What do we know about overall trends in
patient safety in the USA?
Patrick S. Romano, MD MPH
Professor of Medicine and Pediatrics
University of California, Davis
Center for Health Services Research in Primary Care
June 26, 2006
Background
 Two major
studies of preventable adverse events during
hospitalizations, based on medical record reviews by
nurses and physicians:
– New York, 1984
– Colorado and Utah, 1992
Patient Safety Datasources




HCUP Nationwide Inpatient Sample (AHRQ Patient
Safety Indicators)
CDC National Nosocomial Infection Surveillance
Program
Medicare Patient Safety Monitoring System: Adverse
Events
Medical Expenditure Panel Survey: Inappropriate
Medications
AHRQ’s Patient Safety Indicators (PSIs)
Designed to address the perceived need for an inexpensive
surveillance system based on readily available hospitalization data
(using ICD-9-CM diagnoses and procedures)
 Literature
review to identify potential indicators and gather data on
validity from prior studies
 ICD-9-CM coding consultant review
 Clinical expert panel review (modified Delphi rating process)
 Empirical analyses of nationwide rates, hospital variation, impact of
risk adjustment, and relationships among indicators
Medicare Patient Safety Monitoring System




Adverse events from charts
Randomly-selected, nationwide subset of inpatient
medical records of Medicare beneficiaries
Data weighted to produce national estimates
Sample size: about 26,000 charts
– 5,500 surgical cases
– 4,000 central venous catheter insertions
National trends in extremely rare (sentinel) events
HCUP 1994-2002 (solid)
0.011%
0.010%
0.009%
Foreign body left in during procedure
0.008%
0.007%
0.006%
0.005%
0.004%
0.003%
Postoperative hip fracture
0.002%
0.001%
0.000%
1994
1995
1996
1997
1998
1999
2000
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2001
2002
National trends in extremely rare (sentinel) events
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
0.016%
0.014%
0.012%
0.010%
Foreign body left in during procedure
0.008%
0.006%
0.004%
0.002%
Transfusion reaction
0.000%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in very rare event rates
HCUP 1994-2002 (solid)
0.10%
0.09%
Anesthesia reactions and complications
0.08%
0.07%
0.06%
0.05%
0.04%
Postoperative hip fracture
0.03%
0.02%
1994
1995
1996
1997
1998
1999
2000
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2001
2002
National trends in very rare event rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
0.10%
0.09%
Anesthesia reactions and complications
0.08%
0.07%
0.06%
0.05%
0.04%
Postoperative hip fracture
0.03%
0.02%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in rare catheter-related event rates
HCUP 1994-2002 (solid)
0.250%
0.225%
0.200%
Selected infections due to medical care
0.175%
0.150%
Postoperative physiologic/metabolic derangements
0.125%
0.100%
Iatrogenic pneumothorax
0.075%
0.050%
0.025%
1994
1995
1996
1997
1998
1999
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2000
2001
2002
National trends in rare catheter-related event rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
0.250%
0.225%
0.200%
0.175%
Selected infections due to medical care
0.150%
0.125%
0.100%
Postoperative physiologic/metabolic derangements
0.075%
0.050%
Iatrogenic pneumothorax
0.025%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in postoperative medical event rates
HCUP 1994-2002 (solid)
1.2%
1.1%
1.0%
Postoperative sepsis
0.9%
0.8%
0.7%
Postoperative thromboembolism
0.6%
0.5%
0.4%
Postoperative respiratory failure
0.3%
0.2%
1994
1995
1996
1997
1998
1999
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2000
2001
2002
National trends in postoperative medical event rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
1.1%
1.0%
0.9%
Postoperative sepsis
Postoperative respiratory failure
0.8%
0.7%
Postoperative thromboembolism
0.6%
0.5%
0.4%
0.3%
0.2%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in technical surgical event rates
HCUP 1994-2002 (solid)
0.55%
0.50%
0.45%
0.40%
0.35%
Accidental puncture or laceration
0.30%
Postoperative abdominopelvic wound dehiscence
0.25%
0.20%
Postoperative hemorrhage or hematoma
0.15%
1994
1995
1996
1997
1998
1999
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2000
2001
2002
National trends in technical surgical event rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
0.55%
0.50%
0.45%
0.40%
Accidental puncture or laceration
0.35%
0.30%
0.25%
Postoperative abdominopelvic wound dehiscence
Postoperative hemorrhage or hematoma
0.20%
0.15%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in pressure sore rates
HCUP 1994-2002 (solid)
2.6%
2.4%
2.2%
2.0%
Decubitus ulcer
1.8%
1.6%
1.4%
1.2%
1.0%
1994
1995
1996
1997
1998
1999
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2000
2001
2002
National trends in pressure sore rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
2.6%
2.4%
2.2%
Decubitus ulcer
2.0%
1.8%
Decubitus ulcer
1.6%
1.4%
1.2%
1.0%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
National trends in obstetric trauma and FTR-L rates
HCUP 1994-2002 (solid)
22%
Obstetric trauma: vaginal delivery w instrumentation
20%
18%
16%
Failure to rescue
14%
12%
10%
Obstetric trauma: vaginal delivery w/out instrumentation
8%
6%
4%
2%
0%
1994
1995
1996
1997
1998
1999
2000
Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .
2001
2002
National trends in obstetric trauma and FTR-L rates
HCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)
22%
Obstetric trauma: vaginal delivery w instrumentation
20%
18%
16%
14%
12%
Failure to rescue
10%
8%
Obstetric trauma: vaginal delivery w/out instrumentation
6%
4%
2%
0%
1999
2000
2001
2002
Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.
2003
2004
Research/Policy Question
Why are some PSIs increasing in incidence over time while
others are decreasing?
 Selective changes in coding practice
 Changes in severity of illness or underlying risk of potential
safety-related events
 True changes in quality due to technical improvements in
surgical or nursing technique, counterbalanced by
inadequate staffing to prevent some complications
National trends in CDC’s nosocomial infection rates
National Nosocomial Infection Surveillance Program 1998-2003
1998
1999
2000
2001
14
12
per 1,000 ICU days
10
Ventilator-associated pneumonia, adult ICU patients
8
6
CVC-associated bloodstream infections, adult ICU patients
4
2
0
National Health Care Quality Report 2005, downloadable tables
2002
2003
National trends in CDC’s nosocomial infection rates
National Nosocomial Infection Surveillance Program 1998-2003
1998
1999
2000
2001
2002
14
12
per 1,000 ICU days
10
CVC-associated bloodstream infections, LBW neonatal ICU patients
8
6
Ventilator-associated pneumonia, LBW neonatal ICU patients
4
2
0
National Health Care Quality Report 2005, downloadable tables
2003
National trends in Medicare Patient Safety
Monitoring System, 2002-2003
2002
14
2003
Total hip arthroplasty, postoperative adverse events
12
Percentage
10
8
Total knee arthroplasty, postoperative adverse events
6
4
2
0
National Health Care Quality Report 2005, downloadable tables
National trends in Medicare Patient Safety
Monitoring System, 2002-2003
2002
2003
4.0
3.5
CVC placement, insertion-related mechanical events
Percentage
3.0
2.5
CVC placement, insertion site infections
2.0
CVC placement, bloodstream infections
1.5
1.0
0.5
0.0
National Health Care Quality Report 2005, downloadable tables
Inappropriate use of medications by the elderly
Medical Expenditure Panel Survey, 1996-2002
National Health Care Quality Report, 2005
JCAHO Core Measures for AMI
JCAHO Core Measures for heart failure
JCAHO Core Measures for pneumonia
Conclusions
 No
consistent trends across AHRQ Patient Safety
Indicators:
– Most technical errors are slowly decreasing
– Most postoperative medical complications are increasing
– Unclear whether unmeasured risk or coding changes may
explain some of these findings
 Nosocomial infection rates in
– Volunteer hospitals only
ICUs are decreasing
Conclusions
 Postoperative adverse event rates appear
to be
decreasing among Medicare patients:
– Methodology not well described and validated
– Only 2002 and 2003 data
 Substantial improvements in
most JCAHO core measures:
– Performing to the test
– Outcome measures (e.g. AMI mortality) show relatively little
change