RAPIDS (Regulation And Policy for Infectious Disease Stewardship) Network: Recommendations for Quality Measure Development and Revision

The following organizations have participated in the creation or review of this policy brief:

Steering Committee: AAMC, Federation of American Hospitals (FAH), Cepheid, Rubrum Advising

Participating Organizations: AAMC, Cepheid, HCA Healthcare, Infectious Diseases Society of America (IDSA)

Introduction

The RAPIDS (Regulation And Policy for Infectious Disease Stewardship) Network, co-convened by Rubrum Advising, the Federation of American Hospitals (FAH), and AAMC, unites infectious disease stakeholders to strengthen hospital patient care through policy and regulation reform on antimicrobial stewardship (AMS) and infection prevention and control (IPC). To achieve this goal, a series of working groups have 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 reflects discussions from the Quality Measures Working Group, which consists of representatives from eleven organizations, including hospital associations, health systems, infectious diseases professional societies, diagnostic manufacturers, and other quality measure experts. These recommendations do not represent an official endorsement by participating organizations.

The RAPIDS Network Quality Measures Working Group convened to recommend new quality measures that capture previous gaps in antimicrobial stewardship and infection prevention & control data collection and measurement. 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.

A previous policy brief presented a prioritized list of hospital infectious disease quality measures that were recommended to be maintained, revised, removed from the value-based purchasing program during revision, or retired. This policy brief is intended to provide recommendations around the development of new quality measures pertaining to antimicrobial stewardship and infection prevention & control that align with the administration’s public health priorities. We specifically highlight considerations that Technical Expert Panels should address in developing these quality measures to reduce burden while still promoting the health and safety of Americans.

Background

Quality initiatives have been integral to Medicare payment systems since 1965, with quality measures serving as proxies for patient care. CMS regularly evaluates both proposed and existing measures, often in consultation with consensus-based entities (CBE). Recently, there has been growing interest in establishing a more streamlined set of measures with greater direct impact.

Following the 2024 United Nations General Assembly declaration identifying antimicrobial resistance as a major public health risk, multiple hospitals, manufacturers, and expert stakeholders formed a series of working groups to address AMS and IPC.^[1] The initial task was to review the current hospital infectious disease measures, assess whether outcomes met intended goals, and evaluate whether data collection burden outweighed benefits. Each measure’s specifications and need for revision were also scrutinized.

As part of the process, the multi-stakeholder working group identified gaps for future quality measure development, specifically: drug-resistant Candida auris, carbapenemase-producing Enterobacteriaceae, and diagnostic excellence outcomes related to antibiotic overutilization. The following recommendations were developed by the RAPIDS Network Quality Measures Working Group.

Recommendations

Proposed New Measures

Reporting C. auris Infections

Drug-resistant Candida auris was designated by the CDC as an “urgent antimicrobial resistance threat” in 2019 due to the growing prevalence of infections resistant to nearly all existing anti-fungal treatments. Its high risk of transmissibility and lack of reliable treatment options make quality measurement crucial to drive improved IPC practices and thereby minimize clinically relevant healthcare-acquired C. auris infections, such as bloodstream infections (BSI) or device-related infections.

Because C. auris affects multiple care settings, we recommend the development of new quality measures that monitor both hospital-onset and admission-present infections, as well as those occurring in non-hospital facilities, including long-term care facilities. As the quality measure(s) applied in the hospital setting should not penalize hospitals for infections that are present on admission, we believe that public health reporting to capture the community colonization rate, more proximal to onset, could influence IPC practices across care settings.

Given that the detection of C. auris in some non-blood clinical samples is indicative of colonization rather than active infection, the working group advises that the quality measure(s) should limit the numerator to only active infections. We recommend defining the numerator to include cases where C. auris is detected in blood or cerebrospinal fluid cultures, or where an infection diagnosis leads to antifungal treatment. This ensures the measure captures only clinically significant infections.

We further urge measure developers to consider its impact on clinical decision-making related to diagnostic testing. Given the high colonization rate of C. auris, which does not necessarily indicate active infection, penalizing C. auris detection could lead to underdiagnosis of colonization and missed opportunities for IPC to control transmission. Measure developers may follow the precedent set by the HT-CDI measure, which counts only antibiotic-treated C. difficile infections, avoiding excessive hospital-penalties for colonization-based testing as a trigger for initiating IPC protocols. Collaborating with infectious disease professional societies would offer valuable perspective on hospital priorities to account for such unintended consequences in the design of C. auris measures.

Reporting Carbapenemase-Producing Enterobacteriaceae infections

Given that carbapenem resistance can result in failure of last-resort antibiotic treatments, we believe it is vital to track these infections with a quality measure. Hospitals currently report carbapenem-resistant Enterobacteriaceae (CRE) infections to the NHSN under the Antimicrobial Resistance (AR) Surveillance measure within the Medicare Promoting Interoperability program. Currently, hospitals need only attest that CRE cases are reported to NHSN, which provides limited incentive for improvement. Moreover, the existing AR quality measure does not distinguish carbapenemase-producing Enterobacteriaceae (CPE) from broader CRE infections, aggregating multiple resistance mechanisms that each warrant different interventions. We recommend refining this metric to specifically track CPE infections, which are a distinct and clinically critical subset of CRE, requiring separate intervention strategies.

Because mortality rates are highly correlated with delays in appropriate treatment, hospitals should use diagnostic-informed AMS practices to facilitate early detection of CPE.^[2] The group recommends CMS consult with infectious disease professional societies to ensure the measure transitions appropriately to a hospital-onset outcomes measure, aligned with AMS and IPC clinical guidelines. Carbapenemase production is an enzyme-mediated resistance mechanism that is generally plasmid-encoded and easily transferred to other bacteria; as such, surveillance-guided IPC strategies are necessary to prevent further spread. The working group recommends transforming the current attestation measure into an outcome-based measure that specifies CPE rather than the broader CRE category, aligning surveillance with IPC strategies to prevent transmission.

Promoting Diagnosis-Guided Antimicrobial Utilization

The working group believes that incentivizing the implementation of diagnostic excellence principles should be prioritized to enhance AMS efforts, supporting the administration’s focus on curbing drug overutilization. Recognizing the negative health outcomes of antibiotic overutilization (such as disruption of the gut microbiome, inflammatory diseases of the gastrointestinal tract, diabetes, and obesity^[3]-[10]), CDC has outlined best practices to uphold diagnostic excellence to prevent missed, delayed, and incorrect diagnoses towards reducing under diagnosis or overtreatment.¹¹

Historically, the higher cost of diagnostics compared to antibiotics, combined with the low threshold of certainty often used to justify antimicrobial prescription, has discouraged broader adoption of diagnosis-informed treatment paradigms. Moreover, the financial penalization associated with the value-based Hospital-Acquired Conditions Reduction Program structurally disincentivizes detection of hospital-acquired infections and their resistance profiles.¹² While the newly introduced HT-CDI quality measure remedies this unintended consequence in the context of C. difficile, we emphasize the need for a measure that directly incentivizes diagnosis-informed antimicrobial prescription.

To reduce inappropriate antibiotic prescribing, we recommend replacing the attestation-based Antimicrobial Use (AU) Surveillance measure with an outcome measure that incentivizes hospitals to adopt the principles of diagnostic excellence as outlined by the CDC Core Elements of Diagnostic Excellence. Linking diagnostic testing to NHSN antimicrobial use data, which is already submitted to the NHSN AUR Module, would lower reporting burden while promoting more appropriate prescribing. We encourage CMS to consult infectious disease professional societies when designing this measure. We also ask measure developers to also consider developing a related measure in the outpatient setting where inappropriate antibiotic use is common, partially due to insufficient diagnostic utilization.

Proposed Revision of Existing Measure

ACS-CDC Harmonized Procedure Specific Surgical Site Infection

Though collection of this measure was once relevant, many surgeries included within this definition now occur outside hospitals, with inpatient procedures often reserved for only the most severe or complex patients. With many procedures now occurring in outpatient settings, current definitions risk biasing hospital quality assessments. In addition, discrepancies between NHSN and NSQIP measure definitions have led to discordant SSI rates and quality ratings between the two systems at the same hospital, generating confusion around benchmarking and quality improvement algorithms. Therefore, the working group recommends CMS, ACS, and CDC monitor measure utilization and consider discontinuation or major revision if patient population misalignment persists.

In the absence of an actionable quality measure that is adaptable across all relevant care settings, we propose an alternative mechanism for advancing the important goal of reducing the incidence of surgical site infection. We note that hospitals receive no additional payments for treating complications such as surgical site infections, and these costs must be absorbed within the initial bundled payment. Given that IPC and AMS practices have both clinical and financial impact, health systems may be incentivized to adopt best practices for minimizing post-surgical complications due to the cost savings potential within the DRG payment model. For example, appropriate antibiotic prophylaxis and PPE change prior to closure can drive cost-savings, including direct costs (treatment, extended stay, readmissions) and indirect costs (lost bed-days, etc.). Hospitals should track surgical site infection costs over 30-, 60-, or 90-days post-procedure to better demonstrate the clinical and financial benefits of IPC and AMS practices. This mechanism would reduce the administrative burden of reporting a quality measure that over penalizes health systems.