A Method for Identifying Potentially Preventable Complications PPCs in Hospitalized Patients

1
A Method for Identifying Potentially Preventable
Complications (PPCs) in Hospitalized Patients

• Presented by
• 3M Health Information Systems
• May, 2008

2
Overview

• PPC methodology
• Data used to produce reports
• Data quality
• Description of reports
• Objective Provide an understanding of PPC
  methodology

3
A Method to Identify Potentially Preventable
Complications (PPCs) Purpose

• To create a method for identifying in-hospital
  complications using computerized discharge
  abstract data
• To assess the risk of developing in-hospital
  complications according to
• Reason for admission
• Severity of Illness
• Examine observed vs. expected complication rates
  at the hospital level

4
Why Develop a Method to Identify Potentially
Preventable Complications?

• Interest in comparing healthcare provider
  performance to enhance quality of care
• Previous emphasis on length of stay, cost and
  mortality
• Address only limited aspects of quality of care
• Death in hospital is a relatively rare event
• In-hospital complication rates will provide
  additional information on quality of care

5
A New Approach

• Current attempts, including public reports, to
  compare complications rates across hospitals
  using administrative data have had limited scope
  and/or uncertain validity
• Inability to determine if a potential
  complication occurred after admission
• Limited to obvious complication codes (e.g.
  foreign body left) or elective surgery
• Inadequate methods to adjust for patient risk and
  severity of illness

6
The Present on Admission Indicator Allows Better
Evaluation of Potential Complications

• FL, NY, CA and MA now require that each diagnosis
  code contain an additional indicator of whether
  it was present at the time of admission
• Permits more accurate determination of possible
  complications (from diagnoses that arose after
  admission)
• Permits more accurate assessment of severity of
  illness at admission (using only diagnoses
  present on admission)

7
Assumptions Underlying the Comparison of Rates of
PPCs

• Patients who have had a problem with the quality
  of in-hospital care will be more likely to incur
  a PPC
• A patients risk of a PPC is related to
• The reason for admission underlying medical
  conditions
• The severity of illness at the time of admission

8
Method

• Identify Potentially Preventable Complications
  (PPCs) from the secondary diagnoses not present
  at admission
• Determine whether the PPC was potentially
  preventable given the patients reason for
  admission underlying medical conditions
• Determine a patients expected risk of PPCs based
  on the reason for admission and severity of
  illness at admission

9
Preview Rates per 1,000 Patients for the
Pneumonia, Lung Infection PPC Among GI Surgery
Groups By Severity of Illness on Admission
Rates of Pneumonia, Lung Infection PPC from
Statewide California Data 1999-2000
10
Method

• Identify Potentially Preventable Complications
  (PPCs) from the secondary diagnoses not present
  at admission
• Determine whether the PPC was potentially
  preventable given the patients reason for
  admission underlying medical conditions
• Determine a patients expected risk of PPCs based
  on the reason for admission and severity of
  illness at admission

11
Determining Potentially Preventable Complications
a General Rule

• If a hospital or other health care facility has
  a statistically significantly higher rate of a
  complication (or group of complications) than
  comparable hospitals and facilities, reasonable
  clinicians would be concerned that a potential
  quality of care problem exists, and would suggest
  further investigation in order to account for the
  difference.

12
Criteria for Determining Potentially Preventable
Complications

• Not redundant with reason for admission
• Not an inevitable consequence of the reason for
  admission
• Potentially preventable
• Significant impact
• Narrow Spectrum
• Sentinel Events

13
PPC Diagnoses and PPC Groups (PPCs)

• Of 13,367 ICD-9 CM diagnosis codes, we identified
  1,450 as PPC diagnoses
• Each of the 1,450 codes designated as PPC
  diagnoses were assigned to one of 66 mutually
  exclusive PPC Groups (PPCs for short), based on
  similarities in clinical presentation and
  clinical impact

14
Major PPCs(Twenty-nine of the Most Significant
PPCs)

• Other Major
• Medical Complications
• Major GI Complications w transfusion
• Major Liver Complications
• Other Major GI Complications
• Renal Failure with Dialysis
• Post-Hem Other Acute Anemia w transfusion
• Decubitus Ulcer
• Septicemia Severe Infection
• Other Major Complications of Medical Care

• Major Cardiac and
• Pulmonary Complications
• Stroke Intracranial Hemorrhage
• Extreme CNS Complications
• Acute Lung Edema Respiratory Failure
• Pneumonia, Lung Infection
• Aspiration Pneumonia
• Pulmonary Embolism
• Shock
• Congestive Heart Failure
• Acute Myocardial Infarct
• V Fibrillation, Cardiac Arrest
• Pulmonary Vascular Complications Except VT

15
Major PPCs (continued)

• Major Complications of
• Devices, Grafts, Etc.
• Malfunction of Device, Prosthesis, Graft
• Infection, Inflammation, Other Comp of Devices
  and Grafts Excluding Vascular Infection
• Complications of Central Venous Other Vascular
  Catheters Devices
• Major Obstetrical Complications
• Obstetrical Hemorrhage w Transfusion
• Major Obstetrical Complications

• Major Peri-Operative
• Complications
• Post-Op Wound Infection Deep Wound Disruption w
  Procedure
• Reopening or Revision of Surgical Site
• Post-Op Hemorrhage Hematoma w Hemorrhage
  Control Proc or ID Proc
• Post-Op Foreign Body Inappropriate Op
• Post-Op Respiratory Failure with Tracheostomy

16
Occurrence of Major PPC Categories Among
California Hospitalizations 1999-2000
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Method

• Identify Potentially Preventable Complications
  (PPCs) from the secondary diagnoses not present
  at admission
• Determine whether the PPC was potentially
  preventable given the patients reason for
  admission underlying medical conditions
• Determine a patients expected risk of PPCs based
  on the reason for admission and severity of
  illness at admission

18
PPC Exclusions Due to Conditions Present on
Admission

• A PPC category may not reflect quality of care
  for patients admitted with certain conditions
• The PPC may be redundant with the admitting
  diagnosis
• PPC of pneumonia, lung infection in a patient
  admitted with a principal or secondary diagnosis
  of
• Another code for pneumonia
• Any other major respiratory infection
• The PPC may be an inevitable or natural
  consequence of the admitting diagnosis
• PPC of pneumonia, lung infection in a patient
  admitted with a principal or secondary diagnosis
  of
• Pulmonary Edema
• Respiratory Failure
• Respiratory Malignancy

19
Exclusions for the Pneumonia, Lung Infection PPC
Category
20
Additional PPC Exclusions by Reason for Admission

• Global exclusions for patients admitted for
• Trauma
• Major or Metastatic Malignancy
• Cardiac arrest
• All Newborns excluded
• Therefore, designation as a PPC is disease
  specific

21
Effect of the Present on Admission Indicator and
Exclusions on Selection of Patients with Major
PPCs
Of 3.95 Million eligible discharges from
California hospitals in 1999-2000
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Method

• Identify Potentially Preventable Complications
  (PPCs) from the secondary diagnoses not present
  at admission
• Determine whether the PPC was potentially
  preventable given the patients reason for
  admission underlying medical conditions
• Determine a patients expected risk of PPCs based
  on the reason for admission and severity of
  illness at admission
• Reason for admission Severity of Illness as
  determined by APR-DRGs

23
Overview of APR-DRG Patient Assignment Logic

• A patient classification system based on
  computerized discharge abstracts
• Assignment to a Base APR-DRG based on
• Principal Diagnosis, for Medical patients, or
• Most Important Surgical Procedure (performed in
  an O.R.)
• Each Base APR-DRG is divided into 4 subclasses
• Two types of Subclasses
• Severity of Illness (SOI) (organ system
  impairment, extent of physiologic decompensation)
• Risk of Mortality (ROM)
• SOI and ROM assignment take into account the
  interaction among principal secondary
  diagnoses, age, and, in some cases, procedures
• PPC Methodology uses only SOI subclasses

24
Use of APR-DRGs in the PPC Methodology

• PPCs were defined independently of APR-DRGs
• Base APR-DRGs are used to classify the reason
  for admission
• The Base APR-DRG and the admission severity of
  illness subclass are used for risk-adjustment of
  PPC rates

25
Assumption A Patients Risk of a PPC Depends on
the Reason for Admission

• Patients treated for medical conditions will be
  at risk for different complications, and at
  different rates, than patients admitted for
  surgery.
• Aspiration pneumonia more likely in a patient
  admitted with a stroke than with acute urinary
  retention
• Heart failure More likely in a patient admitted
  with an acute MI than one admitted for elective
  cholecystectomy.

26
Number Rate per 1,000 - Patients With One or
More Major PPCs in Selected APR-DRGsCalifornia,
1999-2000
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Assumption A Patients Risk of a PPC Depends on
Severity of Illness at Admission

• High Severity of Illness at admission makes
  patients more susceptible to complications
• Therefore, comparing PPC rates requires
  adjustment for admission severity of illness
• An admission Severity of Illness level can be
  computed with APR-DRGs by eliminating all
  secondary diagnoses not present at admission

28
Number Rate per 1,000 - Patients With One or
More Major PPCs in Selected APR-DRGs, by
Severity Level - California, 1999-2000
29
Number Rate per 1,000 - Patients With One or
More Major PPCs in Selected APR-DRGs, by
Severity Level - California, 1999-2000
30
Summary

• Existing methods that use administrative data
  have a limited ability to identify Potentially
  Preventable Complications.
• Selected states now collect the present on
  admission indicator for secondary diagnoses.
• The present on admission indicator permits a new
  method for evaluating hospital complications.

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Summary

• The Potentially Preventable Complications Module
  does the following
• Identifies PPCs from the secondary diagnoses not
  present at admission
• Determines whether the PPC was potentially
  preventable given the patients reason for
  admission underlying medical conditions
• Determines a patients expected risk of PPCs
  based on the reason for admission and severity of
  illness at admission
• Allows actual and expected rates of PPCs to be
  computed at the hospital level