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Rates of Patient Safety Indicators (PSIs) Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years among VA Patients in the First.

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Presentation on theme: "Rates of Patient Safety Indicators (PSIs) Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years among VA Patients in the First."— Presentation transcript:

1 Rates of Patient Safety Indicators (PSIs) Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years among VA Patients in the First Two Years Following ACGME Resident Hour Reform Following ACGME Resident Hour Reform Amy Rosen, Ph.D. Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC Boston University School of Public Health, Health Policy and Management Department, Boston, MA AcademyHealth ● June 2008 Supported by VA HSR&D IIR# 04.202.1 and NHLBI ROI HL 082637

2 Co-Investigators Susan Loveland, M.A.T. 1,2 Patrick Romano, M.D., M.P.H. 3 Kamal Itani, M.D. 4 Paul Rosenbaum, Ph.D. 5 Jeffrey Silber, M.D., Ph.D. 5,6,7,8 Orit Even-Shoshan, M.S. 6,7 Michael Halenar, B.A. 6,9 Yun Teng, M.S. 7 Jingsan Zhu, M.B.A. 6 Kevin Volpp, M.D., Ph.D. 5,6,7,8,9 1 Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC 2 Boston University School of Public Health, Health Policy and Management Department 3University of California at Davis, School of Medicine, Division of General Medicine and Center for Healthcare Policy and Research 4Boston VA Healthcare System and Boston University, Departments of Surgery 5University of Pennsylvania, The Wharton School 6University of Pennsylvania, School of Medicine 7Center for Outcomes Research, The Children’s Hospital of Philadelphia 8The Leonard Davis Institute of Health Economics, The University of Pennsylvania 9Center of Health Equity Research and Promotion, VA Center of Excellence, Philadelphia VAMC

3 ACGME duty hours regulations implemented on July 1, 2003 to improve safety Do duty hour regulations improve or worsen patients outcomes in more vs. less teaching-intensive hospitals? Previous work shows slight improvement in mortality for VA patients with common medical conditions Little evidence on the effect of ACGME on other outcomes Background

4 To investigate whether rates of the AHRQ Patient Safety Indicators (PSIs) changed following ACGME duty hour reforms in more vs. less teaching-intensive hospitals in VA. Hypotheses: (1) Rates of technical skill-based PSIs (e.g. iatrogenic pneumothorax) would improve (2) Rates of PSIs related to continuity of care (e.g. postoperative sepsis) would worsen (3) Rates of PSIs reflecting collaborative care (e.g. postoperative hip fracture) would not change Objectives and Hypotheses

5 All unique patients (n=828,534) admitted to acute-care VA hospitals (n=131) between July 1, 2000 and June 30, 2005 Index admission: first admission for which there was no prior admission eligible for a given PSI composite within 5 years Exclusions from VA inpatient data: Admissions to hospitals outside the US (n=41,928) Transfers from non-VA hospitals (n=31,049) Admissions spanning July 1, 2003 (n=6,809) Admissions for patients older than 90 years (n=11,398) Study Population

6 VA inpatient data files (VA Patient Treatment File) for diagnoses, age, gender, and discharge status Veterans Health Administration Support Service Center Occupancy Rate Reports for number of beds per hospital VA Office of Academic Affiliations for number of residents Pre-reform period: pre-year 3 (7/01/00-6/30/01), pre-year 2 (7/01/01-6/30/02), and pre-year 1 (7/01/01-6/30/03) Post-reform period: post-year 1 (7/01/03-6/30/04) and post-year 2 (7/01/04-6/30/05) Data Sources/Years

7 Measured by the resident-to-bed ratio (RTB ratio) Calculated as the number of interns plus residents divided by the mean number of operational beds Minor teaching: RTB ratio >0 - <0.25 Major teaching: RTB ratio >0.25 - <0.60 Very major teaching: RTB ratio >0.60 Teaching Intensity

8 Technical Care (795,306 admissions) Iatrogenic pneumothorax Foreign body left in during procedure Accidental puncture or laceration Postoperative hemorrhage or hematoma Continuity of Care (339,504 admissions) Postoperative physiologic or metabolic derangement Postoperative pulmonary embolism/deep vein thrombosis (PE/DVT) Postoperative sepsis Collaborative Care (653,270 admissions) Postoperative hip fracture Postoperative respiratory failure Selected infections due to medical care PSI Composites

9 Multiple time series research design Conditional logistic regression models adjusted for age, gender, comorbidities, secular trends, baseline severity, and stratifying on hospital site Odds ratios measure the degree to which PSI composite rates change differently in more vs. less teaching-intensive hospitals Tested stability by eliminating patients admitted to hospitals in NY State and those patients admitted from nursing homes Analysis

10 Years Pre and Post Duty Hour Reform of 7/1/03 Pre-3Pre-2Pre-1Post-1Post-2 Academic Year Number Admissions 2000-1 178,207 2001-2 184,544 2002-3 185,835 2003-4 192,176 2004-5 197,516 Age (Mean) 63.2163.4063.3163.4563.47 Mean # of Comorbidities 1.431.461.501.581.63 COMPOSITE RATES Technical Care PSIs PSI Events Total Eligible Admissions % Rate 751 154,233 0.49 789 157,594 0.50 876 157,685 0.56 923 161,141 0.57 873 164,653 0.53 Continuity of Care PSIs PSI Events Total Eligible Admissions % Rate 704 65,687 1.07 810 66,392 1.22 800 66,425 1.20 919 69,300 1.33 938 71,700 1.31 Collaborative Care PSIs PSI Events Total Eligible Admissions % Rate 544 129,005 0.42 543 129,936 0.42 497 128,224 0.39 594 132,117 0.45 539 133,988 0.40 Description of VA Sample

11 Non-teaching (0) Minor Teaching (>0-0.25) Major Teaching (0.25-0.6) Very Major Teaching (>0.6) N (%) of facilities 19 (14.50%) 32 (24.43%) 40 (30.53%) 40 (30.53%) N (%) of admissions 36,634 (3.90%) 144,294 (15.38%) 387,667 (41.32%) 369,683 (39.40%) Hospital Characteristics by Teaching Status in VA

12 Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (>0.25 - <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

13 Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (>0.25 - <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

14 Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (>0.25 - <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

15 Technical Care Composite Continuity of Care Composite Collaborative Care Composite Odds Ratio (95% CI) Odds Ratio (95% CI) Odds Ratio (95% CI) Resident/bed ratio*post1 a 1.09 (0.78 - 1.51) P= 0.62 1.01 (0.70 - 1.46) P= 0.95 1.18 (0.75 - 1.85) P= 0.48 Resident/bed ratio*post2 a 1.05 (0.75 -1.45) P= 0.79 1.39 (0.97 - 1.99) P= 0.08 1.60 (1.01 - 2.53) P= 0.04 Number of cases795,306339,504653,270 Adjusted Odds of PSI Composite Events After Duty Hour Reform in More vs. Less Teaching-Intensive VA Hospitals

16 Residents get more sleep, but there are also increased handoffs Residents can still work 30 hours straight Compliance may not be high Possible Explanations for No Major Changes in PSI Rates

17 Strengths National sample of patients from the VA Difference-in-difference approach to reduce likelihood of confounding Utilization of standardized measures of patient safety Limitations No clinical data for risk adjustment Limitations in using PSIs to measure patient safety Unmeasured confounding Strengths/Limitations

18 Rates of Technical Care PSI composite did not improve between more vs. less teaching-intensive hospitals over time Rates of Continuity of Care PSI composite did not worsen - we saw a slight trend in worsening rates in post-reform year 2 in more teaching-intensive hospitals Rates of Collaborative Care PSI increased slightly over time (only in post-reform year 2) in more teaching- intensive hospitals, marginally significant increase (p=0.04) Conclusions

19 Implementation of ACGME had no overall systematic impact on patient safety in more vs. less teaching- intensive hospitals Lack of improvement in any of the PSI composites suggests that more work is needed to improve safety Need to examine the effects of ACGME beyond first 2 years Need more data on facilitators and barriers to improvements in clinical outcomes Implications

20 Thank you!

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