Use of Outcome Measures in Payment Reform: Rationale (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Patrick S. Romano made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2.4 MB) (Plugin Software Help).


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Use of Outcome Measures in Payment Reform: Rationale

Patrick S. Romano, MD MPH
UC Davis Center for Healthcare Policy and Research

AHRQ Annual Conference
Bethesda, MD; September 14, 2009

 

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Overview

  • Variation in quality and outcomes is substantial and is driven (at least somewhat) by provider behavior
  • Suboptimal health care quality and outcomes contribute to excess costs
  • Higher quality is not generally associated with higher overall costs, but improving quality often reduces provider revenue under current payment systems
  • Questions and answers

 

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Variation in quality and outcomes is substantial and is driven (at least somewhat) by provider behavior

 

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Chronic disease proxy outcomes:
Managed care plan distribution, 2006

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%

 PrivateMedicareMedicaid
Mean707349
90th %ile818868
10th %ile605630
Percent of adults with hypertension whose blood pressure <140/90 mmHg
 PrivateMedicareMedicaid
Mean605753
90th %ile686766
10th %ile494639

Note: Diabetes includes ages 18�75; hypertension includes ages 18�85.
Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Hospitals: Quality of care for heart attack, heart failure, and pneumonia

Percent of patients who received recom-mended care for all three conditions*

 20042006
Median8490
Best99100
90th %ile9196
10th %ile7578
Percent of patients who received recommended care for each condition*
 Heart AttackHeart FailurePneumonia
Median969187
90th %ile999895
10th %ile887176

* Composite for heart attack care consists of 5 indicators; heart failure care, 2 indicators; and pneumonia care, 3 indicators.
Overall composite consists of all 10 clinical indicators. See report Appendix B for description of clinical indicators.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Hospital-Standardized Mortality Ratios

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors.
* Medicare national average for 2000=100

 U.S.12345678910
2000-200210185939497100103106106112117
2004-20068274787879818383858689

Decile of hospitals ranked by actual to expected deaths ratios

* See report Appendix B for methodology.
Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2004 to 2006 for conditions leading to 80 percent of all hospital deaths.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Nosocomial infections in intensive care unit patients, 2006

Central line-associated bloodstream infection rate, per 1,000 days use Percentile
Type of ICUNo. of units10%25%50%75%90%
 Medical730.00.02.24.26.2
 Med-surg major teaching630.00.61.93.15.5
 Med-surg all others1020.00.01.02.34.5
 Surgical720.00.92.04.47.4
 Neonatal�Level III (infants weighing 750 grams or less)420.02.55.211.015.6

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Nosocomial infections in intensive care unit patients, 2006

Ventilator-associated pneumonia rate, per 1,000 days use Percentile
Type of ICUNo. of units10%25%50%75%90%
 Medical640.00.92.84.67.2
 Med-surg major teaching580.01.32.55.17.3
 Med-surg all others990.00.01.63.86.2
 Surgical610.01.84.16.410.0
 Neonatal (NICU)(infants weighing 750 grams or less)360.00.01.74.19.5

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Potentially preventable adverse events and complications of care in hospitals among Medicare beneficiaries across states, 2005-2006

 Postoperative complications composite*Adverse drug events composite**Pressure sores
US Average2.49.84.6
Top 10% States1.98.83.6
Bottom 10% States3.610.66.0

*Surgical patients with postoperative pneumonia, urinary tract infection (2005 only), or venous thromboembolic event
** Patients with serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin, or hypoglycemia associated with insulin or oral hypoglycemics.
Data: M. Pineau, Qualidigm analysis of Medicare Patient Safety Monitoring System.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Suboptimal health care quality and outcomes contribute to excess costs

 

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"Business case": Impact of preventing PSI on mortality, LOS, charges
NIS 2000 analysis by Zhan & Miller, JAMA 2003;290:1868-74

IndicatorMort (%)LOS (d)Charge ($)
Postoperative septicemia21.910.9$57,700
Selected infections due to medical care4.39.638,700
Postop abd/pelvic wound dehiscence9.69.440,300
Postoperative respiratory failure21.89.153,500
Postoperative physiologic or metabolic derangement19.88.954,800
Postoperative thromboembolism6.65.421,700
Postoperative hip fracture4.55.213,400
Iatrogenic pneumothorax7.04.417,300
Decubitus ulcer7.24.010,800
Postoperative hemorrhage/hematoma3.03.921,400
Accidental puncture or laceration2.21.38,300

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

 

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"Business case":
Impact of preventing PSI on mortality, LOS, VA cost
VA PTF 2001 analysis by Rivard et al., Med Care Res Rev; 65(1):67-87

IndicatorMort (%)LOS (d)Charge ($)
Postoperative septicemia30.218.8$31,264
Selected infections due to medical care2.79.513,816
Postop abd/pelvic wound dehiscence11.711.718,905
Postoperative respiratory failure24.28.639,745
Postoperative physiologic or metabolic derangement   
Postoperative thromboembolism6.15.57,205
Postoperative hip fracture   
Iatrogenic pneumothorax2.73.95,633
Decubitus ulcer6.85.26,713
Postoperative hemorrhage/hematoma5.13.97,863
Accidental puncture or laceration3.21.43,359

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

 

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Uncertain "business case" for some PSIs
Zhan & Miller, JAMA 2003;290:1868-74
Rosen et al., Med Care 2005;43:873-84

IndicatorMort (%)LOS (d)Charge ($)
Birth trauma-0.1 (NS)-0.1 (NS)300 (NS)
Obstetric trauma �cesarean-0.0 (NS)0.42,700
Obstetric trauma - vaginal w/out instrumentation0.0 (NS)0.05-100 (NS)
Obstetric trauma - vaginal w instrumentation0.0 (NS)0.07220
Complications of anesthesia*0.2 (NS)0.2 (NS)1,600
Transfusion reaction*-1.0 (NS)3.4 (NS)18,900 (NS)
Foreign body left during procedure†2.12.113,300

* All differences NS for transfusion reaction and complications of anesthesia in VA/PTF.
† Mortality difference NS for foreign body in VA/PTF.

 

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Thomson Reuters analysis of PSI business case
Foster et al., AcademyHealth 2009

  • AHRQ Patient Safety Indicators (PSIs) were used to identify selected medical and surgical injuries
  • Thomson Reuters Projected Inpatient Data Base for federal FY 2007 (based on 21.5 million discharge abstracts from 2,620 acute hospitals)
  • Regression models were used to adjust for age, sex, clinical category, and comorbid conditions
  • Model coefficients were used to estimate annual impact attributable to PSI events
  • Total impact:
    • almost 30,000 excess deaths
    • 3.4 million excess hospital days
    • $9 billion in excess hospital costs

 

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International evidence of "business case" from case control analysis of PSIs in NHS England

Admissions, England, 2005-6

Indicator
Excess LOS (days)Excess Mortality (percent)
Pressure ulcer9.113.4
Accidental puncture of lung4.310.6
Central line and device related infections11.45.7
Postoperative hip fracture17.118.2
Postoperative sepsis15.927.1
Obstetric trauma � vaginal with instrument0.6* (NS)
Obstetric trauma � vaginal without instrument0.50.01 (NS)
Obstetric trauma � caesarean0.2 (NS)* (NS)

All differences were statistically significant at p<0.001 except as noted.
Raleigh VS, Cooper J, Bremner SA, Scobie S, Patient safety indicators for England from hospital administrative data, BMJ 2008, 337; a1702.

 

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Quality is not generally associated with overall costs, but improving quality often reduces provider revenue given current payment systems

 

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Total Medicare payments vary widely across Hospital Referral Regions

Map of the United States showing the total rates of reimbursement for noncapitated Medicare per enrollee (by Hospital Referral Region, 2006).

 

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Quality and costs of care for Medicare patients hospital-ized for heart attacks, hip fractures, or colon cancer, by Hospital Referral Regions, 2004

Chart showing the median relative resource use being $27,499.
Quality of Care* (1-Year Survival Index, Median=70%)

* Indexed to risk-adjusted 1-year survival rate (median=0.70).
** Risk-adjusted spending on hospital and physician services using standardized national prices.
Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of Medicare beneficiaries.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Quality of Care according to Level of Medicare Spending in Hospital Referral Region of Residence*

VariableQuintile of EOL-EITest for Trend �
 1
(Lowest)
2345
(Highest)
 
 <-----------------------%-----------------------> 
Acute MI cohort �      
  Received reperfusion within 12 hours55.855.352.353.349.8v
  Received aspirin in the hospital87.787.084.885.383.9v
  Received aspirin at discharge83.582.579.878.574.8v
  Received ACE inhibitors at discharge62.760.056.658.358.5v
  Received ß-blockers in the hospital61.561.054.361.563.9^
  Received ß-blockers at discharge52.753.247.153.553.7>0.05
MCBS cohort      
  Preventive services      
    Received influenza vaccine60.356.354.350.048.1v
    Received pneumonia vaccine29.428.727.225.319.7v
    Received Papanicolaou smear (among women without hysterectomy)40.836.939.639.833.6v
    Received mammography (among women age 65-69 y)48.746.946.247.547.6>0.05

* ACE = angiotensin-converting enzyme; EOL-EI = End-of-Life Expenditure Index; MCBS = Medicare Current Beneficiary Survey; MI = myocardial infarction.
Arrows show the direction of any statistically significant association (P<0.05) between the percentage of patients receiving a specified service and regional EOL-EI differences. An arrow pointing upward indicates that as spending increases across regions, the percentage of patients receiving a specified service increases. A P value greater that 0.05 was considered not significant.
Values are for patients who were ideal candidates for the specific treatment, defined as having no absolute or relative contraindication.

 

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Estimated excess 90-day payments due to AHRQ PSIs, 2001-2 MarketScan Commmercial Claims Database (5.6 m enrollees)

Patient safety event classTotalIndex hospitalReadmitsOutpatientDrugs
Technical problems$646$1,407-$616-$97-$48
Infections19,48015,6742,5941,047165
Pulmonary/vascular7,8386,533659373273
Acute respiratory failure28,21825,8281,70263157
Metabolic problems11,79711,536288-11790
Wound problems1,4261,28510954-22
Nursing-sensitive events12,19611,6574844015

All differences in total excess payments were statistically significant at p<0.001 except for Technical Problems and Wound Problems, after adjusting for propensity based on 92 collapsed DRGs, 20 comorbidities, and 12 other patient characteristics.
Encinosa and Hellinger, HSR 2008;43:2067-85.

 

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Ambulatory care-sensitive hospitalizations (AHRQ PQI) for select conditions across states

Adjusted rate per 100,000 population

 2002/2003^2004
U.S. Average498476
Top 10% states258246
Bottom 10% states631634
 2002/2003^2004
U.S. Average241240
Top 10% states137126
Bottom 10% states299293
 2002/2003^2004
U.S. Average178156
Top 10% states6249
Bottom 10% states242230
Heart failureDiabetes*Pediatric asthma

^ 2002 data for heart failure and diabetes; 2003 data for pediatric asthma. *Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations.
Data: National average�Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution�State Inpatient Databases; not all states participate in HCUP (AHRQ 2005, 2007a).

 

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Medicare admissions for AHRQ PQIs, rates and associated costs, by Hospital Referral Regions

Rate of ACS admissions per 10,000 beneficiaries

 20032005
National mean771700
10th499465
25th610558
75th887816
90th1043926

Percentiles

Costs of ACS admissions as percent of all discharge costs

 20032005
National mean13.412.6
10th10.09.8
25th11.811.1
75th14.713.6
90th16.315.2

Percentiles

See report Appendix B for complete list of ambulatory care-sensitive conditions used in the analysis.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Planned AHRQ QI enhancements to support payment reform

  • Extend Prevention Quality Indicators (PQIs) to EDs
    • Modify and test existing PQIs using State Emergency Department Databases (SEDD)
    • Feed "enhanced PQIs" into the Preventable Hospitalization Costs Mapping Tool
  • Develop AHRQ ED Patient Safety Indicators (EDPSIs)
  • Pilot AHRQ Efficiency and Resource Use Indicators
  • Fully incorporate "Present on Admission" logic into the AHRQ PSIs
    • Current algorithms grafted POA onto previous algorithms, resulting in enhanced PPV/specificity but no gain in sensitivity
    • Reconsider necessity and value of PSI denominator exclusions (i.e., nursing home transfers for Pressure Ulcer) and numerator restrictions (i.e., procedures)

 

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Questions and Discussion

 

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Potentially inappropriate antibiotic prescribing, children with sore throat:
Managed care plan distribution, 2006

Percent of children prescribed antibiotics for throat infection without receiving a "strep" test*

National Average

Year%
1997-200343
200435
Managed Care Plan Distribution, 2006
 PrivateMedicaid
Mean2744
10th %ile1423
90th %ile4374

Note: National average includes ages 3�17 and plan distribution includes ages 2�18.
* A strep test means a rapid antigen test or throat culture for group A streptococcus.
Data: National average�J. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distribution�Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Managed care health plans:
Potentially inappropriate imaging studies for low back pain, by plan type

Percent of health plan members (ages 18�50) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors

 PrivateMedicaid
Mean2622
10th %ile1915
90th %ile3529
Managed care plans (2006)

 2004*20052006
Private252526
Medicaid222122

Annual averages
 

* Denotes baseline year.
Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Unexplained Variation in Care at End of Life

Among chronically ill Medicare beneficiaries who received the majority of their care during 1999-2000 at 77 hospitals ranked as the best in America, there was striking variation in use of resources in the last six months of life, suggesting that where one receives care - more than the nature of one's illness - determines the amount of care that is provided.

Use of services during the last six months of life among Medicare fee-for-service beneficiaries with cancer, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) at 77 U.S. hospitals, 1999-2000

 CancerCOPDCHF
Hospital with the lowest rate8.510.18.9
Hospital with the median rate12.314.915.1
Hospital with the highest rate23.029.632.3
Hospital days per decedent

 CancerCOPDCHF
Hospital with the lowest rate0.61.82.1
Hospital with the median rate1.44.44.3
Hospital with the highest rate8.113.113.4
ICU days per decedent

 CancerCOPDCHF
Hospital with the lowest rate13.015.415.2
Hospital with the median rate26.235.233.9
Hospital with the highest rate64.687.499.3

Physician visits per decedent

Source: Medicare administrative data (Wennberg et al. 2004b). Rates were case-mix adjusted to control for differences in patient's age, sex, race, and desease comorbidities. ICU - intensive care unit.

Current as of December 2009
Internet Citation: Use of Outcome Measures in Payment Reform: Rationale (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/romano/index.html