The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample

Abstract

Object: As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of "never events" that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities.

Methods: This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs.

Results: The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors.

Conclusions: Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.

Keywords: AHRQ = Agency for Healthcare Research and Quality; AVM = arteriovenous malformation; CAS = carotid artery stenting; CEA = carotid endarterectomy; CMS = Centers for Medicaid and Medicare Services; CVP = cerebrovascular procedure; EC-IC = extracranial-intracranial; HAC = hospital-acquired condition; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LOS = length of stay; NIS = Nationwide Inpatient Sample; UTI = urinary tract infection; cerebrovascular disease; hospital performance; stroke; surgery; vascular disorders.