In 2000, the Institute of Medicine (IOM) published “To Err is Human: Building a Safer Health System” (1). This report documented the extent and impact of medical errors on patient quality and safety, and identified potentially preventable outcomes, including healthcare-associated infections (HAIs).

The Centers for Disease Control and Prevention (CDC) defines an HAI as “a condition resulting from an adverse reaction to the presence of an infectious agent or its toxin that occurs in a patient in the healthcare setting and is not present or incubating on admission” (2). Several reports have tried to estimate the prevalence and impact of HAIs on the US health system. Over the past decade, there has been a 36% increased incidence in HAIs (1,3). The CDC estimates that 5% to 10% or 2 million of hospitalized patients develop HAIs annually (4,5). HAIs are associated with approximately $28 to $45 billion in annual attributable costs and 90,000 to 100,000 in annual overall deaths (5, 6, 7). The impact of HAIs on morbidity and mortality appears to vary based on the type of infection. Umscheid et al. (8) reported that catheter-associated bloodstream infections (CABSIs) and ventilator-associated pneumonias (VAPs) account for greater than 66% of HAI-related mortality and are associated with up to five times higher mortality rates compared to other HAIs. These figures regarding patients with HAIs are not only significant in themselves but notably higher than those found in uninfected patients. The 2007 statewide HAI surveillance data from the Pennsylvania Health Care Cost Containment Council (PHC4) reported that mortality rates (12.2% vs. 2%), lengths of stay (mean: 19.7 days vs. 4.4 days; median: 15 days vs. 3 days), and hospital charges (mean: $191,872 vs. $35,168; median: $87,655 vs. $19,748) were all higher in patients with HAIs (9). However, it is unclear what proportion of these differences are directly attributable to infection, since these patients often have underlying comorbidities or have undergone more complex procedures that place them at increased risk for HAIs.

Although there is consensus that HAI rates can and should be decreased, estimates of the proportion of HAIs that are largely preventable vary. Clinical evidence supports the notion that substantially decreasing HAIs, at least for discrete periods of time, is possible. For example, the Pittsburgh Regional Healthcare Initiative, which comprises hospitals in southwestern Pennsylvania, initiated a multifaceted infection control intervention in 2001 with the goal of decreasing CABSIs in intensive care units. The intervention included five components: (i) promoting targeted evidence-based catheter insertion practices (e.g., maximum sterile barrier precautions, chlorhexidine for skin disinfection, and avoiding femoral site insertion), (ii) developing an educational module on CABSI prevention strategies, (iii) promoting standard tools for recording adherence to recommended practices, (iv) providing a standardized list of supplies in catheter insertion kits to adhere to recommended insertion practices, and (v) collecting and distributing data on CABSI rates to participating hospitals. CABSI rates decreased 68% over 4 years, from 4.31 to 1.36 per 1,000 central line days (10). Using data from studies such as this, several overall reductions have been calculated. Reports issued from the CDC Study on the Efficacy of Nosocomial Infection Control calculated that a third of HAIs could be decreased by instituting appropriate infection control programs (4,11). A 2010 study by Umscheid et al. (8) estimated that the proportions of preventable HAIs may vary based on the type of infection. They calculated that catheter- associated urinary tract infections (CAUTIs) may be the most preventable (up to 65-70% or 95,483-387,550 CAUTI annually); followed by CABSIs (up to 65-70% or 44,762-164,127 CABSI annually), VAPs (up to 55% or 95,078-137,613 VAP annually); and lastly, surgical site infections (SSI) (75, 526-156,862 SSI annually) (8). They also estimated that CABSIs were associated with the highest number of preventable deaths and highest impact costwise (8).

Since 2000, there has been growing public and media interest in calling attention to the burden of HAIs, with the emergence of several consumer organization-led efforts including the Consumer Union Stop Hospital Infections and the Reduce Infection Deaths campaigns (12, 13, 14). This increased attention to the burden of HAIs combined with the IOM report, continued efforts to reduce healthcare costs, and public dissatisfaction with the quality of healthcare,
resulted in an increased call for public reporting and the implementation of state and nationwide initiatives mandating public disclosure.

Proponents, including the CDC, believe that making performance information publicly available is an important component of HAI elimination efforts. They advocate that public reporting could potentially decrease HAI rates, and in turn decrease HAI-related mortality and costs, via one of three potential pathways: the selection pathway, the change pathway, and/or the reputation pathway (15,16,17,18). In the selection pathway, consumers would use publicly available information to inform their selection of what they view to be the safest hospitals and providers. Therefore, protecting or improving market shares would motivate efforts on the part of the hospitals or providers. In the change pathway, providing feedback on existing problems or quality deficits would be sufficient in motivating hospitals and providers to implement evidence-based interventions that could decrease HAI rates. In the reputation pathway, maintaining or improving their public image would provide the motivation for hospitals and providers to change. Although each of these pathways may play a role, a study by Hibbard et al. (18), which compared private confidential reporting, which would stimulate change via the change pathway, versus public reporting, which would stimulate change via the reputation pathway, found that the reputation pathway may be the strongest driver to change.

Public reporting is not limited to HAIs, but has also been used to measure other healthcare outcomes and processes of care. The Centers for Medicare and Medicaid Services (CMS) has several programs to publicly disclose healthcare information to consumers including the National Voluntary Hospital Reporting Initiative, the Premier Hospital Quality Incentive Demonstration Project, and the Nursing Home Quality Initiative.