The Centers for Medicare and Medicaid Services’ policy of not paying hospitals for preventable complications has had no effect on rates of nosocomial infections, researchers reported.
For one hospital-acquired infection targeted by the CMS program, catheter-associated bloodstream infections, there was no change in rate after the Oct. 2008 policy was put in place, with an incidence-rate ratio of 1 (95% CI 0.97 to 1.03, P=0.97), according to Grace M. Lee, MD, of Harvard Medical School, and colleagues.
For a second targeted infection, catheter-associated urinary tract infections, there was a tendency toward a small though not significant increase in the rate after the policy was implemented (IRR 1.03, 95% CI 1 to 1.07, P=0.08), the researchers reported in the Oct. 11 issue of the New England Journal of Medicine.
Moreover, for a hospital-acquired infection not targeted by the CMS program, ventilator-associated pneumonia, again there was no effect on the rate (IRR 0.99, 95% CI 0.96 to 1.02, P=0.52).
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In fact, there had already been notable decreases in hospital-acquired infections before the financial disincentive program, possibly resulting from efforts by the government, accreditors, and quality improvement organizations to minimize these preventable events, according to the researchers.
“Although the CMS nonpayment policy has resulted in greater organizational awareness and reported improvements in process measures, greater attention should be given to the design of such nonpayment policies to ensure that they improve outcomes,” wrote Lee and colleagues.
When it became apparent that the “pay for performance” approach of increasing payments when hospitals meet quality goals was having little effect, Congress directed CMS to begin using a more punitive approach, withholding payments for adverse outcomes.
To assess the results of the program, the researchers analyzed quarterly data from 398 hospitals reporting to the CDC’s National Healthcare Safety Network to determine patterns of hospital-acquired infections between 2006 and 2011.
The participating hospitals represented a broad range of institutions, including large urban teaching centers and small rural hospitals, as well as public, for-profit, and not-for-profit centers.
The researchers identified a downward trend of 4.8% per quarter in the incidence of bloodstream infections before the CMS policy was instituted in 2008.
Thereafter, the decrease held steady at 4.7% per quarter.
The rates for urinary tract infections also fell, by 3.9% per quarter before the policy implementation and 0.9% per quarter thereafter.
In addition, the incidence of ventilator-associated pneumonia fell steadily through the years of the study, by 7.3% per quarter before and by 8.2% per quarter after the policy was in place.
The researchers then looked at whether effects were different in states without requirements for mandatory reporting of healthcare-related infections or in hospitals with large Medicare populations.
They found no benefit for bloodstream infections in states without mandatory reporting, but they noted a fall off in the rate of decrease in urinary tract infections (RR 1.06, 95% CI 1.01 to 1.12, P=0.03) in those states after 2008.
That plateauing for urinary tract infections may have reflected changes in surveillance shortly after the CMS policy was instituted, according to the researchers.
There also were no differences in rates of either bloodstream or urinary tract infections according to the proportion of Medicare patients.
Possible reasons for the lack of effect seen with the CMS policy initiative included changes in administrative coding by hospitals and the minimal financial penalties involved, which were estimated at 0.6% of Medicare payments in an average institution.
“Greater financial penalties might induce a greater change in hospital responsiveness to the CMS policy,” the researchers noted.
Limitations of the study included a lack of information about patient insurance and the possibility that even the large sample did not fully represent the totality of U.S. hospitals.
In addition, the researchers did not address other potentially important concerns such as excessive antibiotic use.
“As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of [National Healthcare Safety Network] data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences, and what might be done to improve patient outcomes,” Lee and colleagues concluded.