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Friday, June 05, 2009

CMS's "never events"-so much for reason and let the unintended consequences begin

Aggravated DocSurg offers cogent comments about the seeming lack of logic or common sense in their program of denying payments for so called "never -events". In particular he discusses deep vein thrombosis (DVT). In the recent issue of the NEJM we find an excellent commentary about an even more absurd requirement of this new set of CMS rules,this one involving falls in the hospital.

For those who advocate a "Medicare for all" approach for the United States, I suggest they read what Medicare itself says about the inclusion of falls in their never-events policy.Here is a sample as quoted from the NEJM commentary which explains clearly that CMS is making a requirement for some things that cannot be done.

"There is no evidence that hospital falls "can be consistently and effectively prevented through the application of evidence-based guidelines." The authors of the CMS rule acknowledge this fact. In the final rule, as recorded in the Federal Register on August 22, 2007, they note that "although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission." Although clinical trial results suggest that certain strategies may reduce the risk of falling in community settings, fall prevention in the hospital has been much less studied. What little evidence is available is not encouraging. A recent systematic review suggested that, at best, about 20% of hospital falls can be prevented.1 Moreover, no intervention has yet been shown to reduce the risk of serious injury, the outcome of clinical relevance."

If one follows all the best evidence driven rules and suggestions for how to prevent DVTs, DVTs will still occur. Under the best circumstances of the very best randomized clinical trials which involve meticulous attention to detail , and applications of the very best preventive measures, DVTs still occur. The incidence is not zero. Furthermore, in regard to falls , CMS recognizes as indicated in the quote above that there are no evidence based guidelines but hospitals and physicians have to obtain a zero incidence rate anyway.We don't know how you will do it but you have to do it.

I have been impressed by Thomas Sowell's approach to try and understand some of the actions of governmental agencies that appear to lack in common sense, or appear to be irrational or just plain silly. He says look at the incentives and constraints they face and the feedback or lack thereof to which they are subject. Here, however, it is difficult to understand how anyone (even a committee) could devise and publish for all to see something that is absurd. OK I 'll try and think about their incentives etc. If their aim was to save money and to dress up their work orders in the current jargon of safety and quality, maybe their plan makes sense to them, but for the rest of the world -not so much . If you make rules that are apparently subject to no appeal,your rules don't have to make sense.

1 comment:

Anonymous said...

I am glad someone else sees the lack of common sense in this "never event" idea. I have been a Critical Care nurse for over 10 years, and it is virtually impossible to prevent them all. I agree that patients should not fall in hospitals, but when JCAHO has so limited our use of restraints and side rails, if your patient is alert they can probably fall. If your patient gets a bedsore then it's not paid for, but if they Code because they are too hemodynamically unstable to turn safely, then the money comes in. It creates unethical dilemmas sometimes for the direct caregiver.