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Allaudeen N, Schalch E, Neff M, Poppler K, Vashi AA. Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity. Jt Comm J Qual Patient Saf 2024; 50:638-644. [PMID: 38821745 DOI: 10.1016/j.jcjq.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care. METHODS Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities. RESULTS After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091). CONCLUSION Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.
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Blike GT, Perreard IM, McGovern KM, McGrath SP. A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality. J Patient Saf 2022; 18:659-666. [PMID: 35149621 DOI: 10.1097/pts.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.). METHODS Agency for Healthcare Research and Quality metrics served as the basis for identifying specific complications related to major organ system morbidity associated with death. Complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations using component International Classification of Disease, Tenth Revision codes. Data were included for adults over a 4-year period, with exclusion of hospice patients and complications present on admission. Temporal visualizations of each metric were used to compare past and recent performance at the study hospital and in comparison to peers. RESULTS The complication-specific method showed statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions. The monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths. CONCLUSIONS The method described supplements existing metrics of serious complications that occur during the course of acute hospitalization allowing for enhanced visualization of opportunities to improve care delivery systems. This method leverages existing measure components to minimize reporting burden. Monthly time-series data allow interventions to prevent and/or rescue patients to be rapidly assessed for impact.
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Affiliation(s)
- George T Blike
- From the Center for Surgical Innovation, Dartmouth-Hitchcock Health System, Department of Anesthesiology
| | | | - Krystal M McGovern
- Surveillance Analytics Core, Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Stocking JC, Utter GH, Drake C, Aldrich JM, Ong MK, Amin A, Marmor RA, Godat L, Cannesson M, Gropper MA, Romano PS. Postoperative respiratory failure: An update on the validity of the Agency for Healthcare Research and Quality Patient Safety Indicator 11 in an era of clinical documentation improvement programs. Am J Surg 2020; 220:222-228. [PMID: 31757440 PMCID: PMC10091853 DOI: 10.1016/j.amjsurg.2019.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/28/2019] [Accepted: 11/10/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. STUDY DESIGN Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. RESULTS Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. CONCLUSION The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.
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Affiliation(s)
- Jacqueline C Stocking
- Department of Internal Medicine, University of California Davis, Sacramento, CA, USA.
| | - Garth H Utter
- Department of Surgery, Outcomes Research Group, University of California Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, USA
| | - Christiana Drake
- Department of Statistics, University of California Davis, Davis, CA, USA
| | - J Matthew Aldrich
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Michael K Ong
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alpesh Amin
- Department of Hospital Medicine, University of California Irvine, Irvine, CA, USA
| | - Rebecca A Marmor
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Laura Godat
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Patrick S Romano
- Department of Internal Medicine, University of California Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, USA
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von Itzstein MS, Gupta A, Kernstine KH, Mara KC, Khanna S, Gerber DE. Increased reporting but decreased mortality associated with adverse events in patients undergoing lung cancer surgery: Competing forces in an era of heightened focus on care quality? PLoS One 2020; 15:e0231258. [PMID: 32271810 PMCID: PMC7145007 DOI: 10.1371/journal.pone.0231258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/19/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Advances in surgical techniques have improved clinical outcomes and decreased complications. At the same time, heightened attention to care quality has resulted in increased identification of hospital-acquired adverse events. We evaluated these divergent effects on the reported safety of lung cancer resection. METHODS AND MATERIALS We analyzed hospital-acquired adverse events in patients undergoing lung cancer resection using the National Hospital Discharge Survey (NHDS) database from 2001-2010. Demographics, diagnoses, and procedures data were abstracted using ICD-9 codes. We used the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) to identify hospital-acquired adverse events. Weighted analyses were performed using t-tests and chi-square. RESULTS A total of 302,444 hospitalizations for lung cancer resection and were included in the analysis. Incidence of PSI increased over time (28% in 2001-2002 vs 34% in 2009-2010; P<0.001). Those with one or more PSI had increased in-hospital mortality (aOR = 11.1; 95% CI, 4.7-26.1; P<0.001) and prolonged hospitalization (12.5 vs 7.8 days; P<0.001). However, among those with PSI, in-hospital mortality decreased over time, from 17% in 2001-2002 to 2% in 2009-2010. CONCLUSIONS In a recent ten-year period, documented rates of adverse events associated with lung cancer resection increased. Despite this increase in safety events, we observed that mortality decreased. Because such metrics may be incorporated into hospital rankings and reimbursement considerations, adverse event coding consistency and content merit further evaluation.
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Affiliation(s)
- Mitchell S. von Itzstein
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Arjun Gupta
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kemp H. Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Sahil Khanna
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, United States of America
| | - David E. Gerber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
- Department of Population & Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States of America
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center Dallas, TX, United States of America
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Sheckter CC, Rochlin D, Kiwanuka H, Curtin C, Momeni A. The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US. Breast Cancer Res Treat 2019; 178:177-183. [PMID: 31338643 DOI: 10.1007/s10549-019-05361-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors. METHODS Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes. RESULTS The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced ≥ 1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p < 0.01) and Elixhauser score ≥ 4 (p < 0.01) for the free flap group, and delayed reconstruction (p < 0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p > 0.05). CONCLUSION PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.
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Affiliation(s)
- Clifford C Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
| | - Danielle Rochlin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
| | - Harriet Kiwanuka
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
| | - Catherine Curtin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto, Palo Alto, CA, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA.
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Kiwanuka H, Maan ZN, Rochlin D, Curtin C, Karanas Y, Sheckter CC. Homelessness and Inpatient Burn Outcomes in the United States. J Burn Care Res 2019; 40:633-638. [DOI: 10.1093/jbcr/irz045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations. A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and Patient Safety Indicators (PSIs). 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (P < .001) and Medicaid-insured (P < .001). Flame and frostbite injuries were more likely (P < .001), and the mean %TBSA was smaller (15.0 vs 16.8, P < .001). After adjustment, homeless patients had greater lengths of stay (11.5 vs 9.6, P = .046), greater charges ($73,597 vs $66,909, P = .030), fewer operations (P = .016), and three times higher likelihood leaving against medical advice (P = .002). There was no difference in PSIs or mortality. Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in PSIs or mortality, further research is needed to understand how the challenges within this population affect their recovery.
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Affiliation(s)
- Harriet Kiwanuka
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
| | - Zeshaan N Maan
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
| | - Danielle Rochlin
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
| | - Catherine Curtin
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
- Division of Plastic Surgery, Veterans Affairs Palo Alto, Palo Alto, California
| | - Yvonne Karanas
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
| | - Clifford C Sheckter
- Division of Plastic & Reconstructive Surgery, Stanford University, Stanford, California
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The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns 2018; 45:146-156. [PMID: 30527451 DOI: 10.1016/j.burns.2018.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 06/19/2018] [Accepted: 08/07/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes. METHODS Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges. RESULTS After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001). CONCLUSIONS Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.
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Nguyen MC, Moffatt-Bruce SD, Van Buren A, Gonsenhauser I, Eiferman DS. Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores. Surgery 2017; 163:542-546. [PMID: 29275975 DOI: 10.1016/j.surg.2017.10.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/03/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value-Based Purchasing Program. METHODS A multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight-adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. RESULTS A total of 1,470 cases were flagged for PSI over a 2-year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of $111,773. CONCLUSION Multidisciplinary review processes are practical and effective in identifying false-positive patient safety events. The real-time process affects hospital performance and resultant Medicare reimbursement substantially.
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Affiliation(s)
- Michelle C Nguyen
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH.
| | | | - Anne Van Buren
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Iahn Gonsenhauser
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Daniel S Eiferman
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH
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