Impact of Medicare's Hospital-Acquired Condition policy on infections in safety net and non-safety net hospitals

Pay-for-performance and patient safety in acute care: A systematic review

Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.

Knowledge, Skills, and Compliance of Nurses Related to Central Line-Associated Bloodstream Infection in the Cardiovascular Department at King Faisal Hospital and Research Centre, Riyadh

Background and objective Healthcare-associated infections (HAIs), especially central line-associated bloodstream infections (CLABSI), are among the most critical public health problems worldwide. Knowledge, attitude, and skills of nurses are vital in HAI prevention. In this study, we aimed to assess nurses' knowledge, skills, and compliance related to CLABSI. Method This study was conducted in a heart center as a prospective interventional study. Eighty nurses were selected after obtaining their consent to participate in the pretest, posttest, and skills review. Qualified nurses registered with the Saudi Council and working for at least one month in the relevant unit at the time of the study were included. Nurse managers, interns, and student nurses were excluded. Nurses' skills were analyzed using a competency-based checklist approved by the hospital. Results We enrolled 80 participants in our study. The majority of the participants (51.25%) fell under the age group of 25-34 years. There were 68 females (85%). Participants with an experience of 6-10 years constituted the biggest proportion (37.5%) in the cohort in terms of work experience. The mean CLABSI knowledge-related pretest and posttest scores were 6.7 ±1.09 and 6.8 ±1.11, respectively, while the CLABSI compliance scores were 8.1 ±0.99 and 8.3 ±0.97, respectively. Conclusion Based on our findings, clinical experience of more than five years is associated with good CLABSI knowledge and compliance among nurses. Nurses' level of education also had a significant relationship with CLABSI pretest and posttest scores.

Hospital-Acquired Conditions Reduction Program, Racial and Ethnic Diversity, and Magnet Designation in the United States

OBJECTIVE

A key quality indicator in any health system is its ability to reduce morbidity and mortality. In recent years, healthcare organizations in the United States have been held to stricter measures of accountability to provide safe, quality care. This study aimed to explore the contextual factors driving racial disparities in hospital-acquired conditions incident rates among Medicare recipients in Magnet and non-Magnet hospitals.

METHODS

A cross-sectional observational study was performed using data from Hospital-Acquired Condition Reduction Program. Performance from 1823 hospitals were used to examine the association between Magnet recognition and community's racial and ethnic differences in hospital performance on the Hospital-Acquired Condition Reduction Program. The unit of analysis was the hospital level. A propensity score matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. The outcome measures were risk-standardized hospital performance on the Hospital-Acquired Condition Reduction Program domains and overall performance.

RESULTS

Study findings show that Magnet hospitals had decreased methicillin-resistant Staphylococcus aureus (MRSA) rate (β = -0.22; 95% confidence interval, -0.36 to -0.08) compared with non-Magnet hospitals. No other statistical difference was identified.

CONCLUSIONS

Results from this study show community's racial and ethnic differences in hospital-acquired conditions occurrence differ between Magnet and non-Magnet hospitals for MRSA, indicating its association with nursing practice. However, because this improvement is limited to only MRSA, there are likely opportunities for Magnet hospitals to continue process improvements focused on additional Hospital-Acquired Condition Reduction Program measures.

Hospital-Acquired Conditions Reduction Program, Patient Safety, and Magnet Designation in the United States

OBJECTIVE

The aim of the study was to investigate the association between hospitals' nursing excellence accreditation and patient safety performance-measured by the Hospital-Acquired Conditions Reduction Program (HACRP).

METHODS

We linked data from the American Nursing Credentialing Center Magnet Recognition Program, Centers for Medicare and Medicaid Services HACRP, and the American Hospital Association annual survey from 2014 to 2016. We constrained the analysis to hospitals participating in Centers for Medicare and Medicaid Services' HACRP and deployed propensity score matching models to calculate the coefficients for our HACRP patient safety measures. These measures consisted of (a) patient safety indicator 90, (b) hospital-associated infection measures, and (c) total HAC scores. In addition, we used propensity score matching to assess HACRP scores between hospitals achieving Magnet recognition in the past 2 versus longer and within the past 5 years versus longer.

RESULTS

Our primary findings indicate that Magnet hospitals have an increased likelihood of experiencing lower patient safety indicator 90 scores, higher catheter-associated urinary tract infection and surgical site infection scores, and no different total HAC scores. Finally, when examining the impact of Magnet tenure, our analysis revealed that there were no differences in Magnet tenure.

CONCLUSIONS

Results indicate that the processes, procedures, and educational aspects associated with Magnet recognition seem to provide important improvements associated with care that is controlled by nursing practice. However, because these improvements do not differ when comparing total HAC scores nor Magnet hospitals with different tenure, there are likely opportunities for Magnet hospitals to continue process improvements focused on HACRP scores.

Development of a questionnaire assessing nursing staff’s knowledge, attitude, and practice on the prevention of the nosocomial infection in elderly patients: testing reliability and validity†

Objective

To develop a questionnaire assessing nursing staff’s knowledge, attitude, and practice on the prevention of the nosocomial infection in elderly patients and test its reliability and validity.

Methods

After the drafted questionnaire was developed, two rounds of Delphi survey were conducted by consulting experts to improve the questionnaire. Subsequently, 700 copies of the questionnaire were distributed to nursing staff to assess its reliability and validity.

Results

Exploratory factor analysis (EFA) identifies 3 aspects, namely knowledge, attitude, and practice, with a total of 38 items. The Cronbach’s α coefficients of the questionnaire and each of the aspects are 0.85, 0.80, 0.886, and 0.77 (>0.7), respectively. Confirmatory factor analysis (CFA) of each of the aspects are c2/df = 3.99, 2.26, and 3.32; Goodness-of-fit index (GFI) = 0.91, 0.97, and 0.92; Root mean square error of approximation (RMSEA) = 0.06, 0.04, and 0.05; Comparative fit index (CFI) = 0.91, 0.96, and 0.90.

Conclusions

Through this study, it can be ascertained whether the developed questionnaire enjoys sound reliability and validity in assessing nursing staff’s knowledge, attitude, and practice on preventing the nosocomial infection in elderly patients and thus has certain application value.

Association Between Federal Value-Based Incentive Programs and Health Care-Associated Infection Rates in Safety-Net and Non-Safety-Net Hospitals

IMPORTANCE

In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown.

OBJECTIVE

To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.

EXPOSURES

HACRP and HVBP implementation in fiscal year 2015 or 2016.

MAIN OUTCOMES AND MEASURES

The primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates.

RESULTS

Of the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).

CONCLUSIONS AND RELEVANCE

This study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.

Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt

OBJECTIVE

To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed.

SUMMARY OF BACKGROUND DATA

In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need.

METHODS

100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients.

RESULTS

A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points.

CONCLUSIONS

Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.

An exploration of community partnerships, safety-net hospitals, and readmission rates

OBJECTIVE

To compare hospital-community partnerships among safety-net hospitals relative to non-safety-net hospitals, and explore whether hospital-community partnerships are associated with reductions in readmission rates.

DATA SOURCES

Data from four nationwide hospital-level datasets for 2015-2016, including American Hospital Association (AHA) annual survey, Hospital Inpatient Prospective Payment System (IPPS) data, CMS Hospital Compare, and County Health Rankings National (CHRN) data.

STUDY DESIGN

We first examined how safety-net hospitals partner with nine different community providers, and how the overall and individual partnership patterns differ from those in non-safety-net hospitals. We then explored their association with 30-day readmission rates by diagnosis and hospital wide.

DATA COLLECTION/EXTRACTION METHODS

We included 1979 hospitals across 50 US states.

PRINCIPAL FINDINGS

Safety-net hospitals were more engaged in hospital-community partnerships, especially with local public health, local governments, social services, nonprofits, and insurance companies, relative to their non-safety-net peers. However, we found that such partnerships were not significantly related to reductions in readmission rates. The findings indicated that merely partnering with various community organizations may not be associated with readmission rate reduction.

CONCLUSIONS

Before promoting partnerships with various community organizations for its own sake, further prospective, longitudinal, and evidence-based guidance derived from the study of hospital-community partnerships is needed to make meaningful recommendations aimed at readmission rate reduction in safety-net hospitals.

Pay for performance for hospitals

BACKGROUND

Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care.

OBJECTIVES

Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic.

SELECTION CRITERIA

We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables.

MAIN RESULTS

We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance.

AUTHORS' CONCLUSIONS

It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.

Stethoscope disinfection is rarely done in Ethiopia: What are the associated factors?

Introduction

The stethoscope, which is non-critical medical devices and a symbol of healthcare, is likely to be contaminated by pathogenic microorganisms and can play a contributory role in the transmission of hospital-acquired infection. And regular cleaning of the diaphragm of the stethoscope with a suitable disinfectant is decisive. However, in the resource-constrained setting like many healthcare facilities in Ethiopia healthcare provider’s stethoscope disinfection practice and its associated factors have not been well studied so far. Therefore, this study sought to determine stethoscope disinfection practice and associated factors among the healthcare providers in Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was carried out between April and May 2016. For this study, 576 healthcare providers (physicians, health officers, nurses, midwives, and anesthesiologist) were included from 21 healthcare facilities in Addis Ababa. A pre-tested structured questionnaire was used for data collection. Descriptive statistics were computed. Bivariate and multivariable logistic regression analyses were used to identify factors that were significantly associated with stethoscope disinfection after every use.

Results

A total of 546 healthcare providers participated in this study, for a response rate of 94.7%. Two-fifths, 39.7% (95%CI: 35.9, 44.0%) of healthcare providers disinfecting their stethoscope after every use. And a significant number of participants 34.6% (95%CI: 30.8, 38.5%) never disinfect their stethoscope. Three out of four (76.0%) healthcare providers believe that stethoscope contamination can contribute to the transmission of infections. Safe infection prevention practice (AOR = 3.79, 95%CI: 2.45–5.84), awareness on infection prevention guideline (AOR = 1.93; 95%CI: 1.31, 2.82), and favorable attitude towards infection prevention (AOR = 1.73, 95%CI: 1.02, 2.93) were significantly associated with stethoscope disinfection after every use. The study also found that the odds of stethoscope disinfection were likely to be reduced by 79% among physicians than nurses (AOR = 0.21; 95%CI: 0.09, 0.49).

Conclusions

Only a small proportion of healthcare providers disinfect their stethoscopes after every use. Factors such as safe infection prevention practice, awareness on infection prevention guidelines, and favorable attitude towards infection prevention were the independent predictors of stethoscopes disinfection after every use. Hence, promotion of stethoscope hygiene along with an educational program to enhance disinfection compliance in healthcare facilities may have a positive effect.

Patterns of Health Care Costs Due to External Ventricular Drain Infections

BACKGROUND

External ventricular drain (EVD) infections are a significant cause of morbidity among neurosurgical patients and have been correlated with increased length of hospital stay and longer requirements for intensive care. To date, no studies have examined the financial impact of EVD infections.

METHODS

Patients who underwent EVD placement between December 2010 and January 2016 were included in the study. Clinical records were retrospectively reviewed and health care cost data were obtained from the hospital's finance department. Clinical information included patient demographics, details from the hospital course, and outcomes. Total costs, direct/indirect, and fixed/variable costs were analyzed for every patient.

RESULTS

Over the 5-year study period, 246 EVDs were placed in 243 patients with an overall infection rate of 9.9% (N = 24). The median EVD duration for infected versus noninfected patients was 19 and 9 days, respectively (P < 0.0001). Median length of intensive care unit stay also was increased for patients with EVD infection (30 days vs. 13 days, P < 0.0001). Total health care costs were significantly greater for infected patients (US$ 168,692 vs. US$ 83,919, P < 0.0001). This trend was comparable for all other cost subtypes, including fixed-direct costs, fixed-indirect costs, variable direct costs, and variable-indirect costs.

CONCLUSIONS

EVD infection has a substantial effect on clinical morbidity and healthcare costs. These results demonstrate the imperative need to improve EVD infection prevention, particularly in the setting of a value-based health care system.

An Organization-Specific and Modifiable Inpatient Safety Composite Measure

In early 2013, seeking to apply the principles of value-based purchasing to all Kaiser Permanente hospitals as part of an existing organizationwide value-based performance incentive plan, Kaiser Permanente developed an inpatient safety composite measure that tracks hospital-level performance improvement related to 10 key inpatient safety events. The elements of the composite are weighted equally, and the tool draws on scoring methodologies used by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services Hospital Inpatient Value-Based Purchasing Program. Two years after implementation of the composite measure, hospitals experienced improvement across 9 of the 10 adverse events assessed, though only one improvement achieved statistical significance. The measure successfully distinguishes four levels of improvement and is broadly applicable to hospitals and hospital systems.

Understanding The Role Played By Medicare's Patient Experience Points System In Hospital Reimbursement

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96 percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

The Relationship Between Parenteral Nutrition and Central Line-Associated Bloodstream Infections: 2009-2014

BACKGROUND

Parenteral nutrition (PN) administered via central venous catheter has been identified as an independent risk factor for central line-associated bloodstream infections (CLABSIs). The aim of this study was to provide an updated description of the relationship between PN and CLABSI and assess temporal trends in CLABSI rates for individuals who received PN from 2009-2014, after the Centers for Medicare & Medicaid declared CLABSI a "never event."

METHODS

Using data obtained from all adult patient discharges between January 1, 2009, and December 31, 2014, from 2 affiliated hospitals in a large health system in New York City, univariate and multivariate analyses were performed to examine the relationship between PN and CLABSIs as well as temporal trends.

RESULTS

Among 38,674 patients with central lines, 3517 developed CLABSIs and 767 patients were prescribed PN. PN was an independent risk factor for developing CLABSI among our patients (odds ratio [OR], 2.65; 95% confidence interval [CI], 2.20-3.19). The incidence of CLABSI among patients who were prescribed PN was not significantly different across the years of this study, even after adjusting for severity of illness.

CONCLUSION

PN remains a significant risk factor for CLABSIs; further work is needed to identify effective strategies to reduce rates of CLABSI among patients receiving PN.

Knowledge, attitudes, and practice on the prevention of central line-associated bloodstream infections among nurses in oncological care: A cross-sectional study in an area of southern Italy

The objectives of the cross-sectional study were to delineate the knowledge, attitudes, and behavior among nurses regarding the prevention of central line-associated bloodstream infections (CLABSIs) and to identify their predisposing factors. A questionnaire was self-administered from September to November 2011 to nurses in oncology and outpatient chemotherapy units in 16 teaching and non-teaching public and private hospitals in the Campania region (Italy). The questionnaire gathered information on demographic and occupational characteristics; knowledge about evidence-based practices for the prevention of CLABSIs; attitudes towards guidelines, the risk of transmitting infections, and hand-washing when using central venous catheter (CVC); practices about catheter site care; and sources of information. The vast majority of the 335 nurses answered questions correctly about the main recommendations to prevent CLABSIs (use sterile gauze or sterile transparent semipermeable dressing to cover the catheter site, disinfect the needleless connectors before administer medication or fluid, disinfect with hydrogen peroxide the catheter insertion site, and use routinely anticoagulants solutions). Nurses aged 36 to 50 years were less likely to know these main recommendations to prevent CLABSIs, whereas this knowledge was higher in those who have received information about the prevention of these infections from courses. Nurses with lower education and those who do not know two of the main recommendations on the site’s care to prevent the CLABSIs, were more likely to perceive the risk of transmitting an infection. Higher education, attitude toward the utility allow to dry antiseptic, and the need of washing hands before wearing gloves for access to port infusion were predictors of performing skin antiseptic and aseptic technique for dressing the catheter insertion site. Educational interventions should be implemented to address the gaps regarding knowledge and practice regarding the prevention of CLABSIs and to ensure that nurses use evidence-based prevention interventions.

Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions

BACKGROUND

Medicare's Nonpayment Program of 2008 (hereafter called Program) withholds hospital reimbursement for costs related to hospital-acquired conditions (HACs). Little is known whether a hospital's Medicare patient load [quantified by the hospital's Medicare utilization ratio (MUR), which is the proportion of inpatient days financed by Medicare] influences its response to the Program.

OBJECTIVE

To determine whether the Program was associated with changes in HAC incidence, and whether this association varies across hospitals with differential Medicare patient load.

RESEARCH DESIGN

Quasi-experimental study using difference-in-differences estimation. Incidence of HACs before and after Program implementation was compared across hospital MUR quartiles.

SUBJECTS

A total of 867,584 elderly Medicare stays for acute myocardial infarction, congestive heart failure, pneumonia, and stroke that were discharged from 159 New York State hospitals from 2005 to 2012.

MEASURES

For descriptive analysis, hospital-level mean HAC rates by month, MUR quartile, and Program phase are reported. For multivariate analysis, primary outcome is incidence of the any-or-none indicator for occurrence of at least 1 of 6 HACs. Secondary outcomes are the incidence of each HAC.

RESULTS

The Program was associated with decline in incidence of (i) any-or-none indicator among MUR quartile 2 hospitals (conditional odds ratio=0.57; 95% confidence interval, 0.38-0.87), and (ii) catheter-associated urinary tract infections among MUR quartile 3 hospitals (conditional odds ratio=0.30; 95% confidence interval, 0.12-0.75) as compared with MUR quartile 1 hospitals. Significant declines in certain HACs were noted in the stratified analysis.

CONCLUSIONS

The Program was associated with decline in incidence of selected HACs, and this decline was variably greater among hospitals with higher MUR.

Hospital-Acquired Conditions in Adult Spinal Deformity Surgery: Predictors for Hospital-Acquired Conditions and Other 30-Day Postoperative Outcomes

STUDY DESIGN

A retrospective study of prospectively collected data.

OBJECTIVE

The aim of this study was to identify risk factors in developing hospital-acquired conditions (HACs) and association of HACs with other 30-day complications in the adult spinal deformity (ASD) population.

SUMMARY OF BACKGROUND DATA

HACs are subject to a nonpayment policy by the Center for Medicare and Medicaid Services and provide an incentive for medical institutions to improve patient safety. HACs in the ASD population may further exacerbate the already high rates of postoperative morbidity and mortality.

METHODS

The 2010 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes for adults who had fusion for spinal deformity. Patients were divided into two cohorts on the basis of the development of an HAC, as defined as a case of surgical site infection, urinary tract infection, or venous thromboembolism. Univariate and multivariate logistic regression analyses were employed to determine predictors for HACs and association of HACs with other 30-day postoperative outcomes.

RESULTS

Five thousand eight hundred nineteen patients met the inclusion criteria for the study of whom 313 (5.4%) had an HAC. Multivariate logistic regression analysis revealed that age 61 to 70 versus ≤50 years [odds ratio (OR) = 1.58, 1.10-2.27, P = 0.013], 71 to 80 versus ≤50 years (OR = 1.94, 1.31-2.87, P = 0.001), and >80 versus ≤50 years (OR = 2.30, 1.21-4.37, P = 0.011), dependent/partially dependent versus independent functional status (OR = 1.74, 1.13-2.68, P = 0.011), combined versus anterior surgical approach (OR = 2.46, 1.43-4.24, P = 0.001), and posterior versus anterior surgical approach (OR = 1.64, 1.19-2.25, P = 0.002), osteotomies (OR = 1.61, 1.22-2.13, P = 0.001), steroid use (OR = 2.19, 1.39-3.45, P = 0.001), obesity (OR = 1.38, 1.09-1.74, P = 0.007), and operation time ≥4 hours (OR = 2.42, 1.82-3.21, P < 0.001) were predictive factors in developing an HAC.

CONCLUSION

Several modifiable and nonmodifiable factors (age, functional status, surgical approach, utilization of osteotomies, steroid use, obesity, and operation time ≥4 hours) were associated with developing an HAC. HACs were also risk factors for other postoperative complications.

LEVEL OF EVIDENCE

3.

The unintended consequences of The Centers for Medicare and Medicaid Services pay-for-performance structures on safety-net hospitals and the low-income, medically vulnerable population

Safety-net hospitals are hospitals with patient mix that is substantially composed of the uninsured, underinsured, and low-income, medically vulnerable patient populations. They are the hospitals of last resort for poor patients. This article examined the impact of The Centers for Medicare and Medicaid Services pay-for-performance reimbursement policies on the financial viability of safety-net hospitals. Studies showed that these policies, which are based on the principle of reward and punishment, might have unintentionally placed safety-net hospitals on financial disadvantage compared to other hospital organizations. Several studies implied that these payment structures might have resulted in a situation where safety-net hospitals that are serving poor patient populations become more susceptible to penalties than hospitals that are serving affluent patients.

Impact of Hospital Operating Margin on Central Line-Associated Bloodstream Infections Following Medicare's Hospital-Acquired Conditions Payment Policy

In October 2008, Medicare ceased additional payment for hospital-acquired conditions not present on admission. We evaluated the policy's differential impact in hospitals with high vs low operating margins. Medicare's payment policy may have had an impact on reducing central line-associated bloodstream infections in hospitals with low operating margins. Infect. Control Hosp. Epidemiol. 2015;37(1):100-103.