Wrong Target, Wrong Weapon

The hospital is a dangerous place. Sick people go there.  In fact, its likely the largest concentration of sick people in your town.  I mean sick sick, not seasonal viral cold sick.  So it should come as no surprise that there’s always a risk, when you go into a hospital, that you’ll get sicker.  Post-hospital syndrome is one of those illnesses.  Another is infections.  The CDC estimates that 648,000 patients acquired an infection while in the hospital in 2012.  CMS and the Affordable Care Act, in their infinite wisdom, have decided to target those infections.  Or rather, the government has decided to monetarily penalize hospitals whose patients get a lot of infections.  According to Kaiser Health News, (http://www.kaiserhealthnews.org/Stories/2014/June/23/patient-injuries-hospitals-Medicare-Hospital-Acquired-Condition-Reduction-Program.aspx) 761 hospitals stand to lose 1% of every medicare billing because their infection rates are higher than benchmark.

So which are these disease-laden dens of hygienic iniquity?  Large, city, teaching hospitals with a lot of poor people.  Are there a lot of mean, dirty people working in these hospitals who have no respect for poor people and are careless about cleanliness?  Are residents not washing their hands, or sneezing on patients’ open wounds?  Of course not.  Let’s look at the measures CMS is looking at.

1. Catheter-related infections, both blood and urinary.  So that means intravenous lines into large central veins or arteries, as well as catheters inserted into bladders to drain urine.  Who gets these catheters?  Sick people.  In the case of central lines, the sickest people in the hospital.  Where are the sickest patients?  Large, city, teaching hospitals.

2. Clostridium Difficile (that’s C-Diff to you).  This is an acquired infection in the bowels.  Who gets C-Diff?  People who have been in the hospital for a long time.  Who stays in the hospital for a long time?  Sick people, vulnerable to infections.

3. Methcillin-resistant staphylococcus aureus (MRSA).  If I had a nickel for every “MRSA” infected person in any hospital, I wouldn’t be writing for money.  Geeze, I’ve been in the hospital a lot.  I work there.  Maybe I have MRSA too.  Some places swab everyone’s nose regularly to check for MRSA.  If a patient has a “history of MRSA”, even if its vague, or we’re not sure, or it was 30 years ago, everybody gowns and gloves around that person and waves red alert flags wave everywhere.  Thousands of infection control nurses’ careers have been made off questionable MRSA histories.  I’m not saying real MRSA infections are serious.  They are.  It’s just not a good metric.

Of course there’s the fact that a New England Journal of Medicine study in 2012 found that docking medicare payments doesn’t improve “performance” on things like this (http://www.nejm.org/doi/full/10.1056/NEJMsa1202419).  But even if it did, infection rates are a lot more complicated than four data points.  Certain patient populations are more likely to get hospital-acquired infections.  Patients with diabetes, lung disease, or vascular disease are more susceptible.  The old and/or debilitated are more susceptible.  The poor and those without social supports are more vulnerable.  People getting complicated surgical procedures, especially bowel, are more vulnerable.  All of these conditions are more prevalent in large, city, teaching hospitals, even with the most draconian infection-control policies imaginable.  Once again, CMS is going after the wrong suspect and the largest target.

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