1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Improving Administrative Data for Public Reporting Anne Elixhauser Joe Parker Michael Pine Roxanne Andrews September 9, 2008

2. Advancing Excellence in Health Care 2 Outline Background and rationale Background and rationale Summary of two prior studies: Summary of two prior studies: – Potential safety events present on admission? – Adding clinical information to administrative data Problems in POA coding – California example Problems in POA coding – California example Screens for detecting these problems Screens for detecting these problems Supporting the enhancement of administrative claims data through state pilots Supporting the enhancement of administrative claims data through state pilots

3. Advancing Excellence in Health Care 3 Administrative, or Billing Data Patient demographics (age, sex) Diagnoses & procedures (ICD-9-CM, DRG) Expected payer Length of stay Patient disposition Admission source & type Admission month Charges UB-92 (UB-04) Billing Form

4. Advancing Excellence in Health Care 4 12 States Use AHRQ QIs for Hospital Reporting to the Public

5. Advancing Excellence in Health Care 5 Limitations of Administrative Data Lack clinically important information Lack clinically important information – Limited to ICD-9-CM diagnosis codes Do not distinguish between diagnoses present on admission (POA) and those that originate during the hospital stay Do not distinguish between diagnoses present on admission (POA) and those that originate during the hospital stay Questions regarding use of only administrative data for hospital-specific reporting Questions regarding use of only administrative data for hospital-specific reporting – Inadequate risk adjustment – additional data needed to predict individual patient’s risk of mortality – Concern about penalizing providers with the sickest patients

6. Advancing Excellence in Health Care 6 Tension Between Value of Data and Cost of Obtaining the Data New York and California provide POA coding for diagnoses – now required for Medicare patients and many states will collect for all New York and California provide POA coding for diagnoses – now required for Medicare patients and many states will collect for all Pennsylvania hospitals provided chart- abstracted clinical detail Pennsylvania hospitals provided chart- abstracted clinical detail – Hospital concern about costs of medical record abstraction Electronic medical records not yet poised to provide data efficiently Electronic medical records not yet poised to provide data efficiently – Exception: Lab data

7. Advancing Excellence in Health Care 7 How Often are Potential Patient Safety Events Present on Admission? Study aimed at using POA information to determine what effect it will have on AHRQ Patient Safety Indicators Study aimed at using POA information to determine what effect it will have on AHRQ Patient Safety Indicators Examined face validity of POA coding in two states – California (CA) and New York (NY) Examined face validity of POA coding in two states – California (CA) and New York (NY) Study reported in … Study reported in … – Houchens R, Elixhauser A, Romano P. How often are potential “patient safety events present on admission?” Joint Commission Journal on Quality and Patient Safety. March 2008.

8. Advancing Excellence in Health Care 8 Percent of patient safety events remaining after POA diagnoses were removed* * Based on California data.

9. Advancing Excellence in Health Care 9 Impact of Adding Clinical Data to Administrative Data Assess impact of incrementally adding: Assess impact of incrementally adding: – POA codes for diagnoses – Lab values on admission – Increased number of diagnosis fields – Improved documentation (ICD-9-CM codes) – Vital signs – More difficult to obtain clinical data

10. Advancing Excellence in Health Care 10 Study Reported in … Pine M, Jordan HS, Elixhauser A, et al. Enhancement of claims data to improve risk adjustment of hospital mortality. JAMA 2007; 267(1):71-76. Pine M, Jordan HS, Elixhauser A, et al. Enhancement of claims data to improve risk adjustment of hospital mortality. JAMA 2007; 267(1):71-76. Jordan HS, Pine M, Elixhauser A, et al. Cost-effective enhancement of claims data to improve comparisons of patient safety. Journal of Patient Safety 2007; 3(2) 82-90. Jordan HS, Pine M, Elixhauser A, et al. Cost-effective enhancement of claims data to improve comparisons of patient safety. Journal of Patient Safety 2007; 3(2) 82-90. Fry DR, Pine M, Jordan HS, et al. Combining administrative and clinical data to stratify surgical risk. Annals of Surgery 2007; 246(5): 875-885. Fry DR, Pine M, Jordan HS, et al. Combining administrative and clinical data to stratify surgical risk. Annals of Surgery 2007; 246(5): 875-885. Pine M, Jordan HS, Elixhauser A, et al. Modifying claims data to improve risk-adjustment of inpatient mortality rates. Medical Decision Making (forthcoming) Pine M, Jordan HS, Elixhauser A, et al. Modifying claims data to improve risk-adjustment of inpatient mortality rates. Medical Decision Making (forthcoming)

11. Advancing Excellence in Health Care 11 Indicators Studied MortalityIndicators AAA repair AAA repair CABG surgery CABG surgery Craniotomy Craniotomy AMI AMI CHF CHF Cerebrovascular accident Cerebrovascular accident GI hemorrhage GI hemorrhage Pneumonia Pneumonia Post-operative patient safety events Pulmonary embolism/deep vein thrombosis Pulmonary embolism/deep vein thrombosis Physiologic/metabolic abnormalities Physiologic/metabolic abnormalities Respiratory failure Respiratory failure Sepsis Sepsis

12. Advancing Excellence in Health Care 12 Data Used in Incrementally More Complex Models Model Types of Data Elements ADM-8 Age, sex, principal diagnosis, up to 8 secondary diagnoses, selected surgical procedures POA-8 ADM-8 + diagnoses present on admission POA-24 Increased secondary dx to 24 POA-ICD POA-24 + secondary dx present on admission in clinical database, but not reported using ICD codes LAB POA-24 + laboratory data LAB-ICD POA-ICD + laboratory data FULL LAB-ICD + vital signs + lab data not in LAB (e.g., blood culture results) + key clinical findings abstracted from medical records + composite clinical scores (i.e., ASA Classification)

13. Advancing Excellence in Health Care 13 C-Statistics for Mortality Models

14. Advancing Excellence in Health Care 14 Numerical Lab Data  pH (11)  PTT (10)  Na (9)  WBC (9)  BUN (8)  pO 2 (8)  K (7)  SGOT (7)  Platelets (7)  Albumin (5)  pCO 2 (4)  Glucose (4)  Creatinine (4)  CPK-MB (4) Results of 22 lab tests entered at least one model Results of 14 of these tests entered four or more models: Results of 14 of these tests entered four or more models:

15. Advancing Excellence in Health Care 15 Vital Signs and Other Clinical Data All vital signs entered four or more models All vital signs entered four or more models – Pulse (8) – Temp (6) – Blood pressure (6) – Respirations (5) Ejection fraction and culture results entered two models Ejection fraction and culture results entered two models Composite scores entered four or more models Composite scores entered four or more models – ASA classification (6) – Glasgow Coma Score (4)

16. Advancing Excellence in Health Care 16 Abstracted Key Clinical Findings 35 clinical findings entered at least one model 35 clinical findings entered at least one model Only three findings entered more than two models Only three findings entered more than two models – Coma (6) – Severe malnutrition (4) – Immunosuppressed (4) 14 of these clinical findings have corresponding ICD- 9-CM codes (e.g., coma, malnutrition) 14 of these clinical findings have corresponding ICD- 9-CM codes (e.g., coma, malnutrition)

17. Advancing Excellence in Health Care 17 Summary of Analyses For some measures, POA coding has a significant impact on whether conditions are considered patient safety events For some measures, POA coding has a significant impact on whether conditions are considered patient safety events Administrative data can be improved at relatively low cost by: Administrative data can be improved at relatively low cost by: – Adding POA modifiers – Adding numerical lab data on admission – Improved ICD coding

18. Advancing Excellence in Health Care 18 Other Enhancements Link to vital statistics Link to vital statistics Link across settings Link across settings Readmissions Readmissions Episodes of care Episodes of care Today’s focus: POA and lab data