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Teaching Hospital Update - October 17-21, 2011

Email Alert
October 21, 2011
By Allison Cohen*

CDC: Hospitals Report "Impressive" Drop in Healthcare Infections

Central line infections--which are associated with tubes placed in the neck or chest of a hospital patient to deliver important medicines--dropped by 33% in 2010, according to an analysis announced Wednesday by the Centers for Disease Control and Prevention (CDC). The agency also reported a 10% drop in surgical site infections, and a 7% decline in hospital infections associated with catheters inserted in the urinary tract. And the number of people who contracted methicillin-resistant Staphylococcus aureus (MRSA) infections from healthcare facilities declined by 18%.

The findings suggest that healthcare services can be retooled in a way that improves safety and lowers costs when the public and private sectors unite on achieving specific goals. CDC Director Thomas Frieden said in a news release that hospitals "continue to make impressive progress in driving down certain infections in intensive care units through implementation of CDC prevention strategies."

Declines weren't limited to intensive care units (ICUs), but Frieden said that in general hospitals and state health departments need to do more to extend progress in ICU units to other areas of healthcare delivery and to other types of healthcare infections. He cited as examples dialysis and ambulatory surgery centers and diarrheal infections such as clostridium difficile.

Central line infections are particularly serious because they involve patients who are critically or seriously ill. These infections occur when the central line tube is inserted improperly or isn't kept clean. When that happens, "central lines can become a freeway for germs to enter the body and cause serious bloodstream infections," the CDC news release said.

Frieden revealed the findings at a policy forum in Washington, DC, sponsored by the National Journal. Based on CDC work with Pennsylvania hospitals and an easy-to-follow checklist developed out of Johns Hopkins University, CDC recommendations have spurred hospital staff to take a variety of steps to prevent the infections, she added. Hospitals that carefully follow the checklist have reduced the infections by 70%.

And CMS now requires hospitals that have a central line infection to report it to the agency as part of an emerging program under the health law to lower Medicare payments when healthcare-associated infections occur. The agency's voluntary "Partnership for Safety" program launched this year seeks to widen improvements in reducing infections and enhancing safety.

John Reichard, CDC: Hospitals Report 'Impressive' Drop in Healthcare Infections, CQ Healthbeat News (Oct. 19, 2011).

U.S. Moves to Cut Back Regulations on Hospitals

The Obama Administration moved Tuesday to roll back numerous rules that apply to hospitals and other healthcare providers after concluding that the standards were obsolete or overly burdensome to the industry. Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, said the proposed changes, which would apply to more than 6,000 hospitals, would save providers nearly $1.1 billion a year without creating any "consequential risks for patients."

Under the proposals, issued with a view to "impending physician shortages," it would be easier for hospitals to use "advanced practice nurse practitioners and physician assistants in lieu of higher-paid physicians." This change alone "could provide immediate savings to hospitals," the administration said.

Other proposals would roll back rules for doctors' offices, kidney dialysis centers, organ transplant programs, outpatient surgery centers, and institutions for people with severe mental disabilities.

In January, President Obama ordered his appointees to modify or revoke rules that were outmoded, ineffective, or "excessively burdensome." Republicans in Congress have demanded such changes, arguing that many federal rules have stifled economic growth and job creation.

Many of the new proposals deal with Medicare and Medicaid rules that have not been altered in decades. In general, the proposals do not affect the large number of rules issued under the new healthcare law, which set detailed standards for coverage offered by insurance companies and employers.

One of the new proposals would allow hospital patients to take certain drugs on their own, with the approval of hospital officials but without immediate supervision by a nurse. A hospital may allow a patient to "self-administer both hospital-issued medications and the patient's own medications brought into the hospital," the proposal says. In the past, hospitals have often restricted patients' ability to give medications to themselves.

Another proposal would relax requirements for hospitals to notify the federal government immediately after the death of any patient who had been confined with certain wrist restraints like those used to prevent patients from harming themselves by pulling out intravenous tubes.

Under current rules, each hospital must have its own governing body, which is legally responsible for its operations. Under the proposal, a multi-hospital system could have a single governing body for all its hospitals. The administration will accept public comments on the proposals for sixty days and will review the comments before issuing final rules with the force of law.

Robert Pear, U.S. Moves to Cut Back Regulations on Hospitals, The New York Times (Oct. 19, 2011).

Study Finds Hopeful Sign: Hospital Stays for Heart Failure Fall 30% During Decade

Hospital stays for heart failure fell a remarkable 30% in Medicare patients over a decade, the first such decline in the United States and forceful evidence that the nation is making headway in reducing the billion-dollar burden of a common condition.

But the study of fifty-five million patients, the largest ever on heart failure trends, found only a slight decline in deaths within a year of leaving the hospital, and progress lagged for black men. "While heart failure hospitalizations have decreased nationally overall, certain populations haven't seen the full benefit of that decrease," said the lead author from Yale University School of Medicine.

Possible explanations for the decline in hospital stays abound, including healthier hearts, better control of risk factors like high blood pressure, and more patients treated in emergency rooms and clinics without being admitted to hospitals, said the medical director of the Penn Heart and Vascular Center in Philadelphia.

Fewer hospital stays saves Medicare a lot of money because heart failure is the most common cause of hospitalization in older patients. From 1998-2008, the rate fell from 2,845 hospitalizations per 100,000 Medicare beneficiaries to 2,007 per 100,000, according to research appearing in Wednesday's Journal of the American Medical Association. If the rate had remained the same, there would have been 229,000 more heart failure hospital stays in 2008 at an additional cost to Medicare of $4.1 billion, said the lead author.

Other reasons for declining hospital stays may include specialized pacemakers and better use of medications such as ACE inhibitors that relax blood vessels, diuretics that prevent fluid buildup, digoxin that boosts heartbeat strength, and beta blockers that ease strain on the heart.

Study Finds Hopeful Sign: Hospital Stays for Heart Failure Fall 30% During Decade, The Washington Post (Oct. 18, 2011).

Medicare Releases Patient Safety Ratings for Hospitals

Medicare has begun publishing patient safety ratings for thousands of hospitals as the first step toward paying less to institutions with high rates of surgical complications, infections, mishaps, and potentially avoidable deaths.

The new data, available starting last week on Medicare's Hospital Compare website, evaluate hospitals on how often their patients suffer complications such as a collapsed lung, a blood clot after surgery, or an accidental cut or tear during treatment. The measures also include specific death rates for patients who had breathing problems after surgery, had an operation to repair a weakness in the abdominal aorta, or had a treatable complication after an operation.

In addition, Hospital Compare is evaluating rates of some specific medical errors, such as giving patients the wrong type of blood, leaving surgical implements in patients' bodies during surgery, and falls that occur during their stay.

The evaluations are part of Medicare's broad move from paying hospitals a set amount for each procedure. That change was directed by last year's healthcare law, which set up new "value-based purchasing program" that will begin in October 2012. Over time, hospitals with the lowest quality--as judged by a variety of metrics, not just the new patient safety measures--will be at risk to lose up to 2% of their regular Medicare reimbursements under the health law.

The new data on patient safety moves Medicare further along toward its ultimate goal, which is to base payments on the actual medical outcomes for patients. To rate hospitals, Medicare is comparing them to the national rates for medical complications and hospital-acquired conditions. For instance, on average, 2.1 out of every 1,000 patients discharged suffered an accidental cut and tear from medical treatment. Out of one-hundred patients, 4.4 on average died after surgery to repair a weakness in their abdominal aorta.

By looking at how a hospital compares to the national average on this and other complication statistics, Medicare has come up with overall evaluations of how good hospitals are at avoiding complications and hospital-acquired conditions. Medicare is aiming to incorporate the new patient safety data into payments in the second year of the program.

Making this information public has been long favored by patient safety advocates. "This is pulling the curtain back on preventable healthcare harm to older Americans," said Rosemary Gibson, co-author of The Treatment Trap and editor of a series of articles on overtreatment in the Archives of Internal Medicine. "These are really good things to know. We are really getting into the meat of what can happen to patients in hospitals."

But the latest data is intensifying objections from the hospital industry and some academic researchers that Medicare is using dubious and unfair measurements in ways that will hurt some hospitals, particularly those with sicker patients. The data is based on billing claims that hospitals submit to the government, not clinical medical records. One concern held by hospitals and researchers is that hospitals categorize the same things differently when billing Medicare, skewing comparisons.

The head of advocacy for the Association of American Medical Colleges that represents teaching hospitals, said some of Medicare's measures also make teaching hospitals look worse. "If you're not appropriately risk-adjusting on this, you're already selecting a patient population that's more likely to die," he said. "That's why they come to us, because other people are reluctant to operate on those complex cases."

Jordan Rau, Medicare Releases Patient Safety Ratings for Hospitals, Kaiser Health News (Oct. 17, 2011).

Tough to Predict Who'll Wind Up Back in the Hospital

Hospital readmission risk prediction models--both administrative and clinical--generally perform poorly, a systematic review showed.

The models are used to assess the risk of readmission for the purposes of comparing hospital performance or for targeting high-risk patients for interventions to keep them out of the hospital. Of twenty-six models examined, only a handful met the threshold for at least modest or acceptable discriminative ability, according to a doctor at the Portland VA Medical Center in Oregon, and colleagues.

The poor performance was found in both types of models, administrative and clinical, they reported in the October 19, 2011, issue of the Journal of the American Medical Association.

"The poor discriminative ability of most of the administrative models we examined raises concerns about the ability to standardize risk across hospitals to fairly compare hospital performance," the author and colleagues wrote. "Until risk prediction and risk adjustment become more accurate, it seems inappropriate to compare hospitals in this way and reimburse (or penalize) them on the basis of risk-standardized readmission rates."

The clinical models also had low predictive ability, with some evidence that adding social or functional factors enhanced performance.

Through a literature review, the researchers identified thirty studies that evaluated twenty-six unique readmission risk-prediction models in both a derivation and validation cohort. Most of the studies (twenty-three) were conducted in the United States, with the rest from Australia, Canada, Ireland, Switzerland, or the U.K.

"[R]eadmission risk prediction remains a poorly understood and complex endeavor," the author and colleagues wrote.

It is likely, they added, that hospital and health-system-level factors not found in current risk models may influence the risk of readmission. These factors include:

  • Timeliness of postdischarge follow up;
  • Coordination of care with primary care physicians;
  • Quality of medication reconciliation;
  • Supply of hospital beds; and
  • Quality of inpatient care.

However, they noted that "although the inclusion of such hospital-level factors would conceivably improve the predictive ability of models, it would be inappropriate to include them in models that are used for risk-standardization purposes. Doing so would adjust hospital readmission rates for the very deficits in quality and efficiency that hospital comparison efforts seek to reveal, and which could be targets for quality improvement interventions."

The authors acknowledged that the study was limited in that the applicability of findings from foreign studies to the United States was questionable and by the paucity of studies directly comparing models within the same population.

Todd Neale, Tough to Predict Who'll Wind Up Back in Hospitals, MedPage Today (Oct. 19, 2011)

*We would like to thank Allison Cohen, Esquire (Washington, DC), for providing this week's update.

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.

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