In the focus on improving health care quality, an area that seems easy to target are conditions or problems acquired in the course of receiving health care services. These conditions can include infections, falls, surgical mistakes, etc. Hospitals, for example, often host some of nature’s nastiest bugs, many of which have evolved resistance to almost all antibiotics. Because infections can cause death and serious illness for patients, they are usually included in performance measurement programs and in hospital never-event non-reimbursement initiatives, along with other hospital-acquired conditions. An Agency for Healthcare Research and Quality Statistical Brief examines hospital-acquired conditions for adults in the year 2008 in a sample of over 1300 hospitals from 15 states. (AHRQ Report)
In over 12 million discharges, there were 23,219 HACs, a much less than one percent rate. Blood infections due to a catheter in a large central vein were the leading cause of an HAC, followed by falls, catheter-associated urinary tract infection, manifestations of poor glycemic control and pressure ulcers. For surgeries the leading HACS were deep vein thrombosis and surgical site infection. Sixty-two percent of the HACs occurred in Medicare patients, 12% in Medicaid ones and 21% in privately insured patients. For comparison, Medicare represented 53% of discharges, Medicaid 12% and private insurance 26%. So Medicare sees more than its share of HACs, but this may be due to population characteristics and the types of services delivered to this population.
For example, falls are over-represented in the Medicare population, as are pressure ulcers. In general, older people have a higher rate of HACs than their presence in the rate of hospitalizations would suggest, again probably due to the different health status and services for that age group. An interesting aspect of the never-event payment policy in regard to hospital-acquired conditions is that if the condition was present-on-admission, it is not by definition hospital-acquired, so hospitals can be expected to put substantial effort into identifying all aspects of a patient’s condition when admitted and to be thorough in identifying all such conditions on coding on bills submitted to Medicare and other payers. Undoubtedly these policies will also create some unintended consequences.