Dorothea Handron was so weakened by complications from a hernia
operation that she was placed in a medically induced coma at
Vidant Medical Center (Photo by Jim R. Bounds/AP Images for KHN)
June 24, 2014 - During a hernia
operation, Dorothea Handron’s surgeon unknowingly pierced her bowel. It
took five days for doctors to determine she had an infection. By the
time they operated on her again, she was so weakened that she was placed
in a medically induced coma at Vidant Medical Center in Greenville,
Comatose and on a respirator for
six weeks, she contracted pneumonia. "When they stopped the sedation and
I woke up, I had no idea what had happened to me," said Handron, 60. "I
kind of felt like Rip Van Winkle."
Because of complications like
Handron’s, Vidant, an academic medical center in eastern North Carolina,
is likely to have its Medicare payments docked this fall through the
government’s toughest effort yet to crack down on
infections and other patient
injuries, federal records show.
A quarter of the nation’s hospitals
– those with the worst rates – will lose 1 percent of every Medicare
payment for a year starting in October.
In April, federal officials
released a preliminary analysis of which hospitals would be assessed,
identifying 761. When Medicare sets final penalties later this year,
that list may change because the government will be looking at
performance over a longer period than it used to calculate the draft
penalties. Vidant, for instance, says it lowered patient injury rates
over the course of 2013, and Handron praises their efforts.
The sanctions, estimated to total
$330 million over a year, kick in at a time when most infections
measured in hospitals are on the decline, but still too common. In 2012,
one out of every eight patients nationally suffered a potentially
avoidable complication during a hospital stay, the
government estimates. Even
infections that are waning are not decreasing fast enough to meet
targets set by the government.
Meanwhile new strains of antibiotic-resistant bacteria are making
infections much harder to cure.
Dr. Clifford McDonald, a senior
adviser at the federal Centers for Disease Control and Prevention, said
the worst performers "still have a lot of room to move in a positive
Are The Metrics Right?
Medicare’s penalties are going to
hit some types of hospitals harder than others, according to an analysis
of the preliminary penalties conducted for Kaiser Health News by Dr.
Ashish Jha, a professor at the Harvard School of Public Health. Publicly
owned hospitals and those that treat large portions of low-income
patients are more likely to be assessed penalties.
So are large hospitals, hospitals
in cities and those in the West and Northeast. Preliminary penalties
were assigned to more than a third of hospitals in Alaska, Colorado,
Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin
and Wyoming, Medicare records show.
"We want hospitals focused on
patient safety and we want them laser-focused on eliminating patient
harm," said Dr. Patrick Conway, chief medical officer of the Centers for
Medicare & Medicaid Services.
The biggest impact may be on the
nation’s major teaching hospitals: 54 percent were marked for
preliminary penalties, Jha found. The reasons for such high rates of
complications in these elite hospitals are being intensely debated. Leah
Binder, CEO of The Leapfrog Group, a patient safety organization, said
academic medical centers have such a diverse mix of specialists and
competing priorities of research and training residents that safety is
not always at the forefront. Nearly half of the teaching hospitals — 123
out of 266 in Jha’s analysis —had low enough rates to avoid penalties.
The government takes into account
the size of hospital, the location where the patient was treated and
whether it is affiliated with a medical school when calculating
infection rates. But the Association of American Medical Colleges and
some experts question whether those measures are precise enough. "Do we
really believe that large academic medical centers are providing such
drastically worse care, or is it that we just haven't gotten our metrics
right?" Jha said. "I suspect it's the latter."
Medicare assigned a preliminary
penalty to Northwestern Memorial Hospital in Chicago, for instance, but
Dr. Gary Noskin, the chief medical officer, said hospitals that are more
vigilant in catching problems end up looking worse. "If you don't look
for the clot, you're never going to find it," he said.
Another concern is there may be
little difference in the performance between hospitals that narrowly
draw penalties and those that barely escape them. That is because the
health law requires Medicare to punish the worst-performing quarter of
the nation’s hospitals each year, even if they have been improving.
"Hospitals that have been working
hard to reduce infections may end up in the penalty box," said Nancy
Foster, vice president for quality and public safety at the American
Third Leg Of Medicare’s
Hospital-Acquired Condition (HAC) Reduction
Program, created by the 2010 health law, is the third of the
federal health law’s major mandatory pay-for-performance programs for
hospitals. The first levies penalties against hospitals with
high readmission rates and the
second awards bonuses or penalties based on
two dozen quality measures. Both
are in their second year. When all three programs are in place this
fall, hospitals will be at risk of losing up to 5.4 percent of their
Medicare's Primary Penalties For Hospitals
Medicare’s upcoming penalties for hospitals with high rates of
infections and other patient injuries will fall harder on some
types of institutions than for others. This analysis shows the
disparate effect of the preliminary penalties.
In the first year of the HAC
penalties, Medicare will look at three measures. One is the frequency of
bloodstream infections in patients with catheters inserted into a major
vein to deliver antibiotics, nutrients, chemotherapy or other
treatments. The second is the rates of infections from catheters
inserted into the bladder to drain urine. Both those assessments will be
based on infections during 2012 and 2013.
Finally, Medicare will examine a
variety of avoidable safety problems in patients that occurred from July
2011 through June 2013, including bedsores, hip fractures, blood clots
and accidental lung punctures. Over the next few years, Medicare will
also factor in surgical site infections and infection rates from two
germs that are resistant to antibiotic treatments: Clostridium
difficile, known as
C. diff, and Methicillin-resistant
known as MRSA.
Vidant is worse than average in
catheter-associated urinary tract infections and serious complications
from surgery in the latest statistics Medicare published on its Hospital
Compare website. But in more recent data the medical center voluntarily
on its website, the number of
catheter and urinary tract infections dropped during 2013. Joan Wynn,
Vidant Health’s chief quality and safety officer, said
complications rates are dropping
this year as well.
The prospect of penalties is
“difficult when you know how much your performance is improved,” said
Wynn. She said Vidant has taken many steps to reduce complications,
added patients to internal committees and now reveals on its website the
number of infections, patient falls, medication errors and bed sores.
Vidant asked Handron, a retired
nursing professor injured in 2009, to tell her experience to the
trustees and make a video for the medical staff talking about it. She
continues to advise the hospital. “I know they’re going in the very
right direction,” Handron said. “I would have absolutely zero concern
about myself or a family member going to Vidant for anything now.”
Nationally, rates of some
infections are decreasing. Catheter-related infections, for instance,
dropped 44 percent between 2008 and 2012. Still, the
CDC estimates that in 2011,
about 648,000 patients - 1 in 25 - picked up an infection while in the
hospital, and 75,000 died.
Rates of urinary tract infections
have not dropped despite efforts. These infections are more likely the
longer a line is left in, but sometimes they are not removed promptly
out of convenience for the nurse or patient or simply institutional
lethargy. Swedish Medical Center in Seattle, which has higher urinary
catheter infection rates than do most hospitals, has given nurses more
authority to remove catheters so long as they follow guidelines for when
removal is appropriate, said Dr. Michael Myint, Swedish’s vice president
for quality and patient safety. “Historically, they would just wait for
the physician’s order to come through,” Myint said.
Medicare has been pressuring
hospitals for several years to lower rates of injuries to patients. In
2008 Medicare started refusing to reimburse hospitals for the extra cost
of treating patients for avoidable complications. A subsequent study
by Harvard researchers found no evidence that the change led
to lower infection rates.
“With infections, we are moving in
the right direction,” said Lisa McGiffert, who directs the patient
safety program at Consumers Union, “but I would not say we are anywhere
near where we need to be.”
Patient Advocates Praise Move
Patient advocates say the financial
penalties are long overdue, given how little accountability there has
been. Gerald Guske discovered that in 2012 when he went into Martha
Jefferson Hospital in Charlottesville, Virginia, for an artificial hip
implant. Doctors later had to reopen the incision and wash out Guske’s
implant. Guske, a retired electronic technician, was laid up for a month
in a rehabilitation facility while strong antibiotics were pumped
directly into a vein.
Martha Jefferson told Guske it had
followed proper protocols. “Unfortunately, infection is a known risk of
any surgery, and even when everything is performed correctly and
conditions are ideal, they can occur,” the hospital wrote him afterward.
“Infection does not necessarily indicate that something went wrong.”
Martha Jefferson Hospital said it
could not discuss the case because of patient privacy laws. The
hospital’s infection control specialist, Dr. Keri Hall, said infection
rates have been dropping and “we are every day doing what we can to
hopefully bring our rates down to zero.”
Guske said he has fully recovered,
"other than taking six weeks out of my life," but he attributes the
stress around his complications to a minor stroke his wife suffered. He
said state regulators told him they could not take any action because
the hospital followed proper procedures. The fear of a financial penalty
against a hospital, Guske said, is "the only thing that’s really going
to change matters."
If you experienced an infection
or another mishap while in the hospital, what happened and how did the
hospital respond? Your responses may inform future KHN stories. Email:
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