Hospital report cards for hospital-acquired pressure ulcers: how good are the grades?

BACKGROUND: Value-based purchasing programs use administrative data to compare hospitals by rates of hospital-acquired pressure ulcers (HAPUs) for public reporting and financial penalties. However, validation of these data is lacking. OBJECTIVE: To assess the validity of the administrative data used to generate HAPU rates by comparing the rates generated from these data with those generated from surveillance data. DESIGN: Retrospective analysis of 2 million all-payer administrative records from 448 California hospitals and quarterly hospitalwide surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes (as publicly reported on the CalHospitalCompare Web site). SETTING: 196 acute care hospitals with at least 6 months of available administrative and surveillance data. PATIENTS: Nonobstetric adults discharged in 2009. MEASUREMENTS: Hospital-specific HAPU rates were computed as the percentage of discharged adults (from administrative data) or examined adults (from surveillance data) with at least 1 stage II or greater HAPU (HAPU2+). Categorization of hospital performance based on administrative data was compared with the grade assigned when surveillance data were used. RESULTS: When administrative data were used, the mean hospital-specific HAPU2+ rate was 0.15% (95% CI, 0.13% to 0.17%); when surveillance data were used, the rate was 2.0% (CI, 1.8% to 2.2%). Among the 49 hospitals with HAPU2+ rates in the highest (worst) quartile from administrative data, use of the surveillance data set resulted in performance grades of "superior" for 3 of these hospitals, "above average" for 14, "average" for 15, and "below average" for 17. LIMITATION: Data are from 1 state and 1 year. CONCLUSION: Hospital performance scores generated from HAPU2+ rates varied considerably according to whether administrative or surveillance data were used, suggesting that administrative data may not be appropriate for comparing hospitals. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis.

BACKGROUND: Most (59% to 86%) hospital-acquired urinary tract infections (UTIs) are catheter-associated urinary tract infections (CAUTIs). As of 2008, claims data are used to deny payment for certain hospital-acquired conditions, including CAUTIs, and publicly report hospital performance. OBJECTIVE: To examine rates of UTIs in adults that are coded in claims data as hospital-acquired and catheter-associated events and evaluate how often nonpayment for CAUTI lowers hospital payment. DESIGN: Before-and-after study of all-payer cross-sectional claims data. SETTING: 96 nonfederal acute care Michigan hospitals. PATIENTS: Nonobstetric adults discharged in 2007 (n = 767 531) and 2009 (n = 781 343). MEASUREMENTS: Hospital rates of UTIs (categorized as catheter-associated or hospital-acquired) and frequency of reduced payment for hospital-acquired CAUTIs. RESULTS: Hospitals frequently requested payment for non-CAUTIs as secondary diagnoses: 10.0% (95% CI, 9.5% to 10.5%) of discharges in 2007 and 10.3% (CI, 9.8% to 10.9%) in 2009. Hospital rates of CAUTI were very low: 0.09% (CI, 0.06% to 0.12%) in 2007 and 0.14% (CI, 0.11% to 0.17%) in 2009. In 2009, 2.6% (CI, 1.6% to 3.6%) of hospital-acquired UTIs were described as CAUTIs. Nonpayment for hospital-acquired CAUTIs reduced payment for 25 of 781 343 (0.003%) hospitalizations in 2009. LIMITATIONS: Data are from only 1 state and involved only 1 year before and after nonpayment for complications. Hospital prevention practices were not examined. CONCLUSION: Catheter-associated UTI rates determined by claims data seem to be inaccurate and are much lower than expected from epidemiologic surveillance data. The financial impact of current nonpayment policy for hospital-acquired CAUTI is low. Claims data are currently not valid data sets for comparing hospital-acquired CAUTI rates for the purpose of public reporting or imposing financial incentives or penalties. PRIMARY FUNDING SOURCE: Blue Cross Blue Shield of Michigan Foundation.

Catheter-associated urinary tract infection and the Medicare rule changes.

Catheter-associated urinary tract infection, a common and potentially preventable complication of hospitalization, is 1 of the hospital-acquired complications chosen by the Centers for Medicare & Medicaid Services (CMS) for which hospitals no longer receive additional payment. To help readers understand the potential consequences of the recent CMS rule changes, the authors examine the preventability of catheter-associated infection, review the CMS rule changes regarding catheter-associated urinary tract infection, offer an assessment of the possible consequences of these changes, and provide guidance for hospital-based administrators and clinicians. Although the CMS rule changes related to catheter-associated urinary tract infection are controversial, they may do more good than harm, because hospitals are likely to redouble their efforts to prevent catheter-associated urinary tract infection, which may minimize unnecessary placement of indwelling catheters and facilitate prompt removal. However, even if forcing hospitals to increase efforts to prevent complications stemming from hospital-acquired infection is commendable, these efforts will have opportunity costs and may have unintended consequences. Therefore, how hospitals and physicians respond to the CMS rule changes must be monitored closely.

Accuracy of hospital administrative data in reporting central line-associated bloodstream infections in newborns.

OBJECTIVES: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality in the NICU. In 2010, Medicaid was mandated not to pay hospitals for treatment of CLABSI; however, the source of CLABSI data for this policy was not specified. Our objective was to evaluate the accuracy of hospital administrative data compared with CLABSI confirmed by an infection control service. METHODS: We evaluated hospital administrative and infection control data for newborns admitted consecutively from January 1, 2008, to December 31, 2010. Clinical and demographic data were collected through chart review. We compared cases of CLABSI identified by administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification 999.31) with infection control data that use national criteria from the Centers for Disease Control and Prevention as the gold standard. To ascertain the nature possible deficiencies in the administrative data, each patient's medical record was searched to determine if clinical phrases that commonly refer to CLABSI appeared. RESULTS: Of 2920 infants admitted to the NICU during our study period, 52 were identified as having a CLABSI: 42 by infection control data only, 7 through hospital administrative data only, and 3 appearing in both. Against the gold standard, hospital administrative data were 6.7% sensitive and 99.7% specific, with a positive predictive value of 30.0% and a negative predictive value of 98.6%. Only 48% of medical records indicated a CLABSI. CONCLUSIONS: Our findings from a major children's hospital NICU indicate that International Classification of Diseases, Ninth Revision, Clinical Modification code 993.31 is presently not accurate and cannot be used reliably to compare CLABSI rates in NICUs.

Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated urinary tract infection.

BACKGROUND: The catheter-associated urinary tract infection (CAUTI) measure recommended by the National Healthcare Safety Network (NHSN) accounts for the risk of infection in patients with an indwelling urinary catheter, but might not adequately reflect all efforts aimed to enhance patient safety by reducing urinary catheter use. METHODS: We used computer-based Monte Carlo simulation to compare the NHSN-recommended CAUTI rate (CAUTIs per 1,000 catheter-days) with the proposed "population CAUTI rate" (CAUTIs per 10,000 patient-days). We simulated 100 interventions with a wide range of effects on catheter utilization and CAUTI risk in patients with catheters, and then compared the 2 measures before and after intervention across the simulated interventions. RESULTS: Out of our 100 simulated interventions, 93 yielded reductions in CAUTI; however, in 25 (27%) of these 93 simulations, the NHSN CAUTI rate increased after the intervention. In addition, among the 68 simulations in which both the NHSN and the population CAUTI rates decreased, the percent decreases in the population CAUTI rate were consistently greater than those in the NHSN rate. CONCLUSION: The population CAUTI rate-CAUTIs per 10,000 patient-days-should be calculated along with the NHSN rate, particularly in settings where interventions lead to substantial reductions in catheter placement. We suspect that this population CAUTI rate may eventually emerge as a primary outcome for hospital-based quality improvement interventions for reducing urinary catheter utilization, especially those focusing on avoiding urinary catheter placement.