Appendix. Potentially Preventable Complications (PPCs) identify. complications that can occur during an admission. There are 64

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1 Calikoglu S, Murray R, Feeney D. Hospital pay-for-performance programs in Maryland produced strong results, including reduced hospital-acquired infections. Health Aff (Millwood). 2012;31(12). Appendix MHAC Statistical Methods Potentially Preventable Complications (PPCs) identify complications that can occur during an admission. There are 64 PPCs. Depending on their clinical characteristics, some patients are totally excluded from the PPC analysis, while others are partially excluded (i.e., cannot be considered for some PPCs, but may be considered for others). Risk Adjustment The 3M APR DRG classification system categorizes patients based on their severity of illness and risk of mortality at the time of admission. Version 28.0 of the APR classification system is used for this analysis, which has 314 APR DRG categories, each of which is subdivided into four subclasses for a total of 1,356 unique patient categories. Rates of PPC occurrence are adjusted using APR DRG SOI categories using FY2009 data as the norm file. The rates of PPCs in the normative database are calculated for each APR DRG category and its severity of illness levels by dividing the 1

2 observed number of PPCs by the total number of admissions. APR DRG by SOI categories are excluded from the computation of the actual and expected rates when there are only zero or one at risk admission statewide for the associated APR DRG by SOI category. The PPC norm for a single APR DRG severity of illness level is calculated as follows: Let: N = norm P = Number of discharges with one or more PPCs D = Number of discharges that can potentially have a PPC i = An APR DRG category and a single severity of illness level N = i P i D i Test of Significance A test of significance of the difference between years in PPC rates are performed by comparing observed and expected PPC rates separately within each APR DRG category and subclass using the Cochran-Mantel-Haenszel test (CMH). Cell sizes smaller than forty are excluded from the statistical significance test. 2

3 Estimate of the Marginal Additional Charge of PPCs in Maryland Maryland inpatient acute care all payer statewide hospital data is used for each fiscal year to estimate the marginal additional charge of PPCs in Maryland. Discharges that died or were transferred to another acute care facility were excluded. Further, discharges with charge values below $200 or above $2,000,000 were excluded. Individual case level charges were standardized based the ratio of the statewide average hospital charge per case to the hospital average charge per case to control for cost differences between hospitals. A simple linear regression was specified of the form: Where: Charge i = α + β j PPC j,i + γ k APR-DRG k,i + ε i Charge i is the total charge standardized for discharge i APR DRG k,i is a binary variable (0,1) indicating which of the ~1,356 APR DRG SOIs was assigned to the i th discharge. PPC j,i is a binary variable (0,1) indicating which of the j PPCs were present for the i th discharge α is a constant value applied to each discharge in the model. α is the average baseline charge for a reference APR DRG. γ k is the coefficient associated with APR-DRG k and measures the marginal additional charge above α that is due to the patient s reason for admission and severity of illness level at the time of admission. 3

4 β j is the coefficient associated with PPC j and measures the marginal additional charge above α that is due to the presence of PPC j ε i is the residual error of the model for discharge i The coefficient β j for each PPC is a measure of the marginal additional charges due to the occurrence of the PPC taking into account the patient s reason for admission, severity of illness and the presence of any other post admission complications (PPCs). 4

5 Exhibit 1: Estimated of Average Additional Resource Use of Potentially Preventable Complications, State Fiscal Years 2009, 2010 PPC Number and Description Estimate T-Value Number of Cases Estimate T-Value Number of Cases 1 Stroke & Intracranial Hemorrhage $12, ,005 $11, ,036 2 Extreme CNS Complications $15, $13, Acute Pulmonary Edema and Respiratory Failure without Ventilation $5, ,824 $5, ,274 4 Acute Pulmonary Edema and Respiratory Failure with Ventilation $22, $23, Pneumonia & Other Lung Infections $16, ,470 $14, ,072 6 Aspiration Pneumonia $12, ,853 $11, ,953 7 Pulmonary Embolism $13, $12, Other Pulmonary Complications $9, ,669 $8, ,177 9 Shock $14, ,010 $17, , Congestive Heart Failure $4, ,071 $3, , Acute Myocardial Infarction $5, ,280 $4, , Cardiac Arrythmias & Conduction Disturbances $2, ,119 $1, , Other Cardiac Complications $5, $1, Ventricular Fibrillation/Cardiac Arrest $17, $16, Peripheral Vascular Complications Except Venous Thrombosis $16, $9, Venous Thrombosis $12, ,576 $12, , Major Gastrointestinal Complications without Transfusion or Significant Bleeding $12, $12, , Major Gastrointestinal Complications with Transfusion or Significant Bleeding $11, $7, Major Liver Complications $14, $11, Other Gastrointestinal Complications without Transfusion or Significant Bleeding $14, $14, Clostridium Difficile Colitis $16, ,420 $16, , Urinary Tract Infection $10, ,665 $8, , GU Complications Except UTI $4, $3, Renal Failure without Dialysis $7, ,069 $7, , Renal Failure with Dialysis $34, $28, Diabetic Ketoacidosis & Coma $3, $9, Post-Hemorrhagic & Other Acute Anemia with Transfusion $5, ,191 $4, , In-Hospital Trauma and Fractures $3, $10, Poisonings Except from Anesthesia $1, $1, Poisonings due to Anesthesia - $8, $1, Decubitus Ulcer $21, ,063 $17, , Transfusion Incompatibility Reaction $22, $1, Cellulitis $4, ,194 $4, , Moderate Infectious $17, ,085 $13, , Septicemia & Severe Infections $16, ,789 $16, , Acute Mental Health Changes $4, $4, Post-Operative Infection & Deep Wound Disruption Without Procedure $16, ,246 $14, , Post-Operative Wound Infection & Deep Wound Disruption with Procedure $21, $19, Reopening Surgical Site $16, $22, Post-Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure $7, ,267 $5, , Post-Operative Hemorrhage & Hematoma with Hemorrhage Control Procedure or $17, $10, Accidental Puncture/Laceration During Invasive Procedure $6, ,463 $4, , Accidental Cut or Hemorrhage During Other Medical Care $3, $8, Other Surgical Complication - Mod $17, $10, Post-procedure Foreign Bodies $4, $2, Post-Operative Substance Reaction & Non-O.R. Procedure for Foreign Body - $21, $2, Encephalopathy $13, ,480 $10, , Other Complications of Medical Care $17, $18, Iatrogenic Pneumothrax $6, $6, Mechanical Complication of Device, Implant & Graft $15, $14, Gastrointestinal Ostomy Complications $23, $25, Inflammation & Other Complications of Devices, Implants or Grafts Except Vascu $8, ,163 $9, , Infection, Inflammation & Clotting Complications of Peripheral Vascular Catheters $10, $13, Infections due to Central Venous Catheters $30, $27, Obstetrical Hemorrhage without Transfusion $ ,574 $ , Obstetrical Hemorrhage wtih Transfusion $2, $2, Obstetric Lacerations & Other Trauma Without Instrumentation $ ,219 $ , Obstetric Lacerations & Other Trauma With Instrumentation $ $ Medical & Anesthesia Obstetric Complications $ $ Major Puerperal Infection and Other Major Obstetric Complications $ $ Other Complications of Obstetrical Surgical & Perineal Wounds -$ $ Delivery with Placental Complications $ $ FY2010 FY2009 5

6 Exhibit 2: Box-plots of Clinical Process of Care Measures, Maryland Hospitals Source: Maryland Health Care Commission Hospital Performance Guide ( ) and CMS Hospital Compare Database (2007) NOTES: The length of the box represents the interquartile range (the distance between the 25th and 75th percentiles). The symbol in the box interior represents the group mean. The horizontal line in the box interior represents the group median. The vertical lines (called whiskers) issuing from the box extend to 1.5 interquartile range. Dots outside of the vertical lines indicate outliers. 6

7 Exhibit 3: Trends in Clinical Process of Care Measures, Maryland and US, 2007 and 2010 Measure Code Measure Name Maryland Percent Point Change Percent Point Change MD-US Difference in Trends AMI_1 Heart Attack Patients Given Aspirin at Arrival AMI_2 Heart Attack Patients Given Aspirin at Discharge AMI_3 Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) AMI_4 Heart Attack Patients Given Smoking Cessation Advice/Counseling AMI_5 Heart Attack Patients Given Beta Blocker at Discharge HF_1 Heart Failure Patients Given Discharge Instructions HF_2 Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function HF_3 Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) HF_4 Heart Failure Patients Given Smoking Cessation Advice/Counseling ** PN_2 Pneumonia Patients Assessed and Given Pneumococcal Vaccination PN_3b Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics PN_4 Pneumonia Patients Given Smoking Cessation Advice/Counseling PN_5c Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival PN_6 Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) PN_7 Pneumonia Patients Assessed and Given Influenza Vaccination ** SCIP_INF1 Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection *** SCIP_INF2 Surgery patients who were given the right kind of antibiotic to help prevent infection SCIP_INF3 Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) SCIP_VTE1 Surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries SCIP_VTE2 Patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery ** p<.05 *** p<.01 Source: CMS Hospital Compare Downloads. All years are based on calendar year except for 2010, which includes discharges between April 2010 through March Notes: Hospitals with <25 cases are excluded from the analysis. US 7

8 Exhibit 4: State-wide Trends in Hospital-Acquired Conditions, State Fiscal Year (FY) PPC Number and Name Risk Adjusted Complication Annual Change FY 2009 FY 2010 FY 2011 FY FY YEAR TOTAL COST CHANGE All Complications % *** % *** - $110,957,872 PPC1 Stroke & Intracranial Hemorrhage % % - $250,565 PPC2 Extreme CNS Complications % % - $968,065 PPC3 Acute Pulmonary Edema and Respiratory Failure without Ventilation % ** % *** - $4,739,899 PPC4 Acute Pulmonary Edema and Respiratory Failure with Ventilation % % ** - $2,231,164 PPC5 Pneumonia & Other Lung Infections % *** % *** - $10,286,330 PPC6 Aspiration Pneumonia % ** % - $2,052,555 PPC7 Pulmonary Embolism % *** 2.08% - $357,218 PPC8 Other Pulmonary Complications % *** % - $1,466,468 PPC9 Shock % % *** - $3,654,322 PPC10 Congestive Heart Failure % *** % *** - $2,636,381 PPC11 Acute Myocardial Infarction % *** % *** - $2,332,140 PPC12 Cardiac Arrythmias & Conduction Disturbances % 0.67% - $44,424 PPC13 Other Cardiac Complications % *** % ** - $364,816 PPC14 Ventricular Fibrillation/Cardiac Arrest % *** % - $5,566,386 PPC15 Peripheral Vascular Complications Except Venous Thrombosis % *** % *** - $1,402,443 PPC16 Venous Thrombosis % *** 0.98% - $2,414,287 PPC17 Major Gastrointestinal Complications without Transfusion or Significant Bleeding % *** 0.00% - $2,641,855 PPC18 Major Gastrointestinal Complications with Transfusion or Significant Bleeding % % - $156,733 PPC19 Major Liver Complications % % - $338,033 PPC20 Other Gastrointestinal Complications without Transfusion or Significant Bleeding % % $107,935 PPC22 Urinary Tract Infection % *** % *** - $17,254,363 PPC23 GU Complications Except UTI % * % *** - $468,867 PPC24 Renal Failure without Dialysis % ** % - $1,905,891 PPC25 Renal Failure with Dialysis % % - $461,888 PPC26 Diabetic Ketoacidosis & Coma % 0.00% $35,470 PPC27 Post- Hemorrhagic & Other Acute Anemia with Transfusion % % ** - $608,184 PPC28 In- Hospital Trauma and Fractures % % * - $266,330 PPC31 Decubitus Ulcer % *** 0.73% - $5,554,086 PPC33 Cellulitis % *** % - $798,443 PPC34 Moderate Infectious % ** % *** - $1,626,652 PPC35 Septicemia & Severe Infections % *** % *** - $16,564,123 PPC36 Acute Mental Health Changes % % * - $258,851 PPC37 Post- Operative Infection & Deep Wound Disruption Without Procedure % % ** - $992,140 PPC38 Post- Operative Wound Infection & Deep Wound Disruption with Procedure % % ** - $448,209 PPC39 Reopening Surgical Site % *** 5.00% $1,850,052 PPC40 Post- Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure or I&D Proc % *** % *** - $4,154,100 8

9 Exhibit 4: State-wide Trends in Hospital-Acquired Conditions, State Fiscal Year (FY) Continued PPC41 PPC Number and Name Risk Adjusted Complication Annual Change FY 2009 FY 2010 FY 2011 FY FY Post- Operative Hemorrhage & Hematoma with Hemorrhage Control Procedure or I&D 2 YEAR TOTAL COST CHANGE Proc % 2.42% $134,742 PPC42 Accidental Puncture/Laceration During Invasive Procedure % *** % - $1,254,462 PPC43 Accidental Cut or Hemorrhage During Other Medical Care % % $29,824 PPC44 Other Surgical Complication - Moderate % *** % ** - $1,600,776 PPC47 Encephalopathy % ** % - $1,543,462 PPC48 Other Complications of Medical Care % ** 12.75% ** - $216,874 PPC49 Iatrogenic Pneumothrax % % $83,125 PPC50 Mechanical Complication of Device, Implant & Graft % % * - $780,030 PPC51 Gastrointestinal Ostomy Complications % % - $484,861 PPC52 Inflammation & Other Complications of Devices, Implants or Grafts Except Vascular Infection % *** % ** - $1,956,314 PPC53 Infection, Inflammation & Clotting Complications of Peripheral Vascular Catheters & Infusions % *** % * - $2,127,790 PPC54 Infections due to Central Venous Catheters % *** % * - $2,664,025 PPC56 Obstetrical Hemorrhage wtih Transfusion % 7.94% $189,077 Excluded PPC21 Clostridium Difficile Colitis % *** 3.24% - $2,679,475 PPC29 Poisonings Except from Anesthesia % * 0.00% - $1,059 PPC30 Poisonings due to Anesthesia na PPC32 Transfusion Incompatibility Reaction $22,291 PPC45 Post- procedure Foreign Bodies % 0.00% $4,311 PPC46 Post- Operative Substance Reaction & Non- O.R. Procedure for Foreign Body na PPC55 Obstetrical Hemorrhage without Transfusion % *** 0.54% $284,537 PPC57 Obstetric Lacerations & Other Trauma Without Instrumentation % *** 1.71% na PPC58 Obstetric Lacerations & Other Trauma With Instrumentation % % na PPC59 Medical & Anesthesia Obstetric Complications % *** % na PPC60 Major Puerperal Infection and Other Major Obstetric Complications % * % *** na PPC61 Other Complications of Obstetrical Surgical & Perineal Wounds % 5.34% na PPC62 Delivery with Placental Complications % % na PPC63 Post- Operative Respiratory Failure with Tracheostomy % % * - $2,423,108 PPC64 Other In- Hospital Adverse Events % *** % - $614,643 * p<.10 ** p<0.5 *** p<0.01 **** p<0.001 na: Marginal cost of complication is not statistically significant. Source: HSCRC Inpatient Discharge Data Set. Notes: Rates are risk adjusted using All Patient Refined Diagnosis Related Groups (APR- DRGs) and Severity of Illness Categories (SOI). Cost estimates are based on added cost of each PPC using linear regression analysis of charges in each year. 9