Background and
Development Team
Development of the Medicare
Patient Safety Monitoring
System
• DHHS Patient Safety Task Force
• CMS
– David R. Hunt, MD, FACS
• Qualidigm
Susan L. Abend, MD, FACP
David R. Hunt, MD, FACS
Gaston Mbateng, Ph.D.
Nancy Safer, RN, MSN
Janet P. Tate, MPH
Nancy R. Verzier, RN, MSN, CPHQ
– Connecticut Quality Improvement Organization
• Active Collaborators
– Federal Agency Work Group
• AHRQ, CDC, FDA, VA
– Technical Expert Panel
– Computer Science Corporation (Central Data Abstraction Center)
Goal
To determine the incidence of
specific, clearly defined,
hospitalhospital-acquired adverse
events within the Medicare
population
Design
• Retrospective Cohort Study
• 25,000- 40,000 randomly-selected
discharges/year from the Hospital
Payment Monitoring Program
– Data obtained from medical charts and
Medicare Part A claims database
• HPMP cases
– randomly selected cases from 50 states, D.C.,
Puerto Rico, U.S. Virgin Islands
– sent to CDAC’s to check coding accuracy
Purpose
• Baseline data for CMS national quality
improvement initiatives
– Surgical Care Improvement Project
• Annual data to the National Healthcare
Quality Report
• A method for repeated assessment of
events (tracking and trending) for safety
improvement activities within healthcare
organizations
MPSMS Definition of
Adverse Event
“An unintended patient harm, injury, or loss
more likely associated with an interaction
with the health care delivery system than
from an attendant disease process.”
• Patient centered
– Focuses on patient experience
– Does not presume to assign severity
• Detects an untoward outcome
• Requires defined healthcare exposure
• Not dependent on cause
– Process malfunction (error, negligence)
– Imperfect technology
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Measure Selection
Criteria
Measure Development
Process
• Event and exposure defined
• Boolean algorithm developed to
detect exposure-related event
• Alpha test
• Beta test
• Clinical review
• Production
• Findable/Feasible
• Adverse event(s)
event(s) very likely to be
associated with exposure
• Common (burden on Medicare
population)
• Responsible for serious morbidity
and mortality
• Preventable
Adverse Event Rates
Adverse Event Rates
’02 and ‘03 Medicare Inpatients
’02 and ‘03 Medicare Inpatients
Rate (%) + 95%CI
Rate (%) + 95% CI
Post-Operative Pneumonia
2.5 + 0.3
Ventilator Associated Pneumonia
Post-Operative Venous Thromboemboli
0.6 + 0.1
Hospital-Acquired Bloodstream Infection
Post-Operative Urinary Tract Infection
3.7 + 0.3
CVC-Associated Bloodstream Infection
1.4 + 0.3
Knee Replacement Adverse Events
7.2 + 1.3
CVC-Associated Insertion Site Infection
2.6 + 0.4
CVC-Associated Mechanical Adverse
Events
2.3 + 0.3
Hip Replacement Adverse Events
11.4 + 1.8
11.9 + 1.8
0.30 + 0.05
Average Length of Stay
Inpatient Mortality Rate
’02, ‘03 Medicare Patients With Invasive
Surgical Procedures
’02, ‘03 Medicare Patients With Invasive
Surgical Procedures
30
25
with event
with event
25
no event
no event
20
15
%
DAYS
20
15
10
10
5
5
0
0
Post Op
Pneumonia
Post Op VTE
Post Op UTI
Post Op
Pneumonia
Post Op VTE
Post Op UTI
Error bars indicate 95% CI
Error bars indicate 95% CI
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Phase III Measures
Phase II Measures
In Development
One Year of Data Pending
• In- Hospital Falls
• Postoperative Cardiac Events
• Angiography-Related Adverse Events
• Adverse Drug Events
– AnticoagulantAnticoagulant-related hemorrhagic events
– Insulin/oral hypoglycemic agentagent-related hypoglycemic
events
– Antibioticassociated
C.
Difficile
infection
Antibiotic
– Contrast nephropathy
– Adverse events related to femoral artery
puncture
• Urinary Tract Infections Associated with
Bladder Catheterization
• Pressure Ulcers
Reliability
Agreement Rate of Reported MPSMS Variables
Kappa Statistic for Reported
MPSMS Variables
100
90
> 0.8
0.61 - 0.8
<= 0.6
15%
dichotomous
80
categorical
70
%t
60
50
40
55%
30
30%
20
10
0
>=95%
>=90%and < 95%
>=80%and < 90%
Limitations
• Validation
– No true gold standard yet defined for
determining sensitivity and specificity
• Data source issues
– Retrospective
– Depends on consistent documentation of
exposures and events in medical record
• Events are relatively infrequent
• Limited capability for risk adjustment
Policy Implications
• Complements reporting efforts
– Able to detect denominator
– No reporting bias
• Complements indicators derived from
administrative data alone
– Potential for improved sensitivity
– Richer database of variables
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Policy Implications
cont’d
• Standard definitions
– trackable over time
Summary
• The MPSMS is a reliable tool for measuring adverse
events in hospitalized patients
• Allows hospitals to use common, standard
benchmarks
• Can measure the outcome of errors, suboptimal
systems and/or technologies
• Potential for post-discharge surveillance of
events
• Uses standardized, patient-oriented definitions of
adverse events
• Usable in paper or electronic health records
• Development is transparent and consensus-driven
– Potential for concurrent or prospective use in error
trapping or event avoidance.
– strong collaboration between public and private stakeholders
Conclusion
The MPSMS is a valuable tool for
hospitals and health care organizations
to use in making transformational
changes to create a safe healthcare
environment.
This material was prepared by Qualidigm, the Medicare Quality Improvement Organization
for Connecticut, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy. Pub. # QUALCT-PSMS-200501
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