Thursday, October 11, 2012

Why the No-Pay Policy for In-Hospital Infections Failed

I told you so.

Three months ago, I blogged about the Medicare (CMS) “never events” list, diagnoses that Medicare will no longer reimburse hospitals for. In Medicare’s eyes, these diagnoses are totally preventable, should never happen and will not be reimbursed. I pointed out that several were in fact not 100% preventable despite any institution’s best efforts, and the rates of many of these occurrences would not fall to zero.

Now the esteemed New England Journal of Medicine has published a paper which confirms what I wrote back in July. Its 13 authors compared rates of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), two of the diagnoses on the “never events” list, with ventilator-associated pneumonia, a disease not on the list, as a control.

After reviewing data from 398 hospitals from before and after the establishment of the new Medicare rules, they found that quarterly rates of all three infections did not change and concluded that the “never events” policy was ineffective. The senior author of the study then tweeted “Our paper in NEJM - CMS non-payment policy didn't change infection rates. Do we need much stronger penalties?”

My answer to that question is “No.”

Penalizing hospitals did not work because we may have reached the lowest possible rates of infection already. Some infections will occur no matter what steps are taken. We are dealing with human patients and human care-givers. Perfection is not likely to happen.

Many people erroneously believe that all CLABSIs can be prevented with the implementation of strict sterile precautions when catheters are inserted. That has lowered infection rates but not to zero. Why not? In addition to the technique of insertion, CLABSIs can result from other factors. Solutions may become tainted. The integrity of the IV line itself may be violated during the administration of medications through the line. The dressing covering the line may loosen and allow bacteria to enter the puncture site. Patients may be immunosuppressed and unable to overcome even the slightest hint of contamination. Or maybe it’s just bad luck.

CAUTIs are also not totally preventable. Despite a major push to remove urinary catheters as soon as possible, some patients need them for days to weeks for many reasons. For example, there are patients who simply cannot urinate on their own due to old age, dementia, coma, paralysis, etc. Critically ill patients with marginal urine outputs need urinary catheters for monitoring. Patients who are incontinent of stool may contaminate their catheters despite the best nursing care.

No, much stronger penalties will not work.

How about if we simply decide what is an acceptable rate for these infections and aim for that?


huhet said...

As a pre-clinical medical student, I may be speaking out of turn here, but I don't understand the reason for the policy. I would like to believe that no hospital would intentionally infect a patient as described for financial gain.

I'm all for CMS cuts that prevent fraud, abuse, and unnecessary procedures, but this policy only hurts the patients, assuming they get stuck with the bill. Even if patients don't get billed, how will the hospital's response and care of the infection change with the proposed cuts in mind?

AtYourCervix said...

You have summed it up very concisely. We will never have a 0% nosocomial infection rate, despite all of the high quality nursing and other interventions that we do to try to prevent infection.

Skeptical Scalpel said...

Thanks for commenting.

huhet, I agree. Despite what you might think if you look at newspapers or Twitter, we are not trying to hurt people. That's why penalizing us when things that cannot be avoided happen does not work.

At, I appreciate your agreeing with me.

Anonymous said...

Simply, our bodies were not designed to take any of this stuff. This is the main variable that no one can eliminate. Sure we can be watchful on how to do things better, but the fact remains.

Bacteria evolves faster than we can evolve. More patients will have a rough ride through invasive treatment as time goes. New and different fears will arise.

Legislation of this kind is a waste of billions that could go to better use ...research.


Anonymous said...

While it is true that CLABSIs (and other nosocomial infections) will never reach 0%, the infection rate can be reduced substantially. There are a number of studies that show CVC infection rates can be lowered through implementation of process measures (such as compliance with the IHI bundle) and checklists. In our own hospital we have reduced our CLABSI rate by 400% over 4 years through an intensive intervention including retraining and credentialing all providers in US-guided CVC placement, educating nursing staff in line care, and a QI process with checklists and tracking of all infections.

Viscot said...

As always it sounds like a good idea with good intentions, but in the end it failed. Aiming for zero is a respectable goal, but not realistic with the current technology.
Very good article, thank you for posting.

Skeptical Scalpel said...

Good comments. Infection rates may have been reduced as much as possible. But I don't think they can ever reach zero.

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