AHRQ PSIs and IQIs AHRQ PSIs and IQIs in National Pay for Reportingin National Pay for Reporting

September 14, 2009

AHRQ QI Conference

Shaheen Halim, Ph.D.

Centers for Medicare & Medicaid Services

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CMS’ Office of Clinical Standards and Quality

Lead on quality and clinical issues and policies for the Agency’s programs. Coordinates with external organizations and Agencies.

Promote and monitor quality and quality improvement for the Agency’s programs. Evaluates the success of interventions

Develop, evaluate, adopt and support performance measurement systems (quality indicators) to evaluate care provided to CMS beneficiaries

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OCSQ’s Quality Measurement and Health Assessment Group

Lead for measure development and public reporting of quality measures:

● Hospital Inpatient and Outpatient

● Physician

● Nursing Home

● Home Health

● ESRD

Websites available on http://www.Medicare.gov

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Hospital Pay for Reporting Programs

Reporting Hospital Quality for Annual Payment Update (RHQDAPU)

● MMA 2003: .4% APU to report 10 measure starter set

● DRA 2005: 2% APU to report expanded measure set … 44 measures for the 2010 payment determination

Hospital Outpatient Quality Data Reporting Program (HOP QDRP)

● TRHCA 2006: 2% 2009 APU for 7 measures, 11 measures for 2010 APU, including 4 claims-based measures on Imaging Efficiency

RHQDAPU Over the Years

2004: 10 process measures (AMI, HF, PN, SCIP)

2006: 21 process measures (11 added)

2007: 30-day mortality measures, HCAHPS

2008: 30-day readmission, AHRQ measures, structural measure

2009: 2 structural measures

Currently 46 measures in RHQDAPU Program 27 process, 15 claims-based outcome measures, 3 structural,

HCAHPS

Desire to expand outcomes measurement in RHQDAPU

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AHRQ PSIs and IQIsin RHQDAPU

9 AHRQ Indicators were adopted into CMS’ Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) in FY 2009 IPPS Rule

Allows expansion of RHQDAPU program topics to include Patient Safety, Complications, and In-hospital mortality

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Patient Safety Indicators

AHRQ Patient Safety Indicators adopted: PSI 4: Death among surgical patients with serious, treatable complicationsPSI 6: Iatrogenic PneumothoraxPSI 14: Postoperative Wound DehiscencePSI 15: Accidental Puncture or Laceration

PSI Composite: Complications/Patient Safety for Selected Indicators

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Complication/patient safety for selected indicators

PSI #03 Decubitus Ulcer

PSI #06 Iatrogenic Pneumothorax

PSI #07 Infection Due To Medical Care

PSI #08 Postop Hip Fracture

PSI #09 Postop Hemorrhage or Hematoma

PSI #10 PostopPhysioMetabolDerangmt

PSI #11 Postop Respiratory Failure

PSI #12 Postop PE Or DVT

PSI #13 Postop Sepsis

PSI #14 Postop Wound Dehiscence

PSI #15 Accidental Puncture/Laceration

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Inpatient Quality Indicators

AHRQ Inpatient Quality Indicators adopted:

IQI 11: Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate

IQI 19: Hip Fracture Mortality Rate

IQI Composite: Mortality for Selected Procedures

IQI Composite: Mortality for Selected Conditions

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Mortality for Selected Procedures

IQI #08 In-Hosp Mort Esophageal Resection

IQI #09 In-Hosp Mort Pancreatic Resection

IQI #11 In-Hosp Mort AAA Repair

IQI #12 In-Hosp Mort CABG

IQI #13 In-Hosp Mort Craniotomy

IQI #14 In-Hosp Mort Hip Replacement

IQI #30 In-Hosp Mort PTCA

IQI #31 In-Hosp Mort Carotid Endarterectomy

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Mortality for Selected Conditions

IQI #15 In-Hosp Mort AMI

IQI #16 In-Hosp Mort CHF

IQI #17 In-Hosp Mort Stroke

IQI #18 In-Hosp Mort GI Hemorrhage

IQI #19 In-Hosp Mort Hip Fracture

IQI #20 In-Hosp Mort Pneumonia

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CMS 2009 Dry Run

CMS conducts “Dry run” for claims-based measures to provide methodology information about the measures prior to formal implementation.

Provide hospitals with an opportunity to provide CMS with feedback to inform implementation.

Opportunity to answer questions regarding measure methodology and calculations.

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CMS 2009 Dry Run

Hospital-Specific Reports were generated and released to hospitals via their QualityNet accounts on February 27, 2009. Hospital Specific Performance National, State, and Regional summary statistics

Mock-report and Summary Statistics made available for download on QualityNet.Began 30-day question and comment period to end April 2, 2009.Webinars to provide further information and to answer frequently asked questions about the dry run.

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CMS 2009 Dry Run

● 2006 Inpatient Medicare claims (100% file) Data obtained from Dartmouth Medical School 10 diagnostic and 6 procedural codes were reported No age restriction

AHRQ PSI and IQI software v3.2 Excludes claims missing Age or Sex from all analyses Excludes claims missing other variables (e.g. Admission Source,

Admission Type, Disposition Status, DRG, LOS, etc.) from the denominators of specific measures

3M™ APR™-DRG V3.2 Limited License Grouper software AHRQ PSI and IQI software use this for risk adjustment APR-DRG software downloaded from the AHRQ website

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CMS 2009 Dry Run

● Modifications to our claims data were required because the AHRQ software was designed for use with HCUP, not Medicare claims data

The levels for some categorical variables required reassignment (e.g. Admission Source, Race, etc.)

For example, Hispanic = 5 in our data, AHRQ software specifies that Hispanic = 3

MDC (Major Diagnostic Category) was assigned using the CMS DRG version 23 and 24 Relative Weights files

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CMS 2009 Dry Run

● AHRQ PSI and IQI software Defines the inclusion and exclusion criteria for each

indicator

Generates the numerator, denominator, observed, expected, risk-adjusted and smoothed rates for each indicator

Indicators were reported as rates per 1000 Rate = 200 (per 1000) Rate calculated by multiplying x 1000 = 200 (per 1000)

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CMS 2009 Dry Run

● Population reference: national rates based upon the HCUP State Inpatient Database (SID) Includes 90 million discharges in 2002, 2003, and 2004

from the 38 states participating in the HCUP SID

Equal weight option applied for the Composite Scores In this case, each component indicator is assigned an

identical weight based on the number of indicators. That is, the weight equals 1 divided by the number of indicators in the composite

For example, 1/8 = 0.1250

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CMS 2009 Dry Run

Hospital Specific Reports provided Observed, Expected, Risk Adjusted and Smoothed Rates

Provided definitions for each of the 4 rates and guidance on how to interpret and use them.

State, National and Regional (HHS Region) summary statistics provided for comparison

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2010 Implementation

Initial display onhttp://www.cms.hhs.gov tentatively scheduled for January 2010.

Will be calculated using Medicare claims spanning July 1, 2007 to June 30, 2008 for the FY 2010 payment determination

Hospital preview reports tentatively scheduled for November/December 2009

Reporting on Hospital Compare tentatively scheduled for June 2010 using calculations spanning July 1, 2008 to June 30, 2009.

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Future Implementation

Include Observed Numerator and Denominator in hospital previews

Include Confidence Intervals for rates

Consumer testing to inform future display and language for the AHRQ PSIs and IQIs on Hospital Compare

Possible display of composites similar to current bucket approach for 30-day mortality and 30-day readmission.

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Example Display

Future Issues

Examine POA for future use

Small N threshold

Which rate (predicted or smoothed) for consumer display

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