Did the CMS no-payment rule impact hospital HAI prevention practice?

Beginning in October 2008 CMS stopped reimbursing hospitals for excess costs attributable to CLABSI or CAUTI.  While numerous studies and surveys have linked high compliance with HAI prevention bundles for CLABSI and VAP to reduced infection rates, few studies have looked at whether CMS no payment rules improved HAI prevention process measures.

To answer that question, Sarah Krein at the VA Ann Arbor Healthcare System completed surveys of VA and non-VA hospital HAI prevention practices in 2005 and again in 2009.  Their hypothesis was that if adoption of HAI bundles differed between non-VA and VA facilities, some of this difference could be do to the CMS no payment rules since VA facilities aren't directly affected by CMS rules.

The results are pretty interesting and don't really support any impact from the CMS no payment rules.  For CLABSI, both VA and non-VA hospitals reported significant increases in bundle component use with VA having higher use in both 2005 and 2009 (see graph below).

Similar results were reported for VAP and CAUTI.  The authors conclude by saying that "the CMS payment rule is likely not the primary driver of the increased use of infection prevention practices among US hospitals over the past several years."

Source: Krein et al. JGIM July 2012

There must be a pony in here somewhere...

Before mandatory reporting and pay-for-performance, and before zero became the only acceptable infection rate, it was OK to have somewhat subjective, imperfect definitions for healthcare associated infections. No longer!

Never fear…HICPAC has working groups now grappling with three different definitions: for CLABSI, VAP and SSI (full disclosure: I’m a member of these working groups). Here are just a few desired attributes of any newly-modified HAI definition:

• Must have excellent performance characteristics (most importantly, nearly 100% specificity) when compared with gold standards (note: gold standards do not yet exist).
• Must consist of only objective measures that can be collected by all NHSN participating hospitals, and that are amenable to electronic reporting and easy validation.
• Must demonstrate excellent concordance with clinical definitions of infection, so as not to lose credibility with frontline clinicians (note: because of the subjectivity of clinical definitions, this attribute is not consistent with the attribute above).
• Must not be subject to “gaming”, even by the most creative hospitals (note: even supposedly “objective” measures, like culture and antibiotic use data, are subject to practice changes in response to pressure to reduce HAI rates).
• Must not result in public or political perception that modifications were made in an attempt to lower HAI rates (i.e. “define our way to zero”).

So, keeping these in mind, feel free to submit any suggested changes to current definitions, in the comments section!

Why coding matters or why we shouldn't use ICD-9 codes?

Marin Schweizer, our colleague at Iowa, has a nice post up on the Center for Disease Dynamics, Economics & Policy (CDDEP) blog concerning the downsides and difficulties of using ICD-9-CM codes for HAI research, surveillance or CMS's 'no pay rule'. It's definitely worth the trip over there for a read...

Marin Schweizer's CDDEP post

Laziest possible post about the new CMS rule

I am on vacation. Last week I biked across Iowa with 9,999 other people (see photo below), and I’m now in Michigan, recovering from my bike ride across Iowa. So I haven’t done much deep thinking about the new CMS rule related to healthcare associated infections. From what I understand, participation in the Medicare program (at least receipt of full payment) will soon require surveillance and reporting (through NHSN) of CLABSI (beginning in 2011; ICU only) and SSI (beginning in 2012). The rates will eventually be reported via the hospital compare website. This doesn’t mean a lot to hospitals that already perform CLABSI and SSI surveillance, unless they don’t currently report through NHSN, in which case they’ll have to get enrolled.

We’ve already blogged about pitfalls in public reporting, and about problems with the NHSN definitions, validation, etc. So I really don’t have anything new to say about this rule. I refer all interested readers to a six-part series at Safe Healthcare (only 2 posts so far, 4 to come) on the new rule.