Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
Jordan University of Science and Technology, Irbid, Jordan.
JAMA Netw Open. 2021 Oct 1;4(10):e2132114. doi: 10.1001/jamanetworkopen.2021.32114.
Health care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown.
To examine the association between VBIP implementation and HO-CDI rates.
DESIGN, SETTING, AND PARTICIPANTS: This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals.
Implementation of VBIPs in October 2016.
Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods).
The study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation. Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation.
In this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health care-associated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.
2016 年 10 月，美国疾病控制与预防中心的国家医疗保健安全网络（NHSN）向美国医疗保险和医疗补助服务中心（CMS）的两个基于价值的激励计划（VBIP）报告的医疗机构发病艰难梭菌感染（HO-CDI）率成为了一个目标质量指标。VBIP 与 HO-CDI 率之间的关联尚不清楚。
检验 VBIP 实施与 HO-CDI 率之间的关联。
设计、地点和参与者：这项中断时间序列研究评估了 2013 年 1 月至 2019 年 3 月期间，265 家急性护理医院住院的成年人的 HO-CDI 率。
2016 年 10 月实施 VBIP。
由参与医院向 NHSN 报告的每 10000 个患者日的 HO-CDI 季度发生率，使用广义估计方程拟合负二项回归模型，以估计即时计划效应大小（即水平变化）和 HO-CDI 率斜率的变化，同时控制每个医院主要的 CDI 检测方法（即核酸扩增检测 [NAAT]、毒素酶免疫测定 [EIA]或其他检测方法）。
研究队列包括 24332938 例住院治疗，109371136 个患者日，265 家医院发生 74681 例 HO-CDI 事件（145[55%]家医院有 100-399 张病床；205[77%]家非盈利医院；185[70%]家教学医院；229[86%]家位于大都市区）。与 EIA 相比，当使用 NAAT 检测时，HO-CDI 的发生率更高（调整后的发病率比 [aIRR]，1.55；95%CI，1.40-1.70；P<0.001）和其他检测方法（aIRR，1.47；95%CI，1.26-1.71；P<0.001）。VBIP 实施后，医院立即使用的检测方法没有明显变化。在控制 CDI 检测方法的情况下，VBIP 实施与 HO-CDI 率在政策发布后的立即季度下降 6%（aIRR，0.94；95%CI，0.89-0.99；P=0.01）和每季度下降 4%的斜率（aIRR，0.96；95%CI，0.95-0.97；P<0.001）相关。使用考虑到 HO-CDI VBIP 政策公布后至实施前的 1 年滚动期的敏感性分析，结果相似。
在这项研究中，VBIP 实施与 HO-CDI 率的改善有关，而与 CDI 检测方法无关。鉴于 CMS 的支付政策以前与其他有针对性的医疗相关感染率的改善无关，未来的研究应侧重于阐明导致 HO-CDI 率改善的具体过程，以为未来 VBIP 干预措施的设计提供信息。
