Substantial Shifts in Ranking of California Hospitals by Hospital-Associated Methicillin-ResistantStaphylococcus aureusInfection Following Adjustment for Hospital Characteristics and Case Mix

Abstract

BACKGROUND.States have established public reporting of hospital-associated (HA) infectionsincluding those of methicillin-resistant Staphylococcus aureus (MRSA)-but do not account for hospital case mix or postdischarge events. OBJECTIVE.Identify facility-level characteristics associated with HA-MRSA infection admissions and create adjusted hospital rankings. METHODS.A retrospective cohort study of 2009-2010 California acute care hospitals. We defined HA-MRSA admissions as involving MRSA pneumonia or septicemia events arising during hospitalization or within 30 days after discharge. We used mandatory hospitalization and US Census data sets to generate hospital population characteristics by summarizing across admissions. Facility-level factors associated with hospitals' proportions of HA-MRSA infection admissions were identified using generalized linear models. Using state methodology, hospitals were categorized into 3 tiers of HA-MRSA infection prevention performance, using raw and adjusted values. RESULTS. Among 323 hospitals, a median of 16 HA-MRSA infections (range, 0-102) per 10,000 admissions was found. Hospitals serving a greater proportion of patients who had serious comorbidities, were from low-education zip codes, and were discharged to locations other than home were associated with higher HA-MRSA infection risk. Total concordance between all raw and adjusted hospital rankings was 0.45 (95% confidence interval, 0.40-0.51). Among 53 community hospitals in the poorperformance category, more than 20% moved into the average-performance category after adjustment. Similarly, among 71 hospitals in the superior-performance category, half moved into the average-performance category after adjustment. CONCLUSIONS. When adjusting for nonmodifiable facility characteristics and case mix, hospital rankings based on HA-MRSA infections substantially changed. Quality indicators for hospitals require adequate adjustment for patient population characteristics for valid interhospital performance comparisons.

Fighting MRSA Infections in Hospital Care: How Organizational Factors Matter

“…), invasive devices, comorbid disease, recent and repeated hospitalizations, and residing in an assisted living facility (McHugh and Riley ; Tehrani et al. ; Loftus et al. ).…”

Evaluating the Use of the Case Mix Index for Risk Adjustment of Healthcare-Associated Infection Data: An Illustration using Clostridium difficile Infection Data from the National Healthcare Safety Network

“…8,11 Inclusion of pertinent patient-level characteristics, as for NHSN surgical site infection surveillance, 8 is desirable to facilitate meaningful interfacility comparisons. [4][5][6][7][8][9][10]12,13 However, identification of the relevant set of characteristics is challenging, and routine collection of data for all individual patients within a hospital can be impractical and burdensome.…”

Clostridium difficile infection as a novel marker for hospital quality, efficiency and other factors associated with prolonged inpatient length of stay

“…Due to the increasing incidence and growing costs associated with HAIs, many Network also began reporting CDI events [129,48]. Given this increased availability of public information on hospital incidence of HAIs, studies have now begun using hospital incidence rates of HAIs, such as MRSA and CDI, as measures for making hospital-level comparisons [30,151].…”

“…Organizations such as the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) have already required or called for the reporting and surveillance of the rates of HAIs across hospitals [150,113]. Consequently, in many states, hospitals are now required by law to report their incidence of HAIs, including CDI [2,129,66].…”

“…A motivation of such e↵orts has been to measure and compare healthcare quality and disease presence across hospitals. Studies have already begun using HA CDI incidence, as well as incidence rates for other HAIs, to create rankings across hospitals [30,151]. If CDI incidence also serves as a marker for excess LOS and resource use between hospitals, this information may be useful for policy makers wishing to reduce overall healthcare expenditure.…”