The hospital billing data used to calculate Medicare payment rates and penalties for hospitals may miss many of the hospital-acquired pressure ulcers (HAPUs) that patients are actually getting, according to a study in Health Affairs.
In addition, hospitals’ progress in reducing HAPUs is almost entirely because they prevented less-costly and less dangerous early-stage HAPUs, and not the more severe kind, according to billing data, notes a media release from Michigan Medicine-University of Michigan.
In the study, researchers from the from the University of Michigan looked at two sources of data used to track the rates and progress of HAPUs: administrative data, and chart-based surveillance review.
They recommend better ways of tracking HAPUs for value-based purchasing policies. The program should use the same approach hospitals already use to track infections that patients develop during their stay, and adjust rates and penalties based on patients’ underlying risk, according to the release.
“We find that the data used for policy implementation doesn’t support a ‘victory lap’ yet about the impact of efforts to reduce rates of severe HAPUs, specifically Stage 3 or 4 ones,” says Jennifer Meddings, MD, MSc, the study’s senior author, in the release.
“There has been some change in pressure ulcer rates, to be sure, but not to the extent that many might have assumed,” adds Meddings, an associate professor of internal medicine and pediatrics at Michigan Medicine, U-M’s academic medical center, and a patient safety researcher at the U-M Institute for Healthcare Policy and Innovation and U-M/VA Patient Safety Enhancement Program.
The research team cites recent public reports of progress against HAPUs, which were based on surveillance chart review data from the Medicare Patient Safety Monitoring System that tracks trends in HAPUs and other hospital-acquired conditions.
Those reports found a decrease of 23% in the rate of HAPUs between 2010 and 2014, from 4% to just over 3% of inpatients, and concluded that this resulted in savings of more than $1 billion.
But the data used for these reports—which came from detailed medical chart reviews—aren’t the same as the billing data used to carry out the federal hospital payment policies for HAPUs, according to the release.
Meddings, first author Shawna Smith, PhD, and colleagues looked at billing data from patients in Florida, New York, and Washington State, and calculated that HAPUs dropped 40% from 2009 to 2014. But this drop started from a much lower absolute incidence rate of 0.27% of patients, and fell to 0.16% of patients.
In other words, they note, billing data used for policy purposes only captured about 1 out of every 20 HAPUs documented in chart review data. The progress recently reported from the chart reviews did not distinguish between the most dangerous and expensive advanced-stage HAPUs and less expensive, early-stage HAPUs, the release continues.
More research revealed that 96% of the decline in HAPUs seen in the billing data happened because of a decline in reporting of early-stage (stage 1 and 2) sores. Advanced-stage HAPU rates remained steady at 0.04%, or four per 10,000 discharges.
However, these early-stage HAPUs were also the kind that the federal government stopped using to adjust hospital payments from Medicare in 2008.
The researchers also looked at those patients whose records are excluded from current policies that use billing data, because of their higher risk of HAPUs due to conditions such as paralysis and spinal cord injury.
Among these higher-risk patients, billing data also showed that hospitals did make inroads between 2009 and 2014 in reducing rates of early-stage HAPUs – but rates of late-stage HAPUs in these high-risk patients stayed nearly constant.
“Prevention of stage 1 and 2 sores is important, because they can worsen to stages 3 and 4,” Meddings explains. “But we expected to have been able to see changes in rates of stage 3 and 4 HAPUs also if hospitals were succeeding in preventing stage 1 and 2 sores. And for the most part, we didn’t.”
The authors give three recommendations for improving current policies aimed at monitoring progress in prevention of HAPUs, particularly when tied to hospital payment, the release explains:
- Medicare’s value-based payment programs should develop a new surveillance strategy for HAPUs that’s not just based on administrative billing data. Instead, they should rely on trained staff to do standardized chart-based surveillance, similar to what is done for hospital acquired infections, or require regular in-person surveillance using standard criteria similar to what is done for other quality indicators
- Surveillance for HAPUs must recognize the differences between early-stage (stage 1 or 2) bedsores, and more advanced (stage 3 or 4) HAPUs which are much harder to heal, hold higher risk for severe complications, and cost more to treat.
- Rather than exclude high risk patients from measurement of complication rates, as some value-based purchasing policies currently do, all patients should be included for measurement, and then the Medicare’s value-based purchasing programs could appropriately “risk-adjust” hospital HAPU rates to account for different proportions of higher-risk patients at different hospitals.
“The goal is to motivate hospitals to do better, but when the measure is so dependent on documentation and there’s such a large discrepancy between the system used for payment and the systems used to gauge the impact of value-based purchasing policies, we need to ask if we’re using the right data for public reporting and when comparing hospital performance for penalty assignment,” Meddings notes.
[Source(s): Michigan Medicine-University of Michigan, Newswise]