Friday, June 1, 2012

Central Line Bloodstream Infections & Pay for Performance

The topic of central line bloodstream infection (CLBSI) is interesting to review because of its inclusion as one of the so-called “pay-for-performance” indicators and there is a large amount of research to look at. I want to focus on one aspect of the issue, which is the difference between information obtained from an administrative database and what is clinical valid.

Published ahead of print in the Journal of the American College of Surgeons is an article from the data mines of the Veterans Administration showing that some 63% of CLBSIs seen at VA hospitals over a 5 year period were actually coded incorrectly. They were falsely positive; the patients did not have CLBSIs.

You might wonder, “How can this be?”

Here’s how. When scrutinized carefully by clinician chart review, 27% had thrombophlebitis at a peripheral IV site, 7% had infected surgically placed arterial graft infections and 6% had cellulitis at an IV site that was not a central line. The rest of the false positives were as follows: chart coded as having a CLBSI when the work-up was actually negative for infection; the patient had no evidence of ever having had a central line; the patient had a CLBSI that was present on admission to the hospital and therefore not preventable during the admission being reviewed.

The problem is that the ICD-9 codes used during the study period (2003-2007) were not specific enough. New codes have been developed but are still not suitable as justification to withhold money from hospitals.

The paper also points out that the CDC has published three different sets of criteria for determining whether a central line is infected.

ICD-9 codes were created for billing purposes, not for studying clinical problems. They are also subject to coding errors as the paper clearly depicts. This is one of a number of papers that illustrate the problems associated with the use of administrative data in analyzing clinical problems.

I’m not necessarily against the pay-for-performance concept, but it must be based on accurate data.

What do you think about "pay-for-performance"?

This post appeared on Sermo yesterday and 84% of those physicians voting did not favor the use of pay for performance.


Tonja said...

Agreed. Another problem with ICD-9 codes is that once a patient is coded, they can't be removed without going through a whole mess of appeals, and usually that doesn't even do it! I had a doctor diagnose me as diabetic, and I'm not, but there it is in all my records forever and ever...

Anonymous said...

Are we really talking pay for performance? Who out there with a 0% central line infection rate has seen an increase in Medicare payments or a bonus for doing so well and helping the system save billions of dollars by reducing complications?

Skeptical Scalpel said...

Tonja, Interesting story. I hope you get it sorted out. It could impact your health or life insurance.

Anon, I don't think the rules have gone into effect yet.

Chris Porter MD said...

I'm for pay-for-performance which is process based, but not outcome based. That is, if you put in a central line using the techniques we believe reduce infection risk - get paid. If pay is linked outcome, then you won't necessarily be rewarded for doing everything right when your patient gets an infection anyway.

Skeptical Scalpel said...

Chris, not a bad idea. It makes sense. That's why it will never happen.

Marya Zilberberg said...

I totally agree with Chris above -- too much randomness and variability in the outcome, especially if looking at single institutions and even more among single providers. Outcomes need to be measures in large multi-center studies to see how the processes are doing at achieving these desired outcomes. I have written ad nauseam about using these so-called QI measures as a P4P yardstick This particularly salient for VAP, where we don't even know what VAP is. My impression is that we are spinning our wheels just to make it look like we are trying to remedy the catastrophic loss of life in conjunction with the exposure to healthcare. In reality, an this is supported by Landrigan's paper in the NEJM, we have accomplished very little. The problem? Quality science lacks scientific quality.

Sorry for the rant.

Skeptical Scalpel said...

Marya, Thanks so much for commenting. I agree with you that a lot of what is being done is for "show" and not really useful.

Marya blogs at and has written a book called "Between the Lines: Finding the Truth in Medical Literature."

Post a Comment