Yet more about MRSA...

In the space of two days, our busy Gigamole has produced 2 articles on MRSA in Singapore hospitals. The statistics may be confusing for some.

But first, it is important to acknowledge that there is no single measurement that captures the burden of MRSA on the hospitals as well as the impact of hospitals' activities directed against MRSA. One can use a basket of measurements, but the effort of collating all these results will increase, and some degree of specialization becomes necessary in order to make sense of the results collectively.

The figures quoted in Today a few days ago reflect the prevalence of "new MRSA infections". This somewhat-difficult-to-understand measurement attempts to reflect MRSA infections acquired within the hospital, and is therefore a measure of potentially preventable (within the hospital - as a consequence of transfer of MRSA from other patients or staff) MRSA infections. So if a patient had MRSA infection in the past or is known to be colonized by MRSA, then any MRSA infection within his/her hospitalization is not regarded as being "new" (and by extension, is not a consequence of a new transfer of MRSA from other patients or staff). Confused already? Well, join the club!

The practical implications of this, as both Gigamole and Salma Khalik have both pointed out, is that MRSA infection rates appear to drop substantially. Part of this is because of a change in reporting, and part of this is because of MRSA screening - especially true in hospitals where there is widespread screening of patients for MRSA colonization upon admission. Because those patients who test positive are then subsequently probably not counted if they develop an infection within that period of hospitalization. This does not mean that the true burden of MRSA has not declined in our hospitals - it probably has - just that you should not draw too many conclusions from the figures given. One real danger is that these results gives the impression that the MRSA problem is halfway to being solved, therefore fewer resources might be allocated towards tackling a problem that the hospitals are just coming to grips with.

The UK Health Protection Agency only tracks the incidence of MRSA bacteremias (duplicate culture results removed). This measurement is a surrogate for "severe MRSA infections", and the data are relatively simple to collect and analyze. However, this is again not reflective of the actual burden of MRSA infections in the hospital because the complexity of patients being treated at each hospital takes on greater importance. The proportion of MRSA bacteremias among all MRSA infections is higher in patients who are more ill, have more lines stuck into them, and/or are more immunocompromised. Community hospitals flooded with MRSA-colonized patients may have relatively few bacteremias compared to tertiary hospitals where many surgical operations are carried out. Also, many of these infections may not really be preventable in the sense that we understand - no hospital in Singapore can achieve 0% MRSA if such a measurement (or similar measurement) is used for assessment of the impact of its interventions.

Many hospitals measure the percentage of Staphylococcus aureus infections that are MRSA. This is the simplest but probably least useful measurement because it is dependent on way too many factors, including the number of methicillin-sensitive Staphylococcus aureus infections.

Ultimately, at least 2-3 different measurements of the hospital MRSA burden are required to enable interested parties to have a real grasp of the situation, and for hospitals to have some degree of accountability.

Gigamole also posed a question about the who actually pays for an MRSA infection in the financial sense. I suspect Gigamole already knows the answer and the question was rhetorical. Nonetheless, as the majority of MRSA infections occur in "subsidized" patients in our hospitals, it is likely that the patients pay a small amount (not taking into account the morbidity and mortality from the infection itself, just the money) on average, and the ministry - and therefore ultimately the taxpayers - bear the burden for the majority of the financial costs. To what extent the hospitals themselves pay, is not certain.

Private sector allure

It is about the time of the year when senior specialist doctors in the public sector consider leaving - or have just left - for the private sector. The timing revolves around consideration of annual bonuses, etc.

The number choosing to leave does not seem to have gone down over time, despite efforts at public sector hospitals to achieve parity of income (especially for surgeons). A significant part seems to have been played by Healthway Medical Corporation Limited in recent times. Good luck to those who have gone out to join their clinics (or perhaps good luck to Healthway for this venture?)!

For the majority, it is no longer quite about the money, but rather, hospital push factors. Many in the early days (and some even after many years) of private practice feel that they have returned to their "roots" - doing what they have been trained to do and providing real individualized medical care. Not being forced to do a modicum of research (or to pretend to enjoy/espouse it) or to sit in time-consuming committee meetings is a heady feeling. Being able to spend more time with one's patients rather than having to deal with administrative grouses about "patient waiting time" (because clinics get overloaded with patients - several of whom are slotted at 10-15 minute intervals like a factory line) feels just great. The whole great balancing act of clinical service, research, education, and administrative duties can itself be overwhelming, and most do not have the power to change this very much (without appearing to be prima donna's, for example).

There are the drawbacks, of course:

1. One can get called back at any hour of any day.
2. One does have to pander more to one's patients.
3. Bad debts can accumulate and they are one's problem (unless one is in a large group with administrative services to deal with these things).
4. One can rarely deal with complex multi-disciplinary medical problems the way that tertiary public sector hospitals are able to.
5. Regulatory oversight of the private sector is poor (although some may see this as a plus).
6. One has to get over the guilt trip that some may feel for no longer treating the "poor and underserved".

Private specialist care is evolving rapidly into group practices and multidisciplinary practices - perfectly understandable given the nature of the market - and this may offset some of the drawbacks above. All in all, most people are happier once they have left the public sector, although working up the courage to leave can be nerve-wracking.