Published in the November 2008 issue of Today’s Hospitalist
It looks like the days when UTIs “get no respect” may be coming to a close.
Just last month, the Centers for Medicare and Medicaid Services (CMS) stopped paying for hospital-acquired UTIs, citing the high costs of what it says is a preventable complication: In 2007 alone, Medicare paid to treat 12,000 UTIs at approximately $44,000 per case.
As a result, hospitals are finding that they’re suddenly on the hook for a condition that many have viewed as a common hazard of hospitalization.
“The CMS has now done its part in making sure hospital-acquired UTIs are no longer the Rodney Dangerfield of nosocomial infections,” says Sanjay Saint, MD, MPH, a hospitalist who has authored several studies on UTI prevention. “Now it’s up to individuals at the hospital to take ownership of this problem.”
By individuals, Dr. Saint is referring to hospital epidemiologists, infection control professionals, nurses and hospitalists, who he thinks have a unique opportunity to make sure that their facilities don’t feel the sting of Medicare’s “no-pay” policy. Hospitalists can do that by not only preventing UTIs in their patients, but by working with coders to document instances of patients who already have an infection when they’re admitted.
“Given the CMS rule changes,” Dr. Saint points out, “if a hospital is providing funding for hospitalists, it’s not unreasonable to ask those hospitalists to focus on those complications that would also benefit the hospital’s bottom line.”
Not a “sexy” topic
Dr. Saint, author of two recent studies that explored UTI prevention, says that hospitalists need to start by recognizing why UTIs haven’t been a high priority.
Because hospitals have had little in the way of federal guidance to deal with infections, most have made UTIs a low-priority item. That was an issue that Dr. Saint explored in research that appeared in the Jan. 15, 2008, issue of Clinical Infectious Diseases.
That study, which set out to identify what hospitals were doing to prevent UTIs, found a hodgepodge of methods ” or nothing at all. Less than 10% of hospitals, for instance, were using reminders to make sure that catheters were being removed. Less than one-third of hospitals were using prevention techniques like antimicrobial catheters and bladder ultrasound.
Why do hospitals and physicians have such a poor record when it comes to preventing UTIs? Another study of 14 hospitals found that most considered the infection a low priority. The study, led by Dr. Saint and published in the April 2008 issue of Infection Control & Hospital Epidemiology, found that some facilities didn’t even bother to track UTIs.
As one respondent noted, “I would say there’s a general perception “¦ that urinary tract infections don’t cause a lot of morbidity and mortality compared to the quote, sexy topic such as blood stream infection or surgical site infection or VAP.”
Dr. Saint, a hospitalist at the Ann Arbor VA Medical Center and the University of Michigan in Ann Arbor, says that’s the common mindset among hospital workers. “A urinary catheter is considered like an IV,” he explains. “Insertion is one of the costs of doing business.”
The impact of patient dignity
The April study did find, however, that hospitals recognized the value of early catheter removal, referring to the practice as “medicine 101.” The problem was that early removal was often hampered by the lack of any systematic approach to tracking or removing catheters in a timely manner.
While hospitals cited other priorities, Dr. Saint says that the hard truth is that leaving a catheter in a patient makes life easier for nurses.
“I don’t mean to imply that nurses are doing things out of their own convenience at the expense of patients,” he says. “But having a patient with an indwelling catheter is easier to manage vs. taking someone to the toilet every few hours and changing the bedsheets several times a day.”
The hospitals in the April study that made UTI prevention a priority took a different tack. Instead of focusing on the clinical reasons for removing catheters, they focused on noninfectious complications like patient dignity.
“I thought that was a clever approach,” says Dr. Saint, who is also director of the VA/University of Michigan Patient Safety Enhancement Program. “Even if UTIs are dismissed as less than important, it’s hard to argue that pain, discomfort or lack of mobility isn’t an important reason to remove a catheter that serves no purpose.”
The April study also highlighted the need to enroll physician champions in efforts to prevent UTIs. Researchers found that those champions must work closely with physicians who feel like they’re being nagged about catheters through computers, notes or nurses. “This is a good role for hospitalists,” Dr. Saint says.
Dr. Saint’s April study also highlighted other strategies that raised the visibility of UTI prevention.
Some hospitals that relied on hospital-specific pilot studies, for instance, found that antimicrobial-impregnated urinary catheters could help prevent UTIs. Even hospitals that initially decided against using the more expensive catheters were often eventually persuaded to do so by being given a price discount from a manufacturer that offset the higher price.
Another factor that promoted prevention was public reporting of infection rates, including those of UTIs. However, public reporting raises the issue of adjusting for case mix differences. Because sicker patients are more likely to develop UTIs, a hospital with sicker patients would show higher rates.
“If we can address that challenge, we likely will decrease rates across the board because people will pay more attention to UTIs,” says Dr. Saint.
While Dr. Saint predicts that Medicare’s new “no-pay” policy regarding UTIs will have a positive effect, he cautions that it may also have unintended consequences.
Suppose hospitals decide to perform screening urinalysis and cultures on all patients admitted to the hospital so an infection that was present on admission won’t affect payment. This strategy would not only be costly, but it would put hospitalists in a situation where they have to decide to treat an asymptomatic patient who had a positive test.
And to make sure that they are paid to treat the UTIs of patients who are admitted with an infection, hospitals ” and hospitalists “will have to open up the lines of communication with coders. That’s because the CMS will pay hospitals to treat UTIs only if those infections are coded as “present on admission.”
If a hospital tries to bill Medicare for a UTI on a patient without providing the appropriate code to indicate that the infection was present on admission, the claim will be rejected “or worse. If it isn’t clear that the patient was admitted with a UTI, the hospital could be investigated for billing fraud during a Medicare audit, if that hospital systematically billed Medicare for the costs of treating UTIs that developed during hospitalization. “As of Oct. 1,” Dr. Saint explains, “the CMS has raised the stakes.”
Hospitals may receive more help on how to handle UTIs from a new study being sponsored by the National Institutes of Health and the MHA Keystone Center for Patient Safety and Quality in Lansing, Mich. Researchers are evaluating what’s being called a “bladder bundle,” which is a set of catheter-associated UTI prevention practices similar to those that Dr. Saint and his research team surveyed hospitals on in their January study.
Because no one technique has really proven to be the best practice, this study will try to help hospitals standardize their approach to catheter-acquired UTIs. It will also try to identify UTI prevention champions and determine how many are hospitalists, Dr. Saint adds.
He notes that his January study specifically asked about the role that hospitalists played in UTI prevention efforts, but researchers found that the presence of hospitalists didn’t predict the use of any particular practice. Dr. Saint thinks that may have changed because more hospitals now have hospitalists than when his study was conducted in 2005.
Finally, the CDC is reviewing UTI guidelines last issued in 1981. While the agency is scheduled to release new guidelines soon, Dr. Saint says that for now, hospitals can rely upon guidance from other groups. Last month, for instance, the Society of Epidemiology of America and the Infectious Diseases Society of America issued a compendium of strategies to prevent health care-associated infection in hospitals. That compendium, which included UTIs, was released in the Oct. 8, 2008, issue of Infection Control & Hospital Epidemiology.
As for Dr. Saint, he plans to resurvey hospitals early next year, about six months after Medicare’s rule change. He hopes that research will identify not only the practices that hospitals are using to prevent UTIs, but whether the CMS initiative had had any effect.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.