Michael S. Calderwood
In 2008, to encourage hospitals to strengthen infection prevention measures, CMS stopped reimbursing them for hospital-acquired conditions not present when a patient was admitted. Findings published recently in Infection Control & Hospital Epidemiology show why the policy did not sufficiently impact central line-associated bloodstream infection and catheter-associated urinary tract infection trends.
“Prior work found that the 2008 CMS hospital-acquired conditions (HAC) policy did not impact already declining national rates of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI),” Michael S. Calderwood, MD, MPH, regional hospital epidemiologist at Dartmouth-Hitchcock Medical Center and assistant professor of medicine at the Geisel School of Medicine at Dartmouth College, told Infectious Disease News. “We studied why this policy did not have its intended impact by looking at coding practices and the impact of the policy on the diagnosis-related group assignment for Medicare hospitalizations.”
For their retrospective cohort study, Calderwood and colleagues reviewed inpatient claims data for more than 65.2 million fee-for-service Medicare patients hospitalized in 3,291 acute-care, non-federal United States hospitals between Jan. 1, 2007, and Dec. 31, 2011. The CMS change to the Hospital Inpatient Prospective Payment System (IPPS) no longer allowed hospitals to receive Medicare or Medicaid reimbursement for preventable infections not present on admission.
The researchers analyzed hospital billing practices before and after the CMS policy change was implemented. They specifically looked at the use and “present on admission” designation of codes for CLABSI and CAUTI. According to the study, Calderwood and colleagues also determined the impact on diagnosis-related groups (DRG) determining reimbursement and hospital characteristics associated with the reimbursement impact for the 3-year period following the implementation of the policy change.
When they evaluated billing codes, they found that CLABSI affected 0.23% of fee-for-service Medicare hospitalizations and CAUTI affected 0.06%. Calderwood and colleagues reported observing a significant increase in CLABSI and CAUTI codes marked as present on admission, to 82% and 91%, respectively. They detected few financial impacts on the small number of CLABSI or CAUTI coded as not present on admission.
“We found that that the billing codes that were targeted to identify CLABSIs and CAUTIs were rarely used by hospitals, were commonly listed as ‘present on admission’ in the post-policy period compared with the pre-policy period, and had a limited financial impact on hospitals due to the fact that removing these codes from reimbursement rarely impacted the DRG assignment determining inpatient reimbursement,” Calderwood said.
He noted that a hospital’s infection prevention team is typically tasked with working to reduce health care-associated infections, often in collaboration or under the leadership of an infectious disease physician.
“Hospitals are increasingly held accountable for infections that are deemed preventable, such as central line-associated bloodtream infections and catheter-associated urinary tract infections,” he said. “It is important for ID physicians to understand which data are being used to judge hospital quality and the limitations of these data. In addition, for those who are members of national societies such as the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, it is important to be a voice that drives improvement in quality metrics.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.