2009 Premier Award for Quality
Methodology
Provider comparisons have been viewed as a powerful way to motivate
improvement in the quality of care. Healthcare providers, payers and
consumers are all interested in the evaluation of clinical practice across
hospitals within both disease and physician groups. No particular standard
measure of quality and effectiveness of care have been universally accepted,
but there are certain key elements that are common to most evaluations.
Mortality is an example of a commonly used measure of quality of care, but it alone does not fully cover all dimensions of quality. Therefore, in the CareScience Select Practice™ methodology, adapted for the Premier Award for Quality, quality is measured by the incidence of three adverse outcomes: mortality, morbidity and complications, which are combined into a single Quality Index using the preference weightings from the Corporate Hospital Rating Project (CHRP).
In addition to delivering quality healthcare, a high performing hospital should be able to deliver care in an efficient manner. In the Premier Award for Quality methodology, the Efficiency Index is calculated using length of stay (LOS). It reflects how efficiently hospitals deliver care and serves to approximate how a hospital allocates resources among patients.
Lastly, and probably one of the more commonly used measures of hospital performance, is process of care. It is expected that a hospital that provides high quality care in an efficient manner should have the proper processes of care in place to ensure consistency in care for all patients. With that in mind, a composite score was created with the Hospital Compare data. This measure is based on the Hospital Compare “Starter Set” measures, which are publicly available, with the exclusion of the mortality measure.
Meaningful comparisons of outcomes measures among providers must take
into account systematic variations in the patient mix. Patient-specific risk
assessment is a widely used method that creates a foundation for equally
comparing outcomes, while accounting for systematic variations. A
risk-assessment model creates an expected outcome, derived from the case-mix
that can be compared to any provider’s true outcomes (e.g., mortality rates,
morbidity rates, complication rates, and average length of stay). By
identifying and isolating outcome variation attributable to patient
characteristics, providers with different case mixes can be compared in a
statistically rigorous setting.
Utilizing CareScience Analytics, Premier has developed an in-depth process
for evaluating outcomes performance that is disease specific for
approximately 60 conditions that cover virtually all cases admitted to an
acute care facility. This process recognizes that the volume of discharges
per hospital varies greatly, and a few discharges may not provide a
statistically sound analysis. Thus, a facility must have had at least 100
cases of a given condition in order to qualify for ranking in that
condition. For those hospitals meeting the volume requirement, a Quality
Index and Efficiency Index is calculated for each disease group. To be
considered for the Award for Quality, hospitals had to have at least 10 out
of the 60 disease groups scoring high on both quality and efficiency. In
other words, the hospital fell into the top two quintiles for quality and
efficiency in 10 out of the 60 disease groups. Subsequently a similar
analysis was completed at the hospital level, using all disease groups, and
those hospitals that fell into the top two quintiles in quality and
efficiency at the hospital level were considered high performance hospitals.
Similar to the method used for determining high performance in quality and
efficiency, high performance hospitals in the process of care measurement
domain will be identified by determining which hospitals fall in the upper
two quintiles. The first step in generating the composite score is to sum
all of the possible numerators for each measure in the data set (i.e., grand
numerator) as well as sum all of the possible denominators for each measure
in the data set (i.e., grand denominator) for each hospital. Subsequently,
the grand numerator is divided by the grand denominator to generate the
hospital’s composite score. The quintile thresholds will be determined based
on the distribution of the process of care composite scores for all
hospitals.
The Award for Quality considers each of the three measurement domains to be
independent. Therefore, those hospitals that fall in the top two quintiles
in all measurement domains will be considered for the Premier Award for
Quality.
All acute care inpatient facilities in the United States that submitted data
to the Centers for Medicare and Medicaid Services (CMS) and the CMS Hospital
Compare project were considered for the Premier Award for Quality. Using
MedPar 2006 data, a Quality Index and Efficiency Index were calculated for
all disease groups for which a facility met the volume requirement, and it
was noted if their scores put them into the top two quintiles. Similarly,
for all facilities that reported measures for the Hospital Compare project,
it was noted if their score put them in the top two quintiles. Acute care
facilities attaining the top 1 percent designation are identified as both
having scores in the top two quintiles for quality, efficiency, and process
of care as well as having measures for quality and efficiency that were
equal to or exceeded expected outcomes. Because the report includes all
facilities that attained the top 1 percent designation, all facilities were
considered to be leaders for quality, efficiency, and process of care, and
to have attained the same excellent level of performance, thus negating the
need for specific ranking. Therefore, the report is organized alphabetically
by facility, within the following four groups:
- Teaching facilities ≥ 250 beds
- Teaching facilities < 250 beds
- Non-teaching facilities ≥ 250 beds
- Non-teaching facilities < 250 beds
Definitions for data included in the report:
Facility name, city, state – Hospital name, city, and state as submitted to Medicare.
Medicare discharges – The total number of Medicare discharges for that facility.
Quality Index – The calculation of outcomes for mortality, morbidity and complications for all cases in the facility based on preference weighting from the CHRP.
Efficiency Index – The calculation of the length of stay outcome for all cases in the facility.
Mortality deviation – The difference between the actual and expected mortality rate, as calculated via the CareScience risk analysis model. A negative deviation reflects performance that is better than expected, meaning the outcome was lower than what was predicted. Outcomes that were not statistically significant are represented as NS.
Length-of-stay deviation – The difference between the actual and expected length-of-stay, as calculated via the CareScience risk analysis model. A negative deviation reflects performance that is better than expected, meaning the outcome was lower than what was predicted. Outcomes that were not statistically significant are represented as NS.
Composite process of care score - CPS = N(ijk)/D(ijk), where N is
the grand numerator and D is the grand denominator for each specific measure
(i), for each condition (j), in each hospital (k).