Administrative Data Based Tools for Pediatric and Neonatal ......Administrative Data Based Tools for Pediatric and Neonatal Health Services and Outcomes Research: Risk-Adjustment Corinna

Administrative Data Based Tools for Pediatric and Neonatal Health

Services and Outcomes Research:Risk-Adjustment

Corinna A. Haberland, MD, MSStanford University

Child Health Services Research MeetingJune 26, 2010

Introduction

• For any comparative use of AHRQ Quality Indicators (QIs), adjusting for underlying health status is crucial

• Paucity of methods available for pediatric measures

• Developed methods for both Pediatric QIs (PDIs) and Neonatal QIs (NQIs)

Pediatric QIs – Risk Adjustment -Development

• For the hospital level AHRQ PDIs – developed a method to adjust for four factors

• Reason for Admission – using DRGs

• Age and Gender

• Comorbidities – developed de novo

• Indicator specific categories

Pediatric QIs – Risk Adjustment -Development

• Comorbidity adjustment - Clinical Classification Software (CCS)1 & 2001-2003 State Inpatient Data2

– Clinical Review – CCS categories selected out

– Empirical Analysis – Statistics Generated – Present on admission (POA)

– Relative risks

– Bias estimators

– Clinical list and Empirical list compared - matching CCS categories were placed on an initial risk-adjustment list

– List reviewed clinically again – appropriate CCS groupings added

1 Clinical Classifications Software (CCS) for ICD-9-CM, http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp2 2001-2003 State Inpatient Data, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

Pediatric QIs – Risk Adjustment -Current Application

• Adjustment regression model includes:



– Reason for admission – DRGs




– Age & Gender




– Age & Gender

– Comorbidities


• Comorbidity Adjustment - Using Present on Admission (POA) data:

• Determines whether the record has POA data

• Identifies covariates

• Calculate predicted value for covariate– When POA data are available – able to use actual comorbidity

values

– When POA not available – covariate values generated using comorbidity values and a POA propensity score




– Age & Gender

– Comorbidities

– Indicator specific risk categories

Pediatric QIs – Risk Adjustment –Results

Non-Children’s Hospitals – Overall Rates0

.00

04

76

0.00

1162

0.00

0100

0.0

41

18

0

0.00

1586

0.0

08

93

5

0.0

15

26

9

0.00

1037

0.0

01

15

0

0.00

0536

0.00

1021

0.00

0101

0.0

41

91

1

0.00

1707

0.01

0285

0.01

5062

0.00

1057

0.0

01

12

1

0.000000

0.005000

0.010000

0.015000

0.020000

0.025000

0.030000

0.035000

0.040000

0.045000A

cc P

un

c &

Lac

Pre

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p R

esp

Fai

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Po

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p S

ep

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Po

st-o

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Cat

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ela

Blo

od

Infe

c

Observed

Risk Adjusted


Children’s Hospitals – Overall Rates

0.00

1102

0.00

1549

0.00

0146

0.04

1615

0.00

1842

0.01

4956

0.01

4011

0.00

1317

0.00

3861

0.0

00

54

0

0.00

1213

0.0

00

13

6

0.04

1009

0.0

01

77

2

0.0

11

88

2

0.0

12

71

4

0.00

1369

0.00

1917

0.000000

0.005000

0.010000

0.015000

0.020000

0.025000

0.030000

0.035000

0.040000

0.045000

Acc

Pu

nc

& L

ac

Pre

ss U

lce

r

Iatr

o P

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um

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Pe

d H

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urg

Mo

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Observed

Risk Adjusted


Non-Children’s vs. Children’s Hospitals – Ratios0

.43

2

0.75

0.6

85

0.99

0.86

1

0.5

97

1.09

0.7

88

0.2

98

0.99

4

0.8

42

0.74

5

1.02

2

0.9

63

0.86

6

1.18

5

0.7

72

0.5

85

0.000

0.200

0.400

0.600

0.800

1.000

1.200

1.400

Acc

Pu

nc

& L

ac

Pre

ss U

lce

r

Iatr

o P

ne

um

o

Pe

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urg

Mo

rt

Po

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Po

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p R

esp

Fai

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Po

st-o

p S

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Po

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nd

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Cat

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Infe

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Observed

Risk Adjusted


Children’s Hospitals – Rates by Hospital Volume

Accidental Puncture & Laceration

0.00

0248

2

0.00

0278

9

0.00

0371

2

0.0

00

62

18

0.00

1055

5

0.0

00

53

06

0.0

00

48

03

0.00

0548

6

0.0

00

51

52

0.00

0583

8

0

0.0002

0.0004

0.0006

0.0008

0.001

0.0012

Q1 Q2 Q3 Q4 Q5

Observed

Risk Adjusted



Heart Surgery Mortality0

.04

0.08

0.0

35

01

26

0.0

43

41

68

0.0

40

78

52

0.20

3991

8

0.0

43

31

05

0.0

46

57

34

0.04

4536

0.0

40

10

13

0

0.05

0.1

0.15

0.2

0.25

Q1 Q2 Q3 Q4 Q5

Observed

Risk Adjusted



Catheter Related Bloodstream Infections

0.0

00

28

89

0.0

00

38

27

0.00

0795

2

0.0

01

83

57

0.00

3375

7

0.00

0274

3

0.0

00

59

71 0.

0011

437 0

.00

17

03

5

0.00

1959

7

0

0.0005

0.001

0.0015

0.002

0.0025

0.003

0.0035

0.004

Q1 Q2 Q3 Q4 Q5

Observed

Risk Adjusted

Neonatal QIs – Risk Adjustment -Development

• Preliminary RA model included:

– Birthweight

– Gender

– Multiple Gestation

– Congenital Anomalies

• Groupings derived by Phibbs, et al.1

• By organ system

• Based on mortality rates

1 Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in

very-low-birth-weight infants. New England Journal of Medicine. 2007;356(21):2165-2175 & Supplement.

Neonatal QIs – Risk Adjustment -Current Application

• Current RA model includes:

– Gender

– Outborn / Inborn status

– Birthweight

– Gestational Age

– Congenital Anomalies Groupings

Neonatal QIs – Risk Adjustment -Results

0.00

0797 0.

0018

72

0.0

03

60

8

0.00

5920

0.00

6442

0.00

0915

0.00

3076

0.0

05

14

2

0.00

7081

0.0

08

70

0

0.00

1785

0.0

02

22

6

0.00

2742

0.00

2892

0.00

3171

0.0

01

85

3

0.00

2815

0.0

02

98

1

0.0

03

31

8

0.00

3102

0.000000

0.001000

0.002000

0.003000

0.004000

0.005000

0.006000

0.007000

0.008000

0.009000

0.010000

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

LBW VLBW

Observed

Risk Adjusted

Neonatal Mortality

Neonatal QIs – Risk Adjustment -Results

0.0

03

87

8

0.01

2051

0.0

14

68

2 0.0

18

32

7 0.0

22

15

0

0.0

06

18

9

0.01

4530

0.0

14

96

9

0.02

0306

0.0

25

18

9

0.00

7429

0.01

5681

0.0

16

84

0

0.01

9363 0.

0226

23

0.0

09

53

7

0.01

7542

0.01

6270

0.0

21

22

4 0.02

5604

0.000000

0.005000

0.010000

0.015000

0.020000

0.025000

0.030000

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

LBW VLBW

Observed

Risk Adjusted

Neonatal Blood Stream Infections

Conclusions

• Risk adjustment methods for both QI sets:

– Account for important clinical variations in patients

– Attenuate differences in children’s & non-children’s hospital, and between volume quintile rates

– Will better allow for comparisons of quality outcomes

Additional Slides

Statistic Description Strict Threshold Loose Threshold

SID rate and RRObserved rate and relative risk for CCS category in

2000-2003 SID.

NY and CA SID rate and RRObserved rate and relative risk for CCS category in

2000-2003 New York and California data only.

Rate and RR given

complication

Observed rate and relative risk, using NY and CA

data, including only patients whose CCS triggering

code was NOT POA

Rate and RR given

comorbidity RR (POA)

Observed rate and relative risk, using NY and CA

data, including only patients whose CCS triggering

code was POA

RR > 2 RR > 2

% CCSPercent of indicator denominator represented by

the CCS.% CCS > 1 % % CCS > 1%

% POA Percent of the CCS that is present on admission. % POA > 85% % POA > 85%

Estimator Bias (EB)Measure of bias due to unknown POA status.

Ranges from 0 (no bias) to 1 (high bias).EB ≤ 0.2 EB ≤ 0.3

Comparison Bias (CB)Measure of bias using corrected RR and frequency

of CCS / POACB ≤ 0.015 CB ≤ 0.03

*Each statistic was calculated for each CCS that appeared as a codiagnosis for each indicator.

Diagnostic Risk Group ICD-9 Diagnosis Codes N (1998-2000) and

(% of all coded risks)

Gastrointestinal

Abdominal wall defect 756.70, 756.79 986 (0.054)

Tracheoesophageal fistula 750.3, 750.4 365 (0.020)

Small bowel or upper GI

anomalies

(1) Anomalies NOS

including pyloric

stenosis

(2)

(3) Volvulus or Intestinal

Fixation Problem

750.5, 750.7, 750.8, 750.9,

751.1, 751.5, 751.8, 751.9

751.5

560.2, 751.4

745 (0.040)

903 (0.049)

224 (0.012)

Meckel’s Syndrome 751.0 67 (0.004)

Large Bowel

(1) Atresia, etc.

(2) Hirschprung’s

(3) Meconium obstruction

751.2

751.3

771.1

647 (0.035)

214 (0.012)

1479 (0.080)

Liver, bile duct, pancreas –

(1) Biliary Atresia or

Pancreatic Anomaly

(2) Bile, liver, pancreas

751,61, 751.7

751.60, 751.69

100(0.005)

246 (0.013)

Genitourinary

Renal

(1) Agenesis

(2) Polycystic

(3) Other cystic

(4) Other anomalies

753.0

753.12, 753.14, 753.15

753.10, 753.19

753.3, 753.4

434 (0.024)

294 (0.016)

244 (0.013)

430 (0.023)

Obstructions

(1) High Obstruction

(2) Low Obstruction

(3) Prune Belly, etc.

753.21, 753.22, 753.23

753.6, 753.7, 753.8, 753.9,

753.20

756.71

2154 (0.117)

450 (0.024)

28 (0.002)

CNS

Spina bifida, etc.

(1) Spina bifida

(2) Encephalocele

741.00, 741.01, 741.02,

741.03, 741.90, 741.91,

741.92, 741.93, 742.59

742.0

441 (0.024)

86 (0.005)

Brain

(1)

(2)

(3)

742.1, 742.4

742.2, 742.3

742.8, 742.9

1080 (0.059)

757 (0.041)

252 (0.014)

Pulmonary

CDH 519.4, 553.3, 748.9, 750.6,

756.6

588 (0.032)

Airway 748.3, 748.9 933 (0.051)

Cyst, etc.

(1)

(2)

748.4, 748.60

748.69, 748.8

435 (0.024)

126 (0.007)

Cardiovascular

Aortic valve 746.3, 746.4, 424.1 216 (0.012)

Aortic arch

(1)

(2)

747.10, 747.21, 747.29

747.11, 747.22, 746.81

436 (0.024)

135 (0.007)

HLHS 746.7 321 (0.017)

Endocardial fibroelastosis 425.3 149 (0.008)

Mitral valve

(1) Stenosis

(2) Other mitral

746.5

424.0, 746.6, 746.84

42 (0.002)

436 (0.024)

Transpositions 745.10, 745.19, 745.12 360 (0.020)

Coronary/Myocard 746.85, 425.1 105 (0.006)

Common RV, etc. 745.3, 745.11, 745.0 450 (0.024)

Pulmonary valve – tricuspid

(1)

(2)

746.01, 746.83, 746.2

746.09, 745.2, 746.1

325 (0.018)

693 (0.038)

Cushion, etc. 745.60, 745.61, 745.69 346 (0.019)

Pulmonary veins, etc. 746.82, 747.41, 747.42 177 (0.010)

Great vein 747.40, 747.49 94 (0.005)

Skeletal 756.50, 756.51, 756.55,

756.59

115 (0.006)

Chromosomal Syndromes

(1)

(2)

(3) Conjoined twins

758.3, 758.5, 758.89, 758.9,

759.89, 759.9

759.7

759.4

1484 (0.081)

107 (0.006)

15 (0.001)

Other

(1) Non-immune hydrops

(2) Hamartoses

(3) Congenital anemia

778.0

759.6

776.5

385 (0.021)

34 (0.002)

1846 (0.100)

From: Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH.

Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.

New England Journal of Medicine. 2007;356(21):2165-2175 & Supplement.

Current NQI RA Congenital Anomalies Groupings

Diagnostic Risk Group

1. Gastrointestinal

756.70

756.79

Anomaly of abdominal wall, unspecified

Other congenital anomalies of abdominal wall

750.3

750.4

Tracheoesophageal fistula, esophageal atresia and stenosis

Other specified anomalies of esophagus

750.5

750.7

750.8

750.9

751.1

751.5

751.8

751.9

751.5

560.2

751.4

Congenital hypertrophic pyloric stenosis

Other specified anomalies of stomach

Other specified anomalies of upper alimentary tract

Unspecified anomaly of upper alimentary tract

Atresia and stenosis of small intestine

Other anomalies of intestine

Other specified anomalies of digestive system

Unspecified anomaly of digestive system

Other anomalies of intestine

Volvulus

Anomalies of intestinal fixation

751.0 Meckel's diverticulum

751.2

751.3

771.1

Atresia and stenosis of large intestine, rectum, and anal canal

Hirschsprung's disease and other congenital functional disorders of colon

Congenital cytomegalovirus infection

751.61

751.7

751.60

751.69

Biliary atresia

Anomalies of pancreas

Unspecified anomaly of gallbladder, bile ducts, and liver

Other anomalies of gallbladder, bile ducts, and liver

2. Genitourinary

753.0

753.12

753.14

753.15

753.10

753.19

753.3

Renal agenesis and dysgenesis

Polycystic kidney, unspecified type

Polycystic kidney, autosomal recessive

Renal dysplasia

Cystic kidney disease, unspecified

Other specified cystic kidney disease

Other specified anomalies of kidney


3. CNS

741.00

741.01

741.02

741.03

741.90

741.91

741.92

741.93

742.59

742.0

With hydrocephalusm, unspecified region

With hydrocephalusm, cervical region

With hydrocephalusm, dorsal (thoracic) region

With hydrocephalusm, lumbar region

Without mention of hydrocephalus, unspecified region

Without mention of hydrocephalus, cervical region

Without mention of hydrocephalus, dorsal (thoracic) region

Without mention of hydrocephalus, lumbar region

Other specified anomalies of spinal cord, Other

Encephalocele

742.1

742.4

742.2

742.3

742.8

742.9

Microcephalus

Other specified anomalies of brain

Reduction deformities of brain

Congenital hydrocephalus

Other specified anomalies of nervous system

Unspecified anomaly of brain, spinal cord, and nervous system

4. Pulmonary

519.4

553.3

748.9

750.6

756.6

Disorders of diaphragm

Diaphragmatic hernia

Unspecified anomaly of respiratory system

Congenital hiatus hernia

Anomalies of diaphragm

748.3

748.9

Other anomalies of larynx, trachea, and bronchus

Unspecified anomaly of respiratory system

748.4

748.60

748.69

748.8

Congenital cystic lung

Other anomalies of lung, anomaly of lung, unspecified

Other anomalies of lung, other

Other specified anomalies of respiratory system


5. Cardiovascular

746.3

746.4

424.1

Congenital stenosis of aortic valve

Congenital insufficiency of aortic valve

Aortic valve disorders

747.10

747.21

747.29

747.11

747.22

746.81

Coarctation of aorta (preductal) (postductal)

Other anomalies of aorta, anomalies of aortic arch

Other anomalies of aorta, other

Interruption of aortic arch

Other anomalies of aorta, atresia and stenosis of aorta

Subaortic stenosis

746.7 Hypoplastic left heart syndrome

425.3 Endocardial fibroelastosis

746.5

424.0

746.6

746.84

Congenital mitral stenosis

Mitral valve disorders

Congenital mitral insufficiency

Obstructive anomalies of heart, NEC

745.10

745.19

745.12

Complete transposition of great vessels

Transposition of great vessels, other

Corrected transposition of great vessels

746.85

425.1

Coronary artery anomaly

Hypertrophic obstructive cardiomyopathy

745.3

745.11

745.0

Common ventricle

Double outlet right ventricle

Common truncus

746.01

746.83

746.2

746.09

745.2

746.1

Atresia, congenital

Infundibular pulmonic stenosis

Ebstein's anomaly

Anomalies of pulmonary valve, other

Tetralogy of Fallot

Tricuspid atresia and stenosis, congenital

745.60

745.61

745.69

Endocardial cushion defect, unspecified type

Ostium primum defect

Endocardial cushion defects, other


6. Skeletal

756.50

756.51

756.55

756.59

Osteodystrophy, unspecified

Osteogenesis imperfecta

Chondroectodermal dysplasia

Osteodystrophies, other

7. Chromosomal Syndromes

758.3

758.5

758.89

758.9

759.89

759.9

759.7

759.4

Autosomal deletion syndromes

Other conditions due to autosomal anomalies

Other conditions due to chromosome anomalies, other

Conditions due to anomaly of unspecified chromosome

Other specified anomalies, other

Congenital anomaly, unspecified

Multiple congenital anomalies, so described

Conjoined twins

8. Other

778.0

759.6

776.5

Hydrops fetalis not due to isoimmunization

Other hamartoses, NEC

Congenital anemia



Pressure Ulcer

0.0

02

21

6

0.00

0292

0.00

0245

0.0

01

67

5

0.0

02

28

0

0.0

00

05

2

0.0

00

05

1

0.00

1886

0.000000

0.000500

0.001000

0.001500

0.002000

0.002500

Q1 Q2 Q3 Q4

Observed

Risk Adjusted



Post-Op Hemorrhage & Hematoma

Documents

Administrative Data Based Tools for Pediatric and Neonatal ......Administrative Data Based Tools for Pediatric and Neonatal Health Services and Outcomes Research: Risk-Adjustment Corinna