OECD s Health Care Quality
OECD’s
Indicator Project:
A Perspective from the USA
Patrick S. Romano, MD MPH
Professor of Medicine and Pediatrics
University of California, Davis
June 27, 2010
Outline: A two-way
two way street
Contributing
C
t ib ti measures
and tools
 Sharing evidence
regarding validity of
measures and tools
 Informing policy
discussions and
debates in the USA

AHRQ: Data to Information to Action
Hospital discharge
data are already
being collected
Hospital discharge data
can generate valuable
health care information
Utilization and
Rates of diseases
costs of care
in populations
in hospitals
R t off procedures
Rates
d
in populations
Information can be
used to make decisions
Quality and safety of
care in hospitals
Preventable hospital
stays
t
that
th t indicate
i di t
breakdowns in care
AHRQ Quality Indicators (QIs)


Developed through contract with UCSF-Stanford
Evidence-based Practice Center & UC Davis
Use existing hospital discharge data from the
Healthcare Cost and Utilization Project:
 Uniform
database for cross
cross-State
State studies; includes
clinical, demographic, and resource use information
 Represents
p
all inpatient
p
discharge
g data from 43
participating States, or approximately 90% of all
discharges nationwide
 Standard data elements defined by UHDDS
UHDDS, NUBC

Incorporate severity adjustment methods,
i l di APR
including
APR-DRGs
DRG and
d comorbidity
bidit groupings
i
AHRQ QI development process
INITIAL
EMPRICAL ANALYSES
AND DEFINITION
LITERATURE REVIEW
USER DATA
PANEL EVALUATION
FURTHER
EMPIRICAL ANALYSES
REFINED DEFINITION
FURTHER REVIEW?
FINAL DEFINITION
AHRQ Quality Indicators
Inpatient QIs
Mortality
Mortality,
Utilization,
Volume
Prevention QIs
(Area Level)
A id bl
Avoidable
Hospitalizations /
Other Avoidable
Conditions
Pediatric QIs
Patient Safety
Indicators
Neonatal
QIs
Complications,
Unexpected Death
General uses of the AHRQ QIs

Hospital quality improvement efforts



Aggregate reporting: National
National, state
state, regional



IIndividual
di id l h
hospitals
i l &h
health
l h care systems
Hospital associations and consortia
National Healthcare Quality and Disparities Reports
Commonwealth Fund’s Health Performance Initiative
Research




Tracking quality of care for populations over time and across areas
Tracking disparities in care over time and across areas
Comparing quality between different types of hospitals or hospital
y
systems
Evaluating impact of interventions to reduce costs or improve
quality (e.g., work hours reform, EHR systems, consolidations)
General uses of the AHRQ QIs

V l b
Value
based
d purchasing
h i / pay ffor performance
f
(P4P)




Hospital
p
level p
public reporting
p
g



CMS - Premier Demo
Anthem of Virginia
The Alliance (Wisconsin)
Currently: Statewide public reporting (upcoming slide)
Upcoming: CMS Hospital Compare, including Veterans Affairs
medical
di l centers
t
(
(upcoming
i slide)
lid )
International application by the OECD’s Health Care
Quality Indicator Project
Over half ((60%)) of the US population
p p
has access
to a state public report that uses the AHRQ QIs
Washington
Oregon
Iowa
Wisconsin
New York
Minnesota
Illinois
Ohi
Ohio
Vermont
Massachusetts
Nevada
New Jersey
California
Kentucky
Utah
Colorado
Texas
AHRQ QIs appear in public reports in 19 states
Florida
Okl h
Oklahoma
AHRQ PQIs endorsed by
y OECD






Asthma*
Ch i Obstructive
Chronic
Ob t ti P
Pulmonary
l
Di
Disease**
Congestive Heart Failure*
Angina
Hypertension*
Hypertension
Diabetes
 Short-term
Sh t t
complications*
li ti
*
 Long-term complications
 Lower-extremity
L
t
it amputation*
t ti *
 Uncontrolled
* Published in the 2009 edition of OECD Health at a Glance
OECD review of AHRQ PSIs





Patient safetyy panel
p
constituted with 5 members
(Dr. John Millar, Chair)
50 indicators from 7 sources submitted for
review (US, Canada, Australia)
Modified RAND/UCLA Appropriateness Method
Panelists rated each indicator on importance
and
d scientific
i tifi soundness
d
(2 rounds
d with
ith
intervening discussion)
Retained indicators with median score >7 (1-9
scale) on both domains; rejected indicators with
median score 5 or below on either domain
AHRQ PSIs endorsed by
y OECD
(after review of data limitations)







Foreign body left in during procedure (PSI 5)
Vascular catheter associated bloodstream infection
(PSI 7)
Postoperative pulmonary embolism or deep vein
thrombosis (PSI 12)
Postoperative sepsis (PSI 13)
Accidental puncture and laceration (PSI 15)
Obstetric trauma -- vaginal delivery with instrument
(PSI 18)
Obstetric trauma -- vaginal delivery without
instrument (PSI 19)
Adaptation of AHRQ definitions


ICD-9-CM to ICD-10 conversions led by Saskia
Drösler under the auspices of the International
Methodology Consortium for Coded Health
Information (IMECCHI)
AHRQ definitions except:
 Aged
15+ instead of 18+ years
 Exclusion of day cases (short-stay admissions)
 Mapping between ICD-9-CM
ICD 9 CM and ICD-10
ICD 10 (country(country
specific)
 Procedure coding required country-specific efforts

Based on assumptions regarding definition of
principal diagnosis, secondary diagnoses that
qualify
lif ffor reporting,
ti
etc.
t
Summary
y of PPV estimates from
community hospitals in USA
100%
80%
%c
cases
% Other
60%
% Exclusions
40%
% Miscoding
% POA
% PPV
20%
0%
APL,
n=249
PTX,
n=205
DVT/PE, Selected
n=121 inf, n=191
Postop
sepsis,
n=164
Postop
resp
failure,
n=609
Informing policy discussions
Commonwealth Fund reports and
publications
 Direct testimony in US Congress
 RWJF/Urban Institute report
 Concerns about data comparability
 Can information counteract mythology?

Multinational Comparisons
of Health Systems
y
Data,, 2008
Gerard F. Anderson and Patricia Markovich
Johns Hopkins University
Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors
and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications
when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1371.
International Comparison of Spending on Health
1980 2006
1980–2006
Average spending on health
per capita ($US PPP)
Total expenditures on health
as percent of GDP
16
7000
Australia*
Canada
France
Germany
N h l d
Netherlands
New Zealand
Switzerland
United Kingdom
United States
6000
5000
4000
14
12
10
8
3000
6
Australia
Australia*
Canada
France
Germany
Netherlands
New Zealand
Switzerland
United Kingdom
United States
2000
4
1000
2
0
0
1980
1984
1988
1992
1996
2000
* From Australian Department of Health and Ageing
Source: OECD Health Data 2008, “June 2008”
2004
1980
1984
1988
1992
1996
2000
2004
Concerns about data comparability
Postoperative PE or Deep Vein Thrombosis
N=14 countries, Spearman r=0.670 (p=0.009), R2=0.56
Std. Rate per 100 pts.
USA
1.5
1.4
13
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
02
0.2
0.1
NZL
GBR
IRLE
SW
DEU
BEL
NOR CHE
DNK ESP
CAN
ITA
PRT
0
1
2
3
4
Mean # of secondary Dx codes
5
6
7
Can information counter mythology?
America s health care system is the “best
America’s
best
in the world”
 Resonates with American pride and
“exceptionalism”
p
 Makes health system reform seem
threatening undesirable,
threatening,
undesirable unnecessary
(why change what isn’t broken?)
 But is it true??
