CMS cutbacks get catheters out quicker, but spur questionable testing policies
First analysis of impact of 2008 cuts finds glass half full
By Gary Evans, Executive Editor
The Centers for Medicare and Medicaid Services controversial 2008 policy to cut reimbursement for selected health care associated infections (HAIs) has led to some positive prevention measures while fulfilling some predicted unintended consequences, according to an unpublished national survey of infection preventionists.
Overall, the first research assessment of the impact of the CMS policy finds the glass more full than empty, said Grace Lee, MD, MPH, one of the research leaders and an associate medical director of infection control at Children's Hospital in Boston.
"Our survey suggests that the CMS policy had a significant impact in focusing hospitals more on surveillance, education and prevention," she said. "The concern I have is that there is always a tradeoff in terms of time [and resources]. So without expanding staff, how do you not drop the ball for other infections and preventable complications? I think [the hospitals] found creative ways to do that, particularly where they streamlined their resources and made a positive impact in that way."
The survey also asked about funding for infection programs in the context of the 2008 CMS policy change. Many got the proverbial unfunded mandate — or worse.
"Three-quarters of the programs said they had the exact same amount of funding, despite the increased efforts that they needed to make," Lee said. "Fifteen percent actually said they got a little bit more funding because of this policy, but 6% felt that they got a decrease as a result of the CMS policy."
Lee and colleagues conducted a survey and accompanying research to assess the impact of the 2008 CMS policy changes on IPs and infection prevention resources. Preliminary findings from the study were presented recently in Baltimore at the annual conference of the Association for Professionals in Infection Control and Epidemiology. In an interview with Hospital Infection Control & Prevention at APIC, Lee said the most important measure of the CMS policy remains to be taken. Whether such fiscal incentives or similar HAI reporting requirements translate to actual prevented infections is the $64,000 unanswered question.
"The jury is still out," Lee said. "[We need] better data on whether there truly is an impact on patients. I think what we see [in this research] is the IP's perspective of the hospital's efforts and how they have shifted and allocated resources. In general, I think that it has been a good thing that the hospital `C-Suite' is focusing more on infection prevention. But until we see infection rate data we won't know if it has had the true intended impact to protect patients."
The survey was conducted in December 2010, as Lee and colleagues sought IP perceptions of the impact of the CMS policy change on their hospitals. In addition to the survey data, the researchers began doing "qualitative interviews" with IPs two years ago, a process that included meeting with focus groups at APIC meetings.
"As infection preventionists you are key facilitators of HAI prevention in health care settings," she told APIC attendees. "As IPs on the frontlines of this policy change, we felt that infection preventionists were most likely to experience the tradeoffs that were occurring. We felt that you could provide the most unique perspective on the impact in the hospital."
Overall, 317 (64%) of 500 infection preventionists responded. There was no significant difference in hospital demographics for non-responders, underscoring the validity of the data collected, she said.
In one favorable sign, 57% of the IPs said the CMS policy has spurred closer working relationships between infection control and quality improvement programs to reduce HAIs. And 65% said there was greater collaboration by interdisciplinary teams to prevent HAIs.
"So though funding remained level [in many cases] there were other ways that people found to make more efficient use of their resources given the increased demands on their time," Lee said. "There was streamlined use of existing resources, greater surveillance and education efforts on the part of infection preventionists, and greater use of evidence-based practices as a result of the CMS policy."
Removing catheters, testing patients
In particular, the CMS policy led to clinical changes clearly established with reducing HAI risk. For example, many IPs reported that catheters are being removed in a timelier manner since the CMS no longer pays for the additional costs of catheter-related urinary tract infections and other "preventable" infections not present on admission (e.g., catheter-related vascular infections, infectious complications of mediastinitis.) IP respondents also reported that their hospital was increasing the use of antimicrobial coated urinary caterers (29%), antiseptic dressings (56%) and antimicrobial impregnated central venous systems (36%) as a result of the CMS policy.
Removing catheters promptly has long been recommended as a primary infection prevention measure, but the reality at too many hospitals is that catheters and central lines are "lost in place" — left in patients until the clinical benefit is trumped by the increasing risk of infection.1
"In terms of infection prevention practices, 71% [of IPs] said that frontline staff were more likely to remove urinary catheters more quickly than before — as a result of the CMS policy," Lee said. "In addition, 50% said they removed central venous catheters more quickly."
On the other hand, routine patient testing in the absence of clinical indication — a questionable practice that some predicted would occur if the CMS policy was enacted — was reported by more than a quarter of surveyed IPs.
"I was actually surprised by this very honestly — 27% of hospitals reported that they were routinely obtaining urine cultures on admission for those with urinary catheters," she said. "And 13% said they were routinely obtaining blood cultures on admission for those with central venous catheters. Regardless of clinical indication — as a matter of responding to this [CMS] policy."
One theory driving this practice is that a hospital that tests patients on admission can claim some infections were acquired in the community or at another facility. The CMS policy specifically cuts reimbursment for preventable infections "not present on admission." Nevertheless, the testing practice raises ethical questions, since it essentially amounts to performing a medical procedure more motivated by the hospital's bottom line than the patient's vital signs. It also opens up the possibility of inappropriate treatment.
"I think this [finding] is real," Lee said. "It's surprising that it's sadly driving practice in this direction because people feel they have to respond in some way."
The finding won't surprise Tammy Lundstrom, MD, JD, chief medical officer at Providence Park Hospitals in Southfield, MI, who strongly warned of the preemptive testing possibility in an interview with HIC before the CMS changes were finalized. "Everybody who comes into the hospital is going to get a urine culture to [determine if] they had bacteria when they came in," said Lundstrom, who represented APIC's position against the CMS policy. "That is a concern, because lots of women have bacteria in their urine, but are totally asymptomatic and shouldn't be treated. So if that is the strategy a lot of hospitals take it could cause a lot of people to get unnecessary antibiotics. That is one of the unintended consequences of this CMS approach."
Making the call
According to Lee's survey, infection preventionists are also struggling with another consequence of the CMS policy, unintended or not: As surveillance and reporting of these infections are subjected to analysis and parsing, many IPs find themselves in situations akin to a baseball umpire making an extremely close call.
"We heard this a lot in the qualitative work [that included interviewing IPs]," Lee said. "Some people said the pressure was really on the billing staff and the hospital as a whole to try and modify their coding practices to 'game' the best reimbursement possible. In other hospitals, the IPs were at the frontline trying to coordinate between the physicians and the coders and get this to all work out. Which actually is a huge `time sink' when you think about it — taking you away from all of the other activities that you want to do."
In general, the CMS policy has increased time spent on documentation for many IPs. "Over half (54%) said that their hospital spent a lot of time actually improving documentation in the Medicare records as a consequence of the CMS policy," Lee said. "To be responsive to this change — because this [CMS] policy focused on ICD-9 billing codes. Forty-nine percent said their hospital spent more effort on improving accuracy of documenting practices, which is perhaps not where you would want to be if you would rather spend your effort on prevention."
Indeed, one of the logistical problems encountered by IPs is that the CMS policy uses ICD-9 diagnosis codes for infections not present on admission. In contrast, the gold standard for surveillance and reporting HAIs is the definitions and protocols used by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
"It's really tough because it's apples to oranges," Lee says. "What infection preventionists can and should be dealing with are the NHSN surveillance definitions, and the [CMS'] are based on ICD-9 code definitions. I don't think they [are compatible] at all. They each capture a subset of each other. I don't think either is a perfect definition but at least there has been some process and thought involved in the surveillance definitions for NHSN. I think that the [hospital] billing folks are doing the best they can, given the rules that they have — [that] they are supposed to be based on physician documentation. They can't really make the judgment, and when you are documentation dependent you run into some problems."
As resources are redoubled to correctly bill the infections, other priorities may languish. "I think the real question is: Rather than focusing hospital efforts on improving how they bill [does] it make more sense to improve how to prevent infections? I think a [CMS] refocus on NSHN surveillance definitions would be a good thing."
That may be gradually happening, she told APIC attendees. "I hope that through constant, 'gentle' pressure that [CMS] will actually move away from the ICD9 codes and move toward NSHN data as the gold standard. I think that is the way to go."
- Saint S, Kowalski CP, Kaufman SR. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis 2008; 46:243-250.