What the HAC?!

The University of Wisconsin (UW) Hospital is an excellent institution with a stellar infection prevention program. In fact, last year they won the prestigious U.S. Department of Health and Human Services (HHS) Partnership in Prevention Award, which recognizes “prevention leaders in the U.S … who have achieved wide-scale reduction and progress toward elimination of targeted health care associated infections.” Sadly, this achievement may not be enough to keep HHS from levying financial penalties against UW for high infection rates.

Yes, the Hospital Acquired Condition (HAC) scores have come out, and have been generating a fair bit of media coverage, focused on those hospitals most likely to face financial penalties. Funny thing, though—the hospitals most likely to lose money under this program share a lot of characteristics:

“Who is getting penalized? Large, urban, public, teaching hospitals in the Northeast with lots of poor patients. Who is not getting penalized? Small, rural, for-profit hospitals in the South. Here are the data from the multivariable model: The chances that a large, urban, public, major teaching hospital that has lots of poor patients (i.e. top quartile of DSH Index) will get the HAC penalty? 62%. The chances that a small, rural, for-profit, non-teaching hospital in the south with very few poor patients will get the penalty? 9%.”

Interesting. Explanations for these findings include: (1) small size, rural location, southern region and for-profit status magically translate to higher-quality, safer care, or (2) this HAC metric is bullshit, as it obviously doesn’t adequately control for myriad variables that are associated with the score but that are not indicators of quality and safety. What variables? Intensity and accuracy of surveillance, and variation in infection risk of the different patient populations, for starters.

I can overlook bullshit when it brings more attention (and resources) to the critical task of infection prevention. Unfortunately, this particular form of bullshit does the opposite (unfairly punishing already cash-strapped hospitals with financial penalties). As others have pointed out, the current HAC metric is well-intentioned but obviously flawed, and in desperate need of fixing.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.