Identifying health-related quality of life concepts to inform the development of the WOUND-Q.

OBJECTIVE: The impact of hard-to-heal wounds extends beyond traditional clinical metrics, negatively affecting a patient's health-related quality of life (HRQoL). Yet treatment outcomes are seldom measured from the patient's perspective. The purpose of the present study was to perform in-depth qualitative interviews with patients diagnosed with varying types of hard-to-heal wounds to identify outcomes important to them. METHOD: Participants were recruited from wound care clinics in Canada, Denmark, the Netherlands and the US, and were included if they had a hard-to-heal wound (i.e., lasting ≥3 months), were aged ≥18 years, and fluent in English, Dutch or Danish. Qualitative interviews took place between January 2016 and March 2017. An interpretive description qualitative approach guided the data analysis. Interviews were audio-recorded, transcribed and coded line-by-line. Codes were categorised into top-level domains and themes that formed the final conceptual framework. RESULTS: We performed 60 in-depth interviews with patients with a range of wound types in different anatomic locations that had lasted from three months to 25 years. Participants described outcomes that related to three top-level domains and 13 major themes: wound (characteristics, healing); HRQoL (physical, psychological, social); and treatment (cleaning, compression stocking, debridement, dressing, hyperbaric oxygen, medication, suction device, surgery). CONCLUSION: The conceptual framework developed as part of this study represents the outcome domains that mattered the most to the patients with hard-to-heal wounds. Interview quotes were used to generate items that formed the WOUND-Q scales, a patient-reported outcome measure for patients with hard-to-heal wounds.

International study to develop the WOUND-Q patient-reported outcome measure for all types of chronic wounds.

Patient-reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND-Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field-test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND-Q scales that measure wound characteristics (assessment, discharge, and smell), health-related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND-Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound.

An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection.

BACKGROUND AND OBJECTIVES: Prophylactic lymphovenous anastomosis (LVA) has been shown to decrease the incidence of postoperative lymphedema among patients receiving mastectomy with axillary lymph node dissection (ALND). However, the economic impact of this intervention on overall healthcare costs has not been adequately studied and insurance reimbursement for lymphedema treatment is limited resulting in substantial out-of-pocket patient expenses. METHODS: We performed a cost-minimization decision analysis from the societal perspective to assess two different patient scenarios: (a) mastectomy with ALND alone, (b) mastectomy with ALND and prophylactic LVA. RESULTS: The annual cost of lymphedema-related care is estimated to be $5,691.88 ($3,160.52 direct, $2,531.36 indirect). If all patients undergoing mastectomy with ALND undergo prophylactic LVA, the average expected lifetime cost per patient in the entire population (whether or not they develop lymphedema) is approximately $6,295.61, compared to $13,942.26 if no patients in the same population receive prophylactic LVA. CONCLUSIONS: Prophylactic LVA is economically preferred over mastectomy and ALND alone from a cost minimization perspective, and results in an average of $7,646.65 (45.2%) cost saving per patient over the course of their lifetime.

Patient-reported experience measures are essential to improving quality of care for chronic wounds: An international qualitative study.

Traditional quality measures for chronic wounds have focused on objective outcomes that are challenging to risk adjust, lack patient input, and have limited ability to inform quality improvement interventions. Patient-reported experience measures (PREMs) provide information from the patient perspective regarding health care quality and have potential to improve patient-centredness, increase care efficiency, and generate actionable data for quality improvement. The purpose of this study was to understand patient experiences and health care processes that impact quality of care among patients with chronic wounds. Sixty patients at least 18 years of age with various wound aetiologies were recruited from Canada, Denmark, The Netherlands, and the United States as part of a larger phase 1 qualitative study to develop a patient-reported outcome measure for chronic wounds (WOUND-Q). All patients had a chronic wound for at least 3 months, were fluent in their native speaking language, and able to participate in a one-on-one semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Interpretive description was used to identify recurrent themes relating to patient experience and quality of care. We identified five domains (care coordination, establishing/obtaining care, information delivery, patient-provider interaction, and treatment delivery) and 21 sub-domains (access to patient information, interdisciplinary communication, encounter efficiency, provider availability, specialist referral, staff professionalism, travel/convenience, modality, reciprocity, understandability/consistency, accountability, continuity, credentials, rapport, appropriateness, complication management, continuity, environment/setting, equipment and supply needs, expectation, and patient-centred) as potential opportunities to measure and improve quality of care in the chronic wound population. PREMs for chronic wounds represent an important opportunity to engage patients and longitudinally assess quality across clinical settings and providers. Future research should focus on developing PREMs to complement traditional objective and patient-reported outcome measures for chronic wounds.

The Role of Patient-Reported Outcome Measures in Value-Based Payment Reform.

The U.S. health care system is currently experiencing profound change. Pressure to improve the quality of patient care and control costs have caused a rapid shift from traditional volume-driven fee-for-service reimbursement to value-based payment models. Under the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, providers will be evaluated on the basis of quality and cost efficiency and ultimately receive adjusted reimbursement as per their performance. Although current performance metrics do not incorporate patient-reported outcome measures (PROMs), many wonder whether and how PROMs will eventually fit into value-based payment reform. On November 17, 2016, the second annual Patient-Reported Outcomes in Healthcare Conference brought together international stakeholders across all health care disciplines to discuss the potential role of PROs in value-based health care reform. The purpose of this article was to summarize the findings from this conference in the context of recent literature and guidelines to inform implementation of PROs in value-based payment models. Recommendations for evaluating key perspectives and measurement goals are made to facilitate appropriate use of PROMs to best benefit and amplify the voice of our patients.

Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type.

PURPOSE: To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients. METHODS: Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation. RESULTS: In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients. CONCLUSIONS: Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision III.

Residency characteristics that matter most to plastic surgery applicants: a multi-institutional analysis and review of the literature.

PURPOSE: The National Residency Matching Program Match is a very unique process in which applicants and programs are coupled to each other based on a ranking system. Although several studies have assessed features plastic surgery programs look for in applicants, no study in the present plastic surgery literature identifies which residency characteristics are most important to plastic surgery applicants. Therefore, we sought to perform a multi-institutional assessment as to which factors plastic surgery residency applicants consider most important when applying for residency. METHODS: A validated and anonymous questionnaire containing 37 items regarding various program characteristics was e-mailed to 226 applicants to New York University, Albany, University of Michigan, and University of Southern California plastic surgery residency programs. Applicants were asked to rate each feature on a scale from 1 to 10, with 10 being the most important. The 37 variables were ranked by the sum of the responses. The median rating and interquartile range as well as the mean for each factor was then calculated. A Wilcoxon signed rank test was used to compare medians in rank order. RESULTS: A total of 137 completed questionnaires were returned, yielding a 61% response rate. The characteristics candidates considered most important were impressions during the interview, experiences during away rotations, importance placed on resident training/support/mentoring by faculty, personal experiences with residents, and the amount of time spent in general surgery. The characteristics candidates considered least important were second-look experiences, compensation/benefits, program reputation from Internet forums, accessibility of program coordinator, opportunity for laboratory research, and fellowship positions available at the program. CONCLUSIONS: Applicants value personal contact and time spent in general surgery when selecting residency programs. As the number of integrated programs continues to grow, programs will benefit from learning what factors their applicants value most.

Time and Cost Savings of Virtual Established Plastic Surgery Care Using Time-Driven Activity-Based Costing: Lessons from An Academic Clinic.

BACKGROUND: Various surgical subspecialties, including plastic surgery, have begun to embrace virtual clinic visits, especially since the COVID-19 pandemic. However, the impact of video visits on time optimization and cost incurred in outpatient plastic surgery clinics has not been studied. METHODS: Using the time-driven activity-based costing (TDABC) method, we examined the time and cost of in-person and virtual visits at an academic plastic surgery clinic. We formulated process maps for four visit types: physician-led in-person, physician assistant-led in-person, physician-led virtual, and physician assistant-led virtual. The time associated with each visit type was generated by direct observation. The cost associated with each visit type was calculated from representative salary information and estimation of resource costs. RESULTS: Virtual visits took on average less time (25.3 minutes for physician-led visits and 24.4 minutes for physician assistant-led visits), compared to in-person visits (48.2 minutes for physician-led and 41.1 minutes for physician-assistant-led visits) (p<0.001). Virtual visits were also cheaper, at $52.80 for physician-led visits and $20.70 for physician assistant-led visits, compared to in-person visits ($261.13 for physician-led and $236.00 for physician assistant-led visits). Non-provider activities made up the majority of traditional in-person visits (75.7% of the visit for physician-led and 77.6% for physician assistant-led visits), which contributed to higher overall cost of in-person visits for both groups of providers. CONCLUSIONS: Virtual clinic visits can produce time and cost savings without reducing the amount of face-to-face time between providers and patients. Virtual visits can be a useful adjunct to traditional in-person visits.

Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: a qualitative and quantitative pilot study.

PURPOSE: To explore the quality of life (QOL) and patient expectations among adolescents with neonatal brachial plexus palsy (NBPP)and their parents using qualitative and quantitative approaches. METHODS: A total of 18 adolescents (10-17 y) with residual NBPP impairment and their parents under went separate 1-hour tape-recorded semistructured interviews. We also collected quantitative physical examination measures and patient-rated outcome scores, specifically the Pediatric Outcomes Data Collection Instrument and the Child Health Questionnaire, to quantify the severity of each adolescent's functional deficit and increase our understanding of QOL and patient expectations. RESULTS: Through qualitative analysis, we identified several patient- and system-dependent factors contributing to QOL, such as social impact and peer acceptance, emotional adjustment,aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures. Our study results showed that functional and aesthetic factors were responsible for most observed differences in QOL among NBPP adolescents. We also found that the Pediatric Outcomes Data Collection Instrument might be more sensitive than the Child Health Questionnaire in assessing patient expectations and QOL among this patient population. CONCLUSIONS: Understanding patient expectations and QOL in NBPP adolescents is essential for medical decision making and advancing care. Physical examination measurements alone may not be sufficient for measuring outcome, and knowledge regarding environmental factors and family dynamics is important for clinicians to consider when counseling families of children with NBPP and improving overall outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Early Alveolar Bone Grafting Is Associated with Lower Regraft Rates and Improvements in Long-Term Psychosocial Outcomes.

BACKGROUND: Late childhood (8 to 10 years of age) has emerged as a vulnerable period in children with cleft and craniofacial anomalies such that increased interventions during this period are associated with worse long-term patient-reported anxiety and depressive symptoms. These findings suggest that one possible practice change may be to consider changes in timing for surgical treatment algorithms. In this work, the authors investigated outcomes in altering the timing of the most common operation in late childhood for cleft lip and palate patients, alveolar bone grafting. METHODS: A two-part, multi-institutional cohort study was conducted. To understand the feasibility of changing alveolar bone graft timing with respect to surgical success, reoperation rates were retrospectively compared among patients grafted at different ages (4 to 7, 8 to 10, and 11 to 13 years of age). To understand the long-term effect of changing alveolar bone graft timing on psychosocial outcomes, the psychosocial suite of the Patient-Reported Outcomes Measurement Information System was prospectively administered to teenagers and adults with cleft lip and palate. RESULTS: Among the three age groups, early grafting (4 to 7 years of age) demonstrated the lowest regraft rates compared with the other groups. As these results suggested that early grafting is a viable alternative to standard timing, we next compared the differences in long-term psychosocial outcomes. Patients who were grafted early reported lower levels of anxiety and depressive symptoms as teenagers and adults. CONCLUSION: Altering timing of one stage in cleft lip and palate reconstruction to an earlier age decreases regraft rates and improves long-term patient-reported anxiety and depressive symptoms. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Resuming Elective Surgery during Covid-19: Can Inpatient Hospitals Collaborate with Ambulatory Surgery Centers?

Little is known about the volume and scope of surgical procedures performed in ambulatory surgery centers (ASCs) and the resources that ASCs may provide to assist local health systems. The purpose of this study was to evaluate elective surgical procedures in the inpatient and outpatient ASC setting using currently available administrative claims data. METHODS: We used the 2019 Medicare Point of Service (POS) file to evaluate the geographic distribution of Medicare-certified ASCs in the U.S. To evaluate the volume and scope of elective procedures in the inpatient and outpatient ASC setting, we used the 2016 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the 2018 California HHS Open Data Portal ambulatory surgery database. HCUP software programs were used to clinically categorize procedures and determine Elixhauser comorbidity profiles for each patient. RESULTS: Among the 8,540 Medicare certified ASCs in 2019, the majority are freestanding (99.5%) and privately owned (92.9%). In the inpatient setting, 13.3% of elective operating room procedures occur in patients without any Elixhauser comorbidities and require < 2 days of hospital stay. However, the types of elective procedures performed in the inpatient setting are different from the types of procedures routinely performed in ASCs. CONCLUSIONS: Current administrative data lack robust facility, provider, and procedure level information to inform surge capacity protocols for elective surgery. Plastic surgeons are uniquely positioned to work with other specialties and local health systems to guide future development of surge capacity protocols that maintain and improve patient care.

Publication bias in Kienböck's disease: systematic review.

PURPOSE: Kienböck's disease is considered rare and currently affects fewer than 200,000 people in the United States. Given the inherent challenges associated with researching rare diseases, the intense effort in hand surgery to treat this uncommon disorder may be influenced by publication bias in which positive outcomes are preferentially published. The specific aim of this project was to conduct a systematic review of the literature with the hypothesis that publication bias is present for the treatment of Kienböck's disease. METHODS: We conducted a systematic review of all available abstracts associated with published manuscripts (English and non-English) and abstracts accepted to the 1992 to 2004 American Society for Surgery of the Hand (ASSH) annual meetings. Data collection included various study characteristics, direction of outcome (positive, neutral/negative), complication rates, mean follow-up time, time to publication, and length of patient enrollment. RESULTS: Our study included 175 (124 English, 51 non-English) published manuscripts and 14 abstracts from the 1992 to 2004 annual ASSH meetings. Abstracts from published manuscripts were associated with a 53% positive outcome rate, which is lower than the 74% positive outcome rate found among other surgically treated disorders. Over the past 40 years, studies have become more positive (36% to 68%, p=.007) and are more likely to incorporate statistical analysis testing (0% to 55%, p<.001). Of the 14 abstracts accepted to ASSH, 11 were published in peer-reviewed journals. Ten of the 14 accepted abstracts were considered positive, and there was no significant difference in publication rate between studies with positive (n = 10) and negative (n = 4) outcomes (p>.999). CONCLUSIONS: The acceptance rate for negative outcomes studies regarding Kienböck's disease is higher than for other surgical disorders. This may indicate a relative decrease in positive outcome bias among published Kienböck's disease studies compared with other surgical disorders. However, the increasing positive outcome rate for published Kienböck's disease studies over time may suggest a trend of increasing publication bias among journals toward Kienböck's disease studies.

Application of the brief international classification of functioning, disability, and health core set as a conceptual model in distal radius fractures.

PURPOSE: In 2009, the World Health Organization published a conceptual outcome framework for evaluating upper extremity injury and disease, known as the Brief International Classification of Functioning, Disability, and Health (ICF) Core Set for Hand Conditions. The purpose of this study was to apply the ICF conceptual model to outcomes for distal radius fractures (DRFs) and determine the contribution of each ICF domain to patient satisfaction. METHODS: Patient-rated and objective functional outcome data were collected at 6 weeks, 3 months, and 6 months after surgery. We measured satisfaction using a subsection of the Michigan Hand Outcomes Questionnaire (MHQ) satisfaction score. Measured study variables were linked to their corresponding ICF domain (personal factors, environmental factors, activity and participation, and body function). We then used hierarchical regression to assess the contribution of each ICF domain to variation in overall patient satisfaction at each time point. RESULTS: We enrolled 53 patients with unilateral DRFs treated with the volar locking plating system. Regression analysis indicated that measured study variables explain 93% (6 weeks), 98% (3 months), and 97% (6 months) of variation in patient satisfaction. For all 3 study assessment dates, activity and participation variables (MHQ-Activities of Daily Living, MHQ-Work, and Jebsen-Taylor Score) contributed the most to variation in patient satisfaction, whereas personal and environmental factors had a considerably smaller role in predicting changes in patient satisfaction. CONCLUSIONS: The results demonstrated that it is possible to reliably model the relative contributions of each ICF domain to patient satisfaction over time, and the findings are consistent with previous research (ie, that most outcome variation is due to physical or functional factors). These results are strong enough to support continued use and further research using the ICF model for upper extremity outcomes.

Deriving Evidence from Secondary Data in Hand Surgery: Strengths, Limitations, and Future Directions.

Health services research using secondary data is a powerful tool for guiding quality/performance measure development, payment reform, and health policy. Patient preferences, physical examination findings, use of postoperative care, and other factors specific to hand surgery research are critical pieces of information required to study quality of care and improve patient outcomes. These data often are missing from data sets, causing limitations and challenges when performing secondary data analyses in hand surgery. As the role of secondary data in surgical research expands, hand surgeons must apply novel strategies and become involved in collaborative initiatives to overcome the limitations of existing resources.

Surviving the COVID-19 Pandemic: Surge Capacity Planning for Nonemergent Surgery.

The coronavirus disease 2019 (COVID-19) pandemic has confronted the U.S. health care system with unprecedented challenges amidst a tenuous economic environment. As inpatient hospitals across the country prepare for an overwhelming influx of highly contagious COVID-19 cases, many nonemergent procedures have been cancelled or indefinitely postponed without guidance regarding eventual safe accommodation of these procedures in the future. Given the potentially prolonged impact of the COVID-19 pandemic on health care use, it is imperative for plastic surgeons to collaborate with other medical and surgical specialties to develop surge capacity protocols that allow continuation of safe, high-quality, nonemergent procedures. The purpose of this article is to provide necessary and timely public health information relevant to plastic surgery and also share a conceptual framework to guide surge capacity protocols for nonemergent surgery.

International mixed methods study protocol to develop a patient-reported outcome measure for all types of chronic wounds (the WOUND-Q).

INTRODUCTION: Most patient-reported outcome measures (PROM) for chronic wounds are specific to a single wound type (eg, pressure ulcer) or part of the body. A barrier to outcome assessment in wound care and research is the lack of a rigorously designed PROM that can be used across wound types and locations. This mixed method study describes the protocol for an international collaboration to develop and validate a new PROM called the WOUND-Q for adults with chronic wounds. METHODS AND ANALYSIS: In phase I, the qualitative approach of interpretive description is used to elicit concepts important to people with wounds regarding outcome. Participants from Canada, Denmark, the Netherlands, and the USA are aged 18 years and older and have a wound that has lasted 3 months or longer. Interviews are digitally recorded, transcribed and coded. A conceptual framework and preliminary item pool are developed from the qualitative dataset. Draft scales are formed to cover important themes in the conceptual framework. These scales are refined using feedback from people with chronic wounds and wound care experts. After refinement, the scales are translated into Danish and Dutch, following rigorous methods, to prepare for an international field-test study. In phase II, data are collected in Canada, Denmark, the Netherlands, and the USA. An international sample of people with a large variety of chronic wounds complete the WOUND-Q. Rasch Measurement Theory analysis is used to identify the best subset of items to retain for each scale and to examine reliability and validity. ETHICS AND DISSEMINATION: This study is coordinated at Brigham and Women's Hospital (Boston, USA). Ethics board approval was received at each participating site for both study phases. Findings will be published in peer-reviewed journals and presented at national and international conferences and meetings.

Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years.

PURPOSE: Despite the high prevalence and impact of distal radius fractures (DRFs) on older patients, the currently available literature regarding DRFs in older adults lacks adequate comparative treatment data. The purpose of this prospective, controlled outcomes study is to compare outcomes using the volar locking plating system (VLPS) for DRFs in both older and younger adults and to assert the eligibility of older patients for surgical management with the VLPS. METHODS: Consecutive, eligible patients were enrolled into our prospective study over a 2-year period on the basis of strict inclusion and exclusion criteria. Subjects were entered into 2 cohorts based on age: 20-40 years and >60 years. Patient outcomes and complication rates were evaluated at 3, 6, and 12 months after surgery. Outcome measures included the Michigan Hand Outcomes Questionnaire (MHQ), grip strength, active wrist and forearm range of motion, the Jebsen-Taylor test, and radiographic parameters. RESULTS: Fifty-five patients (30 young and 25 older adults) with unilateral, inadequately reduced DRFs were enrolled and received surgical treatment with the VLPS. We observed no statistically significant difference in any of the outcomes for all 3 follow-up periods, except the Jebsen-Taylor test, which displayed a trend toward a worse outcome in the older-age cohort. Whereas older patients continued to improve throughout their 12-month postoperative visits, younger patients achieved their maximum recovery during the 6-month follow-up period, suggesting different recovery patterns. At the 12-month assessment, older patients were able to achieve a higher mean MHQ score than their younger counterparts (normalized mean: 85% and 82%, respectively). Complication rates were similar between the 2 groups for all 3 time periods, with most occurring on or before the 3-month postoperative visit. CONCLUSIONS: This study indicates that the VLPS is successful in managing DRFs in older patients without increased complications compared to younger patients. For older patients without prohibitive surgical risks, internal fixation using the VLPS yields comparable outcomes to younger patients. However, these conclusions do not necessarily apply to other surgical techniques used to manage DRFs in older adults. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Current utilization of reconstructive upper limb surgery in tetraplegia.

Despite improved surgical techniques and postoperative management protocols for tetraplegic patients undergoing upper extremity functional reconstruction, recent studies have shown that these procedures are profoundly underutilized in the United States. The complex disabilities of tetraplegic patients limit their ability to independently obtain treatment information and travel to medical destinations to receive reconstructive procedures, thus making them a vulnerable patient population susceptible to physician influence regarding treatment decisions. Based on the results of previous research, we believe that increased collaboration among treating physician specialties will enhance patient access to surgical reconstruction.

Evaluation of the Present-on-Admission Indicator among Hospitalized Fee-for-Service Medicare Patients with a Pressure Ulcer Diagnosis: Coding Patterns and Impact on Hospital-Acquired Pressure Ulcer Rates.

OBJECTIVES: To evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates. DATA SOURCES/STUDY SETTING: Medicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011). STUDY DESIGN: Retrospective cross-sectional study. DATA COLLECTION/EXTRACTION METHODS: We evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria. PRINCIPAL FINDINGS: Among admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations. CONCLUSIONS: As payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

Consistency of pressure injury documentation across interfacility transfers.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) are publicly reported in the USA and used to adjust Medicare payment to acute inpatient facilities. Current methods used to identify HAPIs in administrative claims rely on hospital-reported present-on-admission (POA) data instead of prior patient health information. OBJECTIVE: To study the reliability of claims data for HAPIs and pressure injury (PI) stage by evaluating diagnostic coding agreement across interfacility transfers. METHODS: Using the 2012 100% Medicare Provider and Analysis Review file, we identified all fee-for-service acute inpatient discharge records with a PI diagnosis among Medicare patients 65 years and older. We then identified additional facility claims (eg, acute inpatient, long-stay inpatient or skilled nursing facility) belonging to the same patient who had either (1) admission within 1day of hospital discharge or (2) discharge within 1day of hospital admission. Multivariable logistic regression and stratified kappa statistics were used to measure coding agreement between transferring and receiving facilities in the presence or absence of a PI diagnosis at the time of patient transfer and PI stage category (early vs advanced). RESULTS: In our comparison of claims data between transferring and receiving facilities, we observed poor agreement in the presence or absence of a PI diagnosis at the time of transfer (36.3%, kappa=0.03) and poor agreement in PI stage category (74.3%, kappa=0.17). Among transfers with a POA PI reported by the receiving hospital, only 34.0% had a PI documented at the prior transferring facility. CONCLUSIONS: The observed discordance in PI documentation and staging between transferring and receiving facilities may indicate inaccuracy of HAPI identification in claims data. Future research should evaluate the accuracy of hospital-reported POA data and its impact on PI quality measurement.