Diapositive 1

Patient Safety Indicators Experiences in France and in SwitzerlandJean-Marie Januel, PhD, MPH, RNSenior ResearcherUniversity hospital of Lausanne, Institute of Social and Preventive Medicine, Lausanne, Switzerland

Health Services Research Seminar SeriesUC Davis, Center for Healthcare Policy and ResearchSacramento, CA, US May 9, 2013 IUMSPInstitut universitaire de mdecine sociale et prventive, LausanneNDisclosure StatementSpeakers Verbal Disclosure Statement:

Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with the manufacturer of the products or services that will be discussed in this CME activity?

___ Yes

_X_ No

(If yes, please state disclosures and resolutions) Educational objectivesTo describe the French experience of PSI (focusing on feasibility, validity and measurement variations between providers)To describe the Swiss experience of PSI (focusing on the use of PSI for assessing the impact of DRG implementation in all Swiss hospitals)To discuss about an appropriate reference standard for comparing Patient Safety Indicators (example provided by a pilot study to compare the PSI 12 postoperative pulmonary embolism and deep vein thrombosis in hospitalized patients undergoing hip arthroplasty between France and Switzerland)BACKGROUND Hypothesis to Develop New IndicatorsTo use Administrative Databases for assessing adverse events related to healthcare that could be preventableMcDonald K, Romano P, Geppert J, Davies SM, Duncan BW, Shojania KG, et al. Measures of Patient Safety Based on Hospital Administrative Data - The Patient Safety Indicators. Technical Review 5. AHRQ Publication No. 02-0038 . Rockville, MD: Agency for Healthcare Research and Quality

Approach derived from the Complication Screening Program (CSP) by Iezzoni LI et al. Iezzoni LI, Foley SM, Heeren T, Daley J, Duncan CC, Fisher ES, Hughes J. A method for screening the quality of hospital care using administrative data: preliminary validation results. QRB Qual Rev Bull. 1992;18(11):361-371.

ICD Codes for Secondary Diagnoses related to Adverse Event IdentificationPopulation at risk, defined usingDRG codes, Diagnostic codes, Procedure codesPSI =PSI Algorithm ModelProjects20 Patient Safety Indicators (PSI) initially developed by the Agency for Healthcare Research and Quality (AHRQ) using ICD9-CMMcDonald K, et al. Measures of Patient Safety Based on Hospital Administrative Data - The Patient Safety Indicators. Technical Review 5. AHRQ Publication No. 02-0038 . Rockville, MD: Agency for Healthcare Research and QualityICD10 adaptation of 15 PSI by the International Methodology Consortium for Coded Health Information in 2007 (www.imecchi.org)Quan H., et al. AHRQ Advances in Patient safety 2: News Directions and Alternatives Approaches. Vol 1. Assessment. Taxonomies and Measurement. Agency for Health Care Research and Quality Publication 2008. Januel JM, et al. Rev Epidemiol Sante Publique 2011;59:341-350. Achievements for PSIBenchmark (external comparisons)Between healthcare providers (hospitals)Between healthcare systems (countries)

Surveillance (internal comparisons)Longitudinal studies (to assess epidemiological peak)To assess changes in robustness relating of changes in ICD coding rules / version used

The Patient Safety Indicators in the Literature

*Including one citation without abstract; **including two citations without abstract.The French experience of PSI French Pilot Study ObjectivesTo explore French data using PSI algorithms (ICD10 version - IMECCHI) To assess feasibility for PSI by calculating a selection of PSI from nationwide database in 2005 and 2006, respectivelyTo validate selected PSI using chart reviewPSI estimates calculation for feasibility

Stratified analysis for PSI #12 (Postoperative PE /DVT)

MenWomenWomenMenEstimating PPV based on three PSITo compare PSI positive cases to a retrospective chart review of medical recordsBetween 80 and 150 inpatients stays with positive PSI at the university hospital of Lyon, FranceTo calculate the Positive Predictive Value (PPV)To identify potential reasons for false positive cases

PPV of PSI #12 (postoperative PE/DVT) University Hospital, Lyon, France (2008)PPV of PSI #7 (Bacteremia-related to Catheter) University Hospital, Lyon, France (2008)

PPV of PSI #13 (postoperative sepsis) University Hospital, Lyon, France (2008)

The Swiss experience of PSI IDoC Project (Switzerland)To assess the Impact of Diagnosis related groups (DRG) implementation on patient Care and professional practice in Swiss hospitalsOverall Hospitals DRG implementation in Switzerland for inpatient stays payment on 2012, January 1stDesign5 sub-projects based on several outcomes (Ethic; Law; Nursing sensitive; AMI; and PSI)Sub-project PSI To monitor the possible effects of the generalization of DRG-based hospital reimbursement using Patient Safety Indicators (PSI)To take into account the number of SDx in Models (hierarchical) better At inpatient LevelTo control differences in case mix (using categorical variable)At Hospital LevelTo control differences in quality of codingBy assessing adjusted average number of SDx for each hospitals using negative binomial regression modelsSDx in a Previous Analysis of PSI #12

Impact of Changes in ICD10 version on PSI 12 estimates Changes in ICD10 version occurred between 2008 and 2010 in Switzerland 2008: ICD10-WHO2009: ICD10-GM20082010: ICD10-GM2010Trend comparisons across years (2008, 2009 and 2010) using ICD-10-WHOTo compare ICD-10-WHO to ICD-10-GM using:Data from 2009Data from 2010Hierarchical Logistic Regression Model for PSI #12

To Develop a New PSI 13To refine definition from Postoperative Sepsis to Postoperative Hospital-Acquired InfectionsTo develop a New AlgorithmTo compare New Algorithm to PSI 13 (AHRQ)To repeat models using data from 2008 to 2010, with respect to changes in ICD-10 version used each year in SwitzerlandApproach for New Algorithm (ICD10)

New Algorithm vs. PSI #13 (AHRQ)

PSI rate high or low ? A pilot study to compare Swiss and French data for PSI #12 (Postoperative PE/DVT)To which Benchmark / Reference Standard Compare PSI 12 (postoperative PE/DVT)?The HypothesisNeed a BENCHMARK for assessing comparisons across clusters (e.g., hospitals, countries) in studies for healthcare quality improvementPossible benchmarks / reference standardsRisk-adjusted observed vs. expected rate (Funnel plots)Benchmark vs. best in class (Forest plots)Zero eventEvidence-based data / informationDevelopment of an evidence-based benchmark for PSI 12 (postoperative PE/DVT)Proposal: to compare actual values to an evidence-based reference standardThree step methodologyTo develop a reference standard using the baseline risk of Postoperative PE/DVT occurring in hospitalized patients undergoing hip arthroplasty, under appropriate prophylaxis, using a systematic review with meta-analysisTo estimate adjusted occurrence rates of PSI 12 in patients undergoing hip arthroplasty (pilot study using data from Switzerland and France)To compare these rates against the reference standard as a benchmark (or a target) developed using the meta-analysis Systematic Review (Januel JM, et al. JAMA 2012;307(3): 294-303)Original RCT and observational studies published from 1996 to 2011 (PubMed-Medline, EMBASE, Cochrane) Adult patients undergoing hip arthroplasty with appropriate VTE prophylaxis (updated guidelines during the corresponding period)Proportions of symptomatic VTE occurring between arthoplasty and hospital discharge using pooled occurrence rate with random effectsGRADE1 method for assessing quality of included studies and for evaluating the evidence-basis of our systematic review results(1) GRADE working group. www.gradeworkinggroup.orgSystematic Review RESULTS 27 studies21369 adult patients undergoing hip arthroplasty38 prophylactic treatment subgroups58 to 70 years old on averageFollow-up after surgery ranged from 8 to 17 daysPooled VTE 0.53% (95% CI, 0.35% to 0.70%) Heterogeneity: I2=49.4% P