Hospital Outcomes in Inpatient Laparoscopic Cholecystectomy in Medicare Patients.

OBJECTIVE: To compare the risk-adjusted outcomes of hospitals in inpatient Medicare laparoscopic cholecystectomy. BACKGROUND: Reduced length-of-stay for inpatient surgical care requires the inclusion of objective postdischarge outcomes to provide a comprehensive assessment of hospital and surgeon performance for quality improvement. METHODS: The 2010 to 2012 Medicare Limited Data Set was used to develop risk-adjusted prediction models of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths, and 90-day readmissions for inpatient laparoscopic cholecystectomy. To define the opportunity for improved performance, prediction models were used to compute z scores and risk-adjusted adverse outcome rates for all hospitals in the database that had 20 or more evaluable cases for the study period. RESULTS: A total of 83,274 patients from 1570 hospitals had an overall adverse outcome rate of 20.7%; 48 hospitals had outcomes that were 2 z scores better than predicted and 76 had 2 z scores poorer than predicted. Risk-adjusted adverse outcomes were 10.0 % in the best performing decile of hospitals and were 32.1% in the poorest performing decile. Gastrointestinal, infectious, and cardiopulmonary complications of care were the most common causes of readmissions with 46.3% occurring between days 30 and 90 after discharge. CONCLUSIONS: Comparative analysis of overall risk-adjusted inpatient and 90-day postdischarge adverse outcomes identifies considerable opportunity for improved care in this high-risk population of patients.

Harnessing the power of enhanced data for healthcare quality improvement: lessons from a Minnesota Hospital Association Pilot Project.

The imperative to achieve quality improvement and cost-containment goals is driving healthcare organizations to make better use of existing health information. One strategy, the construction of hybrid data sets combining clinical and administrative data, has strong potential to improve the cost-effectiveness of hospital quality reporting processes, improve the accuracy of quality measures and rankings, and strengthen data systems. Through a two-year contract with the Agency for Healthcare Research and Quality, the Minnesota Hospital Association launched a pilot project in 2007 to link hospital clinical information to administrative data. Despite some initial challenges, this project was successful. Results showed that the use of hybrid data allowed for more accurate comparisons of risk-adjusted mortality and risk-adjusted complications across Minnesota hospitals. These increases in accuracy represent an important step toward targeting quality improvement efforts in Minnesota and provide important lessons that are being leveraged through ongoing projects to construct additional enhanced data sets. We explore the implementation challenges experienced during the Minnesota Pilot Project and their implications for hospitals pursuing similar data-enhancement projects. We also highlight the key lessons learned from the pilot project's success.

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.

Controlling costs without compromising quality: paying hospitals for total knee replacement.

BACKGROUND: Unit costs of health services are substantially higher in the United States than in any other developed country in the world, without a correspondingly healthier population. An alternative payment structure, especially for high volume, high cost episodes of care (eg, total knee replacement), is needed to reward high quality care and reduce costs. METHODS: The National Inpatient Sample of administrative claims data was used to measure risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. Empirically identified inefficient and ineffective hospitals were then removed to create a reference group of high-performance hospitals. Predictive models for outcomes and costs were recalibrated to the reference hospitals and used to compute risk-adjusted outcomes and costs for all hospitals. Per case predicted costs were computed and compared with observed costs. RESULTS: Of the 688 hospitals with acceptable data, 62 failed to meet effectiveness criteria and 210 were identified as inefficient. The remaining 416 high-performance hospitals had 13.4% fewer risk-adjusted adverse outcomes (4.56%-3.95%; P < 0.001; χ) and 9.9% lower risk-adjusted total costs ($12,773-$11,512; P < 0.001; t test) than all study hospitals. Inefficiency accounted for 96% of excess costs. CONCLUSIONS: A payment system based on the demonstrated performance of effective, efficient hospitals can produce sizable cost savings without jeopardizing quality. In this study, 96% of total excess hospital costs resulted from higher routine costs at inefficient hospitals, whereas only 4% was associated with ineffective care.

Modifying ICD-9-CM coding of secondary diagnoses to improve risk-adjustment of inpatient mortality rates.

OBJECTIVE: To assess the effect on risk-adjustment of inpatient mortality rates of progressively enhancing administrative claims data with clinical data that are increasingly expensive to obtain. Data Sources. Claims and abstracted clinical data on patients hospitalized for 5 medical conditions and 3 surgical procedures at 188 Pennsylvania hospitals from July 2000 through June 2003. METHODS: Risk-adjustment models for inpatient mortality were derived using claims data with secondary diagnoses limited to conditions unlikely to be hospital-acquired complications. Models were enhanced with one or more of 1) secondary diagnoses inferred from clinical data to have been present-on-admission (POA), 2) secondary diagnoses not coded on claims but documented in medical records as POA, 3) numerical laboratory results from the first hospital day, and 4) all available clinical data from the first hospital day. Alternative models were compared using c-statistics, the magnitude of errors in prediction for individual cases, and the percentage of hospitals with aggregate errors in prediction exceeding specified thresholds. RESULTS: More complete coding of a few under-reported secondary diagnoses and adding numerical laboratory results to claims data substantially improved predictions of inpatient mortality. Little improvement resulted from increasing the maximum number of available secondary diagnoses or adding additional clinical data. CONCLUSIONS: Increasing the completeness and consistency of reporting a few secondary diagnosis codes for findings POA and merging claims data with numerical laboratory values improved risk adjustment of inpatient mortality rates. Expensive abstraction of additional clinical information from medical records resulted in little further improvement.

Inpatient and Postdischarge Outcomes Following Elective Craniotomy for Mass Lesions.

BACKGROUND: Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs). OBJECTIVE: To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care. METHODS: The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr. Predictive logistic models were designed for inpatient mortality, inpatient prolonged length of stay, 90-d postdischarge deaths without readmission, and 90-d readmissions after exclusions. The total observed patients with one or more AOs were then compared to predicted AO values, and z-scores were computed for each hospital that met minimum volume requirements. Risk-adjusted AO rates allowed stratification of eligible hospitals into deciles of performance. RESULTS: The hospital evaluation was performed for 223 facilities with 7624 patients that met criteria. A total of 849 patients (11.1%) died inclusive of 90 d postdischarge; 635 (8.3%) were 3σ length-of-stay outliers; and 1928 patients (25.3%) with one or more 90-d readmissions; 2716 patients experienced one or more AOs (35.6%). Six hospitals were 2 z-scores better than average, and 8 were 2 z-scores poorer. The median risk-adjusted AO rate was 18% for the first decile and 53.4% for the 10th decile. CONCLUSION: There was a 35% difference between best and suboptimal performing hospitals for this operation. Hospitals must know their risk-adjusted AO rates and benchmark their results to inform processes of care redesign.

Risk-adjusted regional outcomes in elective medicare colorectal surgery.

BACKGROUND: Regional differences in utilization of services in healthcare are commonly understood, but risk-adjusted evaluation of outcomes has not been done. METHODS: Risk-adjusted adverse outcomes (AOs) for elective Medicare colorectal resections were studied for 2012-2014. Risk-adjusted metrics were inpatient deaths, prolonged postoperative length-of-stay, 90-day post-discharge deaths, and 90-day relevant post-discharge readmissions. The nine Census Bureau regions of the U.S. were evaluated by using standard deviations of predicted adverse outcomes to evaluate observed versus expected events. RESULTS: Overall AO rate was 24.3% from 86,624 patients in 1497 hospitals. Region 9 (Pacific) had the best outcomes (z-score = -3.06; risk-adjusted AO rate = 22.9%) and Region 1 (New England) the poorest (z-score = +1.86; risk-adjusted AO rate = 25.4%). CONCLUSIONS: A 4.9 SD difference exists among the best and poorest performing regions in risk-adjusted colorectal surgery outcomes. Alternative Payment Models should consider regional benchmarks as a variable for the evaluation of quality and pricing of episodes of care.

Peri-operative emergency department utilization in inpatient and outpatient Medicare laparoscopic cholecystectomy.

BACKGROUND: Preoperative emergency department (ED) visits may reflect the patient's biliary disease, or may signal unstable comorbid conditions that have relevance following inpatient laparoscopic cholecystectomy (ILC) and outpatient laparoscopic cholecystectomy (OLC) in Medicare patients. METHODS: We used the Medicare inpatient and outpatient Limited Datasets to identify elective laparoscopic cholecystectomy patients from 2011 to 2014. ED visits for 30-days before the surgical event were identified and correlated with the probability of patients returning to the ED in the 30-days following the procedure. RESULTS: A total of 129,377 inpatient and 235,339 outpatient LCs were identified. A total of 20,021 (15.5%) of ILCs and 52,025 (22.1%) of OLCs had 30-day preoperative ED visits. ILCs with any 30-day ED visit preoperatively had an Odds Ratio (OR) that predicted a post-discharge ED visit of 1.85 (95% CI = 1.78-1.92; P < 0.0001). OLCs with any 30-day ED visit preoperatively had an OR for post-discharge ED visit of 1.50 (95% CI = 1.46-1.54; P < 0.0001). CONCLUSION: Preoperative ED visits predict postdischarge ED visits for laparoscopic cholecystectomy in Medicare patients.

Comparison of Risk-Adjusted Outcomes in Medicare Open versus Laparoscopic Cholecystectomy.

More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.6 per cent in OC versus 20.9 per cent in laparoscopic cholecystectomy. Conversion of laparoscopic to open procedures was not associated with increased adverse outcomes. Laparoscopic cholecystectomy provides patients with many advantages, but when clinical circumstances are necessary, OC continues to be performed with the same overall adverse outcome rates, and the conversion process is not associated with poorer results in this high-risk population of patients.

Risk-adjusted hospital outcomes in elective carotid artery surgery in patients with Medicare.

BACKGROUND: The risk-adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90-day postdischarge adverse outcomes have not been studied. METHODS: We studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012-2014. Risk-adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3-sigma prolonged duration-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day postdischarge associated readmissions. Standard deviations of predicted overall adverse outcomes were computed for each hospital. Hospital-specific z scores and risk-adjusted adverse outcomes were calculated. RESULTS: There were 77,086 carotid endarterectomy patients from 960 hospitals complicated by 191 inpatient deaths (0.25%), 4,436 prolonged duration of stay (5.8%), 457 90-day postdischarge deaths (0.6%), and 7,956 90-day postdischarge associated readmissions (10.3%). In the 90-day postdischarge associated readmission patients, an additional 561 patients died after readmission, for total deaths of 1,209 (1.6%) for the study period, and 11,928 (15.5%) patients had one or more adverse outcomes. There were 29 best-performing hospitals (3.0%) with z scores of -2.0 or less (P < .05) with a median rate of risk-adjusted adverse outcomes of 7.1%. A total of 61 suboptimal performers (6.3%) had z scores of +2.0 or greater (P < .05) with a median rate of risk-adjusted adverse outcome rate of 26.4%. CONCLUSION: Hospital risk-adjusted adverse outcome rates for carotid endarterectomy are highly variable. Comparisons of hospital performance define the opportunity for improvement.

Medicare risk-adjusted outcomes in elective major vascular surgery.

BACKGROUND: Risk-adjusted outcomes of elective major vascular surgery that is inclusive of inpatient and 90-day post-discharge adverse outcomes together have not been well studied. METHODS: We studied 2012-2014 Medicare inpatients who received open aortic procedures, open peripheral vascular procedures, endovascular aortic procedures, and percutaneous angioplasty procedures of the lower extremity for risk-adjusted adverse outcomes of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day post-discharge associated readmissions after excluding unrelated events. Observed and predicted total adverse outcomes for hospitals meeting minimum risk-volume criteria were assessed and hospital-specific z-scores and risk-adjusted adverse outcomes were calculated to compare performance. RESULTS: The total adverse-outcome rate was 27.8% for open aortic procedures, 31.5% for open peripheral vascular procedures, 19.6% for endovascular aortic procedures, and 36.4% for percutaneous angioplasty procedures. The difference in risk-adjusted adverse-outcome rates between the best- and the poorest-performing deciles were 32.2% for open aortic procedures, 29.5% for open peripheral vascular procedures, 21.5% for endovascular aortic procedures, and 37.1% for percutaneous angioplasty procedures. The 90-day post-discharge deaths and readmissions were the major driver of overall adverse-outcome rates. CONCLUSION: The variability in risk-adjusted outcomes among best- and poorest-performing hospitals is over 20% in all major vascular procedures and indicates that a large opportunity exists for improvement in results.

Risk-adjusted outcomes of inpatient medicare medical admissions.

It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.We studied the risk-adjusted outcomes of 6 medical conditions during the inpatient and 90-day post-discharge period to identify the opportunities for care improvement. The Medicare Limited Dataset for 2012 to 2014 was used to identify acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia (PNEU), cerebrovascular accidents (CVA), and gastrointestinal hemorrhage (GIH). Stepwise logistic predictive models were developed for the adverse outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths, and 90-day readmissions after unrelated events were excluded. Observed and predicted AOs were determined for each hospital with ≥75 cases for each of the 6 medical conditions. Z-scores and risk-adjusted AO rates for each hospital permitted comparative analysis of outcomes after adjusting for covariance among the medical conditions.There were a total of 1,811,749 patients from 973 acute care hospitals with the 6 medical conditions. A total of 41% of all patients had ≥1 AO events. One or more readmissions were identified in 29.8% of patients. A total of 64 hospitals (6.4%) were 2 standard deviations better than the mean for risk-adjusted outcomes, and 72 (7.4%) were 2 standard deviations poorer. The best performing decile of hospitals had mean AO rates of 35.1% (odds ratio = 0.766; 95% confidence interval (CI) CI: 0.762-0.771) and the poorest performing decile a mean AO rate of 48.5% (odds ratio = 1.357; 95% CI: 1.346-1.369). Volume of qualifying cases ranged from 670 to 9314; no association was identified for increased volume of patients (P < .40).Risk-adjusted AO rates demonstrated nearly a 14% opportunity for care improvement between top and suboptimal performing hospitals. Hospitals must be able to benchmark objective measurement of outcomes to inform quality initiatives.

The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database.

BACKGROUND: The treatment of acute decompensated heart failure remains problematic and most often requires parenteral therapies. Significant concerns have been expressed regarding risks and benefits of individual therapies, especially nesiritide (NES), but few studies have compared the relative safety of varied intravenous therapies on clinical outcomes. METHODS: We compared the safety of intravenous diuretics (DIUR), inotropes (INO), and vasodilators (nitroglycerin [NTG]) on mortality rates and worsening renal function in 99,963 inpatients with acutely decompensated heart failure (ADHF). Patients with a diagnosis of ADHF within 48 hours were grouped by intended primary treatment (intravenous agents administered during the first 2 hours of intravenous therapy). Treatments studied were (a) intended monotherapy (DIUR), (b) intended combination therapy (DIUR + NES, NTG, or INO), and (c) sequential therapy (intended DIUR monotherapy followed by a second agent administered >2 hours later). Propensity-matched cohorts and instrumental analysis were used to adjust for differences among patients in treatment groups. RESULTS: Intended DIUR monotherapy yielded an unadjusted inpatient mortality rate of 3.2%. After intended DIUR monotherapy, inpatient mortality was not higher for sequential use of NES than for sequential use of NTG (3.4% vs 6.2%, P = .0028). In all regimens, INOs were associated with higher inpatient mortality than were diuretics or vasodilators used alone. The rate of worsening renal function was higher with combination of diuretic-based regimens with NES (risk ratio 1.44, P < .0001) or NTG (RR 1.2, P = .012) compared with diuretics alone. CONCLUSIONS: Compared with alternative intravenous regimens, administration of vasodilators, including NES, was not associated with increased inpatient mortality. A large randomized controlled clinical trial is being planned to prospectively address the question of risks and benefits of NES for ADHF.

Enhancement of claims data to improve risk adjustment of hospital mortality.

CONTEXT: Comparisons of risk-adjusted hospital performance often are important components of public reports, pay-for-performance programs, and quality improvement initiatives. Risk-adjustment equations used in these analyses must contain sufficient clinical detail to ensure accurate measurements of hospital quality. OBJECTIVE: To assess the effect on risk-adjusted hospital mortality rates of adding present on admission codes and numerical laboratory data to administrative claims data. DESIGN, SETTING, AND PATIENTS: Comparison of risk-adjustment equations for inpatient mortality from July 2000 through June 2003 derived by sequentially adding increasingly difficult-to-obtain clinical data to an administrative database of 188 Pennsylvania hospitals. Patients were hospitalized for acute myocardial infarction, congestive heart failure, cerebrovascular accident, gastrointestinal tract hemorrhage, or pneumonia or underwent an abdominal aortic aneurysm repair, coronary artery bypass graft surgery, or craniotomy. MAIN OUTCOME MEASURES: C statistics as a measure of the discriminatory power of alternative risk-adjustment models (administrative, present on admission, laboratory, and clinical for each of the 5 conditions and 3 procedures). RESULTS: The mean (SD) c statistic for the administrative model was 0.79 (0.02). Adding present on admission codes and numerical laboratory data collected at the time of admission resulted in substantially improved risk-adjustment equations (mean [SD] c statistic of 0.84 [0.01] and 0.86 [0.01], respectively). Modest additional improvements were obtained by adding more complex and expensive to collect clinical data such as vital signs, blood culture results, key clinical findings, and composite scores abstracted from patients' medical records (mean [SD] c statistic of 0.88 [0.01]). CONCLUSIONS: This study supports the value of adding present on admission codes and numerical laboratory values to administrative databases. Secondary abstraction of difficult-to-obtain key clinical findings adds little to the predictive power of risk-adjustment equations.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery.

BACKGROUND CONTEXT: Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs. PURPOSE: To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery. STUDY DESIGN/SETTING: To identify the significant risk factors associated with AOs and to develop risk models that measure performance. PATIENT SAMPLE: Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset. OUTCOME MEASURES: The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models. METHODS: Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals. RESULTS: There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%. CONCLUSIONS: Differences among hospitals defines opportunities for care 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.

Admission Laboratory Results to Enhance Prediction Models of Postdischarge Outcomes in Cardiac Care.

Predictive modeling for postdischarge outcomes of inpatient care has been suboptimal. This study evaluated whether admission numerical laboratory data added to administrative models from New York and Minnesota hospitals would enhance the prediction accuracy for 90-day postdischarge deaths without readmission (PD-90) and 90-day readmissions (RA-90) following inpatient care for cardiac patients. Risk-adjustment models for the prediction of PD-90 and RA-90 were designed for acute myocardial infarction, percutaneous cardiac intervention, coronary artery bypass grafting, and congestive heart failure. Models were derived from hospital claims data and were then enhanced with admission laboratory predictive results. Case-level discrimination, goodness of fit, and calibration were used to compare administrative models (ADM) and laboratory predictive models (LAB). LAB models for the prediction of PD-90 were modestly enhanced over ADM, but negligible benefit was seen for RA-90. A consistent predictor of PD-90 and RA-90 was prolonged length of stay outliers from the index hospitalization.

Adding Laboratory Data to Hospital Claims Data to Improve Risk Adjustment of Inpatient/30-Day Postdischarge Outcomes.

Numerical laboratory data at admission have been proposed for enhancement of inpatient predictive modeling from administrative claims. In this study, predictive models for inpatient/30-day postdischarge mortality and for risk-adjusted prolonged length of stay, as a surrogate for severe inpatient complications of care, were designed with administrative data only and with administrative data plus numerical laboratory variables. A comparison of resulting inpatient models for acute myocardial infarction, congestive heart failure, coronary artery bypass grafting, and percutaneous cardiac interventions demonstrated improved discrimination and calibration with administrative data plus laboratory values compared to administrative data only for both mortality and prolonged length of stay. Improved goodness of fit was most apparent in acute myocardial infarction and percutaneous cardiac intervention. The emergence of electronic medical records should make the addition of laboratory variables to administrative data an efficient and practical method to clinically enhance predictive modeling of inpatient outcomes of care.

Female gender is an independent predictor of operative mortality after coronary artery bypass graft surgery: contemporary analysis of 31 Midwestern hospitals.

BACKGROUND: Women have a higher operative mortality (OM) after coronary artery bypass graft (CABG) surgery than men. Suggested contributing factors have included women's increased age, advanced disease, comorbidities, and smaller body surface area (BSA). It is unclear whether women's increased risk factors fully account for this difference or whether female gender within itself is associated with increased OM. We attempted to determine whether, all other factors being equal, there is a significant difference in OM between men and women undergoing CABG. METHODS AND RESULTS: We retrospectively reviewed a clinical database of 15,440 patients who underwent CABG at 31 Midwestern hospitals in 1999-2000. Each patient record consisted of >400 data elements. Risk-adjusted mortality rates were computed using a predictive equation derived by stepwise logistic regression. Overall, women were older, had a higher incidence of diabetes and valvular disease, and were more likely to be presenting in shock. The OM for the entire population was 2.88% (women 4.24% versus men 2.23%, P<0.0001). Lower BSA was found to be an independent predictor of increased mortality, and a direct inverse relationship between BSA and OM was noted. After adjusting for all comorbidities including BSA, female gender remained an independent predictor of increased mortality (risk-adjusted OM was 3.81% for women and 2.43% for men). Thus, whereas risk adjustment reduced women's OM from 90% higher than men's to 22% higher, a significant difference remained. CONCLUSIONS: In this contemporary data set from 31 Midwestern hospitals, female gender was an independent predictor of perioperative mortality, even after accounting for all comorbidities, including low BSA.