Measuring Hospital Quality: The Discovery Health Hospital Rating Index

1. Measuring Hospital Quality: The Discovery Health Hospital Rating Index Brian Ruff

2. Factors in Measuring Quality: • Risk adjustment • Outcomes measures • Data integrity • Representing scores

3. Risk Adjustment

4. Methodology: Diagnostic Related Groups Condition X Apparent Distribution of Admission Costs per condition X Age < 17 No C.C. With C.C. Case Mix separated Breakdown Distribution of Admission Costs per condition X Compare like with like

5. Highest index and most deaths Highest death rate Most admits With Casemix adjustment: predicted deaths = 1 By deaths Meaningful ranking

6. Methodology: Complication rate - MDC Also clinically meaningful

7. Post launch feedback • Risk adjustment - at the point of admission: • based on co-morbidities • But DRGs do not account for principle disease staging • Pathological Staging for Elective surgery NB for specific situations: • Distinguish repeat vs. primary joint replacements • Required introduction of separate categories at an ICD 10 Coding level to accommodate for disease staging • Acquired MedStat staging software • Staging requires intensive coding

8. Outcome Measures

9. DH HRI Measures: What is Quality? • There is no universal definition of quality of clinical care. • The DH HRI quality measures constitute a clear measure of ‘quality’. • As defined by AHQR: “These Hospital administrative data, which are collected as a routine step in the delivery of hospital services, provide information on diagnoses, procedure, age, gender, admission source, and discharge status. From these data elements, it is possible to construct a picture of the quality of medical care.” Agency for Healthcare Research and Quality, June 2002, “Guide to Inpatient Quality Indicators”, Available at www.qualityindicators.ahrq.gov

10. DH HRI Measures • Quality measures are: • Patient recovers • Patient complicates • Patient dies • Patient readmits • Cost = Cost to the Scheme i.e. Amount Paid (Tariff + non tariff ) • Value = combination i.e. outcomes experienced per resources used (value is a function of cost and quality)

11. DH HRI Measures Quality measures: • Mortality: (50% weighting) patient dies during the admission or within 30 days of admission • Preventable Complications:(30% weighting) • From a list of common preventable complications e.g. bleeding; blood clot; infections • Special focus on hospital acquired infections; data based on microbiology culture & antibiotic claims • Re-admission rate (20% weighting) within 30 days of first admission • General; not specific measures; but widely applicable All measures are risk adjusted using Case Mix

12. Post launch feedback and iterative changes

13. Focus on: Hospital Acquired Infections Hospital Unit infection complication rates: - Rank by volume

14. Musculoskeletal MDC ICU

15. Exclusions from measuring ‘Outcomes’

16. Data Integrity

17. Hospital Acquired Infection: • accommodate for cases admitted with pre-existing infections. • introduced a 2 day lag period before scoring pathology complications

18. Post launch feedback and iterative changes

19. Representing Scores

20. Statistics of Scoring fairly Above Average = 3Average = 2Below Average = 1 Illustrative Scoring System 3.00 2.5% 2.50 2.10% 2.0% Score 2.00 Upper Limit 1.50% 1.5% 1.50 Rate Score Lower Limit 1.0% 1.00 Exp 0.70% 0.5% 0.50 0.40% 0.20% 0.05% 0.0% Hospital a Hospital b Hospital c Hospital Use statistically significant confidence intervals to determine score

21. 75% CI 95% CI 1 4 3 2 5 Scoring Day cases i.e. high-volume low-complexity cases, only 2 : 3 : 4

22. The 5 star rating:

23. Meaningful sub categories • Lungs • Cystic fibrosis • Lung failure • Lung clots • Chest injuries • Lung cancer • Emphysema • Lung / respiratory infections • Asthma and bronchiolitis • Air or fluid collections of the lung • Other diseases of the lung

24. Conclusion • Risk adjustment critical • Iterative Process; not an Event • NB tool for Consumers and GP / other referring doctors • Benefit design possibilities