An Evaluation of Local Health Systems
Michael L Taylor MD FACP
CMO, Truven Health Analytics
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1
Introduction and Overview
 All measures, except for patients satisfaction, are for the
period October 2010 through September 2013
 The “current time period” results are for the October 2012
through September 2013
Timeframes
 Patient satisfaction results are for the calendar years 2011,
2012 and 2013
 The Medicare Provider Analysis and Review (MEDPAR)
File
 Contains data from claims for services provided to all
beneficiaries admitted to Medicare certified acute care hospitals
Data
sources
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 Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)
 A national survey of patients' perspectives of hospital care (i.e.
satisfaction)
2
Introduction and Overview
 The strength of a hospital’s performance can be evaluated as a
function of both its results during the most recent time period and
the trend over time
 For broad measures (e.g. overall complication rate) both the trend
over 12 quarters and the most current year’s results are shown
 All results are presented in terms of an observed to expected ratio
(OE ratio)
 The expected amounts are based upon a national acute care hospital
average, adjusted for the case mix of the hospital or hospital system
being evaluated
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3
Introduction and Overview
Results are reported at the hospital system level for 5 systems
Health
System A
Health
System B
Health
System C
Health
System D
Health
System E
In addition, the results are broken out by 15 hospitals within these
systems that were designated by the client.
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4
Introduction and Overview, Measure Sources
Measure
Measure Source
Cost Per Case (Overall and for Truven Expected Resource Demand
Medicine, General Surgery and model (ERD), the ERD is a set of regression models
Orthopedics)
that predict expected cost, based upon demographic
factors, diagnosis and procedure factors. *
Patient Safety Events
 Overall Rate
Patient Safety Indicators (PSIs), developed by the
 Pressure Ulcer Rate
Agency for Healthcare Research and Quality (AHRQ)
 Post-Op Pulmonary
to capture potentially preventable adverse events that
Embolism or Deep Vein
compromise inpatient patient safety.
Thrombosis
 Death among Surgical Pts
With Treatable
Complications
*Cost is based upon the “Cost to Charge Ratio” and reflects underlying facility cost
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5
Introduction and Overview, Measure Sources
Measure
Complication Rate (Overall
and for Medicine, General
Surgery and Orthopedics)
Measure Source
Truven Expected Complications Rate Index (ECRI)
model is used to determine observed and expected
complication rates using patient demographic and
clinical information.
Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS), a national,
Patient Satisfaction
standardized, publicly reported survey of patients'
perspectives of hospital care. Data are adjusted for the
effects of patient-mix and mode of survey
administration.
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6
Cost
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7
Overall Cost per Admission
Average Cost per Admission
Actual to Expected Ratio
Health System A
+
Health System B
Health System C
Health System D
Health System E
Trend for Actual to Expected Results Over 12 Quarters
(a lower slope is favorable)
-0.09
-0.07
 Hospital systems were
close in performance
and showed almost no
change in performance
over the 12 quarter time
period.
-0.05
-0.03
-0.01
0.01
0.03
 System C showed the
best overall cost
performance and
Systems E and B the
weakest.
0.05
0.07
0.09
1.30
 All 5 systems had costs
which exceed the
expected adjusted
nation average amount.
1.25
1.20
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1.15
1.10
Current Actual to Expected Ratio
(a lower ratio is favorable)
1.05
1.00
8
0.95
0.90
Overall Cost per Admission – By Hospital
Cost per Admission
On an individual hospital
Actual to Expected Ratio
basis, performance within
-0.09
Trend for Actual to Expected Results Over 12 Quarters
(a lower slope is favorable)
system was widely
-0.07
dispersed for both System A
-0.05
and System C—with System
-0.03
B showing somewhat
-0.01
greater dispersion having
0.01
both the best and worst
0.03
performing hospitals among
0.05
the 15 individual hospitals
0.07
0.09
1.40
being compared.
1.35
1.30
1.25
1.20
1.15
1.10
1.05
1.00
Current Actual to Expected Ratio
(a lower ratio is favorable)
Blue axis show the experience for the average of the five Health Systems
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9
0.95
0.90
Cost, Observations - Conclusions
 Hospital system performance did not vary widely and did not
change substantially over time
 System C and System A were the best performing hospital systems
E and B the weakest
 Service line and overall cost performance were closely related
 Hospital systems that were good cost performers overall tended to be good
performers in 2 of the 3 individual service lines examined
 System C showed strong cost performance overall and in all 3 lines of
service
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10
Quality
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11
Quality Overview
Quality Domains
Patient safety events
Complications of care
 The overall performance for the patient safety event rate and
complications was reported by hospital system, individual hospital and
service line
 Performance for the 3 specific patient safety indicators (PSIs) listed
below were reported by hospital system and hospital
 Pressure Ulcers
 Death among surgical patients with serious treatable complications
 Postoperative pulmonary emboli or deep vein thromboses (i.e. clots)
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12
Quality, Complications
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13
Overall Complication Rate
Overall Complication Rate
 Systems B and D were
Actual to Expected Ratio
Health System A
+
the strongest hospitals in
Health System B
Health System C
Health System D
Health System E
this quality domain and
Trend for Actual to Expected Results Over 12 Quarters
(a lower slope is favorable)
-0.09
the only 2 hospital
-0.07
systems to have an
-0.05
overall complication rate
-0.03
lower than expected.
-0.01
 System E was the
0.01
weakest performer by far
0.03
with a complication rate
0.05
almost 20% higher than
0.07
0.09
1.30
expected.
1.25
1.20
1.15
1.10
1.05
1.00
Current Actual to Expected Ratio
(a lower ratio is favorable)
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14
0.95
0.90
Complications, General Surgery – By System
Complications General Surgery 2013 Results
1.40
1.24
1.20
1.09
1.16
1.03
1.00
0.84
0.80
0.60
0.40
0.20
0.00
Health System A
Health System B
Health System C
Health System D
Health System E
While there was a strong correlation between service line performance and overall
performance, this was particularly pronounced for General Surgery. As was the case
across all service lines, B and D systems were the top performers.
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Complications, Medicine – By System
Complications Medicine 2013 Results
1.40
1.20
1.19
1.11
1.00
0.88
0.80
0.76
0.78
Health System C
Health System D
0.60
0.40
0.20
0.00
Health System A
Health System B
Health System E
It is noteworthy that this service line was the only service line where System C, an
at best middle of the pack performer overall and in other service lines, shows
excellent results.
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Complications, Orthopedics – By System
Complications Orthopedics 2013 Results
1.40
1.20
1.20
1.01
1.00
0.80
1.07
0.79
0.68
0.60
0.40
0.20
0.00
Health System A
Health System B
Health System C
Health System D
Health System E
System B was the leader in this quality domain for this service line.
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17
Complications, Further Analyses
 Subsequent to the initial presentation of results Truven Health examined
the relationship between cost and quality, providing some statistical
analysis of the results
 There was a weak negative correlation between cost and quality
performance (r=-.33), hospitals that performed somewhat better in the
cost domain performed somewhat worse in the quality domain
Cost and Quality Performance Comparison by Hospital System
1.40
1.20
1.00
0.80
Complications
0.60
Cost
0.40
0.20
0.00
Health system A
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Health system B
Health system C
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Health system D
Health system E
Quality, Patient Safety Events
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Overall Patient Safety Event Rate
Overall Pt. Safety Event Rate
Actual to Expected Ratio
Health System A
+
Health System B
Health System C
Health System D
Health System E
correlation between the
-0.10
Trend for Actual to Expected Results Over 12 Quarters
(a lower slope is favorable)
 There was a strong
overall patient safety
-0.08
event rate and the
-0.06
complication rate
-0.04
(previous section).
-0.02
Systems B and D are the
0.00
0.02
frontrunners and
0.04
Systems A and E the
0.06
weakest.
0.08
0.10
1.40
1.30
1.20
1.10
1.00
0.90
0.80
Current Actual to Expected Ratio
(a lower ratio is favorable)
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0.70
0.60
Patient Safety Event Rate, General Surgery – By System
Pt Safety Events General Surgery 2013 Results
1.40
1.33
1.32
1.20
1.05
1.04
1.00
0.80
0.64
0.60
0.40
0.20
0.00
Health System A
Health System B
Health System C
Health System D
Health System E
There is a strong correlation between overall performance and performance in this
service line as well as with the complication rate. The hospital systems that
performed well for patient safety for this service line were the same ones that had
low complication rates. In both cases the System D was the top performer with
System B and E also showing good results.
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Patient Safety Event Rate, Medicine – By System
Pt Safety Events Medicine 2013 Results
1.20
1.06
1.13
1.08
1.00
0.80
0.73
0.60
0.42
0.40
0.20
0.00
Health System A
Health System B
Health System C
Health System D
Health System E
The General Medicine and Orthopedics service lines (see next slide) appear to be
System C’s opportunity to stand out. As was the case for complications, it was the
best performing hospital system for the General Medicine service line whereas
elsewhere its performance was not exceptional.
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22
Patient Safety Event Rate, Orthopedics – By System
Pt Safety Events Orthopedics 2013 Results
1.20
1.12
1.00
0.80
0.77
0.79
0.69
0.60
0.40
0.21
0.20
0.00
Health System A
Health System B
Health System C
Health System D
System C was a strong performer across all 3 service lines
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Health System E
Quality, Patient Safety Events - Specific Safety
Indicators
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Quality, Patient Safety Events - Post Op Clotting*
* Postoperative Pulmonary Embolism or Deep Vein Thrombosis
Post Operative Pulmonary or Deep Vein Thrombosis
 There was a good
Actual to Expected Ratio
Health System A
+
Health System B
Health System C
Health System D
Health System E
correlation between the 3
specific patient safety
indicators and the overall
patient safety event rate.
 Consistent with this,
System D was the top
performer across all 3
measures and the C
system the weakest
performer.
 All hospitals exceed
expected performance
levels for this measure.
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25
Quality, Patient Safety Events - Pressure Ulcers
Pressure Ulcer
Actual to Expected Ratio
Health System A
+
Health System B
Health System C
 Again System D showed
Health System D
Health System E
the best performance in
this area as well, far
outdistancing the other
systems.
 They also had the
greatest rate of
improvement.
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26
Quality, Patient Safety Events - Mortality*
*Death among Surgical Inpatients w/Serious Treatable Complications
Death among Surgical Inpatients w/Serious Treatable Complications
Actual to Expected Ratio
Health System A
+
Health System B
Health System C
Health System D
Health System E
 In general,
performance was
poor in this area
compared to the
adjusted national
average.
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27
Quality, Observations - Conclusions
System A was a
consistently weak
performer quality- wise,
showing high rates of
complications and
patient safety events

System B also showed
strong results
System C was very
inconsistent


Because this system
In the General Medicine
experience was broken
service line it had a lower
out by hospital we can
than expected
see that in addition to
complication and patient
Of particular note was
the poor performance of
one of this systems
hospitals, it showed
weak performance for
patient safety events and
complications overall as
well as across all service
lines greatly impacting
the system results
showing good quality
safety event rates
Health System A
Health System B
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results, it also showed

less inter-hospital
variation in performance
Overall patient mortality
rate was very strong

Elsewhere it showed
than the much more
middle or lower
poorly performing
performance
System A.
28
Health System C
Quality, Observations - Conclusions
System D consistently
showed excellent
performance in nearly all
quality areas, it was the
quality leader
Health System D
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While showing better
results in more areas
than the System A,
System E, generally
showed weak quality
performance
Health System E
29
Patient Satisfaction
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Patient Satisfaction
 The responses were to the question, “How do you rate the
hospital overall?”
 Responses are on a 1 to 10 scale, higher is better
 Overall rate is the average score
 The system specific, cross hospital rates are a straight, non-weighted
average across the hospitals in each system
 The satisfaction ratings of the individual hospitals within a
system were consistent with respect to the rate of improvement
 If the system as a whole was improving or deteriorating all of the individual
hospitals tended to do likewise
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Patient Satisfaction
Health System Average Satisfaction
90
Health System A
85
Health System B
80
Health System C
78.89
78.22
76.67
75
Health System D
Health System E
70
Total US
65
2011
2012
2013
 The satisfaction with the hospital systems was similar, the highest and lowest scoring
hospitals were within 6% of each other and all were above the national average in 2013.
 This was particularly true of the top performers. System A, B, and D scores were within
1 point of each other as the top performing hospitals.
 With the exception of System A, all systems showed improvement over the
3 year period.
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32
Satisfaction Observations - Conclusions
 Satisfaction appears to be commodity-like at the system level
 To the extent that differences do exist, the performance of System D
and B were consistent with their strong performance in the quality
area
 The satisfaction ratings of the individual hospitals within a system
were consistent with respect to the rate of improvement
 If the system as a whole was improving or deteriorating all of the
individual hospitals in that system tended to do likewise
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Overall Conclusions
 Cost and quality are not positively correlated
 Higher quality performance does not predict lower cost
 Quality was where hospital systems differentiated themselves
 Hospitals were not widely separated by cost or satisfaction
 System D shows consistent strength in all quality areas and was
highly rated from a satisfaction stand point
 While not the least expensive system on a case mix adjusted basis, it is
in the middle of the pack cost-wise in a very tight market
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34
What’s Next
 Drawing conclusions from the data
 Identify opportunities for improvement
 Identify opportunities for the delivery of cost effective quality care
 Develop baseline metrics
 Identify on-going measurement strategy
 Coordinate of communication
 Work to align with benefits
Remember this is not one and done this is a process
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35
More than Data. Answers.
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