Acknowledgments
Clinical Insights into Implementing the AHRQ
Indicators for Hospital Quality Improvement
Patrick S. Romano, MD MPH
Professor of Medicine and Pediatrics
UC Davis School of Medicine
AcademyHealth 2006 Child Health Services Research Meeting
June 24, 2006
Acknowledgments
We gratefully acknowledge the data organizations in participating
participating states that contributed data
to HCUP and that we used in this study: the Arizona Department of
of Health Services; California
Office of Statewide Health Planning & Development; Colorado Health
Health & Hospital Association;
Connecticut - Chime, Inc.; Florida Agency for Health Care Administration; Georgia:
Georgia: An
Association of Hospitals & Health Systems; Hawaii Health Information
Information Corporation; Illinois
Health Care Cost Containment Council; Iowa Hospital Association; Kansas Hospital
Association; Kentucky Department for Public Health; Maine Health Data Organization;
Maryland Health Services Cost Review; Massachusetts Division of Health Care Finance and
Policy; Michigan Health & Hospital Association; Minnesota Hospital
Hospital Association; Missouri
Hospital Industry Data Institute; Nebraska Hospital Association; Nevada Department of Human
Resources; New Jersey Department of Health & Senior Services; New
New York State Department
of Health; North Carolina Department of Health and Human Services;
Services; Ohio Hospital
Association; Oregon Association of Hospitals & Health Systems; Pennsylvania
Pennsylvania Health Care
Cost Containment Council; Rhode Island Department of Health; South
South Carolina State Budget &
Control Board; South Dakota Association of Healthcare Organizations;
Organizations; Tennessee Hospital
Association; Texas Health Care Information Council; Utah Department
Department of Health; Vermont
Association of Hospitals and Health Systems; Virginia Health Information;
Information; Washington State
Department of Health; West Virginia Health Care Authority; Wisconsin
Wisconsin Department of Health &
Family Services.
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Validate or test key hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
Funded by AHRQ
Support for Quality Indicators II (Contract No. 290-04-0020)
„ Mamatha Pancholi, AHRQ Project Officer
„ Marybeth Farquhar, AHRQ QI Senior Advisor
„ Mark Gritz and Jeffrey Geppert, Project Directors, Battelle Health
and Life Sciences
Data used for analyses:
Nationwide Inpatient Sample (NIS), 19951995-2003. Healthcare Cost and
Utilization Project (HCUP), Agency for Healthcare Research and
Quality
State Inpatient Databases (SID), 19971997-2003 (38 states). Healthcare
Cost and Utilization Project (HCUP), Agency for Healthcare
Research and Quality
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Validate or test key hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
Norton Healthcare Quality Report
We don’
don’t have to do this, but …
In a spirit of openness and accountability,
we will show the public our performance
on nationally endorsed lists of quality
indicators and practices.
„ Not: invent or choose indicators that make us look
good
„ Not: hide or redefine indicators that make us look bad
1
>270 indicators + safe practices
„ National Quality Forum (NQF)
–
–
–
–
–
“How we use PSIs and IQIs”
IQIs”
„ Publicly report rolling 12 months
„ RiskRisk-adjusted (not smoothed) rates
Hospital care
Adult cardiac surgery
NursingNursing-sensitive indicators
Safe practices
Shell in place for ambulatory indicators
straight from AHRQ software. Period.
„ Use KY hospital discharge database,
„ JCAHO
– JCAHO/CMS adult core measures
– National patient safety goals
despite limited # of diagnosis codes
„ Create service line report cards
(only that patient population; no U.S.
benchmark)
„ AHRQ
– Patient safety indicators (PSIs)
– Inpatient quality indicators (IQIs)
„ Others (e.g., pediatric ORYX, NICU mortality)
Also: financials, patient satisfaction
Norton Healthcare Surgery Report Card
brief description
desired
AUD
NH
% surgeries w/
postoperative bleeding
low
0.15
% abdominal surgeries w/
postop wound dehiscence
low
% w/ pneumothorax
resulting from medical care
% surgeries w/ postop
physiologic derangement
SUB
KCH
KY
U.S.
0.23
0.30
0.19
0.22
0.22
0.00
0.20
0.22
0.24
0.16
0.20
low
0.09
0.08
0.05
0.07
0.07
0.08
low
0.05
0.09
0.05
0.03
0.09
0.11
% surgeries w/ postop
respiratory failure
low
0.6
1.6
0.6
0.9
0.8
0.4
% surgeries w/ postop PE or
DVT
low
1.1
1.5
0.8
0.8
0.9
0.9
% surgeries w/ postop
sepsis
low
5.2
3.1
1.8
0
1.9
1.2
% craniotomy patients who
die (AHRQ riskrisk-adjusted)
low
6.5
6.8
6.6
7.4
7.4
Red or green if outside 99% C.I. based on U.S.
SW
September 14, 2005 posting
Impact of implementing the Norton
Healthcare report card
We are still in business.
Better data; less time arguing about the
measure and more time improving
performance.
„
„
–
–
„
„
„
Unused data never become valid.
Even a lousy indicator can drive
improvement.
Limited public reaction
Mostly favorable physician response
Strong desire to be “within normal limits”
limits”
“Why we did it”
it”
„ Accountability as a public asset
– Clinical care is, in fact, our “widget”
widget”
– We talk about our financials with bond raters, the
press, etc.; why not our clinical performance?
„ Proactively influence the the public reporting
arena
– Clinical over purely financial
– Transparent over proprietary
– Evidence based over arbitrary
„ Get the organization moving in a direction that
is inherently inevitable
„ Improve our care; “We’
We’ll manage what we
measure and report”
report”
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Validate or test key hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
2
2005 National Reports on
Quality and Disparities
National trends in PSI rates, 20002000-2003 KID
Extremely rare events (<0.01%)
0.005%
0.005%
Foreign body left in during procedure
0.004%
0.004%
0.003%
0.003%
0.002%
0.002%
0.001%
Transfusion reactions (ABO/Rh)
0.001%
0.000%
2000
2003
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
National trends in PSI rates, 20002000-2003 KID
Rare events (0.01(0.01-0.1%)
0.10%
National trends in PSI rates, 20002000-2003 KID
LowLow-frequency events (0.1(0.1-0.5%)
0.4%
Accidental puncture and laceration
0.09%
0.4%
0.08%
Decubitus ulcer
Postop abdominopelvic wound dehiscence
0.07%
0.3%
0.06%
Selected infections due to medical care
0.3%
0.05%
Iatrogenic PTX - neonate
0.04%
0.2%
0.03%
Postop hemorrhage/hematoma
0.02%
0.2%
Iatrogenic PTX - nonneonatal
0.01%
0.1%
0.00%
2000
2000
2003
2003
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
National trends in PSI rates, 20002000-2003 KID
MediumMedium-frequency events (0.5(0.5-5.0%)
5.0%
National trends in PSI rates, 20002000-2003 KID
HighHigh-frequency events (>5.0%)
40%
4.5%
38%
Pediatric heart surgery mortality
36%
4.0%
34%
3.5%
32%
3.0%
Perforated appendix
30%
Postop sepsis
28%
2.5%
26%
2.0%
24%
1.5%
Postop respiratory failure
22%
20%
1.0%
2000
2003
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
2000
2003
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
3
National trends in PSI rates, 20002000-2003 KID
Potentially avoidable hospital conditions
Area Level PDI by Geographic Region
0.900
0.20%
Gastroenteritis/dehydration
0.800
0.18%
Asthma
0.16%
0.700
0.14%
0.600
0.12%
0.500
0.10%
0.400
Northeast
Midwest
South
West
0.300
0.08%
UTI
0.06%
0.04%
0.200
0.100
Diabetic short-term complications
0.000
0.02%
Asthma
0.00%
2000
Diabetes
Gastroenteritis
UTI
2003
Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
Overview of insights (?)
Kids’ Inpatient Database 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Risk-adjusted Rates.
NACHRI Pediatric Patient Safety
Indicator (PSI) Collaborative
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Validate or test key hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
„ Ran the AHRQ PSIs on NACHRI’
NACHRI’s Case Mix database, containing 3
million discharges from approximately 70 children’
children’s hospitals.
„ Developed the NACHRI Pediatric PSI Collaborative, a selfself-selected group
of 20 hospitals interested in pursuing this analysis further
„ Published a manuscript entitled “Relevance of the AHRQ PSIs for
Children’
Children’s Hospitals”
Hospitals” in the January 2005 journal Pediatrics.
Pediatrics.
„ Developed and released a Patient Safety Indicator Toolkit (available
(available
through NACHRI’
NACHRI’s website) with sample press release, op ed, Q&A, and
background documents for hospitals to educate their communities and the
media on the relevance and utility of PSIs for pediatrics.
„ Developed an online, secure chart review tool that allowed Collaborative
Collaborative
participants to review the preventability of patients flagged as having any
of 11 selected PSI events.
„ Fostered a relationship with AHRQ and Stanford/UC Davis to update
update each
other on NACHRI’
NACHRI’s findings and the PedQI development work.
NACHRI Pediatric Patient Safety
Indicator (PSI) Collaborative
Key findings from NACHRI’
NACHRI’s PSI
physician case reviews
Collaborative Participants
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
AL / Children’
Children’s Hospital of Alabama / Dr. Crayton Farguson*
Farguson*
CA / Lucile Packard CH at Stanford / Dr. Paul Sharek*
Sharek*
CA / UCUC-Davis / Dr. James Marcin**
Marcin**
DC / Children’
Children’s National Medical Center / Dr. Tony Slonim*
Slonim*
CA / Mattel Children’
Children’s at UCLA / Ms. Mary Kimball**
Kimball**
FL / All Children’
Children’s / Dr. Jack Hutto*
Hutto*
KY / Kosair Children’
Children’s Hospital / Dr. Ben Yandell*
Yandell*
LA / Children’
Children’s Hospital New Orleans / Ms. Cindy Nuesslein*
Nuesslein*
MD / Johns Hopkins Children’
Children’s Center / Dr. Marlene Miller*
MA / Children’
Children’s Hospital Boston / Drs. Daniel Nigrin and Don Goldmann
MI / C.S. Mott Children’
Children’s Hospital – U Mich / Dr. Aileen Sedman*
Sedman*
MO / Children’
Children’s Mercy Kansas City / Dr. Cathy Carroll*
Carroll*
OH / The Children’
Children’s Medical Center Dayton / Dr. Thomas Murphy*
Murphy*
OH / Cincinnati Children’
Children’s Medical Center / Drs. Uma Kotagal,
Kotagal, Joseph Luria*
Luria*
OH / Children’
Children’s Hospital Columbus / Dr. Thomas Hansen*
Hansen*
OH / Children’
Children’s Hospital MC of Akron / Dr. Michael Bird
PA / Children’
Children’s Hospital of Philadelphia / Drs. James Stevens, Joel Portnoy
TX / Texas Children’
Children’s Hospital / Dr. Joan Shook*
Shook*
TX / Children’
Children’s Medical Center of Dallas / Dr. Fiona Levy, Ms. Kathy Lauwers*
Lauwers*
WI / Children’
Children’s Hospital of Wisconsin / Dr. Matthew Scanlon*
Scanlon*
“…while
“…while 40% to 50% may seem low for positive predictive
value, in terms of real patients, this means that 4 or 5
out of 10 children had a preventable event for this
indicator. This is worth looking at and the things we
are finding in some instances, will allow for immediate
changes that may impact outcomes for future patients.”
patients.”
[Collaborative physician reviewer]
4
Examples from NACHRI’
NACHRI’s PSI
physician case reviews
ƒ
ƒ
ƒ
ƒ
ƒ
During removal of non functioning port cath the end of the catheter
was noted to be "irregular and not smoooth cut". It appeared the tip
had been embolized for an unknown duration…
duration…
During replacement of pacemaker lead, a fragment of the lead broke
broke
off, embolized and ended up lodged (puncture) in the anterolateral
papillary muscle.
No notation in original operative note or nursing record that
sponge/needle counts were done and correct.
Count was reported as correct. Sponge discovered on xray due to
complaints of abdominal pain by patient.
Child with bone tumor who had mandible removed with subsequent
bone graft and much packing in wound. This was supposedly
removed before extubation,
extubation, but at the time of extubation a remaining
pack blocked her airway causing reintubation with pack removal.
Examples from NACHRI’
NACHRI’s PSI
physician case reviews
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Overview of insights (?)
…occurred during the insertion of a PICC line. The record indicates
indicates on the first attempt a
artery paralleling the basilar vien was cannulated.
cannulated.
Urethral injury after a transurethral ablation of posterior urethral
urethral valves as well as bleeding
post circumcision…
circumcision… both required suturing to repair.
14 year old feamle with spinal bifida and urinary and fecal incontinence who underwent
underwent
appendicovesicostomy,
appendicovesicostomy, continent cecostomy,
cecostomy, bladder neck sling for urinary incontinence and
enteroenterostomy.
enteroenterostomy. … a small perforation was made in the vagina and was repaired.
6 week old with pyloric stenosis who underwent laparoscopic pyloromyotomy.
pyloromyotomy. A small gastric
mucosal perforation occurred at the end and required opening the abdomen to repair.
Colon was perforated during liver transplant.
Pt underwent transrectal drainage of abscess on 7/29 with foley used to drain bladder. Pt
developed hematuria and required surgery exploration when bladder
bladder puncture was
discovered from surgery.
Laparoscopic procedure using harmonic scalpel. Bleeding noted. converted
converted to open
procedure. Aorta repaired.
Laparascopic appendectomy. Small opening made in cecum.
cecum. Repaired at the time of surgery.
After d/c from spinal fusion, patient presented to clinic with drainage from
from operative site.
Seroma noted. Admitted and returned to OR. … lacerated baclofen pump catheter.
Rib removed to use for laryngeal reconstruction-pleura was punctured.
reconstruction--pleura
Effect of work hours reform in NY teaching
hospitals on smoothed PSI rates
Poulose BK, et al., Ann Surg 2005;241:8472005;241:847-860
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Test interesting hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
Effect of work hours reform in NY teaching
hospitals on smoothed PSI rates
Poulose BK, et al., Ann Surg 2005;241:8472005;241:847-860
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Validate or test key hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
5
Approaches to assessing
construct validity
Estimating the impact of preventing each PSI event
on mortality, LOS, charges
NIS 2000 analysis by Zhan & Miller, JAMA 2003;290:18682003;290:1868-74
Δ Mort (%)
Δ LOS (d)
Δ Charge ($)
21.9
10.9
$57,700
Postoperative thromboembolism
6.6
5.4
21,700
Postoperative respiratory failure
21.8
9.1
53,500
Postoperative physiologic or metabolic
derangement
19.8
8.9
54,800
Decubitus ulcer
7.2
4.0
10,800
Selected infections due to medical care
4.3
9.6
38,700
Postoperative hip fracture
4.5
5.2
13,400
Accidental puncture or laceration
2.2
1.3
8,300
Iatrogenic pneumothorax
7.0
4.4
17,300
Postoperative hemorrhage/hematoma
3.0
3.9
21,400
Indicator
„ Is the outcome indicator associated with explicit
processes of care (e.g., appropriate use of
medications)?
„ Is the outcome indicator associated with implicit
process of care (e.g., global ratings of quality)?
„ Is the outcome indicator associated with nurse
staffing or skill mix, physician skill mix, or other
aspects of hospital structure?
„ Is the outcome indicator associated with other
meaningful outcomes of care?
Postoperative septicemia
Estimating the impact of preventing each PSI event
on mortality, LOS, charges
Zhan & Miller, JAMA 2003; key findings replicated by Rosen et al.,
al., 2005
Indicator
Δ Mort (%)
Δ LOS (d)
Δ Charge ($)
Birth trauma
-0.1 (NS)
-0.1 (NS)
300 (NS)
Obstetric trauma –cesarean
-0.0 (NS)
0.4
2,700
Obstetric trauma - vaginal w/out instrumentation
0.0 (NS)
0.05
-100 (NS)
Obstetric trauma - vaginal w instrumentation
0.0 (NS)
0.07
220
9.6
9.4
40,300
-1.0 (NS)
3.4 (NS)
18,900 (NS)
0.2 (NS)
0.2 (NS)
1,600
2.1
2.1
13,300
Postoperative abdominopelvic wound
dehiscence
Transfusion reaction*
Complications of anesthesia*
Foreign body left during procedure†
Some PSI rates are significantly higher in
AfricanAfrican-Americans or Hispanics than in whites
Coffee RM, et al., Med Care 2005;43:I2005;43:I-48 to II-57
* All differences also NS for transfusion reaction and complications of anesthesia in VA/PTF.
† Mortality difference NS for foreign body in VA/PTF.
Some PSI rates are significantly lower in
AfricanAfrican-Americans or Hispanics than in whites
Coffee RM, et al., Med Care 2005;43:I2005;43:I-48 to II-57
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Test interesting hypotheses (research)
„ Is it a coding/documentation issue?
„ Is it a quality issue?
„ Questions and answers
6
ICDICD-9-CM Coding
Coding/documentation issues
„ There is a basic tension between using administrative
data for reimbursement and for defining quality
indicators
–
–
Submitting bills quickly versus coding from a complete
record
Maximizing the coding of complications and comorbidities
versus only coding diagnoses “out of the norm.”
norm.”
„ Variation in QI rates might be due to variation in:
–
–
–
–
Data availability (e.g., number of diagnosis codes, admission
type, external cause of injury codes)
Documentation completeness and accuracy
ICDICD-9-CM and DRG coding
Performance (e.g., processes of care, staffing)
ICDICD-9-CM Coding: Specificity
„ Highest level of specificity
– Avoid overuse of NEC and NOS
designation
„ Examples:
9 Using 512.8 for “pneumothorax NOS”
NOS”
would exclude a case from the numerator
for iatrogenic pneumothorax (512.1)
Coding of secondary diagnoses
„ “Abnormal findings (laboratory, xx-ray, pathologic, and
other diagnostic results) are not coded and reported
unless the physician indicates their clinical
significance.”
significance.”
„ “If the findings are outside the normal range and the
physician has ordered other tests to evaluate the
condition or prescribed treatment, it is appropriate to
ask the physician whether the abnormal finding should
be added.”
added.”
„ “All conditions that occur following surgery…
surgery…are not
complications…
complications… there must be more than a routinely
expected condition or occurrence…
occurrence… there must be a
causecause-andand-effect relationship between the care
provided and the condition…”
condition…”
Adherence to best practices in coding and compliance
with coding guidelines will ensure fair reimbursement
and accurate measurement of quality indicators
„ Use the highest possible level of specificity
– Avoid overuse of NEC and NOS designation
„ Follow guidelines re coding of secondary diagnoses
– Only codes that impact treatment or complications
„ Follow guidelines re coding of procedures
– Only significant procedures to be reported
Coding of secondary diagnoses
„ For reporting purposes the definition for "other diagnoses" is
interpreted as additional conditions that affect patient care in
terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring.
„ UHDDS…
UHDDS…defines Other Diagnoses as “all conditions that
coexist at the time of admission, that develop subsequently, or
that affect the treatment received and/or the length of stay.
Diagnoses that relate to an earlier episode which have no
bearing on the current hospital stay are to be excluded.”
excluded.”
A case study of birth trauma
DallasDallas-Fort Worth Hospital Council
1999
Participating Hospitals
Num
State of Texas (THCIC PUDF)
Hosp A
Hosp B
Hosp C
Hosp D
2000
Participating Hospitals
Num
State of Texas (THCIC PUDF)
Hosp A
Hosp B
Hosp C
Hosp D
2001
Participating Hospitals
Num
State of Texas (THCIC PUDF)
Hosp A
Hosp B
Hosp C
Hosp D
831
6
3
55
1
831
3
2
45
2
763
8
4
53
1
1999
Den
305519
3255
1324
1815
1427
2000
Den
326095
3303
1604
1752
1484
2001
Den
333101
3099
1553
1915
1618
1999
Obs
2.72
1.84
2.27
30.30
0.70
2000
Obs
2.55
0.91
1.25
25.68
1.35
2001
Obs
2.29
2.58
2.58
27.68
0.62
1999
RiskAdj
2.72
1.82
2.27
30.28
0.66
2000
RiskAdj
2.55
0.90
1.27
25.66
1.36
2001
RiskAdj
2.29
2.58
2.58
27.66
0.59
1999
Exp
2.72
2.75
2.72
2.72
2.89
2000
Exp
2.55
2.58
2.51
2.55
2.54
2001
Exp
2.29
2.29
2.29
2.29
2.40
1999
LoCI
1999
HiCI
2.44
-0.91
-2.00
26.63
-3.47
2000
LoCI
2.28
-1.81
-2.61
21.94
-2.68
2001
LoCI
2.02
-0.21
-1.37
24.11
-3.29
3.00
4.55
6.54
33.94
4.79
2000
HiCI
2.82
3.61
5.14
29.38
5.39
2001
HiCI
2.56
5.37
6.53
31.22
4.46
1999
CI
Stat
Sig
( 0.00, 4.55 )
( 0.00, 6.54 )
( 26.63, 33.94 )
( 0.00, 4.79 )
2000
CI
o
o
o
Stat
Sig
( 0.00, 3.61 )
( 0.00, 5.14 )
( 21.94, 29.38 )
( 0.00, 5.39 )
2001
CI
o
o
o
Stat
Sig
( 0.00,
( 0.00,
( 24.11,
( 0.00,
5.37 )
6.53 )
31.22 )
4.46 )
o
o
o
7
Confusion about coding
Birth Trauma―Injury to Neonate
ICDICD-9-CM Coding: Procedures
„ Coding of procedures
Numerator:
Discharges with ICD-9-CM codes for birth trauma in any diagnosis field per 1,000 liveborn births.
Birth Trauma
ICD-9-CM diagnosis codes:
7670
7673
7674
7677
7678
7679
“The UHDDS requires all significant procedures to be
reported…
reported… A significant procedure is defined as one
that meets any of the following conditions:
Is surgical in nature
Carries an anesthetic risk
Carries a procedural risk
Requires specialized training.”
training.”
Subdural and cerebral hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
Injuries to skeleton (excludes clavicle)
Injury to spine and spinal cord
Other cranial and peripheral nerve injuries
Other specified birth trauma
Birth trauma, unspecified
Code Index under “Molding, head”
lists 767.3
ICD-9-CM Coding Manual Definition
767.3 Other Injuries To Skeleton Due To Birth Trauma
Fracture of: long bones, skull
767.4 Injury To Spine And Spinal Cord Due To Birth Trauma
{Dislocation} {Fracture} {Laceration} {Rupture} of spine or spinal cord due to birth trauma
What about central venous catheters?
Examples of ICDICD-9-CM limitations
“Selected infections due to medical care”
care”
“Postoperative hemorrhage or hematoma”
hematoma”
999.3 Other infection
Infection following infusion, injection, transfusion, or vaccination
Sepsis following infusion, injection, transfusion, or vaccination
Septicemia following infusion, injection, transfusion, or vaccination
Excludes: the listed conditions when specified as:
due to implanted device (996.60-996.69)
postoperative NOS (998.51-998.59)
998.1 Hemorrhage or hematoma or seroma complicating a procedure
Excludes: hemorrhage, hematoma or seroma:
complicating cesarean section or puerperal perineal wound (674.3)
due to implanted device or graft (996.70-996.79)
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
Coding Resources
„
American Health Information Management Association (AHIMA)
„
American Hospital Association
www.hospitalconnect.com/ahacentraloffice/ahaco/index.jsp
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„
National Center for Health Statistics
„
Centers for Medicare and Medicaid Services
„
AHIMA Resources and Practice Briefs
www.cdc.gov/nchs/icd9.htm
–
www.cms.gov
–
www.ahima.org/infocenter/practice_tools.asp
Developing a Coding Compliance Policy Document
Developing a Physician Query Process
Ongoing Coding Reviews: Ways to Ensure Quality
HIM’
HIM’s Role in Monitoring Patient Safety
Internet Resources for Coding and Reimbursement Practices
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Relevance of AHRQ PSIs for Children’
Children’s Hospitals
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Test interesting hypotheses (research)
„ Is it a coding issue?
„ Is it a quality issue?
„ Questions and answers
www.ahima.org
–
Sedman A, et al. Pediatrics 2005;115(1):1352005;115(1):135-145
No. reviewed
(total events)
Preventable
(PPV %)
Nonpreventable
Unclear
Complications of anesthesia
74 (503)
11 (15%)
37
25
Death in low-mortality DRG
121 (1282)
16 (13%)
89
16
Decubitus ulcer
130 (2300)
71 (55%)
47
10
Failure to rescue
187 (5271)
15 (8%)
148
11
49 (235)
25 (51%)
14
10
Postop hemorrhage or hematoma
114 (1571)
40 (35%)
51
23
Iatrogenic pneumothorax
114 (1113)
51 (45%)
42
21
Selected infection 2° to med care
152 (7291)
63 (41%)
45
39
Postop DVT/PE
126 (1956)
36 (29%)
61
29
41 (232)
19 (46%)
16
6
133 (4020)
86 (65%)
19
26
PSI
Foreign body left in
Postop wound dehiscence
Accidental puncture or laceration
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Linking the PedQIs to quality
„ New collaboration with NACHRI to conduct chart reviews
for PedQIs,
PedQIs, focused on confirming the event, describing
how it occurred, confirming correct risk stratification, and
assessing preventability.
„ Build collaborative network with other partners, in which
UC/Stanford/Battelle
UC/Stanford/Battelle will provide:
–
–
–
–
–
–
Standardized, pretested abstraction tools
Abstraction guidelines and resources
Training programs for chart reviewers
Online tools for data collection, management, and cleaning
Summarized data reports for partners with suggestions for
improvement (based on data from entire network)
Optional chart overover-reading to establish reliability/validity
Overview of insights (?)
„ Why use the PedQIs?
PedQIs?
– Establish accountability
– Surveillance/track performance over time and
across hospitals/units/services
– Trigger case finding, root cause analyses,
identification of clusters
– Evaluate impact of interventions
– Test interesting hypotheses (research)
„ Is it a coding issue?
„ Is it a quality issue?
„ Questions and discussion
Goals of collaborative projects
„ Tier indicators based on validity or potential
usefulness for CQI and public reporting; flag
indicators that don’
don’t make the grade
„ Inform NQF review process
„ Modify indicator definitions if possible to improve
sensitivity/specificity
„ Identify omitted risk factors to improve riskriskadjustment
„ Identify key loci of preventability (opportunities
for improvement): what should providers with
high rates look for in evaluating their care?
What can hospitals learn from the leaders?
More Information on AHRQ QIs
Quality Indicators Technical Assistance:
„ E-mail:
support@qualityindicators.ahrq.gov
„ Website:
http://qualityindicators.ahrq.gov/
„ Telephone:
(888) 512512-6090 (voice mail)
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