The National Institutes of Health has given researchers at the University of Florida $1.6 million to determine if a new Medicare rule eliminating payment for the cost of treating in-hospital falls will lower the rate of falls among hospital patients.
Geriatricians are concerned that the preventative measure might have an unintended negative effect of increasing the use of physical restraints to keep people confined to beds or chairs.
"This is about how do we simultaneously cut healthcare costs and improve healthcare quality. It's where geriatrics, patient safety, and policy intersect," principal investigator Ronald Shorr, MD, a geriatric researcher who will lead the UF study, said in a media release announcing the funding.
In October 2008, as part of its pay-for-performance initiative, CMS stopped reimbursing hospitals for excess costs of treating eight hospital-acquired preventable conditions, including in-hospital falls. About 30% of falls in older adults result in injury and about 10% result in serious injury, according to the CDC. A separate study suggests that 20% of hospital falls can be prevented.
Patient safety advocates worry that fearing loss of revenue, some hospitals might resort to potentially harmful measures, such as tying patients down or otherwise restraining them.
"Our biggest concern is that the intervention used would be to keep people in bed—the end result would be a decline in mobility in hospitalized patients," said Cynthia J. Brown, MD, the coauthor of a New England Journal of Medicine paper on potential negative consequences of the Medicare rule change. Brown is not involved in the UF study.
Brown's research among older adults has shown that those who have the lowest levels of mobility during hospitalization were much more likely than others to have adverse outcomes, such as functional decline, requiring nursing home placement, and death.
Physical restraints do not protect patients from in-hospital falls, and are instead linked to increased rates of physical and psychological complications, such as loss of function, pressure sores, delirium, asphyxiation, and even death. Conditions that patients develop as a result of being bed-bound also cost extra to treat, Brown's study reported.
Meanwhile, Shorr's research found that up to five falls occur for every 1,000 patient-days in the acute-care setting.
"What's really more the point is that nobody to date has found anything that reduces injury from falls—and that's what costs us money," Brown said. "If a patient falls and breaks a hip that's what we're getting penalized for, but there is no evidence that there is anything that will reduce that. It's hard if you don't have evidence to say 'this is how to do it right.'"
The UF study hopes to identify which components of the regulation work and which do not, which can inform effective fall prevention policies and practices. Co-investigators from Methodist Health Care in Tennessee, Vanderbilt University, Louisiana State University, the University of Tennessee, and the University of Kansas will work with the UF team.
The research will have a three-tiered approach. An analysis will look at practices during the 27 months before the new payment rules went into effect, and during a period of corresponding length after the rule change. Using data from 3,000 nursing units at 1,000 hospitals that feed the National Database of Nursing Quality Indicators, the investigators will look at how many falls and related-injuries occurred, and how many hospital units used of physical restraints.
A more localized study will focus on similar outcomes for four adult hospitals in Memphis, TN. In addition, the team will conduct a case-control study comparing restraint use among people who fell while hospitalized to those who did not fall.
"We'd like to get a better understanding of how hospitals react or are able to react to policies that are set forth by regulatory agencies," said Lorraine Mion, RN, Independence Foundation Professor of Nursing at Vanderbilt University and co-investigator on the study. "Perhaps it will help us understand the ramifications policy has on us in terms of practices, patient outcomes, and cost."