Assessing Inpatient Care Using Assessing Inpatient Care Using Hospital Quality Alliance Patient Level Hospital Quality Alliance Patient Level

Quality DataQuality DataWhat can we learn about inpatient care What can we learn about inpatient care

quality from patient-level dataquality from patient-level data

Jointly funded by The Commonwealth Fund and the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative

Joel S. Weissman, PhD (P.I. ); MGH Institute for Health Policy and Harvard Medical SchoolRomana Hasnain-Wynia, PhD; Northwestern University, Feinberg School of MedicineRaymond Kang, M.A.; American Hospital Association, Health Research and Educational Trust (HRET)Mary Beth Landrum, Ph.D.; Harvard Medical School, Department of Health Care PolicyChristine Vogeli, PhD; MGH Institute for Health Policy

The authors acknowledge the assistance of the IFQHC and the Centers for Medicare and Medicaid Services in providing data which made this research possible. The conclusions prescribed are solely those of the author(s) and do not represent those of IFQHC or CMS.

National Hospital Quality National Hospital Quality AllianceAlliance

Alliance between the Joint Commission and CMS to Alliance between the Joint Commission and CMS to collect and report hospital-level quality.collect and report hospital-level quality.

CMS currently collects data on 31 measures (AMI, HF, CMS currently collects data on 31 measures (AMI, HF, PN, and surgical care).PN, and surgical care).

All payer data.All payer data. Study based on CY 2005 data containing over 2.3 million Study based on CY 2005 data containing over 2.3 million

discharges from 4,450 non-federal hospitals.discharges from 4,450 non-federal hospitals. Discharge (Patient level) data includes information on:Discharge (Patient level) data includes information on:

Attainment of each process / measure Attainment of each process / measure Patient characteristics (race / ethnicity, age, gender)Patient characteristics (race / ethnicity, age, gender) Routine discharge abstract dataRoutine discharge abstract data

Hospital characteristics merged from the AHA Annual Hospital characteristics merged from the AHA Annual Survey.Survey.

HQA Condition Specific Quality HQA Condition Specific Quality MeasuresMeasures

AMI measure setAMI measure set Aspirin at arrivalAspirin at arrival Beta blocker at Beta blocker at

arrivalarrival Thrombolysis w/in Thrombolysis w/in

30 minutes of arrival30 minutes of arrival PCI w/in 120 PCI w/in 120

minutesminutes ACE/ARB for LVSDACE/ARB for LVSD Smoking cessation Smoking cessation

counselingcounseling Aspirin at dischargeAspirin at discharge Beta blocker at Beta blocker at

dischargedischarge

PN Measure set PN Measure set Initial antibiotic Initial antibiotic

selectionselection Initial antibiotic w/in Initial antibiotic w/in

4 hours4 hours Oxygenation Oxygenation

assessmentassessment Pneumococcal Pneumococcal

vaccinationvaccination Blood culture Blood culture

before antibioticbefore antibiotic Influenza Influenza

vaccinationvaccination Smoking cessation Smoking cessation

counselingcounseling

HF Measure setHF Measure set LVF assessmentLVF assessment ACE / ARB for ACE / ARB for

LVSDLVSD Smoking cessation Smoking cessation

counselingcounseling Discharge Discharge

instructions instructions

http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalHQA2004_2007200512.pdf

Composite MeasuresComposite Measures Opportunity WeightedOpportunity Weighted

Sum of numerators / sum of denominators across all measures Sum of numerators / sum of denominators across all measures in the set; with each applicable measure per patient representing in the set; with each applicable measure per patient representing an opportunity. an opportunity.

All-or-NoneAll-or-None Proportion of patients receiving all applicable processesProportion of patients receiving all applicable processes Perceived Strengths:Perceived Strengths:

Sensitive to inter-provider variabilitySensitive to inter-provider variability Reflection of patients’ interests / desiresReflection of patients’ interests / desires System or team approach to improving care. System or team approach to improving care.

Patient PercentPatient Percent The proportion of applicable care processes received by The proportion of applicable care processes received by

patients.patients. Similar to opportunity weighted.Similar to opportunity weighted.

Example of Opportunity-Weighted Example of Opportunity-Weighted Composite Scoring for HFComposite Scoring for HF

Patient 1Patient 1 Patient 2Patient 2 Patient 3Patient 3 Patient 4Patient 4 HospitalHospital

Process Measures Process Measures Num Num DenDen Num Num DenDen Num Num DenDen Num Num DenDen Num Num DenDen

LVF AssessmentLVF Assessment 00 11 11 11 00 00 00 11 11 33

ACE for LVSD ACE for LVSD 00 00 11 11 11 11 00 00 22 22

Smoking Cessation Smoking Cessation Counseling Counseling

0 0 00 11 11 11 11 11 11 33 33

Discharge instructionsDischarge instructions 11 11 00 11 00 00 00 00 11 22

TotalTotal 77 1010

70%70%

Example of All-or-None Example of All-or-None Composite Scoring for HFComposite Scoring for HF

Patient 1Patient 1 Patient 2Patient 2 Patient 3Patient 3 Patient 4Patient 4 HospitalHospital

Process Measures Process Measures Num Num DenDen Num Num DenDen Num Num DenDen Num Num DenDen

LVF AssessmentLVF Assessment 00 11 11 11 00 00 00 11

ACE for LVSD ACE for LVSD 00 00 11 11 11 11 00 00

Smoking Cessation Smoking Cessation Counseling Counseling

0 0 00 11 11 11 11 11 11

Discharge instructionsDischarge instructions 11 11 00 11 00 00 00 00

TotalTotal 11 22 33 44 22 22 11 22

All applicable All applicable processes?processes?

NONO NoNo YesYes NoNo 25%25%

Example of Patient Percent Example of Patient Percent Composite Scoring for HFComposite Scoring for HF

Patient 1Patient 1 Patient 2Patient 2 Patient 3Patient 3 Patient 4Patient 4 HospitalHospital

Process Measures Process Measures Num Num DenDen Num Num DenDen Num Num DenDen Num Num DenDen

LVF AssessmentLVF Assessment 00 11 11 11 00 00 00 11

ACE for LVSD ACE for LVSD 00 00 11 11 11 11 00 00

Smoking Cessation Smoking Cessation Counseling Counseling

0 0 00 11 11 11 11 11 11

Discharge instructionsDischarge instructions 11 11 00 11 00 00 00 00

TotalTotal 11 22 33 44 22 22 11 22

50%50% 75%75% 100%100% 50%50% 69%69%

Why use patient-level Why use patient-level compositescomposites

To examine differences in care quality by To examine differences in care quality by patient characteristics (race/ethnicity, age, patient characteristics (race/ethnicity, age, gender, primary payer, admission source). gender, primary payer, admission source).

To allow uncommon, but important To allow uncommon, but important processes to carry more weight.processes to carry more weight.

To incent excellence.To incent excellence.

Quality of care provided to individual Quality of care provided to individual patients in U.S. hospitals—Results patients in U.S. hospitals—Results

from an analysis of national Hospital from an analysis of national Hospital Quality Alliance dataQuality Alliance data

Christine VogeliChristine VogeliRaymond KangRaymond KangMary Beth LandrumMary Beth LandrumRomana Hasnain-WyniaRomana Hasnain-WyniaJoel S. WeissmanJoel S. Weissman

BackgroundBackground

Prior analyses of hospital level HQA data Prior analyses of hospital level HQA data identified hospital characteristics identified hospital characteristics associated with better quality care.associated with better quality care.

Quality was assessed using composites Quality was assessed using composites that approximate the average proportion of that approximate the average proportion of processes patients receive. processes patients receive.

IOM recommendation => All-or-none IOM recommendation => All-or-none composite that determines whether all composite that determines whether all critical processes provided. critical processes provided.

MethodsMethods Patient-level composites only: All or none and Patient-level composites only: All or none and

patient percentpatient percent Multivariable models (linear and logistic) to Multivariable models (linear and logistic) to

examine independent associations. Adjusted examine independent associations. Adjusted standard errors for clustering within hospitals standard errors for clustering within hospitals using GEE. using GEE.

All-or-none composites stratified by the number All-or-none composites stratified by the number of applicable measures.of applicable measures.

Sequentially excluding specific measures to Sequentially excluding specific measures to asses the contribution of individual measures to asses the contribution of individual measures to the all-or-none composite.the all-or-none composite.

Number of applicable measures Number of applicable measures per patientper patient

The mean The mean number of number of applicable applicable measures per measures per patient is smallpatient is small

The plurality of The plurality of HF patients HF patients have only 2 have only 2 applicable HF applicable HF measuresmeasures

40% of AMI 40% of AMI patients have patients have only 2 applicable only 2 applicable measuresmeasures

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 5 6 7

Number of applicable indicators within each measure set

Per

cent

of p

atie

nts

AMI inpatients (mean = 3.1 measures per patient)

HF inpatients (mean = 2.2 measures per patient)

PN inpatients (mean = 4.3 measures per patient)

Patient-level Composites to Patient-level Composites to Assess Inpatient Care QualityAssess Inpatient Care Quality

Room to improve on all-or-noneRoom to improve on all-or-none Less than half of PN inpatients receive all care Less than half of PN inpatients receive all care

processes.processes. Just over half (57%) receive all HF care processes.Just over half (57%) receive all HF care processes. 83% receive all AMI care processes83% receive all AMI care processes

Composite measureComposite measure AMIAMI HFHF PNEPNE

Patient %: Mean % of Patient %: Mean % of processes receivedprocesses received

93%93% 77%77% 80%80%

All or none: % receiving all All or none: % receiving all applicable processesapplicable processes

83%83% 57%57% 42%42%

All-or-None Performance: Patient All-or-None Performance: Patient Characteristics Characteristics

Transferred patients more likely to receive Transferred patients more likely to receive all processesall processes

Young (18-34) less likely to receive all HF Young (18-34) less likely to receive all HF but more likely to receive all PN but more likely to receive all PN

Minorities less likely to receive all PN Minorities less likely to receive all PN processesprocesses

Patients receiving care in non-profit Patients receiving care in non-profit hospitals more likely to receive all hospitals more likely to receive all processes.processes.

HF patients cared for in 100+ bed HF patients cared for in 100+ bed hospitals more likely to receive all HF.hospitals more likely to receive all HF.

PN patients cared for in major teaching PN patients cared for in major teaching hospitals less likely to receive all PN hospitals less likely to receive all PN processesprocesses

All-or-none performance: All-or-none performance: Hospital CharacteristicsHospital Characteristics

All-or-None Performance: Impact All-or-None Performance: Impact of specific measuresof specific measures

AMI: AMI:

No specific measure had a large impact.No specific measure had a large impact.

HF: HF:

Removal of discharge instruction measure for the HF Removal of discharge instruction measure for the HF set had the largest impact (all-or-none increased by set had the largest impact (all-or-none increased by 27%). 27%).

LVF assessment had almost no impact .LVF assessment had almost no impact . PN: PN:

Pneumonia vaccination and antibiotic had the largest Pneumonia vaccination and antibiotic had the largest impact (all-or-none increased by 9%).impact (all-or-none increased by 9%).

Oxygenation assessment and smoking cessation Oxygenation assessment and smoking cessation counseling had almost no impact. counseling had almost no impact.

LimitationsLimitations

All or none makes implicit assumption that All or none makes implicit assumption that patients should receive all applicable patients should receive all applicable processes processes

Changes / updates in measure Changes / updates in measure specifications since 2005:specifications since 2005: PN antibiotic timing changed from within 4 to PN antibiotic timing changed from within 4 to

within 6 hourswithin 6 hours PCI tightened to w/in 90 minutesPCI tightened to w/in 90 minutes

ConclusionsConclusions

Room to improve all-or-none performanceRoom to improve all-or-none performance Sensitive to the number and type of Sensitive to the number and type of

applicable measures.applicable measures. Variation by patient and hospital Variation by patient and hospital

characteristics.characteristics. Well-accepted professional standards.Well-accepted professional standards.