Variance in Clostridium difficile surveillance reporting: implications for quality improvement outcomes

Transcription

1 Variance in Clostridium difficile surveillance reporting: implications for quality improvement outcomes DAVESON KL 1,2, WILSON C 1, MENZIES A 3. 1 DEPARTMENT OF INFECTIOUS DISEASES, CANBERRA HOSPITAL AND HEALTH SERVICES, CANBERRA, ACT, 2 AUSTRALIAN NATIONAL UNIVERSITY, CANBERRA, ACT, 3 INFECTION PREVENTION AND CONTROL UNIT, CANBERRA HOSPITAL AND HEALTH SERVICES, CANBERRA, ACT

2 Clinical Context - Clostridium difficile infection (CDI) Important cause of health-care associated (HCA) diarrhoea

3 Important outcome indicator of infection prevention and control (IPC) programs antimicrobial stewardship (AMS) program Attractive benchmarking tool locally and nationally

4 Clostridium difficile infection (CDI) drivers CDC 2012

5 Australian Commission on Safety and Quality in Health Care Implementation Guide for Surveillance of Clostridium difficile Infection 2013

6 Extended Surveillance?

7 Hospital Identified Hospitalidentified Other (HIO) ED + OPD Hospital Identified Community associated

8 Surveillance Options - Required Hospital-Identified (HI) intended to apply to hospitals in jurisdictions across Australia as an indicator of the hospital burden of CDI disease Advantages Easier to collect Easier for administration to understand Independent of clinician review Disadvantages Little granularity in expected drivers?usefulness for other QA programs Adds confusion if performing extended surveillance

9 Surveillance Options Extended Surveillance Additional to hospital-identified should be considered by hospitals, organisations and jurisdictions according to priority, local risk assessment and the capacity to categorise cases correctly Advantages Able to determine change in CDI drivers over time Able to be used by varying QA programs to inform quality improvement interventions Disadvantages More complex definitions than HI-CDI More time consuming for surveillance programs Easier to make cross institutional comparisons (CAVEAT) Consider High burden of disease Complex drivers present Other e.g targeted surveillance

10 CDI Control & Antimicrobial Stewardship (AMS) Majority of Interventions were restrictive effects in certain subsets of patients Faezel et al. JAC 2014; 69: 1749.

11 How should we measure CDI to show AMS-based quality improvements?

12 Methods Case ascertainment: prospectively, collected CDI surveillance database Definitions: cases classed by HI and extended surveillance definitions Time period: Sensitivity Analysis: changes in HCA-CDI and HI-CDI rates based on a hypothetical quality improvement program that reduced HCA-CDI rates by 50%.

13 Results Difference in Case Definition HI-CDI:HCA-CDI 3:2 HI-CDI (n) HCA- HCFO (n) HCA-CO (n) CA (n) Indeter (n) HIO (n) (64%) 4 (2%) 68 (32%) 1 (<1%) 3 (1%) (62%) 3 (2%) 54 (34%) 2 (1%) 2 (1%) (62%) 11 (6%) 48 (25%) 4 (2%) 8 (4%)

14 210 (138,68) 160 (102,54) 189 (129,48) Total(HCA,CA) 3->10%

15 AMS Impact Depends on type of intervention Community versus hospital based Hospital based interventions likely to make the most impact on HCA-HCFO Sensitivity Analysis

16 Cases Sensitivity Analysis Rate Comparison Before and After Hypothetical Intervention 20% 40% 60% 80% HCA:HI-CDI HICDI Rate Before Intervention HCA Rate Before Intervention HICDI Rate After Intervention HCA Rate After Intervention

17 Reported QI Reductions Reported Objective Improvements 60% 50% 40% 30% 20% 10% 0% 20% 40% 60% 80% HCA:HICDI Incidence HICDI Difference HCA Difference

18 Case Overestimation HICDI:HCA Public group C-D??? Principal Referral 10% 20% 30% 40% 50% 60% 70% 80% HCA-HICDI Rate

19 How do we progress the choice together: institution/jurisdiction/nationally? Why is important?

20 One Health do we care? Differences important for surveillance from a public health point of view We (will) need to assess and address community and hospital drivers Every program needs to consistently demonstrate its utility