2007 Premier|CareScience Select Practice National Quality Awards
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 has 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, 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) . Please see Appendix A for the 16 variables utilized in the CareScience risk model.
In addition to delivering quality healthcare, a high performing hospital should be able to deliver care in an efficient manner. In the CareScience Select Practice 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.
Meaningful comparisons of outcomes 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, average length of stay, and cost per case). By identifying and isolating outcome variation attributable to patient characteristics, providers with different case mixes can be compared in a statistically rigorous setting.
Premier | CareScience has developed an in-depth process for evaluating 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. High performance hospitals have at least 10 out of the 60 disease groups scoring high on both Quality and Efficiency and fall into the upper two quintiles or higher (see Figure 1). These hospitals are thus eligible for the Premier | CareScience Select Practice National Quality Leader Award.
Figure 1
All acute care inpatient facilities in the United States that submitted
data to the Centers for Medicare and Medicaid Services (CMS) were considered
for the Premier | CareScience Select Practice Quality Leadership Award.
Using MedPar 2005 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 Select Practice category. The
top 1 percent of acute care facilities were identified as having had
outcomes that were equal to or exceeded expected outcomes and having
attained the top quintile in both quality and efficiency. Because the report
included all facilities that attained Select Practice designation, all
facilities were considered to be Select Practice Leaders for quality and
efficiency and to have been at the same level of performance, thus negating
the need for specific ranking. Therefore, the report was 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.
Facility Demographics in 2007 Select Practice National Quality Leader Report:
| 2007 Premier | CareScience Select Practice National Quality Leaders | |
Select Practice disease group count range |
10-37 |
| Average count of disease groups that obtained Select Practice | 18 |
| Average percent of cases that qualified for Select Practice | 65% |
| Average bed size | 190 |
| Percent teaching hospitals | 53% |
| Percent non-teaching hospitals | 47% |
| Geographic distribution | |
| Northeast | 13 |
| South | 9 |
| Midwest | 24 |
| West | 3 |
Appendix A
CareScience Risk Model Variables Factors
- Age – (quadratic form); gestational age/birth weight for neonates
- Sex (female, male, unknown)
- Race (white, black, other, unknown)
- Income (median household income within a ZIP code reported by U.S. Census Bureau)
- Distance traveled (the centroid-to-centroid distance between the ZIP code of the household and the ZIP code of the hospital or provider)
- Principal diagnosis (terminal ICD-9-CM digit, where statistically significant)
- CACR comorbidity scores (count of comorbidities within each of five severity categories on the CACR Likert scale)
- Cancer status (benign, malignant, carcinoma in situ, history of cancer)
- Chronic disease and disease history (such as diabetes, renal failure, hypertension, chronic GI, chronic CP, obesity, and history of substance abuse)
- Defining procedure (as a supplement to diagnosis, where statistically significant)
- Time trend factor for cost and charge outcomes (to control for inflation specific for each disease in the inpatient hospital setting)
- Admission source (Physician Referral, Clinic Referral, HMO Referral, Transfer from a Hospital, Skilled Nursing Facility or another Healthcare Facility, Emergency Room, Court/Law Enforcement, Newborn - Normal Delivery, Premature Delivery, Sick Baby, or Extramural birth), unknown/other
- Admission type (Emergency, Urgent, Elective, Newborn, Delivery, Unknown/Other)
- Payor class (Self-pay, Medicaid, Medicare, BC/BS, Commercial, HMO, Workman’s Compensation, CHAMPUS/FEHP/Other Federal Government, Unknown/Other)
- Discharge Disposition (for some outcomes only) (Home or Self Care, Short-term General Hospital, Skilled Nursing Facility, Intermediate Care Facility, Another Type of Institution, Home under care of organized Home Health Service, Left Against Medical Advice, Discharged Home on IV Medications, Expired, Unknown/Other)
- Facility Type (Urban/rural setting, Geographic region, Ownership type, Teaching status, Size category)