year (FY) 2015, the Centers for Medicare & Medicaid Services (CMS) instituted the Hospital-Acquired Condition (HAC) Reduction Program, which reduces payments to the lowest-performing hospitals. However, it is uncertain whether this program accurately measures quality and fairly penalizes hospitals.OBJECTIVE To examine the characteristics of hospitals penalized by the HAC Reduction Program and to evaluate the association of a summary score of hospital characteristics related to quality with penalization in the HAC program. DESIGN, SETTING, AND PARTICIPANTS Data for hospitals participating in the FY2015 HAC Reduction Program were obtained from CMS' Hospital Compare and merged with the 2014 American Hospital Association Annual Survey and FY2015 Medicare Impact File. Logistic regression models were developed to examine the association between hospital characteristics and HAC program penalization. An 8-point hospital quality summary score was created using hospital characteristics related to volume, accreditations, and offering of advanced care services. The relationship between the hospital quality summary score and HAC program penalization was examined. Publicly reported process-of-care and outcome measures were examined from 4 clinical areas (surgery, acute myocardial infarction, heart failure, pneumonia), and their association with the hospital quality summary score was evaluated.EXPOSURES Penalization in the HAC Reduction Program. MAIN OUTCOMES AND MEASURES Hospital characteristics associated with penalization.RESULTS Of the 3284 hospitals participating in the HAC program, 721 (22.0%) were penalized. Hospitals were more likely to be penalized if they were accredited by the Joint Commission (24.0% accredited, 14.4% not accredited; odds ratio [OR], 1.33; 95% CI, 1.04-1.70); they were major teaching hospitals (42.3%; OR, 1.58; 95% CI, 1.09-2.29) or very major teaching hospitals (62.2%; OR, 2.61; 95% CI, 1.55-4.39; vs nonteaching hospitals, 17.0%); they cared for more complex patient populations based on case mix index (quartile 4 vs quartile 1: 32.8% vs 12.1%; OR, 1.98; 95% CI, 1.44-2.71); or they were safety-net hospitals vs non-safety-net hospitals (28.3% vs 19.9%; OR, 1.36; 95% CI, 1.11-1.68). Hospitals with higher hospital quality summary scores had significantly better performance on 9 of 10 publicly reported process and outcomes measures compared with hospitals that had lower quality scores (all P Յ .01 for trend). However, hospitals with the highest quality score of 8 were penalized significantly more frequently than hospitals with the lowest quality score of 0 (67.3% [37/55] vs 12.6% [53/422]; P < .001 for trend).CONCLUSIONS AND RELEVANCE Among hospitals participating in the HAC Reduction Program, hospitals that were penalized more frequently had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures. These paradoxical findings suggest that the approach for assessing hospital penalties in the HAC Reduction Pro...

a given incentive program. The CVS Caremark employees and their relatives and friends were randomly assigned to one of four incentive programs or usual care for smoking cessation. Two of the incentive programs targeted individuals and two targeted groups of six participants. One of the individual oriented programs and one of the group oriented programs entailed rewards of approximately $800 for smoking cessation, the other entailed refundable deposits of $150 þ $650 in reward payments for successful participants. Usual care was informational resources and free smoking cessation aids. A total of 2538 participants were enrolled. Of patients assigned to reward based programs, 90.0% accepted the assignment as compared with 13.7% of those assigned to deposit programs (P < .001). Attention to treat analysis showed that rates of sustained abstinence from smoking through six months were higher with each of the four incentive programs (range, 9.4-16.0%) than with usual care (6.0%; P < .05 for all comparisons). Superiority of rewards based programs was sustained through 12 months. Group oriented and individual oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P ¼ .29). Reward based programs were associated with higher abstinence rates than deposit based programs (15.7% vs 10.2%; P < .001). Rate of abstinence at six months was 13.2% (95% confidence interval, 3.1-22.8); higher in deposit based programs than reward based programs.Comment: The analysis indicates that incentive programs for smoking cessation that are financially based can be successful but that those programs that ask the participant to put their own money at risk are less effective overall than reward based programs because far fewer people accept the deposit programs placing their own money at risk. However, once that money is at risk, deposit based incentives are as effective as pure reward based incentives. Long term abstinence rates with such programs and whether incentives must be ongoing to help to maintain abstinence is unknown.

Nodal evaluation rates are highest among certain expected subtypes but are generally low. However, nodal metastasis rates for many histologic subtypes in patients selected for lymph node evaluation may be higher than previously reported. Multi-institutional studies should address nodal evaluation for ESTS.