VAP Flap

Vol. 21 •Issue 16 • Page 18
VAP Flap

New Reimbursement Rule Riles Pulmonologists

When Medicare acts, other health care entities follow.

That axiom held true this year when officials at the Centers for Medicare and Medicaid Services (CMS) announced that, as of Oct. 1, they will stop reimbursing hospitals for treating complications from what they term “never events,” that is, preventable adverse medical events.

Sure enough, shortly after Medicare’s announcement, insurance giant CIGNA announced that it, too, will no longer reimburse hospitals for certain “avoidable” conditions effective Oct. 1, including infections from urinary and central vein catheters.

Then, on July 18, the state of Maine issued a law prohibiting hospitals and ambulatory surgery centers from charging patients or their insurers for treatment related to 28 preventable adverse events identified by the National Quality Forum.

And officials at the New York State Medicaid program announced they will deny hospitals reimbursement for 14 “avoidable hospital complications and medical errors,” also beginning in October.

Chief among Medicare’s never events are nosocomial infections, including ventilator-associated pneumonia (VAP) and hospital-acquired Staphylococcus aureus infection.

Clinicians will come under direct financial pressure to prevent the spread of bugs that infect patients and lengthen their hospital stays. Undoubtedly, hand-washing will increase—as it should.

But is it fair to include VAP as a “preventable” adverse event? Can clinicians prevent every case of VAP?

To both questions, pulmonologists across the country are shouting “No!”

Pushing Back

A blanket ruling that penalizes hospitals regardless of how scrupulously they follow VAP-reducing guidelines is inflexible and unfair, they say.

“It’s inappropriate for CMS to deny payment for conditions that can be reduced but not eliminated,” Gary Ewart, director of government relations for the American Thoracic Society (ATS), told ADVANCE. “It’s inappropriate to deny payment to physicians who are doing all the right things.”

In a letter to CMS, a coalition of pulmonary groups that includes ATS and the American Association for Respiratory Care (AARC) stressed that VAP is “not entirely preventable even with preventive measures and clinical practice guidelines.”

Phil Porte, executive director of NAMDRC, said he expects the coalition to actively lobby CMS from now to October to back off its ruling. “Holding hospitals to a zero-percent VAP rate is unrealistic,” he said. “It’s like being struck by lighting while on your neighbor’s property and then demanding that he pays for your care.”

What could happen, Porte said, is that doctors will feel a “strong disincentive” to diagnose cases of VAP. In other words, VAP will still occur, they’ll just call it something else to avoid the financial penalty.

Examine Every Case?

Asking CMS to withhold payments only from hospitals that don’t follow VAP protocols—and not to penalize those that do—sounds like a fair request. But is it practical?

Looked at from the point of view of CMS officials, how could they ever know for sure whether a case of VAP was truly unavoidable or the result of non-compliance with VAP-reducing protocols?

If they simply took a physician’s word for it, non-compliant (and dishonest) doctors could lie and insist they followed all protocols. CMS would have to investigate each and every instance of VAP to determine conclusively if protocols were followed. But is it logistically possible for CMS to examine patient records for every case?

“Financial Ôdiscrimination’ would be incredibly difficult to manage,” observed Mike Reno, vice president of operations at St. Luke’s Episcopal Hospital, Houston. “This, in essence, would require CMS to change their position on all never events to one that supports an Ôalmost never event’ approach and is simply not very feasible. How would CMS distinguish those hospitals Ôdoing all they can’ to prevent VAP from those that weren’t?”

It could be that hospitals, in coping with the CMS rule, will eventually reduce VAP to such innocuous levels that their bottom lines won’t feel the pinch and their accountants will only wince occasionally.

Minnesota Success

Earlier this year, 84 hospitals in Minnesota reduced VAP by 57 percent in 15 months, saving an estimated 53 lives and $7 million.

“Our participating facilities ranged from a large, academic medical center to a small community hospital that infrequently cares for vent patients,” said Mark Sonneborn, vice president of information services for the Minnesota Hospital Association.

The hospitals participated in the Ventilator-Associated Pneumonia Initiative, part of the Institute for Healthcare Improvement’s 100,000 Lives Campaign. It advocates these steps:

1. Elevation of the head of the bed to between 30 and 45 degrees

2. Daily “sedation vacation”

3. Daily assessment of readiness to extubate

4. Peptic ulcer disease prophylaxis

5. Deep venous thrombosis prophylaxis (unless contraindicated).

Reno said he and his patient safety officer, Mark LaRocco, PhD, believe that protocols help, but “I’m not sure there’s universal agreement on protocols for preventing/minimizing VAP.”

But the two remain optimistic about future prospects to significantly reduce VAP. “We generally agree with the experts that, given the current base of knowledge and medical capabilities, VAP can never be eliminated,” Reno said. “However, we also don’t believe in statements like ‘(fill-in-the-blank)’ can never be eliminated. Never is a very long time.”

Aerosolized Antibiotics

Some evidence suggests that aerosolized antibiotics (AAs) can reduce VAP, according to Neil MacIntyre, MD.

“The endotracheal tube impairs the lung’s defenses against VAP,” he explained at the AARC’s 2006 International Congress in Las Vegas.

“The trick is to get (AAs) in the tracheobronchial tree before infection gets into the alveoli,” said MacIntyre, clinical chief in the division of pulmonary, allergy and critical care at Duke University Medical Center, Durham, N.C. “Aerosolized antibiotics can kill bugs in tracheobronchial secretions or sputum.”

He cited a 2006 meta-analysis of randomized controlled trials to evaluate the safety and effectiveness of azoles as antifungal prophylaxis versus placebo in high-risk patients receiving treatment in surgical intensive care units (SICUs).1The researchers concluded prophylactic use of azoles in high-risk SICU patients reduced fungal infections but not all-cause mortality.

“It’s the underlying disease that kills people, not VAP,” said MacIntyre, who added that AAs seem most efficacious when the infection “is just sort of coating the airway,” not when VAP is entrenched.

Counter View

In 1998, investigators decided to see if AAs could reach the lower respiratory tracts of six mechanically ventilated patients and provide some benefit, MacIntyre continued.

All six were trached and colonized with Gram-negative organisms. They received nine courses of nebulized therapy, which consisted of treatments every eight hours of gentamicin (80 mg) or amikacin (400 mg) for 14 to 21 days.

The researchers concluded that nebulizer delivery of aerosolized aminoglycosides is “efficient and predictable” and “can make a significant impact on respiratory secretions.” But their efficacy in treatment of critically ill patients “remains to be determined.”2

But as Bruce Rubin, MD, MEngr, MBA, who spoke against the use of AAs as MacIntyre’s foil in a “pro/con” debate, noted: “There were only six subjects, and it was an uncontrolled study.”

Rubin said a 2004 study concluded that existing data support the use of aerosolized tobramycin in cystic fibrosis patients infected or colonized by Pseudomonas aeruginosa but “widespread aerosolized administration of other agents in cystic fibrosis and non-cystic fibrosis patient populations should not be advocated.”3AAs can induce anti-microbial resistance, noted Rubin, of the department of pediatrics at Wake Forest University School of Medicine, Winston Salem, N.C. And they are expensive; a month’s supply of tobramycin costs about $2,000.

“They may be useful for the right patients—but you should get informed consent,” he advised. “You need the right drugs, the right nebulizer and the right bugs. More data are needed. It’s a good idea, but I can’t recommend its use at this time.”


1. Vardakas K, Samonis G, Michalopoulos A, et al. Antifungal prophylaxis with azoles in high-risk, surgical intensive care unit patients: a meta-analysis of randomized, placebo-controlled trials. Crit Care Med. (2006; 34, 4: 1216-24).

2. Palmer LB, Smaldone GC, Simon SR, et al. Aerosolized antibiotics in mechanically ventilated patients: delivery and response. Crit Care Med. (1998; 26, 1: 31-9).

3. Klepser ME. Role of nebulized antibiotics for the treatment of respiratory infections. Curr Opin Infect Dis. (2004; 17, 2: 109-12).

Michael Gibbons, senior associate editor, can be reached at [email protected].

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