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The Impact of the Medicaid Healthcare-Associated Condition Program on Mediastinitis Following Coronary Artery Bypass Graft

  • Heather E. Hsu (a1) (a2) (a3), Alison Tse Kawai (a2) (a3), Rui Wang (a2) (a3) (a4), Maximilian S. Jentzsch (a2) (a3) (a4), Chanu Rhee (a2) (a3) (a5), Kelly Horan (a2) (a3), Robert Jin (a2) (a3), Donald Goldmann (a1) (a6) and Grace M. Lee (a2) (a3) (a7)...



In 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with the rates of a condition not targeted by the program, deep-space surgical site infection (SSI) after knee replacement.


Interrupted time series with comparison group.


We included surveillance data from nonfederal acute-care hospitals participating in the NHSN and reporting CABG or knee replacement outcomes from January 2009 through June 2017. We examined the Medicaid program’s impact on NHSN-reported infection rates, adjusting for secular trends. The data analysis used generalized estimating equations with robust sandwich variance estimators.


During the study period, 196 study hospitals reported 273,984 CABGs to the NHSN, resulting in 970 mediastinitis cases (0.35%), and 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep-space SSIs (0.32%). There was no significant change in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the postprogram versus preprogram periods (P=.70) or an immediate program effect (P=.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect.


The 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates.

Infect Control Hosp Epidemiol 2018;39:694–700


Corresponding author

Address correspondence to Heather Hsu, MD MPH, Harvard Pilgrim Health Care Institute, 401 Park Drive #401, Boston, MA 02215 (


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PREVIOUS PRESENTATION. Preliminary data for this analysis were presented at the 2017 National Research Service Award (NRSA) Conference on June 24, 2017, in New Orleans, Louisiana.



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1. Healthcare Cost and Utilization Project (HCUP). HCUPnet website. Published 2014. Accessed November 3, 2017.
2. ElBardissi, AW, Aranki, SF, Sheng, S, O’Brien, SM, Greenberg, CC, Gammie, JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg 2012;143:273281.
3. Osnabrugge, RL, Speir, AM, Head, SJ, et al. Prediction of costs and length of stay in coronary artery bypass grafting. Ann Thorac Surg 2014;98:12861293.
4. Edwards, JR, Peterson, KD, Mu, Y, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009;37:783805.
5. Hollenbeak, CS, Murphy, DM, Koenig, S, Woodward, RS, Dunagan, WC, Fraser, VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000;118:397402.
6. Risnes, I, Abdelnoor, M, Almdahl, SM, Svennevig, JL. Mediastinitis after coronary artery bypass grafting risk factors and long-term survival. Ann Thorac Surg 2010;89:15021509.
7. Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725730.
8. LaPar, DJ, Crosby, IK, Rich, JB, et al. A contemporary cost analysis of postoperative morbidity after coronary artery bypass grafting with and without concomitant aortic valve replacement to improve patient quality and cost-effective care. Ann Thorac Surg 2013;96:16211627.
9. Deficit Reduction Act of 2005. Public Law 109-171. Section 5001 (C). Quality adjustment in DRG payments for certain hospital acquired infections. Published 2005. Accessed November 30, 2016.
10. Centers for Medicare and Medicaid Services. 42 CFR Parts 411, 412, 413, 422, and 489. Medicare Program; Changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Federal Register 2008;73:48,433449,083.
11. Calderwood, MS, Kleinman, K, Soumerai, SB, et al. Impact of Medicare’s payment policy on mediastinitis following coronary artery bypass graft surgery in US hospitals. Infect Control Hosp Epidemiol 2014;35:144151.
12. Kawai, AT, Calderwood, MS, Jin, R, et al. Impact of the Centers for Medicare and Medicaid Services hospital-acquired conditions policy on billing rates for 2 targeted healthcare-associated infections. Infect Control Hosp Epidemiol 2015;36:871877.
13. Lee, GM, Kleinman, K, Soumerai, SB, et al. Effect of nonpayment for preventable infections in US hospitals. N Engl J Med 2012;367:14281437.
14. Centers for Medicare and Medicaid Services. 42 CFR Parts 434, 438, and 447. Medicaid program payment adjustment for provider-preventable conditions including health care-acquired conditions: final rule. Federal Register 2011;76:32,816832,838.
15. Patient Protection and Affordable Care Act Health-related portions of the Health Care and Education Reconciliation Act of 2010. Health and Human Service website. Published 2010. Accessed November 30, 2016.
16. Centers for Medicare and Medicaid Services. 42 CFR Parts 412, 413, 414, et al. Medicare program hospital inpatient prospective payment systems for acute care hospitals and the long term care; hospital prospective payment system and fiscal year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status; final rule. Federal Register 2013;78:50,496451,040.
17. Sorensen, A, Jarrett, N, Tant, E, Bernard, S, McCall, N. HAC-POA policy effects on hospitals, other payers, and patients. Medicare Medicaid Res Rev 2014;4(3):E1E13.
18. The Preventing Avoidable Infectious Complications by Adjusting Payment (PAICAP) Project website. Accessed November 3, 2017.
19. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309332.
20. National Healthcare Safety Network (NHSN). National Healthcare Safety Network (NHSN) patient safety component manual. Centers for Disease Control and Prevention website. Published 2017. Accessed November 3, 2017.
21. Schneider, EC, Sorbero, ME, Haas, A, et al. Does a quality improvement campaign accelerate take-up of new evidence? A ten-state cluster-randomized controlled trial of the IHI’s Project JOINTS. Implement Sci 2017;12:51.
22. STS national database: adult cardiac surgery database public reporting. Society of Thoracic Surgeons website. Published 2017. Accessed November 3, 2017.
23. Shahian, DM. The Society of Thoracic Surgeons national database: what’s past is prologue. Ann Thorac Surg 2016;101:841845.
24. American Hospital Association annual survey database. American Hospital Association website. Updated 2017. Accessed November 3, 2017.
25. Shadish, WR, Cook, TD, Campbell, DT. Experimental and Quasi-experimental Designs for Generalized Causal Inference. Boston: Houghton Mifflin; 2001.
26. Lopez Bernal, J, Cummins, S, Gasparrini, A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol 2016:18. doi: 10.1093/ije/dyw098.
27. National Health Safety Network. The NHSN standardized infection ratio (SIR): a guide to the SIR. Centers for Disease Control and Prevention website. Published 2017. Accessed November 3, 2017.
28. Kwong, JZ, Weng, Y, Finnegan, M, et al. Effect of Medicare’s nonpayment policy on surgical site infections following orthopedic procedures. Infect Control Hosp Epidemiol 2017;38:817822.
29. Calderwood, MS, Kleinman, K, Huang, SS, Murphy, MV, Yokoe, DS, Platt, R. Surgical site infections: volume-outcome relationship and year-to-year stability of performance rankings. Med Care 2017;55:7985.
30. Provost, LP, Murray, SK. The Health Care Data Guide: Learning From Data for Improvement, 1st ed. San Francisco, CA: Jossey-Bass; 2011.


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