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CAUTI rates decline after case definition revision, value-based incentive programs
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The concurrent employment of a federal value-based incentive program, coupled with the revision of the surveillance case definition for catheter-associated UTIs, or CAUTIs, resulted in an immediate decline in CAUTIs in 592 hospitals, according to findings published in Infection Control & Hospital Epidemiology.
The National Healthcare Safety Network (NHSN) revised surveillance protocols for many health care-associated infections (HAIs), including CAUTIs, in January 2015. The new case definition for CAUTI excluded urinalysis findings and urine cultures growing nonbacterial organisms or less than 100,000 colony-forming units per milliliter of bacteria.
Concurrently, the Hospital-Acquired Conditions Reduction Program and Hospital Value-Based Purchasing — which are CMS programs that include NHSN HAI metrics in hospital performance assessments — were implemented in October 2014 and October 2015, respectively.
“The case of CAUTIs illustrates the potential pitfalls of failing to account for measurement changes in value-based incentive programs, including artificially inflated or deflated quality scores that aren’t related to true changes in performance, inappropriate financial rewards or penalties for hospitals, and misinterpretation of whether the programs improve outcomes for patients,” Heather E. Hsu, MD, MPH, a pediatric hospitalist at Boston Medical Center and assistant professor of pediatrics at Boston University School of Medicine, told Infectious Disease News.
Hsu and colleagues conducted an interrupted time series to investigate the impact the concurrent actions of the case definition revision and CMS program implementation had on device-associated CAUTI rates.
Between Jan. 1, 2013 and Dec. 31, 2017, 1,185 ICUs from 592 eligible study hospitals across 49 states and Washington, DC, reported CAUTIs diagnosed among adult patients enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study to NHSN.
The hospitals reported 22,572,494 patient days and 13,607,240 indwelling urinary catheter days. Using contemporaneous case definitions, 24,898 CAUTIs were identified.
According to the study, 32% of CAUTIs were due to yeast and 9% were due to low-growth bacteria before the case definition revision.
Despite an immediate 42% reduction in reported CAUTIs (incidence rate ratio [IRR] = 0.58; 95% CI, 0.54-0.63) after the revision, no significant change in CAUTI trends were observed (IRR = 1; 95% CI, 0.99-1.02). A sensitivity analysis also indicated a significant, immediate impact of the NHSN revision on CAUTI rates.
Hsu and colleagues noted that the proportion of ICUs with “better than expected” standardized infection ratios (SIRs) increased from 6% in 2014 to 16% in 2015. Moreover, the proportion of ICUs with “worse than expected” SIRs decreased from 18% in 2014 to 2% in 2015.
“Catheter-associated UTIs declined immediately in 2015 due to surveillance case definition changes, likely leading to artificial inflation of value-based hospital payment program performance scores unrelated to changes in patient safety,” Hsu said. “Studies examining the effectiveness of value-based incentive programs for catalyzing improvements in health care quality should pay close attention to measurement issues within these programs.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
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Sonali Advani , MBBS, MPH
In a recent article in Infection Control & Hospital Epidemiology, Hsu and colleagues found that decreases in CAUTI rates since 2015 were likely due to the 2015 CAUTI surveillance definition change rather than prevention efforts. CAUTIs are preventable HAIs that are tracked as part of the federal value-based incentive programs. These programs provide financial bonuses and penalties to hospitals based on hospital performance measures reported to the CDC’s NHSN. Effective January 2015, significant changes were made to the NHSN CAUTI definition: (1) the removal of urinalysis criteria, (2) an increase in the urine culture bacterial threshold from 103 to 105 colony-forming units and (3) the exclusion of yeasts or molds as potential CAUTI pathogens This change in the NHSN CAUTI definition resulted in a greater than 42% decline in reportable CAUTIs across approximately 600 hospitals, which was around the time that the value-based incentive programs were implemented.
In order to account for these post-revision comparisons, NHSN updated their standardized infection ratios (SIRs) using 2015 data and began reporting “2015 re-baseline” SIRs starting January 2017. However, CMS programs did not immediately adopt the 2015 re-baseline in their hospital performance score calculations until 2019. According to the researchers, these findings are important because change in the NHSN CAUTI definition likely led to artificial inflation of hospitals' performance scores unrelated to changes in patient safety.
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