Low Monitoring Rates of Healthcare-Associated Infection in Japanese Hospitals

To the Editor—We read with interest Krein and colleagues’ article [1] presenting the proportions of hospitals in Japan, Thailand, and the United States that regularly conducted evidence-based practices recommended for preventing healthcare-associated infections (HAIs). The comparison of these proportions across hospitals in the 3 countries disclosed that many practices proven to be effective for preventing HAIs were not adopted in Japan, even among major hospitals.

Of numerous findings in the article, we would like to highlight the fact that the lowest proportion of Japanese hospitals regularly monitored HAI rates (67.3%, 31.5%, and 35.1% for central line–associated bloodstream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection, respectively) compared with Thai and US hospitals (>90% for all of the HAIs). Monitoring HAI rates is a practice directly evaluating the outcome of infection control measures conducted in hospitals but requires high motivation of both managers and practitioners in hospitals because it necessitates a time-consuming effort of staff having comprehensive knowledge on infectious diseases.

In the United States, many states, as well as the Centers for Medicare and Medicaid Services, mandate hospitals to report data of certain HAIs [2, 3]. In contrast, there is no legal duty for HAI reporting in Japan. As of 2012, when the data of Krein et al’s study were collected, the health insurance system in Japan merely encouraged hospitals applying for financial incentives for infection control to participate in HAI surveillance programs [4]. In 2014, the health insurance system revised the payment policy, demanding participation in any type of national or regional HAI surveillance program to receive a higher level of financial incentives. After the policy revision, the number of hospitals participating in Japan’s Nosocomial Infections Surveillance System increased dramatically (from 1000 of approximately 8500 hospitals in 2012 to 1990 in 2017) [5]. However, in contrast to a rise in the number of hospitals participating in the Laboratory Section (a program monitoring drug-resistant organisms), from 734 in 2012 to 1990 in 2017, there was a minimal increase in the Intensive Care Unit Section (158 in 2012 to 193 in 2017), the only national program collecting HAI data in Japan. These trends indicate that the revision of payment policy caused the increase in the number of hospitals initiating laboratory-based surveillance but the number of hospitals monitoring HAI rates remained approximately at the same level as noted in Krein et al’s study.

Krein et al’s study also indicated that the proportion of hospitals with hospital epidemiologists on staff was lower in Japan than the other countries (19.8% vs 39.3% and 48.5% in Thai and US hospitals, respectively). The limitation of experts managing surveillance data may have caused Japanese hospitals to reduce monitoring activities. To overcome these issues, effective regulation, with or without financial supports, should be considered. We hope that the findings of Krein and colleagues’ study, highlighting the current situation in Japanese hospitals, will lead not only hospitals but also the healthcare system to encourage monitoring HAI rates nationwide.

Note

Potential conflicts of interest. Both authors: No reported conflicts of interest. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.