effect of cms nonpayment policy on ssi 821
30 days after surgery and would not be identified in the index admission.27,28 Under the CMS nonpayment policy, which targets only index admissions, most of orthopedic SSIs would not be penalized.13 However, in our sensitivity analyses, which included SSI that occurred within 30 days post- discharge, results were similar to our main analyses that demonstrated significantly reduced rates for both Medicare patients and the control group following the CMS nonpay- ment policy, yet the policy itself was not associated with reduced rates of SSI in the targeted population compared to the unaffected control group. Finally, we considered the possibility that the CMS non-
payment policy might have spillover effects to the non- Medicare population and thus could be associated with reduced rates of SSI in the pre- versus postpolicy period in both the Medicare and non-Medicare control populations. Hospital guidelines and prevention strategies for SSI would not be payer specific and would likely benefit non-Medicare patients aswell, even though previous studies on other targeted HACs suggested that younger non-Medicare patients might not necessarily benefit from this policy.19 However, this sig- nificant change in the SSI rates between the pre- versus post- policy periods in both Medicare and non-Medicare groups was not robust across our sensitivity analyses; analysis using all- capture SID data did not show significant rate changes in any group. Thus, this difference could be due to potential con- founding variables in the sample population. We could not conclude from our findings that the CMS nonpayment policy had a significant impact on both groups and, thus, the lack of a significant difference-in-difference effect. It is more likely that the decrease in SSI rates for both Medicare and non-Medicare populations is due to larger environmental trends driving an overall change in hospital culture related to infections and the concurrent emphasis on patient safety. Nevertheless, because of concerns for spillover effects into non-Medicare popula- tions, we also ran sensitivity analyses with different control groups, including 60–80-year-old patients with Medicare that underwent orthopedic procedures not targeted by Medicare, and we found similar results. This study had several limitations. First, we used a non-
randomized design that cannot prove that the CMS policy caused any differences in SSI rates between the 2 populations. However, we ran extensive sensitivity analyses with a carefully selected control population adjusting for various patient
demographics, which should have reduced the chance that our findings were affected by unobservable confounding factors. While we were limited in our knowledge of how hospitals implement interventions—SSI prevention efforts might have
reduce the risk of infection.24,25 Furthermore,most US hospitals are compliant with the Surgical Care Improvement Project (SCIP), which has identified processes of care to improve sur- gical outcomes.26 Given the numerous prevention strategies in place for all populations, the additional effect of CMS policy in Medicare patients might be minimal. Furthermore, most SSIs occur after discharge but within
improved for both nontargeted and targeted procedures, for example—we did not see a significant reduction in SSI rates for the group undergoing nontargeted procedures. Second, we used administrative data in our study, which might not have differentiated between changes in coding practice and true SSI incidence. Although there have been concerns about under- reporting,29 chart review conducted by CMS for other HACs found minimal discrepancies between administrative and chart data.30 Furthermore, ICD-9-CMcoding in NIS data has also been estimated to be ~80% accurate.31 Third, in the final model, we chose to report unweighted results to reduce type 1 error, as others have done.19 However, our results were robust in the sensitivity analyses, where we tested our models in all- capture state databases. Overall, our findings are consistent with previous studies investigating at other targeted HACs, which also showed minimal to no significant changes in HAC rates following the policy implementation. Studies examining other SSIs after cardiac (ie, mediastinitis) and bariatric surgeries found no significant policy impact on SSI rates.29,32 Nevertheless, some studies have shown significant decreases in the rates of several targeted HACs, suggesting that the impact might be outcome specific and dependent on the availability of proper evidence- based guidelines for prevention.19,33 In conclusion, the CMS nonpayment policy can play
an important role in directing the attention of healthcare providers toward the need to eliminate these serious hospital- acquired complications. However, the limitations of the current policy likely contribute to its minimal effect on reducing SSI rates; the policy does not capture a majority of SSIs that occur postdischarge. AsCMS continues to expand on its programs to reduce HACs,34 it is important to evaluate the policy’s design and effectiveness in achieving intended outcomes for patients.
acknowledgments
The Stanford MedScholars program and the National Institute on Aging had no role in the design and conduct of the study; collection, manage- ment, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Potential conflicts of interest: All authors have no conflicts of interest to
disclose.
Financial support: Funding for this study was provided by the funders of Stanford MedScholars program. Dr Bhattacharya was partially funded by the National Institute on Aging (grant no. R37-AG036791).
Address correspondence to Tina Hernandez-Boussard, Department of
Medicine (Biomedical Informatics), Stanford School of Medicine, 1265 Welch Road, Stanford, CA 94305-5479 (
boussard@stanford.edu).
references
1. VanLare JM, Conway PH. Value-based purchasing–national programs to move from volume to value. N Engl J Med 2012;367:292–295.
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