Aruna Priya

Variation in Diagnostic Coding of Patients With Pneumonia and Its Association With Hospital Risk-Standardized Mortality Rates: A Cross-sectional Analysis

Context Hospital risk-standardized mortality rates for pneumonia are publicly reported but exclude more severe cases of pneumonia, which are coded as sepsis or respiratory failure with pneumonia as a secondary diagnosis. Contribution A sample of U.S. hospitals varied widely in the proportion of all pneumonia cases coded as sepsis or respiratory failure with a secondary diagnosis of pneumonia, even after adjustment for indicators of disease severity. Caution Sampled hospitals may not be fully representative of all U.S. hospitals. Implication Variation among hospitals in risk-standardized rates of mortality from pneumonia may be related to variation in coding practices rather than the quality of care delivered. The Editors Pneumonia is the most common cause of emergency hospitalization in the United States (1). As such, it is an appropriate target for quality improvement initiatives and public reporting of hospital quality. Initial efforts at public reporting focused on processes of care, including the choice and timing of initial antibiotics, pneumococcal vaccination, and assessment of oxygenation within 24 hours of admission. However, these measures correlate only weakly with more important outcomes, such as 30-day mortality (2, 3). In 2008, the Centers for Medicare & Medicaid Services (CMS) added hospital-level risk-standardized mortality to its Hospital Compare Web site (4). These rates reflect adjustment for patient age, sex, and comorbid conditions, and mortality estimates from the administrative prediction model have been shown to correlate well with mortality as measured by reviews of clinical records (5). Beginning in 2012, under value-based purchasing, hospital reimbursement became partly tied to 30-day mortality rates (6). To estimate hospital 30-day risk-standardized mortality rates, CMS includes only patients with a principal diagnosis of pneumonia. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care (7). Patients who are assigned pneumonia as a secondary diagnosis are excluded because, in these cases, pneumonia may represent a complication of hospitalization rather than the reason for admission (5). However, many patients with pneumonia, especially the sicker ones, may also have sepsis or respiratory failure, the definitions of which are subject to interpretation. For example, CMS official coding guidelines recognize 2 or more of the following as indicative of the systemic inflammatory response syndrome: a temperature more than 101F or less than 96.8F, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or leukocyte count greater than 12109 cells/L or less than 4109 cells/L or with greater than 10% bands. Taken together with a source of infection, such as pneumonia, these signs fulfill the definition of sepsis (8). We have previously reported that the recent decrease in the mortality rate of patients hospitalized with pneumonia may be an artifact of the changing use of these codes, whereby the sickest patients have, over time, increasingly received a principal diagnosis of sepsis or respiratory failure. Thus, these patients are not considered in the measure of pneumonia mortality (9). Just as changes in coding over time could lead to erroneous conclusions about decreasing mortality rates, variation in coding across hospitals could lead to biased estimates of relative mortality rates. We hypothesized that hospitals would vary in their threshold for applying the sepsis and respiratory failure codes and that those that apply these principal diagnoses more frequently would seem to have a lower pneumonia mortality rate than similar hospitals that applied the codes less frequently. On its Hospital Compare Web site and for reimbursement purposes, CMS does not emphasize the mortality rates of individual hospitals but identifies each hospital as better, worse, or no different from the national average. We therefore examined changes in hospital outlier status that would result from inclusion or exclusion of patients with a secondary diagnosis of pneumonia but a principal diagnosis of sepsis or respiratory failure in a large and diverse group of U.S. hospitals. Methods Setting and Participants We included all hospitals that participated in Premiers Perspective database between 1 July 2007 and 30 June 2010. Perspective, an administrative database used to measure quality and resource utilization, has been used extensively for quality of care and comparative effectiveness research (10, 11). Participating hospitals represent all regions of the United States and include teaching and nonteaching hospitals of various sizes located in urban or rural settings. They are generally similar to U.S. hospitals as a whole, although the data set is weighted more heavily in the South, urban locations, and teaching hospitals. Available data elements for each patient include sociodemographic information; International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis and procedure codes; and date-stamped charges for all tests and treatments done during hospitalization. The institutional review board at Baystate Medical Center (Springfield, Massachusetts) determined that the study did not constitute human subjects research. We included all patients aged 18 years or older with a diagnosis of pneumonia (principal or secondary if paired with a principal diagnosis of sepsis or respiratory failure) (Appendix Table). We excluded patients with pneumonia marked as not present on admission. In addition, all patients had to have a chest radiograph and receive antibiotic therapy within 48 hours of admission. To ensure a stable mortality estimate, we excluded hospitals with fewer than 100 admissions during the study period. Appendix Table. ICD-9-CM Codes Used in the Definition of Pneumonia, Sepsis, and Respiratory Failure Outcomes Our primary outcome was the hospital risk-standardized mortality rate. For each admission, we identified patient age and sex. To be consistent with the approach used by CMS in calculating a hospitals risk-standardized mortality rate, we did not include race, marital status, or insurance type. CMS also adjusts for preexisting comorbid conditions by using the hierarchical condition categories. The CMS risk-adjustment model for hierarchical condition categories does not include comorbid conditions that may represent complications of care (5). This model requires information about outpatient diagnoses in the previous year, which is not available in Premiers Perspective database. Taking a similar approach, we identified comorbid conditions by using software provided by the Agency for Healthcare Research and Quality. This model, based on the work of Elixhauser and colleagues (12), uses International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify relevant comorbid conditions while excluding complications or other diagnoses related to the principal diagnosis. Both models have acceptable C statistics for predicting mortality, although the hierarchical condition categories model may have better discrimination (13). Statistical Analysis We examined associations of patient and hospital characteristics with principal diagnosis coding (pneumonia vs. sepsis or respiratory failure) by using generalized estimating equations models with a logit link (SAS PROC GENMOD), accounting for clustering of patients within hospitals. To see whether severity of illness varied as the proportion of sepsis or respiratory failure coding increased, we evaluated Spearman correlations of hospital proportion of patients with a diagnosis of sepsis or respiratory failure with mortality rates, as well as with rates of early initiation (hospital day 1 or 2) of mechanical ventilation or vasopressors and admission to the intensive care unit of patients with these principal diagnoses. To assess for nonlinear correlations, we stratified hospitals above and below the median proportion. Following the process that CMS uses to evaluate hospital outcomes (14, 15), we developed multivariable hierarchical generalized linear models by using SAS PROC GLIMMIX with a random effect for hospitals to predict each patients probability of mortality on the basis of age, sex, and comorbid conditions (Supplement). We fit 2 models, 1 limited to admissions with pneumonia coded as a principal diagnosis and 1 including all pneumonia admissions. From each model, each hospitals predicted mortality rate was computed as that which would be anticipated by using the hospitals random effect, given the patient case-mix. The expected mortality rate was computed as that which would be expected if the same patient mix was treated at an average hospital, using the average hospital effect. For each model, a hospital risk-standardized mortality rate was computed as the ratio of predicted to expected mortality standardized by the overall unadjusted mean mortality rate for all admissions in our model. Supplement. Risk-Standardized Mortality Modeling Next, we used bootstrap methods to develop a 95% CI estimate of risk-standardized mortality for each hospital, for admission with a principal diagnosis of pneumonia, and for all pneumonia admissions. Hospitals were rated as better than average if the interval was entirely below the overall patient mean mortality and worse than average if the interval was entirely above the mean. Hospitals with intervals overlapping the mean were rated as no different than average. Finally, to see the effect of sepsis or respiratory failure coding practices on reported performance, we identified hospitals whose ratings changed when cases of sepsis or respiratory failure were included and compared the change in outlier status across the quintiles of sepsis or respiratory failure coding. All analyses were done

Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community Acquired Pneumonia

BACKGROUND Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in

Using highly detailed administrative data to predict pneumonia mortality

-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Prevalence, treatment, and outcomes associated with OSA among patients hospitalized with pneumonia.

Background Mortality prediction models generally require clinical data or are derived from information coded at discharge, limiting adjustment for presenting severity of illness in observational studies using administrative data. Objectives To develop and validate a mortality prediction model using administrative data available in the first 2 hospital days. Research Design After dividing the dataset into derivation and validation sets, we created a hierarchical generalized linear mortality model that included patient demographics, comorbidities, medications, therapies, and diagnostic tests administered in the first 2 hospital days. We then applied the model to the validation set. Subjects Patients aged ≥18 years admitted with pneumonia between July 2007 and June 2010 to 347 hospitals in Premier, Inc.’s Perspective database. Measures In hospital mortality. Results The derivation cohort included 200,870 patients and the validation cohort had 50,037. Mortality was 7.2%. In the multivariable model, 3 demographic factors, 25 comorbidities, 41 medications, 7 diagnostic tests, and 9 treatments were associated with mortality. Factors that were most strongly associated with mortality included receipt of vasopressors, non-invasive ventilation, and bicarbonate. The model had a c-statistic of 0.85 in both cohorts. In the validation cohort, deciles of predicted risk ranged from 0.3% to 34.3% with observed risk over the same deciles from 0.1% to 33.7%. Conclusions A mortality model based on detailed administrative data available in the first 2 hospital days had good discrimination and calibration. The model compares favorably to clinically based prediction models and may be useful in observational studies when clinical data are not available.

Website Characteristics and Physician Reviews on Commercial Physician-Rating Websites

BACKGROUND OSA is associated with increased risks of respiratory complications following surgery. However, its relationship to the outcomes of hospitalized medical patients is unknown. METHODS We carried out a retrospective cohort study of patients with pneumonia at 347 US hospitals. We compared the characteristics, treatment, and risk of complications and mortality among patients with and without a diagnosis of OSA while adjusting for other patient and hospital factors. RESULTS Of the 250,907 patients studied, 15,569 (6.2%) had a diagnosis of OSA. Patients with OSA were younger (63 years vs 72 years), more likely to be men (53% vs 46%), more likely to be married (46% vs 38%), and had a higher prevalence of obesity (38% vs 6%), chronic pulmonary disease (68% vs 47%), and heart failure (28% vs 19%). Patients with OSA were more likely to receive invasive (18.1% vs 9.3%) and noninvasive (28.8% vs 6.8%) forms of ventilation upon hospital admission. After multivariable adjustment, OSA was associated with an increased risk of transfer to intensive care (OR, 1.54; 95% CI, 1.42-1.68) and intubation (OR, 1.68; 95% CI, 1.55-1.81) on or after the third hospital day, longer hospital stays (risk ratio [RR], 1.14; 95% CI, 1.13-1.15), and higher costs (RR, 1.22; 95% CI, 1.21-1.23) among survivors, but lower mortality (OR, 0.90; 95% CI, 0.84-0.98). CONCLUSION Among patients hospitalized for pneumonia, OSA is associated with higher initial rates of mechanical ventilation, increased risk of clinical deterioration, and higher resource use, yet a modestly lower risk of inpatient mortality.

Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia

Patients are increasingly seeking information about physicians online. Nearly 60% report that online reviews are important when choosing a physician.1 Because publicly reported quality data are not reported at the physician level, patients must consult physician-rating websites to find such reviews.2 The purpose of this cross-sectional study was to describe the structure of commercial physician-rating websites and the quantity of physician reviews on these sites.

Outcomes of Patients with Healthcare-Associated Pneumonia: Worse Disease or Sicker Patients?

OBJECTIVES Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. PATIENTS AND METHODS We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. RESULTS Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT. CONCLUSIONS Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.

Outcomes of Noninvasive and Invasive Ventilation in Patients Hospitalized with Asthma Exacerbation

BACKGROUND Healthcare-associated pneumonia (HCAP) is an entity distinct from community-acquired pneumonia (CAP). HCAP has a higher case-fatality rate, due either to HCAP organisms or to the health status of HCAP patients. The contribution of HCAP criteria to case-fatality rate is unknown. METHODS We conducted a retrospective review of adult patients admitted with a diagnosis of pneumonia from July 2007 through November 2011 to 491 US hospitals. HCAP was defined as having at least 1 of the following: prior hospitalization within 90 days, hemodialysis, admission from a skilled nursing facility, or immune suppression. We compared characteristics of patients with CAP and patients with HCAP and explored the contribution of HCAP criteria to case-fatality rate in a hierarchical generalized linear model. RESULTS Of 436,483 patients hospitalized with pneumonia, 149,963 (34.4%) had HCAP. Compared to CAP patients, HCAP patients were older, had more comorbidities, and were more likely to require intensive care unit (ICU) care. In-hospital case-fatality rate was higher among patients with HCAP, compared to those with CAP (11.1% vs 5.1%, P < .001). After adjustment for demographics, comorbidities, presence of other infections, early ICU admission, chronic and acute medications, early tests and therapies, and length of stay, HCAP remained associated with increased case-fatality rate (odds ratio [OR], 1.35 [95% confidence interval (CI), 1.32-1.39]); odds of death increased for each additional HCAP criterion (OR [95% CI]: 1 criterion, 1.27 [1.23-1.31], 2 criteria, 1.55 [1.49-1.62], and 3 or more criteria, 1.88 [1.72-2.06]). CONCLUSIONS After adjustment for differences in patient characteristics, HCAP was associated with greater case-fatality rate than CAP. This difference may be due to HCAP organisms or to HCAP criteria themselves.

Hospitals' Patterns of Use of Noninvasive Ventilation in Patients With Asthma Exacerbation.

RATIONALE Little is known about the effectiveness of noninvasive ventilation for patients hospitalized with asthma exacerbation. OBJECTIVES To assess clinical outcomes of noninvasive (NIV) and invasive mechanical ventilation (IMV) and examine predictors for NIV use in patients hospitalized with asthma. METHODS This was a retrospective cohort study at 97 U.S. hospitals using an electronic medical record database. We developed a hierarchical regression model to identify factors associated with the choice of initial ventilation and used the Laboratory Acute Physiological Score to adjust for differences in the severity of illness. We assessed the outcomes of patients treated with initial NIV or IMV in a propensity-matched cohort. MEASUREMENTS AND MAIN RESULTS Among 13,930 subjects, 73% were women and 54% were white. The median age was 53 years. Overall, 1,254 patients (9%) required ventilatory support (NIV or IMV). NIV was the initial ventilation method for 556 patients (4.0%) and IMV for 668 (5.0%). Twenty-six patients (4.7% of patients treated with NIV) had to be intubated (NIV failure). The in-hospital mortality was 0.2, 2.3, 14.5, and 15.4%, and the median length of stay was 2.9, 4.1, 6.7, and 10.9 days among those not ventilated, ventilated with NIV, ventilated with IMV, and with NIV failure, respectively. Older patients were more likely to receive NIV (odds ratio, 1.06 per 5 yr; 95% confidence interval [CI], 1.01-1.11), whereas those with higher acuity (Laboratory Acute Physiological Score per 5 units: odds ratio, 0.85; 95% CI, 0.82-0.88) and those with concomitant pneumonia were less likely to receive NIV. In a propensity-matched sample, NIV was associated with a lower inpatient risk of dying (risk ratio, 0.12; 95% CI, 0.03-0.51) and shorter lengths of stay (4.3 d less; 95% CI, 2.9-5.8) than IMV. CONCLUSIONS Among patients hospitalized with asthma exacerbation and requiring ventilatory support (NIV or IMV), more than 40% received NIV. Although patients successfully treated with NIV appear to have better outcomes than those treated with IMV, the low rate of NIV failure suggests that NIV was being used selectively in a lower risk group. The increased risk of mortality for patients who fail NIV highlights the need for careful monitoring to avoid possible delay in intubation.

Association Between the Order of Macrolide and Cephalosporin Treatment and Outcomes of Pneumonia

BACKGROUND Limited data are available on the use of noninvasive ventilation in patients with asthma exacerbations. The objective of this study was to characterize hospital patterns of noninvasive ventilation use in patients with asthma and to evaluate the association with the use of invasive mechanical ventilation and case fatality rate. METHODS This cross-sectional study used an electronic medical record dataset, which includes comprehensive pharmacy and laboratory results from 58 hospitals. Data on 13,558 patients admitted from 2009 to 2012 were analyzed. Initial noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) was defined as the first ventilation method during hospitalization. Hospital-level risk-standardized rates of NIV among all admissions with asthma were calculated by using a hierarchical regression model. Hospitals were grouped into quartiles of NIV to compare the outcomes. RESULTS Overall, 90.3% of patients with asthma were not ventilated, 4.0% were ventilated with NIV, and 5.7% were ventilated with IMV. Twenty-two (38%) hospitals did not use NIV for any included admissions. Hospital-level adjusted NIV rates varied considerably (range, 0.4-33.1; median, 5.2%). Hospitals in the highest quartile of NIV did not have lower IMV use (5.4% vs 5.7%), but they did have a small but significantly shorter length of stay. Higher NIV rates were not associated with lower risk-adjusted case fatality rates. CONCLUSIONS Large variation exists in hospital use of NIV for patients with an acute exacerbation of asthma. Higher hospital rates of NIV use does not seem to be associated with lower IMV rates. These results indicate a need to understand contextual and organizational factors contributing to this variability.