# Presentation: 087696

## Examining Deep Vein Thrombosis and Pulmonary Embolism in Academic Medical Centers

**A UHC Benchmarking Project**

*Joanne Cuny RN, MBA*
*Program Director *
*Clinical Performance Improvement*
*University HealthSystem Consortium*

**Annual AHRQ Quality Indicators **
**User Meeting**
**September 28, 2007**

## The University HealthSystem Consortium (UHC)

**An alliance of 97 academic medical centers and 153 of their affiliated hospitals **
**Representing nearly 90% of the nation’s non-profit academic medical centers**
**An idea-generating and information-disseminating enterprise **
**Designed to pool resources, create economies of scale, improve clinical and operating efficiencies, and influence the direction and delivery of health care**

**The University HealthSystem Consortium (UHC)**

## Who is the UHC?

**Who is the UHC?**

**Notes:**
Mission: To advance knowledge, foster collaboration and promote change to help members succeed in their respective markets
Vision: To be a catalyst for change, accelerating the achievement of clinical and operational excellence

## Mission

*To advance knowledge, foster collaboration, and promote change to help members succeed **in their respective markets*

**Mission**

*To be a catalyst for change, *
*accelerating the achievement of clinical *
*and operational excellence*

**Vision**

**Notes:**
UHC’s vision is to be....This vision means that UHC will be an extension of your staff for performance improvement, financial improvement, and perhaps, supply chain optimization.  

## The Benchmarking & Improvement Services Program

**Offering a continuum of resources for...**

- Benchmarking projects (10-12/year)
- Focus on key performance measures for specific diagnoses, procedures, functional areas
- 30-60 AMCs participating
- Performance Opportunity Summary
- Knowledge Transfer meetings

- Better Performer Best Practices
- Commit to *ACT*ion Rapid-cycle Improvement Collaboratives
- Operational Implementation Collaboratives
- Networking Collaboratives and Conference Series

- HQMR & QSMR
- Clinical Outcomes Report
- Core Measures Report Cards
- Performance Updates
- Clinical Data Base (CDB)

- JCAHO
- CMS
- NQF
- AHRQ
- Leap Frog
- Benchmarking            Coordinator Survey

**Measuring**
**Progress**

**Implementing **
**New Strategies**

**Identifying **
**Improvement **
**Opportunities**

## The Benchmarking Process

**The Benchmarking Process**

**Regularly monitor performance**
**Determine processes to be studied**
**Identify relevant performance measures**
**Gather data from multiple hospitals through data collection tools and site visits**
**Analyze data to compare performance**
**Identify focal areas for improvement **
**Identify “Better Performers” and explore their strategies for success**
**Facilitate adoption of best practice processes and implement change **
**Restart the cycle (back to top)**

## Benchmarking: What are we trying to do?

**Explore correlations between operational processes** **and consistency of **care administered at the **patient level**
**Identify** focal areas where **opportunity** for improvement exists
**Identify better performing organizations to share **successful strategies and learn from experiences in best practice performance
- Provide compelling data to **drive improvement** initiatives in an ongoing process

**Benchmarking: What are we trying to do?**

## 2007 DVT/PE Benchmarking Project

**Methods/Inclusion Criteria**
- Retrospective medical record review of a target of 60 cases meeting enrollment criteria
- 15 cases meeting the specific inclusion criteria* for each of 4 cohorts:
*Surgical patients with DVT or PE*
*Surgical patients without DVT or PE*
- Medical *patients with DVT or PE *
*Medical patients without DVT or PE*
- Patients meeting the inclusion criteria for each cohort were randomly selected from eligible cases discharged during Q1/2006 through Q1/2007
**Exclusion Criteria for all patients:**
- Patients with ICD-9-CM codes for DVT/PE in the principal diagnosis field
- (MDC 14) A primary diagnosis or reason for admission related to pregnancy, childbirth or puerperium
- Admitted for comfort care only or comfort care only ordered on the first day of admission

- * Specific inclusion/exclusion criteria for each cohort defined on the following slides

**Notes:**
Methods:	Retrospective review of a minimum of 40 cases meeting the inclusion criteria with a discharge date prior to January 1, 2007 selected in consecutive reverse chronological order by discharge date.
Inclusion Criteria:
Patients > 18 years of age
LOS > 4 DAYS
No previous admission within the last 12 months of the target admission and died during the target admission
Or
Target admission and two (2) previous admissions for any of the 26 selected DRG’s within the last 12 months of the target admission (see clarifications document for DRG listing)

## Surgical Cohort Enrollment Criteria

**Inclusion Criteria for All Surgical Patients**
- Adult patients _>_ 18 years of age
- Surgical patients identified via the AHRQ Patient Safety Indicator SAS software documentation 3.1 (March 12, 2007) (all surgical discharges defined by specific DRGs and ICD-9-CM codes for an elective operating room procedure)
***Cohort #1 Surgical patients with DVT or PE****** – ***Include only cases with         ICD-9-CM codes for DVT or PE in any secondary diagnosis field
***Cohort #2 Surgical patients without DVT or PE****** – ***Exclude cases with    ICD-9-CM codes for DVT or PE in any diagnosis field
**Exclusion Criteria for All Surgical Patients**
- A procedure for interruption of vena cava is the only operating room procedure
- A procedure for interruption of vena cava occurs before or on the same day as the first operating room procedure

**Notes:**
Methods:	Retrospective review of a minimum of 40 cases meeting the inclusion criteria with a discharge date prior to January 1, 2007 selected in consecutive reverse chronological order by discharge date.
Inclusion Criteria:
Patients > 18 years of age
LOS > 4 DAYS
No previous admission within the last 12 months of the target admission and died during the target admission
Or
Target admission and two (2) previous admissions for any of the 26 selected DRG’s within the last 12 months of the target admission (see clarifications document for DRG listing)

## Inclusion Criteria for All Medical Patients
Adult patients > 18 years of age
Patients in one of the following product lines:  Cardiology, Gastroenterology, HIV, Medical Oncology, General Medicine or Neurology
LOS > 2 Days
SOI score of moderate, major or extreme

Cohort #3 Medical patients with DVT or PE – Include only cases with ICD-9-CM codes for DVT or PE in any secondary diagnosis field

Cohort #4 Medical patients without DVT or PE – Exclude cases with ICD-9-CM codes for DVT or PE in any diagnosis field

Exclusion Criteria for All Medical Patients
LOS < 2 days
SOI score of “minor”

- Adult patients _>_ 18 years of age
- Patients in one of the following product lines:  Cardiology, Gastroenterology, HIV, Medical Oncology, General Medicine or Neurology
- LOS > 2 Days
- SOI score of moderate, major or extreme
***Cohort #3 Medical patients with DVT or PE****** – ***Include only cases with ICD-9-CM codes for DVT or PE in any secondary diagnosis field
***Cohort #4 Medical patients without DVT or PE****** – ***Exclude cases with ICD-9-CM codes for DVT or PE in any diagnosis field
**Exclusion Criteria for All Medical Patients**
- LOS _<_ 2 days
- SOI score of “minor”

**Medical Cohort Enrollment Criteria**

**Notes:**
Methods:	Retrospective review of a minimum of 40 cases meeting the inclusion criteria with a discharge date prior to January 1, 2007 selected in consecutive reverse chronological order by discharge date.
Inclusion Criteria:
Patients > 18 years of age
LOS > 4 DAYS
No previous admission within the last 12 months of the target admission and died during the target admission
Or
Target admission and two (2) previous admissions for any of the 26 selected DRG’s within the last 12 months of the target admission (see clarifications document for DRG listing)

## Focus of Performance Measures

- Appropriate screening for increased risk for DVT/PE
- Administration of appropriate guideline-directed DVT prophylaxis
- Early ambulation and/or use of physical therapy
- Prompt recognition of early warning signs
- Use of appropriate diagnostic testing
- Rapid intervention following diagnosis of DVT/PE
- Reduction of related readmission within 30-60 days of discharge

##  AHRQ PSI Postoperative DVT/PE Validation Testing

- Medical Record **chart review** for all study cases:
- Does this patient have documentation / ICD-9-CM diagnosis code for DVT and/or PE as a secondary diagnosis for this admission?
- Yes
- No
- If Yes, specify (check all that apply):
- Patient had **history** of DVT or PE in past
- DVT or PE was **present on admission **
- DVT or PE occurred as a **complication of this admission**
- None of the above is true for this patient (**no DVT/PE**)

- Note:  Utilized the CMS definitions for history of event, present on admission, and complication of admission

## Preliminary Stats

**34 AMC hospitals** submitted patient-level data
**2,100 patient encounters** are included in the analysis
***1,022 Surgical Cases**** *
***1,078 Medical Cases ***
- False positive rate of DVT/PE complication observed              in both Medical and Surgical “with DVT/PE” cohorts
- False positive rate in Medical cases > Surgical cases
**Next Steps**
- Continued analysis of study data
- Select site visits to “Better Performer” hospitals
- Preparation for Knowledge Transfer Meeting conference
- DVT/PE Benchmarking Project** Knowledge Transfer Meeting **on **November 30, 2007 **in Oak Brook Illinois** **

## 2007 Postoperative Respiratory Failure Benchmarking Project

- Patient population will consist of elective surgical cases identified with postoperative respiratory failure (PRF) via  the AHRQ Patient Safety Indicator SAS software documentation 3.1 (March 12, 2007)
- Explore patient characteristics; hospital course and relevant clinical care provided prior to diagnosis of PRF; location and timing of diagnosis
- Will evaluate the sensitivity/accuracy of the AHRQ software in identifying cases with PRF
**Timeline**
- Steering Committee met September 20, 2007
- Project development and preparation: October – November 2007
- Data collection: December 2007 – January 2008
- Data analysis and conference preparation: February – April 2008
- Knowledge Transfer Meeting: May 2008

**2007 Postoperative Respiratory Failure Benchmarking Project**

- UHC contact:
- Joanne Cuny [cuny@uhc.edu]