Abstract
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. 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. 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. Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009). 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. 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. 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.
Highlights
Surgical care composes 30% of hospital admissions,1 50% of overall hospital costs,[1] and 50% of all Medicare spending.[2]
After HospitalAcquired Conditions Present on Admission (HAC-POA) implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points compared with nontargeted procedures
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
Summary
Surgical care composes 30% of hospital admissions,1 50% of overall hospital costs,[1] and 50% of all Medicare spending.[2]. In 2008, the Centers for Medicare & Medicaid Services (CMS) implemented the HospitalAcquired Conditions Present on Admission (HAC-POA) program to reduce high-cost and high-volume complications among Medicare patients, and it remains in effect today. This mandatory pay-forperformance (P4P) policy penalizes hospitals by no longer paying for the treatment of preventable complications developed during a patient’s hospitalization. The HAC-POA program targets 14 selected conditions; those directly related to surgery include foreign objects retained after surgery, surgical site infection (SSI) following coronary artery bypass graft, cardiac implantable electronic device, bariatric surgery, certain orthopedic procedures, and deep vein thrombosis (DVT) or pulmonary embolism following certain orthopedic procedures
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