In the News

Physician-owned vs. non-physician-owned hospitals, evidence on cleaning methods, barrier precautions during arterial catheter insertion, and more.

Physician-owned, non-physician-owned acute care hospitals appear to provide similar care

Acute care physician-owned hospitals (POHs) may treat slightly healthier patients but do not appear to provide lower-value care compared with acute care non-POHs, according to a recent observational study.

Researchers looked at 2,186 acute care hospitals in the United States, 219 POHs and 1,967 non-POHs, to determine whether the 2 groups differed in patient populations, care quality, costs, and payments. They noted that the Affordable Care Act restricts new development of POHs but said that this decision was based solely on data from specialty hospitals. The study's main outcome measures were proportion of Medicaid patients; proportion of ethnic and racial minority patients; metrics of patient experience, care processes, risk-adjusted 30-day mortality, and readmissions; care costs and payments; and Medicare market share. The study results were published online Sept. 2 by The BMJ.

Of the 219 POHs, 120 were general hospitals and 99 were specialty hospitals. POHs were more likely than non-POHs to be small (defined as <100 beds) and urban, and all POHs were for-profit. Patients cared for at POHs were younger (77.4 years vs. 78.4 years; P<0.001) and less likely to be admitted through the ED (23.2% vs. 29.0%; P<0.001) than those cared for at non-POHs; however, patient mix did not appear to differ clinically or statistically between the 2 types of hospitals. Measures of patient experience and processes of care, risk-adjusted 30-day mortality, 30-day readmissions, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia were also similar between POHs and non-POHs.

The authors noted that they did not look at referral patterns by physician-owners or long-term total costs of care and that their findings may not apply to patients who do not have Medicare, among other limitations. However, they concluded that POHs do not appear to avoid caring for potentially less profitable patients and seem to provide care similar to that of non-POHs.

“Our work suggests that some of the major criticisms of POHs, including that they select more profitable patients, provide lower value care, and threaten the financial viability of surrounding hospitals, may no longer be valid,” the authors wrote. They called for additional research to look at which subgroups of hospitals do engage in these practices, so that existing regulations covering all POHs could be revised in a more targeted manner. In addition, they said, payment amounts could be reduced to in turn reduce financial incentives that might encourage “cherry-picking” patients.

The author of an accompanying editorial said that the study was “able to paint starkly different portraits of specialty and general POHs” and noted that proposed U.S. legislation to loosen restrictions on POHs does not make this distinction. “The weight of evidence suggests that specialty hospitals can result in substantial harm to the public's health,” the editorialist wrote. “It is reasonable to worry that physician ownership of specialty facilities exacerbates harm.”

Review evaluates evidence for wipes, UV, and other hospital cleaning methods

More robust research—with patient-centered outcomes—is needed to determine the comparative effectiveness of various methods of cleaning hospitals, a review found.

Researchers reviewed 76 primary studies of environmental cleaning, as well as 4 systematic reviews, finding considerable diversity in both study design and the cleaning/disinfecting and monitoring methods examined. Results were published online Aug. 11 by Annals of Internal Medicine.

Only 5 primary studies (11%) were designed as randomized, controlled trials (RCTs), and there was a lack of direct, rigorous comparative studies of the various methods, according to the review, which also highlighted a limited focus on patient-centered outcomes, such as patient infection or colonization. Surface contamination (such as bacterial burden, number of surfaces cleaned, and positive microbiological cultures) was the most commonly reported outcome in the literature, according to the study.

Six studies integrating various wipes, such as hydrogen peroxide, into preventive strategies reported positive outcomes, including sustained reductions in Clostridium difficile infection rates. Other studies found reductions in vancomycin-resistant enterococci (VRE) and Clostridium difficile rates with the use of bleach-based disinfectants, decreased C. difficile spore levels with use of accelerated hydrogen peroxide, and ineffectiveness of a chlorine-based product in reducing C. difficile rates.

Seventeen studies of no-touch methods (such as UV light and hydrogen peroxide vapor) reported positive findings, and 3 of these specifically found reduced infection rates, according to the review. Seven of 8 studies evaluating enhanced coatings, such as copper-coated surfaces, reported positive findings.

The study authors noted limitations of the review, such as how it did not appraise the risk of bias of individual studies or provide overall ratings of the strength of evidence for each intervention and outcome examined. Also, the review was restricted to studies of C. difficile, methicillin-resistant Staphylococcus aureus, and VRE, so the findings may not be generalizable to interventions aimed at reducing infections caused by other organisms (such as gram-negative pathogens).

The gaps in the evidence base will be filled best by randomized, controlled trials rather than quasi-experimental studies, according to an accompanying editorial. In particular, research on the importance of environmental contamination with gram-negative pathogens in the spread of health care-associated infections is urgently needed because of the declining antimicrobial treatment options, the editorial said.

“In addition to lacking a tight web of evidence, we still lack the means to ensure that the environmental cleaning procedures are followed consistently,” the editorialist wrote. “Even in a facility with a strong culture of safety, environmental service workers are sometimes a marginalized part of the health care staff and may not always appreciate or be appreciated for the patient safety aspect of their work.”

Barrier precautions used inconsistently during arterial catheter insertion, survey finds

Clinicians inserting peripheral arterial catheters in the ICU are often inconsistent in their use of recommended barrier precautions, according to a recent survey.

Researchers performed an anonymous Web survey of clinicians, including physicians, nurse practitioners, physician assistants, respiratory therapists, and registered nurses, who had opted in to e-mails from the Society of Critical Care Medicine. The survey contained 22 questions asking about prevention practices used by clinicians during arterial catheter insertion. The results were published online Aug. 7 by Critical Care Medicine.

Of 11,361 clinicians who received the survey, 1,265 responded (11% response rate). Of these, 1,029 were eligible to be included in the analysis; the remainder were excluded because they lived outside the United States, had not inserted an arterial catheter in the past year, provided incomplete responses, or only inserted arterial catheters in the operating room. In addition, residents and any clinicians who indicated that the size of their ICU was not applicable were excluded from subgroup analyses. Sixty-nine percent of the eligible respondents were attending physicians.

Forty-four percent of eligible respondents reported that they use CDC-recommended limited barrier precautions (hand hygiene, sterile gloves, surgical cap, surgical mask, and small sterile drape) during insertion of arterial catheters, and 15% said that they use full barrier precautions (hand hygiene, cutaneous antisepsis with alcoholic chlorhexidine, sterile gloves, sterile gown, surgical cap, surgical mask, and full-body sterile drape). Participants estimated that the mean and median occurrence rates of bloodstream infections linked to arterial catheters were 0.3 per 1,000 catheter-days and 0.1 per 1,000 catheter-days, lower than the occurrence rate of 0.9 to 3.4 per 1,000 catheter-days shown in the literature. Overall, 39% of participants said that they would support mandatory full barrier precautions during insertion of arterial catheters.

The researchers noted that their results are based on self-reported data, that the survey response rate was low, and that a high percentage of participants were from large, university-based teaching hospitals, among other limitations. However, they concluded that based on their findings, barrier precaution use during arterial catheter insertion in the ICU is inconsistent and compliance with CDC guidelines in this area is less than optimal. They also noted that clinicians underestimated the risk for infection involved with arterial catheters and do not appear to support the use of full barrier precautions.

“This represents a significant deviation from clinical guidelines, on a national level, with regard to a commonly performed procedure in critically ill patients,” the authors wrote. They said that the reasons behind clinicians' noncompliance might be multifactorial and in part reflect lack of awareness of CDC guidelines, but they noted that no matter the causes, “if the results of our survey are representative of clinical practice in the United States, then our current level of compliance with CDC guidelines for [arterial catheter] insertion represents a missed opportunity to prevent [bloodstream infections] in the intensive care setting.” They called for additional studies to determine what strategies would be optimal for lowering bloodstream infection rates in patients who receive arterial catheters.

Elevated heparin-binding protein predicted onset of organ dysfunction

Heparin-binding protein predicted progression of emergency department patients to severe sepsis better than several other biomarkers, a recent study found.

The prospective cohort study was conducted in 7 emergency departments in Sweden, Canada, and the U.S. It included 759 adult patients with suspected infection and at least 1 criterion for systemic inflammatory response syndrome (excluding leukocyte count). Results were published by Critical Care Medicine on Aug. 24.

Plasma levels of heparin-binding protein, procalcitonin, C-reactive protein, lactate, and leukocyte count were measured at admission and 12 to 24 hours later. Infection was diagnosed in 674 patients, 487 of whom did not have organ dysfunction at enrollment. Of those 487 patients, 29% developed organ dysfunction (severe sepsis) during the 72-hour study period. Heparin-binding protein was elevated (>30 ng/mL) prior to development of organ dysfunction in 78% of those patients (median time, 10.5 hours).

Compared to the other studied biomarkers, heparin-binding protein was the best predictor of progression to organ dysfunction (area under the receiver-operating characteristic curve, 0.80). The findings were confirmed in a 104-patient validation sample, leading the study authors to conclude that “heparin-binding protein is an early indicator of infection-related organ dysfunction and a strong predictor of disease progression to severe sepsis within 72 hours.”

They noted that heparin-binding protein seemed to elevate prior to the other biomarkers and that its negative predictive value (89.5%) may make it useful for identifying clinically stable patients who are unlikely to have disease progression. Repeated measurements of the protein during initial care may be beneficial, they noted. One limitation of the study was that the cutoff used for heparin-binding protein (30 ng/mL) was higher than in previous studies.