What do we know about overall trends in patient safety in the USA?

1. What do we know about overall trends in patient safety in the USA? Patrick S. Romano, MD MPH Professor of Medicine and Pediatrics University of California, Davis Center for Health Services Research in Primary Care June 26, 2006

2. Background • Two major studies of preventable adverse events during hospitalizations, based on medical record reviews by nurses and physicians: • New York, 1984 • Colorado and Utah, 1992

5. Patient Safety Datasources • HCUP Nationwide Inpatient Sample (AHRQ Patient Safety Indicators) • CDC National Nosocomial Infection Surveillance Program • Medicare Patient Safety Monitoring System: Adverse Events • Medical Expenditure Panel Survey: Inappropriate Medications

6. AHRQ’s Patient Safety Indicators (PSIs) Designed to address the perceived need for an inexpensive surveillance system based on readily available hospitalization data (using ICD-9-CM diagnoses and procedures) • Literature review to identify potential indicators and gather data on validity from prior studies • ICD-9-CM coding consultant review • Clinical expert panel review (modified Delphi rating process) • Empirical analyses of nationwide rates, hospital variation, impact of risk adjustment, and relationships among indicators

7. Medicare Patient Safety Monitoring System • Adverse events from charts • Randomly-selected, nationwide subset of inpatient medical records of Medicare beneficiaries • Data weighted to produce national estimates • Sample size: about 26,000 charts • 5,500 surgical cases • 4,000 central venous catheter insertions

8. National trends in extremely rare (sentinel) eventsHCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

9. National trends in extremely rare (sentinel) eventsHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

10. National trends in very rare event ratesHCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

11. National trends in very rare event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

12. National trends in rare catheter-related event rates HCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

13. National trends in rare catheter-related event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

14. National trends in postoperative medical event rates HCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

15. National trends in postoperative medical event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

16. National trends in technical surgical event rates HCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

17. National trends in technical surgical event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

18. National trends in pressure sore ratesHCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

19. National trends in pressure sore ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

20. National trends in obstetric trauma and FTR-L rates HCUP 1994-2002 (solid) Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

21. National trends in obstetric trauma and FTR-L ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed) Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

22. Research/Policy Question Why are some PSIs increasing in incidence over time while others are decreasing? • Selective changes in coding practice • Changes in severity of illness or underlying risk of potential safety-related events • True changes in quality due to technical improvements in surgical or nursing technique, counterbalanced by inadequate staffing to prevent some complications

23. National trends in CDC’s nosocomial infection ratesNational Nosocomial Infection Surveillance Program 1998-2003 National Health Care Quality Report 2005, downloadable tables

24. National trends in CDC’s nosocomial infection ratesNational Nosocomial Infection Surveillance Program 1998-2003 National Health Care Quality Report 2005, downloadable tables

25. National trends in Medicare Patient Safety Monitoring System, 2002-2003 National Health Care Quality Report 2005, downloadable tables

26. National trends in Medicare Patient Safety Monitoring System, 2002-2003 National Health Care Quality Report 2005, downloadable tables

27. Inappropriate use of medications by the elderlyMedical Expenditure Panel Survey, 1996-2002 National Health Care Quality Report, 2005

28. JCAHO Core Measures for AMI

29. JCAHO Core Measures for heart failure

30. JCAHO Core Measures for pneumonia

32. Conclusions • No consistent trends across AHRQ Patient Safety Indicators: • Most technical errors are slowly decreasing • Most postoperative medical complications are increasing • Unclear whether unmeasured risk or coding changes may explain some of these findings • Nosocomial infection rates in ICUs are decreasing • Volunteer hospitals only

33. Conclusions • Postoperative adverse event rates appear to be decreasing among Medicare patients: • Methodology not well described and validated • Only 2002 and 2003 data • Substantial improvements in most JCAHO core measures: • Performing to the test • Outcome measures (e.g. AMI mortality) show relatively little change