From: HFMA News – 12/1/15
Following several years of improvements, the rate of hospital-acquired conditions (HACs) did not improve in 2014, according to new federal data.
The rate of HACs, which had fallen 17 percent from 2010 through 2013, was unchanged in 2014, according to preliminary results of a report released Dec. 1 by the U.S. Department of Health and Human Services.
Federal officials underscored the progress to date, which included an estimated 87,000 fewer patient deaths and nearly $20 billion in savings going back to 2010, but acknowledged they do not know why the decline stopped at 121 HACs per 100,000 discharges.
“We don’t have a full answer to that question,” Richard Kronick, PhD, director of the Agency for Healthcare Research and Quality, said in a call with reporters. “Part of the answer is likely that the dramatic improvements that we saw in earlier years were likely the relatively lower-hanging fruit. Hospitals are now working on the more difficult problems.”
Kronick said he expects further reductions from the widespread adoption of the National Action Plan for Adverse Drug Events, which was launched in 2014 and would not have had a measurable impact in the latest available data.
Patrick Conway, MD, principal deputy administrator and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), said the agency is focused on identifying ways to reduce patient harms in “more complex areas,” such as patient falls and adverse drug events.
Industry experts had mixed views on whether the HAC rates would resume improving without additional policy or research developments.
Katharine Luther, vice president at the Institute for Healthcare Improvement (IHI), said that as hospital engagement networks—part of a federal initiative to identify and share best practices—“ramp up over the next few months, they’ll build on the good work they’ve already done and we’ll see the numbers drop even further.”
Effect of Penalties
Medicare cut payments by 1 percent for hospitals with the highest frequency of HACs as part of the latest in a series of CMS programs aimed at reducing the frequency of HACs. The Hospital-Acquired Condition Reduction Program, which took effect Oct. 1, 2014, penalized 721 hospitals in FY15 for excess rates of certain patient injuries, such as central line-associated bloodstream infections, catheter-associated urinary tract infections, and pressure ulcers, according to published reports.
Researchers have questioned the effectiveness of the penalties at driving improvements.
For instance, a July study published in JAMA found that the hospitals penalized most frequently “had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures.” The findings suggested to the researchers that the HAC penalties may not reflect poor quality of care but rather problems around measurement and the validity of the component measures.
Additionally, some have questioned whether the penalty is sufficient to change hospital policies. Specifically, some organizations have concluded that the penalties are less than the cost of the additional supports necessary to avoid the penalty, according to quality care experts.
“It’s clear that financial incentives have an impact, but the financial incentives are definitely mixed,” Michael Millenson, president of Health Quality Advisors, who has written extensively on HACs, said in an interview. “There’s a psychological impact of having some financial incentives, which helps, but I’m not sure how much they can turn up those financial incentives in the current political environment.”
Some disputed the need for further study of ways to reduce patient harms from falls and adverse drug events.
“It’s difficult, but it’s not as if there’s no one who has been successful and published in the literature,” Millenson said about fall-reduction programs.
He expects additional benefit will come from the Partnership for Patients initiative, which can help hospitals identify the more difficult steps needed to further reduce HACs.
“We have also seen a change in culture over the past few years, where hospitals—because of the Partnership for Patients—see that this is possible; they are getting peer support,” Millenson said about the program, which he describes as Weight Watchers for patient safety. “Some people have lost the easy pounds, but it doesn’t mean that everyone has lost the easy pounds and more can’t be done.”
Martin Adel Makary, MD, associate professor of surgery and health policy at Johns Hopkins University, said further improvements in HAC rates may require widespread adoption of systems that allow measurement of data that are clinically valid and specific to the clinician, patient, and incidence—instead of the hospital-wide measures used in the HAC program. For instance, IHI’s Global Trigger Tool measures patient safety automatically using electronic health records.
“We can claim successes with small slivers of care,” Makary said in an interview, “but the truth is the vast majority of care in the United States still has endemic variations in quality, it’s costly, and it results in a lot of harm that is off the grid when it comes to how we measure our performance in health care.”
Improvements in Hospital-Acquired Conditions Stall