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Delirium Dilemma


Delirium Dilemma

I heard that Medicare is thinking about not paying the hospital if a hospitalized patient develops delirium. I am a geriatric hospitalist and unfortunately, this is a common problem in my patient population. This doesn’t sound reasonable. Is this really true?

Delirious in Denver

Dr. Hospitalist responds: For those of you who read this column regularly, you have seen me comment in the past about hospital acquired conditions.

In 2005, Congress authorized the Center for Medicare and Medicaid Services (CMS) to adjust hospital payments to encourage prevention of hospital acquired conditions. This was “part of an array of Medicare value-based purchasing tools that CMS is using to promote increased quality and efficiency of care.”

In August 2007, CMS announced that starting Oct. 1, 2007, hospitals were required to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA). CMS was trying to determine how often patients were developing specific complications while they were hospitalized. This list of conditions included a foreign object retained after surgery, air embolism, blood incompatibility, stage three and four pressure ulcers, injuries due to falls/trauma, catheter-associated urinary tract infections, vascular catheter-associated infection and mediastinitis after coronary artery bypass graft.

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They also announced that beginning Oct. 1, CMS will pay hospitals as though that complication did not occur (i.e., not pay for the additional costs associated with managing these complications). These policy changes sent hospital administrators scrambling to develop and implement plans to prevent these types of incidents from occurring in hospitalized patients.

CMS has continued to work with the Centers for Disease Control and Prevention (CDC) and other stakeholders to identify additional hospital acquired conditions. In April, CMS proposed to make the following list of conditions subject to the POA payment provision in fiscal year 2009. These include:

  • Legionnaires’ disease;
  • Iatrogenic pneumothorax;
  • Ventilator-associated pneumonia;
  • Deep-vein thrombosis (DVT/ pulmonary embolism(PE);
  • Staphylococcus aureus septicemia;
  • Clostridium Difficile-associated disease;
  • Surgical site infections following several elective surgeries (total knee replacement, laparoscopic gastric bypass and gastroenerostomy, ligation, and stripping of varicose veins);
  • Several conditions regarding glycemic control in hospitalized patients (diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma, and hypoglycemic coma); and
  • Delirium.
New CMS reimbursement regulations that go into effect Oct. 1 will punish hospitals when delirium develops during a patient's hospitalization.

New CMS reimbursement regulations that go into effect Oct. 1 will punish hospitals when delirium develops during a patient’s hospitalization.

Last year, when I heard CMS was going to stop paying for the cost of care associated with errors like transfusing the wrong type of blood and leaving foreign objects in patients during surgery, I cheered. The policy was long overdue. At present, I share your concerns when I look at this list of proposed hospital acquired conditions for fiscal year 2009.

I have no problems with CMS not paying for the costs of caring for a patient if a patient slips into a diabetic coma during his or her hospital stay. Careful monitoring and adherence to evidence based guidelines should prevent that. But I agree with you, can we really prevent delirium in all our hospitalized patients?

I took care of a patient recently with known dementia who developed delirium after her hip surgery. Dementia, surgery, and medications are known risk factors for delirium. Despite careful monitoring and thoughtful care, she was delirious after the surgery. Was I surprised? No. Could I have done more to prevent delirium? No. Why should the hospital be punished in this case? It shouldn’t. The patient needed the surgery, and I wasn’t going to withhold the narcotics just to minimize the risk of delirium. I suspect there is room for improvement in our hospitals when it comes to caring for vulnerable populations of patients. We can likely reduce the rates of delirium in our hospitalized patients, but I doubt we can truly prevent all delirium.

CMS published its proposal in April, well in advance of the new fiscal year that begins in October, because CMS is interested in seeking public comments on “the degree to which (each condition) is reasonably preventable through the application of evidence-based guidelines.”

Based on public comment, CMS will choose to select or not select each condition listed as a hospital-acquired condition. CMS is expected to make its decision known by the end of this month. Let it be known that this hospitalist is opposed to the delirium measure. I am not alone. A number of professional societies, including SHM, American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society, among others, have expressed reservations to CMS about several of the proposed hospital-acquired conditions.

These societies believe ventilator-associated pneumonia, DVT/PE, and iatrogenic pneumothorax also should not be included as hospital-acquired conditions because they, like delirium, are not entirely preventable. Further, they believe the incidence of these four conditions can be reduced by adherence to evidence based guidelines but there is insufficient evidence to guide prevention of these conditions.

In addition, SHM raised concern that listing Legionnaires’ disease as a hospital-acquired condition may lead to unintended consequences, such as routine testing for Legionnaires’ in all patients presenting with community acquired pneumonia.

We won’t know until the end of this month whether CMS will make any or all of these conditions subject to the POA payment provision in fiscal year 2009. But kudos to the professional societies and all who have helped CMS think about these important issues. TH

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