Preventable Hospital Infections Not Reduced by Disincentives

Miriam E. Tucker

October 10, 2012

October 10, 2012 — The Centers for Medicare and Medicaid Services (CMS) 2008 policy to discontinue payments for certain preventable hospital infections had no measurable effect on the rates of those infections, according to an assessment of data from 398 US hospitals and health systems.

The study, by Grace M. Lee, MD, senior associate physician in medicine and associate medical director of infection control, Boston Children's Hospital, Massachusetts, and colleagues, was published in the October 11 issue of the New England Journal of Medicine.

The CMS nonpayment policy, implemented on October 1, 2008, in response to a congressional mandate, was intended to remove the prior perverse incentive by which hospitals had received greater reimbursement for the care of certain preventable healthcare-associated infections (such as central catheter–associated bloodstream infections and catheter-associated urinary tract infections), and thereby reduce rates of these infections.

However, this study suggests the policy has not had the desired effect. "[I]n this national evaluation of the effect of the CMS policy of nonpayment for preventable complications on patient outcomes, we found no evidence that financial disincentives reduced infection rates," Dr. Lee and colleagues write.

Rather, they found that infection rates had been declining before the policy change. "There were strong downward secular trends for targeted health care–associated infections well before the implementation or announcement of the CMS policy...with no measurable additional benefit of the policy," write Dr. Lee, who is also with the Center for Child Health Care Studies at Harvard Pilgrim Health Care Institute in Boston, and colleagues.

The data come from the Centers for Disease Control and Prevention's National Healthcare Safety Network, a national public health surveillance system. The 398 participating nonfederal acute care hospitals and health systems, contacted between March 2010 and June 2011, were located in 41 states. Data from January 2006 through March 2011 were included.

Significant decreases in rates of central catheter–associated bloodstream infections of 4.8% per quarter were seen before implementation of the CMS nonpayment policy, and 4.7% afterward, for a nonsignificant difference in trend between the 2 periods (P = .97). For urinary tract infections, the declines were a significant 3.9% per quarter preimplementation vs a nonsignificant 0.9% postimplementation (P = .08 for the difference between periods).

A similar pattern was seen with ventilator-associated pneumonia, a healthcare-associated infection that was not explicitly targeted by the CMS policy. Incidence of those infections had decreased by 7.3% per quarter before the policy and 8.2% after, which is a nonsignificant difference (P = .52).

No relationship was found between the proportion of Medicare patients in a hospital and the effect of the CMS policy on either type of infection, nor did it make a difference whether or not there was state-mandated reporting of either infection. Analyses of different reporting time frames also showed no effect of the policy on infection rates, the authors report.

There are several possible explanations for these findings. Hospitals may have responded to the policy by focusing greater attention on documenting and coding infections as "present on admission" than on preventing infections. Moreover, some infections targeted by the CMS policy were already areas of focus for other nationwide improvement initiatives.

The authors also hypothesize that the financial incentive may not have been large enough to make a difference.

This study was supported by a grant to Dr. Lee from the Agency for Healthcare Research and Quality. One coauthor is an employee of the Centers for Disease Control and Prevention. The other authors have disclosed no relevant financial relationships.

N Engl J Med. 2012;367:1428-1437.