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.

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.

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.

Comparison of Risk-Adjusted Outcomes in Medicare Open 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.

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.

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.

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.

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.

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.

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.

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.

Risk-adjusted outcomes in Medicare inpatient nephrectomy patients.

Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions.

Benchmarking hospital outcomes for improvement of care in Medicare elective colon surgery.

Background: Risk-adjusted outcomes are essential for hospitals to benchmark care improvement.

Methods: We used the Medicare Limited Data Set for 2010 to 2012 to create risk models in elective colon surgery for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day relevant readmissions. Risk models permitted the prediction of AOs for each hospital and the design of hospital-specific standard deviations (SDs) to define performance from observed values.

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.

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.

The appropriate measurement of postdischarge readmissions in Medicare colon surgery.

Background: Readmissions after inpatient care are being used as a metric for clinical outcomes for surgeons and hospitals, but without standardization of the appropriate postdischarge period.

Methods: Elective colon surgery (ECS) for Medicare patients was reviewed to define the frequency and causes of readmission at 30, 60, and 90 days after discharge. Elective, trauma, and cancer readmissions were excluded.

Medicare inpatient and 90-day postdischarge adverse outcomes in carotid artery surgery.

Background: Longitudinal, risk-adjusted measurement of outcomes of carotid artery (CA) surgery is necessary for the evaluation of quality performance and for the assessment of strategies of quality improvement.

Methods: Patients from quality coding hospitals who underwent CA surgery and met procedural and diagnostic coding requirements in the Medicare Inpatient Limited Data Set from 2009 to 2011 were used to design logistic prediction models for the Adverse Outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers (prLOS) among live discharges, 90-day post-discharge deaths without readmission (PD-90), and 90-day post-discharge readmissions (ReAdm-90).

Results: A total of 653 quality coding hospitals had 54,183 CA surgery cases.

Can Adding Laboratory Values Improve Risk-Adjustment Mortality Models Using Clinical Percutaneous Cardiac Intervention Registry Data?

Background: Registry data for percutaneous coronary intervention (PCI) are being used in New York and Massachusetts and by the American College of Cardiology to risk-adjust provider mortality rates. These registries contain very few numerical laboratory data for risk adjustment.

Methods: For 20 hospitals, New York's PCI registry data from 2008-2010 were used to develop statistic models for predicting in-hospital/30-day mortality with and without appended laboratory data.

Enhancing Clinical Content and Race/Ethnicity Data in Statewide Hospital Administrative Databases: Obstacles Encountered, Strategies Adopted, and Lessons Learned.

Objectives: Eight grant teams used Agency for Healthcare Research and Quality infrastructure development research grants to enhance the clinical content of and improve race/ethnicity identifiers in statewide all-payer hospital administrative databases.

Principal Findings: Grantees faced common challenges, including recruiting data partners and ensuring their continued effective participation, acquiring and validating the accuracy and utility of new data elements, and linking data from multiple sources to create internally consistent enhanced administrative databases. Successful strategies to overcome these challenges included aggressively engaging with providers of critical sources of data, emphasizing potential benefits to participants, revising requirements to lessen burdens associated with participation, maintaining continuous communication with participants, being flexible when responding to participants' difficulties in meeting program requirements, and paying scrupulous attention to preparing data specifications and creating and implementing protocols for data auditing, validation, cleaning, editing, and linking.

Incorporating the Last Four Digits of Social Security Numbers Substantially Improves Linking Patient Data from De-identified Hospital Claims Databases.

Objective: Assess algorithms for linking patients across de-identified databases without compromising confidentiality.

Data Sources/study Setting: Hospital discharges from 11 Mayo Clinic hospitals during January 2008-September 2012 (assessment and validation data). Minnesota death certificates and hospital discharges from 2009 to 2012 for entire state (application data).

Composite Measurement of Outcomes in Medicare Inpatient Laparoscopic Cholecystectomy.

Background: Objective measurement of outcomes in surgical care lack standard definitions, effective and consistent surveillance, and identification of significant postdischarge events.

Study Design: Using the Medicare Inpatient file (2009 to 2011), we designed logistic prediction models for inpatient mortality, prolonged length of stay (prLOS) as a measure of serious inpatient complications, and all-cause 90-day postdischarge (90-DPd) deaths and hospital readmissions for elective and nonelective laparoscopic cholecystectomy (LC). Qualifying hospitals had more than 20 cases for the study period and met rigorous present-on-admission coding standards.

Prediction models of Medicare 90-day postdischarge deaths, readmissions, and costs in bowel operations.

Background: The 90-day postdischarge morbidity and mortality rates following elective and emergent bowel surgery remain poorly defined.

Methods: The 2009 to 2011 Medicare inpatient files for patients undergoing elective and emergent small and large bowel operations in 1,024 hospitals that passed present-on-admission coding accuracy standards had prediction models designed for inpatient mortality, prolonged postoperative length of hospital stay (prLOS), 90-day postdischarge mortality and readmissions, and total hospital costs.

Results: Of 118,758 patients studied, there was a 4.

The value of adding laboratory data to coronary artery bypass grafting registry data to improve models for risk-adjusting provider mortality rates.

Background: Clinical databases are currently being used for calculating provider risk-adjusted mortality rates for coronary artery bypass grafting (CABG) in a few states and by the Society for Thoracic Surgeons. These databases contain very few laboratory data for purposes of risk adjustment.

Methods: For 15 hospitals, New York's CABG registry data from 2008 to 2010 were linked to laboratory data to develop statistical models comparing risk-adjusted mortality rates with and without supplementary laboratory data.

Ninety-day postdischarge outcomes of inpatient elective laparoscopic cholecystectomy.

Background: Little information is available about postdischarge adverse events after laparoscopic cholecystectomy.

Methods: Inpatient and 90-day postdischarge adverse events were identified for Medicare patients discharged in 2009-2010 after undergoing elective laparoscopic cholecystectomy on day 0, 1, or 2 of hospitalization at facilities that performed 20 or more laparoscopic cholecystectomies during the study period. A predictive length of stay (LOS) linear regression model was derived and used to identify patients with prolonged LOS (prLOS) whose risk-adjusted LOS exceeded a 3σ upper limit on a moving average control chart.