FY 2019 Annual Performance Plan and Report - Goal 1. Objective 2

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Goal 1. Objective 2: Expand safe, high-quality health care options, and encourage innovation and competition

Strengthening the Nation’s health care system cannot be achieved without improving health care quality and safety for all Americans.  The immediate consequences of poor quality and safety include health care-associated infections, adverse drug events, and antibiotic resistance.

Health care safety is a national priority.  When the Office of Inspector General examined the health records of hospital inpatients in 2008, it determined that hospital care contributed to the deaths of 15,000 Medicare beneficiaries each month.  Health care-associated infections are infections people get while they are receiving medical treatment or undergoing surgery.  At any given time, about 1 in 25 patients have an infection related to hospital care. Infections lead to the loss of tens of thousands of lives and cost the U.S. health care system billions of dollars each year.  Adverse drug events—injuries resulting from medical intervention related to a drug—result in more than 3.5 million physician office visits, 1 million emergency department visits, and 125,000 hospital admissions each year.

HHS investments in prevention have yielded both human and economic benefits. From 2010 to 2014, efforts to reduce hospital-acquired conditions and infections have resulted in a decrease of 17 percent nationally, translating to 87,000 lives saved, $19.8 billion in unnecessary health costs averted, and 2.1 million instances of harm avoided.

The Office of the Secretary leads this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, CDC, CMS, HRSA, OCR, ONC, and SAMHSA. 

Objective 1.2 A Table of Related Performance Measures

Antibiotics have been a critical public health tool since the discovery of penicillin in 1928, saving the lives of millions of people around the world.  Today, however, the emergence of drug resistance in bacteria is reversing the miracles of the past eighty years, with drug choices for the treatment of many bacterial infections becoming increasingly limited, expensive, and, in some cases, nonexistent. CDC estimates that drug-resistant bacteria cause two million illnesses and approximately 23,000 deaths each year in the United States alone.  In 2016, about 64% of U.S. acute care hospitals reported having an antibiotic stewardship program that incorporates all of the CDC Core Elements for Hospital Antibiotic Stewardship Programs.  Thus, CDC exceeded its 2016 target and is on track to meet its 2017 target.  In FY 2018 and 2019, CDC will continue to work with public and private partners to encourage hospitals to continue implementing antibiotic stewardship programs that are fully compliant with CDC Core Elements for Hospital Antibiotic Stewardship Programs to improve health care, decrease health consequences (e.g., C. difficile infections), and ultimately prevent antibiotic resistance.

A “hospital readmission" occurs when a patient who has recently been discharged from a hospital is once again readmitted to a hospital.  A thirty-day period for readmission data has been standard across the quality measure industry for several years.  Discharge from a hospital is a critical transition point in a patient’s care; incomplete handoffs at discharge can lead to adverse events for patients and avoidable readmissions.  Hospital readmissions may indicate poor care, missed opportunities to better coordinate care, and result in unnecessary costs.

While many studies have pointed to opportunities for improving hospital readmission rates, the rate of readmissions for individuals who are dually eligible for both Medicare and Medicaid (also referred to as Medicare-Medicaid Enrollees) is often higher than for Medicare beneficiaries overall.  In 2016 an estimated 11.7 million beneficiaries were dually eligible for Medicare and Medicaid.

Compared to non-dually eligible Medicare beneficiaries, Medicare-Medicaid enrollees have higher rates of chronic and co-morbid conditions and higher rates of institutionalization, as well as challenges posed by socioeconomic issues.  As a result, we seek to assess the impact of interventions on this sub-population.

In calendar year (CY) 2013, CMS implemented two demonstrations focused on improving care for Medicare-Medicaid enrollees.  The first and larger demonstration is the Financial Alignment Initiative, in which CMS partners with state Medicaid agencies to test models for integrated, coordinated care for this population.  The second demonstration is the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. 

This measure is calculated using the number of readmissions per 1,000 eligible beneficiaries.  This is a more sensitive measure for dual-eligible beneficiaries than the rate of readmissions (numerator) divided by admissions (denominator) used in other hospital readmissions measures.  There has been concern that such a ratio does not accurately capture quality improvement outcomes of decreased readmissions and admissions at any given hospital.  For example, such a ratio can remain unchanged if admissions decline at the same rate as readmissions due to hospital quality improvement efforts to reduce both.

Based on national trends reflecting a slowing in readmissions reductions for all Medicare beneficiaries, CMS now proposes a relatively modest target reduction rate of 1 percent from the prior year’s actual result for both CY 2018 and CY 2019.

Patient Safety Cluster

The purpose of this measure is to determine the national impact of patient safety efforts by counting the number of preventable patient harms that take place per 1,000 inpatient discharges.  Examples of some of the preventable patient harms included in this measure are:

• Adverse Drug Events (ADEs);
• Catheter-Associated Urinary Tract Infections (CAUTI);
• Central Line-Associated Bloodstream Infections (CLABSI);
• Falls;
• Pressure Ulcers (PrUl);
• Surgical Site Infections (SSI);
• Ventilator-Associated Pneumonia/Events (VAP/VAE);
• Venous Thromboembolism (VTE); and
• Hospital Readmissions.

These preventable harms can cause additional pain, stress, and costs to the patient and their family during intended treatment, as well as increased spending on the part of payers.  This measure utilizes the AHRQ National Scorecard, which includes abstraction from a nationally representative sample of approximately 30,000 hospital charts per year that yields clinical relevant yet highly standardized national hospital safety metrics.  This system is in active operation, and was originally put into place to measure the impact of the Partnership for Patients (PfP) Center for Medicare & Medicaid Innovation (CMMI) model test.  By itself however, it represents an enormous contribution to the government’s ability to measure, monitor, and improve patient safety at a national scale.  As a composite of many different harms, the AHRQ National Score Card also includes data from the CDC’s National Health care Safety Network (NHSN) and AHRQ’s Health care Cost and Utilization Project (HCUP) databases.

The results of this dataset thus far demonstrate a reduction in harm from 145 harms per 1,000 discharges in the baseline year of CY 2010 (defined prior to the PfP model test), to 115 harms per 1,000 discharges in CY 2015, the latest year for which preliminary data are available at this time.  These data demonstrate a reduction in harm to patients of approximately 21 percent over five years.

Reducing HAIs across all health care settings supports the HHS mission to prevent infections and its complications as well as reduce excess health care costs in the U.S.  These efforts also align with the National Action Plan to Prevent Health care Associated Infections: Roadmap to Elimination (National HAI Action Plan),^[5] and Healthy People 2020 Goals.^[6]  Between CY 2008 and CY 2015, CLABSIs decreased 40 percent nationally in U.S. hospitals.  While the overall Standardized Infection Ratio of 0.60 falls short of the 2015 target, CDC continues to move forward to meet the goals in the National HAI Action Plan.  In 2015, CDC developed a new baseline for all HAIs including CLABSI to better assess national and local prevention progress and identify gaps for tailored prevention.  Beginning with 2015 data, HAI prevention progress will be measured to the new baseline.  CDC will shift the national CLABSI targets for Measure 3.3.3 to incorporate these changes in future performance documents.

Clostridium difficile infection (CDI)^[8] is a preventable, life-threatening bacterial infection that can occur in both inpatient and outpatient health care settings.  CDC provides data-driven strategies and tools for targeted intervention to the health care community to help prevent CDI, as well as resources to help the public safeguard their own health.  CDI prevention is a national priority, with a 2020 target to reduce CDI by 50 percent in the National Action Plan for CARB and the 2015 National HAI Action Plan.^[9]  To better identify and make improvements to prevention efforts for CDI nationwide, CDC created a new CDI metric that consists of two sub-measures, one of which is hospital-onset CDI.  Starting at an initial baseline of 1.00 for this measure in 2014, progress in the CDI measure will assist CDC in targeting resources to where there is the greatest need to make the most impact. 9The baseline year for this measure changed from 2014 to 2015 to align to changes in the 2015 HHS HAI Action Plan.