Creating the Hybrid Database and Overview of Cardiac Care Hybrid Database 06MAR2008.pdf · Creating the Hybrid Database and Overview of Cardiac Care. Michael Pine, M.D., M.B.A. Michael

1lineVirginia Health Information 2008

Creating the Hybrid Database and Overview of Cardiac Care

Michael Pine, M.D., M.B.A.Michael Pine and Associates, Inc

Ramesh K. Shukla, PhDVirginia Commonwealth University


Overview

Background

Empirical evidence

Pilot implementation


Data for Monitoring Clinical Performance

Administrative Data – from Centers for Medicare and Medical Services (CMS) to Agency for Healthcare Research and Quality (AHRQ), VHI and HealthGrades.com

Clinical Data – from APACHE, PHC4 and Health Quality Choice to Specialty Society Registries (e.g., STS, ACC)


Administrative Data v Clinical Data

Data serves as the basis for public reporting, pay-for-performance, and quality improvement initiatives

Must balance the need for data to enhance current risk-adjusted measurement of clinical performance and the cost of data collection


Relative Ease of Data Collection

Standard Administrative

Numerical Laboratory

Vital Signs

Other Clinical DataManual

Automated

Dat

a C

olle

ctio

n

Administrative Data

Clinical Data


Enhancing administrative Data

Present-on-Admission Coding – from Mayo, SPARCS, and OSHPD to the UB-04 and CMS

Numerical Laboratory Data – from MPA to AHRQ

New Hybrid Databases – AHRQ Pilot Projects


Hybrid Database



Vital Signs

Other Clinical Data

Present-on-AdmissionAdministrative Data

Clinical Data

Hybrid Data


Efficient Use of Clinical Data

Hemoglobin FEV1

Albumin Mental Status

Cost to CollectHighLow

Analytic Power

Low

High


Benefits of Enhanced Administrative Data

Better distinguishes between comorbidities and complications

Adds objective findings to more subjective diagnostic designations

Provides finer definition of progression of disease and underlying pathophysiology than does diagnostic codes


Lab Value and Gradation of Risk

CHF

MI

Sepsis

Distribution of Albumin Levels and Mortality Rates17.0

10.4

6.8

4.33.1

2.62.1

1.8 1.5 1.2 1.2 1.42.42.7

3.0

3.33.4 3.6 3.7 3.9

4.0 4.34.5

10.0

0

2

4

6

8

10

12

14

16

18

5 10 20 30 40 50 60 70 80 90 95 100

Percentile Cutoff

Mor

talit

y %

0

2

4

6

8

10

12

Lab

Valu

e C

utof

f

Mortality Rate Albumin in gm/dl


Percentile Cutoff

Mor

talit

y % 16.8

19.5

18.1

12.5

9.8

8.27.8 7.9 8.5

10.7

13.9

20.6

19.0

26.129.2

33.1

35.137.1 39.1

42.145.1

50.1

61.5

75.5

0

5

10

15

20

25

1 5 10 20 30 40 50 60 70 80 90 950

10

20

30

40

50

60

70

80

Lab

Valu

e C

utof

f

Mortality Rate pCO2 Arterial mmHg

Distribution of pCO2 Levels and Mortality Rates

Complex Relation of Lab Value and Risk


AHRQ Inpatient Quality Indicators (Mortality)

Medical Conditions – Acute Myocardial Infarction; Cerebrovascular Accident; Congestive Heart Failure; Gastrointestinal Hemorrhage; Pneumonia

Surgical Procedures – Abdominal Aortic Aneurysm Repair; Coronary Artery Bypass Graft Surgery; Craniotomy


AHRQ Patient Safety Indicators (Complications)

Elective Surgical Procedures

Complications – Physiologic / Metabolic Abnormalities; Pulmonary Embolus / Deep Vein Thrombosis; Sepsis; Respiratory Failure


Data Used in Administrative Models

Age and Sex

Principal Diagnosis

Secondary diagnoses only infrequently acquired during hospitalization

Selected surgical procedures


Data Used in HYBRID Models

All data used in administrative models

Additional secondary diagnoses when clinical data establish that they were present on admission

Numerical laboratory data (e.g., creatinine, white blood cell count) generally available in electronic form


Data Used in CLINICAL Models

All data used in HYBRID models

Vital signs and laboratory data not in HYBRID models (e.g., blood culture results)

Key clinical findings abstracted from medical records (e.g., immunocompromised)

Composite clinical scores (e.g., ASA Class)


Types of Data in CLINICAL IQI Models



Vital Signs andOther Clinical Data

Present-on-Admission15.6 data elements

11.1 data elements

Hybrid Data

9.0 data elements


Types of Data in CLINICAL PSI Models

Standard administrative


Vital Signs andOther Clinical Data

Present-on-Admission21.8 data elements

6.5 data elements

Hybrid Data

6.8 data elements


Bias Due to Suboptimal Risk-Adjustment

+ 2 Std Dev

Good Average Poor

- 2 Std Dev

Measured Performance

+ 0.5 Std Dev

Problematic Problematic

- 0.5 Std Dev

Bias

OK


Bias Due to Suboptimal Data (IQIs)

0%

10%

20%

30%

40%

50%

60%

70%

0.5 1.0 1.5 2.0Upper Threshold for Bias in Standard Deviations

Perc

ent E

xcee

ding

Upp

erTh

resh

old

RAW CLAIMS HYBRID


Recommended Chemistry Data• Aspartate Aminotransferase • Creatine Kinase MB• Albumin • Creatinine• Alkaline Phosphatase • Glucose• Amylase • Lactic Acid • Bicarbonate • Potassium• Bilirubin (Total) • Pro-B Natriuretic Protein• B Natriuretic Peptide • Sodium• Calcium • Troponin I• C-Reactive Protein • Troponin T• Creatine Kinase • Urea Nitrogen


Other Recommended Lab DataBlood Gas Hematology

• Arterial O2 Saturation • Hemoglobin• Arterial pCO2 • International Normalized Ratio• Arterial pH • Neutrophil Bands• Arterial pO2 • Partial Thromboplastin Time• Base Excess • Platelet Count• Bicarbonate • Prothrombin Time• FIO2 (if electronic) • White Blood Count


Enhancing VHI Public Reports of Hospital Performance –

Productivity, Efficiency and Quality Indicators

Ramesh K. Shukla, PhDProfessor and Director

Williamson InstituteDepartment of Health AdministrationVirginia Commonwealth University


Existing Cardiac Care Volume, Mortality and Readmissions

• Open process of development and extensive testing

• Developed by VHI, Ramesh Shukla, Ph.D and extensive provider input

• Severity adjusted to level the playing field

• Based on patient level data• First published in 2002


Enhancing VHI Cardiac Care Information

• Incorporate Lab and POA data into Cardiac Care dataset

• Develop and test model- does new data better explain variation?

• Share results with participating hospitals


Present ModelPLD Data

Analyses APR‐DRGEstimating Expected Mortality

Estimating Actual

Mortality Rates

Mortality Ratio


New & Enhanced ModelPLD

POA

APR-DRG Classification

Estimating Expected Mortality

Estimating Actual

Mortality Rates

MortalityRatio


Model Research Base VHI/WIApproach

APR-DRG Base Model 3M Approach – tested for validity by the Williamson Institute

Cardiology Reports –Medical Cardiology, Invasive Cardiology and Open Heart after Validation by the WI

POA Model –APR-DRG with POA

Pine, et al using Diagnoses codes and POA – not tested with APR-DRG (C=.78)

POA Model will be tested by VHI/WI using APR-DRG and POA Diagnostic Codes

Lab Model –APR-DRG with POA & Lab

Same as above(C=.84)

Lab Model will be tested by VHI/WI using APR-DRG, POA Diagnostic Codes and Lab data

Clinical Model –APR-DRG with POA, Lab And Vital Signs

Same as above(C= .88)

Clinical Model will be tested by VHI/WI using APR-DRG, POA, Lab Data and Vital Signs

Documents

Creating the Hybrid Database and Overview of Cardiac Care Hybrid Database 06MAR2008.pdf · Creating the Hybrid Database and Overview of Cardiac Care. Michael Pine, M.D., M.B.A. Michael