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#Grand Rounds

Does Penalizing Hospitals for Acquired Conditions Actually Lead to Performance Improvements?

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BACKGROUND AND PURPOSE:

  • The Hospital Acquired Condition Reduction Program (HACRP) was created to incentivize hospitals to reduce hospital-acquired conditions
    • Acute care hospitals that fall in the bottom quarter lose 1% of Medicare payments
  • Sankaran et al. (BMJ, 2019) assessed the association between hospital penalization in the HACRP, and impact on clinical outcomes

METHODS:

  • Retrospective cohort (Beginning of review and correction period July 23, 2014 through November 30, 2016)
    • Regression discontinuity design, comparing similar hospitals immediately above and below the penalty threshold
    • Data derived from inpatient Medicare claims
    • Acute care hospitals in the US
  • Participants
    • Medicare fee-for-service beneficiaries discharged from acute care hospitals
    • ‘Targeted’ acquired condition based on AHRQ Patient Safety Indicator-90 composite (e.g., central line infections, DVT, post-op sepsis etc.)
  • Intervention
    • Penalty in the first year of the HACRP: Hospital acquired conditions score ≥7.025 were penalized with a 1% payment reduction  
  • Primary outcomes
    • Mean counts of targeted hospital acquired conditions per 1000 care episodes
    • 30-day readmissions
    • 30-day mortality

RESULTS:

  • 3,238 acute care hospitals | 708 penalized hospitals included in the study | 15,470,334 discharges (Medicare beneficiaries)
  • Mean counts of hospital acquired conditions
    • Penalized hospitals: 2.72 per 1,000 care episodes
    • Non-penalized hospitals: 2.06 per 1,000 care episodes
    • Most common hospital acquired conditions among all study hospitals: Perioperative pulmonary embolism or DVT
  • 30-day readmissions
    • Penalized hospitals: 14.4%
    • Non-penalized hospitals: 14.0%
  • 30-day mortality was
    • Penalized hospitals: 9.0%
    • Non-penalized hospitals: 9.0%
  • Penalized hospitals were more likely to be
    • Large, teaching institutions
    • Greater share of patients with low socioeconomic status
  • HACRP penalties were not associated with statistically significant improvements for the following
    • Hospital acquired conditions per 1000 care episodes: −0.16 (95%, CI −0.53 to 0.20)
    • 30-day readmission: −0.36 percentage points (95% CI, −1.06 to 0.33)
    • 30-day mortality: −0.04 percentage points (95% CI, −0.59 to 0.52)

CONCLUSION:

  • Based on the study results, HACRP is not associated with clinical improvements
  • The authors state that aside from not driving improved care

By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care

Learn More – Primary Sources:

Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study

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