AHRQ PSIs and IQIs in National Pay for Reporting

1. AHRQ PSIs and IQIs in National Pay for Reporting September 14, 2009 AHRQ QI Conference Shaheen Halim, Ph.D. Centers for Medicare & Medicaid Services

2. 2 CMS’ Office of Clinical Standards and Quality Lead on quality and clinical issues and policies for the Agency’s programs. Coordinates with external organizations and Agencies. Promote and monitor quality and quality improvement for the Agency’s programs. Evaluates the success of interventions Develop, evaluate, adopt and support performance measurement systems (quality indicators) to evaluate care provided to CMS beneficiaries

3. 3 OCSQ’s Quality Measurement and Health Assessment Group Lead for measure development and public reporting of quality measures: Hospital Inpatient and Outpatient Physician Nursing Home Home Health ESRD Websites available on http://www.Medicare.gov

4. 4 Hospital Pay for Reporting Programs Reporting Hospital Quality for Annual Payment Update (RHQDAPU) MMA 2003: .4% APU to report 10 measure starter set DRA 2005: 2% APU to report expanded measure set … 44 measures for the 2010 payment determination Hospital Outpatient Quality Data Reporting Program (HOP QDRP) TRHCA 2006: 2% 2009 APU for 7 measures, 11 measures for 2010 APU, including 4 claims-based measures on Imaging Efficiency

5. RHQDAPU Over the Years 2004: 10 process measures (AMI, HF, PN, SCIP) 2006: 21 process measures (11 added) 2007: 30-day mortality measures, HCAHPS 2008: 30-day readmission, AHRQ measures, structural measure 2009: 2 structural measures Currently 46 measures in RHQDAPU Program 27 process, 15 claims-based outcome measures, 3 structural, HCAHPS Desire to expand outcomes measurement in RHQDAPU 5

6. AHRQ PSIs and IQIsin RHQDAPU 9 AHRQ Indicators were adopted into CMS’ Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) in FY 2009 IPPS Rule Allows expansion of RHQDAPU program topics to include Patient Safety, Complications, and In-hospital mortality 6

7. Patient Safety Indicators AHRQ Patient Safety Indicators adopted: PSI 4: Death among surgical patients with serious, treatable complications PSI 6: Iatrogenic Pneumothorax PSI 14: Postoperative Wound Dehiscence PSI 15: Accidental Puncture or Laceration PSI Composite: Complications/Patient Safety for Selected Indicators 7

8. Complication/patient safety for selected indicators PSI #03 Decubitus Ulcer PSI #06 Iatrogenic Pneumothorax PSI #07 Infection Due To Medical Care PSI #08 Postop Hip Fracture PSI #09 Postop Hemorrhage or Hematoma PSI #10 PostopPhysioMetabolDerangmt PSI #11 Postop Respiratory Failure PSI #12 Postop PE Or DVT PSI #13 Postop Sepsis PSI #14 Postop Wound Dehiscence PSI #15 Accidental Puncture/Laceration 8

9. Inpatient Quality Indicators AHRQ Inpatient Quality Indicators adopted: IQI 11: Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate IQI 19: Hip Fracture Mortality Rate IQI Composite: Mortality for Selected Procedures IQI Composite: Mortality for Selected Conditions 9

10. Mortality for Selected Procedures IQI #08 In-Hosp Mort Esophageal Resection IQI #09 In-Hosp Mort Pancreatic Resection IQI #11 In-Hosp Mort AAA Repair IQI #12 In-Hosp Mort CABG IQI #13 In-Hosp Mort Craniotomy IQI #14 In-Hosp Mort Hip Replacement IQI #30 In-Hosp Mort PTCA IQI #31 In-Hosp Mort Carotid Endarterectomy 10

11. Mortality for Selected Conditions IQI #15 In-Hosp Mort AMI IQI #16 In-Hosp Mort CHF IQI #17 In-Hosp Mort Stroke IQI #18 In-Hosp Mort GI Hemorrhage IQI #19 In-Hosp Mort Hip Fracture IQI #20 In-Hosp Mort Pneumonia 11

12. CMS 2009 Dry Run CMS conducts “Dry run” for claims-based measures to provide methodology information about the measures prior to formal implementation. Provide hospitals with an opportunity to provide CMS with feedback to inform implementation. Opportunity to answer questions regarding measure methodology and calculations. 12

13. CMS 2009 Dry Run Hospital-Specific Reports were generated and released to hospitals via their QualityNet accounts on February 27, 2009. Hospital Specific Performance National, State, and Regional summary statistics Mock-report and Summary Statistics made available for download on QualityNet. Began 30-day question and comment period to end April 2, 2009. Webinars to provide further information and to answer frequently asked questions about the dry run. 13

14. CMS 2009 Dry Run 2006 Inpatient Medicare claims (100% file) Data obtained from Dartmouth Medical School 10 diagnostic and 6 procedural codes were reported No age restriction AHRQ PSI and IQI software v3.2 Excludes claims missing Age or Sex from all analyses Excludes claims missing other variables (e.g. Admission Source, Admission Type, Disposition Status, DRG, LOS, etc.) from the denominators of specific measures 3M™ APR™-DRG V3.2 Limited License Grouper software AHRQ PSI and IQI software use this for risk adjustment APR-DRG software downloaded from the AHRQ website 14

15. CMS 2009 Dry Run Modifications to our claims data were required because the AHRQ software was designed for use with HCUP, not Medicare claims data The levels for some categorical variables required reassignment (e.g. Admission Source, Race, etc.) For example, Hispanic = 5 in our data, AHRQ software specifies that Hispanic = 3 MDC (Major Diagnostic Category) was assigned using the CMS DRG version 23 and 24 Relative Weights files 15

16. CMS 2009 Dry Run AHRQ PSI and IQI software Defines the inclusion and exclusion criteria for each indicator Generates the numerator, denominator, observed, expected, risk-adjusted and smoothed rates for each indicator Indicators were reported as rates per 1000 Rate = 200 (per 1000) Rate calculated by multiplying x 1000 = 200 (per 1000) 16

17. CMS 2009 Dry Run Population reference: national rates based upon the HCUP State Inpatient Database (SID) Includes 90 million discharges in 2002, 2003, and 2004 from the 38 states participating in the HCUP SID Equal weight option applied for the Composite Scores In this case, each component indicator is assigned an identical weight based on the number of indicators. That is, the weight equals 1 divided by the number of indicators in the composite For example, 1/8 = 0.1250 17

18. CMS 2009 Dry Run Hospital Specific Reports provided Observed, Expected, Risk Adjusted and Smoothed Rates Provided definitions for each of the 4 rates and guidance on how to interpret and use them. State, National and Regional (HHS Region) summary statistics provided for comparison 18

19. 2010 Implementation Initial display onhttp://www.cms.hhs.gov tentatively scheduled for January 2010. Will be calculated using Medicare claims spanning July 1, 2007 to June 30, 2008 for the FY 2010 payment determination Hospital preview reports tentatively scheduled for November/December 2009 Reporting on Hospital Compare tentatively scheduled for June 2010 using calculations spanning July 1, 2008 to June 30, 2009. 19

20. Future Implementation Include Observed Numerator and Denominator in hospital previews Include Confidence Intervals for rates Consumer testing to inform future display and language for the AHRQ PSIs and IQIs on Hospital Compare Possible display of composites similar to current bucket approach for 30-day mortality and 30-day readmission. 20

21. 21 Example Display