HAPU rates for Medicare’s VBP program implementation are derived only from administrative discharge data, which is routinely generated for each discharge by hospital coders using Federal criteria. Hospital-acquired pressure ulcer (HAPU) rates are used in three Centers for Medicare and Medicaid Services (CMS) VBP programs ( Exhibit 1) designed to promote quality by financially incentivizing better hospital care. 5– 7 Each year, pressure ulcers are reported to affect as many as 2.5 million patients, cost an estimated $9–11 billion, resulting in 60,000 deaths as a direct consequence of developing pressure ulcers. Patient morbidity, as well as the time and costs required to heal the pressure ulcer varies markedly from Early-Stage pressure ulcers (Stages I or II) compared to Advanced-Stage pressure ulcers (Stages III, IV, Unstageable). Pressure ulcers range in severity from early injuries with no open wounds (Stage I) to very advanced wounds that involve breakdown of all skin layers as well as bone, muscle, or tendon (Stage IV). Strategies to reduce pressure ulcers in hospitalized patients include frequent skin monitoring, improving mobility and repositioning patients in bed, and optimizing nutrition. Risk factors include immobility from paralysis by stroke or spinal cord injury, generalized weakness, malnutrition, advanced age, and poor circulation to skin. Pressure ulcers, also known as pressure injuries when renamed by experts in 2016, are injuries 4 to skin and underlying tissue that typically occur over a bony prominences due to pressure, or pressure with shear and/or friction. 1– 3 These differences in HAC measurement and the subsequent policy and financial implications inspired this study, focused on the hospital-acquired pressure ulcer (HAPU), a common, morbid, and expensive complication. Each data collection strategy has advantages and limitations, and can generate different estimates of HAC incidence as well as assessments of how HAC rates change over time. Several metrics derived from different data sources and collection methods have been used to measure HAC rates for Medicare programs. Several “value-based purchasing” (VBP) programs moderating Medicare hospital payment utilize hospital-specific HAC rates with the goal to financially motivate hospitals to prevent HACs. Transitioning from administrative data to surveillance chart review to measure HAPUs (mirroring hospital-acquired infection reporting), accounting for HAPU severity, could improve HAPU measure validity for assessing the clinical and financial impact of interventions.Įfforts to improve quality and reduce cost often focus on reducing complications that patients develop during hospitalization, known as hospital-acquired conditions (HACs). While HAPUs declined in administrative data, 96% of decline was due to fewer less severe HAPUs. HAPU incidence was ~1/20 th of chart-based surveillance incidence. Thus, we assessed HAPU incidence, severity, and trends using 2009–2014 administrative data from 3 states. VBP programs measure and penalize only for more severe ulcers (Stage III, IV, unstageable) that are much more costly than less severe cases (Stage I, II). Yet, it remains unclear if similar improvements are seen in the administrative data used to implement 3 Medicare value-based purchasing (VBP) programs targeting HAPUs, and how success varied by HAPU severity. Tremendous reductions (23% since 2010) in hospital-acquired pressure ulcers (HAPUs) are reported from surveillance chart reviews, equated as $1 billion savings.
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