RAPIDS (Regulation And Policy for Infectious Disease Stewardship) Network:

Recommendations for Quality Measure Prioritization

The following organizations have participated in the creation or review of this policy brief: Steering Committee: Association of American Medical Colleges (AAMC), Federation of American Hospitals (FAH), Cepheid, Rubrum Advising

Participating Organizations: Infectious Diseases Society of America (IDSA), Common Spirit Health, HCA Healthcare, Oracle, Federation of American Hospitals (FAH), Cepheid, Rubrum Advising

Introduction

The RAPIDS (Regulation And Policy for Infectious Disease Stewardship) Network, co-convened by Rubrum Advising, the Federation of American Hospitals (FAH), and the Association of American Medical Colleges (AAMC), brings together a variety of infectious disease stakeholders with the shared goal of improving the quality of care for patients in hospitals through reforming policies and regulations around antimicrobial stewardship and infection prevention & control practices. To achieve this goal, a series of working groups has been established around the three key topics of (1) Quality Measures, (2) CMS Conditions of Participation, and (3) Interoperability with the aim of developing policy and regulatory recommendations. This policy brief has been developed based on discussion within the Quality Measures working group, which consists of representatives from eleven organization, including hospital associations, health systems, infectious diseases professional societies, diagnostic manufacturers, and other quality measure experts. This does not represent an official endorsement by any of the listed organizations.

Given the current administration’s stated priority of creating a more parsimonious and streamlined set of quality measures, the primary objective of the RAPIDS Network Quality Measures Working Group is to produce a prioritized list of hospital infectious disease quality measures for consideration by the Administration. The RAPIDS Network views infectious disease quality measures as a lever to promote more effective treatment and prevention of transmission, including the timely discontinuation of inappropriate antibiotics and the earlier initiation of appropriate ones as well as judicious contact precautions and surveillance for resistance. This can be achieved by incentivizing the adoption of best practices, evidence-based protocols, and the use of appropriate diagnostic tests.

This policy brief is intended to provide key stakeholders, including relevant federal agencies, with an overview of the existing quality measures pertaining to antimicrobial stewardship and infection prevention & control that the working group has recommended to be maintained, revised, removed from the value-based purchasing program during revision, or retired. A subsequent policy brief, planned for dissemination in the coming months, will present the RAPIDS Network’s recommendations for new measure development, specific revisions to existing measures, and opportunities to improve interoperability to reduce program burden.

Background

Since 1965, quality initiatives have been a part of payment under Medicare programs. Quality programs use measures as a proxy for the care provided to patients. Included in federal statute, the programs include the Hospital Inpatient Quality Reporting (IQR) Program, Hospital Value-Based Purchasing (HVBP) Program, Hospital Readmissions Reduction Program (HRRP), and Hospital- Acquired Condition (HAC) Reduction Program. Among the various measures are those related to infection prevention and control (IPC) and antimicrobial stewardship (AMS). While CMS continuously evaluates the measures—for example, through use of the consensus-based entity (CBE)— a recent desire has emerged to establish a more parsimonious set of measures with more direct effectiveness.

 Given the 2024 United Nations General Assembly declaration regarding antimicrobial resistance as a major health risk, a group of hospitals, manufacturers, and expert stakeholders convened a series of working groups to address AMS and IPC¹. The initial goal was to review the current list of infectious disease measures in the hospital programs and determine if the outcomes of these measures achieved the intended goals and whether the data collection burden was greater than any benefit. An analysis of their specifications and need for revision was also assessed for those measures that continue to have value.

Recommendation

As part of the process, the multi-stakeholder working group identified two revision pathways, one exclusively involving definition changes and one of both definition and program involvement changes. Among the measures that were recommended for revision, the group identified those in the Value-Based Purchasing (VBP) program that may result in inappropriate penalization and should therefore be temporarily removed while undergoing revision or replacement, with continued inclusion in the Hospital Inpatient Quality Reporting (IQR) program. The following table summarizes the recommendations of measures to maintain or revise, with rationale below.

We recommend continuation of the following quality measures without revision:

National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-Onset MRSA Bacteremia

This measure has uniform support from members of the working group, as it was determined to be accurate in measurement and is an important topic attributable to hospital care that is within the hospital’s ability to improve. Progress reports show a 16% decrease in observed events across the US from 2022 to 2023. It has also been used anecdotally as an indirect indicator of community hygiene and resistance, furthering the importance of this measure in infection prevention and control.

Antimicrobial Use Surveillance (AU) and Antimicrobial Resistance Surveillance (AR)

These measures are part of the Promoting Interoperability program and query for a simple attestation of public health reporting to NHSN. We agree that AU and AR are important metrics to monitor and believe implementing an outcomes-focused measure in the future will incentivize providers to drive better patient care. Efforts to increase interoperability can improve not only the standardization of AU and AR measurements, but also the translation of this data back to health systems in an actionable format.

We recommend minor revisions of the following quality measures to be addressed in the next re-endorsement cycle:

NHSN Bloodstream Infections (BSI) in Hemodialysis Patients

While this quality measure is effective for driving improvement in BSI reductions, there are opportunities to improve the data captured in this measure through minor definitional revisions that incentivize quicker turn-around times, as the data collected from all measures must be reported back to hospitals from the state and national government promptly and in an actionable format with sufficient detail to allow the use of the information for quality improvement, however, achieving this is particularly problematic with claims-based measures.

Catheter-Associated Urinary Tract Infection (CAUTI) – Stratified for oncology locations

Similar to the core CAUTI measure, the definition requires minor revisions to improve the data captured. The manual data abstraction required for this measure poses a great burden for hospitals and health systems that should be alleviated, possibly through transitioning to a FHIR-based (Fast Healthcare Interoperability Resources) measure. This burden currently limits the potential improvements the measure may bring to patient safety and care.

Central Line-Associated Bloodstream Infection (CLABSI) – Stratified for oncology locations

Similarly to the core CLABSI quality measure, the stratified CLABSI measure has opportunities for improving the data captured that monitors unintended consequences and addresses nonpreventable events. These minor definitional revisions should also consider how this measure could eventually transition to FHIR.

We recommend the following quality measures be removed from the VBP program and maintained in the IQR program while they are revised:

Given that healthcare-acquired infections are not typically reimbursed by insurers, the CMS payments linked to these quality measures incentivize hospitals to follow infection prevention & control practices. Given the concerns regarding the two listed measures, they should be removed from the VBP programs, as the current measure definitions inappropriately penalizes hospitals. We strongly urge that these measures are revised and transitioned back to the VBP program as quickly as possible.

NHSN Central Line Associated Bloodstream Infection (CLABSI)

The working group agreed that this measure has yielded improvements in CLABSI rates. However, the measure can be improved with major definitional revisions regarding the data required to be captured. The current definition has the potential to overestimate the true incidence of CLABSI, given it may be unclear whether the BSI is secondary to the central line or due to another infectious agent.

NHSN Catheter-Associated Urinary Tract Infection (CAUTI)

While this measure is significant and valuable for tracking performance over time, the definition has significant room for improvement. In a major definitional revision, inclusion and exclusion criteria for data capturing must be evaluated to ensure the measure captures only true CAUTI, rather than cultures that test positive for other reasons. Additionally, this measure may not be amenable to FHIR format and thus should be transitioned out of value-based purchasing programs.

We recommend the following quality measures be removed from the VBP program and maintained in the IQR program while the development of replacement measures is accelerated:

Given that healthcare-acquired infections are not typically reimbursed by insurers, the CMS payments linked to these quality measures incentivize hospitals to follow antimicrobial stewardship and infection prevention & control practices. As there are already replacement quality measures under development or consideration, the current measures listed below should be removed from the VBP program and maintained in the IQR program to demonstrate the importance of the ultimate outcome. We strongly urge the accelerated development and adoption of these replacement measures to restore the financial incentives for driving best outcomes in the care of infectious diseases.

NHSN Facility-Wide Inpatient Hospital-Onset Clostridioides difficile infection (CDI)

CDI was identified as a high-priority area. Concerns were voiced around the current quality measure due to the variation of CDI in hospitals, measurement of cases that are not preventable, and unintended consequences related to the use of “last test” algorithm. A new CDI measure, referred to as HT-CDI, was previously created by the CDC and is currently endorsed by Battelle. HT-CDI measures the standardized infection ratio (SIR) based on the fully electronic capture of healthcare facility-onset, antibiotic-treated CDI events among inpatients in the facility. While awaiting accelerated development and adoption of HT-CDI, the current CDI measure should be removed from the VBP program and maintained in the IQR program.

Severe Sepsis and Septic Shock: Management Bundle

Focus on sepsis is extremely important for hospitals and health systems. However, its current format as a process measure, rather than an outcome measure, does not adequately prompt actionable improvements, nor has it enabled meaningful improvement in patient outcomes. A new measure must be shifted to focus on outcomes and a narrower scope to ensure successful implementation. While awaiting replacement, the measure should be removed from the VBP program and maintained in the IQR program to avoid penalizing hospitals that do not demonstrate uniform compliance with the current definition. To effectively prepare hospitals and inform their decision-making around patient care, the federal government must be transparent in their reasoning for temporarily removing the measure from the VBP program.

We recommend major revisions of the following quality measures to be addressed in the next re-endorsement cycle:

ACS-CDC Harmonized Procedure Specific Surgical Site Infection (SSI)

While this measure has the potential to significantly drive care improvement, it is currently not specific and too variable when implemented due to differences in SSI definition between NHSN and NSQIP. The measure requires a uniform definition of SSI across stewards. Additionally, to facilitate greater action, the measure should be more intentional in easing the burden associated with the data and case reporting requirements.

Influenza Immunization

This measure was agreed to be important for hospitals and health systems, as well as other care settings to address all populations. To improve the efficacy of the measure, the definition should be revised to align across settings, as well as to prioritize the months when the vaccine is given, which is typically during the November to February period.

Patient Safety and Adverse Events Composite

While stakeholders agree a measure capturing true harm would be greatly appreciated, many limitations of its current construction prevent it from accurately doing so. The measure requires major definitional revisions, specifically in its general approach and lack of reliability among individual measures in the composite. The coding and administrative claims approach limits improvement at the point of care due to the substantial time delay, limited accuracy and validity, and preventing the use of the data in a meaningful manner.

Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure to Rescue)

Because this measure includes many types of complications and is extremely broad, major definitional revisions are needed to improve internal reliability. The measure is complex and burdens health systems and hospitals, which could be lifted if data were captured directly from the electronic health record.

CMS Death Rate among Surgical Inpatients with Serious Treatable Complications

Similarly, this measure’s definition is too broad and requires major definitional revisions to narrow the scope. The complications included in the numerator must be re-evaluated, as currently, the measure is so complex that it makes it difficult for hospitals and health systems to capture all required elements.

Hospital-Level, Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Because lower-risk surgeries have generally begun moving to outpatient settings, hospital rates may be impacted as they treat higher-risk patients. To address this potential unintended consequence, this measure requires major definitional revisions separating the two care settings or focusing solely on outpatient. Additionally, it is essential to consider why complications are only counted when occurring in admission or re-admission, despite complications arising in many locations and the substantial impacts complications pose for patients, regardless of location or timing.