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Nonpayment for Urinary Tract Infections Based on Faulty Data



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Using claims data to support public quality reporting and nonpayment for hospital-acquired conditions may be flawed, at least when it comes to catheter-associated urinary tract infections.

Such infections were most likely being underreported by hospital coders, and as a result, the ďaccuracy of reporting from the data set is suspect,Ē according to Dr. Jennifer A. Meddings of the University of Michigan, Ann Arbor, and her colleagues. Since the data on catheter-associated urinary tract infections (CAUTIs) are thought to be faulty, quality comparisons and incentive or disincentive payments based on it are also in doubt, they added.

The researchers studied discharge data from 96 acute care hospitals in Michigan, comparing adults discharged in 2007 with those discharged in 2009 (Ann. Intern. Med. 2012;157:305-12). The data were obtained from the Healthcare Cost and Utilization Project state inpatient database.

According to that database, there were 767,531 discharges in 2007 and 781,343 in 2009 in Michigan.

Previous studies have shown that there are 4.5 hospital-acquired infections per 100 hospitalizations; at least a third of those come from the urinary tract. And yet, the authors found an extremely low rate of UTIs reported by Michigan hospitals, whether present on admission or acquired in the hospital. Only 0.3% of discharges involved a hospital-acquired CAUTI.

Only 25 of the 781,343 (0.003%) hospitalizations in 2009 experienced a nonpayment for a CAUTI. The authors estimated that each hospital would have lost no more than $132,675 for each of those cases.

CAUTIs are being underreported for several reasons, Dr. Meddings said. A large proportion of UTIs are catheter-associated, but a review of medical records shows that they are generally not well documented by physicians. Nurses tend to be more accurate in reporting the infections and that they are catheter related, but those notes arenít used by hospital coders to generate diagnoses for billing.

Also, if a coder suspects a UTI occurred after admission, he or she must contact the health care provider, but that doesnít happen very often. Finally, the Centers for Medicare & Medicaid Services does not require coders to list all hospital-acquired conditions in claims data.

And even though some states require reporting of certain hospital-acquired infections, those databases arenít used for nonpayment determinations or for public reporting.

ďThe time has come to either improve the procedures for reporting hospital-acquired events in the claims data set to increase accuracy or abandon claims data for this purpose and change to data sets with more rigorous and standardized assessment about nosocomial events for comparing hospitals, such as surveillance data submitted to the National Healthcare Safety Network,Ē Dr. Meddings and her colleagues concluded.

CMS has been using claims data since 2008 to determine whether it should withhold payment for certain hospital-acquired conditions and as the basis for public reporting on the Hospital Compare website.

There has been a long history of concern about the value and accuracy of administrative data. In this study, it is especially concerning because catheter-associated urinary tract infections are thought to be the most common health care infection, said Dr. Sean M. Berenholtz, associate professor of anesthesia, critical care medicine, and health policy and management at Johns Hopkins University, Baltimore.

There is not a lot of morbidity and mortality associated with CAUTIs, but because they are the most common, the fact that they are being underrepresented on coding is concerning, he said.

Itís still not clear how to increase the accuracy of diagnosis in coding or how to get hospitals to report such complications more often. The incentives and disincentives for poor performance have good meaning and intention, but the system is so complex that it isnít translating into improvements in quality, Dr. Berenholtz said.

Itís been almost 5 years since CMS has not been paying for various complications, but there has not been much evidence to show that the nonpayment has had an impact on quality of care. The study argues for the need to ensure that, if we are going to link financial incentives or disincentives to data, we need to ensure that the data are accurate. And itís unlikely that regulatory pressures are going to get us where we need to go, he noted.

The study is likely generalizable. It has not been replicated yet, but I donít know of any reason why Michigan would be intentionally underreporting these infections. Also this group of researchers is exceedingly talented and well established, he said.

The study was funded by the Blue Cross Blue Shield of Michigan Foundation. The authors reported that they had no relevant disclosures.

 Alicia Ault is an associate editor with IMNG Medical News.

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