ICD-9 Code-Based Venous Thromboembolism Performance Targets Fail to Measure Up.

Venous thromboembolism (VTE) is a common complication among hospitalized patients. Suboptimal prevention practices have prompted payers to consider hospital-associated VTE as a potentially preventable condition for which financial incentives or penalties exist to drive practice improvement. The authors reviewed all cases of hospital-associated VTE at the Johns Hopkins Hospital between July 1, 2010, and June 30, 2011, that were identified by ICD-9 codes used by a state-run pay-for-performance quality improvement program. Of 157 patients identified as having developed hospital-associated, potentially preventable VTE, only 92 (58.6%) patients developed radiographically confirmed VTE that were potentially preventable. This misclassification of VTE overestimates the marginal additional treatment cost by more than $860 000 and amounts to nearly $200 000 in lost reward in one year alone. ICD-9 codes alone have extremely low positive predictive value to identify true VTE events. The authors recommend linking provision of risk-appropriate prophylaxis to VTE outcomes as a better target for performance improvement.

Development of a risk-adjusted blood utilization metric.

BACKGROUND: Blood utilization has become an important outcome measure for surgical patients because of the recognized risks and costs associated with transfusion. However, comparisons of blood utilization between providers or institutions are difficult, because there is no standard method for risk adjustment when assessing surgical blood requirements. We examined whether accepted diagnosis-related group (DRG) case mix indexes can be used for this purpose. STUDY DESIGN AND METHODS: We retrospectively analyzed electronic medical record data from 37,403 surgical inpatients to assess the relationship between intraoperative blood component transfusion requirements and the case mix indexes: weighted Medicare severity DRG and weighted all-patient refined DRG. Thirty-one surgeons from the general surgery service were compared to determine correlations between blood component utilization and case mix index in both a risk unadjusted and an adjusted fashion. RESULTS: Case mix indexes and transfusion requirements were directly correlated for red blood cells (RBCs), plasma, and platelet (PLT) transfusions (p < 0.0001 for all three blood components, for both indexes). Surgeons with greater case mix index values had greater transfusion requirements, and adjustment for case mix index resulted in less variation among surgeons (p < 0.0001, p = 0.0003, and p < 0.0001 for unadjusted vs. adjusted utilization of RBCs, plasma, and PLTs, respectively). CONCLUSIONS: The standard DRG-based case mix indexes used to determine hospital reimbursement were strongly correlated with intraoperative transfusion requirements. We propose that these methods can be used as a risk-adjusted blood utilization metric for surgical patients.

Separate may not be equal: a preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers.

OBJECTIVES: Electronic Medical Records (EMR) have the potential to improve the coordination of healthcare in this country, yet the field of psychiatry has lagged behind other medical disciplines in its adoption of EMR. METHODS: Psychiatrists at 18 of the top US hospitals completed an electronic survey detailing whether their psychiatric records were stored electronically and accessible to non-psychiatric physicians. Electronic hospital records and accessibility statuses were correlated with patient care outcomes obtained from the University Health System Consortium Clinical Database available for 13 of the 18 top US hospitals. RESULTS: 44% of hospitals surveyed maintained most or all of their psychiatric records electronically and 28% made psychiatric records accessible to non-psychiatric physicians; only 22% did both. Compared with hospitals where psychiatric records were not stored electronically, the average 7-day readmission rate of psychiatric patients was significantly lower at hospitals with psychiatric EMR (5.1% vs. 7.0%, p = .040). Similarly, the 14 and 30-day readmission rates at hospitals where psychiatric records were accessible to non-psychiatric physicians were lower than those of their counterparts with non-accessible records (5.8% vs. 9.5%, p = .019, 8.6% vs. 13.6%, p = .013, respectively). The 7, 14, and 30-day readmission rates were significantly lower in hospitals where psychiatric records were both stored electronically and made accessible than at hospitals where records were either not electronic or not accessible (4% vs 6.6%, 5.8% vs 9.1%, 8.9 vs 13%, respectively, all with p = 0.045). CONCLUSIONS: Having psychiatric EMR that were accessible to non-psychiatric physicians correlated with improved clinical care as measured by lower readmission rates specific for psychiatric patients.