by Nico Arnold

Rapid diagnostics transform obstacles into opportunity

2012-10 01-01

Our health care institutions today face clear and present challenges that deserve our focus. Skyrocketing rates of health care-acquired infections (HAIs), new and increasing reporting requirements, and financial pressures are three critical issues. Any one of these items can consume one’s full attention and generate entire programs of “fixes.”

However, it is worth taking a higher-level view. New rapid testing technologies—molecular diagnostics—provide far more than quick testing times. To the thoughtful administrator, the current confluence of challenges and technology offers sizable opportunities for large-scale improvements across the organization.

HAIS AND HEALTH CARE REFORM

HAIs are the most common complication of hospital care and are one of the top 10 leading causes of death in the United States.1 A person is more than twice as likely to die of a hospital-acquired infection than to be involved in a fatal automobile accident.2 According to the latest statistics from the Centers for Disease Control and Prevention (CDC), there are more than 1.7 million hospital-acquired infections3 that add billions of dollars to the country’s already unaffordable health care bill. The cost to society has been estimated at $40 billion. This includes the charges for unnecessary medical care required as a result of a HAI, but not the amount of lost worker time and productivity.

REFORMS: CURRENT AND ONGOING
IT’S EASY TO GET CAUGHT UP IN THE INDIVIDUAL CHALLENGES:
  • Financial pressures
  • Control costs
  • Maintain or even cut headcount
  • Regulatory pressures, largely driven by ACA
  • More reporting
  • More visibility of reporting, consumer ability to compare hospitals
  • Increasing HAI incidence
  • Improved patient and physician satisfaction

On March 23, 2010, President Obama signed the Affordable Care Act (ACA), a law of comprehensive health insurance reforms that will be implemented over the next 8 years. Several of the ACA’s provisions affect standards for providing care, payment methodologies, and the exchange of information.

The ACA established national programs that represent a Pay for Performance (P4P) methodology designed to encourage providers to better coordinate care and share in any resulting savings. It should also be noted that even before the ACA, the Centers for Medicare and Medicaid Services (CMS), as well as many commercial payors, actively engaged in shared savings programs and bundled payment systems. All of this is a shift away from the more traditional fee-for-service method of reimbursing health care services.

P4P programs provide incentive payments for physicians and health care institutions to improve and maintain high-quality services. There are three key steps in any P4P initiative:

  • First, facilities are given a payment incentive to report data on predetermined and standardized quality measures so that payors can calculate a baseline performance. HAI rates may be part of these quality metrics.
  • Second, process measures are incorporated as incentives to use processes that will improve care. An example of one such measure is whether the appropriate antibiotic preventive measures are given prior to surgery.
  • Finally, outcomes measures (such as the reduction of a particular kind of HAI) can be incorporated. Positive payment incentives are given to facilities implementing recognized processes and, ultimately, positive or negative incentives will be applied depending on outcomes achieved

In the next few months, hospitals will be required to report on their rates of MRSA and C. difficile infections. A potential outcome measure could be the reduction of rates of MRSA or C. difficile infections. Overall, payment schemes are continually evolving to reward hospitals and physicians for higher quality and more efficient services that improve patient health care outcomes. Significant health care dollars are potentially at risk. By 2017, up to 8% of hospital-based diagnosis-related group (DRG) payments may be lost if a facility’s quality performance is poor.

A point that should not be overlooked is that in addition to the direct financial impact of the new standards, penalties, and incentives, there will also be impact driven by public perception. Information such as HAI rates will be increasingly visible to the public, since the ACA mandates a consumer-friendly Web site (hospitalcompare.hhs.gov) for easy health care comparison by customers and prospective customers. This Web site will include HAI information reported by hospitals.

NEW TECHNOLOGY: MOLECULAR DIAGNOSTICS

While the seriousness of HAIs has been increasing, and the regulatory and financial challenges of running a hospital are growing ever greater, technology has also been improving. A recent key advance in clinical testing is molecular diagnostics. Molecular tests for HAIs use markers at the genetic level to quickly and accurately identify the disease organisms as markers of interest.

The speed of molecular testing means that answers are provided in minutes to hours, rather than days to weeks. This enables physicians to choose the right treatment or preventative measure right away. Patients don’t have to be kept in isolation for days while waiting for results. Even on the surface, it isn’t difficult to see how this improved turnaround time and accuracy could drive cost-effective HAI-reduction programs, fulfill regulatory requirements, and save precious health care dollars.

In practice, though, can molecular diagnostics substantially impact a hospital’s HAI rates? Loyola University Hospital’s, Chicago, results say yes. After implementing a universal surveillance program using molecular diagnostics, the hospital saw a two-thirds drop in surgical-site infections.8 Cone Health’s, Greensboro, NC, results were similarly outstanding. In 2010, Cone participated in a VHA initiative to prevent health care-associated MRSA infections. Surveillance using molecular diagnostics was a key part of their strategy. As a result of their efforts, MRSA infections were reduced to zero.6

This advance in testing technology means that hospitals can potentially avoid:

  • longer hospital stays or readmissions due to complications;
  • financial penalties for poor performance;
  • bad reputation through public disclosure of infection rates, potentially leading to patients looking for another hospital for elective procedures; and
  • potential lawsuits.

Clearly, molecular diagnostics have advantages over older, slower, and less-accurate tests that can help hospitals meet current and upcoming challenges.

OPPORTUNITIES FOR EXCELLENCE AND EVEN LEADERSHIP

Beyond helping hospitals meet mandated quality of service requirements, molecular testing systems offer other potential benefits. Loyola discovered a revenue opportunity presented by its HAI surveillance program. More than 1,200 patient days were saved, allowing other paying patients to use the freed bed space. This was in addition to the hard savings of $1.5 million to $2 million.8 Cone Health saved more than 1,300 patient days, and cost of care was reduced from $3.7 million to $1.3 million—a savings of $2.4 million.6 There are also opportunities for broader organizational changes to improve operational efficiency. Moderately complex tests, such as those performed on Cepheid’s GeneXpert platform, free up skilled laboratory workers’ time. Housekeeping staff experience similar productivity gains through reduced isolation days and special room cleans, as well as reduced need for protective equipment use. In Loyola’s case, 4,000 isolation days were saved.

However, the largest gain in efficiencies is through cross-departmental collaborations that take advantage of the new rapid testing capability. For example, Loyola found that having a rapid lab turnaround time led to other hospital staff delivering the samples to the lab much more quickly. This further reduced the amount of time patients spent in isolation and/or blocking beds in the emergency department.

As the orthopedics department took a fresh look at its own processes, the orthopedic surgeons realized that patients with an upcoming surgery could be tested for MRSA during their pre-surgery orientation visit. This allowed the patients to be placed on the correct decolonizing medications that same day. This process change not only decreased surgical-site infections,8 but was also more efficient for the orthopedic department and laboratory, and more convenient for the patients!

As a more general example, Figure 4 shows how a hospital’s workflow might change in migrating from a traditional test for C. difficile to a molecular test. Additionally, fully integrated molecular testing platforms such as the GeneXpert offer tests across a broad clinical spectrum. As part of the planning phase, hospital stakeholders will want to explore more specific departmental efficiencies generated by the new capabilities.

Because hospitals seek to control their immediate costs, there is a tendency to choose the technology with the lowest price per test, such as culture-based methods. Consequences are that it can take up to 48 hours before hospitals are able to detect which patient is a potential threat for bringing an HAI into the hospital. This means, however, that in order to contain the risk until the results are available, high-risk patients still will be isolated, resulting in higher costs for patients that ultimately do not need isolation.

As described earlier, surveillance programs have been proven to work. Hospital administrators are taking note, and executives are paying attention as well. A recent market survey among more than 20% of the US hospital base shows a significant increase in US hospitals doing at least some form of surveillance (high-risk or full surveillance). By taking advantage of innovative, on-demand molecular diagnostics as a critical part of their infection control program, hospitals can gain an immediate impact in lowering HAI infections as well as dramatic overall cost reductions. The new health reforms aim to improve quality and drive value through prevention. By quickly and accurately identifying patients who are at the greatest risk of infection, health care providers can make more timely decisions to effectively manage all aspects of patient care.

                        THE CASE FOR ON-DEMAND,  MOLECULAR DIAGNOSTICS

By using a technology that can deliver answers in about 1 hour, when needed, 24 hours a day, with minimal technician time, hospitals can make immediate decisions. the advantages for hai programs alone are many:

  • Enabling improved health outcomes and quality of care;
  • Reducing rates of complications and hospital readmissions;
  • Reducing length of stay;
  • Promoting better antibiotic stewardship; and
  • Maximizing the efficient use of health care resources.
AMONG THE RESOURCES FOR TESTING FOR HAIs:

 

Nico Arnold is a contributing writer for CLP. For more information, contact Editor Judy O’Rourke, [email protected].

REFERENCES
  1. Health Care-Associated Infections. Available at: www.ahrq.gov/qual/hais.htm. Accessed September 7, 2012.
  2. NHTSA Data Resource Website. Fatality Analysis Reporting System (FARS) Encyclopedia. Available at: www-fars.nhtsa.dot.gov/Main/index.aspx. We took 98,987 annual deaths from infections and divided by 2009’s fatal accident number (43,000). Accessed September 7, 2012.
  3. Noskin GA, Rubin RJ, Schentag JJ, et al. The burden of Staphylococcus aureus infections on hospitals in the United States: an analysis of the 2000 and 2001 Nationwide Inpatient Sample Database. Arch Int Med. 2005;165(15):1756-1761.
  4. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis. 2002;34(3):346-353.
  5. Lucado J, Gould C, Elixhauser A. Clostridium difficile Infections (CDI) in Hospital Stays, 2009. HCUP Statistical Brief #124; January 2012; 4.
  6. Morgan MG. The perfect storm: Multi-campus health system fulfills senior management challenge to dramatically reduce HAIs. Impact. 2012;2: 4-7.
  7. Rizk E. Molecular diagnostic testing presents $5 billion conundrum. Available at: www.managedcaremag.com/archives/0904/0904.moleculartesting.html. Accessed September 7, 2012.
  8. Parada JP. Increase revenue and improve patient safety. Impact. 2012;2:8-1