Data was recently published regarding the impact of implementation of CMS’ nonpayment policy for hospital-acquired conditions in 2008 (Lee 2012). The authors concluded that the financial disincentive did not lead to lower rates of certain hospital-acquired conditions. Rates for these complications were already declining prior to CMS’ implementation of its reimbursement policy. Specifically, for CLABSI’s there had been a significant 4.8% decline per quarter prior to implementation and 4.7% afterward. For CAUTI’s the preimplementation decline was 3.9% per quarter and only 0.9% per quarter afterward.
There are many possible explanations for the slowing of the decline in CAUTI rates. Yes, there may have been some game playing and undoubtedly many patients were getting urinalyses and urine cultures on admission to demonstrate that the UTI was already present on admission. That, of course, means a whole lot of patients also likely received unnecessary treatment for asymptomatic bacteruria. But we think that it simply reflects that we were already targeting CAUTI’s long before CMS implemented their policy.
We have long focused on preventing CAUTI’s (see the list below of our multiple prior CAUTI columns) and many organizations had preventive programs in place well before 2008 (though Sanjay Saint and others have noted previously the absence of good programs and practices in many hospitals).
But, to complicate matters, Owen et al. (Owen 2012) recently reviewed the relationship between compliance with SCIP measure Inf-9 and CAUTI rates. SCIP Inf-9 is the measure for discontinuation of indwelling urinary catheters within 48 hours in patients undergoing surgery. They found that compliance with SCIP Inf-9 increased substantially over time, reaching about 90%, but that there was no correlation with improved monthly UTI rates. In their analysis they found that CAUTI rates were actually very low in patients in whom the catheter was removed in less than 48 hours. However, most of the UTI’s occurred in patients “exempted” from the measure. In fact, the odds ratio of developing a postoperative UTI was 8 times higher for patients exempted from SCIP Inf-9. While there are a number of reasons a surgeon can specify to qualify for such exemptions, the most common one in this study was presence of an epidural catheter.
The authors conclude that the high rate of CAUTI’s in “exempt” patients actually supports continuation of the SCIP Inf-9 measure but that the exemptions need to be modified.
While there are undoubtedly some surgeons (and some CFO’s!) who will use these studies to call for elimination of the SCIP Inf-9 measure, we think that continued focus on preventing CAUTI’s is still of great importance from both a patient quality perspective and healthcare cost perspective.
When we implement “evidence-based” quality pay-for-performance metrics we sometimes find out later that the evidence was not so strong and we often get unintended consequences. Remember the metric of antibiotics within 4 hours of arrival in the ER for pneumonia patients? That led to numerous patients who turned out not to have pneumonia getting unnecessary antibiotics. It would be interesting to see how many patients got unnecessary antibiotics for asymptomatic bacteruria because of the CMS nonpayment policy for CAUTI’s. If the latter rate is high that might be a reason to change the metric. But continued focus to avoid CAUTI’s is the right thing to do regardless of whether nonpayment policies are in effect or not.
But surgeons may not be the only ones paying less attention to CAUTI prevention. Another new study has found that a surprising lack of attention to CAUTI prevention policies and procedures in many ICU’s (Conway 2012). Less than a quarter of ICU’s responding to a survey had policies regarding use of bladder ultrasound or condom catheters. Even fewer used catheter removal reminders or nurse-initiated catheter removal protocols. Ironically, smaller hospitals generally did better than large hospitals in adopting at least one CAUTI prevention strategy.
Our other columns on urinary catheter-associated UTI’s:
Lee GM, Kleinman K, Soumerai SB, et al. Effect of Nonpayment for Preventable Infections in U.S. Hospitals. N Engl J Med 2012; 367: 1428-1437
Rachel M. Owen RM, Perez SD, Bornstein WA, Sweeney JF. Impact of Surgical Care Improvement Project Inf-9 on Postoperative Urinary Tract InfectionsDo Exemptions Interfere With Quality Patient Care? Arch Surg. 2012; 147(10): 946-953
Conway LJ, Pogorzelska M, Larson E, Stone PW. Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units. Amer J Inf Control 2012; 40(8): 705-710, October 2012
Print “PDF version”