Medicare Cuts Payments To 721 Hospitals With Highest Rates Of Infections, Injuries

In its toughest crackdown yet on medical errors, the federal government is cutting payments to 721 hospitals for having high rates of infections and other patient injuries, records released Thursday show.

Medicare assessed these new penalties against some of the most renowned hospitals in the nation, including the Cleveland Clinic, Brigham and Women’s Hospital in Boston, the Hospital of the University of Pennsylvania in Philadelphia and Geisinger Medical Center in Danville, Pa.

One out of every seven hospitals in the nation will have their Medicare payments lowered by 1 percent over the fiscal year that began Oct. 1 and continues through September 2015. The health law mandates the reductions for the quarter of hospitals that Medicare assessed as having the highest rates of “hospital-acquired conditions,” or HACs. These conditions include infections from catheters, blood clots, bed sores and other complications that are considered avoidable.

The penalties, which are estimated to total $373 million, are falling particularly hard on academic medical centers: Roughly half of them will be punished, according to a Kaiser Health News analysis.

Dr. Eric Schneider, a Boston health researcher who has interviewed patient safety experts for his studies, said research has demonstrated that medical errors can be reduced through a number of techniques. But “there’s a pretty strong sense among the experts we talked to that they are not widely implemented,” he said. Those methods include entering physician orders into computers rather than scrawling them on paper, better hand hygiene and checklists on procedures to follow during surgeries. “Too many clinicians fail to use those techniques consistently,” he said.

The penalties come as the hospital industry is showing some success in reducing avoidable errors. A recent federal report found the frequency of mistakes dropped by 17 percent between 2010 and 2013, an improvement U.S. Health and Human Services Secretary Sylvia Burwell called “a big deal, but it’s only a start.” Even with the reduction, one in eight hospital admissions in 2013 included a patient injury, according to the report from the federal Agency for Healthcare Research and Quality, or AHRQ.

The new penalties are harsher than any prior government effort to reduce patient harm. Since 2008, Medicare has refused to pay hospitals for the cost of treating patients who suffer avoidable complications. Legally, Medicare can expel a hospital with high rates of errors from its program, but that punishment is almost never done, as it is a financial death sentence for most hospitals. Some states issue their own penalties — California, for instance, levies fines as high as $100,000 per incident on hospitals that are repeat offenders.

The government has also been giving money to some hospitals and quality groups to help improve patient safety efforts.

The HAC program has “put attention to the issue of complications and that attention wasn’t everywhere,” said Dr. John Bulger, Geisinger’s chief quality officer. However, he said hospitals such as his now must spend more time reviewing their Medicare billing records as the government uses those to evaluate patient safety. The penalty program, he said, “has the potential to take the time that could be spent on improvement and making sure the coding is accurate.”

In its toughest crackdown yet on medical errors, the federal government is cutting payments to 721 hospitals for having high rates of infections and other patient injuries, records released Thursday show.

Medicare assessed these new penalties against some of the most renowned hospitals in the nation, including the Cleveland Clinic, Brigham and Women’s Hospital in Boston, the Hospital of the University of Pennsylvania in Philadelphia and Geisinger Medical Center in Danville, Pa.

infections hospital 570One out of every seven hospitals in the nation will have their Medicare payments lowered by 1 percent over the fiscal year that began Oct. 1 and continues through September 2015. The health law mandates the reductions for the quarter of hospitals that Medicare assessed as having the highest rates of “hospital-acquired conditions,” or HACs. These conditions include infections from catheters, blood clots, bed sores and other complications that are considered avoidable.

The penalties, which are estimated to total $373 million, are falling particularly hard on academic medical centers: Roughly half of them will be punished, according to a Kaiser Health News analysis.

Dr. Eric Schneider, a Boston health researcher who has interviewed patient safety experts for his studies, said research has demonstrated that medical errors can be reduced through a number of techniques. But “there’s a pretty strong sense among the experts we talked to that they are not widely implemented,” he said. Those methods include entering physician orders into computers rather than scrawling them on paper, better hand hygiene and checklists on procedures to follow during surgeries. “Too many clinicians fail to use those techniques consistently,” he said.

The penalties come as the hospital industry is showing some success in reducing avoidable errors. A recent federal report found the frequency of mistakes dropped by 17 percent between 2010 and 2013, an improvement U.S. Health and Human Services Secretary Sylvia Burwell called “a big deal, but it’s only a start.” Even with the reduction, one in eight hospital admissions in 2013 included a patient injury, according to the report from the federal Agency for Healthcare Research and Quality, or AHRQ.

Download the data
PENALTIES FOR HOSPITAL-ACQUIRED INFECTIONS
Medicare is penalizing hospitals with high rates of infections. View by hospital, state and other data:

HAC Penalty Chart (PDF)
HAC Penalty Chart (CSV)
The new penalties are harsher than any prior government effort to reduce patient harm. Since 2008, Medicare has refused to pay hospitals for the cost of treating patients who suffer avoidable complications. Legally, Medicare can expel a hospital with high rates of errors from its program, but that punishment is almost never done, as it is a financial death sentence for most hospitals. Some states issue their own penalties — California, for instance, levies fines as high as $100,000 per incident on hospitals that are repeat offenders.

The government has also been giving money to some hospitals and quality groups to help improve patient safety efforts.

The HAC program has “put attention to the issue of complications and that attention wasn’t everywhere,” said Dr. John Bulger, Geisinger’s chief quality officer. However, he said hospitals such as his now must spend more time reviewing their Medicare billing records as the government uses those to evaluate patient safety. The penalty program, he said, “has the potential to take the time that could be spent on improvement and making sure the coding is accurate.”

This KHN story can be republished for free (details).
Hospitals complain that the new penalties are arbitrary, since there may be almost no difference between hospitals that are penalized and those that narrowly escape falling into the worst quarter.

“Hospitals may be penalized on things they are getting safer on, and that sends a fairly mixed message,” said Nancy Foster, a quality expert at the American Hospital Association.

Hospital officials also point out those that do the best job identifying infections in patients may end up looking worse than others. “How hard you look for something influences your results,” said Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System. “We have a huge infection control group, one of the largest in the country. I tell them to go out and find it.” Campbell’s hospital had a high rate of urinary tract infections but was not penalized because it had fewer serious complications than most hospitals, records show.

The penalties come on top of other financial incentives Medicare has been placing on hospitals. This year, Medicare has already fined 2,610 hospitals for having too many patients return within a month of discharge. This is the third year those readmission penalties have been assessed. This is also the third year Medicare gave bonuses and penalties based on a variety of quality measures, including death rates and patient appraisals of their care. With the HAC penalties now in place, the worst-performing hospitals this year risk losing more than 5 percent of their regular Medicare reimbursements.

In determining the HAC penalties, Medicare judged hospitals on three measures: the frequency of central-line bloodstream infections caused by tubes used to pump fluids or medicine into veins, infections from tubes placed in bladders to remove urine, and rates of eight kinds of serious complications that occurred in hospitals, including collapsed lungs, surgical cuts, tears and reopened wounds and broken hips. Medicare tallied that and gave each hospital a score on a 10-point scale. Those in the top quarter — with a total score above 7 — were penalized.

About 1,400 hospitals are exempt from penalties because they provide specialized treatments such as psychiatry and rehabilitation or because they cater to a particular type of patient such as children and veterans. Small “critical access hospitals” that are mostly located in rural areas are also exempt, as are hospitals in Maryland, which have a special payment arrangement with the federal government.

The AHRQ study found that the biggest decreases in errors among those it studied occurred in the two categories of infections Medicare used in setting the penalties. Central-line associated bloodstream infections decreased by 49 percent and catheter-associated urinary tract infections dropped by 28 percent between 2010 and 2013. By contrast, pneumonia cases picked up by patients on ventilators that help them breathe – a condition not covered by the new penalties — decreased by only 3 percent during the same period.

Some of the errors on which the Medicare HAC penalties are based are rare compared to other mistakes the government tracks. For instance, AHRQ estimated that in 2013 there were 760,000 bad drug reactions to medicine that controls blood sugar in diabetics, but only 9,200 central-line infections. Infections from tubes inserted into urinary tracts are more common — AHRQ estimated there were 290,000 in 2013 — but those infections tend to be easier to treat and less likely to be lethal.

On the other measures, the study estimated there were 240,000 falls and more than 1 million bedsores.

In evaluating hospitals for the HAC penalties, the government adjusted infection rates by the type of hospital. When judging complications, it took into account the differing levels of sickness of each hospital’s patients, their ages and other factors that might make the patients more fragile. Still, academic medical centers have been complaining those adjustments are insufficient given the especially complicated cases they handle, such as organ transplants.

Medicare penalized 143 of 292 major teaching hospitals, the KHN analysis found. Penalized teaching hospitals included Ronald Reagan UCLA Medical Center and Keck Medicine of USC in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital and University of Illinois Hospital in Chicago; George Washington University Hospital and Washington Hospital Center in Washington, D.C.

“We know some of the procedures we do — heart transplants or resecting cancerous portions of the esophagus — are going to be just more prone to having some of these adverse events,” said Dr. Atul Grover, the chief public policy officer of the Association of American Medical Colleges. “To lump in all of those things that are very complex procedures with simple things like pneumonia or hip replacements may not be giving an accurate result.”

An analysis of the penalties that Dr. Ashish Jha, a professor at the Harvard School of Public Health, conducted for KHN found that penalties were assessed against 32 percent of the hospitals with the sickest patients. Only 12 percent of hospitals with the least complex cases were punished. Hospitals with the poorest patients were also more likely to be penalized, Jha found. A fourth of the nation’s publicly owned hospitals, which often are the safety net for poor, sick people, are being punished.

“I’ve worked in community hospitals, I’ve worked in teaching hospitals. My personal experience is teaching hospitals are at least as safe if not safer,” Jha said. “But they take care of sicker populations and more complex cases that are going to have more complications. The HAC penalty program is really a teaching hospital penalty program.”

Medicare levied penalties against a third or more of the hospitals it assessed in Colorado, Connecticut, Delaware, Nevada, New Jersey, New Mexico, Rhode Island, Utah, Washington and the District of Columbia, the KHN analysis found.

The penalties are reassessed each year and Medicare plans to add in more kinds of injuries. Starting next October, Medicare will assess rates of surgical site infections to its analysis. The following year, Medicare will examine the frequency of two antibiotic-resistant germs: Clostridium difficile, known as C. diff, and methicillin-resistant Staphylococcus aureus, known as MRSA.

HOLIDAY BOWL THIS FRIDAY!

HOLIDAY BOWL
Friday, December 19th

Housestaff vs Faculty

Starting at noon in D 1.520

The faculty took the win last year in a close battle,
but the housestaff are ready to take back the crown!

(hint: read the blog)

Holiday Bowl and Xmas Sweater

Ludwig’s Angina

Ludwig

  • Infection of the submandibular or sublingual spaces
  • Named after German physician, Wilhelm Friedrich von Ludwig
  • Aggressive, rapidly spreading cellulitis with potential for airway obstruction, carries 5% fatality rate
  • Over 2/3 of Ludwig’s angina have a dental source of infection
  • Once infection established, tongue can swell to 3 times its size
  • Typically polymicrobial infection due to flora from the oral cavity – most common organisms include Streptococcus viridans, Fusobacterium, Bacteroides, Staph aureus, Actinomyces, etc
  • Presentation: tender swelling along mandible with oral pain, neck stiffness and swelling, drooling, and dysphagia
  • Diagnosis: made clinically, imaging by CT scan with contrast or MRI, and surgical drainage with cultures
  • Treatment: Secure airway (intubation or tracheostomy), antibiotics with surgical drainage

Ludwig2

Diagnosis and Management of Neuropsychiatric SLE

Amazing case presentation at Parkland Morning Report of neuropsychatric SLE presenting as severe depression. The diagnosis was made because of the remarkable clinical acumen of our residents! See below for a summary:

Nervous system involvement in systemic lupus erythematosus (SLE) can manifest as a range of neurological and psychiatric features, which are classified using the ACR case definitions for 19 neuropsychiatric syndromes. Approximately one-third of all neuropsychiatric syndromes in patients with SLE are primary manifestations of SLE-related autoimmunity, with seizure disorders, cerebrovascular disease, acute confusional state and neuropathy being the most common. Such primary neuropsychiatric SLE (NPSLE) events are a consequence either of microvasculopathy and thrombosis, or of autoantibodies and inflammatory mediators. Diagnosis of NPSLE requires the exclusion of other causes, and clinical assessment directs the selection of appropriate investigations. These investigations include measurement of autoantibodies, analysis of cerebrospinal fluid, electrophysiological studies, neuropsychological assessment and neuroimaging to evaluate brain structure and function. Treatment involves the management of comorbidities contributing to the neuropsychiatric event, use of symptomatic therapies, and more specific interventions with either anticoagulation or immunosuppressive agents, depending upon the primary immunopathogenetic mechanism. Studies suggest a more favourable outcome for primary NPSLE manifestations.

Neuropsychiatric syndromes in SLE

  • Central nervous system
    • Aseptic meningitis
    • Cerebrovascular disease
    • Demyelinating syndrome
    • Headache
    • Movement disorder
    • Myelopathy
    • Seizure disorders
    • Acute confusional state
    • Anxiety disorder
    • Cognitive dysfunction
    • Mood disorder
    • Psychosis
  • Peripheral nervous system
    • Acute inflammatory demyelinating polyradiculoneuropathy (Guillain–Barré syndrome)
    • Autonomic neuropathy
    • Mononeuropathy
    • Myasthenia gravis
    • Cranial neuropathy
    • Plexopathy
    • Polyneuropathy

NPSLE Fig 1

Investigations in NPSLE

  • Measurement of autoantibodies (antineuronal, antiribosomal P and antiphospholipid antibodies)
  • CSF analysis to exclude infection and measure autoantibodies, inflammatory mediators, and degradation proteins
  • EEG assessment
  • Neuropsychological assessment
  • Neuroimaging: structure (CT, MRI, MTI, DWI, DTI) and function (PET, SPECT, MRA, MRS, fMRI)

NPSLE mediators

Management of neuropsychiatric events in patients with SLE

  • Establish diagnosis of neuropsychiatric SLE: Investigations might include CSF examination (primarily to exclude infection), autoantibody profiling, neuroimaging, and neuropsychological assessment.
  • Identify confounding factors: Comorbidities contributing to the neuropsychiatric event can include hypertension, infection and metabolic abnormalities.
  • Symptomatic therapy: The symptoms of some neuropsychiatric events might be eased by treatment with anticonvulsant, psychotropic and anxiolytic agents.
  • Immunosuppression: Immunosuppressive agents such as corticosteroids, azathioprine, cyclophosphamide, mycophenolate mofetil and B‑lymphocyte depletion can be used to treat neuropsychiatric events arising primarily from inflammatory injury.
  • Anticoagulation: Neuropsychiatric manifestations arising primarily from a prothrombotic vascular injury should be treated with anticoagulants such as acetylsalicylic acid, heparin and warfarin.

Hanly, J. G. Nat. Rev. Rheumatol. 10, 338–347 (2014); published online 11 February 2014; doi:10.1038/nrrheum.2014.15

Mumps – Outbreak in the National Hockey League (NHL)

Since October 2014, there have been over 20 NHL players diagnosed or suspected of having mumps including star player Sidney Crosby from the Pittsburgh Penguins. According to the CDC, since 2010 there have been over 15 outbreaks of mumps each involving at least 20 cases. Check out the article below from The New York Times and a quick summary of mumps from the Johns Hopkins ABX Guide:

The Mumps, a Scourge of Dormitories, Spreads Through the N.H.L.

  • Caused by the paramyxocirus (Rubulavirus) and spread by respiratory transmission or exposure to oral secretions with symptom onset 12-25 days post exposure
  • Patients contagious up to 6 days prior to symptoms and 10 days after symptom resolution
  • Most cases ages 5-14 years old but increasing rates in young adults/college students
  • Typical symptoms: low grade fever, malaise, headache, anorexia, cough, parotiditis (salivary gland swlling)
  • Adolescent and adult males may experience testicular pain/orchitis
  • Serious complications: encephalitis, ovarian inflammation, deafness, pancreatitis
  • Diagnosis: Serology tests available including antibody titers but viral cultures/PCR may need to be processed at health departments including CDC as it may not be commercially available
  • Treatment: Symptom duration usually 10-14 days, supportive treatment including NSAID’s
  • Prevention:
    • Adults born prior to 1957 considered immune
    • Typically MMR used but MMRV (MMR+varicella) also available
    • Routine infant immunization: 12-15 months, 2nd dose at 4-6 years but no later than 11-12 years
    • Durability of immune response: Detectable antibodies in 74-95% of 2-dose recepients at 12 years
    • MMR re-vaccination recommended for travelers in high risk groups including college students, healthcare workers, military personnel, pregnant women

Pulmonary Kaposi’s Sarcoma

General Information:

Kaposi sarcoma is a low-grade mesenchymal tumor involving blood and lymphatic vessels. There are four variants of this disease, each presenting a different clinical manifestation: classic or sporadic, African or endemic, organ transplant-related or iatrogenic, and AIDS-related or epidemic. Kaposi sarcoma is the most common tumor among patients with HIV infection. The pulmonary involvement in Kaposi sarcoma occurs commonly in critically immunosupressed patients who commonly have had preceding mucocutaneous or digestive involvement.

Etiology:

The etiology of Kaposi sarcoma is not precisely established; genetic, hormonal, and immune factors, as well as infectious agents, have all been implicated. There is evidence from epidemiologic, serologic, and molecular studies that Kaposi sarcoma is associated with human herpes virus type 8 infection. The disease starts as a reactive polyclonal angioproliferative response towards this virus, in which polyclonal cells change to form oligoclonal cell populations that expand and undergo malignant transformation.

Diagnosis:

The diagnosis of pulmonary involvement in Kaposi sarcoma usually can be made by a combination of clinical, radiographic, and laboratory findings, together with the results of bronchoscopy and transbronchial biopsy. Chest high-resolution computed tomography scans commonly reveal peribronchovascular and interlobular septal thickening, bilateral and symmetric ill-defined nodules in a peribronchovascular distribution, fissural nodularity, mediastinal adenopathies, and pleural effusions. Correlation between the high-resolution computed tomography findings and the pathology revealed by histopathological analysis demonstrate that the areas of central peribronchovascular infiltration represent tumor growth involving the bronchovascular bundles, with nodules corresponding to proliferations of neoplastic cells into the pulmonary parenchyma. The interlobular septal thickening may represent edema or tumor infiltration, and areas of ground-glass attenuation correspond to edema and the filling of air spaces with blood. These findings are a result of the propensity of Kaposi sarcoma to grow in the peribronchial and perivascular axial interstitial spaces, often as continuous sheets of tumor tissue.

Treatment:

There is increasing evidence that HAART and an improved immune response are associated with complete or partial regression of KS lesions, a decrease in the number of patients suffering from KS, improved survival, and protection of HIV-infected patients against the development of KS. In patients using HAART, regression of the lesions correlates with a decrease in plasma HIV load and improved immune response. Some studies showed that HAART alone can lead to stabilization and regression of KS, often eliminating the need of chemotherapy and radiation therapy, and prolonging remission among patients with a complete response. Patients with pulmonary KS using HAART showed a median survival time of 1.6 years compared with a median survival time of 4 months in the pre-HAART era.

Chemotherapy may result in rapid resolution of KS-associated symptoms and thereby improve quality of life. Cytotoxic chemotherapy is indicated for patients with extensive mucocutaneous KS, rapidly progressive cutaneous disease (more than 10 new lesions per month), symptomatic visceral disease, pulmonary disease, or extensive symptomatic lymphedema. A wide variety of chemotherapeutic agents, individually and in combination, have been evaluated for the treatment of KS. The broad range of KS response rates to single agents (21-80%) is a result of differences in the efficacy of the agents tested, variations in the patient populations treated (including level of immune function, history of prior opportunistic infections, and tumor burden), and lack of standardization of the criteria used to stage these patients or to evaluate their response to treatment. In general, the phase III clinical trials completed since 1990 define the study population and treatment outcomes more rigorously, applying the ACTG staging and response criteria.

KS

From: Orphanet Journal of Rare Diseases 2009, 4:18  doi:10.1186/1750-1172-4-18; and HIV InSite Knowledge Base Chapter 2003. Treatment of HIV-Associated Kaposi Sarcoma.

Shigella!

gmshigella

  • Shigellosis can be caused by very low infectious inoculums (<100 organisms) via foodborne and fecal-oral transmission.
  • Four species of Shigella can cause diarrheal illness (flexneri, sonnei, boydii, and dysteneriae).
  • Most frequently presents as dysentery with abdominal pain, tenesmus, high fevers, mucoid stools.
  • Thought to be caused by colonic invasion of organisms causing inflammation.
  • Diagnosis made by stool culture
  • Empiric treatment should begin if dysentery is clinically suspected and confirmation is pending
  • Treatment is recommended for all patients with a positive culture for Shigella.
  • Decreases the duration of bacterial shedding and limit secondary spread of infection, even if symptoms have resolved by the time culture results are available.
  • Most isolates remain susceptible to fluoroquinolones, and treatment with one of these agents for 5 days is recommended.

Autoimmune vs. Autoinflammatory

A century ago Paul Ehrlich proposed that immune reactivity against self, which he called “horror autotoxicus” and which is now called autoimmunity, would be incompatible with life because of potentially devastating consequences for the host. But Ehrlich was proven wrong after the demonstration of autoantibodies and the emergence of a theoretical basis for autoreactivity. Conceptually, autoimmunity is viewed as a defect of either B or T lymphocyte selection, with aberrant lymphocytic responses to autoantigens. In recent years, an improved genetic understanding of both common and rare diseases, collectively associated with mutations reflecting immune system perturbations—ranging from the thymus, to B and T cells, to T regulatory cells—has vindicated the autoimmunity paradigm.

Nevertheless, there are several difficulties with the autoimmunity concept when considering self-directed tissue inflammation. These difficulties include a lack of major histocompatibility complex (MHC) and autoantibody associations in many diseases, tentatively labelled as autoimmune. A gradual appreciation of these difficulties has led to revised definitions of autoimmunity, but this approach fails to define when self-directed tissue inflammation is not autoimmune in origin.

AIvAI

And there is yet another weakness in the concept of autoimmunity: the idea that the immune system functions by making a distinction between self and nonself has come under scrutiny for failing to explain a number of findings. For example, “Why do we fail to reject tumors, even when many clearly express new or mutated proteins? Why do most of us harbor autoreactive lymphocytes without any sign of autoimmune disease, while a few individuals succumb?”.

To answer these questions, Polly Matzinger proposed the “danger signal theory,” which proposes that the immune system is not so much concerned with self/nonself discrimination but with mounting responses to danger signals, including exogenous pathogenic bacteria and endogenous damaged tissues. However, the danger model does not account adequately for the exquisite specificity of the adaptive immune responses in autoimmune diseases. This article draws on recent advances from genetic and molecular studies and improved clinical insights into disease in order to propose a unified classification and theoretical framework for all immunological diseases.

From: McGonagle D, McDermott MF (2006) A Proposed Classification of the Immunological Diseases. PLoS Med 3(8): e297. doi:10.1371/journal.pmed.0030297

Connective Tissue Disease

The ANA is positive. So is it Lupus, SLE, mixed connective tissue disease, or just a normal variant!? Dr. Davila helps us answer some of these questions with an excellent breakdown of auto-antibodies and connective tissue diseases.

(Note that the slide presentation is not viewable in email format – must visit the actual blog website to access the information).