Fran Lowry

June 29, 2015

After Medicare's Hospital-Acquired Conditions Payment Policy came into effect, infections, such as central-line-associated bloodstream infections, decreased in hospitals with low operating margins.

In fact, it was in the hospitals with the least amount of money at their disposal that the improvement in infection rates was best. In the first year of the policy, there was a 3% decline in bloodstream infections per quarter, according to new research.

However, although the policy ended reimbursement for infections that were acquired in the hospital, infection rates in American hospitals as a whole were unchanged.

Dr Grace Lee

"In previous work, we found no impact of the policy on rates of targeted hospital-acquired infections reported to the National Healthcare Safety Network, but we were worried that the policy might have unintended consequences, particularly in hospitals that were already resource-constrained," investigator Grace Lee, MD, from Boston Children's Hospital and Harvard Medical School, told Medscape Medical News.

Dr Michael Calderwood

"This is important, as hospitals operating at a financial loss have been found to have worse performance in terms of quality measures," said another investigator, Michael Calderwood, MD, from Brigham and Women's Hospital and Harvard Medical School.

According to the research the pair presented at the Association for Professionals in Infection Control and Epidemiology 2015 Annual Meeting in Nashville, Tennessee, resource-constrained hospitals actually reduced their infection rates after the policy was implemented.

"This suggests that these hospitals may have focused greater effort on preventing these infections in the face of potential financial penalties," Dr Calderwood said.

The team used data from the Centers for Disease Control and Prevention's National Healthcare Safety Network that had been reported by hospitals participating in the Preventing Avoidable Infectious Complications by Adjusting Payment project.

The investigators looked at the operating margins of the 358 participating hospitals. The 92 hospitals in the lowest quartile were operating at an annual loss of at least 5.78%. Not surprisingly, there were more not-for-profit and safety-net providers in the lowest quartile. The 90 hospitals in the highest quartile were operating at an annual profit of at least 3.64%.

They then analyzed trends in reported rates of infection and ventilator-associated pneumonia before and after the policy was implemented.

For hospitals in the lowest quartile, the decrease in infection rates per quarter was significantly lower before the policy was implemented than after (3% vs 8%; P < .01).

For hospitals in the highest quartile, the decrease in infection rates per quarter was not significantly different before and after the policy was implemented (4% vs 5%; P = .93).

For ventilator-associated pneumonia, there was no significant rate change for hospitals in either quartile.

Dr Lee was asked whether financial disincentives should be discontinued.

Pay-for-performance and pay-for-value seem like they are here to stay.

"Pay-for-performance and pay-for-value seem like they are here to stay," she explained. "The intent of these programs — to align quality of care with payment — makes a lot of sense. But it's important to make sure we remain vigilant for unintended consequences, particularly if they affect the most vulnerable populations. It is important that these policies continue to adapt and evolve as the complexities of implementation are better understood."

"I think what we are seeing in some cases is that payment incentives and financial penalties may have an effect on where hospitals target their surveillance and infection-control efforts," said Linda Greene, RN, MPS, from the Highland Hospital at the University of Rochester in New York.

"It is important that each hospital not only understand the impact of hospital pay-for-performance and penalty programs by evaluating their outcomes and setting target goals," Greene told Medscape Medical News, "they must also continue to examine the infection risks unique to their own patient population by tracking progress and implementing evidence-based interventions aimed at bringing the highest quality of care to the bedside.

Association for Professionals in Infection Control and Epidemiology (APIC) 2015 Annual Meeting: Abstract 81769. Presented June 26, 2015.


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