# Presentation: 045177

## Day 2: Session IIIConsiderations in Comparative and Public Reporting

- Presenters: Patrick Romano, UC Davis
- Shoshanna Sofaer, Baruch College
- AHRQ QI User Meeting
- September 26-27, 2005

## Selecting AHRQ Quality Indicatorsfor public reporting and pay-for-performance

- Type or conceptual framework
- Face validity or salience to providers
- Impact or opportunity for improvement
- Reliability or precision
- Coding (criterion) validity
- Construct validity
- Susceptibility to bias

## Types of provider-level quality indicators

- Structure: the conditions under which care is provided
- Volume (AAA repair, CEA, CABG, PCI, esophageal or pancreatic resection, pediatric heart surgery)
- Process: the activities that constitute health care
- Use of desirable/undesirable procedures (C/S, VBAC, bilateral cardiac cath, incidental appendectomy, laparoscopic cholecystectomy)
- Outcome: changes attributable to health care
- Risk-adjusted mortality (AMI, CHF, GI hemorrhage, hip fracture, pneumonia, stroke, AAA repair, CABG, craniotomy, esophageal resection, pancreatic resection, THA, pediatric heart surgery)
- Risk-adjusted complications or “potential safety-related events” (Patient Safety Indicators)

## Key features of structural measures

- Enabling factors that make it easier (harder) for professionals to provide high-quality care (i.e., facilitators or markers)
- Weakly associated with process/outcome measures
- Easy to measure, but hard to modify
- Few intervention studies, causal relationships unclear – do better structures lead to different processes, or do better processes lead to different structures?
- Use structural indicators when acceptable process or outcome measures are not available (“free ride” problem)
- Focus on modifiable structures OR settings in which hospitals that cannot modify structures are allowed to close (excess capacity)

## Minimum hospital volume needed to detect doubling of mortality rate (α=0.05, β=0.2)

- Ref: Dimick, et al. *JAMA.* 2004;292:847-851.

## Impact: Estimated lives saved by implementing hospital volume standards (NIS)Birkmeyer et al., Surgery 2001;130:415-22

| 
Volume indicator | 
RR mortality
LVH vs HVH | 
Patients at LVHs in MSAs | Potential lives saved by volume standards |
| --- | --- | --- | --- |
| CABG | 1.38 | 164,261 | 1,486 |
| Coronary angioplasty/PCI | 
1.33 | 
121,292 | 
345 |
| AAA repair | 1.60 | 18,534 | 464 |
| Carotid endarterectomy | 
1.28 | 
82,544 | 
118 |
| Esophagectomy | 3.01 | 1,696 | 168 |

## Key features of process measures

- Directly actionable by health care providers (“opportunities for intervention”)
- Highly responsive to change
- Validated – or potentially “validatable” – in randomized trials (but NOT the AHRQ QIs)
- Illustrate the pathways by which interventions may lead to better patient outcomes
- Focus on modifiable processes that are salient to providers, and for which there is clear opportunity for improvement

## Key features of outcome measures

- What really matters to patients, families, communities
- Intrinsically meaningful and easy to understand
- Reflect not just what was done but how well it was done (difficult to measure directly)
- Morbidity measures tend to be reported inconsistently (due to poor MD documentation and/or coding)
- Outcome measures may be confounded by variation in observation units, discharge/transfer practices, LOS, severity of illness
- Many outcomes of interest are rare or delayed
- Are outcomes sufficiently under providers’ control?
- Focus on outcomes that are conceptually and empirically attributable to providers (e.g., process linkages), and for which established benchmarks demonstrate opportunity for improvement.

## Literature review (all)
To identify quality concepts and potential indicators 
To find previous work on indicator validity
ICD-9-CM coding review (all)
To ensure correspondence between clinical concept and coding practice
Clinical panel reviews (PSI’s, pediatric QIs)
To refine indicator definition and risk groupings
To establish face validity when minimal literature 
Empirical analyses (all)
To explore alternative definitions
To assess nationwide rates, hospital variation, relationships among indicators
To develop methods to account for differences in  risk

- To identify quality concepts and potential indicators
- To find previous work on indicator validity
- ICD-9-CM coding review (all)
- To ensure correspondence between clinical concept and coding practice
- Clinical panel reviews (PSI’s, pediatric QIs)
- To refine indicator definition and risk groupings
- To establish face validity when minimal literature
- Empirical analyses (all)
- To explore alternative definitions
- To assess nationwide rates, hospital variation, relationships among indicators
- To develop methods to account for differences in  risk

- AHRQ QI development: General process

## AHRQ QI development: References

**AHRQ Quality Indicator documentation web page at**** **_[http://](http://www.qualityindicators.ahrq.gov/downloads.htm)__[www.qualityindicators.ahrq.gov/downloads.htm](http://www.qualityindicators.ahrq.gov/downloads.htm)_** **
*Refinement of the HCUP Quality Indicators (Technical Review)*, May 2001
*Measures of Patient Safety Based on Hospital Administrative Data - The Patient Safety Indicators*, August 2002
**Peer-reviewed literature (examples):**
*AHRQ’s Advances in Patient Safety: From Research to Implementation* (4-volume compendium)
- Romano, et al. Health Aff (Millwood). 2003; 22(2):154-66.
- Zhan and Miller. JAMA. 2003; 290(14):1868-74.
- Sedman, et al. Pediatrics. 2005; 115(1):135-45.
- Rosen et al., Med Care. 2005; 43(9):873-84.

## Face validity: Clinical panel review

- Intended to establish consensual validity
- Modified RAND/UCLA Appropriateness Method
- Physicians of various specialties/subspecialties, nurses, other specialized professionals (e.g., midwife, pharmacist)
- Potential indicators were rated by 8 multispecialty panels; surgical indicators were also rated by 3 surgical panels
- All panelists rated all assigned indicators (1-9) on:
- Overall usefulness
- Likelihood of identifying the occurrence of an adverse event or complication (i.e., not present at admission)
- Likelihood of being preventable (i.e., not an expected result of underlying conditions)
- Likelihood of being due to medical error or negligence (i.e., not just lack of ideal or perfect care)
- Likelihood of being clearly charted
- Extent to which indicator is subject to case mix bias

## Evaluation framework for PSIs

- Pre-conference ratings and comments/suggestions
- Individual ratings returned to panelists with distribution of ratings and other panelists’ comments/suggestions
- Telephone conference call moderated by PI, with note-taker, focusing on high-variability items and panelists’ suggestions (90-120 mins)
- Suggestions adopted only by consensus
- Post-conference ratings and comments/ suggestions	`

**Medical error**

**Unavoidable**
**Complications**

## Example reviews of PSIsMultispecialty panels

- Overall rating
- Not present on admission
- Preventability
- Due to medical error
- Charting by physicians
- Not biased by case mix

## Final selection of PSIs

- Retained indicators for which “overall usefulness” rating was “Acceptable” or “Acceptable-”
- Median score 7-9; AND
- Definite agreement (“acceptable”) if no more than 1 or 2 panelists rated indicator below 7
- Indeterminate agreement(“acceptable-”) if no more than 1 or 2 panelists rated indicator in 1-3 range
- 48 indicators reviewed (15 by 2 separate panels)
- 20 “accepted” based on face validity
- 2 dropped due to operational concerns
- 17 “experimental” or promising indicators
- 11 rejected

## Panel ratings of PSI “preventability”

- a Panel ratings were based on definitions different than final definitions. For “Iatrogenic pneumothorax,” the rated denominator was restricted to patients receiving thoracentesis or central lines; the final definition expands the denominator to all patients (with same exclusions). For “In-hospital fracture” panelists rated the broader Experimental indicator, which was replaced in the Accepted set by “Postoperative hip fracture” due to operational concerns.
- b Vascular complications were rated as Unclear (-) by surgical panel; multispecialty panel rating is shown here.

## International expert panel ratings of PSIsOrganization for Economic Cooperation and Development

## Impact: Estimated cases in 2000 (NIS)Romano et al., Health Aff 2003;22(2):154-66

| Indicator | Frequency±95% CI | Rate/100 |
| --- | --- | --- |
| Postoperative septicemia | 14,055 ± 1060 | 1.091 |
| Postoperative thromboembolism | 75,811 ± 4,156 | 0.919 |
| Postoperative respiratory failure | 12,842 ± 938 | 0.359 |
| Postoperative physiologic or metabolic derangement | 4,003 ± 419 | 0.089 |
| Decubitus ulcer | 201,459 ± 10,104 | 2.130 |
| Selected infections due to medical care | 54,490 ± 2,658 | 0.193 |
| Postoperative hip fracture | 5,207 ± 327 | 0.080 |
| Accidental puncture or laceration | 89,348 ± 5,669 | 0.324 |
| Iatrogenic pneumothorax | 19,397 ± 1,025 | 0.067 |
| Postoperative hemorrhage/hematoma | 17,014 ± 968 | 0.206 |

## Estimating the impact of preventing each PSI event on mortality, LOS, charges (ROI)NIS 2000 analysis by Zhan & Miller, JAMA 2003;290:1868-74

| Indicator | Δ Mort (%) | Δ LOS (d) | Δ Charge ($) |
| --- | --- | --- | --- |
| Postoperative septicemia | 21.9 | 10.9 | $57,700 |
| Postoperative thromboembolism | 6.6 | 5.4 | 21,700 |
| Postoperative respiratory failure | 21.8 | 9.1 | 53,500 |
| Postoperative physiologic or metabolic derangement | 19.8 | 8.9 | 54,800 |
| Decubitus ulcer | 7.2 | 4.0 | 10,800 |
| Selected infections due to medical care | 4.3 | 9.6 | 38,700 |
| Postoperative hip fracture | 4.5 | 5.2 | 13,400 |
| Accidental puncture or laceration | 2.2 | 1.3 | 8,300 |
| Iatrogenic pneumothorax | 7.0 | 4.4 | 17,300 |
| Postoperative hemorrhage/hematoma | 3.0 | 3.9 | 21,400 |

## Estimating the impact of preventing each PSI event on mortality, LOS, charges (ROI) VA PTF analysis by Rosen et al., Med Care 2005;43:873-84

| Indicator | Δ Mort (%) | Δ LOS (d) | Δ Charge ($) |
| --- | --- | --- | --- |
| Postoperative septicemia | 35.7 | 18 | $39,531 |
| Postoperative thromboembolism | 10.2 | 7 | 12,856 |
| Postoperative respiratory failure | 29.3 | 19 | 39,848 |
| Postoperative physiologic or metabolic derangement | 44.5 | 15 | 37,460 |
| Decubitus ulcer | 10.9 | 5 | 5,887 |
| Selected infections due to medical care | 9.8 | 11 | 18,706 |
| Postoperative hip fracture | 17.9 | 10 | 18,906 |
| Accidental puncture or laceration | 3.9 | 3 | 11,626 |
| Iatrogenic pneumothorax | 10.1 | 5 | 8,039 |
| Postoperative hemorrhage/hematoma | 8.1 | 6 | 14,384 |

## Impact: Estimated cases in 2000 (NIS) Romano et al., Health Aff 2003;22(2):154-66

| Indicator | Frequency±95% CI | Rate per 100 |
| --- | --- | --- |
| Birth trauma | 27,035 ± 5,674 | 0.667 |
| Obstetric trauma –cesarean | 5,523 ± 597 | 0.593 |
| Obstetric trauma - vaginal w/out instrumentation | 249,243 ± 12,570 | 8.659 |
| Obstetric trauma - vaginal w instrumentation | 60,622 ± 3,104 | 24.408 |
| Postoperative abdominopelvic wound dehiscence | 3,858 ± 289 | 0.193 |
| Transfusion reaction | 138 ± 49 | 0.0004 |
| Complications of anesthesia | 5,305 ± 455 | 0.056 |
| Foreign body left during procedure | 2,710 ± 204 | 0.008 |

## Impact of patient safety events in 2000Zhan & Miller, JAMA 2003; replicated by Rosen et al., 2005

| Indicator | Δ Mort (%) | Δ LOS (d) | Δ Charge ($) |
| --- | --- | --- | --- |
| Birth trauma | -0.1 (NS) | -0.1 (NS) | 300 (NS) |
| Obstetric trauma –cesarean | -0.0 (NS) | 0.4 | 2,700 |
| Obstetric trauma - vaginal w/out instrumentation | 0.0 (NS) | 0.05 | -100 (NS) |
| Obstetric trauma - vaginal w instrumentation | 0.0 (NS) | 0.07 | 220 |
| Postoperative abdominopelvic wound dehiscence | 9.6 | 9.4 | 40,300 |
| Transfusion reaction* | -1.0 (NS) | 3.4 (NS) | 18,900 (NS) |
| Complications of anesthesia* | 0.2 (NS) | 0.2 (NS) | 1,600 |
| Foreign body left during procedure† | 2.1 | 2.1 | 13,300 |

- * All differences NS for transfusion reaction and complications of anesthesia in VA/PTF.
- † Mortality difference NS for foreign body in VA/PTF.

## National trends in PSI rates, 1994-2002Rare events (<0.1%)

**HCUPNet at **_[http://www.hcup.ahrq.gov/](http://www.hcup.ahrq.gov/)_**, accessed 9/19/05.****  **

## National trends in PSI rates, 1994-2002Low-frequency medical complications (0.05-0.5%)

**HCUPNet at **_[http://www.hcup.ahrq.gov/](http://www.hcup.ahrq.gov/)_**, accessed 9/19/05.****  **

## National trends in PSI rates, 1994-2002High-frequency medical complications (0.5-2.5%)

**HCUPNet at **_[http://www.hcup.ahrq.gov/](http://www.hcup.ahrq.gov/)_**, accessed 9/19/05.****  **

## National trends in PSI rates, 1994-2002Surgical/technical complications

**HCUPNet at **_[http://www.hcup.ahrq.gov/](http://www.hcup.ahrq.gov/)_**, accessed 9/19/05.****  **

## National trends in PSI rates, 1994-2002Obstetric complications

**HCUPNet at **_[http://www.hcup.ahrq.gov/](http://www.hcup.ahrq.gov/)_**, accessed 9/19/05.****  **

## Reliability or precision: signal ratio

- Source: 2002 State Inpatient Data. Average Signal Ratio across all hospitals (N=4,428)

## Year-to-year correlation of hospital effects

- Source: 2001-2002 State Inpatient Data, hospitals with at least 1,000 discharges (N=4,428). Risk-adjusted unsmoothed rates.

## Coding (criterion) validity based on literature review (MEDLINE/EMBASE)

- Validation studies of Iezzoni et al.’s CSP
- At least one of three validation studies (coders, nurses, or physicians) confirmed PPV at least 75% among flagged cases
- Nurse-identified process-of-care failures were more prevalent among flagged cases than among unflagged controls
- Other studies of coding validity
- Very few in peer-reviewed journals, some in “gray literature”

## Validation (%) of Complications Screening ProgramMed Care 2000;38:785-806,868-76; Int J Qual Health Care 1999;11:107-18

| CSP Indicator | PSI | Coder:
Complic
Present | RN: process problem | MD:
Complic
present | MD:
Quality
problem |
| --- | --- | --- | --- | --- | --- |
| Postprocedural hemorrhage/ hematoma | #9 narrower: requires proc code + dx | 83 (surg)
49 (med) | 66 vs 46
13 vs 5 | 57 (surg)
55 (med) | 37 vs 2
31 vs 2 |
| Postop pulmonary compromise | #11 narrower:
includes only resp failure | 72 | 52 vs 46 | 75 | 20 vs 2 |
| DVT/PE | #12 surgical only
Slight changes | 59 (surg)
32 (med) | 72 vs 46
69 vs 5 | 70 (surg)
28 (med) | 50 vs 2
20 vs 2 |
| In-hosp hip frx and falls | #8 surgical only, no E codes | 57 (surg)
11 (med) | 76 vs 46
54 vs 5 | 71 (surg)
11 (med) | 24 vs 2
5 vs 2 |

## Criterion validity of PSIs linked to NSQIP, VA hospitalsTsilimingras, Romano, et al., AcademyHealth 2005

| 
Indicator | Sensitivity |  | PPV |  |
| --- | --- | --- | --- | --- |
|  | Current
Inpatient | Better
Inpatient | Current
Inpatient | Better
Inpatient |
| Postop sepsis | 32% | 37% | 44% | 45% |
| Postop thromboembolism | 
56% | 
58% | 
22% | 
22% |
| Postop respiratory failure | 
19% | 
67% | 
74% | 
66% |
| Postop physiologic/  metabolic derangement | 
44% | 
48% | 
54% | 
63% |
| Postop abdominopelvic wound dehiscence | 
29% | 
61% | 
72% | 
57% |

## Construct validity based on literature review (MEDLINE/EMBASE)

- Approaches to assessing construct validity
- Is the outcome indicator associated with explicit processes of care (e.g., appropriate use of medications)?
- Is the outcome indicator associated with implicit process of care (e.g., global ratings of quality)?
- Is the outcome indicator associated with nurse staffing or skill mix, physician skill mix, or other aspects of hospital structure?

## Summary of construct validity evidence in literature

| Indicator | Explicit process | Implicit process | Staffing |
| --- | --- | --- | --- |
| Complications of anesthesia |  |  |  |
| Death in low mortality DRGs |  | + |  |
| Decubitus ulcer |  |  | ± |
| Failure to rescue |  |  | ++ |
| Foreign body left during procedure |  |  |  |
| Iatrogenic pneumothorax |  |  |  |
| Selected infections due to medical care |  |  |  |
| Postop hip fracture | + | + |  |
| Postop hemorrhage or hematoma | ± | + |  |
| Postop physiologic/metabolic derangements |  |  | –- |
| Postop respiratory failure | ± | + | ± |
| Postop thromboembolism | + | + | ± |
| Postop sepsis |  |  | –- |
| Accidental puncture or laceration |  |  |  |
| Transfusion reaction |  |  |  |
| Postop abdominopelvic wound dehiscence |  |  |  |
| Birth trauma |  |  |  |
| Obstetric trauma – vaginal birth w instrumentation |  |  |  |
| Obstetric trauma – vaginal w/out instrumentation |  |  |  |
| Obstetric trauma – cesarean birth |  |  |  |

## Construct validity: Do indicators track together?Factor loadings from 2001 VA/PTF

## Construct validity: Do indicators track together?Factor loadings from 2001 VA/PTF

## PSI risk adjustment methods

- Must use only administrative data
- APR-DRGs and other canned packages may adjust for complications
- Final model
- DRGs (complication DRGs aggregated)
- Modified Comorbidity Index based on list developed by Elixhauser et al.
- Age, Sex, Age-Sex interactions

## Susceptibility to bias at the hospital level:Impact of risk-adjustment, 1997 SID (summary)

| High Bias | Medium Bias | Low Bias |
| --- | --- | --- |
| Failure to rescue 
(44% change 2 deciles) | Postoperative respiratory
failure (11%) | Postop abdominopelvic
wound dehiscence (4%) |
| Accidental puncture or
laceration (24%) | Postoperative hip fracture
(8%) | Obstetric trauma –
cesarean birth (2%) |
| Decubitus ulcer (26%) | Iatrogenic pneumothorax
(14%) | Postop hemorrhage
or hematoma (4%) |
| Postop thromboembolism
(14%) | Postop physio/metabolic
derangement (5%) | Complications of
anesthesia (<1%) |
| Death in low mortality
DRGs (13%) | Obstetric trauma – 
vaginal w instrument (5%) | Obstetric trauma –
vaginal w/out instrument |
| Postoperative sepsis
(11%) | Selected infections due to
medical care (10%) | Birth trauma (0%) |

## Measurement for quality-based purchasing and public reporting: Conclusions

- Quality-based purchasing and public reporting may stimulate improvement in quality of care, or at least more attention to quality indicators
- Measures/indicators must be selected based on local priorities and limitations of available data – AHRQ QIs appropriate for public reporting may differ across states and regions
- Results must be presented and disseminated in a manner that earns the confidence of providers, purchasers/consumers, and other stakeholders
- Reference: Remus D, Fraser I. *Guidance for Using the AHRQ Quality Indicators for Hospital-level Public Reporting or Payment*.
- 	AHRQ Publication No. 04-0086-EF.

## Acknowledgments

**Funded by AHRQ**
- Support for Quality Indicators II (Contract No. 290-04-0020)
- Mamatha Pancholi, AHRQ Project Officer
- Marybeth Farquhar, AHRQ QI Senior Advisor
- Mark Gritz and Jeffrey Geppert, Project Directors, Battelle Health and Life Sciences
**Data used for analyses:**
- Nationwide Inpatient Sample (NIS), 1995-2000. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality
- State Inpatient Databases (SID), 1997-2002 (36 states). Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality

## Acknowledgments

- We gratefully acknowledge the data organizations in participating states that contributed data to HCUP and that we used in this study: the Arizona Department of Health Services; California Office of Statewide Health and Development; Colorado Health and Hospital Association; CHIME, Inc. (Connecticut); Florida Agency for Health Care Administration; Georgia Hospital Association; Hawaii Health Information Corporation; Illinois Health Care Cost Containment Council; Iowa Hospital Association; Kansas Hospital Association; Maryland Health Services Cost Review Commission; Massachusetts Division of Health Care Finance and Policy; Missouri Hospital Industry Data Institute; New Jersey Department of Health and Senior Services; New York State Department of Health; Oregon Association of Hospitals and Health Systems; Pennsylvania Health Care Cost Containment Council; South Carolina State Budget and Control Board; Tennessee Hospital Association; Utah Department of Health; Washington State Department of Health; and Wisconsin Department of Health and Family Service.

## Questions?