infection control & hospital epidemiology july 2017, vol. 38, no. 7 original article
Effect of Medicare’s Nonpayment Policy on Surgical Site Infections Following Orthopedic Procedures
Jereen Z. Kwong, BA;1 Yingjie Weng, MHS;2 Micaela Finnegan, BA;1 Robyn Schaffer, BA;1 Austin Remington, BS;1 Catherine Curtin, MD;2 Kathryn M. McDonald, MM/MBA;3 Jay Bhattacharya, MD, PhD;3 Tina Hernandez-Boussard, PhD, MPH4,2
objective. Orthopedic procedures are an important focus in efforts to reduce surgical site infections (SSIs). In 2008, the Centers for Medicare and Medicaid (CMS) stopped reimbursements for additional charges associated with serious hospital-acquired conditions, including SSI following certain orthopedic procedures. We aimed to evaluate the CMS policy’s effect on rates of targeted orthopedic SSIs among the Medicare population.
design. We examined SSI rates following orthopedic procedures among the Medicare population before and after policy implementation compared to a similarly aged control group. Using the Nationwide Inpatient Sample database for 2000–2013, we estimated rate ratios (RRs) of orthopedic SSIs among Medicare and non-Medicare patients using a difference-in-differences approach.
results. Following policy implementation, SSIs significantly decreased among both the Medicare and non-Medicare populations (RR, 0.7; 95% confidence interval [CI], 0.6–0.8) and RR, 0.8l; 95% CI, 0.7–0.9), respectively. However, the estimated decrease among the Medicare population was not significantly greater than the decrease among the control population (RR, 0.9; 95% CI, 0.8–1.1).
conclusions. While SSI rates decreased significantly following the implementation of the CMS nonpayment policy, this trend was not associated with policy intervention but rather larger secular trends that likely contributed to decreasing SSI rates over time.
Infect Control Hosp Epidemiol 2017;38:817–822
Quality healthcare delivery and patient safety are a priority to all healthcare stakeholders, and recent changes in national health policies reflect this focus on quality of care. Many healthcare reforms focus on payments, such as value- purchasing programs that reward better outcomes delivered at lower costs.1 To identify target outcomes that can be monitored in such programs, the national quality forum defined several serious medical errors that are of concern to both patients and providers and are potentially preventable with focused quality improvement efforts, commonly known as “never events.”2 In October 2008, to improve patient safety and reduce
medical errors, the Centers for Medicare and Medicaid Services (CMS) implemented a policy that penalizes hospitals for certain never events occurring during hospitalization among the Medicare population. Surgical site infection (SSI) following certain orthopedic procedures was among these targeted hospital-acquired conditions (HACs). Under this new
policy, hospitals could no longer use a higher-level Medical Severity Diagnosis-Related Group (MS-DRG) denoting a complication that would result in higher reimbursements if the complication occurred after admission.3,4 Orthopedic procedures, which are among the most com-
monly performed surgical procedures in the United States,5 have become an important focus among efforts to reduce SSI rates.6 The CMS policy specifically prohibits the designation of a higher-reimbursement MS-DRG group for SSIs following spine fusion, shoulder and elbow arthrodesis and repair, and spinal refusion procedures, but it does not include more common, less invasive orthopedic procedures such as hip and knee replacements. Surgical site infection rates range from 1% to 14% for these surgeries, and spinal fusion surgeries are usually associated with a higher risk of complications and mortality due to the invasiveness of these procedures and the placement of foreign implants.7–9 Taken together, the estimated annual cost to Medicare for SSIs following these
Affiliations: 1. Stanford School of Medicine, Stanford University, Stanford, California; 2. Department of Surgery, Stanford School of Medicine, Stanford
University, Stanford, California; 3. Stanford University Center for Health Policy, Stanford, California; 4. Department of Medicine, Stanford School of Medicine, Stanford University, Stanford, California.
PREVIOUS PRESENTATION. This work was presented at the 2016 Academy Health Annual Research Meeting, Boston, Massachusetts, on June 25, 2016. © 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3807-0008. DOI: 10.1017/ice.2017.86
Received December 15, 2016; accepted April 3, 2017; electronically published May 10, 2017
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