# Presentation: 646469

## Hospital Measures Reporting in Ohio
Michele Shipp, MD, DrPH 

- Michele Shipp, MD, DrPH

- AHRQ QUALITY INDICATORS USERS MEETING
- Wednesday September 9, 2008

- AHRQ ANNUAL CONFERENCE 2008

- Selecting Indicators for Public Reporting:
- The Ohio Experience

## Hospital Performance Measures Selection

- Ohio Department of Health

- Alvin Jackson, MD
- Madelyn Dile, JD
- Jodi Govern, JD
- Kaliyah Shaheen, MPH

**Notes:**
Dr. Jackson, the Director of the Health Department,  served as the Chair of the Hospital Measures Advisory Council;

Madelyn Dile – Assistant Chief for the Division of Quality Assurance - Facilitated the meetings;

Jodi Govern JD, also at the Division of Quality Assurance, filled in in case of Madelyn’s absence and facilitated the Infection control Group meeting;

Kaliyah Shaheen, Data Manager for the Division of Quality Assurance,  was appointed by Dr. Jackson as his Data Expert and served as a member on the Data Expert Group along with serving as a member of the Infection Control Group and has been the contact for Council members. Also, Ms. Shaheen has been the main data person involved in the process at ODH; she also will be managing the reporting website. 

## BACKGROUND

## HOUSEBILL 197

**HB 197 became law in November 2006**
- Requires Ohio hospitals to report performance measure data to the Ohio Department of Health for the purpose of public reporting

**Notes:**
Bullet 1 and sub-bullet 1

Representative James Raussen sponsored HB 197.  The concept was first introduced in 2004 and evolved over time from originally mandating the collection of patient level records from hospitals to its current enactment which requires hospital to calculate all measures and report the calculated result directly to ODH.

ODH did not have the staff resources needed to extract data from patient charts.

Because no funding was attached to the mandate ODH has struggled allocating resource to the project.

The intent of the Bill has always been to assist with consumer decision-making through public reporting, and to promote transparency among hospitals.

## HOUSEBILL 197

**Required Measure Sets**
- Centers for Medicare and Medicaid Services (CMS)
- The Joint Commission (JC)
- National Quality Forum (NQF) endorsed measures
- Agency for Healthcare Research and Quality (AHRQ)

**Notes:**

Sub-bullet 2
At least one measure from each of the above mentioned organizations must be recommended, but other measures could be recommended from additional organizations not mentioned in the statute. Some members wanted to only consider measures from the above organizations and resisted considering any other measures being recommended.  Especially in the realm of infection control measures.   
Other organizations considered: CDC, Vermont Oxford Network, American College of Cardiology, New York State... and others

## Creation of Advisory Council

- A Hospital Measures Advisory Council was created by statute and consisted of:
- Director of Health (Council Chair)
-  Two members of the House of Representatives
-   Two members of the Senate
-  Superintendent of Insurance
-  Executive Director of the Commission on Minority Health
-  Representatives from several agencies

**Notes:**
Bullet 1
All  17 members of the council were appointed by the House and Senate with the exception of the Director of health, Superintendent of Insurance and Director of Minority Health.
Timeline:
The Bill was enacted in November 2006
The Senate appointed all of it members March 15, 2007
The House appointed all but one of its members July 31, 2007
The House appointed its last member August 16, 2007
The council had one year from August 16, 2007 to make its recommendations back to the Director of Health
All sub bullets
Appointments made by the Senate:
Two members of the Senate, and a representative from each of the following; physicians specializing in public health, hospitals, health service researchers, health care consumers and large employers
During the process all members appointed by the Senate were very involved in the process and attended the majority of the meeting
Appointments made by the House:
Two members of the House, and a representative from each of the following; health insurers, small employers, organized labor, physicians in general practice and children’s hospitals 
During the process all members except the two House Representatives were very involved in the process and attended the majority of the meetings
Representatives
Health Insurers, Small and Large Employers, Organized Labor, Physicians in General Practice, Physicians Specializing in Public Health, Children’s Hospitals, Hospitals, Health Care Consumers and Health Services Researchers

## Creation of other Groups

- 	Mandated Groups
- A Data  Expert Group
-   An Infection Control Group
- 	Ad Hoc Groups
- The Advisory Council created Pediatric and Perinatal workgroups

**Notes:**
Bullet 1
Each member of the Hospital Measures Advisory Council was required to appoint a data expert 
The majority of the data experts appointed were dedicated to the process and drove from all parts of Ohio to attend monthly meetings. The two House Representative members did not appoint Data Expert Group members.

Bullet 2
An infection Control Group -was also required to provide information about infection measures
The Directors Committee on Emerging Infections which was made up of several ODH staff and Infection control specialists from across Ohio had been interested in being involved in the process. This existing group had asked the Advisory Council to consider them as the Infection Control Group for the purposes of HB 197.  The Advisory Council agreed this group could serve that function and asked that they add consumer representation.

Note: Because the Hospital Measures Advisory Council, Data Expert Group and Infection Control Group were statutorily mandated groups, the meetings were subject to the public meetings laws and had to be held in person.

Bullet 3
These group looked at measures specific to these populations – not mandated

The Advisory Council member representing Children’s Hospitals had asked the Advisory Council to consider allowing the Group of Children’s hospitals from across Ohio review and make recommendations on pediatric measures.  The Council agreed  this not mandated workgroup.  

After the Advisory Council reviewed the initial selection of perinatal measures all of which were AHRQ measures they felt they did not have the expertise necessary to make recommendations on perinatal measures and thus asked ODH to convene a group of experts in the perinatal field to make recommendations.

Note: Because the pediatric and perinatal workgroups were not written in statute they were not subject to public meeting laws and therefore could convene via phone or private meetings.

## Process for Measures Selection

- Data Expert Group monthly meetings
- Creation of set criteria as guidelines
- Examination of measure specifications
-   Selection of measures
-  Recommendations to Advisory Council on selected measures

- * **Measures related to Adult care,  Chronic Diseases, Patient Safety – Slide 9**

**Notes:**

Bullet 1
The Data Expert Group was truly the workhorse behind the selection of measures. 
Data Expert Group met monthly to review each measure created by the organizations mentioned in the law [about 300 to 400 measures related to hospital quality] by condition category

Bullet 2
The Data Expert Group created a set of criteria that would serve as guidelines for selection of measures in each category.

The guidelines for measure selection on the next two slides were created by ODH staff and amended by the Data Expert Group.  All members agreed that these were the areas most important when considering measures for public reporting.

The specifications for each measure were examined and it was determined whether or not it met the majority of the criteria

## Measure Selection Criteria

- Importance
-  Do the measures reflect unequivocally important aspects of patient care?
- Preventability
-  Can a poor score be prevented through proper care?
-  Is excess variation in the data accounted for by factors unrelated to hospital quality?
- Genuine quality improvement
-  Can a hospital’s rate be improved without improving quality?

**Notes:**
No notes – self explanatory

## Measure Selection Criteria (cont.)

- Data integrity
-  Can a hospital accurately collect the data from its records?
-  Does the measure adequately measure the construct it attempts to measure?
- Ability to publicly report
-  Is the measure of use to consumers?
-  Is the measure comprehensible to consumers?
-  Do hospitals have a sufficient case load to accurately report quality?
- Burden
-  Does calculating the measure place undue burden on hospitals?

**Notes:**

Bullet 5

## Measure Selection Criteria (cont.)

- Evidence-based
-  Is there scientific research demonstrating the accuracy and importance of the measure?
- Variance
-  Is there sufficient variability in performance among hospitals to allow for comparison?
- National Quality Forum endorsement
-  Is the measure endorsed by the National Quality Forum?

**Notes:**
Bullet 3
National Quality Forum
Particular emphasis was stressed by both the Data Expert Group and the Advisory Council that NQF endorsement be used as a gold standard for whether or not a measure should be recommended. 

This was important because of the process used by NQF to endorse measures:
The measure must be evidence based
The measure specifications must be publicly available
The guideline for the measure must be consistent with current clinical    practice guidelines
Measure is well defined
Testing of the measure shows validity about quality
Adequate risk-adjustment exists

## Overview of Selected Measures

-  All measures from 4 required sources considered
- Total of 84  measures were recommended to the Advisory Council
- 47  CMS measures
- 17  AHRQ measures
- 10  JC measures
- 10 Infection measures

**Notes:**
Sub-bullet 1– AHRQ
A set of 84  measures were recommended to the Advisory Council by the Data Expert Group, Infection Control Group and the pediatric workgroup 

I will discuss AHRQ measures on the upcoming slides

Sub-bullet 2 -CMS
The Group did not have a difficult time deciding on the recommendation of CMS’ Acute Myocardial Infraction, Heart Failure and Pneumonia or Surgical Care  measures. These measures are core measures that are already being collected by CMS and Joint Commission quarterly. The Council also decided to “bundle” (all-or-none measures) for the CMS data.  For example: All of the Heart Failure measures collected would be bundled into a new measure that would identify if the hospital provided all applicable care to all eligible patients.

Sub-bullet 3 – JC
All ten Joint Commission Stroke measures were agreed upon and recommended for delayed reporting (2 years after the adoption of rules).  This lag time will allow for hospitals to become comfortable collecting this new set of measures, which is currently in pilot stages.

Sub-bullet 4 – Infection measures
The infection control measures received the most press and contention. The Infection Control Group met only three times, but was very focused and succinct in their recommendations. They recommended the collection of Clostridium Difficile and MRSA/MSSA along with questions regarding infection control staffing and handwashing practices.  Some members of the Council raised concerns regarding the collection of this data saying it was not risk adjusted and there was a lack of testing. On the other-hand C. diff had been collected in Ohio in 2006, therefore Ohio hospitals are familiar with reporting this measures and MRSA/MSSA is pulled from lab reports therefore would not be overly burdensome to hospitals. All measures recommended by the Infection Control Group passed by majority vote

## AHRQ: Patient Safety Indicators

-  The Data Expert Group recommended the following  AHRQ Patient Safety Indicators to the Advisory Council
- PSI-1: Complications of Anesthesia
- PSI-3: Decubitus Ulcer
- PSI-5: Foreign Body Left During Procedure
- PSI-9: Postoperative Hemorrhage or Hematoma
- PSI-16: Transfusion Reaction
- PSI-17: Birth Trauma—Injury to Neonate
-  PSI-18: Obstetric Trauma– Vaginal Delivery with  Instrument
-  PSI-19: Obstetric Trauma—Vaginal Delivery without instrument
- PSI-20: Obstetric Trauma—Cesarean Delivery

**Notes:**

Bullet 1
The Data Expert Group believed the above AHRQ Patient Safety indicators (PSI) were the best for purposes of public reporting out of all the PSI measures. 

Note – see slide 12 for discussion of the selection of AHRQ measures go from 17 considered to the 7 passed for collection:
Transfusion Reaction and Postoperative Hemorrhage or Hematoma did not pass voting by the Advisory Council.  

Transfusion reaction was believed to not be the most meaningful to consumers  in terms of comparison.  Considering that this measures is a “never event” and the majority of the data that would be displayed publicly would wither be no cases or not enough cases.

Postoperative Hemorrhage or Hematoma was not passed because the Advisory Council believed a more meaningful measure to the consumer would be unscheduled return visits' to the operating room.  Since such a measure did not already exist the council deferred this for future consideration.

## AHRQ : Inpatient Quality Indicators

-  The Data Expert Group recommended the following AHRQ  Inpatient Quality Indicators for inclusion
- IQI-5: CABG volume
- IQI-6: PCTA volume
- IQI-12: CABG mortality rate
- IQI-30: PCTA mortality rate
- IQI-21: Cesarean Delivery Rate
- IQI-22: Vaginal Birth after Cesarean Rate, Uncomplicated
- IQI-33: Primary Cesarean Delivery Rate
- IQI-34: Vaginal Birth after Cesarean Rate, All

**Notes:**
Bullet 1
The Data Expert Group believed the above AHRQ Inpatient Quality Indicators (IQI) were the best for purposes of public reporting out of all the IQI measures.

Sub-bullet 3 and 4
Discussions surrounding mortality measures were intense.  The members representing consumers and public health agreed that mortality was data consumers wanted to see.  While hospitals and physicians believed the mortality measures were not risk adjusted appropriately and issues such as do not resuscitate are neither appropriately nor consistently dealt with across hospitals, thereby making mortality rates misleading to a consumer.

Sub-bullets 8 – 10 this slide and 6- 10 on slide 10
There was  quite a bit opposition surrounding the birth measures.  The majority of the discussion was around the topic of ICD-9 codes and whether or not these measures were truly an indication of hospital quality. The Council decided to reject all of them and ask the Department to convene a perinatal workgroup to make recommendations on perinatal measures.  These recommendations are not yet final and it is anticipated that the list of perinatal measures will be presented to the Advisory Council sometime in October 2008.

## AHRQ: Recommended Measures 

- After consideration and voting by the Advisory Council, 7 of the 17 AHRQ measures were recommended to the Director of Health for public reporting
- PSI -1: Complications of Anesthesia
- PSI-3: Decubitus Ulcer
- PSI-5: Foreign Body Left During Procedure
- IQI-5: CABG volume
- IQI-6: PCTA volume
- IQI-12: CABG mortality rate
- IQI-30: PCTA mortality rate
- If passed through the rule making process hospitals will begin reporting these measures in late 2009

**Notes:**
Bullet 1
These 7 AHRQ measures were decided to be the most appropriate for public reporting.  

When considering AHRQ measures for selection there were those in favor and those opposed.  

Members representing the Senate, health insurance, and public health were in favor of AHRQ measures because of the ease of extracting  the information from billing records and the ease of calculating the measures through the provide AHRQ software. Some of the members representing hospitals and physicians expressed concerns about:
reliability of the ICD-9 coding – are hospitals using the correct codes and is the patient record being interpreted properly
lack of current reporting – hospitals are not currently required to report on these measures
Transition to software to CMS Medicare Severity Diagnosis Related Groups (MS-DRG) Grouper.

Complications of anesthesia, decubitus ulcer and foreign body left in during procedure where chosen because they are easily understood by the consumer.

While there was opposition to mortality measures in general, PCTA and CABG mortality measures where thought to be good for public reporting because volume data and surgical site infection data for CABG would also be collected.  This would give the consumer a spectrum of data to review and not just the mortality rate.

## Current Hospital Reporting in Ohio

- April 2007 Hospital reporting start date by HB 197
- ODH selected 11 measures for interim reporting
- 2 of these measures were from AHRQ
- Reporting done April and October 2007, 2008

**Notes:**
Bullet 1
While House Bill 197 required the creation of an Advisory Council, it also required that reporting begin as of April 2007

Bullet 2
ODH moved forward with a small selection of measures for hospitals to begin reporting as of April 2007
Because the Council’s report of recommendations was not due until August 16, 2008, ODH worked with Ohio Hospital Association in selecting a small set of measure to be reported in the interim.  

Bullet 3
Although not intended the interim reporting has identified issues with the statutory mandates including:  
The law requires all hospitals to report for all measures however, not all measures apply to all hospitals - for example; rehabilitation, psychiatric and children’s hospitals.
The law requires hospitals to report a years worth of data each April and October.  This results in a six month overlap of data each time hospitals report.

## Hospital Reporting Beginning April 2007

- Postoperative Respiratory Failure
- Adult
- Pediatric
- Iatrogenic Pneumothorax
- Adult
- Pediatric
- Neonate

**Notes:**
Sub-bullet 1
Postoperative Failure was initially selected for interim reporting because high quality of care can reduce the risk of respiratory failure.

Sub-bullet 2
Iatrogenic pneumothorax was selected because it can be prevented by good surgical techniques and close observation of ventilator patients.

## Current ReportingFeedback from Hospitals

- Postoperative Respiratory Failure
- Ohio has found the numbers are too small for Iatrogenic Pneumothorax and may not be the best measure for the purpose of public reporting
- Only 2 hospitals in the adult category and 1 hospital in the neonatal category had reportable data

**Notes:**
Majority of hospitals  [from 187]  made no comment.  

About 10 offered comments about 

Bullet 1

Ohio hospitals have said they are using ICD-9 code 518.5 (Pulmonary insufficiency following trauma and surgery) for postoperative respiratory failure not ICD-9 code 518.81, Acute respiratory failure or 518.84, Acute and chronic respiratory failure

## Iatrogenic Pneumothorax - Pediatrics

- October 1, 2006 – September 30, 2007

- 187 hospitals

## Other Measures Currently Being Reported

- Aspirin at Arrival for Acute Myocardial Infarction
- Beta Blocker at Arrival for Acute Myocardial Infraction
- Pneumococcal Vaccination for Pneumonia
- Blood Culture before Initial Antibiotic for Pneumonia
- ACEI or ARB Left Ventricular Systolic Dysfunction for Heart Failure
- Evaluation of Left Ventricular Systolic function for Heart Failure

## Next Steps

-  Adopt rules reflecting recommended measures
-  Six to nine month process
- Public comment period
- Public hearing
-  Reporting of new measures to begin no earlier than October  2009
-  Development of the consumer website
-  To be operational by January 2010

**Notes:**
Bullet 1
Timeframe for the adoption of rules may take longer depending on amount of opposition and nature of testimony during the public hearing process.  Which may delay the reporting of the new measures.

Bullet 2
No funding was provided for the development of the website. 

The Advisory Council’s recommendations borrow from New York’s website for display and comparison functionality and from the New Jersey website for informational text regarding measures and will allow for consumer feedback.

Consumer feedback will occur during the beta testing stage of the website and will be obtained through Advisory Council member constituents.

## If you have any questions please contact Kaliyah Shaheen at 614-995-4982 or kaliyah.shaheen@odh.ohio.gov
September 2008

- September 2008

- Thank You

**Questions??**