Penalties not lowering hospital-acquired infection rates

(Reuters Health) – A penalty program established to reduce infections and other complications in U.S. hospitals hasn’t made these events less likely or reduced fatalities or repeat hospitalizations, a large study suggests.

The program was created as part of the Affordable Care Act, known as Obamacare, to provide stronger incentives for hospitals to prevent infections and other illnesses that can make hospitalized patients sicker, researchers note in The BMJ.

The study team examined data on more than 15 million patients aged 65 and older who were treated at 3,238 hospitals between July 2014 and November 2016. This covered the first two fiscal years when hospitals were aware of their potential to be penalized for low quality scores.

Among 708 hospitals penalized in fiscal 2015 for quality measures, an average of 2.72 patients per 1,000 got hospital-acquired conditions, compared with 2.06 patients per 1,000 at hospitals that were not penalized.

Both groups of hospitals had about 9% of patients die within 30 days of discharge, another measure used to levy penalties. The proportion of patients with repeat admissions was similar: 14.4% at penalized hospitals and 14% at other hospitals.

“We showed that penalization in the (U.S. Hospital Acquired Condition Reduction Program, or HACRP) was not associated with subsequent improvement in safety,” said lead study author Roshun Sankaran of the University of Michigan Medical School in Ann Arbor.

Safety net and teaching hospitals were penalized more often. “As a result,” Sankaran said by email, “we are concerned that penalization may worsen inequities while not driving improvements in safety.”

Hospitals scoring in the bottom quarter on quality measures are penalized 1% of total Medicare payments. Overall, 724 hospitals were penalized a total of $373 million in fiscal 2015; the study sample included 708 of these hospitals.

The most common hospital acquired conditions in the study were post-operative blood clots in major blood vessels; air or gas leaks in the space between the lungs and chest wall that cause chest pain and shortness of breath; bloodstream infections; and pressure sores.

The study wasn’t designed to prove whether or how penalties might alter the quality of care. Researchers also lacked data on what specific efforts hospitals made to target certain quality issues, and it’s possible that some hospitals focused improvement programs on things that weren’t directly measured by the HACRP scores, the study authors note.

Even so, the results add to growing evidence suggesting that the program designed to prevent infections and other hospital-acquired conditions “is paradoxically penalizing high-performing hospitals and those hospitals taking care of socioeconomically disadvantaged patients,” said Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine in Chicago.

“The individual measures and overall methodology continue to have critical flaws that need to be addressed,” Bilimoria, who wasn’t involved in the study, said by email, referring to the penalty system. “Thus, it is not surprising that (penalties) have failed to result in better patient outcomes.”

SOURCE: The BMJ, online July 3, 2019.


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