Mandatory Reporting

1
Mandatory Reporting Public Disclosure of
Nosocomial InfectionsThe Virginia Experience
Michael Edmond, MD, MPH, MPA Hospital
Epidemiologist Chair, Division of Infectious
Diseases
2
Mandatory Reporting Legislative Activity in VA
through 2004
Source Virginia General Assembly website.
3
Post-Legislative Activity in 2004

• Survey of surveillance methodology HR
  requirements in VA acute care hospitals
• Collaborative effort of VDH, VA-APIC VCUMC
  Infection Control
• VA Board of Health reviewed survey results in
  July 2004 requested that an advisory panel be
  convened to address (1) whether HAI reporting
  should be mandated, and (2) what methods to use
  if reporting is mandated
• Advisory panel met in September 2004
• No consensus reached on whether reporting should
  be mandated or which indicators to use should
  reporting be mandated
• Recommended further study by the legislative
  Joint Commission on Health Care
• Board of Health, VHHA supported study by JCHC

4
An Aha! Moment

• Strongly opposed mandatory reporting through the
  2004 session of the General Assembly
• Immediately after the subcommittee hearing in
  which the patron tabled the bill in exchange for
  our survey of hospitals, he askedIsnt there
  something you can measure?
• Message from the political/policy standpoint,
  this is about the concept, not outcome,
  certainly not process
• Began to work with VA-APIC to come up with a
  policy alternative

5
Goals of the Ideal Mandatory Reporting
Disclosure Program

• Maximize accuracy of data collection
• Standardize methodology for data collection
  analysis
• Minimize costs to hospitals government agencies
• Produce data that are valid, fair to hospitals,
  useful to consumers

Edmond MB. In Hospital Infections, 5th ed., 2007.
6
Options for Reporting HAIs

• Continue status quo (no reporting)
• Mandate reporting of outcomes indicators
• Require hospitals to report data as currently
  collected
• Require hospitals to join an existing
  surveillance system
• Create a statewide surveillance system for NI de
  novo
• Use administrative claims data
• Mandate reporting of process indicators
• Mandate public disclosure

7
Options for Reporting Nosocomial Infections
Utilizing CDCs Surveillance Program

• Advantages
• All hospitals will be required to utilize
  standardized definitions for infections uniform
  data collection methodology
• Costs are minimized (no fees to hospitals or VDH
  no development costs)
• Data submission to CDC feedback will be
  electronic allowing for timely reporting
  analysis
• Will allow for the development of robust
  benchmarks developed from a large, nationwide
  cohort of hospitals
• CDCs program is considered the most advanced
  surveillance system for NIs in the US

8
VA Survey of NI Surveillance Activity

• One-page questionnaire was mailed to the
  infection control department of each acute care
  hospital in Virginia (n94)
• Goals
• Obtain data useful for drafting NI legislation in
  VA
• Characterize current NI surveillance activities
  methods in order to identify common practices
• Assess current human resources involved in
  infection control activities
• Estimate human resources needed to implement
  hospitalwide NI surveillance
• Survey response 79

Edmond MB et al. Am J Infect Control
200533480-2.
9
NI Surveillance in VA Hospitals

Edmond MB et al. Am J Infect Control
200533480-2.
10
ResourcesICPs in Virginia Hospitals
Mean 1.0 Median 1.0
1 FTE 64
lt1 FTE 21
gt1 FTE 14
Survey response 79
Edmond MB et al. Am J Infect Control
200533480-2.
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ResourcesICPs Additional Responsibilities
Percent
Edmond MB et al. Am J Infect Control
200533480-2.
12
Estimated Additional ICP FTE for Hospitalwide
Surveillance

• Range 0 8 FTE
• Mean 1.7 FTE
• 68 of hospitals would require at least 1.0 FTE
• Statewide
• 160 additional ICPs
• 11.5 million yearly

Edmond MB et al. Am J Infect Control
200533480-2.
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Unfunded Mandate

• I dont want this to cost anyone any money.

Delegate H.R. Purkey
14
Location, Location, Location!
VCU Medical Center
General Assembly Building
State Capitol
State Health Dept.
15
Virginia House Bill 1570Patron Del. Harry R.
Purkey

• The Board of Health shall develop a procedure
  whereby aggregate information on each hospitals
  incidence of nosocomial infections, without
  patient identifiers, (i) may be released to the
  public, upon request (ii) shall be filed in the
  hospitals licensure records within the
  Department of Health and (iii) shall be
  transmitted to the Division of Consumer Counsel
  and the Administrator of Consumer Affairs for use
  in determining any necessary actions to protect
  the interests of Virginias consumers. The Board
  of Health shall promulgate regulations to
  implement the provisions of this act to be
  effective within 280 days of its enactment.
• Prefiled December 9, 2004 introduced January 12,
  2005

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Key Policy Positions

• Del. Purkey
• Report all infections
• No attention to methodology
• No resources provided to hospitals or VDH

Virginia Hospital Healthcare Association Oppose
all reporting

• Our Solution
• Report some infections
• Mandate methodology
• Minimize cost to hospitals VDH

• Consumers Union
• Report all infections
• Mandate standardized methodology
• Extensive external input oversight
• No consideration of cost

17
Virginia House Bill 1570 (final)

• Acute care hospitals shall report information
  about nosocomial infections to the Centers for
  Disease Control and Prevention's National
  Healthcare Safety Network. Such hospitals shall
  release their infection data to the Board of
  Health. The specific infections to be reported,
  the hospitals required to report, and patient
  populations to be included shall be prescribed by
  Board regulation. Such hospital infection rate
  data may be released to the public by the Board,
  upon request. The provisions of this act shall
  become effective on July 1, 2008.
• 1/20/05 Passed House Health, Welfare,
  Institutions Committee (21-Y, 0-N)
• 1/25/05 Passed House (97-Y, 0-N, 1-A)
• 2/10/05 Passed Senate Committee on Education
  Health (15-Y, 0-No)
• 2/14/05 Passed Senate (40-Y, 0-N)
• 3/21/05 Signed by Governor Mark Warner

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Mandatory NI Reporting in Virginia Effective
July 1, 2008
State Health Department
Hospitals
CDC
CDC calculates risk-adjustedHAI rates makes
data available to hospitals VDH via web
VDH releases data to the public on request
ICPs transmit data to CDCs NHSN electronically
Board of Health determines HAIs patient
populations for surveillance
ICPs collect HAI data using CDC definitions
methodology
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Postscript

• Death of high school student in southwest
  Virginia in October 2007 due to invasive MRSA
  infection made national headlines
• Multiple school closings due to single cases of
  MRSA skin infections
• Governor Tim Kaine issued an emergency order
  making invasive MRSA infections a reportable
  disease
• Governor revisited the HAI reporting issue
  informed VDH that reporting plans were too narrow

20
Current Challenges

• Reporting begins July 1, 2008 however, the
  metrics to be reported are not yet known
• Logistical issues associated with hospitals
  joining NHSN
• Steep learning curve for ICPs without experience
  in surveillance and unfamiliarity with CDC
  definitions methodology