F., & Fazio, V. W. (2009). Surgical site infections in a “high outlier” institution: Are colorectal surgeons to blame? Diseases of the Colon and Rectum, 52, 374379.

Biographies

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. References
  7. Biographies
  • Martin A. Makary, MD, MPH, is national leader in patient safety and served in leadership positions for the United Nations World Health Organization (WHO) and the International Union of Risk Management. He is a national advocate for transparency in medicine and shared-decision making. Dr. Makary is an advanced laparoscopic and pancreatic surgeon at Johns Hopkins and is active in the American College of Surgeons NSQIP and safety culture programs.

  • Monica S. Aswani, MSPH, is a Lister Hill Health Policy Fellow in the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins University School of Medicine, Baltimore, Maryland.

  • Andrew M. Ibrahim is the Doris Duke Fellow in Clinical Research in the Department of Surgery at Johns Hopkins University School of Medicine and a medical student at Case Western Reserve University, School of Medicine.

  • Julie Reagan, PhD, JD, MPH, is an attorney and healthcare consultant who has been practicing law since 1993. Dr. Reagan's healthcare consulting practice currently focuses solely on healthcare-associated infection issues. Her 2010 dissertation topic, The Movement Toward Patient Safety: State Action Related to Reporting and Disclosure of Healthcare-Associated Infections, presented a comparative analysis of state reporting and public disclosure laws among U.S. states and territories. She currently serves as a community member on the New Mexico Healthcare-Associated Infections Committee.

  • Elizabeth C. Wick is a board-certified colorectal surgeon and an assistant professor of surgery and oncology at Johns Hopkins University. She has a strong interest in surgical site infections and prevention strategies.

  • Peter J. Pronovost, MD, PhD, is a practicing anesthesiologist and board certified critical care physician, teacher, researcher, and international patient safety leader with his doctorate in clinical investigation. Dr. Pronovost is a Professor in the Johns Hopkins University School of Medicine (Departments of Anesthesiology and Critical Care Medicine, and Surgery) in the Bloomberg School of Public Health (Department of Health Policy and Management) and in the School of Nursing, Baltimore, MD. He is also Medical Director for the Center for Innovation in Quality Patient Care, which supports quality and safety efforts at the Johns Hopkins Hospitals and established the Quality and Safety Research Group to advance the science of safety.