Sometimes, The Stick Doesn’t Work

Pressure ulcers, catheter-associated UTIs, central-line infections, and injuries from falls are all iatrogenic injuries associated with healthcare and hospitalization.  Fewer of all these events would be ideal.

Of course, since asking nicely isn’t much of a motivation for healthcare delivery systems to improve practice, Medicare had a different solution – non-payment.  In 2008, Medicare ceased allowing hospitals to claim higher severity diagnosis related group codes to account for costs incurred by eight “never event” complications.  Money, on the other hand, is a strong motivator for change.  This study tries to evaluate just how successful such a heavy stick is at influencing care delivery.

These authors looked at the National Database of Nursing Quality Indicators, counting reported ulcers, falls, CLABSI, and CAUTI occurring between 2006 and 2010.  The trends reported for each differ starkly.  For CLABSI and CAUTI, in the quarters leading up to CMS policy change, the prevalence of each was gradually increasing.  After 2008, however, both trends show abrupt and consistent reversal and downward movement.  For pressure ulcers and injurious falls, however, the prevalence was gradually decreasing at the time of CMS policy implementation, and the slope of the line after 2008 is consistent with that same gradual decline.

The authors go into the limitations of each data source, but, the general takeaway is likely still valid – some “never events” just aren’t consistently, systematically preventable.  There are concerted, teachable best-practices involved with decreasing CLASBI and CAUTI.  Fall prevention and pressure ulcer prevention, on the other hand, are less amenable to care bundles, and seem to depend on gradual cultural changes and vigilance.  Thus, while outcomes-focused quality improvement using a financial motivator, while a reasonable method to try, will probably have the greatest impact and yield where a validated, evidence-based strategy can be implemented.

“Effect of Medicare’s Nonpayment for Hospital-Acquired Conditions Lessons for Future Policy”