Sustainability of Quality Improvement Following Removal of Pay-for-Performance Incentives

ArticleinJournal of General Internal Medicine 29(1) · August 2013with40 Reads
Impact Factor: 3.42 · DOI: 10.1007/s11606-013-2572-4 · Source: PubMed
Abstract

Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed. To investigate sustainability of performance levels following removal of performance-based incentives. Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010. VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals. Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives. Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained. This is a quasi-experimental study without a comparison group; causal conclusions are limited. The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare's value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.

Full-text

Available from: Justin K Benzer, Oct 14, 2014
Sustainability of Quality Improvement Following Removal
of Pay-for-Performance Incentives
Justin K. Benzer, PhD
1,2
, Gary J. Young, PhD
1,3
, James F. Burgess Jr PhD
1,2
, Errol Baker, PhD
1,2
,
David C. Mohr, PhD
1,2
, Martin P. Charns, DBA
1,2
, and Peter J. Kaboli, MD, MS
4,5
1
Center for Organization, Leadership, and Management Research (COLMR) at the VA Boston Healthcare System (152 M), Boston, MA, USA;
2
Boston University School of Public Health, Boston, MA, USA;
3
Northeastern University Center for Health Policy and Healthcare Research, Boston, MA,
USA;
4
Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA;
5
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
BACKGROUND: Although pay -for-performance (P4P)
has become a central strategy for improving quality in
US healthcare, questions persist about the effectiveness
of these programs. A key question is whether quality
improvement that occurs as a result of P4P programs is
sustainable, particularly if incentives are removed.
OBJECTIVE: To invest igate sustainability of perfor-
mance levels following removal of performance-based
incentives.
DESIGN, SETTING, AND PARTICIPANTS: Observa-
tional cohort study that capitalized on a P4P program
within the Veterans Health Administration (VA) that
included adoption and subsequent removal of perfor-
mance-based incentives for selected inpatient quality
measures. The study sample comprised 128 acute care
VA hospitals where performance was assessed between
2004 and 2010.
INTERVENTION: VA system managers set annual per-
formance goals in consultation with clinical leaders, and
report performance scores to medical centers on a
quarterly basis. These scores inform performance-based
incentives for facilities and their managers. Bonuses are
distributed based on the attainment of these performance
goals.
MEASUREMENTS: Seven quality of care measures for
acute coronary syndrome, heart failure, and pneumo-
nia linked to performance-based incentives.
RESULTS: Significant improvements in performance
were observed for six of seven quality of care measures
following adoption of performance-based incentives and
were maintained up to the removal of the incentive;
subsequently, the observed performance levels were
sustained.
LIMITATIONS: This is a quasi-experimental study with-
out a comparison group; causal conclusions are limited.
CONCLUSION: The maintenance of performance levels
after removal of a performance-based incentive has impli-
cations for the implementation of Medicares value-based
purchasing initiative and other P4P programs. Additional
research is needed to better understand human and
system-level factors that mediate sustainability of perfor-
mance-based incentives.
KEY WORDS: inpatients; physician incentive plans; quality
improvement; quality indicators; reimbursement; incentive; salaries ;
fringe benefits.
J Gen Intern Med
DOI: 10.1007/s11606-013-2572-4
© Society of General Internal Medicine 2013
INTRODUCTION
Pay-for-Performance (P4P) has become a central strategy
for improving the quality of health care in the US, Canada,
and the UK, and such programs have become widely
adopted among private and public health insurance pro-
grams over the last decade.
13
Of particular note, the Patient
Protection and Affordable Care Act (ACA) mandates the
adoption of P4P (i.e., value-based purchasing) for hospitals
and physicians participating in the M edicare program.
Although P4P programs vary markedly in their design,
two common features are: 1) defined performance goals for
selected quality measures, and 2) associated financial
incentives that can be targeted to institutions, individuals
or both.
Despite the growing prevalence of P4P programs,
numerous questions persist about their effectiveness in
improving quality of care, particularly about sustainability
once the incentive is removed. While some studies of P4P
demonstrate positive improvements in quality of care,
4
other studies report disappointing results, as documented in
several reviews of the literature.
5
Moreover, among studies
that do indicate improvements in quality measures, almost
no attention has been paid to whether such improvements
are sustainable over time,
6
especially if the performance
goals and incentives are removed.
The sustainability of performance levels is a key
consideration, as it may not be desirable or practical to
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-013-2572-4) contains supplementary material,
which is available to authorized users.
Received January 11, 2013
Revised May 17, 2013
Accepted July 18, 2013
Page 1
maintain performa nce-based incentives indefinitely. For
example, removal of performance-based incentives may
seem warranted when performance for a measure rises to
the upper end of the performance scale (i.e., topped out)
(e.g., aspirin in acute myocardial infarction), or is otherwise
at a level that is not likely to be exceeded in the current
clinical environment. In the design of Medicares hospital
value-based purchasing (VBP) program, considerable de-
bate regarding topped out measures occurred, resulting in a
decision to exclude process measures that have attained this
status.
7
Another reason for removing performance-based
incentives is to expand the reach of a P4P program to a new
range of clinical conditions or areas of focus. Performance-
based incentives may be routinely removed from some
measures for specified time periods and assigned to other
measures to limit the total number of performance measures
under evaluation at any point in time.
Despite the i mportance of sustainability for current
healthcare policy, there is limited research on the sustain-
ability of performance levels.
810
There has been no
research on the removal of incentives for inpatient medicine
quality measures such as those included in Medicares VBP.
A multi-year P4P initiative within the Veterans Health
Administration (VA) that included adoption and removal of
performance-based incentives for selected quality measures
provides the opportunity to conduct such research using a
quasi-experimental study design. The objective of this study
was to evaluate the empirical support for a hypothesis that
performance gains realized during a P4P program would
decrease after the removal of the performance-based
incentives.
METHODS
Setting
The Veterans Health Administration (VA), US Department
of Veterans Affairs, is the largest integrated healthcare
provider in the US, with more than 8.5 million enrollees in
2012. VA medical centers are organized into regional
networks managed by a network director, use a common
electronic medical record, and a P4P quality measurement
and reporting system.
11
For purposes of P4P, VAs central
office sets performance goals in consultation with clinical
leaders and reported performance scores to medical centers
quarterly. As such, this system-level intervention entailed
both public reporting and financial incentives. With respect
to public reporting, performance data were available to both
clinicians and managers quarterly, and were also included in
publicly available annual reports. Performance bonuses
were distributed, based on the attainment of performance
goals, to both regional network and facility-level senior
managers, who, in turn, had discretion to distribute bonus
payments to front-line clinicians and other employees.
The unit of analysis for the study was the VA medical
center (N=128).
Performance Measures
Since 2004, VA has tracked over 30 performance measures
relevant to acute coronary syndrome (ACS), heart failure
(HF), and pneumonia (PNU). Following The Joint Com-
mission standards, sampling has been conducted for all
patients with these three conditions. Performance measures
were developed based on published scientific evidence and
established clinical guidelines. The performance measure-
ment system for these quality measures is standardized and
includes specified data collection protocols (Appendix A;
available online). Performance measure guideline adherence
is measured through VAs External Peer Review Program,
an independent chart review of randomly selected patients
who meet specified inclusion and exclusion criteria. Goals
for each performance measure are set annually by the VA
central office, and incentives are awarded based on
achievement of those goals. Performance goals have also
been raised for some measures as the mean performance
level has risen over time. In addition, for seven of these
measures, the performance-based incentives were removed
between 2007 and 2009, but continued to be measured and
reported for at least a year. Although no explicit criteria
existed for the removal of incentives, high performance
level was likely a factor. For six of the seven performance
measures, mean performance was over 90 % prior to
removal of the incentives. We focused on these seven
quality measures, and for each indicated the percent of
hospitalized patients who satisfied the inclusion/exclusion
criteria and received guideline concordant care.
Acute Coronary Syndrome (ACS)
&
Cardiology Involvement:Highormoderate-highrisk
patients with cardiology involvement within 24 hours of
arrival, or if acute myocardial infarction (AMI) during
inpatient stay, within 24 hours of initial electrocardiogram
(ECG) or first positive troponin, whichever is earlier.
&
Troponin Returned: First troponin result returned
within 60 min of order.
&
Diagnostic Catheterization: High or moderate-high
risk patients who received a diagnostic catheterization
prior to discharge.
Heart Failure (HF)
&
ACE-I or ARB: For patients with ejection fraction less
than 40 %, presence of an angiotensin-c onverting
Benzer et al.: Sustainability of QI after Removing Incentives JGIM
Page 2
enzyme inhibitor (ACE-I) or angiotensin receptor
blocker (ARB) prior to admission (i.e., a continuous
care met ric targeting the quality of care in the outpatient
setting).
&
Weight Monitoring: Documentation of instruction for
monitoring weight prior to admission (i.e., a continuous
care met ric targeting the quality of care in the outpatient
setting).
Pneumonia (PNU)
&
Timely Antibiotic: Initial antibiotic dose administered
no earlier than 15 min prior to or no later than 240 min
following hospital arrival.
&
Pneumococcal Immunization: Receipt of pneumococ-
cal immunization prior to admission (i.e., a continuous
care met ric targeting the quality of care in the outpatient
setting).
Patient Sample
313,600 VA patient records were peer reviewed between
FY2004 and FY2010 across the seven measures. Sample
sizes for a single year ranged from 3,588 for HF: ACE-I or
ARB in FY2010 to 13,777 for HF: Weight monitoring in
FY2009. For each performance measure, the average
numbers of patients sampled per facility per quarter are
reported in Table 1.
Statistical Analyses
Quarterly performance data were obtained from FY2004 to
FY2010 from VA administrative data. Each measure was a
percentage score representing the number of patients
meeting the performance criteria divided by the total
number of eligible patients. Medical centers served as their
own controls in analyses. Missing data were an issue for
between four to nine study sites. These sites had more than
50 % missing data, whereas all other sites averaged 1 %
missing data. Sensitivity analyses with and without the high
missing data sites demonstrated that conclusions would not
differ based on the decision to include or exclude sites. The
sites with substantial missing data were excluded. For the
remaining sites, we imputed missing data using maximum
likelihood estimation during analyses. Latent growth
models implemented with MPLUS Version 5.2 were used
to estimate slopes across years. A piecewise latent growth
model was used for each performance measure to estimate an
intercept and slopes for each year in the model, accounting for
autocorrelations across time periods (Appendix B; available
online). A significant slope indicates that the rate of change is
significantly different from zero. For example, PNU: Timely
Antibiotic was measured from FY2005 to FY2009 so analyses
estimate the slopes for each of the 5 years. This model permits
evaluation of changes in performance between years where the
performance goal changed, years where the performance
goal remained constant, and years during which the
performance goal was removed. A significant negative
slope in the year following incentive removal indicates that
performance was not sus tained. Power is a concern because
the absence of a significant negative slope will be
interpreted as sustained performance. Thus, we performed
power calculations. Analyses had 86 % power to detect
whether the slope was at least 2 % in the year following
incentive removal.
RESULTS
Table 1 presen ts the introduction and re moval of t he
performance-based incentives for each performance mea-
sure. Only two measures (PNU: Timely Antibiotic and
ACS: Diagnostic Catheterization) had a true baseline period
where reporting f or t he meas ure oc curred before the
adoption of performance-based incentives. Performance-
Table 1. Performance Goals for Each Quality Measure (FY2004FY2010)
Measure N FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Acute Coronary Syndrome
Cardiology Involvement 17 N/A 82 % 87 % 87 % 91 % none none
Troponin Returned 15 N/A 75 % 85 % 89 % 95 % none none
Diagnostic Catheterization 15 Baseline 90 % 90 % none N/A N/A N/A
Heart Failure
ACE-I or ARB 11 N/A 90 % 90 % 90 % none none none
Weight Monitoring 25 90 % 90 % 90 % 90 % none none N/A
Pneumonia
Timely Antibiotic 18 N/A Baseline 73 % 80 % none none N/A
Pneumococcal Immunization 20 85 % 85 % 85 % 85 % none none N/A
Percentage scores indicate the performance standard for that year. N/A indicates that the measure was not assessed that year. Baseline indicates
the measure was collected, but was not incentivized for that year. None indicates that the performance-based incentive was removed. N=Average
number of patients per hospital per quarter
Benzer et al.: Sustainability of QI after Removing IncentivesJGIM
Page 3
based incentives were removed between 24 years follow-
ing adoption.
Rates of change for each measure are shown by quarter in
Fig. 1 for the latent growth models. The three ACS measures
are displayed together in Fig. 1a, the two HF measures in
Figure 1b, and the two PNU measures in Fig. 1c. Each line
represents the overall trend for a single year regarding the
rate of change after removal of the performance-based
incentives, as indicated by the arrows in Figure 1.
The overall mean score changes for the period where
performance-based incentives were adopted and the
period where performance-based incentives were re-
moved are summarized in Table 2. Prior to the removal
of incentives, we found that performance significantly
improved for six of the seven measures. The most
dramatic improvement occurred with the PNU: Timely
Antibiotic measure, where performance improved from
64%to82%in2yearsfollowingtheadoptionof
performance-based incentives. The only measure that did
not demonstrate significant improvement was the heart
failure: ACE-I measure.
Results did not support the hypothesis that performance
decreased after incentives were removed. Six of the seven
measures did not demonstrate a significant slope in the year
following incentive removal. The seventh measure, weight
monitoring, demonstrated a significant positive slope in the
year following incentive removal. However, a significant
negative slope was observed in the following year and a
non-significant slope in the third post-removal year. Given
that the design provides adequate power to detect changes
in performance, results indicate that performance was
sustained for all measures following removal of incentives.
DISCUSSION
In this observational cohort study evaluating P4P over
7 years in 128 VA hospitals, we found evidence of
improvement in performance measures following the
adoption of performance-based incentives, and that after
removal of the incentives, perf ormance neither further
improved nor deteriorated. As the US makes a substantial
investment in P4P, both financially and intellectually, it is
imperative that researchers capitalize on opportunities to
learn about the potential effectiveness of such programs on
quality of care. Current national policy discussions involve
both use of quality measures and choices regarding when to
retire measures. Our findings have important implications
for Medicares value-based purchasing program as we
focused on the same types of hospital inpatient measures
included in the Medicare program.
Our study contributes to a growing literature on P4P for
which there is a lack of consistent evidence regarding the
effectiveness of such programs. The mixed findings in the
literature suggest that the effectiveness of P4P likely
depends on contextual factors that researchers have yet to
fully explicate with conceptual frameworks and empirical
testing. In this vein, the particular implementation of P4P in
the VA and the nature of the VA system may have improved
the likelihood of performance sustaina bility. As noted,
performance-based incentives in the VA are awarded to
facilities and their managers, who decide whether and how
to distribute them to clinicians. This type of incentive
arrangement is similar to those established by Medicare and
private health plans for purposes of contracting with
0.4
0.5
0.6
0.7
0.8
0.9
1
2004 2005 2006 2007 2008 2009 2010 2011
Performance (%)
Fiscal Year (Oct-Sep)
Acute Coronary Syndrome
Diagnostic Catheterization
Troponin Returned
Cardiology Involvement
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1
2004 2005 2006 2007 2008 2009 2010 2011
Performance (%)
Fiscal Year (Oct-Sept)
Heart Failure
Weight Monitoring
ACEI or ARB
0.4
0.5
0.6
0.7
0.8
0.9
1
2004 2005 2006 2007 2008 2009 2010
Performance (%)
Fiscal Year (Oct-Se
p
)
Pneumonia
Pneumococcal
Immunization
Timely Antibiotic
a
b
c
Figure 1. Graph of latent growth model analyses for seven
performance measures. Dependent variable is the number of
patients who receive guideline-adherent care divided by the
number of eligible patients. Trend lines are estimated for each year
to demonstrate how the trend changes over time. Arrows indicate
the point at which incentives are either introduced or removed.
Dashed lines indicate periods in which performance-based incen-
tives were removed. Significant slopes are indicated by larger
point size lines.
Benzer et al.: Sustainability of QI after Removing Incentives JGIM
Page 4
accountable car e organizations (ACO). In most such
programs, ACOs are also the unit of accountability for
performance-based incentives, and ACO senior managers
have discretion as to whether and how incentive payments
are distributed to front-line clinicians.
Limitations to our study include a relatively small
number of performance measures for investigation, a brief
post-incentive removal period of between 1 and 3 years,
and the absence of a comparison group. The current paper
indicates that once hospitals achieve a high level of
performance, it may be possible to sustain that high
performance after incentives are removed. However, this
study does not indicate how performance may change if
incentives are removed before a high level of performance
is reached. Further, the absence of a comparison group
limited our ability to isolate the effects of the performance-
based incentives from other factors, such as a secular trend
or public reporting that may have contributed to changes in
the performance measures during the study period. In this
vein, some evidence exists indicating that public reporting
of performance measures alone can lead to performance
improvemen ts in hospitals.
1215
Although a study that
compared the performance effects of combining financial
incentives and public reporting to public reporting alone
found that incentives raise performance levels above those
obtained from just public reporting, the added increase was
quite modest.
16
As such, it is possible that the VA would
have experienced similar patterns, though perhaps not at
identical levels, of performance improvement and sustain-
ability from reporting the performance of its facilities on the
selected measures even without offering performance-based
incentives.
Future research, perhaps using mixed methods, should
address how incentives are most effectively implemented
and how incentives may have unintended positive or
negative effects in complex health care delivery sys-
tems.
17
In general, sustainability of quality improve-
ments may depend on changes in clinical systems that
do not consistently add to the workload of busy clinical
staff. However, sustainability may also vary depending
on who receives the incentives. Incentives targeted
toward physicians may cause them to focus their efforts
on patient-level clinical issues related to the performance
measures, whereas incentives targeted toward managers
may cause them to focus their efforts on system issues.
Increased effort by clinical staff may be needed to
improve performance initially, but changes in clinical
systems may be required for the improvements to be
sustainable.
In summary, this study found that performance
improvements that occurred in VA medical centers for
three common conditions (i.e., ACS, HF, and PNU)
were sustained for up to 3 years after performance-based
incentives were removed. These sustained improvements
may represent adoption of new standards of care that
were driven by P4P and, once adopted, the incentive
was no longer necessary to maintain a high level of
quality. If these findings can b e reproduced, they could
help guide the adoption and discontinuation of P4P
measures.
Acknowledgements: The work reported herein was supported by
the Department of Veterans Affairs, Veterans Health Administration,
Health Services Research and Development Service (IIR 08-067-1)
and an Investigator Award in Health Policy to Gary Young from the
Robert Wood Johnson Foundation. The authors had full access to
and take full responsibility for the integrity of the data. The views
expressed in this article are those of the authors and do not
necessarily represent the views of the Department of Veterans
Affairs. The authors would like to thank Terry Duncan for consulta-
tion on implementing time series models in MPLUS.
Conflict of Interest: The authors declare that they do not have any
conflicts of interest.
Corresponding Author: Justin K. Benzer, PhD; C e n t er fo r
Organization, Leadership, and Management Research (COLMR) at
the VA Boston Healthcare System (152 M), 150 South Huntington
Avenue, Boston, MA 02860, USA (e-mail: Justin.benzer@va.gov).
Table 2. Overall Change in Performance Measures from Initial to Final Measurement Among VA Facilities
Measure Adoption of performance-based incentives Removal of performance-based incentives
First quarter Last quarter Diff P value First quarter Last quarter Diff P value
Acute Coronary Syndrome
Cardiology Involvement 74 (24) 94 (13) 20 < 0.001 90 (16) 91 (22) 1 0.93
Troponin Returned 74 (29) 96 (8) 22 < 0.001 94 (13) 92 (18) 2 0.35
Diagnostic Catheterization 91 (21) 95 (12) 4 0.03 94 (17) 93 (19) 1 0.26
Heart Failure
ACE-I or ARB 89 (23) 92 (15) 3 0.26 90 (17) 89 (19) 1 0.50
Weight Monitoring 80 (23) 92 (13) 12 < 0.001 91 (11) 90 (16) 1 0.66
Pneumonia
Timely Antibiotic 64 (21) 82 (19) 18 < 0.001 81 (13) 85 (17) 4 0.06
Pneumococcal Immunization 85 (14) 92 (13) 7 < 0.001 89 (10) 92 (13) 3 0.05
Values represent mean percentage scores with standard deviation of the percentage in parentheses; Diff indicates the absolute difference in mean
percentage scores; p values indicate whether mean scores significantly changed overall across each measurement period; paired t-tests (two-tailed)
conducted to provide an overall summary of the change, results are consistent with latent growth models
Benzer et al.: Sustainability of QI after Removing IncentivesJGIM
Page 5
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Benzer et al.: Sustainability of QI after Removing Incentives JGIM
Page 6
    • "27 Two studies examined changes in incentives within the VHA. Benzer et al. (2013) evaluated the effect of incentive removal and found that all improvements were sustained for up to 3 years. 22 Similarly, Hysong and others (2011) evaluated changes in measure status, that is, the effect on performance when measures shift from being passive monitored (i.e., no incentive) to actively monitored (i.e., incentivized), and vice versa. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P. Methods: We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight. Results: Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence. Discussion: There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
    No preview · Article · Mar 2016 · Journal of General Internal Medicine
    • "Any of these consequences may lead to providers gaming the system for higher reimbursement [28] [29]. Another consequence associated with pay for performance is excessive testing, which may not improve quality of care [28]. "
    [Show abstract] [Hide abstract] ABSTRACT: The goal of this study was to evaluate the trend in urinary tract infections (UTIs) from 2005 to 2009 and determine the initial impact of Medicare's nonpayment policy on the rate of UTIs in acute care hospitals. October 2008 commenced Medicare's nonpayment policy for the additional care required as a result of hospital-acquired conditions, including catheter-associated urinary tract infections (CAUTIs). CAUTIs are the most common form of hospital-acquired infections. Rates of CAUTIs were analyzed by patient and hospital characteristics at the hospital level on a quarterly basis, yielding 20 observation points. October 2008 was used as the intervention point. A time series analysis was conducted using the 2005-2009 Nationwide Inpatient Sample datasets. A repeated measures Poisson regression growth curve model was used to analyze the rate of CAUTIs by hospital characteristics. The annual rate of CAUTIs continues to rise; however the annual rate of change is starting to decline. The change in rate of CAUTIs was not significantly different before and after the policy's payment change. The results of the adjusted time series analysis show that various hospital characteristics were associated with a significant decline in rate of CAUTIs in quarters 16-20 (after the policy implementation) compared to the rate in time 1-15 (before the policy implementation), while other characteristics were associated with a significant increase in CAUTIs. Medicare's nonpayment policy was not associated with a reduction in hospitals' CAUTI rates. The use of administrative data, improper coding of CAUTIs at the hospital level, and the short time period post-policy implementation were all limitations in this study.
    No preview · Article · Dec 2013 · Health Policy
  • No preview · Article · Dec 2013 · Journal of General Internal Medicine
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