Voluntary Hospital
Public Reporting:
PCI Readmission
Collaboration between:
The Centers for Medicare & Medicaid Services
The American College of Cardiology
Center for Outcomes Research and Evaluation
1
Agenda
•
•
•
•
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Introduction and Roles (next)
Why Measure PCI Readmission?
Voluntary Public Reporting Overview
Measure Overview
Interpreting Your Results
Hospital Compare Display
Conclusion and Questions
2
Introduction and Roles
• The American College of Cardiology (ACC)
• Centers for Medicare & Medicaid Services (CMS)
• Yale New Haven Health Services Corporation –
Center for Outcomes Research and Evaluation
(YNHHSC/CORE)
3
Agenda
•
•
•
•
•
•
•
Introduction and Roles
Why Measure PCI Readmission? (next)
Voluntary Public Reporting Overview
Measure Overview
Interpreting Your Results
Hospital Compare Display
Conclusion and Questions
4
PCI Procedures
• Common cardiac procedure
– More than 600,000 performed in US
• Improves patient survival and quality of life
5
PCI Readmission
• Common, potentially preventable event
• Major driver of cost in health care system
• Variation across hospitals suggests
opportunity for improvement
• Evidence that hospitals can reduce
readmission rates
– Project RED
– BOOST
6
Opportunity for Improvement
Distribution of CathPCI Registry® Hospital 30-Day RiskStandardized Readmission Rates following PCI (2010-2011)
• CathPCI Registry®
readmission rate:
11.9%
• Risk-standardized
readmission rate
ranges from 8.6% to
16.8%
7
Agenda
• Introduction and Roles
• Why Measure PCI Readmission?
• Voluntary Public Reporting Overview
(next)
• Measure Overview
• Interpreting Your Results
• Hospital Compare Display
• Conclusion and Questions
8
Aims of Voluntary Public Reporting
• Inform health care providers about opportunities
to improve care
• Provide public with information on readmissions
after PCI procedures without additional data
collection burden to hospitals
• Promote investment in QI initiatives
9
Overarching Goal of This Effort
Shifting and Narrowing the Curve
10
Plans for Implementation
• ACC, YNHHSC/CORE, and CMS provide
measure results to CathPCI Registry®
hospitals in March
• Hospitals can choose to voluntarily
publicly report their measure results in the
July 2013 release on Hospital Compare
11
Timeline
12
Purpose of Preview Period
• Educate hospitals about measure in
advance of voluntary public reporting
• Provide hospitals with results and data
• Help hospitals interpret results and data
• Explain how they can participate in
voluntary public reporting
• Allow hospitals to ask questions
13
Preview Period Overview
• NCDR website
• Hospitals have received:
– CathPCI Registry® Results Summary and Data File Instructions
– Hospital-Specific Data and Results Excel® File
• Publicly available resources:
– 2013 Measure Update Report, 2009 Technical Report, FAQs
– Data Release Consent Forms (to participate)
– NCDR@acc.org
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Agenda
•
•
•
•
•
•
•
Introduction and Roles
Why Measure PCI Readmission?
Voluntary Public Reporting Overview
Measure Overview (next)
Interpreting Your Results
Hospital Compare Display
Conclusion and Questions
15
Measure Summary
• Hospital risk-standardized 30-day
readmission rate following PCI
• Results for CathPCI Registry® hospitals
with at least one eligible PCI
16
Measure Design
• Medicare claims linked to CathPCI Registry® data
• Risk model uses CathPCI Registry® data
• Readmissions identified using claims data
– Excludes planned readmissions
• Estimates hospital-level risk-standardized
readmission rate (RSRR)
17
Inclusion criteria
• Medicare FFS patients aged 65+
• Received PCI at a CathPCI Registry®
hospital
• Discharged between 1/1/2010 and
11/30/2011
18
Exclusion Criteria
•
•
•
•
•
•
•
Not enrolled in Medicare FFS at the time of the PCI
PCI performed >10 days after admission
In hospital deaths
Transfers out
Patient discharged against medical advice.
PCI without 30-day follow-up data
PCI performed within 30 days of a prior PCI
19
Risk adjustment
• Accounts for differences in patient
characteristics and comorbidities across
hospitals
• Risk adjustment variables from CathPCI
Registry® data
– Age
– Gender
– 18 additional variables
20
Outcome
• All-cause unplanned readmission
– To any acute care hospital
– Within 30 days of discharge
• Yes/No outcome
• Attributed to hospital discharging the
patient to a non-acute setting
21
Top 10 Reasons for Unplanned
Readmission
22
Planned Readmissions
• Not a signal of hospital quality
• Not counted in measure outcome
• Measure identifies planned readmissions
using algorithm
23
Planned Readmission Definition
*When the measure is used
with all-payer data,
readmissions for cesarean
section or forceps, vacuum, or
breech delivery are considered
planned
**When the measure is used
with all-payer data,
readmissions for forceps or
normal delivery are considered
planned
Readmission
Readmission is for bone marrow,
kidney, or other organ transplant*
(Table A 1)
Yes
No
Readmission is for maintenance
chemotherapy or rehabilitation**
(Table A 2)
Yes
No
Yes
Readmission includes a
potentially planned
procedure
(Table A3)
Yes
No
Readmission follows stent
deployment
No
UNPLANNED
No
Readmission includes a
potentially planned
procedure
(Table A4)
Yes
Yes
Primary discharge diagnosis of
readmission is acute or
complication of care (Table A5)
No
PLANNED
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Top 10 Planned Readmissions
(With stent)
Top 10 Planned Procedures among Planned Readmissions Following PCI Discharge In 2010 (without stent)
Number of
Planned
Procedures
Procedure
CCS
Procedure Description
45
Percutaneous transluminal coronary angioplasty (PTCA)
2161
48
Insertion; revision; replacement; removal of cardiac pacemaker or cardioverter/defibrillator
477
44
Coronary artery bypass graft (CABG)
300
49
62
59
51
157
52
43
Other OR heart procedures
Other diagnostic cardiovascular procedures
Other OR procedures on vessels of head and neck
Endarterectomy; vessel of head and neck
Amputation of lower extremity
Aortic resection; replacement or anastomosis
Heart valve procedures
126
120
102
98
55
55
48
25
Top 10 Planned Readmissions
(Without stent)
Top 10 Planned Procedures among Planned Readmissions Following PCI Discharge In 2010 (without stent)
Number of
Planned
Procedures
Procedure
CCS
Procedure Description
44
Coronary artery bypass graft (CABG)
221
45
Percutaneous transluminal coronary angioplasty (PTCA)
169
48
Insertion; revision; replacement; removal of cardiac pacemaker or cardioverter/defibrillator
73
49
51
99
59
62
84
43
Other OR heart procedures
Endarterectomy; vessel of head and neck
Other OR gastrointestinal therapeutic procedures
Other OR procedures on vessels of head and neck
Other diagnostic cardiovascular procedures
Cholecystectomy and common duct exploration
Heart valve procedures
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15
14
14
13
12
12
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Agenda
•
•
•
•
•
•
•
Introduction and Roles
Why Measure PCI Readmission?
Voluntary Public Reporting Overview
Measure Overview
Interpreting Your Results (next)
Hospital Compare Display
Conclusion and Questions
27
Categorizing Hospital Performance
•
•
•
•
No different than CathPCI Registry® rate
Worse than CathPCI Registry® rate
Better than CathPCI Registry® rate
Number of cases too small
28
Worksheet 1
PCI Readmission Results
CathPCI Registry® and Your Hospital’s Results on the 30-Day PCI Readmission Measure for the 2010-2011 Reporting Period
**DO NOT TRANSMIT THIS FILE**
This file contains personally identifiable information.
Note: This data is for demonstration only
Number of
Number of
Number of
Number of
Your
Your
Your
Unadjusted
Hospitals
Hospitals No
Hospitals
CathPCI
Your
CathPCI
Hospital's
Hospital's
Hospital's
CathPCI
Better than Different than Worse than
Registry®
Hospital's
Registry®
Eligible
Unadjusted RSRR (Lower Registry®
CathPCI
CathPCI
CathPCI
Hospitals
Comparative
Hospitals with
Patient Stays Readmission 95% CI, Upper Readmission
Registry®
Registry®
Registry®
Included in
Performance
too few cases
(#)
Rate
95% CI)
Rate
Readmission Readmission Readmission
Measure
(<25)
Rate
Rate
Rate
No different
than CathPCI
Registry® rate
50
12.0%
11.5% (10.5%,
12.0%)
11.9%
21
29
1031
24
120
1196
Worksheet 3
Patient Stay Information
Your Hospital's Detailed Patient Stay Information for Readmissions Following PCI for the 2010-2011 Reporting Period
**DO NOT TRANSMIT THIS FILE OR ANY OF THE CONTENTS OF THIS TABLE**
This file contains personally identifiable information. If you have questions about the information provided below please
refer to Excel row numbers.
Note: Simulated data for demonstration only
Principal
Discharge
Date of
Readmission
Diagnosis for Admission for
Type
Readmission
Readmission
(ICD-9-CM Code)
NCDR Patient
ID
Date of Index
Procedure
Date of
Discharge for
Index
Procedure
123456
07/31/11
08/04/11
Unplanned
410.3
123567
10/03/10
10/08/10
Unplanned
123678
07/17/11
07/18/11
Planned
Date of
Discharge for
Readmission
Readmitted
to your
Hospital
CCN of
Readmitting
Hospital
08/13/11
8/20/11
No
1235
410.2
10/30/10
11/3/10
Yes
N/A
410.1
07/31/11
08/01/11
No
1234
30
Worksheet 5
Case Mix Profile
Case Mix Profile for Your Hospital and All CathPCI Registry® Hospitals for the 2010-2011 Reporting Period
**DO NOT TRANSMIT THIS FILE**
This file contains personally identifiable information.
Note: Simulated data for demonstration only
Risk Factor
Age (mean)
Female
Body Mass Index (mean)
History of Heart Failure
Previous Valvular Surgery
Cerebrovascular Disease
Peripheral Vascular Disease
Chronic Lung Disease
Diabetes Status - No Diabetes
Diabetes Status - Non-Insulin Requiring
Diabetes
Diabetes Status - Insulin Requiring
Diabetes
GFR Not Measured
GFR < 30
30 ≤ GFR < 60
60 ≤ GFR < 90
GFR ≥ 90
Renal Failure - Dialysis
Hypertension
History of Tobacco Use
Previous PCI
Presented with Heart Failure
Your Hospital (%)
74.2
39.5
27.3
17.5
3.1
17.3
16.3
19.1
65.0
CathPCI Registry® (%)
75.1
40.0
27.0
16.6
2.2
17.8
16.8
18.9
64.0
25.0
22.9
10.0
13.1
5.0
5.0
30.0
45.0
15.0
3.1
85.0
14.2
39.8
14.2
5.7
5.0
32.8
44.7
11.7
2.7
86.9
13.6
40.7
13.3
(5 additional risk factors – table truncated to fit slide)
31
Agenda
•
•
•
•
•
•
•
Introduction and Roles
Why Measure PCI Readmission?
Voluntary Public Reporting Overview
Measure Overview
Interpreting Your Results
Hospital Compare Display (next)
Conclusion and Questions
32
About Hospital Compare
• Official Medicare website
• Displays results on hospital quality
measures
• CathPCI Registry® Hospitals can
voluntarily publicly report PCI readmission
results
– Must submit Data Release Consent Form (DCRF) by
May 3 For July posting
– Can submit DRCF by beginning of August for October
posting
33
Hospital Compare Display
The PCI
Readmission
Measure will
appear on the
Hospital Spotlight
The PCI
Readmission
Measure can also
be found using
typical search
function
34
Example:
Hospital Compare Data Table
Hospital 30-Day Risk-Standardized Readmission Rates (RSRR) Following Percutaneous Coronary Intervention (PCI)
Note: Simulated data for demonstration only
Footnotes:
1: The number of cases is too small to reliably tell how well a hospital is performing.
5: No data are available from the hospital for this measure.
21: Data aren’t available for the voluntary public reporting of this measure
CCN
State
Hospital Name
Participation in
Voluntary Public
Reporting
Performance Category
RSRR
Lower 95% CI,
Upper 95% CI
Footnote
123456
AL
General Hospital
Yes
No different than NCDR registry
11.2
8.5, 14.0
222222
CT
Community Hospital
Yes
Better than NCDR registry
7.1
5.0, 8.0
111111
CT
Memorial Hospital
Yes
No different than NCDR registry
11.0
8.9, 12.4
333333
TN
City Hospital
Yes
Worse than NCDR registry
14.0
13.0, 15.5
444444
CO
Government Hospital
Yes
Number of cases too small
Not applicable Not applicable
1
555555
CO
University Hospital
Yes
Number of cases too small
Not applicable Not applicable
1
456789
GA
Research Hospital
Yes
---
No cases
No cases
5
234567
AZ
Specialty Hospital
No
---
---
---
21
567891
ME
Rural Hospital
No
---
---
---
21
35
Agenda
•
•
•
•
•
•
•
Introduction and Roles
Why Measure PCI Readmission?
Voluntary Public Reporting Overview
Measure Overview
Interpreting Your Results
Hospital Compare Display
Conclusion and Questions (next)
36
Data Release Consent Form
• Click here for data release consent form
37
Dates to remember
• May 3
– Last opportunity to submit the Data Release Consent
Form for July Hospital Compare posting
• July 2013
– Results published on Hospital Compare
38
Resources
• Visit NCDR Website
• Email NCDR@acc.org
NOTE: Please do not email or attach to
emails any patient identifiable
information
39
Questions
• Type questions into chat window
– Questions will be archived if we are unable to address them in
the live webinar.
• Call in via audio line
– (866) 574-8547 ID#: 20463925
– Please mute your computer speakers before dialing in.
– Once your question has been answered you will be
disconnected. Any follow-up questions will require you to call in
again or use chat.
– Remember to reactivate your speakers after your call is
complete.
40
ADDITIONAL SLIDES
41
Calculating risk-standardized rates
Predicted outcome
RSRR =
Expected outcome
42
CathPCI Registry®
unadjusted rate
PCI Readmission Model
Description
OR (LOR, UOR)
Intercept
Age/10
Female
BMI/5
CHF - Previous History
Previous Valvular Surgery
Cerebrovascular disease
Peripheral Vascular Disease
Chronic Lung disease
Non-Insulin diabetes
Insulin diabetes
GFR: 0=Not measured
GFR: 1="0<=GFR<30"
GFR: 2="30<=GFR<60"
GFR: 4="GFR>=90"
Renal Failure - Dialysis
Hypertension
History of Tobacco Use
Previous PCI
CHF - Current Status
No MI on admission
MI after 24 hours on admission
EFP: 1=Not measured
EFP: 2="0<=EFP<30"
EFP: 3="30<=EFP<45"
PCI status: 2=Urgent
PCI status: 3=Emergency
PCI status: 4=Salvage
pRCA/mLAD/pCIRC
pLAD
Left Main
Highest Pre-Procedure TIMI Flow: None
1.26 (1.22, 1.29)
1.29 (1.25, 1.34)
0.88 (0.86, 0.90)
1.31 (1.25, 1.38)
1.21 (1.07, 1.37)
1.21 (1.15, 1.26)
1.22 (1.16, 1.28)
1.40 (1.34, 1.46)
1.12 (1.08, 1.18)
1.39 (1.31, 1.47)
1.04 (0.94, 1.15)
1.76 (1.61, 1.92)
1.17 (1.12, 1.22)
1.17 (1.09, 1.25)
1.48 (1.32, 1.67)
1.08 (1.03, 1.14)
0.95 (0.93, 0.98)
0.92 (0.89, 0.96)
1.34 (1.27, 1.41)
0.88 (0.83, 0.92)
1.11 (1.03, 1.19)
1.23 (1.18, 1.29)
1.45 (1.34, 1.57)
1.25 (1.18, 1.32)
1.39 (1.33, 1.45)
1.46 (1.36, 1.57)
1.71 (1.16, 2.52)
1.04 (1.00, 1.09)
1.13 (1.07, 1.19)
1.16 (1.04, 1.30)
1.09 (1.02, 1.16)
43
Worksheet 2:
CathPCI Registry® Distribution
Distribution of Hospital 30-Day PCI Risk-Standardized Readmission Rates among CathPCI Registry® Hospitals
for the 2010-2011 Reporting Period (n = 1,197)
**DO NOT TRANSMIT THIS FILE**
This file contains personally identifiable information.
Description
Risk-Standardized Readmission Rate (%)
100% (Maximum RSRR)
16.8
99%
15.6
95%
14.3
90%
13.6
75%
12.8
50% (Median RSRR)
11.8
25%
11.0
10%
10.2
5%
9.7
1%
8.9
0% (Minimum RSRR)
8.6
44
Worksheet 4:
Principal Discharge Diagnoses
Most Frequent Principal Discharge Diagnoses Associated with Unplanned Readmissions for all CathPCI
Registry® Hospitals and Your Hospital for the 2010-2011 Reporting Period
**DO NOT TRANSMIT THIS FILE**
This file contains personally identifiable information.
Note: Simulated data for demonstration only
Description of Principal
Discharge Diagnosis of
Readmission
Heart Failure
Respiratory or Chest
Symptoms
Ischemic Heart Disease
Acute Myocardial Infarction
Arrhythmia
Septicemia
Complication from
Procedure
Pneumonia
Gastrointestinal Hemorrhage
Acute Renal Failure
All Other Principal Discharge
Diagnoses
ICD-9-CM Code
(To Third Digit)
Your Hospital's Patient
Stays (#)
Your Hospital's Patient
Stays (%)
CathPCI Registry® Patient
Stays (%)
428
16
16.0
13.6
786
20
20.0
7.9
414
410
427
038
15
10
5
5
15.0
10.0
5.0
5.0
7.7
6.2
5.0
2.7
996
1
1.0
2.6
486
578
584
5
1
1
5.0
1.0
1.0
2.6
2.5
2.5
-
31
31.0
46.8
45
Worksheet 6:
Impact of Risk Factors
Patient Risk Factor Odds Ratios and 95% Confidence Intervals for PCI Readmission Measure for the 2010 2011 Reporting Period
**DO NOT TRANSMIT THIS FILE**
This file contains personally identifiable information.
Risk Factor
Odds Ratio
95% Confidence Interval
1.27
1.25
0.89
1.33
1.23
1.16
1.16
1.51
Reference
(1.25, 1.30)
(1.22, 1.29)
(0.87, 0.91)
(1.29, 1.38)
(1.14, 1.32)
(1.12, 1.19)
(1.13, 1.20)
(1.47, 1.56)
.
Diabetes Status - Non-Insulin Requiring Diabetes
1.14
(1.11, 1.18)
Diabetes Status - Insulin Requiring Diabetes
1.44
(1.39, 1.49)
1.01
1.78
1.20
Reference
1.06
1.45
1.14
1.07
0.94
1.33
(0.95, 1.07)
(1.68, 1.89)
(1.17, 1.23)
.
(1.01, 1.10)
(1.35, 1.56)
(1.09, 1.18)
(1.03, 1.11)
(0.91, 0.96)
(1.28, 1.38)
Age
Female
Body Mass Index
History of Heart Failure
Previous Valvular Surgery
Cerebrovascular Disease
Peripheral Vascular Disease
Chronic Lung Disease
Diabetes Status - No Diabetes
GFR Not Measured
GFR < 30
30 ≤ GFR < 60
60 ≤ GFR < 90
GFR ≥ 90
Renal Failure - Dialysis
Hypertension
History of Tobacco Use
Previous PCI
Presented with Heart Failure
5 Additional Risk Factors (table truncated to fit slide )
46