Impact of CMS designated Hospital Acquired Condition (HAC) regulations compared to a currently non-CMS regulated hospital acquired infection—Clostridium difficile

INTRODUCTION: Healthcare-associated infections (HAIs) are among the leading causes of death in the United States. Many HAIs are preventable, considering the fact that effective strategies to reduce the incidence of HAIs are readily available. According to the U.S. Department of Health and Human Services (HHS), up to 70% of central line-associated bloodstream infections can be prevented. In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a policy intended to reduce the incidence of specific preventable conditions and to restrict reimbursement for services provided to treat such conditions. CMS has initially designated ten conditions as hospital-acquired conditions (HACs) or complications deemed preventable if not documented as present on admission (POA). Three of these conditions are HAIs—catheter-associated urinary tract infections, surgical site infections, and vascular catheter-associated infections.

METHODS: The purpose of this study is to assess the incidence of a designated HAC (central line-associated blood stream infection) compared to a non-HAC, hospital-acquired infection (Clostridium difficile). In order to do so, an interrupted time series design with a comparator group will be used to assess for any changes in Clostridium difficile infection (CDI) ICU rates compared to ICU rates of central line-associated blood stream infection (CLABSI) both before and after the implementation of reduced reimbursement for the treatment of HAIs designated as HACs by CMS. A case-series study design will also be performed to assess for potential opportunities for intervention prior to discharge for patients readmitted within 30 days of a previous admission that have C. difficile enteritis documented as the principle diagnosis upon readmission.

RESULTS: ICU CLABSI rates did not statistically change over time during the study time period (Student’s t test 1.04, p=0.3); meanwhile, ICU CDI rates trended in an upward direction during the study period (Student’s test 2.68, p=0.01). For patient specific data analysis, 54 patients were readmitted for C. difficile enteritis coded as the principle diagnosis upon readmission. 33 of these 54 patients (61.1%) were discharged home prior to the readmission. Reasons for readmission varied but included new onset CDAD (10), potentially premature discharge (8), medication reconciliation discrepancies including patients being discharge on a gastric acid suppressant without a valid indication for therapy (5), poor adherence to medication therapy on an outpatient basis (4), duration of therapy less than recommended guidelines (3), and relapse or failed a previous therapy regimen (3).

CONCLUSIONS: While efforts have been made to reduce HAIs at the local, state, and national; the incidence of CDI in the ICU setting at an adult teaching hospital trended in an upward direction and the incidence of CLABSI in the same ICU setting did not significantly change over time during the study time period. Patient specific data revealed that potential interventions prior to discharge for patients readmitted with C. difficile enteritis documented as the primary diagnosis upon readmission include: utilization of a CDI severity assessment prior to discharge to minimize premature discharges, optimization of treatment strategies following IDSA guidelines, and completion of medication reconciliation prior to discharge.