Defining Potentially Preventable Adverse Outcomes in Medicare Elective Lung Resections.

OBJECTIVE: The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery. METHODS: The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events. The probability of adverse events for each hospital was used to compute the hospital-specific standard deviation (SD) tailored to patient risk profiles. Observed versus predicted adverse events divided by the hospital-specific SD identified the z score for each hospital. Risk-adjusted OA rates were then computed for comparing hospital performance. RESULTS: A total of 39,405 lung resection patients from 739 hospitals had 768 inpatient deaths (1.9%), 3147 had prolonged LOS (8.0%), 514 had 90-day postdischarge deaths without readmission (1.3 %), and 7701 had one or more 90-day readmissions (19.5%); 10,924 patients (27.7%) had one or more of these OAs. Twenty-six hospitals were two SDs better than predicted and 34 hospitals were two SDs poorer than predicted. When evaluated by deciles of risk-adjusted OAs, the top performing decile of hospitals had rates of 14.3% and the poorest performing decile had OA rates of 41.0%. CONCLUSIONS: The differences in risk-adjusted comparative outcomes between top- and suboptimal-performing hospitals in lung resections define the potential opportunities for care improvement. Identification of risk factors associated with OAs and causes for readmissions provides direction for specific areas of care redesign for improvement.

Risk-Adjusted Hospital Outcomes in Medicare Total Joint Replacement Surgical Procedures.

BACKGROUND: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison. METHODS: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied. Logistic risk models were designed for adverse outcomes of inpatient mortality, prolonged length-of-stay outliers in the index hospitalization, 90-day post-discharge deaths without readmission, and 90-day readmissions after excluding non-related readmissions. For each hospital, models were used to predict total adverse outcomes, the number of standard deviations from the mean (z-scores) for hospital performance, and risk-adjusted adverse outcomes for each hospital. RESULTS: A total of 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement were studied. The observed overall adverse outcome rates were 12.0% for total hip replacement and 11.6% for total knee replacement. The z-scores for 1,483 hospitals performing total hip replacements varied from -5.09 better than predicted to +5.62 poorer than predicted; 98 hospitals were ≥2 standard deviations better than predicted and 142 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.6% for the best-decile hospitals and 19.8% for the poorest-decile hospitals. The z-scores for the 2,349 hospitals performing total knee replacements varied from -5.85 better than predicted to +11.75 poorer than predicted; 223 hospitals were ≥2 standard deviations better than predicted and 319 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.4% for the best-decile hospitals and 19.3% for the poorest-decile hospitals. CONCLUSIONS: Risk-adjusted outcomes demonstrate wide variability and illustrate the need for improvement among poorer-performing hospitals for bundled payments of joint replacement surgical procedures. CLINICAL RELEVANCE: Adverse outcomes are known to occur in the experience of all clinicians and hospitals. The risk-adjusted benchmarking of hospital performance permits the identification of adverse events that are potentially preventable.

Risk-adjusted outcomes in Medicare inpatient nephrectomy patients.

Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions. From the 4 prediction models, total predicted adverse outcomes were determined for each hospital in the dataset that met a minimum of 25 evaluable cases for the study period. Standard deviations (SDs) for each hospital were used to identify specific z-scores. Risk-adjusted adverse outcomes rates were computed to permit benchmarking each hospital's performance against the national standard. Differences between best and suboptimal performing hospitals defined the potential margin of preventable adverse outcomes for this operation.A total of 449 hospitals with 23,477 patients were evaluated. Overall AO rate was 20.8%; 17 hospitals had risk-adjusted AO rates that were 2 SDs poorer than predicted and 8 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 10.2% while the lowest performing decile had 32.1%. With a minimum of 25 cases for each study hospital, no statistically valid improvement in outcomes was seen with increased case volume.Inpatient and 90-day postdischarge risk-adjusted adverse outcomes demonstrated marked variability among study hospitals and illustrate the opportunities for care improvement. This analytic design is applicable for comparing provider performance across a wide array of different inpatient episodes.

Benchmarking hospital outcomes for improvement of care in Medicare elective colon surgery.

BACKGROUND: Risk-adjusted outcomes are essential for hospitals to benchmark care improvement. METHODS: We used the Medicare Limited Data Set for 2010 to 2012 to create risk models in elective colon surgery for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day relevant readmissions. Risk models permitted the prediction of AOs for each hospital and the design of hospital-specific standard deviations (SDs) to define performance from observed values. Risk-adjusted AO rates were computed for hospital comparisons. RESULTS: In all, 1,903 hospitals with 129,861 patients were studied. Overall AO rate was 27.8%; 84 hospitals had AO performance that was 2 SDs poorer than average and 66 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 15.8%, whereas the lowest performing hospital's rate was 39.4%. CONCLUSIONS: Benchmarking risk-adjusted AOs identifies the opportunity for care improvement in elective colon surgery in Medicare patients.

The appropriate measurement of postdischarge readmissions in Medicare colon surgery.

BACKGROUND: Readmissions after inpatient care are being used as a metric for clinical outcomes for surgeons and hospitals, but without standardization of the appropriate postdischarge period. METHODS: Elective colon surgery (ECS) for Medicare patients was reviewed to define the frequency and causes of readmission at 30, 60, and 90 days after discharge. Elective, trauma, and cancer readmissions were excluded. A prediction model at 90 days after discharge was designed to identify risk factors that were associated with readmissions. RESULTS: A total of 107,459 live discharges after ECS had 12,746 readmissions at 30 days, 4,601 1st-time readmissions at 31 to 60 days, and another 4,042 1st-time readmissions from days 61 to 90; 40% of initial and nearly 50% of all readmissions occurred from days 31 to 90. Primary causes for readmission were gastrointestinal, infectious, and cardiopulmonary events. CONCLUSIONS: The 90-day postdischarge time period provides the most accurate measurement interval for relevant readmissions after ECS.