Two major policy approaches are used currently to motivate hospitals to prevent hospital-acquired complications (HACs): 1) public reporting of hospital performance regarding patient safety (e.g., the website Hospital Compare), and 2) """"""""value-based purchasing,"""""""" which ties hospital payment with better patient outcomes, such as the Hospital-Acquired Conditions Initiative implemented by the Centers for Medicare &Medicaid Services (CMS) to stop hospitals from receiving extra payment for specific """"""""reasonably preventable"""""""" complications. This CMS initiative also enables public reporting of HACs by requiring hospitals to identify discharge diagnoses as """"""""present-on-admission"""""""" or not (i.e., hospital-acquired), changing a routinely-generated administrative dataset into a new data source to generate rates of HACs to compare hospitals. Though intended to improve patient safety (and save money), these changes regarding data collection, payment, and public reporting of HACs have occurred without preliminary evaluations concerning: 1) the validity of these new data regarding HAC rates, and 2) what clinical impacts these changes may have on patients. These two knowledge gaps are significant, as public reporting of other patient outcomes (e.g., hospital mortality) has demonstrated that evaluating and reporting outcome data is complicated, and can have both intended and unintended consequences for patients - particularly for complex patients (i.e., with multiple chronic conditions) with higher baseline risks for poor outcomes including HACs. The candidate Dr. Jennifer Meddings, who will focus her research on the growing population of complex patients, will pursue a mentored research plan designed to enhance her skills concerning methods needed to evaluate the clinical impact of quality improvement initiatives for complex patients, with two specific aims:
Aim 1. To validate measures of hospital-acquired complications derived from administrative data as indicators of hospital quality, by triangulation with measures from different data sources.
Aim 2. To evaluate unintended outcomes (i.e., collateral benefits and damages) for patients as downstream or spillover effects of non-payment and public reporting for specific hospital-acquired complications, with a focus on impacts for complex patients. Using multiple years of patient-level administrative data, Aim 2's analyses will focus on three outcomes that could improve (as collateral benefit) or worsen (as collateral damage) as hospitals respond to non-payment or public reporting for specific HACs: 1) early readmission, 2) level of care after discharge (such skilled nursing facility), and 3) secondary complications, related to developing or treating the initial HAC. This research and advanced coursework will facilitate Dr. Meddings's development into a leading independent investigator in performance measurement and improvement, whose research will inform policy decisions to improve care for complex patients.

Public Health Relevance

As the elderly population increases, the number of """"""""complex"""""""" patients (i.e., with multiple chronic diseases) is rising dramatically. Because complex patients have higher rates of hospitalizations, with longer lengths of stay and higher rates of hospital-acquired complications, complex patients are perhaps the most important population to assess and monitor the impact of two quality improvement strategies being used to motivate hospitals to decrease hospital-acquired complications: 1) public reporting of hospital performance regarding patient safety (such as the website Hospital Compare), and 2) """"""""value-based purchasing,"""""""" which ties hospital payment with better outcomes, such as the recently implemented Hospital-Acquired Conditions Initiative by the Centers for Medicare &Medicaid Services (CMS) to stop hospitals from receiving extra payment to treat specific """"""""reasonably preventable"""""""" hospital-acquired complications. The proposed research will assess the merit of the new data for complication rates as indicators of hospital quality, and will assess the clinical impacts (intended and unintended) of value-based purchasing and public reporting initiatives for complex patients;this research will provide critical early feedback to the public, clinicians, hospitals, and CMS to reduce unintended harm to complex patients as well as to inform approaches for developing and evaluating future healthcare reforms designed to motivate improved care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Clinical Investigator Award (CIA) (K08)
Project #
Application #
Study Section
HSR Health Care Research Training SS (HCRT)
Program Officer
Anderson, Kay
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Michigan Ann Arbor
Internal Medicine/Medicine
Schools of Medicine
Ann Arbor
United States
Zip Code
Smith, Shawna N; Reichert, Heidi A; Ameling, Jessica M et al. (2017) Dissecting Leapfrog: How Well Do Leapfrog Safe Practices Scores Correlate With Hospital Compare Ratings and Penalties, and How Much Do They Matter? Med Care 55:606-614
Meddings, Jennifer; Saint, Sanjay; Krein, Sarah L et al. (2017) Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents. J Hosp Med 12:356-368
Meddings, Jennifer; Reichert, Heidi; Greene, M Todd et al. (2017) Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives. BMJ Qual Saf 26:226-235
Meddings, Jennifer; Smith, Shawna N (2017) Response to Letter to the Editor Regarding, Dissecting Leapfrog: How Well Do Leapfrog Safe Practices Score Correlate With Hospital Compare Ratings and Penalties, and How Much Do They Matter? Med Care 55:636-638
Manojlovich, Milisa; Saint, Sanjay; Meddings, Jennifer et al. (2016) Indwelling Urinary Catheter Insertion Practices in the Emergency Department: An Observational Study. Infect Control Hosp Epidemiol 37:117-9
Meddings, Jennifer; Saint, Sanjay; Fowler, Karen E et al. (2015) The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med 162:S1-34
Meddings, Jennifer; Reichert, Heidi; Rogers, Mary A M et al. (2015) Under Pressure: Financial Effect of the Hospital-Acquired Conditions Initiative-A Statewide Analysis of Pressure Ulcer Development and Payment. J Am Geriatr Soc 63:1407-12
Mody, Lona; Meddings, Jennifer; Edson, Barbara S et al. (2015) Enhancing Resident Safety by Preventing Healthcare-Associated Infection: A National Initiative to Reduce Catheter-Associated Urinary Tract Infections in Nursing Homes. Clin Infect Dis 61:86-94
Meddings, Jennifer; Rogers, Mary A M; Krein, Sarah L et al. (2014) Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 23:277-89
Greene, M Todd; Fakih, Mohamad G; Fowler, Karen E et al. (2014) Regional variation in urinary catheter use and catheter-associated urinary tract infection: results from a national collaborative. Infect Control Hosp Epidemiol 35 Suppl 3:S99-S106

Showing the most recent 10 out of 16 publications