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    Original Investigation
    Health Policy
    July 8, 2020

    Association Between Federal Value-Based Incentive Programs and Health Care–Associated Infection Rates in Safety-Net and Non–Safety-Net Hospitals

    Author Affiliations
    • 1Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
    • 2Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
    • 3Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 4Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 5Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
    JAMA Netw Open. 2020;3(7):e209700. doi:10.1001/jamanetworkopen.2020.9700
    Key Points español 中文 (chinese)

    Question  How is the implementation of federal value-based incentive programs associated with disparities in health care–associated infection rates in safety-net and non–safety-net hospitals in the US?

    Findings  In this interrupted time series study of 618 hospitals, implementation of federal value-based incentive programs was not associated with any improvements in targeted health care–associated infection rates or with changes in disparities in infection rates among safety-net and non–safety-net hospitals.

    Meaning  Results of this study suggest that, given the persistent disparities in health care–associated infection rates, value-based incentive programs currently function as a disproportionate financial penalty system for safety-net hospitals that provide no measurable population-level benefits.

    Abstract

    Importance  In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non–safety-net institutions. Whether these programs differentially change the rates of targeted health care–associated infections in safety-net vs non–safety-net hospitals is unknown.

    Objective  To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care–associated infections and disparities in rates among safety-net and non–safety-net hospitals.

    Design, Setting, and Participants  This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.

    Exposures  HACRP and HVBP implementation in fiscal year 2015 or 2016.

    Main Outcomes and Measures  The primary outcomes were rates of 4 health care–associated infections: central line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care–associated infection rates and disparities in infection rates.

    Results  Of the 618 acute care hospitals included in this study, 473 (76.5%) were non–safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care–associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non–safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non–safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).

    Conclusions and Relevance  This study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care–associated infections among safety-net or non–safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care–associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.

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