# Presentation: 318162

## Day 1: Session I

- Presenter: Sam Shalaby, General Motors Corporation
- AHRQ QI User Meeting
- September 26-27, 2005

## General Motors / AHRQ Quality PartnershipMeasuring and Managing Quality with AHRQ Quality Indicators

***Sam Shalaby***
***Director of Community Health Care Initiatives   ***
***General Motors Corporation ***

- September 26,2005

## Quality & Cost Drivers of Health Care 

**Value****Purchasing**

**Managed****Indemnity**

**Community Initiatives**

**Managed****Care**

**LifeSteps**

**Advocacy**

**Reimbursement**

## GM and AHRQ: Goals

***Improving the Quality and Cost of Health Care for GM’s  Employees  By Translating Research Innovations into Action – A business and Science Partnership***
*** ******Utilize AHRQ Clinical Information, Tools and Consumer Information to Add Value to Current GM’s Initiatives***

## Overview

***Measuring Health Care Quality With the AHRQ Prevention Quality Indicators( PQIs), Area Level Inpatient Quality Indicators(IQIs), Area Level Patient Safety Indicators(PSIs)***
***Applying the Three Indicators to Michigan Data***
*** ******For all indicators – Provide GM employee density (by county, by age applicable to indicator) and cost data (by county) ***

## Prevention Quality Indicators (PQIs): 

Focuses on ambulatory care sensitive conditions

 Area-Level Inpatient Quality Indicators (IQIs):

 Examines area-level utilization indicators that reflect the rate of hospitalization in the area for specific procedures. 

Area-Level Patient Safety Indicators (PSIs):
 Captures all cases of predefined potentially preventable complications that occur either during hospitalization or resulting in subsequent hospitalization.  

***Focuses on ambulatory care sensitive conditions***
*** *****Area-Level Inpatient Quality Indicators (IQIs):**
*** ******Examines area-level utilization indicators that reflect the rate of hospitalization in the area for specific procedures******. ***
**Area-Level Patient Safety Indicators (PSIs):**
** *****Captures all cases of predefined potentially preventable complications that occur either during hospitalization or resulting in subsequent hospitalization.  ***

_**Evaluating Community Care: **__**Area Level AHRQ QIs**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Prevention Quality Indicators (16)

***Bacterial pneumonia***
***Dehydration***
***Pediatric gastroenteritis ***
***Urinary tract infection***
***Perforated appendix***
***Low birth weight ***
***Angina without procedure***
***Congestive heart failure ***

***Hypertension***
***Adult asthma ***
***Pediatric asthma ***
***COPD***
***Diabetes cx - short term ***
***Diabetes cx - long term ***
***Uncontrolled diabetes ***
***Lower extremity amputation ***

**Notes:**
Low Birth Weight 
– Not a measure that is being used in the National Report, used for a reference to assist in interpretation of the PSIs.   States will get information we have.

## Area-level IQIs (4) and PSIs (6)

***Foreign Body Left During Procedure***
***Iatrogenic Pneumothorax***
***Selected Infections Due to Medical Care***
***Postoperative Wound Dehiscence***
***Accidental Puncture or Laceration***
***Transfusion Reaction***

***Coronary Artery Bypass Graft (CABG) area rate***
***Hysterectomy area rate***
***Percutaneous transluminal coronary angioplasty (PTCA) area rate***
***Laminectomy or spinal fusion area rate***

**Notes:**
Low Birth Weight 
– Not a measure that is being used in the National Report, used for a reference to assist in interpretation of the PSIs.   States will get information we have.

## Data Source:  Healthcare Cost and Utilization Project (HCUP) Michigan State Inpatient Database (SID), 2001 and 2002
Software: AHRQ PQI v 2.1, revision 3; AHRQ IQI v 2.1, revision 4; AHRQ PSI v 2.1, revision 3
Standardize data values to QI software requirements
2001 MI SID PQI Analytical File = 1,250,358 total inpatient discharges
2002 MI SID PQI Analytical File = 1,250,706 total inpatient discharges 
Cases primarily excluded due to missing data (e.g., age, sex) or residence outside of MI.  The focus is admissions among MI residents. 

***Software: AHRQ PQI v 2.1, revision 3; AHRQ IQI v 2.1, revision 4; AHRQ PSI v 2.1, revision 3***
***Standardize data values to QI software requirements***
***2001 MI SID PQI Analytical File = 1,250,358 total inpatient discharges***
***2002 MI SID PQI Analytical File = 1,250,706 total inpatient discharges ***
***Cases primarily excluded due to missing data (e.g., age, sex) or residence outside of MI.  The focus is admissions among MI residents. ***

_**Applying the community or area-level **__**QIs to Michigan Data**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## To calculate area rates it was necessary to have access to the state and county (FIPS code) of patient residence.
The QI software produces observed and risk-adjusted rates
Output converted to rates
All rates expressed per 100,000 population with the exception of perforated appendix (rate per 100 admissions) and low birth weight births (rate per 100 births)

***The QI software produces observed and risk-adjusted rates***
***Output converted to rates***
***All rates expressed per 100,000 population with the exception of perforated appendix (rate per 100 admissions) and low birth weight births (rate per 100 births)***

_**Applying the QIs to Michigan Data **__**(cont.)**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## QI Data Tables
Present risk-adjusted rates and confidence intervals
Using color, the data tables indicate areas that are significantly higher than the state average (red) or significantly lower than the state average (green)
Focus on areas with red for improvement, areas with green for best practices

***Present risk-adjusted rates and confidence intervals***
***Using color, the data tables indicate areas that are significantly higher than the state average (red) or significantly lower than the state average (green)***
***Focus on areas with red for improvement, areas with green for best practices***

_**QI Data Interpretation**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## QI Data Interpretation - Example

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Cost Data Tables (electronic)
Detail the average (mean) cost per discharge for each indicator in the county.  Display the number of discharge per year, total costs, and potential cost savings if the number of discharges were reduced by 10%, 20$, 30%, 40%, or 50%. 
No tests of statistical significance.

***Detail the average (mean) cost per discharge for each indicator in the county.  Display the number of discharge per year, total costs, and potential cost savings if the number of discharges were reduced by 10%, 20$, 30%, 40%, or 50%. ***
***No tests of statistical significance.***

_**Cost Data Interpretation**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Slide 14

## Risk-adjusted PQI and area-level IQI and PQI rates of all Michigan counties were grouped into quintiles – five equal groupings
Group 1 = any up to 20% (bottom 1/5), lowest rates
Group 2 = 20 to 39%
Group 3 = 40 to 59%
Group 4 = 60 to 79%
Group 5 = 80% up (top 1/5), highest rates
Visually presents five colors representing the ranges above with actual data ranges (rates) noted
Lower rates are in green; higher rates in red
Hospital locations (by zip code within a county) placed on map for reference only – this does not indicate any relationship to the rates in the counties

***Group 1 = any up to 20% (bottom 1/5), lowest rates***
***Group 2 = 20 to 39%***
***Group 3 = 40 to 59%***
***Group 4 = 60 to 79%***
***Group 5 = 80% up (top 1/5), highest rates***
***Visually presents five colors representing the ranges above with actual data ranges (rates) noted***
***Lower rates are in green; higher rates in red***
***Hospital locations (by zip code within a county) placed on map for reference only – this does ***_***not ***_***indicate any relationship to the rates in the counties***

_**Presentation of Data on Maps**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## The size of the “stick person” represents beneficiary density within three groups:  the smallest size figure for low employee density, middle size for medium density, and large size to represent a high number of beneficiaries in the county.   An example from PQI 1 is shown.

_**Presentation of Data on Maps **__**(2)**_

***GM beneficiary density data was divided into three groups for visual presentation.  A “stick figure” was inserted in each county to represent the number of covered beneficiaries residing in that county.  The age ranges of the beneficiaries are those appropriate to the indicator reported, e.g., the diabetes PQI measures are applicable to adults so the ages of beneficiaries was limited to 25 years and older.  The pediatric PQIs are from 0 to 25 years.  ***

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## 
Maps
Present indicator data in quintiles – shows range of variances
No indication of statistical significance
Present employee density using “stick figures”
Focus on areas with red or high rates and a large number of GM beneficiaries

***Maps***
***Present indicator data in quintiles – shows range of variances***
***No indication of statistical significance***
***Present employee density using “stick figures”***
***Focus on areas with red or high rates and a large number of GM beneficiaries***

_**Map Data Interpretation**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Slide 18

## 
Indicator and Cost Summary – Prioritization of Opportunities
Counties listed were limited to those with more than 5,000 GM beneficiaries regardless of age or more than 1,000 GM beneficiaries within selected age subgroups (e.g., pediatrics).
Highlighting was used to call attention to the counties with the highest opportunity for cost savings with a reduction in the number of admissions by just 10% for the specified indicator.  So highlight represents influence of the number of cases as well as the cost per admission.

***Indicator and Cost Summary – Prioritization of Opportunities***
***Counties listed were limited to those with more than 5,000 GM beneficiaries regardless of age or more than 1,000 GM beneficiaries within selected age subgroups (e.g., pediatrics).***
***Highlighting was used to call attention to the counties with the highest opportunity for cost savings with a reduction in the number of admissions by just 10% for the specified indicator.  So highlight represents influence of the number of cases as well as the cost per admission.***

_**Indicator and Cost Data Summary -Interpretation and Prioritization**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Slide 20

## Data Interpretation
Focus on indicators and counties that have significant opportunities for improvement (e.g., statistically significantly higher than state average); high number of GM beneficiaries; high potential cost savings with reduction in admissions / events
Top performers, those counties with lower than state average rates, may be a resource for best practices

***Focus on indicators and counties that have significant opportunities for improvement (e.g., statistically significantly higher than state average); high number of GM beneficiaries; high potential cost savings with reduction in admissions / events***
***Top performers, those counties with lower than state average rates, may be a resource for best practices***

_**Potential Next Steps**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Community Collaborations
Identify stakeholders who can assist with and/or may be impacted by community quality improvement projects
Identify best practices and improvement strategies.  Resources include:
Top performing communities – what are they doing right?
CDC, AHRQ and other national resources – what has worked in other areas?

***Identify stakeholders who can assist with and/or may be impacted by community quality improvement projects***
***Identify best practices and improvement strategies.  Resources include:***
***Top performing communities – what are they doing right?***
***CDC, AHRQ and other national resources – what has worked in other areas?***

_**Potential Next Steps **__**(2)**_

**Notes:**
Reduce preventable admissions
Customizing the project to GM’s specific needs
Dovetailing with present community initiatives

Measurement:  
-Units of analysis can include states, counties, hospitals
-All conditions or specific diseases?
	Diabetes, cardiac care, pneumonia, asthma, depression
-Establishing benchmarks:  “Best in class” performance demonstrates what
		high level of performance has been achieved
-Understanding gaps and opportunities:  A particular communities 			performance can be compared to overall 			variation and benchmarks.
-Setting management goals:  What performance targets are agreed to and 			tracked.
-Provide training for performance improvement:  AHRQ can help coordinate
-Track performance and reward results:  AHRQ can offer consultation.

## Implementation  and Challenges

***           ***_***Proposed Actions***_
*** ******Integrate action plans with other Community Initiatives projects***
*** ******Consider Pay for Performance for providers in specific counties***
*** ******Dovetail with Save Dollars / Save lives Project in SE MI***
*** ******Focus on the vital few projects ( PTCA, CABG, CHF, Bacterial  Pneumonia, COPD & Diabetes)***

***                  ***_***Challenges***_
*** ******Limitation of  administrative data***
***Determination of Best in Class***
***Coordination with other Community Stakeholders to achieve desired improvement***
*** ******Funding to implement projects at a community level***