Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study

Abstract

Objective To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes. Design Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims. Setting 3238 acute care hospitals in the United States. Participants Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334). Intervention Hospital receipt of a penalty in the first year of the HACRP. Main outcome measures Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality. Results Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of −0.16 hospital acquired conditions per 1000 episodes (95% confidence interval −0.53 to 0.20), −0.36 percentage points in 30 day readmission (−1.06 to 0.33), and −0.04 percentage points in 30 day mortality (−0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics. Conclusions Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.

Association Between Federal Value-Based Incentive Programs and Health Care–Associated Infection Rates in Safety-Net and Non–Safety-Net Hospitals

“…9 The reason for the disparities is likely multifactorial and associated with a complex mix of health care environmental factors and patient-related clinical and social factors, [31][32][33] including the adverse effects of structural racism, discrimination, and toxic stress among patients disproportionately served by safety-net institutions such as those with low income and/or those who identify as members of racial/ ethnic minority groups. [34][35][36][37] Whatever their cause, these disparities in health care-associated infection rates contribute to the disproportionate representation of safety-net hospitals among penalized institutions 11,13 and may have unintended consequences for the financial stability of the safety net and the quality of health care for the patients served. Although Medicaid expansion under the Affordable Care Act reduced uncompensated care costs for many safety-net hospitals, 38,39 these hospitals continue to have low operating margins and often rely on nonclinical sources of revenue 40 or state and federal funds, particularly DSH payments, 41 to offset financial losses associated with remaining uncompensated care and Medicaid reimbursement that is below actual costs.…”

“…[3][4][5][6][7][8] Safety-net hospitals that care for a higher proportion of patients with low socioeconomic status also tend to demonstrate worse performance, even after accounting for case mix. 9 As a result, safety-net institutions are more likely than non-safety-net facilities to incur financial penalties, [9][10][11][12][13] which may have potential implications for the patients served. 3,[14][15][16] In the case of health care-associated infections, the disproportionate assessment of financial penalties for safety-net institutions could be a factor in worsening financial hardships and subsequently disparities affecting these hospitals.…”

Measuring the cost of adverse events in hospital

“…Hospitals in the US are penalized financially under the Hospital Readmissions Reduction Program for above-expected readmission rates and under the Hospital-Acquired Condition Reduction Program for above-expected rates of select adverse events. 10,11 Although hospital harm is a known contributor to readmissions, other modifiable factors may be equally or more important. Comprehensive, high-quality transitional care has successfully prevented readmissions by improving patient self-management and continuity of care, while reducing adverse drug events after discharge.…”

Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions

“…1). While early evaluations of HACRP reported cumulative reductions in hospital-acquired conditions [1,2], more recent studies [3][4][5][6][7] have not found a clear association between receipt of the HACRP penalty and hospital quality of care. For example, recent evidence suggests that HACRP penalized hospitals had more accreditations for quality, offered a larger number of advanced services, were major teaching institutions, and had better performance on other process and outcome measures [7].…”