Accentuate the negative

Dan has posted previously on how difficult it is for authors to get negative studies published.  Perhaps this is the real reason why the STAR*ICU study took 4+ years to make it to press.  I suspect that if the study was completed the exact same way that it was but found a benefit for barrier precautions, it would have appeared in press around 2009 or even earlier.  Just a guess.

Mike has posted at least twice on Ben Goldacre and his blog/book called Bad Science (part 1 and part 2).  Ben has a new post in the Guardian that discusses how medicine, academia and popular culture all favor positive, eye-catching and potentially spurious trial results and ignore important negative studies.  His discussion centers around a paper published last year that seemed to provide evidence of precognition - you know it before it actually happens.  That "positive" paper received tons of press, while a new negative study can't see the light of day.  I think this sort of bias plays a large role in infection prevention research - it is so much easier to publish a positive quasi-experimental study showing a benefit than a negative study.  This is why it was so great that after 4+ years of waiting the STAR*ICU study, which was a negative study, was published at the same time as the VA study, which showed a benefit.  This way, we could have a rational discussion with the positive/negative evidence receiving "almost" equal billing.

Ben Goldacre "Backwards step on looking into the future" Guardian 4/23/2011

Control groups are for losers

That’s what I learned from today’s New York Times editorial. In their review of the two NEJM studies we covered last week (here and here), they describe the VA study as “broader” (true, if by broader they mean larger) and “possibly more rigorous” (untrue). They also point out that “if other hospitals could replicate the effort, thousands of patients might be saved from needless infections”. The editorial board at the NY Times should know that hospitals across the country are already saving thousands as MRSA HAI rates drop nationwide! And many of these hospitals are saving lives without also stimulating the economy by doing universal MRSA screening. A bundle with multiple interventions, one of which is unproven and hugely resource intensive, doesn’t seem in keeping with the spirit of health care reform. And sadly, determining the proper role of the most expensive element in the VA's MRSA bundle requires studies that use something we epidermatologists like to call a “control group”.

Special Invited Veterans Day Post on MRSA

By Dan Morgan

For the Veterans Day post, it is worthwhile mentioning the role of the VA in advancing research on infection prevention. Despite some bureaucratic hurdles, the VA has supported some of the more creative work over the years and having one of the few fully electronic medical record systems, has the potential to implement a more sophisticated approach to infection prevention.

A recent, high profile intervention in the VA is the MRSA Prevention Initiative. Mobilizing millions of dollars with a top down mandate, the VA has focused efforts on infection control, especially as it relates to MRSA. The majority of the intervention relates to improved hand hygiene and compliance with Standard and Contact Precautions and encourages involvement of local healthcare workers through positive deviance. More controversial was the mandate to perform active surveillance for MRSA, swabbing patients admitted to acute-care facilities almost ceaselessly (admission, transfer and discharge, obtaining > 90% compliance in many facilities). While no verdict has been reached on the effectiveness of active surveillance for MRSA, the VA, to its credit, has supported research into alternative approaches.

One of these alternative approaches was hatched by a mentor of mine known to this blog simply as Eli. Focusing on the known risk factors for MRSA as a means of identifying patients at high risk for carriage, he and I looked at simple rules that could predict patients who should be targeted for MRSA (and VRE) screening. In a closed system like the VA with a fully electronic medical record, these prediction rules could be automated. In the Baltimore VA, we examined possible prediction rules and found that documentation of antibiotic use within the past year identified 84% of the risk of MRSA transmission and 98% of the risk of VRE transmission. In other words, if the electronic medical record had documentation of antibiotic use, an order could have been automatically generated at time of admission for MRSA or VRE culturing. This testing would identify virtually all patients with VRE and most with MRSA while culturing half the patients currently subjected to swabbing. The full effect of such an approach needs investigation in other VA populations but is promising.

At a time when attention is turning towards generating solid data on sometimes intrusive infection control interventions, I’d like to salute the VA for taking the lead on supporting research that may help transform hospital epidemiology from expert opinion to a scientifically outcomes based field.

Morgan DJ et al. Infect Control Hosp Epidemiol. December 2010

Note: Special thanks to our guest blogger and author of the discussed ICHE paper, Dan Morgan. Dan is an assistant professor at the University of Maryland and currently supported by an AHRQ K-award to study the non-infectious consequences of contact isolation.

What happens in Vegas...

...stays in Vegas? Always a good catchphrase, although not necessarily a good movie. I do often wonder if we should adopt a slogan in infection prevention such as "What happens in the ICU, stays in the ICU," where the happens part is MRSA or MDR-Acinetobacter acquisition.

It looks like there is a move afoot in Nevada to mandate universal MRSA screening. Sheila Leslie, D-Reno, whose otherwise healthy cousin recently died from MRSA infection at a California hospital, is considering drafting a bill on the subject. A recently posted Las Vegas Sun piece focused on the MRSA surveillance mandate in the VA system and quoted from the usual and also unusual subjects in the never ending debate around MRSA control.

Some of the more interesting quotes from the article:

“You get paid and paid and paid for doing the wrong thing in medicine. You don’t get paid for keeping people well,” said Phillip Longman, author of “Best Care Anywhere: Why VA Health Care Is Better Than Yours.”

“I know the bundled approach works, but I don’t know which component of the bundle is the most essential component of success.” Dr. Rajiv Jain, who leads the VA’s MRSA prevention program.

It appears that Nevada will look to the VA's data and experience in MRSA control. What isn't clear is if states or hospitals or even local health systems should try to apply data from a federal system with >150 acute-care hospitals. I do welcome the VA publishing their results and hope we see some nice VA-based interrupted time series data analyzed soon. When it comes to the results of the VA's MRSA mandate, what happens in the VA shouldn't stay in the VA.

Las Vegas Sun Article

Keeping veterans safe

As we pause on Memorial Day to remember those who have died fighting our wars, it seems fitting to recognize the strides that Veterans Health Administration (VHA) hospitals have made in patient safety, including prevention of healthcare associated infections. Over the nine years I was hospital epidemiologist at the Iowa City VAMC, I became convinced that most U.S. hospitals could learn a lot from the VA system (beginning with their early implementation of an electronic medical record that remains superior to the one we have implemented in our university hospital). While I can nitpick about the way certain directives came down, overall I think the VHA has been ahead of the curve, which may also be a commentary on progress in the rest of our fragmented healthcare system.

The VHA is the largest integrated healthcare system in the United States. It can and should serve as a model for healthcare-associated infection prevention.