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    White Coat Notes

    Penalty, infection link hard to gauge

    Since 2006, hospitals across the country have become safer on at least one count: The rate at which patients acquire infections from catheters to their heart or bladder has declined considerably.

    But the improvement has little to do with a federal penalty program launched in 2008 to target the problem, according to a study by Harvard researchers published last week by the New England Journal of Medicine.

    The results are notable as the Center for Medicare & Medicaid Services and other organizations that pay for health care are rolling out new programs using penalties to push providers to keep patients healthy.


    Starting in October 2008, the federal agency refused to pay hospitals for the extra care they provided to patients when such infections and other hospital-acquired conditions, such as pressure ulcers, occurred. The idea was that the infections are avoidable, and hospitals should not be paid more money for providing faulty care.

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    A group led by Dr. Grace Lee, associate professor at Harvard Pilgrim Health Care Institute and Harvard Medical School, evaluated data from 398 hospitals in 41 states, looking at rates for two conditions: central line-associated bloodstream infections and catheter-associated urinary tract infections.

    The infection rates were declining before and after the policy took effect, and the pace of that decline did not change when the penalties began.

    “It had really nothing to do with the CMS policy,” Lee said.

    The researchers also compared patterns in the two types of infections with the trend in ventilator-associated pneumonia, an infection for which hospitals were not docked pay.


    The infections all followed similar patterns, Lee said.

    In some cases, the rate of decrease slowed after the penalties took effect. Hospitals may have already taken big steps to control infections prior to 2008 so that improvements were harder to make, Lee said.

    The authors said the penalties were modest, averaging six-tenths of a percent of Medicare revenue, and may not have been enough to push hospitals to change. Lee said another issue may be that the penalties are based on billing data, not actual infection rates, which can cloud the issue as hospitals adjust how they enter payment codes.

    As the Centers for Medicare & Medicaid Services rolls out more penalty-based programs — one that takes effect this month docks hospitals’ pay if they have a high rate of patients treated for certain conditions who are hospitalized again within 30 days of discharge — the study shows that the way such programs are implemented matters, Lee said.

    “It makes a lot of sense to align quality and cost” in health care payments, Lee said. “Ideally, what you would want to see is an improvement in health outcomes.”

    Chelsea Conaboy can be reached at Follow her on Twitter @cconaboy.