Nonpayment for Urinary Tract Infections Based on Faulty Data

Abstract

Using claims data to support public quality reporting and nonpayment for hospital-acquired conditions may be flawed, at least when it comes to catheter-associated urinary tract infections. Such infections were most likely being underreported by hospital coders, and as a result, the “accuracy of reporting from the data set is suspect,” according to Dr. Jennifer A. Meddings of the University of Michigan, Ann Arbor, and her colleagues. Since the data on catheter-associated urinary tract infections (CAUTIs) are thought to be faulty, quality comparisons and incentive or disincentive payments based on it are also in doubt, they added. The researchers studied state discharge data from 96 acute care hospitals in Michigan, comparing adults discharged in 2007 with those discharged in 2009 (Ann. Intern. Med. 2012;157:305-12). There were 767,531 discharges in 2007 and 781,343 in 2009 in the state. Previous studies have found 4.5 hospital-acquired infections per 100 hospitalizations, at least a third in the urinary tract. And yet the authors said that only 0.3% of the Michigan discharges involved a hospital-acquired CAUTI. Only 25 of the 781,343 (0.003%) hospitalizations in 2009 experienced a nonpayment for a CAUTI. (The authors estimated a $132,675 loss for each of those cases.) CAUTIs are being underreported for several reasons, Dr. Meddings said. A large proportion of UTIs are catheter-associated, but a review of medical records shows that they are generally not well-documented by physicians. Nurses tend to be more accurate in reporting the infections and that they are catheter-related, but those notes aren't used by hospital coders for billing. Also, if a coder suspects a UTI occurred after admission, he or she is supposed to contact the health care provider, but that doesn't happen very often. Finally, the Centers for Medicare & Medicaid Services does not require coders to list all hospital-acquired conditions in claims data. CMS has been using claims data since 2008 to determine whether it should withhold payment for certain hospital-acquired conditions and as the basis for public reporting on the Hospital Compare website. There has been a long history of concern about the value and accuracy of administrative data. In this study, it is especially concerning because CAUTIs are thought to be the most common health care infection, said Dr. Sean M. Berenholtz, associate professor of anesthesia, critical care medicine, and health policy and management at Johns Hopkins University, Baltimore. There is not a lot of morbidity and mortality associated with CAUTIs, but because they are the most common, the fact that they are being underrepresented on coding is concerning, he said. It's still not clear how to increase the accuracy of diagnosis in coding or how to get hospitals to report such complications more often. The incentives and disincentives for poor performance have good meaning and intention, but the system is so complex that it isn't translating into improvements in quality, Dr. Berenholtz said. It's been almost 5 years since CMS has stopped paying for various complications, but there has not been much evidence to show that the nonpayment has had an impact on quality of care, he said. The study argues for the need to ensure that accurate data are used for financial incentives or disincentives, he added. The study is probably generalizable, Dr. Berenholtz said. It has not been replicated yet, he added, but there is no obvious reason that Michigan would be intentionally underreporting infections. He called the researchers exceedingly talented and well-established. The study was funded by the Blue Cross Blue Shield of Michigan Foundation. The authors reported that they had no conflict of interest.