Tranparency in the VA

VA and Center for Medicaid and Medicare Service

Hospital Compare

M L arta

L. R d en

der, M D. .,

Peter L. Almenoff, M.D.
Transparency

• Rationale

– Public’s right to know about outcomes and make choices bas

performance; implicit is that information is accurate and meapatient access to services remains unchanged.

– Ability to transfer “best practices” from strong hospitals acro

– Increased scrutiny of quality and performance locally

• Risk

– Adequate data collection and measurement instruments– Assuring consistent data quality data quality– Adequate risk models that account for severity across the sp

severity
Drivers in Tranparency

• IOM s’ report Crossing Crossing the quality quality chasm• Accrediting organization required publi

release of data

• AHRQ invested in creating standardized

measures of i i pat ent experiences (IQI PS

(IQI,PS

CAHPS)

• Internet access to results

• CMS incentives for p p articipation

Romano PS, Burstin H. National Standardization of metrics and d
Evidence

• Intended to accelerate improvement in hospita

– Modest increment in improvement at hospitals w

compared to those with reporting only.

– OR Hospital mortality Hospital mortality PA 0 59 . to 0 79 . across 6 clin

clin

conditions compared to 0.72 to 0.92 prior to pub

reporting.

– R i esn c d ib ecr es an f ll a i i f i in proportion of patients w

cardiogenic shock getting revascularization in NY 

MA coincident with reporting PCI mortality.

– No variation in 30‐d post op mortality, VTE, or sur

infection when stratified by adherence rate of EB

hospitals.

Lindenauer PK. NEJM 2007;356:486 – 96 Hollenbeak CS. Am J Med Qual 2008; 23:27Resnic FS. J Am Coll Card 2009;53:825 Nicholas LH. Arch Surg 2010:145:999‐ 1004
New drivers

Patient Patient Protection Protection and Affordable Affordable Care Act 20

Act 20

y N ti l a ona Q lit ua y I t mprovement St t ra egy

y Identification of quality gaps in present quality appro

contract for standardization of measures for g pa s

y Inter agency working group

y Value based p g urchasing p g ro rams implemented

y New organizations encouraged (Accountable care

organizations)

y Rating system for qualified health plansy Electronic health recordsy Increased registries
Audience for information abo

healthcare system performan• Providers• Insurers

• Healthcare systems themselves

• Consumers, family members
Key elements elements in evaluating evaluating web

web

y Method used Method used to attribute attribute patients patients to provider providery Measures endorsed by NQF or other consensusy Data so rces Data sourcesy Case mix adjustment appliedy R li bili Reliability of measures assessedy Physicians/ healthcare systems allowed to review 

prior to publication; publication; Physicians Physicians allowed allowed to recons

recons

results and make corrections

y Framework to make interpretations easier for co
Sources to get information abo

h lh ea t care provid d ers and servi

• 126 sites

– State governments (44%)– Hospital associations (25%)– Multi stakeholder collaboratives stakeholder collaboratives (15%)– Employer organizations (15%)

• H it lC HospitalCompare (M di ) (Medicare)

• Commonwealth Fund

Cronin C, Damberg C, Riedel A, France J. State of the Art of hospohysiican/physician Group Public Reports
Hospital Compare

• Process measures for AMI, , PNA

CHF, SCIP

• Risk adjusted mortality and

readmission for AMI/ CHF/ PNA; 3

year sample, updated annually, no

time series

• HCAPS results

• Medical imaging (CT abd Chest % w

and wo contrast, callbacks

mammogram, early MRI back wo

conservative trial)

• Patient Safety indicators Inpatient

quality indicators ( download ‐Dec

2011)




New measures

April 2011y Website Website data will be refreshed refreshed.

y Link to an ED Throughput flat file placed on Hospital Compare for early, voluntary adopters.

y Link to a HAC flat file from Medicare claims placed on Hospital Compare.

October 2011

y Web is te data will be ref hd res e .

y AHRQ Patient Safety and Inpatient Quality Indicators will be added to the Website.

y Two new AHRQ PSIs will be added as this time as well:

{ Post‐operative respiratory failure and{ P t os ‐operati l ve pu monary emb li o sm or d i th b i deep vein thrombosis.

January 2012

y Website data will be refreshed.

y The following new inpatient measures will be added to the Website in January 2012:

{ AMI‐10 ‐ Statin at discharge

{ Central Line Associated Blood Stream Infection (CLABSI)

{ ED‐1 ‐ Median Time from ED Arrival to ED Departure for Admitted ED Patients

{ ED‐2 ‐ Admit Decision Time to ED Departure Time for Admitted Patients
CMS Hospital Compare
Transparency in Veterans Affa

Hospitals

• Participation Participation in TJC website website for ORYX / 

measures for years

• Secretary Secretary of Veterans Veterans Affairs Affairs made deci

deci

that VA hospitals would participate in C

Hosp p ital Compare in January 2010

– Honest broker, match methods in private s

disp y la comparison relevant to consumers

• CMS Hospital compare

(http://www.hospitalcompare.hhs.gov/
CMS Hospital compare

Annual data management pla

• Model Maintenance Maintenance in the summer prior t

release

• Update the model with final data (/ 

Jan Feb

• Release hospital specific reports in Apr/ M

access to patient identifiers

• Public release in June / l Ju y 2011.• The earli t es possible d t a e for mort lit a y /

readmission results (Jul 2011) was later thdesirable.
Improving transparency transparency in th

• Delay is getting comparable VA data up on HospitalCompare rel

• CMS methods• Law that does not permit sharing of HCAPS data• VA Requirement Requirement that VA data has data has to be displayed displayed FIRST on a VA web

web

being displayed outside of the VA

• Given delay getting VA risk adjusted mortality and readmission 

interim interim solution solution was to build VA hospital hospital compare compare

(http://www.hospitalcompare.va.gov/)

• Uses CMS risk models and SAS code• Updated Updated quarterly quarterly, mortality mortality / readmissions readmissions in 3 rolling rolling years (PNA, 

• High and low outliers estimated at 95%CI in hierarchical model

• Process measures for CHF, AMI, PNA, SCIP posted on VA and CM

compare in M h arc 2010
VA Hospital compare

http://www.hospitalcompare.va.gov/


Kicking it up a notch

• Medicare Medicare is limited limited to data elements elements comm

comm

available in private public hospitals primaradministrative data.

• VA has much broader and more specific da

available to create information information.

– Laboratory data– Ph d armacy data

– Outcome data including hospital acquired infe
VA ASPIRE

VA TRANSPARENCY INITIATIVE
ASPIRE



Other Measures in

Aspire

2011

2010 
LINKS

VA TRANSPARENCY INITIATIVE
LinKS – Linking information, knowledge, and s
LinKS
LinKS
THE VA AND CMS COMBINE

VA Transparency initiative
Mortality risk Mortality risk models

• Co oh rt 3 year sa p e m l

(rolling in VA results)

• Administrative model

• C statistic ≈ 0.70• Hierarchical regression

model with hospital

identifier as a random

effect (SAS V9.2

GLIMMIX procedure)
Results: Risk adjusted outcomes f

hospitals in CMS models
Issues combining VA and CMS 

• CMS cohort

– F f i ee or service M di e care b fi i i beneficiaries not capit t 

a 

(HMO’s).

– Medicare beneficiaries with 12 months of enrollm

(enrollment is difficult to determine in VA data)

– Exclusions

• Patients discharged on the day of admission or

following day (and not transferred or died) or l

• Transferred Transferred from another another acute care hospital hospital o

hospital (Attributed to transferring hospital)

• Inconsistent mortality data

• Hospice enrollment
Methods Methods : CMS combining combining VA 

y Data source : National Patient Care databasey Case Selection: Index hospitalizations based on principal d

using same ICD‐9‐CM codes for AMI, HF, and PNA.

y Merging with Merging with CMS data: Based on SSN, DOB, gender, linke

patients to CMS enrollment file identifying their correspon

HIC number (97% ID’d)

{ Comb d ine VA / non fd l e era f l aci ities into singl h e co ort

y Establishing hospital ID ‐ VA stations sharing a single CMS 

number (CCN) treated as single institution

y Data differences : VA data includes 34 diagnosis and 46 pr

codes (vs 10/6); retained all diagnoses and only first 6 pro

codes in index
Characteristics of VA hospita

compared to CMS h l ospitals

Case Size RSMR/RSR

All Hospitals All Hospitals VA Hospitals VA Hospitals All Hospitals All Hospitals VA 

VA 

AMI Mortality 117 82 15.9 

HF Mortality 225 233 11.4 

PN Mortality 223 229 12.0 

AMI Readmission 118 87 19.5 

HF Readmission 271 293 24.9 

PN Readmission 231 248 18.4 



AMI breakdown

Characteristic VA CMS Combined VA d CMS VA and CMSNumber of Hospitals 122 4,556 4,678Hospital Volume

Mean Number of Admissions Mean Number of Admissions

(SD) 81.1 (83.8) 119.9 (169.5) 118.9 (168.0)

Range (min. – max.) 1 – 657 1 – 1,345 1 – 1,34525th Percentile 23 12 13

50th Percentile 65 45 46

h 75t Percentile 107 165 163

RSMR (%) (Percentiles below weighted by hospital volume)

Mea (S ) nD 15.3 ( .7) 1 15.5 ( .7) 1 15.5 ( .7) 1

Range (min. – max.) 11.8 – 20.5 10.1 – 23.2 10.1 – 23.225th Percentile+ 14.1 14.4 14.4

50th Percentile+ 15.1 15.5 15.575th Percentile+ 16.1 16.6 16.6
Risk Adjusted Mortality Ra

Performance Category

U.S.

National

Better than 

U.S. 

National

No Different

than U.S. 

National

Wo

than 

Nat

Measure

National

Rate

National

Rate

National

Rate

Nat

R

AMI 30-day Mortality

15.9%

Out of 4,645 hospitals in the U.S., the number that performed...

101

(2.2%)

2,740

(59.0%)

3

(0.

5 9%

Out of 121 VA hospitals in the U.S., the number that performed...

2

(1.7%)

89

(73.6%)

(0.

HF 30-day Out of 4,841 hospitals in 

Mortality 194 3 880 1

11.3%

the U.S., the number that performed...

194

(4.0%)

3,880

(80.2)

1

(2.

Out of 124 VA hospitals in the U.S., the number that performed

10

(8 1)

113

(91 1)

(0 

that performed... (8.1) (91.1) (0.

PN 30-day Mortality

11.9%

Out of 4,877 hospitals in the U.S., the number that performed...

201

(4.1%)

4,089

(83.8%)

2

(4.

Out of 124 VA hospitals in the U.S., the number that performed...

5

(4.0%)

109

(87.9%)

(7.
Risk Adjusted Readmission Ra

Performance Category

Better than No Different Wo

Measure U.S. National Rate

Better than

U.S. 

National 

Rate

No Different

than U.S. 

National 

Rate

Wo

than 

Nat

R

AMI 30-day Readmission

Out of 4,553 hospitals in the U.S., the number that 

performed

30

(0 7%)

2,417

(53 1%)

3

(0 

19.8%

performed... (0.7%) (53.1%) (0.Out of 121 VA hospitals 

in the U.S., the number that performed...

0

(0.0%)

86

(71.7%)

(2.

HF 30-day O t f 4 857 h it l i

Readmission

24.8%

Out of 4,857 hospitals in 

the U.S., the number that performed...

117

(2.4%)

3,969

(81.7%)

1

(4.

Out of 124 VA hospitals 

in the U.S., the number 1 111 1

that performed... (0.8%) (89.5%) (8.

PN 30-day Readmission

18.4%

Out of 4,897 hospitals in the U.S., the number that performed...

45

(0.9%)

4,356

(89.0%)

1

(2.

18.4%

Out of 124 VA hospitals 

in the U.S., the number that performed...

0

(0.0%)

114

(91.9%)

(7.
Work for the future

• Presentation techniques

– Vary based on user of information– Patients Patients use this information information at transition transition poi

poi

all the time

• Metrics• Ability to drill down to ask the questions t

finds relevant

– Diabetes proportion to HgbA1C 8%, one doc g

high risk to 8%, the other gets all low risk to 8
Challenges to Public Report

Report

• Selection of measures/off label use o

measures

• Hospital Burden

• Dynamic measurement Dynamic measurement environment

• Unintended consequences• Time lags and feedback lags and feedback• Need for proof of effectiveness
Next Frontiers of Public Rep 

or

• Clinician and consumer engagement• Measurement of other dimensions of 

• Scoring g methodologies

• Benchmarking• Incentives/Performance‐based

Reimbursement

• Health Information Technology• Transformational change in health car