Hospital-Acquired Condition Reduction Program Research Articles

Teaching and Safety-Net Hospital Penalization in the Hospital-Acquired Condition Reduction Program

The Hospital-Acquired Condition Reduction Program (HACRP) evaluates acute care hospitals on the occurrence of patient safety events and health care-associated infections. Since its implementation, several studies have raised concerns about the overpenalization of teaching and safety-net hospitals, and although several changes in the program's methodology have been applied in the last few years, whether these changes reversed the overpenalization of teaching and safety-net hospitals is unknown. To determine hospital characteristics associated with HACRP penalization and penalization reversal. This retrospective cross-sectional study assessed data from 3117 acute care hospitals participating in the HACRP. The HACRP penalization and hospital characteristics were obtained from Hospital Compare (2020 and 2021), the Inpatient Prospective Payment System impact file (2020), and the American Hospital Association annual survey (2018). Hospital characteristics, including safety-net status and teaching intensity (no teaching and very minor, minor, major, and very major teaching levels). The primary outcome was HACRP penalization (ie, hospitals that fell within the worst quartile of the program's performance). Multivariable models initially included all covariates, and then backward stepwise variable selection was used. Of 3117 hospitals that participated in HACRP in 2020, 779 (25.0%) were safety-net hospitals and 1090 (35.0%) were teaching institutions. In total, 771 hospitals (24.7%) were penalized. The HACRP penalization was associated with safety-net status (odds ratio [OR], 1.41 [95% CI, 1.16-1.71]) and very major teaching intensity (OR, 1.94 [95% CI, 1.15-3.28]). In addition, non-federal government hospitals were more likely to be penalized than for-profit hospitals (OR, 1.62 [95% CI, 1.23-2.14]), as were level I trauma centers (OR, 2.05 [95% CI, 1.43-2.96]) and hospitals located in the New England region (OR, 1.65 [95% CI, 1.12-2.43]). Safety-net hospitals with major teaching levels were twice as likely to be penalized as non-safety-net nonteaching hospitals (OR, 2.15 [95% CI, 1.14-4.03]). Furthermore, safety-net hospitals penalized in 2020 were less likely (OR, 0.64 [95% CI, 0.43-0.96]) to revert their HACRP penalization status in 2021. Findings from this cross-sectional study indicated that teaching and safety-net hospital status continued to be associated with overpenalization in the HACRP despite recent changes in its methodology. Most of these hospitals were also less likely to revert their penalization status. A reevaluation of the program methodology is needed to avoid depleting resources of hospitals caring for underserved populations.

Impact of Repeated Reimbursement Penalties on Hospital Total Quality Scores.

The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores. A quantitative comparative analysis of U.S. health care data was conducted. Data on quality outcomes and hospital characteristics were sourced from the Hospital-Acquired Condition Reduction Program from fiscal years 2018 and 2019 and the Centers for Medicare & Medicaid Services Inpatient Prospective Payment System impact files, respectively. In total, 3123 U.S. hospitals were analyzed to compare differences between total HAC scores of hospitals with and without penalties in consecutive years. Hospitals with repeated penalties had significantly greater improvement in scores ( t497.262 = -13.00, P < 0.001), and the impact was greatest in small hospitals (<100 beds). Repeated penalties had a smaller impact on disproportionate share hospitals (Cohen d = 0.73). Among all hospitals, the effect of repeated penalties was large (Cohen d = 0.75). This study suggests that repeated penalties can improve quality scores in U.S. hospitals. However, the effect may be exaggerated for smaller hospitals and those that serve patient populations with a relatively higher socioeconomic status. The reason disproportionate share hospitals did not show as much improvement as nondisproportionate hospitals may be because hospitals serving vulnerable populations often have fewer resources.

Quality Assurance and Safety Culture in a Healthcare Organization

Patient care and quality management have as one of their primary focuses ensuring the safety of their patients. The four principles of biomedical ethics presented by Beauchamp and Childress are one quality management paradigm that emphasizes the importance of the patient. The Institute of Medicine's six improvement goals capture the essence of excellent medical treatment. Care, money, and health are the three pillars upon which the Institute for Healthcare Improvement's Triple Aim rests. The present review was written with the aforementioned contexts in mind, with the intention of highlighting the system's initiatives to address various efforts of enhancing quality and patient safety. We provide a reflective overview of healthcare legislation, policy, and regulation with special attention paid to the ideas of informed consent and informed refusal. This analysis also details the steps taken and regulations enforced by the administration and management to provide care that is focused on the individual patient. Finally, we discuss model policies like the Delivery System Reform Incentive Payment Program, which incorporates quality management frameworks, the Hospital-Acquired Conditions Reduction Program, which promotes patient safety, and the Hospital Readmissions Reduction Program, which aims to reduce hospital readmissions.

Proven Impact of an Advanced Air Purification System in the Reduction of Infectious Airborne and Surface Pathogens, Concomitant Reduction of Hospital-acquired Infections and Length of Stay, and Improvement in Health-care Economics.

Proven Impact of an Advanced Air Purification System in the Reduction of Infectious Airborne and Surface Pathogens, Concomitant Reduction of Hospital-acquired Infections and Length of Stay, and Improvement in Health-care Economics.

Size-biased sensitivity analysis for matched pairs design to assess the impact of healthcare-associated infections

Abstract: Healthcare-associated infections are serious adverse events that occur during a hospital admission. Quantifying the impact of these infections on inpatient length of stay and cost has important policy implications due to the Hospital-Acquired Conditions Reduction Program in the United States. However, most studies on this topic are flawed because they do not account for when a healthcare-associated infection occurred during a hospital admission. Such an approach leads to selection bias because patients with longer hospital stays are more likely to experience an infection due to their increased exposure time. Time of infection is often not incorporated into the estimation strategy because this information is unknown, yet there are no methods that account for the selection bias in this scenario. To address this problem, we propose a sensitivity analysis for matched pairs designs for assessing the effect of healthcare-associated infections on length of stay and cost when time of infection is unknown. The approach models the probability of infection, or the assignment mechanism, as proportional to a power function of the uninfected length of stay, where the sensitivity parameter is the value of the power. The general idea is to incorporate the degree of exposure into the probability of an infection occurring. Under this size-biased assignment mechanism, we develop hypothesis tests under a sharp null hypothesis of constant multiplicative effects. The approach is demonstrated on a pediatric cohort of inpatient encounters and compared to benchmark estimates that properly account for time of infection. The results reaffirm the severe degree of bias when not accounting for time of infection and also show that the proposed sensitivity analysis captures the benchmark estimates for plausible and theoretically justified values of the sensitivity parameter.

The US hospital-acquired condition reduction program: A linear and logistic regression analysis of domains and penalty status

ABSTRACT Background Section 3008 of the 2010 Patient Protection and Affordable Care Act established the Hospital-Acquired Condition Reduction Program (HACRP). Objective The objective of this study is to reasonably decipher those factors that make a hospital vulnerable to be positioned in the bottom quartile of all reporting hospitals; and therefore, be partially reimbursed. Methods Data was sourced from CMS QualityNet public use data files and the American Hospital Directory® website. Linear and logistic regression models were used to analyze continuous and categorical dependent variables, respectively. Results For a one unit increase in inpatient days and the length of stay, the Total HACRP score increased by 0.02 (95% CI: 0.01 0.03 P = .00), and 0.04 (95% CI: −0.02 −0.06 P = .00) units, respectively, when all other variables were held constant. The odds of incurring penalty was 2% less likely (odds ratio = 98 95% CI: 0.97 0.99 P = .00) if the hospital had lesser as opposed to having a greater number of Total Discharges. The odds of incurring penalty was 3% more likely (odds ratio = 1.03 95% CI: 1.02 1.04 P = .00) if the hospital had more as opposed to less Inpatient Days, when all other variables are held constant. Conclusion We infer that greater number of total discharges and inpatient days are predictors of acquiring a far from conducive HACRP score. We, furthermore, infer that greater the number of total discharges and more inpatient days, greater is the likelihood of incurring a reimbursement penalty under this policy.

Patient safety and quality care: Time to focus on nonventilator hospital-acquired pneumonia

Background: A growing body of evidence has reported on the harm and cost of nonventilator hospital-acquired pneumonia (NVHAP), currently the most common hospital-acquired infection (HAI). Although the US Congress and the Center for Medicare and Medicaid Services (CMS) have acted to reduce rates of some HAIs through the Hospital-Acquired Condition Reduction Program (HACRP), NVHAP is not currently included. Thus, most hospitals do not engage in active prevention. Here, we report the findings from our analysis of Medicare claims data on hospital length of stay (LOS), cost for patients with hospital-acquired pneumonia (HAP), including both ventilator-associated pneumonia and NVHAP, and mortality. Methods: We used Medicare claims data for Federal Fiscal Year 2019 for inpatient and postdischarge services. Beneficiaries who died, were without continuous Medicare Part A and B enrollment, and patients eligible for Medicare for end-stage renal disease were excluded. Inpatient payments and 30-, 60-, and 90-day postdischarge episodes for 2,457 beneficiaries with HAP were examined and compared to a non-HAP control group of 2,457 beneficiaries. Groups were matched on age, sex, race, and the diagnosis-related group (DRG) for their index hospitalization. Results: Most HAP was NVHAP (N = 2,222; 89%) versus VAP (N = 275; 11%). LOS stay was significantly (p HAP patients were 2.8 times more likely to die vs non-HAP. Conclusions: These findings provide additional support to previous research on the harm and cost associated with NVHAP. Previous HACRP HAI initiatives, such as catheter-associated urinary tract infection (CAUTI) and surgical-site infection (SSI), have resulted in measurable HAI reductions. Although recent evidence-based NVHAP and initiatives indicate that NVAHP is largely preventable, to date, no acute-care inpatient hospital quality improvement program implemented by Medicare includes measures for NVHAP prevention. The time is right to include NVHAP as an HACRP HAI initiative.Funding: StrykerDisclosures: None

Hospital-Acquired Conditions Reduction Program, Racial and Ethnic Diversity, and Magnet Designation in the United States.

A key quality indicator in any health system is its ability to reduce morbidity and mortality. In recent years, healthcare organizations in the United States have been held to stricter measures of accountability to provide safe, quality care. This study aimed to explore the contextual factors driving racial disparities in hospital-acquired conditions incident rates among Medicare recipients in Magnet and non-Magnet hospitals. A cross-sectional observational study was performed using data from Hospital-Acquired Condition Reduction Program. Performance from 1823 hospitals were used to examine the association between Magnet recognition and community's racial and ethnic differences in hospital performance on the Hospital-Acquired Condition Reduction Program. The unit of analysis was the hospital level. A propensity score matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. The outcome measures were risk-standardized hospital performance on the Hospital-Acquired Condition Reduction Program domains and overall performance. Study findings show that Magnet hospitals had decreased methicillin-resistant Staphylococcus aureus (MRSA) rate (β = -0.22; 95% confidence interval, -0.36 to -0.08) compared with non-Magnet hospitals. No other statistical difference was identified. Results from this study show community's racial and ethnic differences in hospital-acquired conditions occurrence differ between Magnet and non-Magnet hospitals for MRSA, indicating its association with nursing practice. However, because this improvement is limited to only MRSA, there are likely opportunities for Magnet hospitals to continue process improvements focused on additional Hospital-Acquired Condition Reduction Program measures.

Hospital-Acquired Condition Rate of Admitting Facility Does Not Predict Mortality in Traumatically Injured Patients.

Background: Hospital-acquired conditions (HACs) are increasingly scrutinized as markers of hospital quality and are subject to increasing regulatory and financial pressure. Despite this, there is little evidence that HACs are associated with poor outcomes in traumatically injured patients, or that lower HAC rates are a marker of a better quality of care. Our study compares mortality rates in hospitals with high versus low rates of HAC. Our hypothesis is that high HAC trauma centers have higher mortality.Methods: The latest editions of the National Trauma Data Bank (NTDB) containing facility identification keys (2011 to 2015) were combined. The HACs targeted by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) were identified. Hospital-acquired conditions per 1000 patient-days were calculated for individual trauma centers, and these facilities were stratified into quartiles by HAC rate. Propensity score matching was used to match patients admitted to hospitals in the highest versus the lowest quartiles.Results: Complete data was available for 3,510,818 patients; 58,296 (1.67%) developed HACs recorded in the NTDB. Good performing centers had a mean of 0.84 HACs per 1000 patient-days compared to 7.82 at poor-performing centers. After propensity matching, patients treated at good performing centers had higher mortality of 1.22% versus 1.02% at poor-performing centers (p<0.001). The facility characteristics most over-represented in the poor performing quartile were: University (45.19% vs 10.59%, p<0.001), American College of Surgeons (ACS) Level I Status (31.85% vs 2.24%, p<0.001), and bed size > 600 (28.15% vs 5.5%, p<0.001).Conclusion: Injured patients treated at poor-performing centers (high HAC) have reduced mortality relative to good performing centers (low HAC). Large academic centers were overwhelmingly represented in the poor-performing quartile. Hospital-acquired conditions may be markers of a non-modifiable underlying patient and facility characteristics rather than markers of poor hospital quality.

767. Incidence of C. difficile infection (CDI) Cases by CDI-Standardized Infection Ratio (SIR) Among Centers for Medicare and Medicaid Services (CMS)-Participating Short-Term Acute Care Hospitals (ACH) Post Implementation of the Hospital-Acquired Condition Reduction Program (HAC-RP)

Abstract Background The HAC-RP is a Medicare pay-for-performance program that links Medicare Part A payments to ACH healthcare quality. Starting in 2015, ACHs ranking in the lower 25% for HAC quality measures are subject to a 1% payment reduction. C. difficile infection (CDI) is 1 of 6 quality measures included in the HAC-RP. Hospitals with a CDI-SIR ≥1, indicating that observed yearly CDI cases exceed predicted CDI cases, are subject to a payment reduction, depending on their performance on other HAC quality measures. Little data are available on the CDI-SIR and observed CDI cases among CMS-participating ACH. Methods The HAC hospital data were obtained from CMS (publicly available at https://data.cms.gov/). Definitive Healthcare imported the data using a Structured Query Language based program and linked the CMS data (October yearly reports) with key hospital-level variables in the Definitive Healthcare Data Platform. Data on CDI cases between 2015 - 2018 among CMS-participating short-term ACHs were obtain from Definitive Healthcare and stratified in quartiles by hospital discharges per year. Within each quartile, the number of observed CDI cases were compared descriptively among ACHs with a CDI-SIR ≥1 vs. &amp;lt; 1 by year. Results Number of ACHs with a CDI-SIR ≥1 vs. &amp;lt; 1 within each hospital discharge quartile by year is displayed in Figure 1. The number of ACHs with CDI-SIR ≥1 increased in 2015, were maintained in 2016, declined in 2017 and again in 2018. Within each quartile, the average observed cases per year were higher for ACHs with CDI-SIR ≥ 1 (Figure 2). After 2015 total observed cases declined in ACHs with CDI-SIR ≥ 1 but remained unchanged in ACH with CDI-SIR &amp;lt; 1 (Figure 3). Figure 1. Number of ACH with CDI-SIR ≥1 vs. &amp;lt;1 Within Each Hospital Discharge Quartile Between 2015-2018 Figure 2. Average Number of and Total Observed Cases per ACH within Each Hospital Discharge Quartile by CDI-SIR ≥1 Figure 3. Total Observed Cases by CDI-SIR ≥ between 2015-2018 Conclusion Observed cases were similar regardless of CDI-SIR score, although approximately 75% of ACHs had a CDI-SIR &amp;lt; 1. HAC-RP penalizes short-term ACHs with a CDI-SIR ≥1 and appears to be effective in reducing CDI cases. However, the observed increase of cases over the 4-year period among ACHs with CDI-SIR &amp;lt; 1 post HAC-RP implementation is concerning. Greater focus is needed to reduce CDI cases across all ACHs, irrespective of CDI-SIR given the burden of disease and associated morbidity and mortality. Disclosures Mauricio Rodriguez, Jr., PharmD, BCPS, BCCCP, BCIDP, Paratek Pharmaceuticals, Inc. (Employee, Shareholder) Surya Chitra, PhD, Paratek Pharmaceuticals, Inc. (Consultant) Paige Lavallee, BA, Definitive Healthcare (Employee) Thomas Lodise, Jr., PharmD, PhD, Astra-Zeneca (Consultant)Bayer (Consultant)DoseMe (Consultant, Advisor or Review Panel member)ferring (Consultant)genentech (Consultant)GSK (Consultant)Melinta (Consultant)merck (Consultant, Independent Contractor)nabriva (Consultant)paratek (Consultant, Advisor or Review Panel member, Speaker's Bureau)shionogi (Consultant, Advisor or Review Panel member, Speaker's Bureau)Spero (Consultant)tetraphase (Consultant)Venatrox (Consultant) Thomas Lodise, Jr., PharmD, PhD, Melinta Therapeutics (Individual(s) Involved: Self): Consultant; Merck (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Paratek (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant, Speakers' bureau; Spero (Individual(s) Involved: Self): Consultant; Tetraphase Pharmaceuticals Inc. (Individual(s) Involved: Self): Consultant

The Association of Hospital Magnet® Status and Pay-for-Performance Penalties.

The Centers for Medicare and Medicaid Services' Pay-for-Performance (P4P) programs aim to improve hospital care through financial incentives for care quality and patient outcomes. Magnet® recognition-a potential pathway for improving nurse work environments-is associated with better patient outcomes and P4P program scores, but whether these indicators of higher quality are substantial enough to avoid penalties and thereby impact hospital reimbursements is unknown. This cross-sectional study used a national sample of 2,860 hospitals to examine the relationship between hospital Magnet® status and P4P penalties under P4P programs: Hospital Readmission Reduction Program, Hospital-Acquired Conditions (HAC) Reduction Program, Hospital Value-Based Purchasing (VBP) Program. Magnet® hospitals were matched 1:1 with non-Magnet hospitals accounting for 13 organizational characteristics including hospital size and location. Post-match logistic regression models were used to compute a hospital's odds of penalties. In a national sample of hospitals, 77% of hospitals experienced P4P penalties. Magnet® hospitals were less likely to be penalized in the VBP program compared to their matched non-Magnet counterparts (40% vs. 48%). Magnet® status was associated with 30% lower odds of VBP penalties relative to non-Magnet hospitals. Lower P4P program penalties is one benefit associated with achieving Magnet® status or otherwise maintaining high-quality nurse work environments.

Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions

BackgroundSince October 2014, the Centers for Medicare and Medicaid Services has penalized 25% of U.S. hospitals with the highest rates of hospital-acquired conditions under the Hospital Acquired Conditions Reduction Program (HACRP). While early evaluations of the HACRP program reported cumulative reductions in hospital-acquired conditions, more recent studies have not found a clear association between receipt of the HACRP penalty and hospital quality of care. We posit that some of this disconnect may be driven by frequent scoring updates. The sensitivity of the HACRP penalties to updates in the program’s scoring methodology has not been independently evaluated.MethodsWe used hospital discharge records from 14 states to evaluate the association between changes in HACRP scoring methodology and corresponding shifts in penalty status. To isolate the impact of changes in scoring methods over time, we used FY2018 hospital performance data to calculate total HAC scores using FY2015 through FY2018 CMS scoring methodologies.ResultsComparing hospital penalty status based on various HACRP scoring methodologies over time, we found a significant overlap between penalized hospitals when using FY 2015 and 2016 scoring methodologies (95%) and between FY 2017 and 2018 methodologies (46%), but substantial differences across early vs later years. Only 15% of hospitals were eligible for penalties across all four years. We also found significant changes in a hospital’s (relative) ranking across the various years, indicating that shifts in penalty status were not driven by small changes in HAC scores clustered around the penalty threshold.ConclusionsHACRP penalties have been highly sensitive to program updates, which are generally announced after performance periods are concluded. This disconnect between performance and penalties calls into question the ability of the HACRP to improve patient safety as intended.

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

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. To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. 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. 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. Penalties in the prestratification vs poststratification schemes. 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. 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.

Association Between Federal Value-Based Incentive Program Implementation and Hospital-Onset C. difficile Infection Rates

Background: The Hospital-Acquired Conditions Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) are federal value-based incentive programs that financially reward or penalize hospitals based on quality metrics. Hospital-onset C. difficile infection (HO-CDI) rates reported to the CDC NHSN became a target quality metric for both HACRP and HVBP in October 2016, but the impact of these programs on HO-CDI rates is unknown. Methods: We used an interrupted time-series design to examine the association between HACRP/HVBP implementation in October 2016 and quarterly rates of HO-CDI per 10,000 patient days among incentive-eligible acute-care hospitals conducting facility-wide HO-CDI NHSN surveillance between January 2013 and March 2019. Generalized estimating equations were used to fit negative binomial regression models to assess for immediate program impact (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital’s predominant method for CDI testing (nucleic acid amplification including PCR (NAAT), enzyme immunoassay for toxin (EIA), or other testing method including cell cytotoxicity neutralization assay and toxigenic culture). Results: Of the 265 study hospitals studied, most were medium-sized (100–399 beds, 55%), not-for-profit (77%), teaching hospitals (70%), and were located in a metropolitan area (87%). Compared to EIA, rates of HO-CDI were higher when detected by NAAT (incidence rate ratio [IRR], 1.55; 95% CI, 1.41–1.70) or other testing methods (IRR, 1.47; 95% CI, 1.26–1.71). Controlling for CDI testing methods, HACRP/HVBP implementation was associated with an immediate 6% decline in HO-CDI rates (IRR, 0.94; 95% CI, 0.89–0.99) and a 4% decline in slope per year-quarter thereafter (IRR, 0.96; 95% CI, 0.95–0.97) (Fig. 1). Conclusions: HACRP/HVBP implementation was associated with both immediate and gradual improvements in HO-CDI rates, independent of CDI testing methods of differing sensitivity. Future research may evaluate the precise mechanisms underlying this improvement and if this impact is sustained in the long term.Funding: NoneDisclosures: None

Association Between Infection Control Resource Use and the Number of Penalties Under Medicare’s Hospital-Acquired Condition Reduction Program

Background: The Hospital-Acquired Condition Reduction Program (HACRP) is a pay-for-performance Medicare program that promotes reducing patient harm, particularly healthcare-associated infections (HAIs). We examined the association between infection-control–related activities and the number of penalties a hospital received between fiscal years 2015 and 2018. Methods: We used logistic regression with ordered categories to assess infection control resource use and the number of penalties, an ordered categorical dependent variable with 5 categories ranging from 0 to 4, as of 2018. Data sources included National Healthcare Safety Network, American Hospital Association Annual Survey, Medicare Impact and Cost Report files, and Data.Medicare.gov. We excluded hospitals lacking data to calculate any HACRP score or component score for HAI and hospitals missing observations for model variables (301 hospitals). We assessed the following model variables: teaching hospital status, infection preventionists (IP) per 1,000 beds, surveillance hours per week per bed, other infection control activities per week per bed, nurse-to-bed ratio, housekeeping expenditure per 10,000 beds, nursing position vacancies per bed, bed size, electronic health record (EHR) implementation, number of skilled nursing beds, rural or urban location, and Medicare patient case-mix (cmi_quartiles). Results: In our model, negative logit model point estimates indicated that increased values of the variable are associated with a lower odds of having a higher number of penalties. The final data set consisted of 3,004 US hospitals. Lower penalties were significantly associated with higher IP-to-bed ratio. Although the point estimates were &lt;1, an association between lower penalties and higher nurse-to-bed ratios or electronic health records was not demonstrated (Table 1). Conclusions: Our results suggest that after controlling for selected hospital structural factors, incremental resources related to infection control have a protective association with HCARP penalties.Funding: NoneDisclosures: None

Review of “Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-Serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt” by Zogg CK, et al. Ann Surg 2020;271(6):985–993

Review of “Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-Serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt” by Zogg CK, et al. Ann Surg 2020;271(6):985–993

P73. Clinical review of spine surgery patient safety indicators avoids CMS payment reductions

BACKGROUND CONTEXT The Hospital Acquired Conditions Reduction Program provides a financial incentive to reduce Patient Safety Indicators (PSI), defined as potentially preventable hospital-related events associated with harmful outcomes for patients. PSI are identified by ICD coding. However, ICD coding does not always reflect the true medical course of the patient. PURPOSE To determine if addition of a clinician to the review process results in a reduction of incorrectly generated PSI. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients who had spine surgery at a single institution from 2015 to 2019. OUTCOME MEASURES N/A METHODS All PSI generated at our institution were collected over a 57-month period. The number and type of spine-related PSI were compared before and after the implementation a clinical reviewer to identify incorrectly generated PSI. The financial impact of this intervention was also calculated. RESULTS From 2015 to 2019, a total of 1,290 PSI were reported with 140 (11%) attributable to spine surgery. Prior to implementation of a clinical reviewer, 112 PSI were reported over 40 months (2.8 PSI/month). Following implementation, 28 PSI were reported over 17 months, a statistically significant decrease by 1.2 PSI/month (p<0.000). In addition, 10 different PSI types were reported prior to, compared to six after implementation. This resulted in our organization avoiding a 1% CMS cost reduction, ranging from $3 to 4 million. CONCLUSIONS Implementation of a review process with clinician collaboration to ensure ICD-10 coding accurately reflects the medical course for a patient may lead to more precise PSI reporting, with substantial cost-savings for hospitals. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. The Hospital Acquired Conditions Reduction Program provides a financial incentive to reduce Patient Safety Indicators (PSI), defined as potentially preventable hospital-related events associated with harmful outcomes for patients. PSI are identified by ICD coding. However, ICD coding does not always reflect the true medical course of the patient. To determine if addition of a clinician to the review process results in a reduction of incorrectly generated PSI. Retrospective chart review. Patients who had spine surgery at a single institution from 2015 to 2019. N/A All PSI generated at our institution were collected over a 57-month period. The number and type of spine-related PSI were compared before and after the implementation a clinical reviewer to identify incorrectly generated PSI. The financial impact of this intervention was also calculated. From 2015 to 2019, a total of 1,290 PSI were reported with 140 (11%) attributable to spine surgery. Prior to implementation of a clinical reviewer, 112 PSI were reported over 40 months (2.8 PSI/month). Following implementation, 28 PSI were reported over 17 months, a statistically significant decrease by 1.2 PSI/month (p<0.000). In addition, 10 different PSI types were reported prior to, compared to six after implementation. This resulted in our organization avoiding a 1% CMS cost reduction, ranging from $3 to 4 million. Implementation of a review process with clinician collaboration to ensure ICD-10 coding accurately reflects the medical course for a patient may lead to more precise PSI reporting, with substantial cost-savings for hospitals.

Value-Based Care: An Executive Briefing

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape.

Identifying Leadership Practices for Success in Healthcare‐Associated Infection Prevention

Research ObjectiveHospitals face policy pressure to reduce health care–associated infections (HAIs) as part of the Hospital‐Acquired Condition (HAC) Reduction Program that financially penalizes hospitals in the lowest quartile of HAIs. While clinical approaches to reducing HAIs are well established, management practices supporting the clinical efforts are less clear. To address this gap, this study aims to identify and describe organizational approaches to facilitate HAI prevention.Study DesignWe conducted site visits at seventeen U.S. hospitals between 2017 and 2019 to interview hospital staff about management practices in place to facilitate prevention of HAIs. Using a semistructured interview guide, we asked questions primarily focused on preventing central line–associated bloodstream infections (CLABSIs) and catheter‐associated urinary tract infections (CAUTIs). Interview transcripts were coded and analyzed using a deductive dominant thematic analysis, allowing for categorization of data as well as identification of emergent themes. This approach allowed for comparison of themes across sites in order to characterize management practices important for infection prevention.Population StudiedUsing a purposive sampling approach, hospitals were invited to participate in this study. To ensure geographic variability, we attempted to recruit “pairs” of higher‐ and lower‐performing hospitals within regions, and considered variability on the basis of different organizational characteristics (ie, size and number of ICUs). Hospital performance was evaluated by comparing CLABSI and CAUTI rates to the national benchmarks acquired from 2017 to 2018 Hospital Compare data. At each site, a total of 450 people including hospital administrators, clinical leadership, infection preventionists, and frontline staff were interviewed about their experience with infection prevention.Principal FindingsAcross hospitals and across interviewees, three themes emerged as critical for management approaches to preventing HAIs: (1) leadership support; (2) meaningful rewards; and (3) goal setting. Specific tactics used by leadership included providing both financial and human resources to support infection prevention; engaging with frontline staff; maintaining visibility on units; and participating in a tiered huddle system. Leaders used several methods to recognize success in infection prevention. Rewards included positive feedback from leadership shared in person and in newsletters and emails; celebrations on units; positive recognition during huddles and staff meetings; and tangible rewards. Goals set by leaders were recognized by staff at all levels, were often reiterated at staff meetings, and reinforced with visual reminders demonstrating progress displayed on bulletin boards in break rooms.ConclusionsHospitals have limited evidence to base management approaches to preventing HAIs. Our findings identified three mechanisms through which hospitals can support HAI prevention: leadership support, meaningful rewards, and goal setting.Implications for Policy or PracticeOur findings persisted throughout levels of an organization, from the frontline to executive leaders. This prevalence suggests that management approaches to preventing HAIs should include all members of an organization and develop specific strategies that embrace the unique position of different organizational members. Additionally, our findings have important implications for the HAC Reduction Program: The evidence that incentives can motivate HAI prevention efforts suggests that the effectiveness of the policy may benefit from inclusion of inducements along with the existing penalties.Primary Funding SourceThe study was funded by the Agency for Healthcare Research and Quality.

Association Between Federal Value-Based Incentive Programs and Health Care–Associated Infection Rates in Safety-Net and Non–Safety-Net Hospitals

In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown. To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals. This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019. HACRP and HVBP implementation in fiscal year 2015 or 2016. The primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates. Of the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20). This study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.