# Presentation: 277300

** **
**Blue Cross Blue Shield of Illinois**
**Use of AHRQ Quality Indicators**
- Carol Wilhoit, M.D., M.S.
- Medical Director, Quality Improvement

## BCBSIL Approach to Patient Safety

- In response to the IOM reports, large employer groups expect health plans to implement programs that will motivate hospitals to improve patient safety.  Leapfrog is a specific focus of some employers.
- Patient safety is now included in health plan accreditation standards.
- BCBSIL chose to evaluate multiple indicators related to hospital quality and patient safety.  Results are summarized in the BCBSIL Hospital Profile.
- To create a system that motivates improvement and rewards performance and outcomes, some profile-related indicators are being publicly reported and some are incorporated into the hospital contracting process.

## Input From Hospitals

- The BCBSIL Hospital Advisory Group was created to provide a forum for obtaining input from network hospitals.
- The advisory group, representing diverse hospitals, reviewed draft Hospital Profile criteria and preliminary data.
- Recommendations from the advisory group were used in determining how to adjust AHRQ indicator results to improve comparability between hospitals.

## 2005:  Third Annual BCBSIL Hospital Profile

| Measures | Data Sources |
| --- | --- |
| Leapfrog | Leapfrog Website, TMIT and BCBSIL Hospital Survey |
| Member Survey | BCBSIL Member Survey |
| AHRQ Indicators* | BCBSIL Claims+ MedPar Data |
| Efficiency* | BCBSIL Claims Data |
| Physician Survey | BCBSIL Physician Surveys |
| Structural Indicators | JCAHO + HFAP Websites and BCBSIL Hospital Survey |
| Hospital Quality Alliance Indicators | Joint Commission Resources |
| Participation in National QI Initiatives | BCBSIL Hospital Survey |

- *For some indicators, hospitals are compared to other hospitals within their “peer group.”

## 3rd Annual BCBSIL Hospital Profile: AHRQ Indicators

- Patient Safety Indicators:
- Selected Infections Due to Medical Care
- Postoperative PE/DVT
- Postoperative Respiratory Failure
- Postoperative Septicemia, Obstetric Trauma (without instrument)
- Decubitus Ulcer
- Failure to Rescue
- Accidental Puncture or Laceration

- Mortality Rates for Conditions:
- Acute myocardial infarction
- Congestive heart failure
- Acute stroke
- Gastrointestinal hemorrhage
- Hip fracture
- Pneumonia
- Mortality rates are aggregated into one score for reporting

## Methodology

- To evaluate outcomes using AHRQ Quality Indicators and Patient Safety Indicators, BCBSIL uses HealthShare data analysis tools
- The data source is a database including both MedPar and BCBSIL claims data.
- Adjustments made to improve comparability between hospitals include:
- exclusion of admissions involving a transfer in from another hospital
- use of ARDRGs for risk adjustment
- age adjustment:  standardization of each hospital’s complication rate based on its relative mix of patients at every age-ARDRG level (indirect standardization)
- In the past, when Illinois all-payor data were available, Medicaid admissions were excluded.

## Methodology

- An additional modification to the AHRQ methodology for Postoperative Respiratory Failure and Postoperative Sepsis:
- As written, these indicators include only elective admissions.
- Because BCBSIL claims data do not include the admission type, elective admissions cannot be identified.
- Therefore, the indicators are reported using all admissions.
- However, using ER admission source as a proxy for non-elective admissions, a final adjustment is made based upon whether or not admissions were from the ER.

## Considerations in reporting results

- Results are not reported for specialty hospitals (rehabilitation, behavioral health, pediatric, cancer).
- Indicators with very small numerators and/or denominators are not scored as they are of limited value in identifying differences between hospitals.  Examples:
- Complications of Anesthesia
- Death in Low Mortality DRGs
- Foreign Body Left in During Procedure
- However, even though indicators with small numbers may not discriminate between hospitals, they can still be used to provide feedback for quality improvement purposes.
- Indicator results are not reported when a specific hospital has a small denominator. Cut-off points are separately calculated for each indicator.

## Small Numbers

- AHRQ Patient Safety Indicators:  Obstetric Trauma – Cesarean Section
- The hospital-specific rate was calculated for 134 Illinois hospitals.  The  data source included MedPar data plus BCBSIL admission claims.
- There were a total of 57 complications among 10,276 cases at risk (0.6%).
- The number of cases at risk (denominator) per hospital ranged from 1 to 662.
- The number of cases with complications (numerator) ranged from 0 to 6.
- Every hospital with more than two complications had a high volume of cases at risk.
- Conclusion:  Due to the small numbers, the indicator did not identify meaningful differences in performance between hospitals.
- However, even though this indicator does not discriminate between hospitals, it can still be used to provide valuable information for quality improvement purposes.

| # of complications | # of hospitals |
| --- | --- |
| 0 | 103 |
| 1 | 18 |
| 2 | 8 |
| 3 | 1 |
| 4 | 1 |
| 5 | 2 |
| 6 | 1 |

## Cut off volume 

- Cut off volume

## Peer Groups

- Urban Hospitals – 5 peer groups are identified based on:
- Case mix
- Number of beds
- Resident to bed ratio
- Transplant volume
- Open heart surgery volume
- Trauma center status
- Neonatal ICU status

- Rural hospitals – 3 peer groups are identified based on:
- Case mix
- Number of beds

- Scoring of AHRQ indicators on the BCBSIL Hospital Profile is based upon a comparison of the adjusted rate for hospitals within the same “peer group.”

## Mean

**Mean**

## Results:  Decubitus Ulcer

## 3rd Annual BCBSIL Hospital Profile Scores

- Urban Hospitals Peer Groups 1-4

## Urban Hospital Cost and Quality Value Report

**Urban Hospital Cost and Quality Value Report**

**Cost**

**Hospital Profile Score (%)**

**Lower Cost**
**Higher Quality**

**Higher Cost**
**Higher Quality**

**Lower Cost**
**Lower Quality**

**Higher Cost**
**Lower Quality**

- Higher
-  Quality

- Lower
-  Quality

- Higher
-  Cost

- Lower
-  Cost

## Public Reporting

## Performance-Based Recognition

- Indicators related to the hospital profile have been incorporated into many BCBSIL hospital contracts.
- The criteria used for the performance-based compensation is likely to evolve over the next several years.
- AHRQ indicators have not yet been included in the BCBSIL Blue StarSM Hospital Report, but will likely be included in the future.