Effect of nonpayment for preventable infections in US hospitals

Image: CC/S.Fruitsmack

Key findings:

1. Changes in Medicare reimbursement for health care associated infections had no effect on the rate for catheter-associated bloodstream and urinary tract infections.

Primer: Healthcare associated infections are a leading cause of morbidity and mortality. A 2007 CDC study estimated healthcare-associated infection accounted for over 98,000 deaths in 2002, including approximately 36,000 deaths from pneumonia, 31,100 from bloodstream infections, and 13,000 from urinary tract infections. Some have theorized that paying hospitals to treat preventable infections created perverse financial incentives to not improve care. In November 2007, the Centers for Medicare and Medicaid Services announced a plan to implement pay-for-performance incentives for several measures, including certain hospital-acquired infections, and the new reimbursement system was implemented in 2008.

Background reading:

1. HHS Action Plan to Prevent Healthcare-Associated Infections: Incentives and Oversight: http://www.hhs.gov/ash/initiatives/hai/incentives.html
2. Klevens, RM, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports, 122, 161-166.

The [retrospective] study: Lee, et al. compared quarterly rates of catheter-associated bloodstream infections, catheter-associated urinary tract infections and ventilator associated pneumonia per 1000 patient-days from 2006 to 2011 before and after CMS implemented pay-for-performance changes in October 2008 for the catheter-associated infections but not for the ventilator-associated infections.

The authors observed a trend of decreasing infections prior to the change in reimbursement. Controlling for this trend, there was no significant difference in the incidence of catheter-associated bloodstream infections, catheter-associated urinary tract infections, or ventilator-associated pneumonia. The authors note that the hospitals included in their sample were not representative of all US hospitals, but after adjusting their sample for these differences, the authors still found no significant change from the policy. In addition, the authors found no difference attributable to hospital size, teaching status, and private or public ownership.

In sum: It is unclear if this analysis may be generalized to other performance-based reimbursement. The changes in reimbursement were relatively small, and larger incentives and penalties may have a greater effect; the effect may also vary for different procedures and complications. The authors also note that they relied on ICD-9 codes for CMS data on infections, which have low sensitivity for hospital-acquired infections and billing practices may have changed in response to the new reimbursement.

Click to read in NEJM

By [AS]

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