Oct 312012
Preventing Hospital Acquired Infections: Stopping Payment Had No Effect

In October 2008, the U.S. Centers for Medicare and Medicaid Services (CMS) stopped paying for two hospital-acquired infections: urinary infections due to indwelling catheters (UTIs) and central catheter-associated bloodstream infections (CABSI). At the time the policy was announced years ago, it was described as an incentive to hospitals to clean up their acts and adhere to best practices -- which would reduce these so-called "never events" dramatically, even to zero. Hospital administrators countered that they were already following best practices, and that a small number of hospital-acquired infections (nosocomial infections) are an inevitable part of medical care in the best of circumstances.

Grace Lee, Ken Kleinman, Ashish Jha et al analyzed data from 398 hospitals before and after implementation of the nonpayment policy, and found evidence to suggest the administrators may have had a point. Hospital-acquired infection rates for catheter-related UTIs and central line-associated bloodstream infections were on the decline for years before 2008 (possibly due to improved practices due to institutional fear of the upcoming nonpayment era). From 2008 to 2011, nosocomial infection rates did not change at all in comparison to the pre-2008 rates (with before/after ratios of almost exactly 1.0 for these two infections).

Ventilator-associated pneumonia rates also may have reached rock-bottom, with no reduction in incidence since 2008. CMS has not stopped payment for VAP yet, but has said it plans to.

The other possibility for the decline, authors suggest, is cynical changes in coding practices by hospitals -- simply avoiding the nosocomial infection codes that CMS has decided not to pay for, and substituting some other, more vague billing code that still generates revenue. I've heard numerous physicians note the rise of "ventilator associated tracheobronchitis" -- a diagnosis metamorphosis that occurs when, under suggestion by an infection control team or "quality officer," a subtle opacity in the lung base suddenly looks more like atelectasis than pneumonia.

However, authors found the stability in "before/after" hospital-acquired infection rates to be remarkably consistent across hospitals throughout the U.S., regardless of the percentage of Medicare patients they treated, whether they were for-profit, non-profit, academic or community-based.

It's easy to throw stones at Medicare, but since by all accounts they're on hyperdrive to bankruptcy, it's just as easy to understand their attempts to shift some costs back to the hospitals ... and anyone else they can.

Grace M Lee et al. Effect of Nonpayment for Preventable Infections in U.S. Hospitals. NEJM 2012; 367: 1428-1437.

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Hospital-acquired infections: stopping Gov’t payment did not reduce their incidence