1. Health Statistics, Research, and Quality Improvement11
Health Statistics, Research,
and Quality Improvement

2. Pretest (True/False)
Children’s asthma care is an example of one of the core measure sets for which hospitals are required to collect and transmit data to the Joint Commission.
When a hospital does not have enough cases to meet the minimum needed for data sampling, then sampling is not done.

3. Pretest (True/False) (continued)
The formula to calculate a ratio is x/y = ratio.
Rates are used to measure events occurring over a period of time.
In statistics, the mean is the average.

4. Forms of Secondary Health Records
Indexes
Either separate files or pointers to data within primary health records
Registries
Usually separate databases created to track specific types of data like cancer tumors, implanted devices, or childhood immunizations

5. Forms of Secondary Health Records (continued)
Custom data sets
Used for reporting performance (HEDIS, NHQM)

6. Indexes Created manually in a paper system
Created automatically in EHR system
Used for both internal and external reporting purposes and studies
Organized by various categories, such as disease, attending physician, surgeon, procedures, discharge status, patient’s age or zip code, and so on

7. Internal and External Uses of Indexes
Permit healthcare organizations to locate, count, analyze data for quality and process improvement

8. Internal and External Uses of Indexes (continued)
Allow quick identification and sorting of records for external reporting
Allow automatic identification of records for abstracting for both internal or external registries

9. Registries Separate databases created to track specific types of data
Available to either internal or external users
Hospitals use to improve performance or processes
May be required by outside sources for data reporting

10. Registries (continued)
Examples: trauma, cancer tumor, implanted device, childhood immunization registries

11. Cancer Registries One of earliest registries (1926)
Facility-based cancer registrar enters data about cases by abstracting it from the health records of patients diagnosed with some form of cancer
Identifies cases using disease index, discharge reports, pathology reports, patient registration

12. Cancer Registries (continued)
Internal use of data
Facility quality assessment, research, measure success of various treatment modalities
External use of data
Aggregated and reported to state, national cancer registries; used to identify trends and changes

13. Index Versus Registry Index
Points to medical record containing one or more fields to be reported or studied
Example: disease index includes all patients

14. Index Versus Registry (continued)
Separate database into which certain data elements have been imported or manually entered
Example: hospital trauma registry would include entries added by selecting cases with certain diagnosis codes

15. HEDIS
Created by NCQA as a tool by which it could compare quality of care patients receive under various health plans
Consists of 71 measures across eight domains of care
Allows employers to use results of NCQA reports to select best plan for employees

16. HEDIS (continued) NCQA has accreditation program for health plans
NCQA collects HEDIS data directly from managed care HMO and PPO organizations
Data transferred to IDSS in XML format and consists of secondary records

17. HEDIS (continued) Researchers may use HEDIS data to study trends
Does not contain PHI

18. ORYX
Helps integrate outcomes and other performance measurement data into accreditation process
Supports healthcare organizations in internal quality improvement efforts

19. ORYX (continued)
Standardized with CMS, allowing facility to collect and report same data set for both Joint Commission and CMS initiatives
Called National Hospital Quality Measures (NHQM

20. Available Core Measure Sets
Acute myocardial infarction (AMI)
Heart failure (HF)
Pneumonia (PN)
Pregnancy and related conditions (PR)
Hospital-based inpatient psychiatric services (HBIPS)
Children’s asthma care (CAC)

21. Available Core Measure Sets (continued)
Surgical Care Improvement Project (SCIP)
Hospital outpatient program quality measures (HOP)

22. XML Data Benefits
XML file can be opened and reviewed using ordinary browser such as Internet Explorer
New fields can be added to the specification at any time without disturbing structure
ANSI X12n and HL7 currently developing XML versions of standards

23. Figure 11-3 Abridged sample of HEDIS data in XML format.

24. Data Sampling
Data analysis includes applying mathematical formulas to produce statistical studies
Sample size refers to number of cases necessary to make sample meaningful
Data must also include type of cases that apply to measure and exclude those that are not applicable

25. Data Sampling (continued)
Joint Commission and CMS have determined minimum number of cases that would produce statistically valid samples for each measure set

26. Figure 11-4 Steps for sampling NHQM data.

27. Algorithms
Predefined set of rules that helps break down complex processes into simple, repetitive steps
Used to process data to arrive at desired result
Used to select initial population in data sampling for the measure set

28. Figure 11-5 Flow of algorithm for acute myocardial infarction measure set.

29. Ratios
Can be used to show the relationship between two different things
Usually written as 2 numbers separated by colon, such as 9:1
Formula: x/y = ratio

30. Figure 11-7 Miles per gallon is a ratio of two different things.

31. Proportions Type of ratio Numerator is always a subset of the whole
Denominator is always whole set
Always express relationship between two counts of the same thing
Formula: x/(x+y) = proportion

32. Figure 11-8 Proportion of patients given aspirin to a whole set of AMI patients.

33. Rates
Measure events occurring over a period of time or to express ratio or proportion as percentage
Numerator: 30 AMI patients for which primary PCI done within 90 minutes
Denominator: 48 total AMI patients who received a primary PCI

34. Rates
Rate: 30/48 = 0.625
To convert to a percentage, multiply by 100:  100 = 62.5%

35. Figure Quality measure rate of patients receiving PCI within 90 minutes of arrival at the hospital.

36. Continuous Variable Values being measured, such as time
Frequency of distribution is how frequently data occurs at given points along continuous variable

37. Central Tendency
The distribution of a variable, measured by statistics (mean, median, mode)

38. Figure 11-10 Table of AMI patients’ “Time Until PCI” sorted by minutes.

39. Mean Average, or sum, of values divided by the frequency
Example: the sum of the values (1,650 minutes) divided by the frequency (30 patients)
30: 1,65030 = 55

40. Median
Midpoint in a group of ranked values that divides the data into two equal parts
For odd numbers, median is value at center of list
For even numbers, median is average of center two values
Not influenced by extreme values and outlier cases

41. Mode A value that occurs most often in frequency of distribution
Not influenced by extreme values and outlier cases
Number may not be unique; for example, a sample could contain several values for which there were an equal number of cases

42. Figure 11-11 Timeline showing distribution of AMI cases receiving PCI

43. Range
Difference from highest value in the frequency distribution to the lowest
Review Figure 11-11
Formula: Maximum – Minimum = Range

44. Calculating Variance Determine mean; example: 55
Subtract mean from each item in frequency distribution and square the result: (90 – 55)2 = 1,225
Repeat for each case in set, then sum the totals; example: 12,812

45. Calculating Variance (continued)
To determine variance, divide sum by number of cases minus 1: 12,812/(30 – 1) =

46. Standard Deviation
Standard deviation is the square root of variance

47. Figure 11-12 Standard deviation of minutes until PCI.

48. Pay For Performance (P4P)
New development by CMS and other payers
Ties reimbursement to improvements in quality
Example: CMS’s Hospital Quality Initiative links reporting of NHQM to hospital payments for each discharge

49. Pay For Performance (P4P) (continued)
CMS also developing for physicians and nursing home care
Doctors who meet or exceed performance standards receive bonus payments