Patient Safety Tip of the Week
December 18, 2012
Unintended Consequences of the CAUTI Measure?
We’ve long been staunch supporters of the CAUTI pay-for-performance (P4P) measure. Avoiding CAUTI’s was one of our very first quality improvement projects on a neurology service way back in the 1980’s. The key to success is obviously avoiding unnecessary use of indwelling urinary catheters and limiting duration in those cases where such originally has a legitimate indication. So we were on board when CMS began its program of nonpayment for CAUTI’s. But now, multiple years into the CMS program, we’re beginning to see that there may be unintended consequences of continuing to use CAUTI as a P4P measure.
In our November 2012
What’s New in the Patient Safety World column “CAUTI
Conundrum” we pointed out a recent article (Lee 2012) that
concluded that the financial disincentive of CMS’ nonpayment policy for
hospital-acquired conditions did not lead to lower rates of CAUTI. Rates for
CAUTI’s were already declining prior to CMS’ implementation of its
reimbursement policy. Specifically, for CAUTI’s the preimplementation decline
was 3.9% per quarter and only 0.9% per quarter afterward.
Though we discussed
many potential explanations for this, we think that it simply reflects that we
were already targeting CAUTI’s long before CMS implemented their policy so
there was little change in CAUTI rates before and after implementation.
But in that column
we cautioned that when we implement “evidence-based” quality
pay-for-performance metrics we sometimes find out later that either the evidence
was not so strong or that we get unintended consequences. We think that the
evidence base for preventing CAUTI’s is strong. But what about the
unintended consequences? We noted that 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.
The U.S. Preventive
Services Task Force Guideline on Screening for Asymptomatic Bacteriuria in Adults
(USPSTF
2008) recommends against screening in men and nonpregnant women. The USPSTF
does recommend screening for asymptomatic bacteruria in pregnant women at 12-16
weeks’ gestation or at the first prenatal visit, if later. Other indications
include those undergoing invasive urological procedures where mucosal bleeding
is likely and possibly surgical procedures with implant material (Wagenlehner
2005, Nicolle
2005).
Even though treatment
of asymptomatic bacteruria is not recommended in most circumstances we have
seen multiple hospitals in which urine cultures are done on admission so that
if the patient later develops a UTI following an indwelling urinary catheter
the hospital can say this was “present on admission” and not have to report it
as a CAUTI. Some of those patients do get antibiotic treatment for their
asymptomatic bacteruria. And while there is little evidence of a beneficial
effect of treatment in such cases, the treatment has the potential to have
adverse effects.
The Infectious
Diseases Society of America (IDSA) guidelines note that potential unintended
consequences of treatment of asymptomatic bacteriuria include subsequent
antimicrobial resistance, adverse drug effects, and cost (Nicolle
2005). Other potential unintended consequences would be increased hospital
lengths of stay, delays in procedures, and the potential for diarrhea and C.
difficile infections.
Now a new study (Drekonja
2012) makes us further question whether the CAUTI measure (as either a
patient safety measure or P4P measure) may be inadvertently leading to other
unintended and unwanted complications. The authors did a retrospective review
of urine culture practices preoperatively in patients undergoing nonurologic
surgeries in a VA hospital setting. In 25% of the surgeries a urine culture was
obtained prior to surgery, though the frequency varied greatly by the service
involved. Bacteruria was detected in 11% of these cultures though in most cases
it was not treated. However, when they compared those patients in whom the
preop bacteruria was treated with antibiotics vs. those not treated, the
results were unexpected. The treated group had higher rates of surgical site
infections (SSI’s) and higher rates of post-op UTI’s.
The above study had
relatively small numbers and there may have been confounding factors (eg. were
factors that led to the decision to treat the preoperative bacteruria also ones
that led to higher rates of SSI’s?). So the study is not a definitive one but
rather a hypothesis-generating one. A larger prospective study would need to be
done. If it does turn out that obtaining urine cultures on admission in
asymptomatic patients leads to unnecessary antibiotic treatment and that the
treatment leads to an increase in post-op infections we clearly have an
unintended consequence of the CMS metric of CAUTI as a never event. Thus, it
may be time to retire CAUTI as the CMS metric. A more appropriate metric might
simply be the percentage of urinary catheters meeting appropriateness criteria.
Continued focus on
avoiding CAUTI’s is the right thing to do from a quality and patient safety
perspective regardless of whether P4P or nonpayment policies are in effect or
not. However, we need to make sure that using CAUTI’s as a P4P metric or flag
for nonpayment is not causing more harm than good. The time may have come to
retire the CAUTI metric.
Our other columns on urinary catheter-associated UTI’s:
- May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
- January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
- April 2008 What’s New in the
Patient Safety World column “More
on Nosocomial UTI’s”
- June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
- April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
- June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
- March 2010 “IDSA
CAUTI Guidelines”
- February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
- January 2012 “CAUTI’s
Still Get No Respect”
- May 2012 “Foley
Catheter Hazards”
- November 2012 “CAUTI Conundrum”
References:
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
http://www.nejm.org/doi/full/10.1056/NEJMsa1202419
U.S. Preventive
Services Task Force (USPSTF). Screening for Asymptomatic Bacteriuria in Adults.
July 2008
http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm
Wagenlehner FME,
Naber KG, Weidner W. Asymptomatic Bacteriuria in Elderly Patients: Significance
and Implications for Treatment. Drugs & Aging 2005; 22(10): 801-807
Nicolle LE, Bradley S,
Colgan R, et al. Infectious Diseases Society of America Guidelines for the
Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clinical
Infectious Diseases 2005; 40: 643–54
Drekonja DM,
Zarmbinski B, Johnson JR, et al. Preoperative Urine Cultures at a Veterans
Affairs Medical Center. Arch Intern Med 2012; (): 1-2
Published online
December 2012
http://archinte.jamanetwork.com/article.aspx?articleid=1470566
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