Susan M. Nedza

Quality in Clinical Practice

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.

Risk-Adjusted Hospital Outcomes in Medicare Total Joint Replacement Surgical Procedures

Background: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison. Methods: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied. Logistic risk models were designed for adverse outcomes of inpatient mortality, prolonged length-of-stay outliers in the index hospitalization, 90-day post-discharge deaths without readmission, and 90-day readmissions after excluding non-related readmissions. For each hospital, models were used to predict total adverse outcomes, the number of standard deviations from the mean (z-scores) for hospital performance, and risk-adjusted adverse outcomes for each hospital. Results: A total of 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement were studied. The observed overall adverse outcome rates were 12.0% for total hip replacement and 11.6% for total knee replacement. The z-scores for 1,483 hospitals performing total hip replacements varied from −5.09 better than predicted to +5.62 poorer than predicted; 98 hospitals were ≥2 standard deviations better than predicted and 142 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.6% for the best-decile hospitals and 19.8% for the poorest-decile hospitals. The z-scores for the 2,349 hospitals performing total knee replacements varied from −5.85 better than predicted to +11.75 poorer than predicted; 223 hospitals were ≥2 standard deviations better than predicted and 319 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.4% for the best-decile hospitals and 19.3% for the poorest-decile hospitals. Conclusions: Risk-adjusted outcomes demonstrate wide variability and illustrate the need for improvement among poorer-performing hospitals for bundled payments of joint replacement surgical procedures. Clinical Relevance: Adverse outcomes are known to occur in the experience of all clinicians and hospitals. The risk-adjusted benchmarking of hospital performance permits the identification of adverse events that are potentially preventable.

Hospital Outcomes in Inpatient Laparoscopic Cholecystectomy in Medicare Patients

OBJECTIVE To compare the risk-adjusted outcomes of hospitals in inpatient Medicare laparoscopic cholecystectomy. BACKGROUND Reduced length-of-stay for inpatient surgical care requires the inclusion of objective postdischarge outcomes to provide a comprehensive assessment of hospital and surgeon performance for quality improvement. METHODS The 2010 to 2012 Medicare Limited Data Set was used to develop risk-adjusted prediction models of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths, and 90-day readmissions for inpatient laparoscopic cholecystectomy. To define the opportunity for improved performance, prediction models were used to compute z scores and risk-adjusted adverse outcome rates for all hospitals in the database that had 20 or more evaluable cases for the study period. RESULTS A total of 83,274 patients from 1570 hospitals had an overall adverse outcome rate of 20.7%; 48 hospitals had outcomes that were 2 z scores better than predicted and 76 had 2 z scores poorer than predicted. Risk-adjusted adverse outcomes were 10.0 % in the best performing decile of hospitals and were 32.1% in the poorest performing decile. Gastrointestinal, infectious, and cardiopulmonary complications of care were the most common causes of readmissions with 46.3% occurring between days 30 and 90 after discharge. CONCLUSIONS Comparative analysis of overall risk-adjusted inpatient and 90-day postdischarge adverse outcomes identifies considerable opportunity for improved care in this high-risk population of patients.Objective: To compare the risk-adjusted outcomes of hospitals in inpatient Medicare laparoscopic cholecystectomy. Background: Reduced length-of-stay for inpatient surgical care requires the inclusion of objective postdischarge outcomes to provide a comprehensive assessment of hospital and surgeon performance for quality improvement. Methods: The 2010 to 2012 Medicare Limited Data Set was used to develop risk-adjusted prediction models of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths, and 90-day readmissions for inpatient laparoscopic cholecystectomy. To define the opportunity for improved performance, prediction models were used to compute z scores and risk-adjusted adverse outcome rates for all hospitals in the database that had 20 or more evaluable cases for the study period. Results: A total of 83,274 patients from 1570 hospitals had an overall adverse outcome rate of 20.7%; 48 hospitals had outcomes that were 2 z scores better than predicted and 76 had 2 z scores poorer than predicted. Risk-adjusted adverse outcomes were 10.0 % in the best performing decile of hospitals and were 32.1% in the poorest performing decile. Gastrointestinal, infectious, and cardiopulmonary complications of care were the most common causes of readmissions with 46.3% occurring between days 30 and 90 after discharge. Conclusions: Comparative analysis of overall risk-adjusted inpatient and 90-day postdischarge adverse outcomes identifies considerable opportunity for improved care in this high-risk population of patients.

Benchmarking hospital outcomes for improvement of care in Medicare elective colon surgery

BACKGROUND Risk-adjusted outcomes are essential for hospitals to benchmark care improvement. METHODS We used the Medicare Limited Data Set for 2010 to 2012 to create risk models in elective colon surgery for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day relevant readmissions. Risk models permitted the prediction of AOs for each hospital and the design of hospital-specific standard deviations (SDs) to define performance from observed values. Risk-adjusted AO rates were computed for hospital comparisons. RESULTS In all, 1,903 hospitals with 129,861 patients were studied. Overall AO rate was 27.8%; 84 hospitals had AO performance that was 2 SDs poorer than average and 66 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 15.8%, whereas the lowest performing hospitals rate was 39.4%. CONCLUSIONS Benchmarking risk-adjusted AOs identifies the opportunity for care improvement in elective colon surgery in Medicare patients.

Risk-adjusted outcomes in Medicare inpatient nephrectomy patients

AbstractWithout risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions. From the 4 prediction models, total predicted adverse outcomes were determined for each hospital in the dataset that met a minimum of 25 evaluable cases for the study period. Standard deviations (SDs) for each hospital were used to identify specific z-scores. Risk-adjusted adverse outcomes rates were computed to permit benchmarking each hospitals performance against the national standard. Differences between best and suboptimal performing hospitals defined the potential margin of preventable adverse outcomes for this operation.A total of 449 hospitals with 23,477 patients were evaluated. Overall AO rate was 20.8%; 17 hospitals had risk-adjusted AO rates that were 2 SDs poorer than predicted and 8 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 10.2% while the lowest performing decile had 32.1%. With a minimum of 25 cases for each study hospital, no statistically valid improvement in outcomes was seen with increased case volume.Inpatient and 90-day postdischarge risk-adjusted adverse outcomes demonstrated marked variability among study hospitals and illustrate the opportunities for care improvement. This analytic design is applicable for comparing provider performance across a wide array of different inpatient episodes.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery

BACKGROUND CONTEXT Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs. PURPOSE To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery. STUDY DESIGN/SETTING To identify the significant risk factors associated with AOs and to develop risk models that measure performance. PATIENT SAMPLE Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset. OUTCOME MEASURES The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models. METHODS Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals. RESULTS There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%. CONCLUSIONS Differences among hospitals defines opportunities for care improvement.

Risk-adjusted hospital outcomes in elective carotid artery surgery in patients with Medicare

Background. The risk‐adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90‐day postdischarge adverse outcomes have not been studied. Methods. We studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012–2014. Risk‐adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3‐sigma prolonged duration‐of‐stay outliers, 90‐day postdischarge deaths without readmission, and 90‐day postdischarge associated readmissions. Standard deviations of predicted overall adverse outcomes were computed for each hospital. Hospital‐specific z scores and risk‐adjusted adverse outcomes were calculated. Results. There were 77,086 carotid endarterectomy patients from 960 hospitals complicated by 191 inpatient deaths (0.25%), 4,436 prolonged duration of stay (5.8%), 457 90‐day postdischarge deaths (0.6%), and 7,956 90‐day postdischarge associated readmissions (10.3%). In the 90‐day postdischarge associated readmission patients, an additional 561 patients died after readmission, for total deaths of 1,209 (1.6%) for the study period, and 11,928 (15.5%) patients had one or more adverse outcomes. There were 29 best‐performing hospitals (3.0%) with z scores of −2.0 or less (P < .05) with a median rate of risk‐adjusted adverse outcomes of 7.1%. A total of 61 suboptimal performers (6.3%) had z scores of +2.0 or greater (P < .05) with a median rate of risk‐adjusted adverse outcome rate of 26.4%. Conclusion. Hospital risk‐adjusted adverse outcome rates for carotid endarterectomy are highly variable. Comparisons of hospital performance define the opportunity for improvement.

Medicare risk-adjusted outcomes in elective major vascular surgery

Background: Risk‐adjusted outcomes of elective major vascular surgery that is inclusive of inpatient and 90‐day post‐discharge adverse outcomes together have not been well studied. Methods: We studied 2012–2014 Medicare inpatients who received open aortic procedures, open peripheral vascular procedures, endovascular aortic procedures, and percutaneous angioplasty procedures of the lower extremity for risk‐adjusted adverse outcomes of inpatient deaths, 3‐sigma prolonged length‐of‐stay outliers, 90‐day post‐discharge deaths without readmission, and 90‐day post‐discharge associated readmissions after excluding unrelated events. Observed and predicted total adverse outcomes for hospitals meeting minimum risk‐volume criteria were assessed and hospital‐specific z‐scores and risk‐adjusted adverse outcomes were calculated to compare performance. Results: The total adverse‐outcome rate was 27.8% for open aortic procedures, 31.5% for open peripheral vascular procedures, 19.6% for endovascular aortic procedures, and 36.4% for percutaneous angioplasty procedures. The difference in risk‐adjusted adverse‐outcome rates between the best‐ and the poorest‐performing deciles were 32.2% for open aortic procedures, 29.5% for open peripheral vascular procedures, 21.5% for endovascular aortic procedures, and 37.1% for percutaneous angioplasty procedures. The 90‐day post‐discharge deaths and readmissions were the major driver of overall adverse‐outcome rates. Conclusion: The variability in risk‐adjusted outcomes among best‐ and poorest‐performing hospitals is over 20% in all major vascular procedures and indicates that a large opportunity exists for improvement in results.

Inpatient and Postdischarge Outcomes Following Elective Craniotomy for Mass Lesions

BACKGROUND Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs). OBJECTIVE To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care. METHODS The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr. Predictive logistic models were designed for inpatient mortality, inpatient prolonged length of stay, 90-d postdischarge deaths without readmission, and 90-d readmissions after exclusions. The total observed patients with one or more AOs were then compared to predicted AO values, and z-scores were computed for each hospital that met minimum volume requirements. Risk-adjusted AO rates allowed stratification of eligible hospitals into deciles of performance. RESULTS The hospital evaluation was performed for 223 facilities with 7624 patients that met criteria. A total of 849 patients (11.1%) died inclusive of 90 d postdischarge; 635 (8.3%) were 3σ length-of-stay outliers; and 1928 patients (25.3%) with one or more 90-d readmissions; 2716 patients experienced one or more AOs (35.6%). Six hospitals were 2 z-scores better than average, and 8 were 2 z-scores poorer. The median risk-adjusted AO rate was 18% for the first decile and 53.4% for the 10th decile. CONCLUSION There was a 35% difference between best and suboptimal performing hospitals for this operation. Hospitals must know their risk-adjusted AO rates and benchmark their results to inform processes of care redesign.

Defining Potentially Preventable Adverse Outcomes in Medicare Elective Lung Resections.

OBJECTIVE The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery. METHODS The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events. The probability of adverse events for each hospital was used to compute the hospital-specific standard deviation (SD) tailored to patient risk profiles. Observed versus predicted adverse events divided by the hospital-specific SD identified the z score for each hospital. Risk-adjusted OA rates were then computed for comparing hospital performance. RESULTS A total of 39,405 lung resection patients from 739 hospitals had 768 inpatient deaths (1.9%), 3147 had prolonged LOS (8.0%), 514 had 90-day postdischarge deaths without readmission (1.3 %), and 7701 had one or more 90-day readmissions (19.5%); 10,924 patients (27.7%) had one or more of these OAs. Twenty-six hospitals were two SDs better than predicted and 34 hospitals were two SDs poorer than predicted. When evaluated by deciles of risk-adjusted OAs, the top performing decile of hospitals had rates of 14.3% and the poorest performing decile had OA rates of 41.0%. CONCLUSIONS The differences in risk-adjusted comparative outcomes between top- and suboptimal-performing hospitals in lung resections define the potential opportunities for care improvement. Identification of risk factors associated with OAs and causes for readmissions provides direction for specific areas of care redesign for improvement.