Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents.

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care. OBJECTIVE: To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility. DESIGN: Observational study using California Minimum Data Set Section S. PARTICIPANTS: A total of 296,276 people with a stay in 1,220 California nursing homes in 2011. MAIN MEASURES: The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes. KEY RESULTS: During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid. CONCLUSIONS: Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.

Using Both Clinical Registry and Administrative Claims Data to Measure Risk-adjusted Surgical Outcomes.

OBJECTIVE: To examine the validity of hybrid quality measures that use both clinical registry and administrative claims data, capitalizing on the strengths of each data source. BACKGROUND: Previous studies demonstrate substantial disagreement between clinical registry and administrative claims data on the occurrence of postoperative complications. Clinical data have greater validity than claims data for quality measurement but can be burdensome for hospitals to collect. METHODS: American College of Surgeons National Surgical Quality Improvement Program records were linked to Medicare inpatient claims (2005-2008). National Quality Forum-endorsed risk-adjusted measures of 30-day postoperative complications or death assessed hospital quality for patients undergoing colectomy, lower extremity bypass, or all surgical procedures. Measures use hierarchical multivariable logistic regression to identify statistical outliers. Measures were applied using clinical data, claims data, or a hybrid of both data sources. Kappa statistics assessed agreement on determinations of hospital quality. RESULTS: A total of 111,984 patients participated from 206 hospitals. Agreement on hospital quality between clinical and claims data was poor. Hybrid models using claims data to risk-adjust complications identified by clinical data had moderate agreement with all clinical data models, whereas hybrid models using clinical data to risk-adjust complications identified by claims data had routinely poor agreement with all clinical data models. CONCLUSIONS: Assessments of hospital quality differ substantially when using clinical registry versus administrative claims data. A hybrid approach using claims data for risk adjustment and clinical data for complications may be a valid alternative with lower data collection burden. For quality measures focused on postoperative complications to be meaningful, such policies should require, at a minimum, collection of clinical outcomes data.

Improving Hospital Reporting of Patient Race and Ethnicity--Approaches to Data Auditing.

OBJECTIVE: To investigate new metrics to improve the reporting of patient race and ethnicity (R/E) by hospitals. DATA SOURCES: California Patient Discharge Database (PDD) and birth registry, 2008-2009, Healthcare and Cost Utilization Project's State Inpatient Database, 2008-2011, cancer registry 2000-2008, and 2010 US Census Summary File 2. STUDY DESIGN: We examined agreement between hospital reported R/E versus self-report among mothers delivering babies and a cancer cohort in California. Metrics were created to measure root mean squared differences (RMSD) by hospital between reported R/E distribution and R/E estimates using R/E distribution within each patient's zip code of residence. RMSD comparisons were made to corresponding "gold standard" facility-level measures within the maternal cohort for California and six comparison states. DATA COLLECTION: Maternal birth hospitalization (linked to the state birth registry) and cancer cohort records linked to preceding and subsequent hospitalizations. Hospital discharges were linked to the corresponding Census zip code tabulation area using patient zip code. PRINCIPAL FINDINGS: Overall agreement between the PDD and the gold standard for the maternal cohort was 86 percent for the combined R/E measure and 71 percent for race alone. The RMSD measure is modestly correlated with the summary level gold standard measure for R/E (r = 0.44). The RMSD metric revealed general improvement in data agreement and completeness across states. "Other" and "unknown" categories were inconsistently applied within inpatient databases. CONCLUSIONS: Comparison between reported R/E and R/E estimates using zip code level data may be a reasonable first approach to evaluate and track hospital R/E reporting. Further work should focus on using more granular geocoded data for estimates and tracking data to improve hospital collection of R/E data.

Comparison between clinical registry and medicare claims data on the classification of hospital quality of surgical care.

OBJECTIVE: To compare the classification of hospital statistical outlier status as better or worse performance than expected for postoperative complications using Medicare claims versus clinical registry data. BACKGROUND: Controversy remains as to the most favorable data source for measuring postoperative complications for pay-for-performance and public reporting polices. METHODS: Patient-level records (2005-2008) were linked between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare inpatient claims. Hospital statistical outlier status for better or worse performance than expected was assessed using each data source for superficial surgical site infection (SSI), deep/organ-space SSI, any SSI, urinary tract infection, pneumonia, sepsis, deep venous thrombosis, pulmonary embolism, venous thromboembolism, and myocardial infarction by developing hierarchical multivariable logistic regression models. Kappa statistics and correlation coefficients assessed agreement between the data sources. RESULTS: A total of 192 hospitals with 110,987 surgical patients were included. Agreement on hospital rank for complication rates between Medicare claims and ACS-NSQIP was poor-to-moderate (weighted κ: 0.18-0.48). Of hospitals identified as statistical outliers for better or worse performance by Medicare claims, 26% were also identified as outliers by ACS-NSQIP. Of outliers identified by ACS-NSQIP, 16% were also identified as outliers by Medicare claims. Agreement between the data sources on hospital outlier status classification was uniformly poor (weighted κ: -0.02-0.34). CONCLUSIONS: Despite using the same statistical methodology with each data source, classification of hospital outlier status as better or worse performance than expected for postoperative complications differed substantially between ACS-NSQIP and Medicare claims.

The impact of continuous Medicaid enrollment on diagnosis, treatment, and survival in six surgical cancers.

OBJECTIVE: To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians. DATA SOURCES: California Cancer Registry (CCR), California's Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008. STUDY DESIGN: We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables. DATA COLLECTION/EXTRACTION METHODS: All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment. PRINCIPAL FINDINGS: Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment. CONCLUSIONS: Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California.

Are procedures codes in claims data a reliable indicator of intraoperative splenic injury compared with clinical registry data?

BACKGROUND: Identifying iatrogenic injuries using existing data sources is important for improved transparency in the occurrence of intraoperative events. There is evidence that procedure codes are reliably recorded in claims data. The objective of this study was to assess whether concurrent splenic procedure codes in patients undergoing colectomy procedures are reliably coded in claims data as compared with clinical registry data. STUDY DESIGN: Patients who underwent colectomy procedures in the absence of neoplastic diagnosis codes were identified from American College of Surgeons (ACS) NSQIP data linked with Medicare inpatient claims data file (2005 to 2008). A κ statistic was used to assess coding concordance between ACS NSQIP and Medicare inpatient claims, with ACS NSQIP serving as the reference standard. RESULTS: A total of 11,367 colectomy patients were identified from 212 hospitals. There were 114 patients (1%) who had a concurrent splenic procedure code recorded in either ACS NSQIP or Medicare inpatient claims. There were 7 patients who had a splenic injury diagnosis code recorded in either data source. Agreement of splenic procedure codes between the data sources was substantial (κ statistic 0.72; 95% CI, 0.64-0.79). Medicare inpatient claims identified 81% of the splenic procedure codes recorded in ACS NSQIP, and 99% of the patients without a splenic procedure code. CONCLUSIONS: It is feasible to use Medicare claims data to identify splenic injuries occurring during colectomy procedures, as claims data have moderate sensitivity and excellent specificity for capturing concurrent splenic procedure codes compared with ACS NSQIP.

Identification of modifiable factors for reducing readmission after colectomy: a national analysis.

BACKGROUND: Rates of hospital readmission are currently used for public reporting and pay for performance. Colectomy procedures account for a large number of readmissions among operative procedures. Our objective was to compare the importance of 3 groups of clinical variables (demographics, preoperative risk factors, and postoperative complications) in predicting readmission after colectomy procedures. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Patient demographics (n = 2), preoperative risk factors (n = 23), and 30-day postoperative complications (n = 17) were identified from ACS-NSQIP, whereas 30-day postoperative readmissions and costs were determined from Medicare. Multivariable logistic regression models were used to examine risk-adjusted predictors of colectomy readmission. RESULTS: Among 12,981 colectomy patients, the 30-day postoperative readmission rate was 13.5%. Readmitted patients had slightly greater rates of comorbidities and indicators of clinical severity and substantially greater rates of complications than non-readmitted patients. After risk adjustment, patients with a complication were 3.3 times as likely to be readmitted as patients without a complication. Among individual complications, progressive renal failure and organ-space surgical site infection had the highest risk-adjusted relative risks of readmission (4.6 and 4.0, respectively). Demographic, preoperative risk factor, and postoperative complication variables increased the ability to discriminate readmissions (reflected by the c-statistic) by 5.3%, 23.3%, and 35.4%, respectively. CONCLUSION: Postoperative complications after colectomy are more predictive of readmission than traditional risk factors. Focusing quality improvement efforts on preventing and managing postoperative complications may be the most important step toward reducing readmission rates.

Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings.

OBJECTIVE: To estimate the effect of preventing postoperative complications on readmission rates and costs. BACKGROUND: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure. RESULTS: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year. CONCLUSIONS: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.

Linkage of a clinical surgical registry with Medicare inpatient claims data using indirect identifiers.

BACKGROUND: A variety of data sources are available for measuring the quality of health care. Linking records from different sources can create unique and powerful databases that can be used to evaluate clinically relevant questions and direct health care policy. The objective of this study was to develop and validate a deterministic linkage algorithm that uses indirect patient identifiers to reliably match records from a surgical clinical registry with Medicare inpatient claims data. METHODS: Patient records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), years 2005-2008, were linked to claims data in the Medicare Provider Analysis and Review file (MedPAR) by the use of a deterministic linkage algorithm and the following indirect patient identifiers: hospital, age, sex, diagnosis, procedure and dates of admission, discharge, and procedure. We validated the linkage procedure by systematically reviewing subsets of matched and unmatched records and by determining agreement on patient-level coding of inpatient mortality. RESULTS: Of the 150,454 records in ACS-NSQIP eligible for matching, 80.5% were linked to a MedPAR record. This percentage is within the expected match range given the estimated percentage of ACS-NSQIP patients likely to be Medicare beneficiaries. Systematic checks revealed no evidence of bias in the linkage procedure and there was excellent agreement on patient-level coding of mortality (kappa 0.969). The final linked database contained 121,070 patient records from 217 hospitals. CONCLUSION: This study demonstrates the feasibility and validity of a method for linking 2 data sources without direct personal identifiers. As clinical registries and other data sources continue to proliferate, linkage algorithms such as described here will be critical for quality measurement purposes.

A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications.

OBJECTIVES: To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry. BACKGROUND: Policymakers are increasingly discussing use of postoperative complication rates for value-based purchasing. There is debate regarding the optimal data source for such measures. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient and outpatient claims data sets. We assessed the ability of (1) Medicare inpatient claims and (2) Medicare inpatient and outpatient claims to detect a core set of ACS-NSQIP 30-day postoperative complications: superficial surgical site infection (SSI), deep/organ-space SSI, any SSI (superficial and/or deep/organ-space), urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, venous thromboembolism (DVT and/or pulmonary embolism), and myocardial infarction. Agreement of patient-level complications by ACS-NSQIP versus Medicare was assessed by κ statistics. RESULTS: A total of 117,752 patients from more than 200 hospitals were studied. The sensitivity of inpatient claims data for detecting ACS-NSQIP complications ranged from 0.27 to 0.78; the percentage of false-positives ranged from 48% to 84%. Addition of outpatient claims data improved sensitivity slightly but also greatly increased the percentage of false-positives. Agreement was routinely poor between clinical and claims data for patient-level complications. CONCLUSIONS: This analysis demonstrates important differences between ACS-NSQIP and Medicare claims data sets for measuring surgical complications. Poor accuracy potentially makes claims data suboptimal for evaluating surgical complications. These findings have meaningful implications for performance measures currently being considered.

A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia.

OBJECTIVES: To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment. DESIGN: Controlled trial. SETTING: Two community medical groups. PARTICIPANTS: Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment. INTERVENTION: Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention. MEASUREMENTS: Percentage of quality indicators satisfied measured using a 13-month medical record abstraction. RESULTS: Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35-46% vs 25%, 95% CI=20-30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care. CONCLUSION: A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.

Comparison of administrative data and medical records to measure the quality of medical care provided to vulnerable older patients.

BACKGROUND: Administrative data are used to determine performance for publicly reported in health plan "report cards," accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare. METHODS: We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care. RESULTS: Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, kappa = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P < 0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively. CONCLUSIONS: The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.

Circulating activators of peroxisome proliferator-activated receptors are reduced in preeclamptic pregnancy.

We previously described activators of peroxisome proliferator-activated receptor gamma (PPAR gamma) in the serum of pregnant women. We have also characterized this activating component by using a hexane-extracted serum fraction to examine PPAR activator levels in normal and preeclamptic (PE) pregnancies. In this study we report that the pregnancy PPAR activator is present in similar concentrations in serum and plasma. We also found that the activating fractions from pregnancy sera stimulate not only PPAR gamma, but also PPAR alpha, and are capable of inhibiting the production of inflammatory cytokines, consistent with known PPAR ligands. In experiments comparing extracts from normal and PE patients, we found that extracts from women with severe PE showed a reduced level of PPAR activation compared with extracts from normal pregnant women. This reduction was more pronounced for PPAR gamma than PPAR alpha activation. Finally, this reduction in circulating PPAR activator was observed weeks and sometimes months before the clinical diagnosis of PE. Based on these results, we conclude that PPAR activation is reduced in preeclamptic pregnancy before the onset of maternal symptoms. We speculate that endogenous regulators of PPAR play a role in maternal metabolism and immune function in normal and pathological pregnancies.

The quality of medical care provided to vulnerable community-dwelling older patients.

BACKGROUND: Many people 65 years of age and older are at risk for functional decline and death. However, the resource-intensive medical care provided to this group has received little evaluation. Previous studies have focused on general medical conditions aimed at prolonging life, not on geriatric issues important for quality of life. OBJECTIVE: To measure the quality of medical care provided to vulnerable elders by evaluating the process of care using Assessing Care of Vulnerable Elders quality indicators (QIs). DESIGN: Observational cohort study. SETTING: Managed care organizations in the northeastern and southwestern United States. PATIENTS: Vulnerable older patients identified by a brief interview from a random sample of community-dwelling adults 65 years of age or older who were enrolled in 2 managed care organizations and received care between July 1998 and July 1999. MEASUREMENTS: Percentage of 207 QIs passed, overall and for 22 target conditions; by domain of care (prevention, diagnosis, treatment, and follow-up); and by general medical condition (for example, diabetes and heart failure) or geriatric condition (for example, falls and incontinence). RESULTS: Patients were eligible for 10 711 QIs, of which 55% were passed. There was no overall difference between managed care organizations. Wide variation in adherence was found among conditions, ranging from 9% for end-of-life care to 82% for stroke care. More treatment QIs were completed (81%) compared with other domains (follow-up, 63%; diagnosis, 46%; and prevention, 43%). Adherence to QIs was lower for geriatric conditions than for general medical conditions (31% vs. 52%; P < 0.001). CONCLUSIONS: Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions.