Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

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).


Slide 1


 

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

 

Slide 2


 

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

 

Slide 3


 

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

 

Slide 4


 

Chronic disease proxy outcomes:
Managed care plan distribution, 2006

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

  Private Medicare Medicaid
Mean 70 73 49
90th %ile 81 88 68
10th %ile 60 56 30
Percent of adults with hypertension whose blood pressure <140/90 mmHg
  Private Medicare Medicaid
Mean 60 57 53
90th %ile 68 67 66
10th %ile 49 46 39

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

 

Slide 5


 

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

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

  2004 2006
Median 84 90
Best 99 100
90th %ile 91 96
10th %ile 75 78
Percent of patients who received recommended care for each condition*
  Heart Attack Heart Failure Pneumonia
Median 96 91 87
90th %ile 99 98 95
10th %ile 88 71 76

* 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

 

Slide 6


 

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. 1 2 3 4 5 6 7 8 9 10
2000-2002 101 85 93 94 97 100 103 106 106 112 117
2004-2006 82 74 78 78 79 81 83 83 85 86 89

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

 

Slide 7


 

Nosocomial infections in intensive care unit patients, 2006

Central line-associated bloodstream infection rate, per 1,000 days use   Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
 Medical 73 0.0 0.0 2.2 4.2 6.2
 Med-surg major teaching 63 0.0 0.6 1.9 3.1 5.5
 Med-surg all others 102 0.0 0.0 1.0 2.3 4.5
 Surgical 72 0.0 0.9 2.0 4.4 7.4
 Neonatal�Level III (infants weighing 750 grams or less) 42 0.0 2.5 5.2 11.0 15.6

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

 

Slide 8


 

Nosocomial infections in intensive care unit patients, 2006

Ventilator-associated pneumonia rate, per 1,000 days use   Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
 Medical 64 0.0 0.9 2.8 4.6 7.2
 Med-surg major teaching 58 0.0 1.3 2.5 5.1 7.3
 Med-surg all others 99 0.0 0.0 1.6 3.8 6.2
 Surgical 61 0.0 1.8 4.1 6.4 10.0
 Neonatal (NICU)(infants weighing 750 grams or less) 36 0.0 0.0 1.7 4.1 9.5

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

 

Slide 9


 

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 Average 2.4 9.8 4.6
Top 10% States 1.9 8.8 3.6
Bottom 10% States 3.6 10.6 6.0

*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

 

Slide 10


 

Suboptimal health care quality and outcomes contribute to excess costs

 

Slide 11


 

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

Indicator Mort (%) LOS (d) Charge ($)
Postoperative septicemia 21.9 10.9 $57,700
Selected infections due to medical care 4.3 9.6 38,700
Postop abd/pelvic wound dehiscence 9.6 9.4 40,300
Postoperative respiratory failure 21.8 9.1 53,500
Postoperative physiologic or metabolic derangement 19.8 8.9 54,800
Postoperative thromboembolism 6.6 5.4 21,700
Postoperative hip fracture 4.5 5.2 13,400
Iatrogenic pneumothorax 7.0 4.4 17,300
Decubitus ulcer 7.2 4.0 10,800
Postoperative hemorrhage/hematoma 3.0 3.9 21,400
Accidental puncture or laceration 2.2 1.3 8,300

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

 

Slide 12


 

"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

Indicator Mort (%) LOS (d) Charge ($)
Postoperative septicemia 30.2 18.8 $31,264
Selected infections due to medical care 2.7 9.5 13,816
Postop abd/pelvic wound dehiscence 11.7 11.7 18,905
Postoperative respiratory failure 24.2 8.6 39,745
Postoperative physiologic or metabolic derangement      
Postoperative thromboembolism 6.1 5.5 7,205
Postoperative hip fracture      
Iatrogenic pneumothorax 2.7 3.9 5,633
Decubitus ulcer 6.8 5.2 6,713
Postoperative hemorrhage/hematoma 5.1 3.9 7,863
Accidental puncture or laceration 3.2 1.4 3,359

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

 

Slide 13


 

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

Indicator Mort (%) LOS (d) Charge ($)
Birth trauma -0.1 (NS) -0.1 (NS) 300 (NS)
Obstetric trauma �cesarean -0.0 (NS) 0.4 2,700
Obstetric trauma - vaginal w/out instrumentation 0.0 (NS) 0.05 -100 (NS)
Obstetric trauma - vaginal w instrumentation 0.0 (NS) 0.07 220
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† 2.1 2.1 13,300

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

 

Slide 14


 

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

 

Slide 15


 

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 ulcer 9.1 13.4
Accidental puncture of lung 4.3 10.6
Central line and device related infections 11.4 5.7
Postoperative hip fracture 17.1 18.2
Postoperative sepsis 15.9 27.1
Obstetric trauma � vaginal with instrument 0.6 * (NS)
Obstetric trauma � vaginal without instrument 0.5 0.01 (NS)
Obstetric trauma � caesarean 0.2 (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.

 

Slide 16


 

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

 

Slide 17


 

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).

 

Slide 18


 

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

 

Slide 19


 

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

Variable Quintile of EOL-EI Test for Trend �
  1
(Lowest)
2 3 4 5
(Highest)
 
  < ----------------------- % ----------------------- >  
Acute MI cohort �            
  Received reperfusion within 12 hours 55.8 55.3 52.3 53.3 49.8 v
  Received aspirin in the hospital 87.7 87.0 84.8 85.3 83.9 v
  Received aspirin at discharge 83.5 82.5 79.8 78.5 74.8 v
  Received ACE inhibitors at discharge 62.7 60.0 56.6 58.3 58.5 v
  Received ß-blockers in the hospital 61.5 61.0 54.3 61.5 63.9 ^
  Received ß-blockers at discharge 52.7 53.2 47.1 53.5 53.7 >0.05
MCBS cohort            
  Preventive services            
    Received influenza vaccine 60.3 56.3 54.3 50.0 48.1 v
    Received pneumonia vaccine 29.4 28.7 27.2 25.3 19.7 v
    Received Papanicolaou smear (among women without hysterectomy) 40.8 36.9 39.6 39.8 33.6 v
    Received mammography (among women age 65-69 y) 48.7 46.9 46.2 47.5 47.6 >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.

 

Slide 20


 

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

Patient safety event class Total Index hospital Readmits Outpatient Drugs
Technical problems $646 $1,407 -$616 -$97 -$48
Infections 19,480 15,674 2,594 1,047 165
Pulmonary/vascular 7,838 6,533 659 373 273
Acute respiratory failure 28,218 25,828 1,702 631 57
Metabolic problems 11,797 11,536 288 -117 90
Wound problems 1,426 1,285 109 54 -22
Nursing-sensitive events 12,196 11,657 484 40 15

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.

 

Slide 21


 

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

Adjusted rate per 100,000 population

  2002/2003^ 2004
U.S. Average 498 476
Top 10% states 258 246
Bottom 10% states 631 634
  2002/2003^ 2004
U.S. Average 241 240
Top 10% states 137 126
Bottom 10% states 299 293
  2002/2003^ 2004
U.S. Average 178 156
Top 10% states 62 49
Bottom 10% states 242 230
Heart failure Diabetes* 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).

 

Slide 22


 

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

Rate of ACS admissions per 10,000 beneficiaries

  2003 2005
National mean 771 700
10th 499 465
25th 610 558
75th 887 816
90th 1043 926

Percentiles

Costs of ACS admissions as percent of all discharge costs

  2003 2005
National mean 13.4 12.6
10th 10.0 9.8
25th 11.8 11.1
75th 14.7 13.6
90th 16.3 15.2

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

 

Slide 23


 

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)

 

Slide 24


 

Questions and Discussion

 

Slide 25


 

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 %
1997-2003 43
2004 35
Managed Care Plan Distribution, 2006
  Private Medicaid
Mean 27 44
10th %ile 14 23
90th %ile 43 74

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

 

Slide 26


 

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

  Private Medicaid
Mean 26 22
10th %ile 19 15
90th %ile 35 29
Managed care plans (2006)

  2004* 2005 2006
Private 25 25 26
Medicaid 22 21 22

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

 

Slide 27


 

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

  Cancer COPD CHF
Hospital with the lowest rate 8.5 10.1 8.9
Hospital with the median rate 12.3 14.9 15.1
Hospital with the highest rate 23.0 29.6 32.3
Hospital days per decedent

  Cancer COPD CHF
Hospital with the lowest rate 0.6 1.8 2.1
Hospital with the median rate 1.4 4.4 4.3
Hospital with the highest rate 8.1 13.1 13.4
ICU days per decedent

  Cancer COPD CHF
Hospital with the lowest rate 13.0 15.4 15.2
Hospital with the median rate 26.2 35.2 33.9
Hospital with the highest rate 64.6 87.4 99.3

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://archive.ahrq.gov/news/events/conference/2009/romano/index.html

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care