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Hospital Performance Measurement and
Quality Improvement Initiatives
Insights from the US Surgical Care Improvement
Project
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
Oklahoma Foundation for Medical Quality
Outline
• Factors driving policy related to quality
measurementt and
d paymentt incentives
i
ti
• Infrastructure for measurement and
reporting
g
Care Improvement
p
Project
j
• The Surgical
• Unintended consequences of performance
measurement
1
Cost and Quality Problems
• Well documented deficiencies in the
quality of care
– Substantial underuse of recommended care
regardless of income, race, or age
• Substantial regional variation in the use of
healthcare services without evidence of
additional
dditi
l benefit
b
fit tto patients
ti t iin hi
high
h
utilization regions
• Costs
Cost and Quality Problems
• $2.2 trillion on healthcare this year alone
• $600 billion for Medicare and Medicaid
– By 2030, at present rate of growth will consume 50%
of Federal budget
• Disconnect between payments and performance
– Paid the same regardless of quality
– Often paid more for care that results in avoidable
complications
Volume-based Payment
2
Figure 1. International Comparison of Spending on Health,
1980–2005
Average spending on health
per capita ($US PPP)
7000
6000
United States
Germany
Canada
France
Australia
United Kingdom
Total expenditures on health
as percent of GDP
16
14
5000
12
4000
10
8
3000
6
2000
4
1000
2
0
United States
Germany
Canada
France
Australia
United Kingdom
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
0
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of
U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007
OECD data
Problem #2 = Variation
Dartmouth Atlas of Healthcare
6
3
Front page – New York Times, August 18, 2006.
Elyria has three times the rate of
angioplasties of Cleveland, 30 miles away!
4
#3 – Quality of Care
http://www.ahrq.gov/qual/nhqr07/nhqr07.pdf
“Health care quality is improving only modestly, at best,” said AHRQ Director
Carolyn M. Clancy, M.D. “Given that health care spending is rising much
faster, these findings about quality underscore the urgency to improve the
value Americans are getting for their health care dollars.”
5
Problems with healthcare quality and safety
are commonly exposed in lay press…
6
Policy to Accelerate Improvement
7
What is the best policy to accelerate
improvement?
• Voluntary reporting of nationally
standardized measures of hospital quality
• Strategies for accelerating quality
improvement:
– Pay-for-reporting (P4R)
– Pay-for-performance (P4P)
Despite limited evidence demonstrating benefit,
P4R and P4P are being widely advocated
Congressional Action
• 2003 Medicare Modernization Act (MMA)
– Established Pay-for-Reporting
y
p
g ((P4R)) p
program
g
for
Section (d) hospitals under Medicare
• Report on 10 clinical measures or receive 0.4% reduction
in Annual Payment Update (APU) on inpatient services
• 2005 Deficit Reduction Act (DRA)
– Expanded required performance measures
– 2.0% reduction in APU on inpatient services for nonnon
reporting
– Secretary to develop Value-based Purchasing (i.e.
P4P) for Medicare hospital services
8
Does public reporting accelerate
quality improvement?
Hospital Public Reporting – Role of
Payment Incentives for Reporting
0.4% payment incentive to
report 10 measures listed in
the Medicare Modernization
Act of 2003
4043
4192
1952
1407
434
August, 2003
February, 2004
May, 2004
October, 2004
March, 2005
Number of Reporting Hospitals
9
N Engl J Med 2005;353:255-64.
Williams S et al. N Engl J Med 2005;353:255-264
N Engl J Med 2005;353:255-64.
10
Lindenauer PK et al. N Engl J Med 2007;356:486-496.
Improvement in Composite Process Measures among Hospitals Engaged in Both Pay for
Performance and Public Reporting and Those Engaged Only in Public Reporting
Lindenauer PK et al. N Engl J Med 2007;356:486-496.
11
Infrastructure for Measurement
and Improvement
12
www.hospitalcompare.hhs.gov
The Consensus Development Process
The National Quality Forum
www.qualityforum.org
26
13
National Technology and Transfer
Advancement of Act of 1995 (NTTAA)
• Defines the five key attributes of a “voluntary
consensus standards-setting
standards setting body
body” (i.e.,
(i e
openness, balance of interest, due process,
consensus, and an appeals process)
• Obligates Federal government to adopt
voluntary consensus standards (when the
government is adopting standards)
All “core” hospital performance measures
are submitted for endorsement by the
National Quality Forum and are not used for
public reporting until endorsed.
27
Genesis of the Hospital “Core”
Measures
• For all p
performance measurement
initiatives, development based on:
– Disease impact (morbidity, mortality, patient
QoL, costs of care)
– Guidelines that provide evidence-base to
support measures
– Gaps in performance
14
Data Reporting Infrastructure
• Performance measure specifications based on
guidelines and vetted with recognized experts
– Specific inclusions and exclusions, analytic
algorithms, etc (Measure Information Forms)
• Detailed data element specifications created and
used to program electronic data collection tools
– Used byy hospitals
p
for self-abstraction of medical
records
– Hospital abstraction subject to random validation
audits
Details of measures and data elements available at: www.qualitynet.org
under the Hospital – Inpatient tab (Specifications Manual)
Current Core Topics
• Acute myocardial infarction
– Leading cause of death in the US
• Heart failure
– Most common reason Medicare patients are hospitalized
• Pneumonia
– Second most common reason that Medicare patients are
hospitalized
• Surgical Care Improvement Project
– More than 30 million operations with wide variation in outcomes
15
Reporting Samples – Q1, 2007
Reporting
Hospitals
Cases reported
Acute Myocardial Infarction
3,415
103,334
Heart Failure
4,211
230,088
Pneumonia
4,359
221,921
Surgical Care
3,565
283,630
Core topic
*all numbers close approximates.
The Surgical Infection Prevention
and Surgical Care Improvement Projects
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Why focus on surgical quality
Impact
• 30 million major
j operations
p
in US annually
y
• Patients who experience a postoperative
complication have dramatically increased
hospital length of stay, hospital costs, and
mortality
– Odds of dying within 60 days increases 3.4fold in patients with a complication*
*Silber JH, et al. Changes in prognosis after the first
postoperative complication. Med Care. 2005;43:122-131.
Who Pays for Surgical Complications?
Hospital
Reimbursement
$
Costs of care
$
Profit
$
Profit margin
%
14266
(uncomplicated)
10978
3288
23.0
21911
(complicated)
21156
755
3.4
Complications
p
were always
y associated with an
increase in costs to healthcare payors:
complications were associated with an average
increase in payment of $7,645 (54%) per patient.
Dimick JB, et al. Who pays for poor surgical quality? Building a business
case for quality improvement. J Am Coll Surg. 2006;202:933-7.
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Surgical Care Improvement Project
(SCIP)
• Preventable Complication Modules
– Surgical infection prevention
– Cardiovascular complication prevention
– Venous thromboembolism prevention
Odds of Death after First Postoperative
Complication Within 60 days
100
92
Odds Ratio
80
60
40
21
20
19
7.3
7.2
5.1
5
4.3
4.2
2.2
0
M
o
aj
a
rc
ia
rd
c
r
St
e
ok
T
DV
G
e
le
Ib
s
Re
ra
pi
d
ry
to
co
m
om
pr
e
is
CH
F
Pn
m
eu
i
on
a
p
Se
e
De
s
si
p
w
nd
ou
i
e
nf
n
io
ct
i
Ur
ry
na
tra
ct
ct
fe
in
n
io
Silber JH, et al. Changes in prognosis after the first
postoperative complication. Med Care. 2005;43:122-131.
18
Guidelines Available
Guidelines Available
19
Guidelines Available
Prevention of
Venous
Th
Thromboembolism
b
b li
Seventh ACCP
Consensus
Conference on
Antithrombotic
Therapy
W. Geerts, chair
G. Pineo
J. Heit
D. Bergqvist
M. Lassen
C. Colwell
J. Ray
Chest 2004;126:338S-400S
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CLASS I
1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina,
symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (Level of Evidence: C)
2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the
finding of ischemia on preoperative testing. (Level of Evidence: B)
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Gaps in Performance
Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
Gaps in Performance
Discontinuation of Antibiotics
100
100
90.7
88
85.8
79.5
80
73 3
73.3
60
60
50.7
40.7
40
40
26.2
22.6
14.5
20
Cumulative Percent
Percent
80
20
10
6.2
93
9.3
6.3
2.7
2.2
0
96
>
496
>8
284
>7
072
>6
860
>4
648
>3
436
>2
224
>1
12
or
l
es
s
0
Hours After Surgery End Time
Patients were excluded from the denominator of this performance measure if there was
any documentation of an infection during surgery or in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
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SCIP Steering Committee
•
•
•
•
•
American College of Surgeons
American Hospital Association
American Society of
Anesthesiologists
Association of peri-Operative
Registered Nurses
Agency for Healthcare Research
and Quality
•
•
•
•
•
Centers for Medicare & Medicaid
Services
Centers for Disease Control and
Prevention
Department of Veteran’s Affairs
Institute for Healthcare
Improvement
Joint Commission on
Accreditation of Healthcare
Organizations
Collaborating organizations essential to initial
hospital and physician recruitment!
Technical Expert Panels for all Modules
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Reporting Hospitals (Voluntary)
Surgical Care Improvement Project
4000
“Proposed” CMS rule suggested that
hospitals needed to start reporting antibiotic
measures in January to avoid losing 2% of
their Medicare annual payment update. Final
rule did not require reporting until July 2006.
3500
# Hospitals
3000
3670 3668 3720 3680
3247 3240
2500
2000
1492
1500
1623
1718
1297
1000
808
500
237
265
271
337
470
894
450
42
30
0
02
20
3
Q
02
20
4
Q
03
20
1
Q
03
20
2
Q
03
20
3
Q
03
20
4
Q
04
20
1
Q
04
20
2
Q
04
20
3
Q
04
20
4
Q
05
20
1
Q
05
20
2
Q
05
20
3
Q
05
20
4
Q
06
20
1
Q
06
20
2
Q
06
20
3
Q
06
20
4
Q
07
20
1
Q
07
20
2
Q
Changes in National Performance
Abx 60 min
100
Guideline Abx
Abx discontinued
93 7
93.7
92.6
90
87.6
Percent
80
82.9
70
60
55.7
50
40
40.7
30
//
2001*
Q1
2005
Q2
2005
Q3
2005
Q4
2005
Q1
2006
Q2
2006
Q3
2006
Q4
2006
Q1
2007
Q2
2007
*National sample of 39,000 Medicare patients undergoing surgery in US hospitals during 2001.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
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Changes in National Performance
Recommended VTE prophylaxis
VTE prophylaxis received
100
Percent
90
82.4
84.1
84.8
79.6
80.5
Q1 2007
Q2 2007
80
77.8
71.9
70
69.7
//
60
Q1, 2005*
Q2 2006
Q3 2006
Q4 2006
*National sample of 19,497 Medicare patients undergoing surgery in US hospitals during the first quarter of 2005.
Surgical Care Improvement Project
Hospital Voluntary Self-Reporting, Qtr. 2, 2007
National Average*
99.5
98.6
100
Benchmark
87 6
87.6
82.9
100
98.8
97.4
93.7
99.3
93.7
85
81.2
Percent
80
60
40
20
0
Antibiotics w/in
1 hour
Correct
Antibiotic
Antibiotic DCed Glucose Control
w/in 24 hours
(cardiac)
No Razor
Normothermia
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of
CareTM methodology (http://main.uab.edu/show.asp?durki=14527). Based on approximately 266,202 cases submitted to the clinical data
warehouse.
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Surgical Care Improvement Project
Hospital Voluntary Self-Reporting, Qtr. 2, 2007
National Average*
Benchmark
99.7
100
98.6
85.7
97.2
84.8
80.5
Percent
80
60
40
20
0
Perioperative Beta-blockers
Recommended VTE Prophylaxis
Timely VTE Prophylaxis
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of
CareTM methodology (http://main.uab.edu/show.asp?durki=14527). Based on approximately 266,202 cases submitted to the clinical data
warehouse.
Surgical Care Improvement Project
Hospital Voluntary Self-Reporting, Qtr. 2, 2007
Low performers
99.5
98.6
100
Benchmark
100
98.8
97.4
99.3
77.8
80
Percent
66.1
60
55.5
55.6
51.3
38.9
40
20
0
Antibiotics w/in
1 hour
Correct
Antibiotic
Antibiotic DCed Glucose Control
w/in 24 hours
(cardiac)
No Razor
Normothermia
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of
CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
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Surgical Care Improvement Project
Hospital Voluntary Self-Reporting, Qtr. 2, 2007
Low performers
Benchmark
99.7
100
98.6
97.2
Percent
80
60
51.7
54.6
48.6
40
20
0
Perioperative Beta-blockers
Recommended VTE Prophylaxis
Timely VTE Prophylaxis
Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of
CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
Do Process Measures Matter?
“Hospital
performance
measures predict
small differences in
hospital risk-adjusted
mortality rates.”
26
Outcomes Measures
0
5
Hospital density
10
15
20
25
Risk-stratified Mortality - Pneumonia
0.1
0.15
0.20
30-day risk-standardized mortality rate
0.25
Risk-standardized mortality rates for the 4,684 hospitals are based on the administrative claims using data
for 449,296 Medicare patients discharged during calendar year 2000 (Bratzler DW, et al. in review).
Are There “Unintended Consequences”
• The incentives used to stimulate and
accelerate
l t quality
lit iimprovementt may resultlt
in inappropriate care and even patient
harm because of efforts to achieve high
performance rates
– Direct harm
– Indirect harm
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Unintended Consequences?
Antibiotics within 4 hours of hospital arrival
Do emergency
physicians
change the way
they address
patient care solely
for the purposes
of getting the
hospital a high
score on a
measure?
Levofloxacin 750 mg
Attention: if you have cough,
fever, or shortness of breath, OR
if you think you have pneumonia,
take one and have a seat.
More patients in 2005 had a hospital admission diagnosis of
CAP without radiographic abnormalities compared to 2003
(2005, [28.5%]; 2003, [20.6%]; p 0.04), and more patients
received antibiotics within 4 h of triage (2005, [65.8%]; 2003,
[53.8%]; p 0.007).
28
Arch Intern Med. 2008;168:351-356.
Reduction in the required time to first antibiotic dose from 8 to
4 hours seems to reduce the accuracy by which ED physicians
diagnose pneumonia….
In a rural hospital 15 cases of severe CDAD developed – 12 of the
patients were being treated with antibiotics for pneumonia (started
and not stopped). Independent chart review revealed that 6 of the 12
patients did not have clinical findings consistent with pneumonia.
5 patients died!
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Unintended Consequences
Indirect Harm
• Caregivers shift attention to those conditions that
are subject to payment incentives
– e.g., triage pneumonia patients in preference to
abdominal pain patients
– Focusing on glucose control in a diabetic patient while
ignoring their hyperlipidemia
– Reallocating resources to excel on measures with
payment
p
y
incentives
– Risk avoidance – turn away high risk patients (has
been a concern of reporting measures of hospital
mortality)
“teaching to the test”
How do we avoid unintended
consequences?
• While “perfect” care is desirable even in
the best systems,
systems errors occur
– “perfect” care assumes “perfect” measures
• The measure specifications for many
measures address the most common
reasons for exclusion,
exclusion but rarely address
every possible clinical scenario
While the target rate of performance for most
measures may be very high, it is not (and should
not be) 100%!
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Surgical Care Improvement
Project: Why the effort?
We could p
prevent up
p to:
13,027 perioperative deaths
271,055 surgical complications
….in the Medicare population alone
* Major surgical cases
Patient Outcomes Can Improve
The overall surgical infection rate fell 27%, from 2.28% (215
infections among 9435 surgical cases) in the first 3 months to
1.65% (158 infections among 9584 cases) between the first and the
last 3 reporting months.
Dellinger EP, et al. Am J Surg.2005;190:9–15.
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Ongoing Improvement
• Nearly 4,000 hospitals reporting data
• National
N ti
l SCIP lilistt serve with
ith more th
than
2,500 active participants
– One of the most active list serves with very
active participation of many nurses,
physicians, and performance improvement
managers
– Barrier of competition between providers not
evident – free sharing of tools and
improvement ideas
Quality Improvement and
Performance Measurement:
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
Oklahoma Foundation for Medical Quality
Presentation at the 2007 American
College of Chest Physicians
meeting, Chicago, IL.
32
Measuring Hospital Quality
• The Good: guideline adherence has improved
– Better outcomes are documented
• The Bad: Use of performance measurement for
accountability (particularly P4P) is largely
unstudied
– Calls for caution in assuming incentives lead to better
care or outcomes
• The Ugly: Are there unintended consequences?
– The target is high….. But, in the absence of
“perfect” measures, is not 100%
dbratzler@okqio.sdps.org
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