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Penalizing Hospitals For Being Unsafe

Ashish JhaAdverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally.  Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth.  As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay.  Many of these are debilitating, life-threatening, or even fatal.  Things are not much better for younger Americans.

Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers.  Well, things are changing – and while some of that change is good, some of it worries me.  Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions.  CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs).  PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS.  However, there are three potential problems with PSIs:  hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.

So, HACs are imperfect – but the bottom line is, every metric is imperfect.  Are HACs particularly imperfect?  Are the problems with HACs worse than with other measures?  I think we have some reason to be concerned.

HACs – Who Gets Penalized?

Our team was asked by Jordan Rau of Kaiser Health News to run the numbers.  He sent along a database that listed CMS’s calculation of the HAC score for every hospital, and the worst 25% that were likely to get penalized. So, we ran some numbers, looking at characteristics of hospitals that do and do not get penalized:

Table1

These are bivariate relationships – that is, major teaching hospitals were 2.9 times more likely to be penalized than non-teaching hospitals.  This does not simultaneously adjust for the other characteristics because as a policy matter, it’s the unadjusted value that matters.  If you want to understand to what degree academic hospitals are being penalized because they also happen to be large, then you need multivariate analyses – and therefore, we went ahead and ran a multivariable model – and even in the multivariable model (logistic model with each of the above variables in the model), the results are qualitatively similar although not all the differences remain statistically significant.

What Does This Mean?

So how should we interpret these data?  A simple way to think about it is this:  who is getting penalized?  Large, urban, public, teaching hospitals in the Northeast with lots of poor patients.  Who is not getting penalized?  Small, rural, for-profit hospitals in the South.  Here are the data from the multivariable model:  The chances that a large, urban, public, major teaching hospital that has lots of poor patients (i.e. top quartile of DSH Index) will get the HAC penalty?  62%.  The chances that a small, rural, for-profit, non-teaching hospital in the south with very few poor patients will get the penalty? 9%.

Is that a problem?  You could make the argument that these large, Northeastern teaching hospitals are terrible places to get care – while the hospitals that are really doing it well are the small, rural, for-profit hospitals in the south. May be. I suspect this is much more about the underlying patient population and vigilance than actual safety.  Beth Isarel Deaconess Medical Center (BIDMC) in Boston is one of the very few hospitals in the country with exceptionally low mortality rates across all three publicly reported conditions and a hospital that I have written about as having great leadership and a laser focus attention on quality. And yet, it is being penalized as being one of the hospitals with, according to the HAC metric, a poor record on safety.  So is Brigham and Women’s (though I’m affiliated there, so watch my bias) – a pioneer in patient safety whose chief quality and safety officer is David Bates, one of nation’s foremost safety gurus.  So are the Cleveland Clinic and Barnes Jewish, RWJF Medical Center, LDS Hospital in Salt Lake, and Indiana University Hospital, to name a few.

So what are we to do?  Is this just whining that our metrics aren’t perfect?  Don’t we have to do something to move the needle on patient safety?  Absolutely.  But, we are missing a great opportunity to do something much more useful.  Patient safety as a field has been stuck.  It’s been 15 years since the IOM’s To Err is Human report came out – and by all counts, progress has been painstakingly slow.  Therefore, I am completely on board with the sentiment behind Congressional intent and CMS’s efforts.  We have to do something – but I think we should do something a little different.

If you look across the safety landscape, one thing becomes clear:  when we have good measures, we make progress.  We have made modest improvements in hospital acquired infections – because of tremendous work by the CDC (and their clinically-based National Hospital Surveillance Network) that collects good data on patient safety and feeds it back to hospitals. We have also made some progress on surgical complications, partly because a group of hospitals are willing to collect high quality data, and feed it back to their institutions.  But the rest of the field of patient safety?  Not so much.  What we need are good measures.  And, luckily, there is still a window of opportunity if we are willing to make patient safety a priority.

How to Move Forward

This gets us to the actual solution:  harnessing the power of meaningful use in the Electronic Health Records incentive program.  We need clinically-based, high quality patient safety metrics.  Electronic health records can capture these far more effectively than billing codes can.  The federal government is giving out billions of dollars to doctors and hospitals that “meaningfully use” certified EHRs.  A couple of years ago, David Classen and I wrote a piece in NEJM that outlined how the federal government, if it wanted to be serious about patient safety, could require, that EHR systems measure, track, and feed back patient safety events as part of certification and requirements for meaningful use.  The technology is there.  Lots of companies have developed adverse event monitoring tools.  It just requires someone to decide that improving patient safety is important – and that clinically-based metrics are useful.

So here we are – HACs.  Well intentioned – and a step forward, I think, in the effort to make healthcare better.  Everyone I know thinks HACs have important limitations – but reasonable people disagree over whether their flaws make them unusable for financial incentives or not.  The good news is that all of us can agree that we can do much better.  And now is the time to do it.

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free trafficL. Cliff McDonald, MDPerryDavid C.Karen Sibert MD Recent comment authors
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L. Cliff McDonald, MD
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We thank Dr. Jha for his positive comments regarding our healthcare-associated infection measures that form a component of the overall patient safety landscape. However, we need to continue to move forward in creating measures that are more imbedded in pathways of clinical care and thereby less ‘game-able’ and better risk adjusted. We also agree with Dr. Jha that the way forward is to capture the power of the EHR by reusing clinical data that have been recorded in structured, electronic form. However, we would also add the importance of deep subject matter expertise that leverages understanding of pathogenesis and clinical… Read more »

David C.
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This is a very important topic and deserves more shares and discussion on higher level. Medical errors have claimed lives of many people not just in US, but all around the world. There is a critical need for us to come up with a plan to at least reduced the number of such cases. Penalizing hospitals is a good move.

Perry
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Perry

That’s right:
The beatings will continue until morale improves.

Karen Sibert MD
Guest

There is a very real problem with confounding all adverse events or HAC’s with the term “injury”. Read this: http://skepticalscalpel.blogspot.com/2014/06/1-in-5-elderly-us-patients-injured-by.html When critically ill patients need mechanical ventilation for a prolonged period of time, some of them will get pneumonia. The incidence will never be zero. But what would the mortality be if they were not mechanically ventilated in the first place? Probably close to 100%. Of patients with acute problems such as intestinal perforation due to diverticulitis, some will have underlying coronary artery disease or cerebral vascular disease, and will have perioperative complications due to those underlying disease processes. The… Read more »

FS
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FS

Ten of thousands of people shouldn’t need to be dying due to the lack of good patient safety in healthcare. People come into hospitals to get the proper treatment they need for a sickness that has brought them there. When respectable procedures are made, we will see advancement. I believe the CDC has been doing fairly well in protecting hospitals. If everyone in a hospital worked together and followed all the guidelines and took proper procedures, such lack of safety can be significantly reduced. I strongly support the affordable care act’s decision in punishing healthcare facilities with Hospital Acquired Conditions.… Read more »

David Do, MD
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David Do, MD

Great article. I’m all for “harnessing the power of meaningful use in the Electronic Health Records incentive program”. However, what makes adverse event reporting suitable for being built into an EMR? It’s hard for a software package to do all these things well. The authors of “Escaping the EHR trap” write, “Just as consumers select and manage myriad technologies — Facebook for social networking, Twitter for microblogging, Google for search, iTunes for music — so should physicians.” Sure, reporting is easier when built into the same interface, and you may derive some information about adverse events from the notes, but… Read more »

Rob
Guest

I see trouble here. First, as you showed, choice of data is critical to have true meaningful results. The unfortunate thing is that the folks choosing the data points are often not right in what they choose. Bad data will potentially mark relatively good providers as being deficient, which will do nothing to build trust in these systems, much less increase actual quality. Second, the EHR systems are not always systemic tools (i.e. One patient doesn’t usually have all doctors using a single EHR product), but rather individual tools for the providers. Meaningful use checks are sent to providers, not… Read more »

Vik Khanna
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Vik Khanna

Ashish, I like the idea of using the EHR as a reporting tool, but I think that the problems raised in some of the other comments complicate the picture. As you and others have written, EHRs themselves are often problematic. It’s not just that the EHR itself may be the proximate cause of an adverse event, but where does the data go, in what timeframe, for access by whom, and how to handle the whining, complaining, and regulatory footdragging by hospitals that want to challenge, either administratively or in court, how their data has been represented? If the EHR becomes… Read more »

Granpappy Yokum
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Granpappy Yokum

So who reviews all this data on adverse events? The ABA?

Ashish Jha
Guest

GY — hospitals already spend a lot of money reviewing charts. We did a study years ago that found that it would take a pharmacist about 5 to10 hours a week (real $ but not undoable) to review all the possible adverse drug event alerts and track down which ones are real — and that would not only save lives but also $. Same for other types of adverse events.

Not a provider
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Not a provider

Inexpensive care v Quality care v Safe care… Not possible. Just teach consumers that hospitals are dangerous and to stay healthy so they don’t have to go to one.

Whatsen Williams
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Whatsen Williams

There is a problem. You failed to consider the EHR device as a cause for the neglect and errors.

After all, with the $$$$$ billions spent, adverse events, never events, falls, and overall outcomes do not show any ROI.

Any discussion about MU and safety should issue a disclaimer: EHR devices running all care have not been assessed for safety, and may be the cause of new errors.

Datum
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Datum

My god, this is an important post!

The key to the righting the meaningful use program is to rethink how we define “meaningful.” This much-maligned program can do the good its well-intended designers intended if we aim it in the right direction.

Requiring EMRs to track patient safety is an important step towards giving this program teeth. We already have the technology we need. Why are we waiting?

Actually don’t answer that question, everybody knows why. Please tell us more about how this works, instead!

Ashish Jha
Guest

Thank you Datum for your comment. There are a lot of tools that allow for automated monitoring of adverse events — they vary in their utility but most that I have seen are a big step forward from where we are today (either nothing or just billing data).