Measuring Complications of Treatment: Diagnoses Not Present on Admission. Henry Johnson, MD MPH Medical Director June 6, 2007

Measuring Complications of Treatment: Diagnoses Not Present on Admission Henry Johnson, MD MPH Medical Director June 6, 2007

Summary Present on Admission (POA) Field for Secondary Diagnoses. History. Research supporting its use to find complications of care. UB 04. Deficit Reductions Act of 2005, use by Medicare. Profile of POA frequency in a sample hospital. Current use of the field in DataVision. ReporTrack use for Care Management 7.0 rev8 or higher.

Introduction 2007: All secondary diagnoses will be designated as Present on Admission (POA) or not. UB 04 has fields for this data. Medicare begins collecting data October 2007. 2008: Medicare will choose at least two sets of two or more DRG s where there is a secondary diagnosis which triggers a CC DRG, and deny payment for the higher paying DRG [with CC], if the secondary diagnosis that triggers the CC was not present at admission.

How can POA help us? Knowing which secondary diagnoses were present on admission, allows you (as well as Medicare) to find those patients who went home with that little extra something: UTI Pneumonia CHF Hip Fracture

Current State At discharge, every inpatient chart is abstracted. ICD-9 codes are assigned for every diagnosis and procedure. A grouper assigns a DRG.

Current State, continued Principal Diagnosis: That condition established after study to be chiefly responsible for occasioning the admission. (Uniform Hospital Discharge Data Set, UHDDS)

Current State, continued Secondary Diagnoses: Everything else. UB-92: All secondary diagnoses listed without further notation. UB-04: All diagnoses will be designated as present on admission (Y), not present at admission (N), No information in the record (U), Clinically undetermined (W), or Exempt from POA Reporting (Unreported/Not Used).

Current State, continued All other data must be entered manually. Core measures. Specialty databases: Society of Thoracic Surgeons. Transplant databases. There is little tolerance for collecting more data manually: Abstracted/Coded data is our Interstate and we must make best use of it.

Background: Measuring performance based on administrative data: 1991: Naessens et. al. reported that the separation of secondary diagnoses into preexisting vs. acquired could: Be reliably undertaken by discharge abstractors. Be efficient in adding minimal time to coding. Enhance the validity and usefulness of data and increase physician acceptance. Naessens JM, Brennan MD, Boberg CJ, Amadio PC, Karver PH, Podratz RO. Acquired conditions: an improvement to hospital discharge abstracts. Qual Assur Helath Care 1991;3(4):257-62

Background, continued: 1990 s: California Office of Statewide Health Planning and Development (OSHPD) ran the California Hospital Outcomes Project: Romano, Remy and Luft (UC Davis and UCSF) created regression models to risk adjust the data. Problem: Is a secondary diagnosis a pre-existing condition that puts patients in a higher risk category, or a complication of care (adverse outcome). Example: AMI patients with secondary diagnosis of CHF: Risk factor, or complication of care?

Background, continued:... misclassifying conditions diagnosed after admission as risk factors leads to significant bias in the Model B regression coefficients.... This finding supports OSHPD s decision to report the results of the two models separately, and confirms the importance of adding a data element indicating whether each diagnosis was present at admission to the hospital discharge data system. Romano, Remy and Luft, Second Report of the California Hospital Outcomes Project (1996): Acute MI Volume Two: Technical Appendix-Chapter 15 The data element for diagnosis present at admission added to California hospital reporting in January 1996.

83 yo woman, 12 day admission. DRG 557 PCI w/ drug eluting stent w/ maj CV Dx Code Diagnosis POA DX1 410.51 AMI LATERAL NEC, INITIAL Present on Admission DX2 414.01 CRNRY ATHRSCL NATVE VSSL Present on Admission DX3 427.31 ATRIAL FIBRILLATION Not Present on Admission DX4 707.19 ULCER OTH PART LOW LIMB Present on Admission DX5 428.0 CHF NOS Present on Admission DX6 584.9 ACUTE RENAL FAILURE NOS Not Present on Admission DX7 570 ACUTE NECROSIS OF LIVER Not Present on Admission DX8 276.1 HYPOSMOLALITY Not Present on Admission DX9 459.81 VENOUS INSUFFICIENCY NOS Present on Admission DX10 401.9 HYPERTENSION NOS Present on Admission DX11 574.20 CHOLELITHIASIS NOS Present on Admission DX12 451.84 PHLBTS VN NOS UP EXTRM Not Present on Admission DX13 250.00 DMII WO CMP NT ST UNCNTR Present on Admission DX14 041.11 STAPHYLOCOCCUS AUREUS Present on Admission DX15 V09.0 INF MCRG RSTN PNCLLINS Present on Admission

83 yo woman, 12 day admission. DRG 557 PCI w/ drug eluting stent w/ maj CV Dx Code Diagnosis POA DX1 410.51 AMI LATERAL NEC, INITIAL Present on Admission DX2 414.01 CRNRY ATHRSCL NATVE VSSL Present on Admission DX3 427.31 ATRIAL FIBRILLATION Not Present on Admission DX4 707.19 ULCER OTH PART LOW LIMB Present on Admission DX5 428.0 CHF NOS Present on Admission DX6 584.9 ACUTE RENAL FAILURE NOS Not Present on Admission DX7 570 ACUTE NECROSIS OF LIVER Not Present on Admission DX8 276.1 HYPOSMOLALITY Not Present on Admission DX9 459.81 VENOUS INSUFFICIENCY NOS Present on Admission DX10 401.9 HYPERTENSION NOS Present on Admission DX11 574.20 CHOLELITHIASIS NOS Present on Admission DX12 451.84 PHLBTS VN NOS UP EXTRM Not Present on Admission DX13 250.00 DMII WO CMP NT ST UNCNTR Present on Admission DX14 041.11 STAPHYLOCOCCUS AUREUS Present on Admission DX15 V09.0 INF MCRG RSTN PNCLLINS Present on Admission

41 yo man, 18 day admission. DRG 110, Mayor CV procedures with CC Code Diagnosis POA DX1 410.11 AMI ANTERIOR WALL, INIT Present on Admission DX2 518.81 ACUTE RESPIRATRY FAILURE Present on Admission DX3 584.9 ACUTE RENAL FAILURE NOS Present on Admission DX4 427.41 VENTRICULAR FIBRILLATION Present on Admission DX5 427.5 CARDIAC ARREST Present on Admission DX6 785.51 CARDIOGENIC SHOCK Present on Admission DX7 428.0 CHF NOS Present on Admission DX8 996.72 COMP-OTH CARDIAC DEVICE Not Present on Admission DX9 507.0 FOOD/VOMIT PNEUMONITIS Not Present on Admission DX10 599.0 URIN TRACT INFECTION NOS Not Present on Admission DX11 348.30 ENCEPHALOPATHY NOS Not Present on Admission DX12 414.01 CRNRY ATHRSCL NATVE VSSL Present on Admission DX13 401.9 HYPERTENSION NOS Present on Admission DX14 300.00 ANXIETY STATE NOS Present on Admission DX15 272.4 HYPERLIPIDEMIA NEC/NOS Present on Admission

41 yo man, 18 day admission. DRG 110, Mayor CV procedures with CC Code Diagnosis POA DX1 410.11 AMI ANTERIOR WALL, INIT Present on Admission DX2 518.81 ACUTE RESPIRATRY FAILURE Present on Admission DX3 584.9 ACUTE RENAL FAILURE NOS Present on Admission DX4 427.41 VENTRICULAR FIBRILLATION Present on Admission DX5 427.5 CARDIAC ARREST Present on Admission DX6 785.51 CARDIOGENIC SHOCK Present on Admission DX7 428.0 CHF NOS Present on Admission DX8 996.72 COMP-OTH CARDIAC DEVICE Not Present on Admission DX9 507.0 FOOD/VOMIT PNEUMONITIS Not Present on Admission DX10 599.0 URIN TRACT INFECTION NOS Not Present on Admission DX11 348.30 ENCEPHALOPATHY NOS Not Present on Admission DX12 414.01 CRNRY ATHRSCL NATVE VSSL Present on Admission DX13 401.9 HYPERTENSION NOS Present on Admission DX14 300.00 ANXIETY STATE NOS Present on Admission DX15 272.4 HYPERLIPIDEMIA NEC/NOS Present on Admission

Is there any evidence to support collecting this data (POA) on all secondary diagnoses? CAUTION: Research

Naessens JM, Huschka TR: Distinguishing hospital complications of care from pre-existing conditions. International Journal for Quality in Health Care 2004: Volume 16, Supplement 1: pp i27-i35 Objective: To compare cases identified through the Complications Screening Program (CSP) with cases using the same ICD-9 secondary diagnosis codes, where the identifying diagnosis is also indicated as not present at admission. Setting: 84,436 discharges from Mayo Clinic Rochester.

Naessens JM, Huschka TR: Distinguishing hospital complications of care from pre-existing conditions. International Journal for Quality in Health Care 2004: Volume 16, Supplement 1: pp i27-i35 Outcome: % of algorithm complication cases indicated as developing in the hospital. % of acquired conditions of that type detected by the computer algorithms. Incremental hospital charges, length of stay and mortality associated with acquired complications.

All admissions CSP Dx Acquired

Naessens JM, Huschka TR: Distinguishing hospital complications of care from pre-existing conditions. International Journal for Quality in Health Care 2004: Volume 16, Supplement 1: pp i27-i35 Results: % of cases identified through the computer algorithm that were also coded as acquired varied from 8.8% to 100%. The ability of the computer algorithms to detect acquired conditions of that type varied from 2% to 99%.

Complication Cases with complication as defined by algorithm, N Positive Predictive Value % algorithm complications identified as developing in hospital Cases with acquired conditiion coded, N Sensitivity Percent of acquired conditions detected by algorithm % Septicemia 25 48.00% 238 5.00% Shock or cardiorespiratory arrest in hospital 13 46.20% 174 3.40% Postoperative acute myocardial infarction 125 52.80% 215 30.70% Venous thrombosis and pulmonary embolism 241 20.30% 118 41.50% Wound infection 572 47.60% 274 99.30% Post-procedural hemorrhage or hematoma 1602 66.20% 1064 99.70% Inhospital hip fracture or fall 66 40.90% 30 90.00%

Naessens JM, Huschka TR: Distinguishing hospital complications of care from pre-existing conditions. International Journal for Quality in Health Care 2004: volume 16, Supplement 1: pp i27-i35 Conclusions: Complication rates based strictly on standard discharge abstracts prior to UB-04 have limited use due to insensitivity of existing computer algorithms to exclude conditions present on admission from true complications. Adding an indicator identifying which diagnoses were present on admission greatly increases the accurate identification of complications for internal quality and patient safety improvement.

UB-04 Expanded field size to accommodate ICD-10 for both procedures and diagnoses. Box to indicate which ICD version hospital is using. Room for 16 diagnosis codes (UB-92 had 9). Larger field size for procedure codes on outpatient claims. Fields to designate each diagnosis as Y Yes N No U No information in the record W Clinically Undetermined (unreported, not used) Exempt from POA reporting

Medicare: Deficit Reduction Act of 2005

Deficit Reduction Act of 2005 In addition, this section would reduce payments to hospitals in some cases when the patient acquires an infection during a hospital stay. In particular, the Secretary of Health and Human Services would be required to select at least two sets of two or more diagnosis-related groups (DRGs) in which it is common for patients who otherwise would be assigned to a lowerpaying DRG to be assigned to the higher-paying DRG when there is a secondary diagnosis that results from infections acquired during the hospital stay. For discharges occurring on or after October 1, 2008, Medicare would set the payment rate for cases involving those DRGs at the level of the lower-paying DRG if the secondary diagnoses that resulted in assignment to the higher-paying DRG were not present at the time of admission.

CMS, Proposed Rules for 2008 include: [Released April 13, 2007] Severity adjust DRG s. No payment for additional costs of hospital acquired conditions. Expanded list of publicly reported measures.

CMS: Proposed Selection of Hospital-Acquired Conditions: Proposed Rule FY2008 [April 13, 2007] Catheter associated urinary tract infections. Pressure ulcers (decubitus ulcers). Serious preventable event object left in surgery. Serious preventable event air embolism. Serious preventable event blood incompatibility. Staphylococcus aureus septicema. Ventilator associated pneumonia. Vascular catheter associated infections. Clostridium difficile-associated disease. Methicillin-resistent staphylococcus aureus. Surgical site infections. Serious preventable event wrong surgery. Falls.

Top Six: Catheter associated urinary tract infections: Good codes, triggers CC pair, prevention guidelines exist, high cost and high frequency. Pressure ulcers (decubitus ulcers): Good codes, high volume, high cost, prevention guidelines exist, codes triggers CC in a pair, Serious preventable event object left in surgery. Good codes, rare event with high costs (removal), prevention exists, triggers CC, Serious preventable event air embolism: Rare, but meets criteria. Serious preventable event blood incompatibility. Rare, but meets criteria. Staphylococcus aureus septicema. Codes complex, but meets criteria.

Also Ran: Ventilator associated pneumonia. No unique codes. Vascular catheter associated infections. No specific code. Clostridium difficile-associated disease. Preventable? No best practice. Methicillin-resistent staphylococcus aureus. Prevention issues. Surgical site infections. Code too broad Serious preventable event wrong surgery. No DRG CC pair for this. Falls. Cannot identify coding issue.

Sample Frequency Distributions: What to expect when we begin to code secondary diagnoses as present (or not) on admission.

Sample Hospital: Discharges by MDC, 12 months MDC Description Total % NPOA Totals 1 Nervous System Sum of All POA 1026 Sum of 1 or More NPOA 154 15.0% 1180 2 Eye Sum of All POA 53 Sum of 1 or More NPOA 3 5.7% 56 3 ENT Sum of All POA 322 Sum of 1 or More NPOA 23 7.1% 345 4 Respiratory Sum of All POA 1518 Sum of 1 or More NPOA 244 16.1% 1762 5 Circulatory Sum of All POA 2051 Sum of 1 or More NPOA 466 22.7% 2517 6 Digestive Sum of All POA 1240 Sum of 1 or More NPOA 312 25.2% 1552 7 Hepatobiliary and Pancreas Sum of All POA 526 Sum of 1 or More NPOA 112 21.3% 638 8 Muscuskeletal System and Conn T. Sum of All POA 1802 Sum of 1 or More NPOA 442 24.5% 2244 9 Skin, SQ Tissue, and Breast Sum of All POA 777 Sum of 1 or More NPOA 67 8.6% 844 10 Endo, Nutrit, Metabolic Sum of All POA 1984 Sum of 1 or More NPOA 260 13.1% 2244

MDC 5, Circulatory, top 19 DRG s by volume DRG DRG Desc Cases >= 1 Dx Total %NPOA NPOA 127 HEART FAILURE & SHOCK 315 42 357 12% 124 CIRCULATORY DISORDERS EXCEPT AMI, W CAR 116 19 135 14% 138 CARDIAC ARRHYTHMIA & CONDUCTION DISORD 105 11 116 9% 143 CHEST PAIN 102 4 106 4% 121 CIRCULATORY DISORDERS W AMI & MAJOR COM 72 23 95 24% 144 OTHER CIRCULATORY SYSTEM DIAGNOSES W C 78 16 94 17% 141 SYNCOPE & COLLAPSE W CC 78 8 86 9% 107 CORONARY BYPASS W CARDIAC CATH 37 45 82 55% 116 OTH PERM CARDIAC PACEMAKER IMPLANT OR P 73 7 80 9% 130 PERIPHERAL VASCULAR DISORDERS W CC 67 12 79 15% 125 CIRCULATORY DISORDERS EXCEPT AMI, W CAR 64 7 71 10% 132 ATHEROSCLEROSIS W CC 55 2 57 4% 110 MAJOR CARDIOVASCULAR PROCEDURES W CC 11 34 45 76% 122 CIRCULATORY DISORDERS W AMI W/O MAJOR C 39 2 41 5% 120 OTHER CIRCULATORY SYSTEM O.R. PROCEDUR 25 15 40 38% 109 CORONARY BYPASS W/O CARDIAC CATH 20 13 33 39% 134 HYPERTENSION 29 4 33 12% 113 AMPUTATION FOR CIRC SYSTEM DISORDERS EX 15 16 31 52% 105 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC P 16 14 30 47%

Uses in MIDAS+/DV Software On server: DV Navigator: Excel export and macros. Physician Profiles. ReporTrack Reporting. Care Management 7.0 rev 8 or higher.

CHF Frequency/1000 ACA DRG 127: July 05 to June 06

CHF Frequency/1000 ACA DRG 127: July 05 to June 06 Complications of Care Total Cases 232 # Cases with all Dx present on admission 212 # Cases with one or more Dx Not Present on Admission 20 Major Complications Not Present On Admission Acute Myocardial Infarction 0 Pneumonia 3 Congestive Heart Failure 0 Acute Renal Failure 1 Ischemic Stroke 0 Sepsis 0 Pulmonary Embolus 0 Deep Venous Thrombosis 0

CHF Frequency/1000 ACA DRG 127: July 05 to June 06 Other Complications Not Present On Admission Diagnosis Total URIN TRACT INFECTION NOS 3 ACUTE RESPIRATRY FAILURE 3 ATRIAL FIBRILLATION 2 CARDIAC ARREST 2 HYPOPOTASSEMIA 2 HYPOSMOLALITY 2 HYPOTENSION NOS 2 NAUSEA WITH VOMITING 2

Pivot Table Count of Account No. Not POA Count2 One or More Years End Dt 0 Dx Not POA Grand Total 2005 Jul 15 1 16 Aug 17 2 19 Sep 11 1 12 Oct 12 12 Nov 17 4 21 Dec 17 1 18 2006 Jan 21 21 Feb 22 1 23 Mar 23 2 25 Apr 25 1 26 May 16 2 18 Jun 16 5 21 Grand Total 212 20 232

DV Navigator: Physician Profiles

All inpatient encounters, all providers

ReporTrack Reporting You can identify patients based on any secondary diagnosis not present on admission in Care Management 7.0 rev 8 or higher.

Summary Present on Admission (POA) Field for Secondary Diagnoses. History. Research supporting its use to find complications of care. UB 04. Deficit Reductions Act of 2005, use by Medicare. Profile of POA frequency in a sample hospital. Current use of the field in DataVision. ReporTrack use for Care Management 7.0 rev8 or higher.