title: Is the Centers for Medicare and Medicaid Service's lack of reimbursement for postoperative urinary tract infections in elderly emergency surgery patients justified?
abstract: BACKGROUND
  Urinary tract infections, a risk factor for readmission, have been deemed a potentially preventable problem and, therefore, not reimbursable by the Centers for Medicare and Medicaid Services since 2008. Defining the risk factors for development of urinary tract infection in the postoperative period will provide risk stratification for development of urinary tract infection in these challenging patients.
  
  
  METHODS
  Pre-, intra-, and postoperative characteristics were collected for patients ≥65 years who underwent an emergency abdominal operation from the 2005 to 2012 National Surgical Quality Improvement Program Participant User File, a database of 374 participating hospitals. In-hospital urinary tract infections occurring within 30 days of the operation were identified. Multivariable logistic regression analysis was conducted to identify risk factors of urinary tract infection.
  
  
  RESULTS
  In total, 53,879 patients were included, 1,881 (3.5%) of whom were diagnosed with a postoperative urinary tract infection before discharge. In-hospital urinary tract infection was associated with a longer hospital stay (27 vs 13 days, P < .001) and greater 30-day mortality rates (18% vs 16%, P = .003). The rate of urinary tract infection decreased from 4.5% before the Centers for Medicare and Medicaid Services decree to 3.2% thereafter (P < .001). Multivariable logistic regression demonstrated advanced age, female sex, insulin-dependent diabetes mellitus, dependent functional status, open wound, hypoalbuminemia, increased American Society of Anesthesiologists class, operative approach, and prolonged operative time were independent risk factors for development of postoperative urinary tract infection.
  
  
  CONCLUSIONS
  Although postoperative rates of urinary tract infection decreased after the Centers for Medicare and Medicaid Services decree, the lack of reimbursement is not justified, as few modifiable risk factors to further improve postoperative urinary tract infection rates in elderly emergency surgical patients were identified. Although targeted interventions may be developed, this complication is not easily preventable and will continue to plague acute care surgeons taking care of this challenging patient population.
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address: zielinski.martin@mayo.edu.
authors.forename: Martin D
authors.initials: MD
authors.lastname: Zielinski
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Kristine M
authors.initials: KM
authors.lastname: Thomsen
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Stephanie F
authors.initials: SF
authors.lastname: Polites
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Mohammad A
authors.initials: MA
authors.lastname: Khasawneh
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Donald H
authors.initials: DH
authors.lastname: Jenkins
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Habermann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000191:economics*; D004630:Emergencies; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008484:Medicaid / Q000191:economics*; D006278:Medicare / Q000191:economics*; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000191:economics* / Q000453:epidemiology / Q000209:etiology; D012051:Reimbursement Mechanisms; D020379:Risk Adjustment; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D014552:Urinary Tract Infections / Q000191:economics* / Q000453:epidemiology / Q000209:etiology