Using Administrative Discharge Diagnoses to Track Hospital-Acquired Pressure Ulcer Incidence-Limitations, Links, and Leaps

摘要

Hospital-acquired pressure ulcers are expensive, painful, and often-but not always-preventable. Before October 2008, hospitals could receive additional payment for a pressure ulcer diagnosis as a comorbidity, whether as present-on-admis-sion (POA) or a hospital-acquired event. This additional payment served as a type of perverse incentive because hospitals could be financially rewarded when a patient experienced a hospital-acquired pressure ulcer (HAPU). In response, two Medicare programs have been initiated with the dual goals of motivating hospitals to prevent pressure ulcers while also reducing spending by removal of payment related to pressure ulcers. First, the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Conditions Initiative, implemented in October 2008, greatly changed payment for pressure ulcers by removing all pressure ulcers as payable comorbid-ities in administrative data except for POA stage Ⅲ or Ⅳ pressure ulcers. The initiative's implementation required use of POA status codes and new stage-specific codes to provide in addition to location-specific diagnosis codes in administrative data. With these new codes, administrative data were transformed from a dataset in which hospital incidence rates of pressure ulcers (unknown status at admission, unknown stage) that were billed as diagnoses for requesting payment to a dataset that could be used to easily calculate incidence rates of stage-specific pressure ulcers (such as hospital-acquired stages Ⅲ or Ⅳ) to publicly report, compare hospital performance, and penalize hospitals accordingly. As a next step, the Hospital-Acquired Conditions Reduction Program, implemented in October 2014, generates composite complication scores for pressure ulcer events and other hospital-acquired conditions, as assessed by the Agency for Healthcare Research and Quality's (AHRQ's) Patient Safety Indicators (PSIs) algorithms applied to administrative data, for hospital comparison and penalization of the hospitals with the highest (that is, worst) complication rates by reducing overall Medicare payments.