Patient Care

Medicare Nonpayment for Hospital-Acquired Conditions May Have Reduced Infection Rates


Clinical question: What was the effect of the Centers for Medicare and Medicaid Services’ (CMS) nonpayment for hospital-acquired conditions?

Background: In 2008, CMS implemented the Hospital-Acquired Conditions (HAC) initiative, denying incremental payment to hospitals for complications of hospital care, including central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers, and injurious patient falls.

Study design: Quasi-experimental data review, pre-post comparison of outcomes.

Setting: Nearly 1,400 U.S. hospitals contributing data to the National Database of Nursing Quality Indicators (NDNQI).

The authors examined 1,894 patients undergoing cardiac surgery over a six-month period. They determined the number and type of lab tests drawn on each patient during hospitalization, as well as the estimated total blood volume drawn on each patient.

Synopsis: Using time points before and after implementation of the CMS initiative, the authors found that the rates of CLABSIs and CAUTIs dropped significantly after implementation (11% reduction of CLABSIs, 10% reduction of CAUTIs). The rates of pressure ulcers and falls did not change significantly.

Findings differ from an earlier study, which found the HAC initiative did not lead to a reduction in the rates of CLABSIs or CAUTIs. The authors point out that the databases used were different, as was the time frame of data collection.

The authors hypothesize that the reason CLABSI and CAUTI rates decreased while fall and pressure ulcer rates were unchanged was better evidence supporting infection prevention practices for the former. An accompanying editorial argues that the differential outcomes may have been due to increased challenges in implementing practices for the latter measures rather than differential evidence.

Limitations of the study include characteristics of hospitals reporting to the NDNQI and accuracy of data capture by individual reporting hospitals. Changes over time may also be attributed to factors other than the HAC initiative.

Bottom line: Nonpayment for HACs may have led to decreases in rates of CLABSIs and CAUTIs, but rates of pressure ulcers and falls remained unchanged.

Citation: Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for hospital-acquired conditions. JAMA Intern Med. 2015;175(3):347-354.

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