The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences

Healthcare-associated infections and conditions in the era of digital measurement

As the third edition of the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals is released with the latest recommendations for the prevention and management of healthcare-associated infections (HAIs), a new approach to reporting HAIs is just beginning to unfold. This next generation of HAI reporting will be fully electronic and based largely on existing data in electronic health record (EHR) systems and other electronic data sources. It will be a significant change in how hospitals report HAIs and how the Centers for Disease Control and Prevention (CDC) and other agencies receive this information. This paper outlines what that future electronic reporting system will look like and how it will impact HAI reporting.

In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Drug eluting antimicrobial vascular catheters: Progress and promise

Vascular catheters are critical tools in modern healthcare yet present substantial risks of serious bloodstream infections that exact significant health and economic burdens. Drug-eluting antimicrobial vascular catheters have become important tools in preventing catheter-related bloodstream infections and their importance is expected to increase as significant initiatives are expanded to eliminate and make the occurrence of these infections unacceptable. Here we review clinically significant and emerging drug-eluting antimicrobial catheters within the categories of antibiotic, antiseptic, novel bioactive agents and energy-enhanced drug eluting antimicrobial catheters. Important representatives of each category are reviewed from the standpoints of mechanisms of action, physical-chemical properties, safety, in vitro and clinical effectiveness.

Implementation of the Centers for Medicare & Medicaid Services' Nonpayment Policy for Preventable Hospital-Acquired Conditions in Rural and Nonrural US Hospitals

Preventable adverse patient outcomes and hospital characteristics in rural versus nonrural US hospitals under the new Centers for Medicare & Medicaid Services reimbursement policy were examined using the American Hospital Association Annual Survey and Hospital Compare data. Under the new Centers for Medicare & Medicaid Services policy, rural hospitals tended to have fewer hospital-acquired conditions than nonrural hospitals except for patient falls. Case mix was consistently related to falls after controlling for hospital characteristics.

Infection Prevention in the Hospital from Past to Present: Evolving Roles and Shifting Priorities

Hospital epidemiologists are vital components of integrated health centers. This central place in the healthcare landscape has rapidly evolved over a half century. Early hospital epidemiologists possessed a visionary focus on patient safety many decades prior to the quality revolution of the 1990s. A systematic and scientific approach to infection prevention has facilitated the evolution of hospital epidemiology, along with advances in technology, and increasing public attention to infectious complications in the hospital. Currently, the growing expansion of tasks and moving regulatory targets strain existing resources. These challenges threaten to limit the effectiveness of some infection-prevention activities, while also providing important opportunities for improving care. It will be increasingly important to advocate for appropriate resources to address a diverse set of changing infection prevention priorities.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

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.

Present or absent on admission: results of changes in National Healthcare Safety Network surveillance definitions

In January 2013, the National Healthcare Safety Network definition of "present on admission" was created. Using existing surveillance data from 2013, we identified health care-associated infections (HAIs) that met prior present on admission criteria but not the new definition. We identified a number of infections classified as HAI despite evidence that infection was clinically present on admission. These findings have important implications for states with mandatory HAI reporting using National Healthcare Safety Network definitions.

Impact of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions Policy on Billing Rates for 2 Targeted Healthcare-Associated Infections

BACKGROUND

The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable.

OBJECTIVE

To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI).

STUDY POPULATION

Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy. DESIGN We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI.

RESULTS

Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11-1.23]; for CAUTI, 1.19 [1.16-1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69-0.81]; for CAUTI, 0.87 [0.79-0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97-0.99]; for CAUTI, 0.99 [0.97-1.00]).

CONCLUSIONS

The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.

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

BACKGROUND

Policymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.

OBJECTIVE

To determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non-safety net hospitals.

DESIGN

Interrupted time-series design.

SETTING AND PARTICIPANTS

Nonfederal acute care hospitals that reported central line-associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention's National Health Safety Network from July 1, 2007, through December 31, 2013.

RESULTS

We did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84-1.09]) or non-safety net (0.99 [0.90-1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non-safety net hospitals (P for 2-way interaction, .87).

CONCLUSIONS

The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line-associated bloodstream infection in safety net or non-safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.

HAC-POA policy effects on hospitals, other payers, and patients

BACKGROUND

Prior to the implementation of the Hospital-Acquired Condition-Present on Admission (HAC-POA) payment policy, concerns regarding its potential impact were raised by a number of organizations and individuals. The purpose of this study was to explore direct and indirect effects of the HAC-POA payment policy on hospitals, patients, and other payers during the policy's first 3 years of implementation.

METHODS

The study included semi-structured telephone interviews with representatives of national organizations, hospitals, patient advocacy organizations, and other payers. Interview notes were coded using QSR NVivo qualitative analysis software using inductive and deductive qualitative analysis techniques. We conducted interviews with 106 individuals representing 56 organizations. Hospital staff included physicians, nurses, patient safety officers, coders, and finance, senior management, and information management staff. Individuals from other organizations represented leadership positions.

RESULTS

Key changes to hospitals included: cultural shifts involving attention, commitment, and support from hospital leadership for patient safety; hiring new staff to assure the accuracy of clinical documentation and POA oversight structures; increased time burden for physicians, nurses, and coders; need to upgrade or purchase new software; and need to collaborate with hospital departments or staff that did not interface directly in the past. The policy was adopted by a majority of other payers, although the list of conditions and payment penalties varies. The HAC-POA policy is invisible to patients; therefore, the presence or lack of unintended consequences to patients cannot be fully assessed at this time. Understanding of policy effects to all stakeholders is important for maximizing its successful implementation and desired impact.

Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital

BACKGROUND

Although surgical site infections (SSIs) are known to be associated with increased length of stay (LOS) and additional cost, their impact on the profitability of surgical procedures is unknown.

AIM

To determine the clinical and economic burden of SSI over a two-year period and to predict the financial consequences of their elimination.

METHODS

SSI surveillance and Patient Level Information and Costing System (PLICS) datasets for patients who underwent major surgical procedures at Plymouth Hospitals NHS Trust between April 2010 and March 2012 were consolidated. The main outcome measures were the attributable postoperative length of stay (LOS), cost, and impact on the margin differential (profitability) of SSI. A secondary outcome was the predicted financial consequence of eliminating all SSIs.

FINDINGS

The median additional LOS attributable to SSI was 10 days [95% confidence interval (CI): 7-13 days] and a total of 4694 bed-days were lost over the two-year period. The median additional cost attributable to SSI was £5,239 (95% CI: 4,622-6,719) and the aggregate extra cost over the study period was £2,491,424. After calculating the opportunity cost of eliminating all SSIs that had occurred in the two-year period, the combined overall predicted financial benefit of doing so would have been only £694,007. For seven surgical categories, the hospital would have been financially worse off if it had successfully eliminated all SSIs.

CONCLUSION

SSI causes significant clinical and economic burden. Nevertheless the current system of reimbursement provided a financial disincentive to their reduction.

Medicare non-payment of hospital-acquired infections: infection rates three years post implementation

BACKGROUND

Medicare ceased payment for some hospital-acquired infections beginning October 1, 2008, following provisions in the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005.

OBJECTIVE

We examined the association of this policy with declines in rates of vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infection (CAUTI).

DATA

Discharge data from the Florida Agency for Healthcare Administration from 2007 to 2011.

STUDY DESIGN

We compared rates of hospital-acquired vascular catheter-associated infections (HA-VCAI) and catheter-associated urinary tract infections (HA-CAUTI) before and after implementation of the new policy (January 2007 to September 2008 vs. October 2008 to September 2011). This pre-post, retrospective, interrupted time series study was further analyzed with a generalized hierarchical logistic regression, by estimating the probability of a patient acquiring these infections in the hospital, post-policy compared to pre-policy.

PRINCIPAL FINDINGS

Pre-policy, 0.12% of admitted patients were diagnosed with CAUTI; of these, 32% were HA-CAUTI. Similarly, 0.24% of admissions were diagnosed as VCAI; of these, 60% were HA-VCAI. Post-policy, 0.16% of admissions were CAUTIs; of these, 31% were HA-CAUTI. Similarly, 0.3% of admissions were VCAIs and, of these, 45% were HA-VCAI. There was a statistically significant decrease in HA-VCAIs (OR: 0.571 (p < 0.0001)) post-policy, but the reduction in HA-CAUTI (OR: 0.968 (p < 0.4484)) was not statistically significant.

CONCLUSIONS

The results suggest Medicare non payment policy is associated with both a decline in the rate of hospital-acquired VCAI (HA-VCAI) per quarter, and the probability of acquiring HA-VCAI post- policy. The strength of the association could be overestimated, because of concurrent ongoing infection control interventions.

A benchmark too far: findings from a national survey of surgical site infection surveillance

BACKGROUND

The national surgical site infection (SSI) surveillance service in England collates and publishes SSI rates that are used for benchmarking and to identify the prevalence of SSIs. However, research studies using high-quality SSI surveillance report rates that are much higher than those published by the national surveillance service. This variance questions the validity of data collected through the national service.

AIM

To audit SSI definitions and data collection methods used by hospital trusts in England.

METHOD

All 156 hospital trusts in England were sent questionnaires that focused on aspects of SSI definitions and data collection methods.

FINDINGS

Completed questionnaires were received from 106 hospital trusts. There were considerable differences in data collection methods and data quality that caused wide variation in reported SSI rates. For example, the SSI rate for knee replacement surgery was 4.1% for trusts that used high-quality postdischarge surveillance (PDS) and 1.5% for trusts that used low-quality PDS. Contrary to national protocols and definitions, 10% of trusts did not provide data on superficial infections, 15% of trusts did not use the recommended SSI definition, and 8% of trusts used inpatient data alone. Thirty trusts did not submit a complete set of their data to the national surveillance service. Unsubmitted data included non-mandatory data, PDS data and continuous data.

CONCLUSION

The national surveillance service underestimates the prevalence of SSIs and is not appropriate for benchmarking. Hospitals that conduct high-quality SSI surveillance will be penalized within the current surveillance service.

Including catheter-associated urinary tract infections in the 2008 CMS payment policy: a qualitative analysis

The study presented in this article addresses the impact of the 2008 nonpayment policy of the Centers for Medicare and Medicaid Services (CMS) on catheter-associated urinary tract infections (CAUTIs) from the perspective of infection preventionists. With rich qualitative data, it sheds light on the day-to-day impact of this recent health policy on CAUTI prevention.

Effect of nonpayment for preventable infections in U.S. hospitals

BACKGROUND

In October 2008, the Centers for Medicare and Medicaid Services (CMS) discontinued additional payments for certain hospital-acquired conditions that were deemed preventable. The effect of this policy on rates of health care-associated infections is unknown.

METHODS

Using a quasi-experimental design with interrupted time series with comparison series, we examined changes in trends of two health care-associated infections that were targeted by the CMS policy (central catheter-associated bloodstream infections and catheter-associated urinary tract infections) as compared with an outcome that was not targeted by the policy (ventilator-associated pneumonia). Hospitals participating in the National Healthcare Safety Network and reporting data on at least one health care-associated infection before the onset of the policy were eligible to participate. Data from January 2006 through March 2011 were included. We used regression models to measure the effect of the policy on changes in infection rates, adjusting for baseline trends.

RESULTS

A total of 398 hospitals or health systems contributed 14,817 to 28,339 hospital unit-months, depending on the type of infection. We observed decreasing secular trends for both targeted and nontargeted infections long before the policy was implemented. There were no significant changes in quarterly rates of central catheter-associated bloodstream infections (incidence-rate ratio in the postimplementation vs. preimplementation period, 1.00; P=0.97), catheter-associated urinary tract infections (incidence-rate ratio, 1.03; P=0.08), or ventilator-associated pneumonia (incidence-rate ratio, 0.99; P=0.52) after the policy implementation. Our findings did not differ for hospitals in states without mandatory reporting, nor did it differ according to the quartile of percentage of Medicare admissions or hospital size, type of ownership, or teaching status.

CONCLUSIONS

We found no evidence that the 2008 CMS policy to reduce payments for central catheter-associated bloodstream infections and catheter-associated urinary tract infections had any measurable effect on infection rates in U.S. hospitals. (Funded by the Agency for Healthcare Research and Quality.).

Organizational Transformation

Health care organization leaders and policy makers seeking ways to reform the delivery of health care have become increasingly interested in transformational change. To foster understanding of how organizational transformation occurs and to stimulate further research, we report findings from a systematic review of empirical research on transformational change in the health care and non–health care literature, with a focus on the antecedents, processes (or paths), and outcomes of transformational change. Fifty-six studies, of which 13 were in health care, met our selection criteria. With one exception, all were published since 1990, indicating the recent upsurge of interest in this area. Limited differences were found between health care and non–health care studies. Available research documents the multiplicity of factors affecting change and the complexity of their interactions, but less information is available about the processes of transformational change than about its antecedents and consequences. Research and practice implications are discussed.

Perceived impact of the Medicare policy to adjust payment for health care-associated infections

BACKGROUND

In 2008, the Centers for Medicare and Medicaid Services (CMS) ceased additional payment for hospitalizations resulting in complications deemed preventable, including several health care-associated infections. We sought to understand the impact of the CMS payment policy on infection prevention efforts.

METHODS

A national survey of infection preventionists from a random sample of US hospitals was conducted in December 2010.

RESULTS

Eighty-one percent reported increased attention to HAIs targeted by the CMS policy, whereas one-third reported spending less time on nontargeted HAIs. Only 15% reported increased funding for infection control as a result of the CMS policy, whereas most reported stable (77%) funding. Respondents reported faster removal of urinary (71%) and central venous (50%) catheters as a result of the CMS policy, whereas routine urine and blood cultures on admission occurred infrequently (27% and 13%, respectively). Resource shifting (ie, less time spent on nontargeted HAIs) occurred more commonly in large hospitals (odds ratio, 2.3; 95% confidence interval: 1.0-5.1; P = .038) but less often in hospitals where front-line staff were receptive to changes in clinical processes (odds ratio, 0.5; 95% confidence interval: 0.3-0.8; P = .005).

CONCLUSION

Infection preventionists reported greater hospital attention to preventing targeted HAIs as a result of the CMS nonpayment policy. Whether the increased focus and greater engagement in HAI prevention practices has led to better patient outcomes is unclear.