IMPORTANCEIn 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy denying incremental payment for 8 complications of hospital care, also known as never events. The regulation's effect on these events has not been well studied.OBJECTIVE To measure the association between Medicare's nonpayment policy and 4 outcomes addressed by the HACs Initiative: central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls. DESIGN, SETTING, AND PARTICIPANTSQuasi-experimental study of adult nursing units from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), a program of the American Nurses Association. The NDNQI data were combined with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes. Multilevel models were used to evaluate the effect of Medicare's nonpayment policy on never events.EXPOSURES United States hospitals providing treatment for Medicare patients were subject to the new payment policy beginning in October 2008. MAIN OUTCOMES AND MEASURESChanges in unit-level rates of HAPUs, injurious falls, CLABSIs, and CAUTIs after initiation of the policy. RESULTS Medicare's nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs (incidence rate ratio [IRR], 0.89; 95% CI, 0.83-0.95) and a 10% reduction in the rate of change in CAUTIs (IRR, 0.90; 95% CI, 0.85-0.95), but was not associated with a significant change in injurious falls (IRR, 0.99; 95% CI, 0.99-1.00) or HAPUs (odds ratio, 0.98; 95% CI, 0.96-1.01). Consideration of unit-, hospital-, and market-level factors did not significantly alter our findings. CONCLUSIONS AND RELEVANCEThe HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes yield better outcomes. However, the HACs Initiative was not associated with improvements in HAPU or injurious fall trends, conditions for which there is less evidence that changing hospital processes leads to significantly better outcomes.

Specialty certification enhances patient safety in health care by validating that practice is consistent with standards of excellence. The purpose of this research was to explore the relationship between direct-care, specialty-certified nurses employed in perioperative units, surgical intensive care units (SICUs), and surgical units and nursing-sensitive patient outcomes in SICUs and surgical units. Lower rates of central-line-associated bloodstream infections in SICUs were significantly associated with higher rates of CPAN (certified postanesthesia nurse) (β = -0.09, P = .05) and CNOR/CRNFA (certified nurse operating room/certified RN first assistant) (β = -0.17, P = .00) certifications in perioperative units. Unexpectedly, higher rates of CNOR/CRNFA certification in perioperative units were associated with higher rates of hospital-acquired pressure ulcers (β = 0.08, P = .03) and unit-acquired pressure ulcers (β = 0.13, P = .00), possibly because of a higher risk of pressure ulcers in the patient population. Additional research is needed to clarify this relationship. Our findings lend credence to perioperative, SICU, and surgical nurses participating in lifelong learning and continuous professional development, including achievement of specialty certification.

Objective. In 2005, 27% of adults reported doctor-diagnosed arthritis, and 14% reported chronic joint symptoms but no doctor-diagnosed arthritis (i.e., possible arthritis). We evaluate the value of including persons classified as having possible arthritis in surveillance of arthritis. Methods. In 2005, Kansas, Oklahoma, North Carolina, and Utah added extra questions to their Behavioral Risk Factor Surveillance System (BRFSS) telephone survey targeted to a subsample of those classified as having possible arthritis. Results. Persons classified as having possible arthritis (n ‫؍‬ 2,884) were younger, more often male, and had less activity limitation than persons with doctor-diagnosed arthritis. Of those classified as having possible arthritis, half had seen a doctor for their symptoms, 12.5% reported arthritis, and 61.9% gave other causes. Of the half who had not seen a doctor, most reported mild symptoms (64.8%). Conclusion. Only 6.3% of those classified as having possible arthritis had what we considered to be arthritis. Most who did not see a doctor reported mild symptoms and, therefore, would be unlikely to be amenable to medical and public health interventions for arthritis. Although including possible arthritis would slightly improve the sensitivity of detecting arthritis in the population, it would increase false-positives that would interfere with targeting state intervention efforts and burden estimates. The ability to add back questions to the BRFSS survey allows for the reintroduction of possible arthritis in case national surveillance indicates it necessary or if studies document an increased rate at which possible arthritis turns into arthritis. Currently, possible arthritis does not need to be included in state arthritis surveillance efforts, and limited question space on surveys is better spent on other arthritis issues.

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