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Findings Question Measures Used to Assess Hospital Quality

Major teaching hospitals penalized more often

Hospitals that were penalized more frequently in the Hospital-Acquired Condition (HAC) Reduction Program offered advanced services, were major teaching institutions, and had a better performance on other publicly reported process-of-care and outcome measures, according to a new study published in JAMA. These findings suggest that penalization in this program may not reflect poor quality of care but rather may be due to measurement and validity issues of the HAC program’s component measures.

The Patient Protection and Affordable Care Act established the HAC program in an effort to reduce the incidence of preventable adverse events that occur during hospitalizations in the U.S. This program reduces payments to the lowest-performing hospitals. However, it is uncertain whether the program accurately measures quality and fairly penalizes hospitals, according to background information in the article.

Karl Y. Bilimoria, MD, MS, of the Feinberg School of Medicine, Northwestern University, Chicago, and colleagues evaluated the characteristics and performance of hospitals penalized in the HAC Reduction Program. Data for hospitals participating in this program for FY2015 were obtained from the Centers for Medicare and Medicaid Services’ Hospital Compare program and were combined with the 2014 American Hospital Association Annual Survey and FY2015 Medicare Impact File. The authors examined the association between hospital characteristics and HAC program penalization.

An eight-point hospital quality summary score was created using hospital characteristics related to clinical volume, accreditations, and the offering of advanced care services. Publicly reported process-of-care and outcome measures were examined in four clinical areas (surgery, acute heart attack, heart failure, and pneumonia).

Of the 3,284 hospitals participating in the HAC program, 721 (22%) were penalized. Hospitals were more likely to be penalized if they were accredited by the Joint Commission (24% accredited vs. 14% not accredited); if they were major teaching hospitals or “very major” teaching hospitals (42% and 62%, respectively, vs. 17% for non-teaching hospitals); if they cared for more-complex patient populations based on the case-mix index; or if they were safety-net hospitals compared with non–safety-net hospitals (28% vs. 20%, respectively).

Hospitals with higher-quality summary scores had significantly better performance on nine of 10 publicly reported process and outcomes measures compared with hospitals that had lower-quality scores. However, hospitals with the highest quality score of 8 were penalized significantly more often than were hospitals with the lowest quality score of 0 (67% vs. 13%, respectively).

The researchers speculate that one explanation for these findings may be that these component measures are affected by surveillance bias, in which differences in clinical practice result in varying rates of identifying an adverse outcome. “Hospitals that look more for adverse events frequently identify more events and incorrectly appear to have worse performance,” they write.

In addition, hospital-to-hospital differences in information technology may also result in differences in the detection of adverse events.

The authors conclude that “these paradoxical findings suggest that the approach for assessing hospital penalties in the HAC Reduction Program merits reconsideration to ensure it is achieving the intended goals.”

Sources: Medical Xpress; July 28, 2015; and JAMA; July 28, 2015.

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