1. Assessing Inpatient Care Using Hospital Quality Alliance Patient Level Quality Data What can we learn about inpatient care quality from patient-level data Jointly funded by The Commonwealth Fund and the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative Joel S. Weissman, PhD (P.I. ); MGH Institute for Health Policy and Harvard Medical School Romana Hasnain-Wynia, PhD; Northwestern University, Feinberg School of Medicine Raymond Kang, M.A.; American Hospital Association, Health Research and Educational Trust (HRET) Mary Beth Landrum, Ph.D.; Harvard Medical School, Department of Health Care Policy Christine Vogeli, PhD; MGH Institute for Health Policy The authors acknowledge the assistance of the IFQHC and the Centers for Medicare and Medicaid Services in providing data which made this research possible. The conclusions prescribed are solely those of the author(s) and do not represent those of IFQHC or CMS.

2. National Hospital Quality Alliance Alliance between the Joint Commission and CMS to collect and report hospital-level quality. Alliance between the Joint Commission and CMS to collect and report hospital-level quality. CMS currently collects data on 31 measures (AMI, HF, PN, and surgical care). CMS currently collects data on 31 measures (AMI, HF, PN, and surgical care). All payer data. All payer data. Study based on CY 2005 data containing over 2.3 million discharges from 4,450 non-federal hospitals. Study based on CY 2005 data containing over 2.3 million discharges from 4,450 non-federal hospitals. Discharge (Patient level) data includes information on: Discharge (Patient level) data includes information on: Attainment of each process / measure Attainment of each process / measure Patient characteristics (race / ethnicity, age, gender) Patient characteristics (race / ethnicity, age, gender) Routine discharge abstract data Routine discharge abstract data Hospital characteristics merged from the AHA Annual Survey. Hospital characteristics merged from the AHA Annual Survey.

3. HQA Condition Specific Quality Measures AMI measure set Aspirin at arrival Aspirin at arrival Beta blocker at arrival Beta blocker at arrival Thrombolysis w/in 30 minutes of arrival Thrombolysis w/in 30 minutes of arrival PCI w/in 120 minutes PCI w/in 120 minutes ACE/ARB for LVSD ACE/ARB for LVSD Smoking cessation counseling Smoking cessation counseling Aspirin at discharge Aspirin at discharge Beta blocker at discharge Beta blocker at discharge PN Measure set Initial antibiotic selection Initial antibiotic w/in 4 hours Oxygenation assessment Pneumococcal vaccination Blood culture before antibiotic Influenza vaccination Smoking cessation counseling HF Measure set LVF assessment LVF assessment ACE / ARB for LVSD ACE / ARB for LVSD Smoking cessation counseling Smoking cessation counseling Discharge instructions Discharge instructions http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalHQA2004_2007200512.pdf

4. Composite Measures Opportunity Weighted Opportunity Weighted Sum of numerators / sum of denominators across all measures in the set; with each applicable measure per patient representing an opportunity. Sum of numerators / sum of denominators across all measures in the set; with each applicable measure per patient representing an opportunity. All-or-None All-or-None Proportion of patients receiving all applicable processes Proportion of patients receiving all applicable processes Perceived Strengths: Perceived Strengths: Sensitive to inter-provider variability Sensitive to inter-provider variability Reflection of patients’ interests / desires Reflection of patients’ interests / desires System or team approach to improving care. System or team approach to improving care. Patient Percent Patient Percent The proportion of applicable care processes received by patients. The proportion of applicable care processes received by patients. Similar to opportunity weighted. Similar to opportunity weighted.

5. Example of Opportunity-Weighted Composite Scoring for HF Example of Opportunity-Weighted Composite Scoring for HF Patient 1 Patient 2 Patient 3 Patient 4 Hospital Process Measures NumDenNumDenNumDenNumDenNumDen LVF Assessment 0111000113 ACE for LVSD 0011110022 Smoking Cessation Counseling 0011111133 Discharge instructions 1101000012 Total710 70%

6. Example of All-or-None Composite Scoring for HF Example of All-or-None Composite Scoring for HF Patient 1 Patient 2 Patient 3 Patient 4 Hospital Process Measures NumDenNumDenNumDenNumDen LVF Assessment 01110001 ACE for LVSD 00111100 Smoking Cessation Counseling 00111111 Discharge instructions 11010000 Total12342212 All applicable processes? NONoYesNo25%

7. Example of Patient Percent Composite Scoring for HF Example of Patient Percent Composite Scoring for HF Patient 1 Patient 2 Patient 3 Patient 4 Hospital Process Measures NumDenNumDenNumDenNumDen LVF Assessment 01110001 ACE for LVSD 00111100 Smoking Cessation Counseling 00111111 Discharge instructions 11010000 Total12342212 50%75%100%50%69%

8. Why use patient-level composites To examine differences in care quality by patient characteristics (race/ethnicity, age, gender, primary payer, admission source). To examine differences in care quality by patient characteristics (race/ethnicity, age, gender, primary payer, admission source). To allow uncommon, but important processes to carry more weight. To allow uncommon, but important processes to carry more weight. To incent excellence. To incent excellence.

9. Quality of care provided to individual patients in U.S. hospitals—Results from an analysis of national Hospital Quality Alliance data Christine Vogeli Raymond Kang Mary Beth Landrum Romana Hasnain-Wynia Joel S. Weissman

10. Background Prior analyses of hospital level HQA data identified hospital characteristics associated with better quality care. Prior analyses of hospital level HQA data identified hospital characteristics associated with better quality care. Quality was assessed using composites that approximate the average proportion of processes patients receive. Quality was assessed using composites that approximate the average proportion of processes patients receive. IOM recommendation => All-or-none composite that determines whether all critical processes provided. IOM recommendation => All-or-none composite that determines whether all critical processes provided.

11. Methods Patient-level composites only: All or none and patient percent Patient-level composites only: All or none and patient percent Multivariable models (linear and logistic) to examine independent associations. Adjusted standard errors for clustering within hospitals using GEE. Multivariable models (linear and logistic) to examine independent associations. Adjusted standard errors for clustering within hospitals using GEE. All-or-none composites stratified by the number of applicable measures. All-or-none composites stratified by the number of applicable measures. Sequentially excluding specific measures to asses the contribution of individual measures to the all-or-none composite. Sequentially excluding specific measures to asses the contribution of individual measures to the all-or-none composite.

12. Number of applicable measures per patient The mean number of applicable measures per patient is small The plurality of HF patients have only 2 applicable HF measures 40% of AMI patients have only 2 applicable measures

13. Patient-level Composites to Assess Inpatient Care Quality Room to improve on all-or-none Less than half of PN inpatients receive all care processes. Just over half (57%) receive all HF care processes. 83% receive all AMI care processes Composite measure AMIHFPNE Patient %: Mean % of processes received 93%77%80% All or none: % receiving all applicable processes 83%57%42%

14. All-or-None Performance: Patient Characteristics Transferred patients more likely to receive all processes Transferred patients more likely to receive all processes Young (18-34) less likely to receive all HF but more likely to receive all PN Young (18-34) less likely to receive all HF but more likely to receive all PN Minorities less likely to receive all PN processes Minorities less likely to receive all PN processes

15. Patients receiving care in non-profit hospitals more likely to receive all processes. Patients receiving care in non-profit hospitals more likely to receive all processes. HF patients cared for in 100+ bed hospitals more likely to receive all HF. HF patients cared for in 100+ bed hospitals more likely to receive all HF. PN patients cared for in major teaching hospitals less likely to receive all PN processes PN patients cared for in major teaching hospitals less likely to receive all PN processes All-or-none performance: Hospital Characteristics

16. All-or-None Performance: Impact of specific measures AMI: AMI: No specific measure had a large impact. No specific measure had a large impact. HF: HF: Removal of discharge instruction measure for the HF set had the largest impact (all-or-none increased by 27%). Removal of discharge instruction measure for the HF set had the largest impact (all-or-none increased by 27%). LVF assessment had almost no impact. LVF assessment had almost no impact. PN: PN: Pneumonia vaccination and antibiotic had the largest impact (all-or-none increased by 9%). Pneumonia vaccination and antibiotic had the largest impact (all-or-none increased by 9%). Oxygenation assessment and smoking cessation counseling had almost no impact. Oxygenation assessment and smoking cessation counseling had almost no impact.

17. Limitations All or none makes implicit assumption that patients should receive all applicable processes All or none makes implicit assumption that patients should receive all applicable processes Changes / updates in measure specifications since 2005: Changes / updates in measure specifications since 2005: PN antibiotic timing changed from within 4 to within 6 hours PN antibiotic timing changed from within 4 to within 6 hours PCI tightened to w/in 90 minutes PCI tightened to w/in 90 minutes

18. Conclusions Room to improve all-or-none performance Room to improve all-or-none performance Sensitive to the number and type of applicable measures. Sensitive to the number and type of applicable measures. Variation by patient and hospital characteristics. Variation by patient and hospital characteristics. Well-accepted professional standards. Well-accepted professional standards.