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In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends.
Retrospective cohort study.
Acute-care hospitals in the United States.
Fee-for-service Medicare patients discharged January 1, 2007, through December 31, 2011.
Using inpatient Medicare claims data, we analyzed billing practices before and after the HAC policy was implemented, including the use and POA designation of codes for CLABSI or CAUTI. For the 3-year period following policy implementation, we determined the impact on diagnosis-related groups (DRG) determining reimbursement as well as hospital characteristics associated with the reimbursement impact.
During the study period, 65,205,607 Medicare fee-for-service hospitalizations occurred at 3,291 acute-care, nonfederal US hospitals. Based on coding, CLABSI and CAUTI affected 0.23% and 0.06% of these hospitalizations, respectively. In addition, following the HAC policy, 82% of the CLABSI codes and 91% of the CAUTI codes were marked POA, which represented a large increase in the use of this designation. Finally, for the small numbers of CLABSI and CAUTI coded as not POA, financial impacts were detected on only 0.4% of the hospitalizations with a CLABSI code and 5.7% with a CAUTI code.
Part of the reason the HAC policy did not have its intended impact is that billing codes for CLABSI and CAUTI were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.
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.
Four species of malaria parasite, Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium knowlesi infect humans living in the Khanh Phu commune, Khanh Hoa Province, Vietnam. The latter species also infects wild macaque monkeys in this region. In order to understand the transmission dynamics of the three species, we attempted to detect gametocytes of the three species in the blood of infected individuals, and sporozoites in the salivary glands of mosquitoes from the same region. For the detection of gametocyte-specific mRNA, we targeted region 3 of pfg377, pvs25, pmg and pks25 as indicators of the presence of P. falciparum, P. vivax, P. malariae and P. knowlesi gametocytes, respectively. Gametocyte-specific mRNA was present in 37, 61, 0 and 47% of people infected with P. falciparum (n = 95), P. vivax (n = 69), P. malariae (n = 6) or P. knowlesi (n = 32), respectively. We found that 70% of mosquitoes that had P. knowlesi in their salivary glands also carried human malaria parasites, suggesting that mosquitoes are infected with P. knowlesi from human infections.
In October 2008, Medicare ceased additional payment for hospital-acquired conditions not present on admission. We evaluated the policy’s differential impact in hospitals with high vs low operating margins. Medicare’s payment policy may have had an impact on reducing central line–associated bloodstream infections in hospitals with low operating margins.
Infect. Control Hosp. Epidemiol. 2015;37(1):100–103
The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable.
To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI).
Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy.
We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI.
Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11–1.23]; for CAUTI, 1.19 [1.16–1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69–0.81]; for CAUTI, 0.87 [0.79–0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97–0.99]; for CAUTI, 0.99 [0.97–1.00]).
The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.
Infect. Control Hosp. Epidemiol. 2015;36(8):871–877
Policymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.
To determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non–safety net hospitals.
Interrupted time-series design.
SETTING AND PARTICIPANTS
Nonfederal acute care hospitals that reported central line–associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention’s National Health Safety Network from July 1, 2007, through December 31, 2013.
We did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84–1.09]) or non–safety net (0.99 [0.90–1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non–safety net hospitals (P for 2-way interaction, .87).
The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line–associated bloodstream infection in safety net or non–safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.
Limited studies exist regarding whether incorporating micronutrient supplements during tuberculosis (TB) treatment may improve cell-mediated immune response. We examined the effect of micronutrient supplementation on lymphocyte proliferation response to mycobacteria or T-cell mitogens in a randomized trial conducted on 423 patients with pulmonary TB. Eligible participants were randomly assigned to receive a daily dose of micronutrients (vitamins A, B-complex, C, E, and selenium) or placebo at the time of initiation of TB treatment. We found no overall effect of micronutrient supplements on lymphocyte proliferative responses to phytohaemagglutinin or purified protein derivatives in HIV-negative and HIV-positive TB patients. Of HIV-negative TB patients, the micronutrient group tended to show higher proliferative responses to concanavalin A than the placebo group, although the clinical relevance of this finding is not readily notable. The role of nutritional intervention in this vulnerable population remains an important area of future research.
Large-eddy simulation (LES) is utilized to investigate flow physics and lower-fidelity modelling assumptions in the simulation of an oblique shock impinging on a supersonic turbulent boundary layer (OSTBLI). A database of LES solutions is presented, covering a range of shock strengths and Reynolds numbers, that is utilized as a surrogate-truth model to explore three topics. First, detailed conservation budgets are extracted within the framework of parametric investigation to identify trends that might be used to mitigate statistical (aleatory) uncertainties in inflow conditions. It is found, for instance, that an increase in Reynolds number does not significantly affect length of separation. Additionally, it is found that variation in the shock-generating wedge angle has the effect of increasing the intensity of low-frequency oscillations and moving these motions towards longer time scales, even when scaled by interaction length. Next, utilizing the LES database, a detailed analysis is performed of several existing models describing the low-frequency unsteady motion of the OSTBLI system. Most significantly, it is observed that the length scale of streamwise coherent structures appears to be dependent on Reynolds number, and at the Reynolds number of the present simulations, these structures do not exist on time scales long enough to be the primary cause of low-frequency unsteadiness. Finally, modelling errors associated with turbulence closures using eddy-viscosity and stress-transport-based Reynolds-averaged Navier–Stokes (RANS) simulations are investigated. It is found that while the stress-transport models offer improved predictions, inadequacies in modelling the turbulence transport terms and the isotropic treatment of the dissipation is seen to limit their accuracy.
Monitor of All-sky X-ray Image (MAXI) on board International Space Station is capable of
observing gamma-ray bursts (GRBs) and sending notices of GRBs or other transient events,
using real time connection to the ground. MAXI observed 32 GRBs or short X-ray transients
as of the end of September 2012. Among them, eleven events were simultaneously detected by
other satellites. The observed rate of the MAXI GRBs is about one event per month. This
rate is comparable to a past observation with larger effective area and larger field of
view. The fact indicates that MAXI has better sensitivity to observe GRBs because of low
background. The distribution of the spectral hardness of MAXI GRBs is similar to the
results of a past instrument, which is sensitive to similar energy range.
We have investigated a correlation between electronic deep levels and current collapses in AlGaN/GaN hetero-structures by capacitance-voltage and photo-capacitance spectroscopy techniques, using Schottky barrier diodes. Three specific deep levels located at ~2.07, ~2.80, ~3.23eV below the conduction band were found to be significantly enhanced for the severe current collapse. These levels probably originate in Ga vacancies and residual C impurities and are probably responsible for the current collapses of the AlGaN/GaN hetero-structures.
There are few data on circulatory pro-inflammatory cytokine levels and cytokine gene polymorphisms in H. pylori-positive patients. A cross-sectional study was conducted to examine the effects of H. pylori infection, gastric atrophy, and the IL-8 T-251A polymorphism on plasma IL-8 levels in 98 Japanese adults. Seventy-one subjects were positive for H. pylori infection. The geometric mean of plasma IL-8 concentration was significantly higher in subjects with H. pylori infection than in those without (P=0·001). The development of atrophy was negatively associated with IL-8 levels in the H. pylori-positive subjects, although not significantly. Plasma IL-8 levels in the T/T genotype were associated with H. pylori infection and atrophy status (P=0·016). Our findings suggested that circulating IL-8 levels were associated with H. pylori infection. The effect of H. pylori infection on plasma IL-8 levels was not clearly modified by the IL-8 T-251A polymorphism.
Propagation of electrostatic electron waves whose frequency is smaller than the electron plasma frequency in a large unmagnetized plasma is investigated both experimentally and theoretically. When a receiver is close to a transmitter, free-streaming electrons are detected owing to their large capacity for excitation. When the distance between the receiver and the transmitter becomes large, the third-order Landau mode is observed due to its smaller damping than that of free-streaming electrons. Finally, a dip in amplitude of the wave, caused by interference by the higher-order Landau modes, is seen. The results are in reasonable agreement with numerical calculation assuming a dipole excitation for the wave.
In the daily RATAN-600 monitoring of the radio variability of the microquasar GRS1915+105 we detected a clear correlation of the flaring radio emission and X-rays “spikes” at 2–12 keV emission (1–2 Crab) detected with RXTE (ASM data) during nine bright (200–600 mJy) radio flares in October 2005. The spectra of these flares in maximum were optically thick at ν<2.3 GHz and optically thin at ν≥2.3 GHz. During radio flares the spectra of the X-ray spikes became definitely softer than those of a quiescent radio state. Thus these data indicated transitions from very high/hard states to high/soft ones during which massive ejections are probably happened, and the ejections are detected as the radio flares.