# Presentation: 698944

## Quality Reporting Initiatives: State Trends and Issues

- AHRQ Quality Indicators Users Group Meeting
- September 27, 2005
- Denise Love, RN, MBA
- National Association of Health Data Organizations

## Outline

- State Hospital Reporting Systems Overview
- What they are
- Who they are
- How they vary
- What’s driving state quality measurement today?
- Transparency and patient safety laws
- NAHDO Survey of state use of national measures
- NAHDO’s response to quality reporting trends
- Summary and future directions

## Attributes of 48 Statewide Hospital Reporting Systems

- Collect hospital discharge data from acute care hospitals, expanding to non-inpatient data over time
- Collect data based on the national uniform billing standard (the minimum)
- Some states enhance or collect additional data elements
- Standardize individual hospital data into a statewide analytic file
- Make the data available to multiple users for multiple uses (research, market, policy)
- Locally funded
- Thirty-eight states supply discharge data to AHRQ’s Healthcare Cost and Utilization Project (HCUP)

## Inpatient hospital discharge data....

- ...are ***all-payer*** data (including self and uninsured) for all patients admitted to ***acute care (non-federal) hospitals*** in the state for a fiscal/calendar year/or quarterly periods, and collected into an annual data base. Records are collected ***by hospitalization***, not by individual, and are represented at the ***discharge level*** rather than as aggregated statistics.

## States with Legislative Mandates to Collect Hospital Data

- DC

**H.B. 1629**
**Patient charge**
**Outcomes data**
**On Internet**

**H.B. 1629**
**Patient charge**
**Outcomes data**
**On Internet**

- =>States with inpatient legislative mandates

**Notes:**
The next wave:  We seem to be at a crossroads, moving in the direction of transparency.  Too soon to know if it sticks.  How do we ensure that disproportionate share providers, rural and sole community providers are able to report, compete, and implement the hoped for change.  

## Overview: States vary in their approaches to data collection

- Three models of statewide data collection systems1:
- Provider-driven (voluntary data collection by hospital associations)
- Payer-driven (collection/use of data by purchasers/payers for negotiation, P4P)
- State-compelled (mandated collection by states or their delegated agent)
- All may result in public information at some level
- State agencies are more likely to have public reporting as their primary or major mission

- 1 National Association of Health Data Organizations, Love, Paita, Custer

## Issues Related to Data Collection

- Legislative scope varies:
- Data suppliers: broad to encompass a range of data suppliers or specific (inpatient, ambulatory surgery, ED, only)
- Funding sources vary (appropriations, assessments)
- Legislation may dictate a process or may not
- Governance:  Data commissions or advisory bodies
- Delegated authority (hospital association or other third party)
- Data content:
- Hospital billing standard or as defined by state
- May prohibit collection of certain data elements (patient, physician identifier, non-billing elements)

## Issues Related to Data Management and Technical Capacity

- Individual hospitals vary in standards and formats, requiring state agencies to standardize to a common state format
- States vary in their submittal formats and standards for required hospital reporting
- States vary in their data quality provisions and requirements
- Data agencies are chronically underfunded

## Administrative Data

**Strengths**
- Readily available
- Politically feasible, low reporting burden
- Relative uniformity across providers
- Reflect provider reimbursement
- Can be enhanced with additional data

**Limitations**
- Lack clinical detail
- Coding variation and bias
- Lags in timeliness

## Issues Related to Data Dissemination

- Legislative disclosure provisions vary:
- Some states prohibited from releasing hospital identifiers
- Other states are charged with releasing consumer-friendly cost and quality comparative reports
- Severity adjustment methodologies may be legislatively required
- State analytic capacity varies, affecting the level of dissemination activities

## States with Legislative Mandates to Collect Hospital Data

- DC

- Transparency and Quality Reporting Laws 2004

**PA: Nosocomial Infection Reporting**

**H.B. 1629**
**Patient charge**
**Outcomes data**
**On Internet**

**SB 1487**
**Public reporting**
**Hospital infections**** **

**Patient Safety Reporting System**
**S.B. 32 Consumer**

**S.B. 59: Central line infections**
**Ventilator PNM**
**Class I surgery wound infs**

**H.B. 1629**
**Patient charge**
**Outcomes data**
**On Internet**

**H.B. 1629**
**Patient charge**
**Outcomes data**
**On Internet**

**Notes:**
The next wave:  We seem to be at a crossroads, moving in the direction of transparency.  Too soon to know if it sticks.  How do we ensure that disproportionate share providers, rural and sole community providers are able to report, compete, and implement the hoped for change.  

## NAHDO’s Quality Reporting Workgroup

- Formed in response to increased requests for legislative and technical guidance around quality reporting initiatives
- To promote the use of administrative data for the public reporting of quality and respond to emerging demands for new measures for states (quality outcomes, efficiency, etc.)
- Building on 20 years of experience with state-to-state mentoring, knowledge transfer of lessons learned

## NAHDO Quality Reporting Workgroup: Survey

- Are you legislative mandated to provide consumer information on hospitals?
- What quality measures are you/will you plan to publish?
- AHRQ IQIs—all or select
- AHRQ PSIs—all or select
- CMS Measures—all or select
- NQF measures—all or select
- State-specific measures (outcomes reports)
- Level of reporting and audience for reports

## NAHDO Quality Reporting Workgroup: Survey

- Surveys distributed (46)
- Surveys completed (33)
- 25 States, 4 Hospital Associations, 4 Other Users (employer coalition, private agency, researcher)

## AHRQ Inpatient Quality Indicators (IQI) by States (all or select)

|  | Uncertain | Public report | Internal/QI only | Total |
| --- | --- | --- | --- | --- |
| State agency | 3 | 10 | 3 | 16 |
| Hosp
Assn |  |  | 2 | 2 |
| Other agency | 2 |  | 1 | 3 |
| Total | 5 | 10 | 6 | 21 |

## AHRQ Patient Safety Indicators (PSI) by States (all or select)

|  | Uncertain | Public report | Internal/QI only | Total |
| --- | --- | --- | --- | --- |
| State agency | 2 | 7 | 3 | 12 |
| Hosp
Assn |  |  | 3 | 3 |
| Other agency | 1 | 1 | 1 | 3 |
| Total | 3 | 8 | 7 | 16 |

## CMS Core Measure Use by States (all or select)

|  | Not Used | Used | Total |
| --- | --- | --- | --- |
| State agency | 11 | 3 | 14 |
| Hosp
Assn |  | 1 | 1 |
| Other agency |  | 2 | 2 |
| Total | 11 | 6 | 17 |

## Unique challenges to quality reporting by states

- States release comparative quality information in a political environment
- Either must adopt defensible scientific methodology or make conservative assumptions
- Examples of reporting decisions:
- Small numbers issues
- Interpretive issues (better/worse, higher/lower)
- Purchasers demanding outcomes and cost information from states

## Summary

- There is an increased interest in public reporting on all aspects of health care, not just hospitals
- States are moving to the model of administrative data for data collection for reasons of cost and availability
- Process measures avoid the outcomes/risk adjustment issue but are not sufficient for most state reporting agendas
- States are prepared to tweak/augment administrative data

## What can the scientific community do?

- Continue to develop standardized, evidence based measures, including non-inpatient administrative data
- Increase technical assistance and tools for states
- Join NAHDO and others to advocate for national standards to improve administrative data:
- ICD-10
- Present on Admission/Arrival indicator
- Guidance for evidence-based data element enhancements to administrative data
- Support your local health data agency to assure continued data availability and funding

## www.nahdo.org

- dlove@nahdo.org