Measuring Nursing Outcomes, with a Focus on Inpatient Complications

Transcription

1 1 Measuring Nursing Outcomes, with a Focus on Inpatient Complications Barbara Doyle MSN, CRNP Clinical Consultant CareScience, a Quovadx Division barbara.doyle@quovadx.com

2 Agenda 2 Nursing Outcomes Measurement Risk Adjustment Models Nurse-sensitive measures ü Areas with Opportunity ü Outcomes by Nursing Unit ü Suggested areas for improvement ü Tracking measures over time Electronic Data Collection Pros & Cons

3 Nursing Outcomes Measurement 3

4 Outcomes Sensitive to Nursing Practice per Magnet Status Requirements 4 Six nursing sensitive indicators are required: ü Patient falls ü Pressure ulcers * ü Patient satisfaction ü Nursing staff satisfaction ü Skill mix of RN/LVN and unlicensed staff ü Nursing care hours per patient day Two additional quality indicators are required ü LOS* ü UTI * ü Upper GI Bleed* ü Pneumonia* ü Shock* ü Cardiac arrest* ü Sepsis* ü Deep vein thrombosis* ü Failure to rescue * May be obtained through Electronic Data

5 Nursing Measures via Electronic Data Utilize Administrative Coding Data 5 High Volume Diagnoses ICD9 Code Infection, urinary tract NOS 5990 Pneumonia, organism NOS 486 Hemorrhage, gastrointestinal NOS 5789 Arrest, cardiac 4275 Infection NEC postoperative Thrombosis, venous NEC 4538 Symptom, shock, cardiogenic Septicemia NOS 389 Ulcer, decubitus 7070 Other Diagnoses ICD9 Code Other Diagnoses ICD9 Code Infct d/t indwelling urine catheter Septicemia, gram-neg organism NOS 3840 Infct d/t oth genitourinary device Septicemia, Pseudomonas 3843 Infected postoperative seroma Septicemia, staphylococcal aureus 3811 Pneumonia d/t gram-negative NEC Septicemia, staphylococcal NEC 3819 Pneumonia d/t Klebsiella pneumoniae 4820 Septicemia, staphylococcal NOS 3810 Pneumonia d/t Pseudomonas 4821 Septicemia, streptococcal 380 Pneumonia d/t Staphylococcus aureus Shock, postoperative 9980 Pneumonia, bacterial NOS 4829 Symptom, shock NOS Septicemia NEC 388 Symptom, shock w/o trauma NEC Septicemia, E. coli 3842 Thrombosis, venous NOS 4539 Septicemia, gram-neg organism NEC 3849

6 Risk Adjustment Models 6

7 Risk Adjustment Questions to Ask & Example Models 7 What data is utilized? What are variables identified for risk adjustment? Is data risk-adjusted at the patient level? APR-DRGs Patient 1 Patient 2 Patient 3 CareScience Continuous Risk Adjustment Patient 1 Patient 2 Patient 3

8 CareScience Patient Risk Assessment 8 Variables Clinical Principal Diagnosis Severity Weighted Comorbidities Procedures Urgency of Admission Neonatal birth weight Presence of Cancer Demographic Age Gender Income Referral and Selection Admission source (e.g. Transfer in) Payor Class Travel Distance Disease Specific Outcomes Mortality Morbidity Complications LOS Cost Charges

9 Regression Model Concept 9 Complication = b 0 + b 1 age + b 2 sex + b 3 distance + b 4 proc +... Comp * * * * * * * * * * * * * * * * * * * * * b 1 = From client base sample age

10 Risk Adjustment (beta values) Process Beta values created based on Principal Diagnosis from the Calibrated CareScience Customer Data Base 2. Beta values are then derived for each of the six outcomes for each of the 136 disease strata 3. Each outcome (mortality, morbidity, complications, LOS, cost, charges) has unique beta values based on the impact of the independent risk factors (age, distance traveled, comorbidities etc.) 4. The beta values remain time stable and are the same for all facilities using CareScience

11 CareScience Complications 11 P[Comorbidity] = 0.80 Pneumonia CHF P[Complication] = 0.20 Principal Diagnosis Secondary Diagnoses Complication Incidence Complications are based on a probabilistic model which calculates the probability of a secondary diagnosis being a complication or a comorbid condition Principal diagnoses/secondary diagnoses pairings undergo analysis by physician panels Physician panel results are basis of the probabilistic model

12 Probability Model: Distribution of Secondary Diagnoses by Complication vs. Comorbid Condition 12 Of the 116 patients coded with A. Fib as a secondary diagnosis, CareScience probabilities predict that 64 (55%) were admitted with it as a comorbid condition, and that 52 (45%) developed it as a complication after admission. # of Cases Pneumonia Patients n=602 Comorbidity Complication 37 4 Acute Resp Failure (n=41) UTI (n=80) Atrial Fib (n=116) Volume depletion (dehydration) (n=151) CHF (n=182)

13 Nursing Measures Outcomes Analysis 13

14 Outcome Comparison 3 Acute Facilities ** 1Acute has highest deviations for complications. better...deviation...worse ** ** ** ** ** Mortality(%) Morbidity (%) Complications (%) LOS (days) ** Significant at 90% confidence level ** ** ** ** ** Acute (n=12,381) 2Acute (n=40,120) 3Acute (n=23,233) Mortality (%) Morbidity (%) Complications (%) GM LOS (Days) Actual Expected Actual Expected Actual Expected Actual Expected 1Acute (n=12,381) 3.0% 2.5% 11.2% 7.5% 39.5% 33.4% Acute (n=40,120) 1.6% 1.6% 7.1% 6.2% 37.9% 33.2% Acute (n=23,233) 2.5% 1.9% 7.1% 6.2% 27.7% 27.9% Source, CareScience, 1 year of data

15 Nursing Outcomes Measure Comparison 15 2Acute (n=40,120) 3Acute (n=23,233) 1Acute (n=12,381) Percent Patients 3.5 % 3.0 % 2.5 % 2.0 % 1.5 % 1.0 % 0.5 % 0.0 % 1Acute has higher rates of pneumonia & UTI. UTI Pneumonia Post-op Infection DVT Complication 2Acute 3Acute 1Acute (n=40,120) (n=23,233) (n=12,381) UTI 2.0 % 1.7 % 3.1 % Pneumonia 1.2 % 1.5 % 2.4 % Post-op Infection 0.2 % 0.3 % 0.2 % DVT 0.3 % 0.5 % 0.2 % Decubitus Ulcer 0.0 % 0.0 % 0.1 % GI Hemorrhage 0.2 % 0.2 % 0.4 % Cardiac Arrest 0.2 % 0.2 % 0.2 % Cardiogenic Shock 0.1 % 0.1 % 0.1 % Sepsis 0.0 % 0.0 % 0.1 % Shock, NOS 0.1 % 0.0 % 0.0 % Source, CareScience, 1 year of data

16 Quarterly Trends Facility 1Acute % 3.0 % Percent Patients 2.5 % 2.0 % 1.5 % 1.0 % 0.5 % UTI Pneumonia Pneumonia rates fluctuating. UTI rates increasing. 0.0 % Q1 (n=3,119) Q2 (n=3,102) Q3 (n=3,141) Q4 (n=3.019) Number of Patients Complication Q1 (n=3,119) Q2 (n=3,102) Q3 (n=3,141) Q4 (n=3.019) Total Source, CareScience, 1 year of data UTI Pneumonia GI Hemorrhage Cardiac Arrest Post-op Infection DVT Cardiogenic Shock Decubitus Ulcer CareScience, a Quovadx Sepsis Division

17 Outcomes by Complication Facility 1Acute 17 better...deviation...worse ** ** ** ** ** ** Patients with Pneumonia have worse outcomes (especially mortality) than the rest of the population. ** Significant at 90% confidence level Mortality(%) Morbidity (%) Complications (%) LOS (days) ** ** ** ** ** Pneumonia (n=465) UTI (n=688) All Others (n=11,282) Mortality (%) Morbidity (%) Complications (%) GM LOS (Days) Actual Expected Actual Expected Actual Expected Actual Expected Pneumonia (n=465) 19.9% 14.0% 76.6% 29.0% 87.8% 58.3% UTI (n=688) 6.0% 5.6% 20.1% 14.2% 80.8% 47.7% All Others (n=11,282) 2.2% 1.9% 7.9% 6.2% 34.8% 31.5% Source, CareScience, 1 year of data

18 Nursing Measures by Nursing Unit Facility 1Acute % 6.0 % UTI Pneumonia Percent Patients 5.0 % 4.0 % 3.0 % 2.0 % 1.0 % UTI 3.1% Pneumonia 2.4% 0.0 % 2 East (n=2,417) 3 West (n=2,155) 4 East (n=1,992) Pediatrics (n=1,826) 4 West (n=1,722) CCU - 1 (n=1,611) CCU -2 (n=397) Complication Hospital Rate 2 East (n=2,417) 3 West (n=2,155) 4 East (n=1,992) Pediatrics (n=1,826) 4 West (n=1,722) CCU - 1 (n=1,611) CCU -2 (n=397) UTI 3.1 % 3.0 % 4.7 % 3.1 % 4.1 % 4.4 % 3.5 % 5.8 % Pneumonia 2.4 % 2.9 % 2.8 % 1.2 % 3.0 % 3.9 % 6.4 % 4.5 % Cardiac Arrest 0.2 % 0.5 % 0.2 % 0.1 % 0.1 % 0.1 % 1.6 % 0.0 % GI Hemorrhage 0.4 % 0.3 % 0.5 % 0.4 % 0.5 % 0.6 % 1.2 % 0.9 % Post-op Infection 0.2 % 0.1 % 0.0 % 0.9 % 0.2 % 0.2 % 1.0 % 0.8 % Sepsis 0.1 % 0.1 % 0.0 % 0.1 % 0.0 % 0.1 % 0.4 % 0.3 % Cardiogenic Shock 0.1 % 0.3 % 0.0 % 0.0 % 0.0 % 0.0 % 0.9 % 0.0 % DVT 0.2 % 0.2 % 0.3 % 0.1 % 0.2 % 0.4 % 0.4 % 0.3 % Decubitus Ulcer 0.1 % 0.0 % 0.2 % 0.0 % 0.1 % 0.1 % 0.0 % 0.1 % Source, CareScience, 1 year of data

19 Pneumonia Patients (Facility 1Acute) Data Drilldown 19

20 Complication Distribution Pneumonia Patients 20 Percent Patients 30% 25% 20% 15% 10% 5% 25.6% 8.5% > 25% of patients with pneumonia develop Acute Respiratory Failure as a complication. Pneumonia patients have higher rates of nursing sensitive measures than the facility-wide population. 5.8% 4.8% 4.2% 2.5% 0% Acute Resp Failure CHF Atrial Fib UTI Dehydration C. Diff Enteritis Nursing Measure Facilitywide Patients Pneumonia GI Hemorrhage 0.4% 1.9% Cardiac Arrest 0.2% 1.3% Post-op Infection 0.2% 0.9% Cardiogenic Shock 0.1% 0.6% DVT 0.2% 0.6% Sepsis 0.1% 0.5% Decubitus Ulcer 0.1% 0.3% Source, CareScience, 1 year of data

21 Comorbidity Distribution Pneumonia Patients 21 Hypertension 33% COPD 25% CHF Type II DM Bronchitis A. Fib Tobacco Use CAD 17% 17% 16% 14% 12% 11% 25% of patients with pneumonia have COPD as a comorbid condition. Esoph. Reflux 9% 0% 5% 10% 15% 20% 25% 30% 35% Percent Patients Source, CareScience, 1 year of data

22 Population Characteristics Pneumonia Patients Admission Source 1% 69% admitted via ED 68% were > 65 years of age 19% died 22 30% 0 through 17 years 3% Age Distribution 18 years through 64 years 30% 69% Emergency Room (n=322) Physician Referral (n=140) Other (n=5) 40% 35% 37% 65 + years 68% 0% 10% 20% 30% 40% 50% 60% 70% 80% D/C Disposition 30% 25% 20% 21% 19% 15% 10% 5% 12% 10% 0% D/C to Home D/C to SNF Expired D/C to Rehab Other Source, CareScience, 1 year of data

23 Impact of Admission Source on Outcomes Pneumonia Patients 23 Patients admitted via MD Referral have higher raw mortality rates & higher mortality deviations, than patients admitted via ED. MD Referral/Stepdown (n=8) MD Referral/General Care (n=102) MD Referral/ICU (n=28) All ED (n=322) better...deviation...worse Path Mortality(%) Morbidity (%) Complications (%) LOS (days) Raw % Overall Mortality # Lives Mortality % Admits Rate MD Referral/ICU (n=28) 51.9% % 6.0% ED/ICU (n=53) 38.0% % 11.3% MD Referral/General Care (n=102) 17.8% % 21.8% Other (n=59) 15.3% 9 9.6% 12.6% ED/General (n=225) 14.0% % 48.2% Source, CareScience, 1 year of data

24 Pneumonia Patients ICU Utilization 24 Patients in ICU Return to ICU Transfers to ICU 0.0% 5.0% 10.0% 15.0% Patients in ICU 12.7% Transfers to ICU 7.4% Return to ICU 3.6% Average ICU Days 7.2 days Percent ICU Days 12.9% Source, CareScience, 1 year of data

25 LOS in General Care Before ICU Admission, Pneumonia Patients 25 Percent Patients 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 46% of patients who transfer to higher levels of care or return to ICU, are transferred in 0-1 days from previous site of care. 0 to 1 2 to 5 6 to Days to Transfer Return to ICU (n=14) Tx to Higher Level of Care (n=72) Source, CareScience, 1 year of data

26 Selected Procedure Distribution Pneumonia Patients 26 Procedure (All) Procedures Cases % Cases Other continuous mech ventilation (967) % Small intestine diagnostic proc (451) % Gastrostomy (431) % Lung/bronchus diagnostic procedure (332) % Bone marrow diagnostic procedure (413) % Temporary tracheostomy (311) % Angiocardiography (885) % Conversion of cardiac rhythm (996) % Cholecystectomy (512) % Removal of coronary artery obstruct (360) % Lower extremity joint replacement (815) % Spinal cord diagnostic procedure (033) % Diagnostic procedure on liver (501) % Pacemaker insertion/revision (377) % Source, CareScience, 1 year of data

27 Impact of Procedures on Mortality Pneumonia Patients 27 Cardioversion & Ventilation with biggest impact on mortality. 120% 100% 80% 44% 38% 33% 25% 21% 18% 15% 60% 70% Died Lived 40% 20% 0% Conversion of cardiac rhythm (n=10) Other continuous mech ventilation (n=81) Gastrostomy (n=21) Cholecystectomy (n=9) Bone marrow diagnostic procedure (n=16) Lung/bronchus diagnostic procedure (n=19) Temporary tracheostomy (n=11) Small intestine diagnostic proc (n=39) Source, CareScience, 1 year of data

28 Timing of Ventilation & Cardioversion by Day of Stay, Pneumonia Patients 28 Percent Patients 70% 60% 50% 40% 30% 20% 10% 0% 60.6% Ventilation Timing 19.0% 11.0% 9.4% Days 1-2 Days 3-6 Days 7-14 Days 15+ ICD9 Procedure Almost 40% of patients go on a vent on or after Day 3 of hospitalization. Day of Stay Days Between Med Rec Admission Date Number Date Admit & Proc ICD9 Procedure (3-digit) Patient 1 03-Jun Jun Conversion of cardiac rhythm (996) Patient 2 13-Jun Jun Conversion of cardiac rhythm (996) Patient 3 22-Mar Mar Conversion of cardiac rhythm (996) Patient 4 19-Nov Nov Conversion of cardiac rhythm (996) Patient 5 27-Jul-2004 Conversion of cardiac rhythm (996) Patient 6 24-Sep-2004 Conversion of cardiac rhythm (996) Patient 7 27-Sep-2004 Conversion of cardiac rhythm (996) Patient 8 07-Jun Jun Conversion of cardiac rhythm (996) Patient 9 07-Apr-2004 Conversion of cardiac rhythm (996) Patient Sep-2004 Conversion of cardiac rhythm (996) Source, CareScience, 1 year of data

29 Core Measures Compliance 29

30 Oxygenation Assessment Pneumococcal Screening Oxygenation assessment 102.0% 100.0% 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% ( ( ( ( ( Pneumococcal screening and/or vaccination (42 At or above JCAHO observed rate (22 Year-Month (Cases) ( ( ( ( (46 Observed Rate JCAHO Obs Rate 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% ( ( ( ( ( (24 At or above JCAHO observed rate (11 Year-Month (Cases) ( ( ( ( (29 Observed Rate JCAHO Obs Rate Source, CareScience, 1 year of data

31 Blood Cultures Adult Smoking Cessation Blood cultures 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ( ( ( ( ( Adult smoking cessation advice/counseling Sometimes below JCAHO observed rate ( (12 Year-Month (Cases) ( ( ( ( (24 Observed Rate JCAHO Obs Rate 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% ( ( ( ( ( (4 At or above JCAHO observed rate (4 Year-Month (Cases) ( ( ( ( (12 Observed Rate JCAHO Obs Rate Source, CareScience, 1 year of data

32 Antibiotic Timing Antibiotic timing Consistently below JCAHO observed rate Observed Rate JCAHO Obs Rate ( ( ( ( ( ( ( ( ( ( ( (34 Year-Month (Cases) Source, CareScience, 1 year of data

33 Core Measure Compliance by Admission Unit Antibiotic Timing (n>5) 33 50% 2 East & 4 West have worst rates for antibiotic timing. 40% 30% 20% 10% 0% < hrs 2-3 hrs 3-4 hrs >4 hrs CCU1 (n=38) Pediatrics (2W) (n=21) 3 West (n=42) 2 East (n=21) 4 West (n=18) Source, CareScience, 1 year of data

34 Core Measure Compliance by Admission Unit Blood Cultures (n>5) % 80.0% 2 East & Pediatrics have worst rates blood cultures. (2 East is a Cardiac floor) 60.0% 40.0% 20.0% 0.0% Blood Not Collected Blood Collected Pediatrics (2W) (n=22) 2 East (n=21) 3 West (n=42) CCU 1 (n=39) 4 West (n=18) Source, CareScience, 1 year of data

35 Resource Utilization 35

36 Selected Resource Utilization Pneumonia Patients 36 % Cases Total Average % Total CDM Resource Mean Use with Use Charges Charge Charges XR CHEST SINGLE VIEW ( ) 89.5% 5.6 $643,856 $ % OXYGEN THERAPY PER DAY ( ) 82.6% 7.5 $1,708,885 $ % CULTURE BLOOD ( ) 70.1% 2.9 $202,231 $ % BLOOD GAS ( ) 67.7% 11.1 $1,620,316 $ % SOL IV NS 9 PERC 1000ML ( ) 65.8% 4.3 $144,020 $ % KIT URINE COLLECTION MIDSTREAM ( ) 64.7% 1.8 $6,801 $12 0.0% CEFTRIAXONE 250MG (1G/D5W 50ML) ( ) 52.0% 4.6 $182,414 Do patients need $ % CULTURE URINE COLONY COUNT 47.5% 5.6 CXRs? 1.5 $27,362 $81 0.1% ( ) 02 SAT MONITORING MULTI USE 7.5 days of oxygen therapy? 46.2% 1.0 $19,103 $87 0.1% ( ) CEFTRIAXONE 250MG (1G VIAL) ( ) 37.0% 1.3 $44,004 $ % Only 70% of patients have blood MORPHINE 10MG TUBEX ( ) 36.6% 6.8 $53,026 $46 0.1% cultures ECHO - 2D/M MODE ONLY ( ) 35.3% 1.0 $138,259 $ % SOLU MEDROL METHYLPRED 40MG 1ML ( ) 31.6% 14.3 $80,066 $38 0.2% ZITHROMAX AZITHROMYCIN 500MG ( ) 31.2% Why 4.2 are 29% $65,230 of pts getting $110 blood? 0.2% PT EVALUATION - 15 MIN ( ) 29.7% 1.0 $23,703 $ % LEUKOCYTE POOR RBC CHG ( ) 29.0% 3.5 $119,507 $ % LEVAQUIN/LEVOFLOX. 250MG )500MG/D ( ) 24.3% 4.7 $96,816 $ % Source, CareScience, 1 year of data

37 Resource Utilization by Day Pneumonia Patients 37 80% Oxygen use does not taper ~ 40% of population getting CXR daily Pulse Ox use very low not documented and/or charged? Cephalosporins most used Antibiotic 60% 40% 20% 0% Day 1 (n=465) Day 2 (n=460) Day 3 (n=439) Day 4 (n=426) Day 5 (n=397) CXR, Single View Oxygen Therapy CEPHALOSPORINS Pulse Oximetry CXR, PA & Lat Source, CareScience, 1 year of data

38 Red Blood Cell Utilization by Nursing Unit Pneumonia Patients 38 Consider unit specialties when interpreting RBC Utilization blood utilization data. 60% 50% Percent Patients w/use Mean Use Percent Pts w/use 40% 30% 20% 10% Mean Use 0% 0 4 West (n=110) 2 East (n=104) Pediatrics (2W) (n=83) 3 West (n=101) CCU2 (n=28) CCU1 (n=166) 4East (n=39) Source, CareScience, 1 year of data

39 Selected Resource Utilization by Nursing Unit, Pneumonia Patients 39 4 West (n=110) 2 East (n=104) Pedes (2W) (n=83) 3 West (n=101) CCU2 (n=28) CCU1 (n=166) 4East (n=39) Mean Use CXR, Single Percent Patients View 91.8% 95.2% 77.1% 90.1% 100.0% 98.2% 94.9% w/use Mean Use CXR, PA & Lat Percent Patients w/use 42.7% 49.0% 55.4% 32.7% 25.0% 30.7% 38.5% Mean Use Oxygen Percent Patients Therapy 88.2% 89.4% 80.7% 84.2% 87.2% 84.9% 92.9% w/use Mean Use Pulse Oximetry Percent Patients w/use 40.0% 57.7% 42.2% 63.4% 28.2% 50.0% 50.0% Mean Use CEPHALOSPO Percent Patients RINS 72.7% 76.0% 77.1% 74.3% 75.0% 72.9% 89.7% w/use Mean Use RBC Percent Patients Transfusion 18.3% 22.9% 23.8% 25.0% 45.2% 53.8% w/use 0 Above threshold set by facility Source, CareScience, 1 year of data

40 Suggested Areas for Improvement & Tracking Improvements over Time 40

41 Summary of Pneumonia Findings with Suggested Areas for Improvement 41 Only 30% of patients admitted via Physician referral, but they accounted for >40% of all mortality. ü Evaluate Physician Referral methods. What is criteria to send patients to the ED? ü Consider evaluation by Physician Service &/or pt. volume 46% of patients transferred to higher level of care or return to ICU within 0-1 days ü Evaluate both ICU admission and discharge criteria Pneumonia rates higher on 3West (Neurology), 4West (Oncology), Pediatrics (2W), and CCU2 ü Consider targeted education on these units ü Consider ID involvement to evaluate air quality/filtration Resource Utilization requires further investigation ü Duration Oxygenation & Pulse Ox utilization/documentation ü Duration Ventilation ü Single View CXR utilization (stat?) Why so many? ü Blood Transfusion practices

42 Suggested Metrics for Pneumonia Critical Few Pneumonia Rates by Unit 2. Admit Source Rates & Outcomes (especially mortality) ü Physician Referral and ED Admits 3. Rates & Timing of ICU Transfers 4. Resource Utilization align with Core Measures where possible ü Blood Cultures ü Antibiotic Timing ü Oxygen duration ü CXR Utilization ü Pulse Oximetry Use 5. Potential Additional Analysis ü Consider investigating impact of COPD as a comorbid condition on outcomes - Do these patients have worse outcomes? What is their rate of Acute Respiratory Failure? ü Consider investigating the impact of age on outcomes - Do older patients have worse outcomes?

43 Administrative Data Pros & Cons 43 Types of Administrative Data ü ICD9 Codes Diagnosis & Procedure Codes ü CPT-4 Codes Procedure Codes ü DRGs Inpatient billing groups ü CDM (Charge Description Master) Pros ü Easily Accessible ü Consistent across facilities ü Timeliness Cons ü Limitations to how much can be documented (eg 7 procedures, 10 diagnoses) ü Developed for billing purposes, not clinical analyses (eg DRGs with and without Cc) ü Timeliness

44 44 Barbara Doyle MSN, CRNP Clinical Consultant CareScience, a Quovadx Division barbara.doyle@quovadx.com