Hospital-Acquired Conditions & The Hospitalist

The Hospitalist. 2010 March;2010(03):

March 1, 2010 | The Hospitalist

Dr. Meddings

The big questions surrounding HACs: Could they reasonably be prevented through the application of evidence-based guidelines? How preventable are HACs? Who decides if a complication is preventable, and therefore payment for services is withheld?

They’re concerns that are widespread among physicians, hospital administrators, and regulators alike.

“The legislation required the conditions to be ‘reasonably preventable’ using established clinical guidelines,” Dr. Straube says. “We did not have to show 100% prevention. In an imperfect world, they might still take place occasionally, but with good medical care, almost all of these are preventable in this day and age.”

For CMS, the preventable conditions are an either/or situation: Either they existed prior to admission and are subject to payment, or they did not exist at admission and additional payment for the complication will not be made. “HACs do not currently consider a patient’s individual risk for complications,” says Jennifer Meddings, MD, MSc, clinical lecturer and health researcher in the Department of Internal Medicine at the University of Michigan Health System in Ann Arbor. “We know the best strategies to prevent complications in ideal patients, and these are reflected in the HACs. In real life, many of our patients just don’t fit into the guidelines for many reasons—and you have to individualize care.”

Dr. Meddings points to DVT as a prime example. For a certain number of inpatients, the guidelines can be followed to perfection. In other patients (e.g., those with kidney conditions), previous reactions to a medication or an individual’s predisposition to clotting might interfere with treatment. However, CMS doesn’t allow appeals of nonpayment decisions for HACs based on individual circumstances.

Some experts think the rigidness of the payment policy forces physicians to treat patients exactly to guidelines. Even then, payment could be declined if an HAC develops.

“One of the points of most discussion is how preventable some of these are, particularly when choosing those you are no longer going to pay for,” Dr. Meddings says. “Many of the complications currently under review have patients that are at higher risk than others. How much our prevention strategies can alleviate or reduce the risk varies widely among patients.”

A brief History of Never Events

Over the years, multiple lists of adverse medical events that are deemed preventable have been published. CMS released a group of hospital-acquired complications (HACs) that they will no longer pay for. The Joint Commission published its National Patient Safety Goals and implemented it as part of their accreditation process. The National Quality Foundation (NQF) has Serious Reportable Events. All of these have been thrown under the title of “never events,” to the confusion of many.

“In 2003, then-NQF chief executor officer Ken Kaiser coined the term ‘never events’ to describe things that should just never happen in healthcare,” says Peter Angood, MD, the foundation’s senior advisor for patient safety. “Although there is some overlap, each of these lists was developed by different entities for different reasons, using different criteria for inclusion. NQF now uses the term Serious Reportable Events and regularly updates its list to include the newest evidence.”

Efforts to harmonize the language and criteria across the various organizations have been made, and some believe a coordinated list will alleviate the confusion brought about by various lists. “While there have been many types of initiatives taken over the last decade or so, the fact remains that ongoing improvements are still required for patient safety in patient care, as well as the efficiency of that care,” Dr. Angood says. “Efforts around reportable events, no matter who they are reported to, are one component in spurring safer, higher-quality care.”—KU