COMPARE

Problem Statement: What can be done to reduce central line associated bloodstream infections (CLABSI)?

Substantial stakeholders in decreasing CLABSI’s include:

Patients -  health care consumers - Individuals who are receiving or scheduled for healthcare services.  Patients’  principal desires for the health care system  are quality, access, and minimal individually incurred costs (Shaywitz, 2011). There are multiple organizations and associations that advocate for patients.  Consumer Reports via their policy and action arm, Consumers Union, provides educational material about CLABSI,  and advocates for healthcare system changes that result in its decrease (Consumers Union, 2016). The Patient Safety Movement Organization has a goal of reducing preventable deaths to zero by 2020 and has specifically targeted reducing CLABSI (Patient Safety Movement, 2016).  They advocate for policy that results in evidence-based central line placement and maintenance. Similarly, the European Patients Forum has called for guidelines to reduce the incidence of HAI’s (Immonen-Charalambous & Padeanu, 2016).

Providers  – Allied health professionals, nurses, and physicians who provide health care to patients.  A representative society in the United States is the Society of Interventional Radiology (SIR). The SIR “is a national organization of physicians, scientists and allied health professionals dedicated to improving public health through disease management and minimally invasive, image-guided therapeutic interventions” (The Society of Interventional Radiology, 2016). A significant percentage of the 3.4 million central venous access catheters (CVACS)  that are  put into patients each year in the United States are placed by interventional radiologists (The Society of Interventional Radiology, 2004).   The SIR has a strong interest in CVAC outcomes and publishes a variety of  relevant educational,  reporting, and standards of practice documents including one that specifically deals with central line associated bloodstream infections (CLABSI) (Miller & O'Grady, 2012). The SIR maintains a political action committee (SIRPAC) “dedicated to advancing the interests of SIR members, their practices and patients before Congress” (The Society of Interventional Radiology, 2016).  In 2015,  the SIR  launched the Venous Access National Guideline and Registry Development (VANGUARD)  to  further develop terminology,  reporting requirements, registries, standards, and guidelines to help improve outcomes following CVAC placement including the reduction of CLABSI (The Society of Interventional Radiology, 2015).   Kevin Baskin, the director of VANGUARD, has told me that he hopes the project will develop evidence and engender enough public interests that it helps move the national public policy agenda regarding CLABSI forward.  The analogous society to the SIR in Europe is the Cardiovascular and Interventional Radiology Society of Europe (CIRSE) (CIRSE, 2016). The SIR and the CIRSE  have collaborated on a number of quality improvement projects and guidelines (The Society of Interventional Radiology, 2016).

Legislators -  The people who make laws. Legislators and government executives principal concerns about health care are how it will be financed and delivered (Jaffe, 2009). A legislative group particularly interested in healthcare is the Congressional Healthcare Caucus. It was founded at the beginning of the 111th Congress by Michael C. Burgess, M.D. (R-Texas) (Congressional Healthcare Caucus, 2009).  The Caucus is focused on educating legislators on healthcare issues.  Activities include policy forms and member briefings. The Caucus has presented possible solutions to a multitude of health care issues.

Government executives  -  Government executive branch personnel at a variety of jurisdictional levels who execute and enforce laws.   The National Governors Association (NGA) represents governors of the various states within the United States. The NGA seeks to “share best practices, speak with a collective voice on national policy and develop innovative solutions that improve state government and support the principles of federalism” (National Governors Association, 2016).  The NGA shares best practices in different states, including on how to reduce medical errors (National Governors Association, 2005).  They have also circulated information about reducing the incidence  of infections (National Governors Association, 2016).

Insurance Companies -  Businesses that cover the cost of healthcare expenses for individuals and employers who pay premiums. The principal motivation of insurance companies is profit (Ubel, 2014).  The leading trade organization for the healthcare insurance companies in the United States is America’s Health Insurance Plans (AHIP). “AHIP advocates for public policies that expand access to affordable health care coverage to all Americans through a competitive marketplace that fosters choice, quality, and innovation” (America’s Health Insurance Plans, 2016). AHIP undertakes a variety of patient safety initiatives including those specifically aimed at reducing healthcare associated infections (HAIs) (America's Health Insurance Plans, 2011).

Government payers and/or providers of healthcare  -   In the United States, state-run Medicaid programs and the Center for Medicare and Medicaid services (CMS) that cover the costs of healthcare for their constituents. CMS maintains a variety of CLABSI reporting standards (National Healthcare Safety Network, 2016). CLABSI  is included in CMS’ Hospital-Acquired Condition (HAC) Reduction Program,  which withholds payment for reasonably preventable conditions such as CLABSI (CMS, 2014).  Spain has a national health system known as Sistema Nacional de Salud (SNS) (García-Armesto, García-Armesto, Durán, Hernández-Quevedo, & Bernal-Delgado, 2010). SNS has multiple programs in place to reduce HAIs and CLABSI.  Governments are strongly interested in the cost of care and in particular desire to improve preventive care and reduce medical errors in order to reduce those costs.

Hospitals -  Institutions that provide in-patient medical and surgical care to patients.   The  principal goals of hospitals  depends upon whether they are  nonprofit,   for-profit  or government facilities (Horwitz, 2005).  According to Jill Horowitz, writing in Health Affairs “For-profits are most likely to offer relatively profitable medical services; government hospitals are most likely to offer relatively unprofitable services; nonprofits often fall in the middle (Horwitz, 2005). The American Hospitals Association (AHA) leads, represents and serves hospitals, health systems and other related organizations that are accountable to the community and committed to health improvement” (American Hospital Association, 2016). The AHA’s mission is “to advance the health of individuals and communities. The AHA in partnership with the Health Research & Educational Trust has developed a CLABSI “Change Package” for hospitals participating in the Centers for Medicare and Medicaid’s (CMS) Partnership for Patients (PFP) Hospital Engagement Network (HEN) 2.0 project. The “Change Package” advocates not only for changes in practice but also for changes in culture particularly on the part of physicians. In particular, the “Change Package” advocates for standardized, multidisciplinary approach to reducing CLABSI (Health Research & Educational Trust, 2016).  Spanish institutions participate in the healthcare associated infection surveillance network  whose purpose is to reduce HAIs  including CLABSI (The Joint Commission, 2013).

Public Agenda and Window of Opportunity -  as evidenced by the discussion above, CLABSI is getting a great deal of attention from all of the major Stakeholders.  It is therefore high on the public agenda although I would temper this claim by recognizing that a significant portion of the general population is probably not aware of CLABSI.  Because the problem is well recognized, policy is available, and the stakeholders are aligned in their desire to solve the problem the window of opportunity is open (in keeping with the requirements of this assignment the problem background and the policy options are not presented herein).     

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