The world of quality metrics is supposed to be coalescing around data that all stakeholders agree leads to higher quality care, better outcomes, and improved patient safety. But according to a study in the July 25 issue of the Journal of the American Medical Association, hospitals that do well in a variety of quality metrics and those that are accredited by The Joint Commission or other accrediting organizations are more likely to be found wanting in the CMS HAC Reduction Program and are more likely to be penalized 1% of their Medicare reimbursement for poor performance.
The authors created an eight-point quality score based on items that have been shown in peer-reviewed literature to relate to high-quality care. One point was awarded for each of the following1:
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the highest quartile of inpatient admission volume,
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accreditation by The Joint Commission,
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accreditation by the Commission on Cancer,
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whether the facility provides transplant services,
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level of trauma center,
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the highest quartile of nurse-to-bed ratio,
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membership in the Council of Teaching Hospitals, and
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participation in a clinical surgery registry.1
Along with this eight-point score, the authors looked at Hospital Compare data related to outcomes and process of care measures for pneumonia, heart failure, surgery, and heart attack patients. The measures from those included in the study were1:
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For heart attack patients, those prescribed a statin at discharge.
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For heart failure patients, those who received discharge instructions, and those with left ventricular systolic dysfunction who received ACE-inhibitors are angiotensin receptor blockers.
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For pneumonia patients, those given the right initial antibiotics.
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For surgical patients (depending on the type of surgery performed), preoperative beta blockers continued post-surgically, prophylactic antibiotics discontinued within 24 hours of surgery, and/or catheter removed within two days post-operatively.
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Outcomes measures included 30-day mortality rates used in the CMS Value-based Purchasing Program for acute myocardial infarction (AMI), heart failure, and pneumonia in 2015.1
The composite score and the measures from Hospital Compare were used to compare hospitals with the list of those that were penalized under the HAC reduction program — 721 of the 3,284-plus hospitals studied by the authors. The characteristics of the penalized facilities were shocking:
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Larger hospitals (35.4% vs. 13.5%)
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Those accredited by the Joint Commission (24% vs. 14.4%)
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Those with the highest nurse-to-bed ratio vs. lowest (29.3% vs. 17.4%)
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Level 1 trauma center vs. non level 1 (47.4% vs. 19.1%)1
To continue the counterintuitive findings: 17% of non-teaching hospitals, 42.3% of major teaching hospitals, and 62.2% of major teaching hospitals were penalized, the authors found. Hospitals with more complex patients to care for were also more likely to be penalized.1
The quality summary score that authors gave to hospitals, which is based on items long-held to signal quality, also showed an inverse relationship to penalties under the HAC reduction program. “Although hospitals with higher hospital quality summary scores had better performance on 9 of 10 publicly reported process and outcome measures evaluated,” the study notes, “they were penalized significantly more frequently in the HAC Reduction Program than those with lower hospital quality summary scores.”1
The big question is why. The authors suggest that the HAC program doesn’t reflect the poor quality it seeks to change, and that there could be issues with the metrics selected and problems within some of the specific measures.
Among the concerns they mooted in the report: surveillance bias — those hospitals that are looking for problems like venous thromboembolism (VTE) are more likely to find it, and the more cases you find, the more likely you are to be penalized. In addition, the hospitals most likely to find more cases of VTE are those accredited by The Joint Commission (or any other accreditor), those who have a good nurse-to-patient ratio, and those with a higher complexity of patient.1
Similarly, those hospitals that participate in surgical registries may have more robust standardized procedures for gathering data and identifying adverse events, which makes them more likely to be penalized, the authors say. Another element could be that very small hospitals with few discharges in specifically targeted conditions don’t have their own data used, but a national average, which makes them look better, perhaps, than they are, and larger hospitals worse.1
“We suspected there were some issues with the program, but the findings were surprising,” says study author Karl Bilimoria, MD, MS, vice chair for quality for Northwestern Medicine and director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine in Chicago. “We did not expect there to be such a paradoxical relationship between factors reflecting hospital quality and penalization in the HAC Reduction Program. It may actually be capturing the inverse of quality.”
If the HAC isn’t capturing quality, but instead has a set of flawed measures that are merely leading hospitals to incur penalties, what should quality departments do?
Bilimoria says that they should take a closer look at the issues raised in the study and “see if you aren’t simply chasing metrics and employing time-consuming quality improvement efforts where you don’t really have a problem.”
Whether CMS acts on this information remains to be seen.
For more information on this topic, contact Karl Bilimoria, MD, MS, Vice Chair for Quality, Northwestern Medicine, Director, Surgical Outcomes and Quality Improvement Center, Northwestern University, Feinberg School of Medicine, Chicago, IL. Telephone: (312) 695-4853. Email: [email protected].
REFERENCE
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Rajaram R, Chung JW, Kinnier CV, Bilimoria KY et al. Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. JAMA. 2015; 314(4):375-383. doi:10.1001/jama.2015.8609
