AHRQ Quality Indicators: History and Application May-June 2007

1. AHRQ Quality Indicators: History and Application May-June 2007

2. Indicator Development AHRQ � Agency for Healthcare Research and Quality (www.qualityindicators@ahrq.gov) Originally developed by the Health Care Utilization Project of AHRQ in the early 1990s Expanded and refined by AHRQ�s Evidence Practice Center at UCSF and Stanford Goal: Accessible, reliable indicators of quality Per the RAND study, as of October 2006 there were 114 usersPer the RAND study, as of October 2006 there were 114 users

3. Three Types of Measures Volume of Inpatient Procedures A link has been demonstrated between the number of procedures performed and outcomes In-hospital Mortality Examines outcomes following procedures and for common medical conditions Utilization Procedures for which questions have been raised about overuse, underuse, and misuse

4. WHAIC Indicator Reports 2003-2005 Required per HFS 120.26 and contract with WI Department of Administration Based on hospital data collected by the �department� Reformatted to be consistent with nationally recognized quality indicators Presents variations in the delivery of inpatient care at individual hospitals without identifying hospitals WHAIC acts as an agent of the state, therefore we fill the role of the �department� Limitation on hospital identification is why WHAIC is limited to publishing a statewide report publicly, but we have provided individual results to hospitals on their requestWHAIC acts as an agent of the state, therefore we fill the role of the �department� Limitation on hospital identification is why WHAIC is limited to publishing a statewide report publicly, but we have provided individual results to hospitals on their request

5. Accessing WHAIC Quality Indicator Reportshttp://whainfocenter.com/dataresources.htm

6. Limitations Variation among hospitals in the coding of diagnoses and procedures Conditions present on admission are not currently identified Lack of specificity in ICD-9-CM coding Limitations of data content Great emphasis on improved coding due to severity adjusted DRGs, POA, and use of data for AHRQ indicators WHAIC will start collecting POA 1/1/08. Will need to determine if the data quality is strong enough to incorporate POA in AHRQ indicators for 2008. Greater specificity with ICD-10 Does not include lab values, vital signs, etc.Great emphasis on improved coding due to severity adjusted DRGs, POA, and use of data for AHRQ indicators WHAIC will start collecting POA 1/1/08. Will need to determine if the data quality is strong enough to incorporate POA in AHRQ indicators for 2008. Greater specificity with ICD-10 Does not include lab values, vital signs, etc.

7. Hospice Care In general, included Hospitals instructed to exclude records of patients admitted to hospice care Includes records of patients with a DNR order (at this time) if not hospice Records with condition code �P1� may be excluded in the future Condition Code P1 is available for use on the UB04. The code indicates that a DNR order was written at the time of or within the first 24 hours of patient�s admission to the hospital and is clearly documented in the patient�s medical record. It does not affect claim payment. Hospitals need good internal systems to identify DNR orders per this definition and to enter the code in the claims system.Condition Code P1 is available for use on the UB04. The code indicates that a DNR order was written at the time of or within the first 24 hours of patient�s admission to the hospital and is clearly documented in the patient�s medical record. It does not affect claim payment. Hospitals need good internal systems to identify DNR orders per this definition and to enter the code in the claims system.

8. Annual Improvements ICD codes are updated October 1 of each year. These changes are incorporated into the software. Composite measures provide an overall score for a group of measures such as inpatient mortality for selected procedures. A few of the benefits are to summarize quality across multiple indicators, improve ability to detect quality difference, and to identify important domains and drivers of quality. Another measure to consider for the future. Population Rate - The reference population rate for each indicator based on the HCUP data. O/E Ratio � The observed rate divided by the expected rate. AHRQ recommends using the O/E ratio for comparative purposes. Will refer to the O/E ratio later in the presentation.ICD codes are updated October 1 of each year. These changes are incorporated into the software. Composite measures provide an overall score for a group of measures such as inpatient mortality for selected procedures. A few of the benefits are to summarize quality across multiple indicators, improve ability to detect quality difference, and to identify important domains and drivers of quality. Another measure to consider for the future. Population Rate - The reference population rate for each indicator based on the HCUP data. O/E Ratio � The observed rate divided by the expected rate. AHRQ recommends using the O/E ratio for comparative purposes. Will refer to the O/E ratio later in the presentation.

9. Advantages of Administrative Data Accessible No extra work for hospitals Data subject to several edit checks/no separate WHA audit required Indicators selected can be measured accurately with discharge data Already coding, billing and sending data to WHAIC under chapter 153 Already coding, billing and sending data to WHAIC under chapter 153

10. Validation Studies Summary Evidence on the IP Quality Indicators � http://www.qualityindicators.ahrq.gov Inpatient Quality Indicators Guide Version 3.0 (February 2006) pages 14-70 AHRQ Summary Statement on Comparative Hospital Public Reporting RAND Evaluation of the use of AHRQ and Other Quality Indicators Version 3.0 is the version we used for the 2005 data, but there has been another release since that time.Version 3.0 is the version we used for the 2005 data, but there has been another release since that time.

11. CheckPoint Indicators Mortality Rates � Medical Services Acute heart attack Acute heart attack without transfer cases Acute stroke Congestive heart failure Gastrointestinal hemorrhage Hip fracture Pneumonia

12. CheckPoint Indicators Mortality Rates � Procedures Abdominal aortic aneurysm (AAA) repair Coronary artery bypass graft (CABG) Carotid endarterectomy (CEA) Craniotomy Esophageal resection Hip replacement Pancreatic resection Percutaneous transluminal coronary angioplasty (PTCA) �

13. CheckPoint Indicators Volume Measures Abdominal aortic aneurysm repair (AAA) Carotid endaterectomy (CEA) Coronary artery bypass graft (CABG) Esophageal resection Pancreatic resection Percutaneous transluminal coronary angioplasty (PTCA)

14. CheckPoint Indicator Utilization � Incidental appendectomy among the elderly

15. IQI Calculations and Reporting for CheckPoint Mortality and Utilization � 30 cases in the denominator Volume � 5 cases Will be initially reported for calendar year 2005 and then updated on an annual basis Will be reported using the observed/expected ratio WHAIC used 50 cases in the denominator and reported all volumes O/E ratio is risk adjusted for patient characteristics Notes to self � RAR = risk adjusted to the population Dividing by a common factor Proportions are the sameWHAIC used 50 cases in the denominator and reported all volumes O/E ratio is risk adjusted for patient characteristics Notes to self � RAR = risk adjusted to the population Dividing by a common factor Proportions are the same

16. Indicators Excluded by WHAIC Volume Pediatric Heart Surgery Mortality � Procedures Esophageal Resection Pancreatic Resection Pediatric Heart Surgery Due to the low number of hospitals that perform pediatric heart surgery these indicators were deleted so as not to identify the facilities. Mortality procedure indicators were deleted due to the 50 case thresholdDue to the low number of hospitals that perform pediatric heart surgery these indicators were deleted so as not to identify the facilities. Mortality procedure indicators were deleted due to the 50 case threshold

17. Indicators Excluded by WHAIC Utilization Bilateral Cardiac Catheterization Vaginal Birth After Cesarean, all Laparoscopic Cholecystectomy VBAC, all controversial Bilateral cardiac cath and lap choles � frequently done on an outpatient basisVBAC, all controversial Bilateral cardiac cath and lap choles � frequently done on an outpatient basis

18. Indicators Excluded by CheckPoint Utilization Indicators Cesarean delivery rate Primary Cesarean delivery rate Vaginal Birth After Cesarean, uncomplicated

19. IQI Approval Process for CheckPoint Reporting Proposal presented to CheckPoint Measures Team Teleconference to Hospital Quality Staff Proposal Finalized and Approved by WHA Board in October 2006

20. CheckPoint Approval Process for IQIs Hospital CEO completes a form indicating whether WHA is authorized to report these measures Form can be faxed or mailed to WHA, due back June 29 Authorization can be updated at any time

21. Hospital Authorization for CheckPoint IQIs Per Hospital, Signed by CEO Please indicate if your hospital will participate in the reporting of Inpatient Quality Indicators (Inpatient Mortality, Volume, and Utilization): o���� Yes, I would like to participate in reporting Inpatient Mortality, Volume and Utilization Measures � o���� No, I would not like to participate in reporting Inpatient Mortality, Volume and Utilization Measures at this time � �

22. CheckPoint Timeline for IQIs June 29, 2007 Authorization forms due back to WHA Aug 17, 2007 Hospital preview of IQIs in CheckPoint Aug 31, 2007 IQIs publicly released in CheckPoint

23. CheckPoint Report Display

24. Potential Uses of IQIs

25. Communication

26. Where does the data come from?Today, next and the future� Current Reporting: Medical, Surgical and Index data submitted through Core Measure systems and reported by QI Error prevention and demographic data provided by hospitals Next reporting: Inpatient Quality Indicator Measures from WHA Information Center Future Reporting: Perinatal measures provided from the PeriData.Net systemCurrent Reporting: Medical, Surgical and Index data submitted through Core Measure systems and reported by QI Error prevention and demographic data provided by hospitals Next reporting: Inpatient Quality Indicator Measures from WHA Information Center Future Reporting: Perinatal measures provided from the PeriData.Net system

27. Questions? WHA Contacts: Dana Richardson drichardson@wha.org Kathleen Caron kcaron@wha.org Contact us if you have questions. Maybe a FAQ would be good to publish and put on new enhanced website. Contact us if you have questions. Maybe a FAQ would be good to publish and put on new enhanced website.