Determinants of Inpatient
Smoking
S
ki
Cessation
C
ti
Quality
Q lit
D
Douglas
l Levy,
L
PhD
dlevy3@partners.org
Massachusetts General Hospital and Harvard Medical School
Supported by the Robert Wood Johnson Foundation
S b t
Substance
Ab
Abuse Policy
P li Research
R
h Program
P
C ll b
Collaborators
t

Ray Kang, MA
– Northwestern University, Feinberg School of Medicine

Christine Vogeli, PhD
– Massachusetts General Hospital, Harvard Medical School

Nancy Rigotti
Rigotti, MD
– Massachusetts General Hospital, Harvard Medical School
National Hospital Inpatient
Quality Measures



In 2002, Joint Commission adopted National
Hospital Inpatient Quality (NHQ) measures
Hospitals participating in the Hospital Quality
Alliance / Hospital Compare report data to CMS
Focus on 3 conditions
– AMI,
AMI heart
h t failure,
f il
pneumonia
i

Provision of smoking cessation advice/ counseling
(SCA) is
i only
l metric
t i for
f allll three
th
conditions
diti
D t
Determinants
i
t off quality
lit

Patient characteristics
– LOS? Race? Comorbidities?

Hospital characteristics
– Teaching hospital (better AMI process)
– Percent minority patients (worse process
measures for high minority hospitals)

Region
g
– Performance on quality metrics vary by HRR
R
Research
h questions:
ti

What entity has the greatest influence
on the provision of SCA?
– Patient? Hospital? Region?

Wh t specific
What
ifi characteristics
h
t i ti off these
th
nested entities determine SCA rates?
P
Patient
Patientti t-level
l
l data
d t



Acquired
A
i d from
f
CMS
2005--2008
2005
NHQ measures
– yes/no SCA

Patient demographic and clinical
characteristics
– Age, sex, race, insurance, LOS, discharge status,
comorbidities
Hospital and Regional level data

Hospital
– AHA survey data (2007)
Size (# beds), ownership (public, NFP, FP),
t
teaching
hi status
t t
 Assume constant across study period

– Aggregated patient characteristics from
NHQ patientpatient-level file (by condition)


race payer
race,
payer, smoking rate
rate, non
non--SCA quality
Region – defined as Dartmouth HRR
Population characteristics
2005--2008
2005
AMI
HF
PN
Annual avg. # smoking
patients in sample
141k
146k
200k
Unique hospitals
3,688
3 688 4,588
4 588 4,828
4 828
Annual avg. %
community hospitals
61
82
88
P ti t demographics
Patient
d
hi
Female
White
Black
Hispanic
<=64
65--79
65
80
>=80
AMI
31%
81
11
5
74
22
4
HF
39%
60
32
6
59
32
9
PN
50%
79
15
5
64
28
8
Additional patient
characteristics
Payer
Medicare
Medicaid
Private
Unk. Ins.
LOS
Dischg. to an
Institution
AMI
HF
PN
28%
9
48
12
4.9
48%
16
25
10
4.9
42%
15
31
11
6.0
6
10
14
C
Common
comorbidities
biditi
Hypertension
Chronic Lung
g
Disease
Diabetes
Electrolyte/
Fluid Disorders
Obesity
Anemia
AMI
57%
HF
59%
PN
44%
28
22
54
30
65
19
12
10
8
21
12
19
34
7
17
SCA rates
t – patient
ti t level
l
l
100%
90%
80%
AMI
HF
PN
70%
60%
50%
2004
2005
2006
2007
2008
2009
SCA rates
t – hospital
h
it l level
l
l
100%
90%
80%
AMI
HF
PN
70%
60%
50%
2004
2005
2006
2007
2008
2009
What factors affect SCA
rates?

Use mixed effects models
– Random intercepts for patient, hospital,
HRR
– Unconditional model (no covariates)

Intraclass correlation coefficient as an
estimate of how much of variability in SCA
rates is at each level of hierarchy
– Conditional model (adds covariates)
Wh
Where
is
i variability?
i bilit ? AMI
80%
70%
60%
ICC
50%
Patient
Hospital
HRR
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
Wh
Where
is
i variability?
i bilit ? HF
80%
70%
60%
ICC
50%
Patient
Hospital
HRR
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
Wh
Where
is
i variability?
i bilit ? PN
80%
70%
60%
ICC
50%
Patient
Hospital
HRR
40%
30%
20%
10%
0%
2004
2005
2006
2007
2008
2009
Effect of patient
characteristics on SCA
AMI
HF
PN
2005
2008
2005
2008
2005
2008
-8%
-1%
-3%
-1%
-6%
-2%
Black
-2
ns
-1
ns
-3
-1
Hispanic
-2
ns
-2
-1
-4
-1
Asian
-3
-1
ns
ns
-6
-3
-.1/day
ns
.1/day
.04/day
-.1/day
-.03/day
-14
-4
-12
-5
-14
-7
Age >=80
LOS
Disch’d to
I tit ti
Institution
p <0.05 unless marked “ns”
Effect of patient
comorbidities on SCA
AMI
HF
PN
2005
2008
2005
2008
2005
2008
2%
ns
3%
1%
3%
1%
Anemia
-1
-.3
-1
-.3
-1
-.4
Chrn. Lung
1
.4
2
.5
4
1
Diabetes
-1
ns
-1
ns
-1
-.3
Lymphoma
-4
ns
-2
ns
-5
-1
Mets
-8
-1
-6
-1
-6
-2
Paraplegia
p g
-5
-1
-3
-1
-4
-1
Tumor
-6
ns
-2
ns
-5
-1
Alcoholism
p <0.05 unless marked “ns”
Effect of hospital
characteristics on SCA
AMI
HF
PN
2005
2008
2005
2008
2005
2008
10pt.  %Smokers in dx
2.4
-.4
1.7
1.4
ns
2.7
10pt.  non
non--SCA quality
5
3
6
5
6
5
10pt  % Medicaid
10pt.
-.1
1
ns
-.8
8
-.8
8
ns
-1.2
12
# Beds (∆
(∆/10 beds)
.1
.05
.2
.07
.2
.1
Private FP
2
3
2
ns
3
2
Public
-5
-2
-3
-3
-4
-5
Maj. Teach
-5
ns
-6
ns
-6
ns
p <0.05 unless marked “ns”
Summary
S
(1)


SCA rates climbed substantially during study
period
i d
SCA for HF and PN lags AMI
– CCU effect?

Major
j shift from patientpatient
p
-level determinants
to hospitalhospital-level determinants over study
p
period
– Hospital initiatives resulting in all patients being
p
treated the same is a likelyy explanation
Summary
S
(2)



Hospitals w/ more smokers in a given
diagnosis tend to do better at SCA
SCA quality is predicted by quality on other
measures
Private FP hospitals generally doing better
than private NFP hospitals
– public hospitals lag both

Major teaching hospitals have made up their
deficit relative to nonnon-teaching
Li it ti
Limitations

Do not know what SC advice/
counseling
li took
t k place
l
– SCA in hospital is not enough to
meaningfully
i f ll improve
i
cessation
i rates
– Revised SC measure being piloted



All patients, includes postpost-discharge f/u
Included many,
y, but not all hospitals
p
Models not ideal for binary outcomes
C
Conclusion
l i

Most hospitals have been very
effective at responding to the quality
measurement initiatives
– Some better than others

Still some lag for vulnerable hospitals
and patients
Effect of patient
characteristics on SCA
AMI
HF
PN
2005
2008
2005
2008
2005
2008
-8%
-1%
-3%
-1%
-6%
-2%
Black
-2
ns
-1
ns
-3
-1
Hispanic
-2
ns
-2
-1
-4
-1
Asian
-3
-1
ns
ns
-6
-3
-.1/day
ns
.1/day
.04/day
-.1/day
-.03/day
-14
-4
-12
-5
-14
-7
Age >=80
LOS
Disch’d to
I tit ti
Institution
p <0.05 unless marked “ns”
Effect of hospital
characteristics on SCA
AMI
2005
2008
HF
PN
2005
2008
2005
2008
10pt.  %Smokers in dx
2.5
-.4
.9
ns
3
10pt.  %Black
ns
ns
ns
ns
ns
10pt  %Hispanic
10pt.
ns
-.8
8
ns
-1
ns
10pt.  % Medicaid
-1.1
ns
-3
ns
2
# Beds (∆
(∆/10 beds)
.2
.2
.1
.2
.1
Private FP
ns
ns
3
ns
4
Public
-.7
-8
-7
-7
-9
ns
-6
ns
-7
pMaj.
<0.05Teach
unless marked “ns”