A population-based study conducted by Nick Daneman and colleagues in Ontario, Canada reports on the association between population reporting of hospital infection rates and a reduction in population burden of Clostridium difficile colitis.
The role of public reporting in improving hospital quality of care is controversial. Reporting of hospital-acquired infection rates has been introduced in multiple health care systems, but its relationship to infection rates has been understudied. Our objective was to determine whether mandatory public reporting by hospitals is associated with a reduction in hospital rates of Clostridium difficile infection.
Methods and Findings
We conducted a longitudinal, population-based cohort study in Ontario (Canada's largest province) between April 1, 2002, and March 31, 2010. We included all patients (>1 y old) admitted to 180 acute care hospitals. Using Poisson regression, we developed a model to predict hospital- and age-specific monthly rates of C. difficile disease per 10,000 patient-days prior to introduction of public reporting on September 1, 2008. We then compared observed monthly rates of C. difficile infection in the post-intervention period with rates predicted by the pre-intervention predictive model. In the pre-intervention period there were 33,634 cases of C. difficile infection during 39,221,113 hospital days, with rates increasing from 7.01 per 10,000 patient-days in 2002 to 10.79 in 2007. In the first calendar year after the introduction of public reporting, there was a decline in observed rates of C. difficile colitis in Ontario to 8.92 cases per 10,000 patient-days, which was significantly lower than the predicted rate of 12.16 (95% CI 11.35–13.04) cases per 10,000 patient-days (p<0.001). Over this period, public reporting was associated with a 26.7% (95% CI 21.4%–31.6%) reduction in C. difficile cases, or a projected 1,970 cases averted per year (95% CI 1,476–2,500). The effect was specific to C. difficile, with rates of community-acquired gastrointestinal infections and urinary tract infections unchanged. A limitation of our study is that this observational study design cannot rule out the influence of unmeasured temporal confounders.
Public reporting of hospital C. difficile rates was associated with a substantial reduction in the population burden of this infection. Future research will be required to discern the direct mechanism by which C. difficile infection rates may have been reduced in response to public reporting.
Please see later in the article for the Editors' Summary
A stay in hospital can be lifesaving but can expose people to health care–associated infections. One of these—Clostridium difficile infection—is a major cause of infectious disease illness and death in developed countries. C. difficile bacteria cause diarrhea and, more rarely, life-threatening inflammation of the gut (colitis). They are present in the gut of about 3% of adults but do not normally cause any problems because other “good” bacteria keep them in check. However, antibiotics destroy these good bacteria, and if a person who has taken antibiotics becomes infected with C. difficile before good bacteria repopulate the gut, C. difficile can multiply rapidly and produce toxins that cause illness. Because C. difficile is usually acquired from other infected patients and their contaminated environments, and because antibiotic use is highly prevalent in hospitals, most C. difficile infections are acquired in hospitals and nursing homes. Infections can be prevented by practicing good hygiene in health care environments (for example, washing hands regularly with soap and water), by isolating patients who are infected with C. difficile, and by prescribing antibiotics for other infections sparingly.
Why Was This Study Done?
Hospitals often need encouragement to improve infection control and other aspects of care. One potential way to improve the quality of hospital care is mandatory public reporting of measures of care quality. This intervention may help hospitals identify areas of poor performance to target for improvement or may motivate them to improve care quality to avoid the shame of a bad performance report. Although many health care systems have introduced public reporting of hospital-acquired infections, the effects of this intervention have been poorly studied. In this longitudinal cohort study, the researchers use population-based health care data to evaluate the impact of the introduction of mandatory hospital public reporting of the rates of hospital-acquired C. difficile infection in Ontario, Canada. Since September 1, 2008, hospitals in Ontario have been required to send monthly data on hospital-acquired C. difficile infections to the Ontario Ministry of Health and Long-Term Care for posting on a public website.
What Did the Researchers Do and Find?
The researchers used health care administrative data for all patients older than one year admitted to acute care hospitals in Ontario between April 1, 2002, and March 31, 2010, to develop a model to predict monthly rates of C. difficile disease per 10,000 patient-days based on rates in the period before the introduction of public reporting. They then compared the observed rates of C. difficile disease after the introduction of public reporting with the rates predicted by this model. In the pre-intervention period, there were nearly 34,000 cases of C. difficile disease during about 39 million hospital days. Rates of C. difficile disease increased from 7.01 cases per 10,000 patient-days in 2002 to 10.79 cases per 10,000 patient-days in 2007. After the introduction of public reporting, the C. difficile disease rate fell to 8.92 cases per 10,000 patient-days, which is significantly (that is, unlikely to have occurred by chance) lower than the 12.16 cases per 10,000 patient-days predicted by the pre-intervention model. Finally, the researchers estimate that public reporting was associated with a 26.6% reduction in C. difficile disease cases and that it averted about 1,900 cases per year.
What Do These Findings Mean?
These findings suggest that mandatory public reporting of hospital rates of C. difficile disease may reduce the population burden of this serious infection. Because this is an observational study, these findings do not prove that the introduction of mandatory public reporting actually caused a reduction in infection rates. Some other uncharacterized factor might be responsible for the decrease in C. difficile disease in Ontario hospitals since late 2008. Moreover, the many assumptions included in the predictive model means that the estimated number of cases averted by the introduction of public reporting may be inaccurate. Although further research is needed to determine how public reporting might affect C. difficile disease rates, the researchers suggest that, in this study, mandatory public reporting may have increased the prominence of C. difficile on hospital quality improvement agendas and may have motivated hospitals to adhere more closely to best practices in C. difficile prevention.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001268.
The US Centers for Disease Control and Prevention provides detailed information about C. difficile infection, including an article called Making Health Care Safer: Stopping C. difficile Infections
The UK National Health Service Choices website provides information about C. difficile infections
The Health Protection Agency provides information about mandatory reporting of C. difficile infections in England and Wales and a fact sheet on C. difficile
Information about public reporting of hospital C. difficile rates in Ontario is available (in English and French)
MedlinePlus provides links to further resources about C. difficile infections (in English and Spanish)
The UK Clostridium Difficle Support website has a forum containing personal stories about C. difficile infection