The Unwanted Visitor
Nadia Christensen, MD
Unfortunately, it happens all the time. You take your elderly father into the hospital for a routine surgery such as a total hip replacement, and while being treated for the hip, he ends up with a Hospital-Acquired Condition (HAC). Think of an HAC as your bothersome Aunt Ethel, an unwanted house guest who shows up when you least expect her, bringing in suitcases full of complications, and leaving a trail of havoc in her wake. Simply stated, an HAC is a potentially avoidable infection or complication that occurs while a patient is hospitalized for an unrelated condition. Years ago, people referred to these conditions as Healthcare-Associated Infections (HAIs) or nosocomial infections. However, today many preventable conditions, which are not infections such as pressure ulcers or DVTs, have been added to the list and term broadened to HACs.
Trends in HAIs and HACs before HACRP
In 2013 the AHRQ showed a 17% decrease in HACs. This reduction was linked to a prevention of 50,000 deaths and a cost savings of $12 billion dollars. Despite this encouraging trend, an estimated 10% of hospitalized patients were still experiencing one or more HACs.
On the infection front, in 2014 the CDC estimated that on any given day, 1 in 25 hospitalized patients would develop at least one HAI. Although this number had seemed very high, the CDC, in its annual National and State Healthcare-Associated Infections Progress Report, found that rates of HAIs are actually decreasing. There was a 50% decrease in central line-associated bloodstream infection and a 17% decrease in surgical site infection after abdominal hysterectomy. Furthermore, there was a 13% decrease in hospital-onset MRSA blood infection and an 8% decrease in C. difficile infection.
Although the trends in HAIs and HACs were going in the right direction, from a legislative perspective, efforts were made to further decrease HAC-related mortality, morbidity, and cost. The Hospital-Acquired Condition Reduction Program (HACRP) beginning in fiscal year 2015 required CMS to reduce payments to hospitals who are in the lowest 25% of all hospitals in HAC performance score.
HACs Measured & Hospitals Participating
HACRP doesn’t measure all potential HACs. It measures a subgroup of HACs divided into two domains:
Domain 1 – AHRQ Patient Safety Indicator (PSI) 90 Composite (includes pressure ulcers, pneumothorax, CVCBSI, hip fracture, PE/DVT, postop sepsis, wound dehiscence, accidental puncture/laceration)
Domain 2 –NHSN Healthcare-Associated Infection (HAI) measures:
- Central Line-Associated Bloodstream Infection (CLABSI)
- Catheter-Associated Urinary Tract Infection (CAUTI)
- Surgical Site Infection (SSI) – colon and hysterectomy
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
- Clostridium difficile Infection (CDI)
The two domains are measured over a two-year time period, followed by a brief period of review and correction, and the payment adjustment is applied to the following fiscal year. The time periods for the two domains are staggered – so, in essence, the measurement occurs over a 2.5-year period.
For example: for 2017, HACs were measured from 2012-2015, data review occurred in 2016, and the payment adjustment will be applied to this coming fiscal year.
For 2017, 3023 hospitals are included in HACRP. The program includes acute care hospitals but excludes long-term care hospitals, critical access hospitals, rehabilitation hospitals, psychiatric hospitals, children’s hospitals, and IPPS exempt cancer hospitals, and religious nonmedical health care institutions. In Guam, US Virgin Islands, Northern Mariana Islands, and American Samoa, it also excludes short term acute care hospitals.
Even Hospitals Dread Report Card Day
The payment adjustment for the HACRP is a payment penalty. There is no financial incentive opportunity. No matter how much they study for the HACR “exam”, there’s no extra credit! To calculate if a hospital will be subject to payment reduction, each of the above listed measures is assigned a score between 1 and 10 based on the hospital’s performance – with higher scores indicating worse performance. Note, if a hospital does not have sufficient data for a given measure, the measure is excluded from the calculation. Also, the measures in the two domains are not weighted equally. For 2017, Domain 1 has a 15% weight and Domain 2 has an 85% weight in the hospital’s total score.
This program “grades” hospitals on a curve. Just like the old classroom days, hospitals are competing against each other on a yearly basis. As rates of HACs decrease across all hospitals, hospitals must work even harder to improve and keep their score in the top 75%. For FY 2017, hospitals with a total HAC score greater than 6.5700 are subject to the 1% payment reduction. But, talk about a painful report card “F”! The payment reduction is applied to all the hospital’s CMS payments for the year.
HAC Penalties for 2017
CMS states that 769 of 3,203 hospitals ranked in the worst performing quartile will be subject to the 1% penalty in 2017. This is compared to 751 hospitals out of 3,211 hospitals penalized in 2016.
HACRP, with its huge penalties totaling $364M last year, is coming under scrutiny in the year end, as clinicians question the validity of their calculations. In a recently published study, data shows that large hospitals are more likely to be identified as poor performers for measures that have a very low probability of complications. Additionally, prior studies have found there is a surveillance bias for more vigilant hospitals looking for complications. No good deed goes unpunished, they say.
The bottom line
There is an overabundance of programs available to help hospitals reduce HACs. On a national level, the CDC itself provides a variety of assessment tools, strategies, toolkits, and checklists that a hospital may implement. On state level, many evidence-based initiatives are available to aid in reduction of HACs. As hospitals work on many of these programs, they struggle to identify the interventions will help them pull ahead of the curve and keep them in the top 75% of hospitals.
In this new era of medicine, tools are available to hospitals that, a decade ago, clinicians would have described as figments of a sci-fi lover’s imagination. Technologies built on cognitive computing are now available to provide real time detection of HACs before they happen. Imagine a piece of technology “smart” enough to know that an upward trending white blood cell count in a post-operative patient with a urinary catheter should be brought to a physician’s attention. Getting this information to the right clinical team member, before the patient develops a urinary catheter-associated infection, is truly turning the traditionally reactive practice of medicine into a proactive one!
Early identification and detection of patients needing closer monitoring and/or interventions will not only improve the quality of patient care, lower mortality, decrease LOS, but will also help hospitals keep their hard-earned CMS dollars in the bank. And more importantly, it keeps those pesky, luggage-toting unwanted visitors out!