Day 2: Session III Contemplations in Similar and Open Reporting.


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Day 2: Session III Contemplations in Near and Open Reporting Moderators: Patrick Romano, UC Davis Shoshanna Sofaer, Baruch School AHRQ QI Client Meeting September 26-27, 2005 Selecting AHRQ Quality Markers for open reporting and pay-for-execution Sort or applied system
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Day 2: Session III Considerations in Comparative and Public Reporting Presenters: Patrick Romano, UC Davis Shoshanna Sofaer, Baruch College AHRQ QI User Meeting September 26-27, 2005

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Selecting AHRQ Quality Indicators for open reporting and pay-for-execution Type or reasonable system Face legitimacy or notability to suppliers Impact or open door for development Reliability or accuracy Coding (model) legitimacy Construct legitimacy Susceptibility to inclination

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Types of supplier level quality pointers Structure: the conditions under which care is given Volume (AAA repair, CEA, CABG, PCI, esophageal or pancreatic resection, pediatric heart surgery) Process: the exercises that constitute medicinal services Use of attractive/undesirable techniques (C/S, VBAC, two-sided cardiovascular cath, coincidental appendectomy, laparoscopic cholecystectomy) Outcome: changes owing to social insurance Risk-balanced mortality (AMI, CHF, GI discharge, hip crack, pneumonia, stroke, AAA repair, CABG, craniotomy, esophageal resection, pancreatic resection, THA, pediatric heart surgery) Risk-balanced difficulties or “potential wellbeing related events” (Patient Safety Indicators)

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Key elements of basic measures Enabling variables that make it less demanding (harder) for experts to give astounding consideration (i.e., facilitators or markers) Weakly connected with procedure/result measures Easy to gauge, however difficult to alter Few intercession examines, causal connections vague – improve structures lead to distinctive procedures, or improve procedures lead to diverse structures? Use auxiliary pointers when satisfactory procedure or result measures are not accessible (“free ride” issue) Focus on modifiable structures OR settings in which healing facilities that can\'t change structures are permitted to close (overabundance limit)

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Minimum clinic volume expected to identify multiplying of death rate ( α =0.05, β =0.2) Ref: Dimick, et al. JAMA.  2004;292:847-851.

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Impact: Estimated lives spared by actualizing doctor\'s facility volume guidelines (NIS) Birkmeyer et al., Surgery 2001;130:415-22

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Key elements of procedure measures Directly noteworthy by medicinal services suppliers (“opportunities for intervention”) Highly receptive to change Validated – or possibly “validatable” – in randomized trials (yet NOT the AHRQ QIs) Illustrate the pathways by which mediations may prompt better patient results Focus on modifiable procedures that are striking to suppliers, and for which there is clear open door for development

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Key elements of result measures What truly matters to patients, families, groups Intrinsically important and straightforward Reflect what was done as well as how well it was done (hard to quantify specifically) Morbidity measures have a tendency to be accounted for conflictingly (because of poor MD documentation and/or coding) Outcome measures may be bewildered by variety in perception units, release/exchange hones, LOS, seriousness of sickness Many results of hobby are uncommon or postponed Are results adequately under providers’ control? Concentrate on results that are theoretically and observationally inferable from suppliers (e.g., process linkages), and for which set up benchmarks exhibit open door for development.

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AHRQ QI improvement: General procedure Literature audit (all) To recognize quality ideas and potential pointers To discover past take a shot at marker legitimacy ICD-9-CM coding survey (all) To guarantee correspondence between clinical idea and coding practice Clinical board surveys (PSI’s, pediatric QIs) To refine pointer definition and danger groupings To build up face legitimacy when insignificant writing Empirical examinations (all) To investigate elective definitions To evaluate across the country rates, doctor\'s facility variety, connections among pointers To create strategies to represent contrasts in danger

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AHRQ QI advancement: References AHRQ Quality Indicator documentation page at http://www.qualityindicators.ahrq.gov/downloads.htm Refinement of the HCUP Quality Indicators (Technical Review) , May 2001 Measures of Patient Safety Based on Hospital Administrative Data - The Patient Safety Indicators , August 2002 Peer-looked into writing (cases): AHRQ’s Advances in Patient Safety: From Research to Implementation (4-volume abridgment) Romano, et al. Wellbeing Aff (Millwood). 2003; 22(2):154-66. Zhan and Miller. JAMA. 2003; 290(14):1868-74. Sedman, et al. Pediatrics. 2005; 115(1):135-45. Rosen et al., Med Care. 2005; 43(9):873-84.

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Face legitimacy: Clinical board survey Intended to set up consensual legitimacy Modified RAND/UCLA Appropriateness Method Physicians of different strengths/subspecialties, attendants, other particular experts (e.g., maternity specialist, drug specialist) Potential markers were appraised by 8 multispecialty boards; surgical pointers were likewise evaluated by 3 surgical boards All specialists appraised every doled out pointer (1-9) on: Overall value Likelihood of recognizing the event of an antagonistic occasion or entanglement (i.e., not display at affirmation) Likelihood of being preventable (i.e., not a normal consequence of hidden conditions) Likelihood of being because of restorative slip or carelessness (i.e., not simply absence of perfect or impeccable consideration) Likelihood of being plainly diagrammed Extent to which pointer is liable to case blend inclination

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Evaluation system for PSIs Medical mistake and complexities continuum Unavoidable Complications Pre-gathering appraisals and remarks/proposals Individual appraisals came back to specialists with circulation of evaluations and other panelists’ remarks/recommendations Telephone phone call directed by PI, with note-taker, concentrating on high-variability things and panelists’ recommendations (90-120 mins) Suggestions received just by accord Post-meeting appraisals and remarks/proposals ` Medical lapse

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Postop Pneumonia Decubitus Ulcer (5) (8) (7) (8) (4) (8) (8) (2) (7) (6) (3) (7) Example audits of PSIs Multispecialty boards Overall rating Not introduce on confirmation Preventability Due to therapeutic blunder Charting by doctors Not one-sided by case blend

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Final determination of PSIs Retained markers for which “overall usefulness” rating was “Acceptable” or “Acceptable-” Median score 7-9; AND Definite assention (“acceptable”) if close to 1 or 2 specialists appraised marker beneath 7 Indeterminate agreement(“acceptable-”) if close to 1 or 2 specialists evaluated marker in 1-3 territory 48 pointers looked into (15 by 2 separate boards) 20 “accepted” taking into account face legitimacy 2 dropped because of operational concerns 17 “experimental” or promising markers 11 rejected

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Panel evaluations of PSI “preventability” a Panel evaluations depended on definitions not quite the same as last definitions. For “Iatrogenic pneumothorax,” the evaluated denominator was confined to patients getting thoracentesis or focal lines; the last definition grows the denominator to all patients (with same rejections). For “In-clinic fracture” specialists appraised the more extensive Experimental pointer, which was supplanted in the Accepted set by “Postoperative hip fracture” because of operational concerns. b Vascular intricacies were appraised as Unclear (- ) by surgical board; multispecialty board rating is appeared here.

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International master board evaluations of PSIs Organization for Economic Cooperation and Development

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Impact: Estimated cases in 2000 (NIS) Romano et al., Health Aff 2003;22(2):154-66

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Estimating the effect of keeping every PSI occasion on mortality, LOS, charges (ROI) NIS 2000 investigation by Zhan & Miller, JAMA 2003;290:1868-74

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Estimating the effect of keeping every PSI occasion on mortality, LOS, charges (ROI) VA PTF examination by Rosen et al., Med Care 2005;43:873-84

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Impact: Estimated cases in 2000 (NIS) Romano et al., Health Aff 2003;22(2):154-66

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Impact of patient security occasions in 2000 Zhan & Miller, JAMA 2003; recreated by Rosen et al., 2005 * All distinctions NS for transfusion response and complexities of anesthesia in VA/PTF. † Mortality distinction NS for remote body in VA/PTF.

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National patterns in PSI rates, 1994-2002 Rare occasions (<0.1%) HCUPNet at http://www.hcup.ahrq.gov/, got to 9/19/05.

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National patterns in PSI rates, 1994-2002 Low-recurrence medicinal entanglements (0.05-0.5%) HCUPNet at http://www.hcup.ahrq.gov/, got to 9/19/05.

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National patterns in PSI rates, 1994-2002 High-recurrence restorative intricacies (0.5-2.5%) HCUPNet at http://www.hcup.ahrq.gov/, got to 9/19/05.

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National patterns in PSI rates, 1994-2002 Surgical/specialized difficulties HCUPNet at http://www.hcup.ahrq.gov/, got to 9/19/05.

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National patterns in PSI rates, 1994-2002 Obstetric confusions HCUPNet at http://www.hcup.ahrq.gov/, got to 9/19/05.

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Reliability or accuracy: signal proportion Source: 2002 State Inpatient Data. Normal Signal Ratio over all doctor\'s facilities (N=4,428)

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Year-to-year connection of healing center impacts Source: 2001-2002 State Inpatient Data, clinics with no less than 1,000 releases (N=4,428). Danger balanced unsmoothed rates.

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Coding (basis) legitimacy in light of writing audit (MEDLINE/EMBASE) Validation investigations of Iezzoni et al.’s CSP At minimum one of three acceptance contemplates (coders, medical attendants, or doctors) affirmed PPV no less than 75% among hailed cases Nurse-recognized procedure of-consideration disappointments were more common among hailed cases

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