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Quality measurement for Clostridium difficile infection: turning lemons into lemonade
  1. Marc Philip Pimentel1,
  2. Michael Klompas2,3,
  3. Allen Kachalia3
  1. 1 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  2. 2 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
  3. 3 Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Allen Kachalia, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; akachalia{at}

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W Edwards Deming is famously quoted as having said, “If you can’t measure it, you can’t manage it”. In truth, Deming’s full quotation reads, “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth”.1 2 In our journey to improve our hospital’s rates of Clostridium difficile, we learned first-hand the truth of Deming’s full statement—that in fact, even without the ability to measure perfectly, imperfect measures can still help us improve quality.

US hospitals are currently required to report hospital-acquired C. difficile rates as a condition of participation in several Centers for Medicare and Medicaid Services (CMS) pay-for-performance programmes. CMS is seeking to shed light on this type of preventable patient harm and raising the stakes by putting financial penalties and a hospital’s public reputation at risk. However, there is a vigorous debate in the medical community over the C. difficile measurement technique used by CMS. CMS’s C. difficile rates are based on the National Healthcare Safety Network’s C. difficile ‘LabID’ measure. This metric identifies C. difficile infections solely by positive laboratory test results, without regard to patients’ clinical signs or symptoms. This approach makes case assignments very objective (and therefore reduces ‘gaming’), but comes at the risk of misclassifying colonised patients as infected. The C. difficile tests we have only tell us whether C. difficile is present or not. They do not differentiate between colonisation and infection. This is particularly true of PCR-based testing that looks for the presence of the C. difficile toxin gene but does not determine whether the gene is producing toxin or not. The most specific test we have is the C. difficile toxin immunoassay, but even this is imperfect.

The lack of specificity is the Achilles heel of the C. difficile LabID measure because …

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  • Contributors Viewpoint concept and design: MPP, MK, AK. Drafting of the manuscript: MPP. Critical revision of the manuscript for important intellectual content: MPP, MK, AK.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.