Lessons learnt on patient safety in dentistry through a 5-year nationwide database study on iatrogenic harm.

Safe delivery of care is a priority in dentistry, while basic epidemiological knowledge of patient safety incidents is still lacking. The objectives of this study were to (1) classify patient safety incidents related to primary dental care in Denmark in the period 2016-2020 and study the distribution of different types of dental treatment categories where harm occurred, (2) clarify treatment categories leading to "nerve injury" and "tooth loss" and (3) assess the financial cost of patient-harm claims. Data from the Danish Dental Compensation Act (DDCA) database was retrieved from all filed cases from 1st January 2016 until 31st December 2020 pertaining to: (1) The reason why the patient applied for treatment-related harm compensation, (2) the event that led to the alleged harm (treatment category), (3) the type of patient-harm, and (4) the financial cost of all harm compensations. A total of 9069 claims were retrieved, of which 5079 (56%) were found eligible for compensation. The three most frequent categories leading to compensation were "Root canal treatment and post preparation"(n = 2461, 48% of all approved claims), "lack of timely diagnosis and initiation of treatment" (n = 905, 18%) and "surgery" (n = 878, 17%). Damage to the root of the tooth accounted for more than half of all approved claims (54.36%), which was most frequently a result of either parietal perforation during endodontic treatment (18.54%) or instrument fracture (18.89%). Nerve injury accounted for 16.81% of the approved claims. Total cost of all compensation payments was €16,309,310, 41.1% of which was related to surgery (€6,707,430) and 20.4% (€3,322,927) to endodontic treatment. This comprehensive analysis documents that harm permeates all aspects of dentistry, especially in endodontics and surgery. Neglect or diagnostic delays contribute to 18% of claims, indicating that harm does not solely result from direct treatment. Treatment harm inflicts considerable societal costs.

Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures.

Importance: Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers. Objective: To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs. Design, Setting, and Participants: A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-in-differences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between November 1, 2020, and May 7, 2021. Exposures: Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009). Main Outcomes and Measures: Incidence of surgical site infections and deep vein thrombosis, length of stay, in-hospital mortality, and hospital costs. Analyses were adjusted for patient and hospital characteristics and indicators for procedure type, hospital, and year. Results: In our propensity score-weighted sample, the intervention procedures group comprised 1 047 351 (88.5%) individuals who were White and 742 734 (60.6%) women; mean (SD) age was 75 (6.9) years. The control procedures group included 94 715 (88.0%) individuals who were White, and 65 436 (60.6%) women; mean (SD) age was 75 (7.1) years. After HAC-POA implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points (95% CI, -0.5 to -0.1 percentage points; P = .02) compared with nontargeted procedures. The program was associated with a reduction in length of stay by 0.5 days (95% CI, -0.6 to -0.4 days; P < .001) and hospital costs by 8.1% (95% CI, -10.2% to -6.1%; P < .001). No significant changes in deep vein thrombosis incidence and mortality were noted. Conclusions and Relevance: The findings of this study suggest that the HAC-POA program is associated with small decreases in surgical site infection and length of stay and moderate decreases in hospital costs for patients enrolled in Medicare. Policy makers may consider these findings when evaluating the continuation and expansion of this program for other surgical procedures, and payers may want to consider adopting a similar policy.

Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury.

BACKGROUND: Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients' quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy. METHODS: A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated. RESULTS: In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900. CONCLUSION: Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program.

Importance: The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown. Objective: To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. Design, Setting, and Participants: This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied. Exposures: Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall. Main Outcomes and Measures: Penalties in the prestratification vs poststratification schemes. Results: The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status. Conclusions and Relevance: This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.

Cost of Quality Pilot: A Systematic Methodology for Examining the Cost of Pressure Injury.

Health care costs in the United States are considerable, and total national cost of preventable adverse events in the United States ranges from billions to trillions of dollars annually. Achieving the highest quality of health services requires delivering care that mitigates the risk of patient adverse events. Pressure injuries are a significant and costly adverse event. Mitigating or eliminating harm from pressure injuries not only improves quality and increases patient safety but also decreases costs of care. The purpose of this article is to pilot a systematic methodology for examining the differences in the cost of care for a subset of patients with and without hospital-acquired pressure injuries in an acute care setting.

A comprehensive evaluation of the long-term clinical and economic impact of minor bile duct injury.

BACKGROUND: Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury. METHODS: Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades. RESULTS: A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P < .001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P < .001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient). DISCUSSION: Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.

Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt.

OBJECTIVE: To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed. SUMMARY OF BACKGROUND DATA: In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. METHODS: 100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients. RESULTS: A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points. CONCLUSIONS: Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.

Blending Evidence-Based Practice and Lean Six Sigma Methodology to Reduce Hospital-Acquired Pressure Injuries in a Progressive Care Unit.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) continue to challenge acute care facilities. Best practice to reduce HAPI includes assessment, documentation, positioning, and treatment. LOCAL PROBLEM: In spite of using evidence-based practices, the hospital's gastrointestinal/genitourinary progressive care unit had more HAPIs each month than the other units in the hospital. METHODS: A combination of Lean Six Sigma and evidence-based practice was used to decrease HAPIs. INTERVENTIONS: The T program (turn, touch, and tidy) was developed to address the areas of concern identified in the root cause analysis. RESULTS: HAPIs were reduced from 22 in the previous 2 quarters to zero for 3 consecutive quarters with a cost avoidance to $379 767. CONCLUSIONS: The successful implementation of the T program was the result of blending Lean Six Sigma and evidence-based practice.

Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement.

In 2013 the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the program has been successful in improving patient safety has not been independently evaluated. We used clinical registry data on rates of hospital-acquired conditions in 2010-18 from a large surgical collaborative in Michigan to estimate the impact of the policy. While rates of all such conditions declined from 133.4 per 1,000 discharges in the pre-program period to 122.2 in the post-program period, greater improvements were observed for nontargeted measures. We conclude that the program did not improve patient safety in Michigan beyond existing trends. These findings raise questions about whether the program will lead to improvements in patient safety as intended.

The impact of hospital harm on length of stay, costs of care and length of person-centred episodes of care: a retrospective cohort study.

BACKGROUND: There is a lack of data in Canada on the longitudinal effects of adverse events that occur in hospital, specifically in the period after discharge. Our objective was to quantify the impact of adverse events on hospital length of stay, length of person-centred episodes of care (PCEs) and costs of PCEs, as well as their impact on the total health system. METHODS: We conducted a population-based, retrospective cohort study using linked health administrative databases. We included adults in Ontario who had an acute hospital admission between Apr. 1, 2015, and Mar. 31, 2016. We grouped hospital admissions into 1 of 9 episode types and used the Canadian Institute for Health Information methodology for hospital harm to measure adverse events. We specified generalized linear models to estimate the impact of hospital harm on the following: incremental length of index acute hospital admission, incremental length of the PCE, and incremental costs of the PCE. RESULTS: Out of 610 979 hospital admissions, 36 004 (5.9%) involved an occurrence of harm. The impact of harm on the incremental length of hospital stay ranged from 0.4 to 24.2 days (p < 0.001); the incremental length of the PCE ranged from 0.3 to 30.2 days (p < 0.001); and the incremental costs of the PCE ranged from $800 to $51 067 (p < 0.001). Total hospital days attributable to hospital harm amounted to 407 696, and the total attributable cost to the Ontario health system amounted to $1 088 330 376. INTERPRETATION: We found that experiencing harm in hospital significantly affects both in-hospital and post-discharge use of health services and costs of care, and constitutes an enormous expense to Ontario's publicly funded health system.

Iatrogenic hypoglycemia-related hospital admissions identified through databases: economic burden and causes.

Background Hypoglycemia is an acute and frequent complication of diabetes. Objectives To assess the number of hospital admissions due to iatrogenic hypoglycemia in Alsace (France) over a year, to estimate the associated economic burden and to identify causes. Method A retrospective analysis was performed using data extracted from hospital databases. Costs were calculated from French official tariffs. Setting 31 public and private hospitals. A review of the medical records of patients with iatrogenic hypoglycemia-related hospital admissions was performed at the University Hospital of Strasbourg. Main outcome measures Hypoglycemia-related hospital admissions: number, costs and causes. Results Out of 42,381 hospitalizations, 147 iatrogenic hypoglycemia-related hospital admissions (0.4%) were identified; 41 patients with type 1 diabetes mellitus and 106 with type 2. The total cost associated to the 147 events was € 407,441. The median cost per patient was € 1,224.6 [563.0-2,505.7 (interquartile range)] for type 1 diabetes mellitus and € 3,670.9 [2,505.7-3,670.9] for type 2. Forty-six patients over the 147 were coming from the University Hospital of Strasbourg. In this hospital, the most common origin of the hypoglycemia was missed meals (n = 7), the second was a mismatch between antidiabetic medicines and carbohydrate intake (n = 6), the third was an incorrect use of antidiabetic medicines (n = 5). Conclusions 147 hospitalizations due to iatrogenic hypoglycemia were identified with an estimated global cost of € 407,441. Optimizing therapy with low-risk hypoglycemic medicines, improving access to continuous glucose monitoring systems and offering adequate education, could help address the causes of hypoglycemia.

A comprehensive evaluation of the long-term economic impact of major bile duct injury.

BACKGROUND: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

The national cost of hospital-acquired pressure injuries in the United States.

Our objective was to estimate the US national cost burden of hospital-acquired pressure injury (HAPI) using economic simulation methods. We created a Markov simulation to estimate costs for staged pressure injuries acquired during hospitalisation from the hospital perspective. The model analysed outcomes of hospitalised adults with acute illness in 1-day cycles until all patients were terminated at the point of discharge or death. Simulations that developed a staged pressure injury after 4 days could advance from Stages 1 to 4 and accrue additional costs for Stages 3 and 4. We measured costs in 2016 US dollars representing the total cost of acute care attributable to HAPI incidence at the patient level and for the entire United States based on the previously reported epidemiology of pressure injury. US HAPI costs could exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full-thickness wounds, which occupy clinician time and hospital resources. HAPIs remain a concern with regard to hospital quality in addition to being a major source of economic burden on the US health care system. Hospitals should invest more in quality improvement of early detection and care for pressure injury to avoid higher costs.

[Medico-legal risk in urology: Analysis of a portfolio of insured persons by a French insurance company between 2009 and 2018]. / Risque médico-légal en urologie : analyse d'un portefeuille d'assurés auprès d'une compagnie d'assurances française entre 2009 et 2018.

OBJECTIVE: Presentation of data collected on urology claims from the register of a French insurance company. MATERIAL AND METHOD: Compensation claims involving urologists covering the period 2009-2018 were identified and analyzed. RESULTS: A total of 37 files were found. Oncological and functional surgical interventions accounts for 78% of repair claims. Postoperative complications represent 76% of the cases. The most represented acts are total prostatectomy (5) and promonto-fixation (4). The average time of complaint is 28.6 months [1-144 months], the average duration of a procedure (opening-closing) is 32.8 months [12-72 months]. The Conciliation and Compensation Commissions (CCC) and the High Court Courts (HCC) were solicited respectively in 51% and 33% of the proceedings. An amicable agreement is found in 16% of cases. There was no criminal or disciplinary proceedings. The average cost of a closed urology file is 7836 € [0-31,120 €]. In total, 64.8% of the expertises confirm practices in the respect of the rules of the art. CONCLUSION: This series presents the first forensic analysis of a portfolio of urologists on a period of 9 years in French urology. There is a rate of responsibility retained against the practitioner in only 27% of cases. The low rate of faulty files, the absence of a conviction for breach of the duty to provide information and in connection with antibiotic prophylaxis seem to confirm that the practice of urology in France is of good quality, a further study on a longer period of time and on a larger cohort of urologists would allow a finer medico-legal approach. LEVEL OF EVIDENCE: 3.

A long wait: barriers to discharge for long length of stay patients.

INTRODUCTION: Reducing long length of stay (LLOS, or inpatient stays lasting over 30 days) is an important way for hospitals to improve cost efficiency, bed availability and health outcomes. Discharge delays can cost hundreds to thousands of dollars per patient, and LLOS represents a burden on bed availability for other potential patients. However, most research studies investigating discharge barriers are not LLOS-specific. Of those that do, nearly all are limited by further patient subpopulation focus or small sample size. To our knowledge, our study is the first to describe LLOS discharge barriers in an entire Department of Medicine. METHODS: We conducted a chart review of 172 LLOS patients in the Department of Medicine at an academic tertiary care hospital and quantified the most frequent causes of delay as well as factors causing the greatest amount of delay time. We also interviewed healthcare staff for their perceptions on barriers to discharge. RESULTS: Discharge site coordination was the most frequent cause of delay, affecting 56% of patients and accounting for 80% of total non-medical postponement days. Goals of care issues and establishment of follow-up care were the next most frequent contributors to delay. CONCLUSION: Together with perspectives from interviewed staff, these results highlight multiple different areas of opportunity for reducing LLOS and maximising the care capacity of inpatient hospitals.

Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection.

BACKGROUND: The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods. STUDY DESIGN: This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm. RESULTS: Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n = 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p = 0.0461) or MSQC models (0.77, p < 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p < 0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP. CONCLUSIONS: This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward or penalty.

Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study.

Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.

Clinical Impact and Economic Burden of Hospital-Acquired Conditions Following Common Surgical Procedures.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures. SUMMARY OF BACKGROUND DATA: HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety. METHODS: Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database. RESULTS: Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ±â€Š0.04 days longer (P < 0.001) and payments were $8893 ±â€Š$148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ±â€Š0.02 and 0.38 ±â€Š0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ±â€Š0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively). CONCLUSION: HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not. LEVEL OF EVIDENCE: 3.