Ross JS, Bernheim SM, Lin Z, Drye EE, Chen J, Normand ST, et al. Based on key measures, care quality for Medicare enrollees at safety-net and non-safety-net hospitals was almost equal. Health Aff (Millwood). 2012;31(8). APPENDIX EXHIBITS Appendix Exhibit A1: ICD-9-CM Diagnostic Codes page 2 Appendix Exhibit A2: Patient Comorbidity Codes Used To Risk- Standardize Hospital Mortality and Readmission Rates page 10 Appendix Exhibit A3: Patient Characteristics page 16 Appendix Exhibit A4: Hospital Characteristics page 20 Appendix Exhibit A5: Mortality Rate Histograms page 23 Within-MSA Mortality and Readmission Rates between Safety and Non-Safety Hospital, stratified by: Appendix Exhibit A6: Teaching Status page 25 Appendix Exhibit A7: Revascularization Capacity page 27 Appendix Exhibit A8: Condition-Specific Volume page 29 Appendix Exhibit A9: Bed Size page 31 Appendix Exhibit A10: Readmission Rate Histograms page 33 1
Appendix Exhibit A1: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes used to identify patients who were hospitalized for acute myocardial infarction, heart failure, and pneumonia. Acute Myocardial Infarction Heart Failure Pneumonia ICD-9-CM Description ICD-9-CM Description ICD-9-CM Description 410.00 Acute Myocardial Infarction (anterolateral wall) episode of care unspecified 410.01 Acute Myocardial Infarction (anterolateral wall) initial episode of care 402.01 Malignant hypertensive heart disease with heart failure 402.11 Benign hypertensive heart disease with heart failure 480.3 Pneumonia due to Severe Acute Respiratory Syndrome (SARS)- associated coronavirus 480.8 Viral pneumonia: pneumonia due to other virus not elsewhere classified 410.10 Acute Myocardial 402.91 Hypertensive heart 480.9 Viral pneumonia: 2
Infarction (other anterior wall) episode of care unspecified 410.11 Acute Myocardial Infarction (other anterior wall) initial episode of care 410.20 Acute Myocardial Infarction (inferolateral wall) episode of care unspecified 410.21 Acute Myocardial Infarction (inferolateral disease with heart failure 404.01 Malignant hypertensive heart and renal disease with heart failure 404.03 Malignant hypertensive heart and renal disease with heart failure and renal failure 404.11 Benign hypertensive heart and renal disease with heart viral pneumonia, unspecified 481 Pneumococcal pneumonia (Streptococcus pneumoniae pneumonia) 482.0 Other bacterial pneumonia: pneumonia due to Klebsiella pneumoniae 482.1 Other bacterial pneumonia: pneumonia due to 3
wall) initial episode of care 410.30 Acute Myocardial Infarction (inferoposterior wall) episode of care unspecified 410.31 Acute Myocardial Infarction (inferoposterior wall) initial episode of care 410.40 Acute Myocardial Infarction (other inferior wall) episode of care failure 404.13 Benign hypertensive heart and renal disease with heart failure and renal failure 404.91 Hypertensive heart and renal disease with heart failure 404.93 Hypertensive heart and renal disease with heart failure and renal failure Pseudomonas 482.2 Other bacterial pneumonia: pneumonia due to Hemophilus influenzae (H. influenzae) 482.30 Pneumonia due to Streptococcus: Streptococcus, unspecified 482.31 Pneumonia due to Streptococcus: Group A 4
unspecified 410.41 Acute Myocardial Infarction (other inferior wall) initial episode of care 428.0 Congestive heart failure 482.32 Pneumonia due to Streptococcus: Group B 410.50 Acute Myocardial Infarction (other lateral wall) 428.1 Left heart failure 482.39 Pneumonia due to Streptococcus: Other Streptococcus episode of care unspecified 410.51 Acute Myocardial Infarction (other lateral wall) initial episode of care 428.9 Heart failure, unspecified 482.41 Pneumonia due to Staphylococcus: Pneumonia due to Staphylococcus, unspecified 410.60 Acute Myocardial 482.42 Pneumonia due to 5
Infarction (true posterior wall) episode of care unspecified 410.61 Acute Myocardial Infarction (true posterior wall) initial episode of care 410.70 Acute Myocardial Infarction (subendocardial) Staphylococcus: Pneumonia due to Staphylococcus aureus 482.49 Pneumonia due to Staphylococcus: Other Staphylococcus pneumonia 482.81 Pneumonia due to other specified bacteria: Anaerobes episode of care unspecified 410.71 Acute Myocardial Infarction (subendocardial) 482.82 Pneumonia due to other specified bacteria: 6
initial episode of care 410.80 Acute Myocardial Infarction (other specified site) episode of care unspecified 410.81 Acute Myocardial Infarction (other specified site) initial episode of care 410.90 Acute Myocardial Infarction (unspecified site) episode of care Escherichia coli (E. coli) 482.83 Pneumonia due to other specified bacteria: Other gram-negative bacteria 482.84 Pneumonia due to other specified bacteria: Legionnaires disease 482.89 Pneumonia due to other specified bacteria: Other specified bacteria unspecified 7
410.91 Acute Myocardial Infarction (unspecified site) initial episode 482.9 Other bacterial pneumonia: Bacterial pneumonia unspecified of care 483.0 Pneumonia due to other specified organism: Mycoplasma pneumoniae 483.1 Pneumonia due to other specified organism: Chlamydia 483.8 Pneumonia due to other specified organism: Other specified organism 8
485 Bronchopneumonia, organism unspecified 486 Pneumonia, organism unspecified 487.0 Influenza with pneumonia 9
Appendix Exhibit A2: Patient demographic characteristics, cardiovascular past medical history, and co-morbid conditions included in risk-standardization models for 30-day mortality and 30-day readmission for acute myocardial infarction, heart failure, and pneumonia hospitalizations. Acute Myocardial Infarction Heart Failure Pneumonia RSMR RSRR RSMR RSRR RSMR RSRR Demographics Mean Age * * * * * * Female, % * * * * * * Cardiovascular Past Medical History,* % History of PTCA * * * * History of CABG Surgery * * * * * * Heart Failure (CC 80) * * * * * * Myocardial Infarction (CC 81) Anterior MI (ICD-9 410.00-410.19) Inferior/Lateral/ Posterior MI (ICD-9 410.20-410.69) * * * * * * * * * * 10
Unstable Angina (CC 82) * * * * * * Chronic Atherosclerosis (CC 83-84) Cardiopulmonary-Respiratory Failure and Shock (CC 79) Valvular Heart Disease (CC 86) * * * * * * * * * * * * * * * * * Arrhythmia (CC 92-93) * * * Other Unspecified Heart Disease (CC 94) * Co-morbid Condition,* % Hypertension (CC 89, 91) * * * Stroke (CC 95-96) * * * * * * Cerebrovascular Disease (CC 97-99, 103) Peripheral Vascular Disease (CC 104-106)* * * * * * * * * * Renal Failure (CC 131) * * * * * * End-Stage Renal Disease (CC 129-130) * * * Nephritis (CC 132) * Urinary Tract Infection (CC 135) * 11
Urinary Tract Disorders (CC 136) Chronic Obstructive Pulmonary Disease (CC 108) * * * * * * * * * Fibrosis of Lung and Other Chronic Lung Disorders (CC * * * 109) Asthma (CC 110) * * * * Pneumonia (CC 111-113) * * * * * * Pleural Effusion/Pneumothorax (CC * 114) Other Lung Disorders (CC 115) * Diabetes (CC 15-20, 120) * * * * * Protein-Calorie Malnutrition (CC 21) Fluid and Electrolyte Disorders (CC 22-23) * * * * * * * * * Dementia (CC 49-50) * * * * * * Functional Disability (CC 67-69, 100-102, 177-178) * * * * * * Metastatic Cancer (CC 7-12) * * * * * * 12
Major Psychiatric Disorders (CC 54-56) Other Psychiatric Disorders (CC 60) * * * * * * * Depression (CC 58) * * Drug/Alcohol Abuse (CC 51-53) Chronic Liver Disease (CC 25-30) * * * * * * Peptic Ulcer and other Specified GI Disorders (CC * 34) Other GI Disorders (CC 36) * * Severe Hematological Disorder (CC 44) * * * Iron Deficiency (CC 47) * * * * Parkinson s and Huntington s Diseases (CC * 73) Seizure Disorders and Convulsions (CC 74) * Vertebral Fractures (CC * * 13
157) Trauma in Last Year (CC 154-156, 158-162) * * * Other Injuries (CC 162) * Decubitus Skin Ulcer (CC 148-149) Other History of Infection (CC 1, 3-6) * * * * * Septicemia/Shock (CC 2) * Notes: The hospital-specific RSMR and RSRR for each condition is calculated from estimates derived from two-level (patient and hospital) hierarchical generalized linear models. First-level modeling adjusted 30-day mortality rates for patient age, sex, and clinical characteristics using a logit-link. Second-level modeling included hospital-level random intercepts assumed to be normally distributed in order to account for the clustering (non-independence) of patients within the same hospital, permitting separation of within-hospital and between-hospital variation after adjusting for patient characteristics. RSMR = Risk-Standardized Mortality Rate; RSRR = Risk-Standardized Readmission Rate; PTCA = Percutaneous Transluminal Coronary Angioplasty; CABG = Coronary Artery Bypass Graft; CC = Centers for Medicare and Medicaid Service (CMS) Condition Category; GI = Gastrointestinal. 14
* Peripheral vascular disease CMS condition categories for mortality measures included CCs 104 and 105, readmission measures included CCs 104-106. Metastatic cancer CMS condition categories for mortality measures included CCs 7 and 8, readmission measures included CCs 7-12, except for the pneumonia readmission measure which included CCs 7-10. Chronic liver disease CMS condition categories for mortality measures included CCs 25-27, the heart failure readmission measure included CCs 25-30. 15
Appendix Exhibit A3: Select patient demographic characteristics, cardiovascular past medical history, and co-morbid conditions for fee-for-service Medicare beneficiaries admitted for (mortality analyses) or discharged after (readmission analyses) acute myocardial infarction, heart failure, and pneumonia from 2006-2008 at an urban hospital located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital, stratified by hospital safety net status. Acute Myocardial Infarction Heart Failure Pneumonia Mortality Readmission Mortality Readmission Mortality Readmission Analyses Analyses Analyses Analyses Analyses Analyses Safe ty Safe ty Safe ty Safe ty Safe ty Safe ty Non- Safe ty Non- Safe ty Non- Safe ty Non- Safe ty Non- Safe ty Non- Safe ty Total No. of Patients (%) 63,2 89 (20. 239, 075 (79. 66,7 81 (21. 251, 470 (79. 117, 595 (20. 456, 272 (79. 149, 863 (20. 568, 457 (79. 107, 241 (20. 427, 666 (80. 114, 212 (20. 450, 776 (79. 16
9) 1) 0) 0) 5) 5) 9) 1) 0) 0) 2) 8) Demographics Age: mean (SD) 78.4 (8.0 ) 79.3 (8.0 ) 78.0 (7.9 ) 78.7 (7.9 ) 79.6 (8.1 ) 80.9 (7.9 ) 79.3 (8.0 ) 80.5 (7.9 ) 79.6 (8.2 ) 80.5 (8.0 ) 79.4 (8.1 ) 80.3 (8.0 ) Female, % 50.2 51.1 49.9 50.5 57.3 57.2 56.7 56.3 55.5 56.7 55.4 56.5 Cardiovascula r Past Medical History,* % History of PCI History of CABG Surgery 8.0 7.8 9.0 8.8 7.1 7.1 -- -- 3.4 3.6 -- -- 6.4 6.0 6.7 6.1 10.8 11.0 11.9 12.2 4.8 5.0 5.0 5.2 Heart Failure 31.5 30.5 34.3 33.1 74.0 73.2 77.5 76.4 38.6 38.1 39.0 38.4 Co-morbid 17
Condition,* % Hypertension 81.2 80.6 -- -- 87.0 85.4 -- -- 80.2 79.3 -- -- Stroke 8.8 8.6 8.6 8.5 10.7 11.2 10.7 11.2 11.3 11.4 11.3 11.4 Renal Failure 18.4 17.6 19.2 18.4 36.9 35.6 38.7 37.2 20.6 19.3 20.5 19.3 COPD 29.6 29.2 30.6 30.1 46.7 45.8 47.6 46.6 54.5 54.2 55.4 55.0 Pneumonia 23.7 23.3 23.9 23.5 41.4 42.6 42.0 41.9 42.9 42.2 44.8 43.8 Dementia 17.9 17.5 17.0 16.6 20.8 21.3 20.3 20.6 29.4 29.0 29.2 28.8 Chronic Liver Disease 1.2 1.0 -- -- 2.5 2.1 -- -- 1.9 1.6 -- -- Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Notes: SD = Standard Deviation; PCI = Percutaneous Coronary Intervention; CABG = Coronary Artery Bypass Graft; COPD = Chronic Obstructive Pulmonary Disease. Double dashed lines (- -) indicate that this variable was not included in the risk-adjustment model for this measure. Risk-adjustment models included age, sex, and the same clinical characteristic variables used for the risk-standardization measures developed for each condition 18
independently for the Centers for Medicare & Medicaid Services and endorsed by the National Quality Forum (NQF) for hospital performance evaluation. For a full list of included characteristics, please see Appendix Table 2. * Cardiovascular past medical history and co-morbid conditions were based on hierarchical condition categories, with the exception of history of PTCA and CABG surgery. 19
Appendix Exhibit A4: Hospital characteristics for urban hospitals located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital that hospitalized fee-for-service Medicare beneficiaries for acute myocardial infarction, heart failure, and pneumonia from 2006-2008, stratified by hospital safety net status. Acute Myocardial Infarction Heart Failure Pneumonia Safety Safety Safety Non- Safety Non- Safety Non- Safety Total No. of 310 953 376 1057 384 1063 Hospitals (%) (24.5) (75.5) (26.2) (73.8) (26.5) (73.5) Mean Annual Condition- 215.4 263.9 398.6 537.8 297.4 424.1 Specific (248.4) (272.3) (365.4) (420.2) (229.0) (294.6) Volume (SD) Cardiac Revasculariza tion Capacity, % 20
CABG Surgery 52.9 43.6 45.0 39.5 43.8 39.2 PCI only 22.6 17.6 20.2 16.8 19.8 16.6 PCI 24.5 38.8 34.8 43.8 36.5 44.2 Ownership Status, % For-Profit 10.7 23.9 11.4 25.3 11.7 25.2 Profit 36.1 76.1 33.5 74.7 32.8 74.8 Public 53.2 0 55.1 0 55.5 0 Teaching Status, % Non-teaching 48.7 69.9 52.1 71.4 53.7 71.3 Residency or fellowship 20.7 18.9 20.7 18.0 19.5 18.1 Non-CABG/Non- Not-For- programaffiliated COTH Member 30.7 11.2 27.1 10.6 26.8 10.6 Mean Medicaid Caseload* (SD) 0.29 (0.13) 0.14 (0.07) 0.29 (0.14) 0.14 (0.07) 0.29 (0.15) 0.14 (0.07) Mean No. 362.3 292.1 324.4 274.4 322.6 273.3 Hospital Beds (232.4) (215.3) (232.0) (213.9) (235.0) (213.7) 21
Set Up and Staffed (SD) Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Notes: SD = Standard Deviation; PCI = Percutaneous Coronary Intervention; CABG = Coronary Artery Bypass Graft; COTH = Council of Teaching. * Medicaid caseload is the ratio of Medicaid hospital discharges to total hospital admissions. 22
Appendix Exhibit A5: Histogram frequency distributions for safety net and non-safety net hospital 30-day risk-standardized mortality rates for patients admitted for acute myocardial infarction (A), heart failure (B), and pneumonia (C), 2006-2008. A. B. C. 23
Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Note: Because there were substantially greater numbers of non-safety net hospitals than safety net hospitals, rather than plot the RSMR distributions using number of hospitals along the y axis, we used density, or the number of hospitals per unit of area, with the unit of area set at 1 for each distribution. 24
Appendix Exhibit A6: Mean absolute within-msa percentage differences between safety net and non-safety net hospital 30-day all-cause risk-standardized mortality and readmission rates for urban hospitals located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital that hospitalized fee-forservice Medicare beneficiaries for acute myocardial infarction, heart failure, and pneumonia from 2006-2008, stratified by hospital teaching status of the safety net hospital(s). Within-MSA Mean Risk-Standardized Rate Percentage Difference (95% Confidence Interval) Safety net hospital* is a teaching hospital Safety net hospital* is a non-teaching hospital Acute Myocardial Infarction Mortality Rate 0.60 (0.16, 1.05) 0.71 (0.30, 1.13) Readmission Rate 0.57 (0.26, 0.88) 0.10 (-0.18, 0.39) Heart Failure Mortality Rate -0.13 (-0.41, 0.15) 0.29 (-0.05, 0.63) Readmission Rate 0.93 (0.59, 1.27) 0.73 (0.30, 1.17) 25
Pneumonia Mortality Rate 0.73 (0.34, 1.12) -0.01 (-0.38, 0.36) Readmission Rate 0.67 (0.38, 0.96) 0.15 (-0.14, 0.43) Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Note: If MSA contained only a singly safety net hospital, this hospital was used to determine teaching status. If MSA contained more than one safety net hospital, teaching status was determined using the majority of patients who obtained care at a safety net hospital within the MSA. 26
Appendix Exhibit A7: Mean absolute within-msa percentage differences between safety net and non-safety net hospital 30-day all-cause risk-standardized mortality and readmission rates for urban hospitals located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital that hospitalized fee-forservice Medicare beneficiaries for acute myocardial infarction, heart failure, and pneumonia from 2006-2008, stratified by hospital cardiovascular revascularization capacity of the safety net hospital(s). Within-MSA Mean Risk-Standardized Rate Percentage Difference (95% Confidence Interval) Safety net hospital* has capacity to provide cardiovascular revascularization services Safety net hospital* does not have capacity to provide cardiovascular revascularization services Acute Myocardial Infarction Mortality Rate 0.55 (0.19, 0.92) 1.29 (0.64, 1.95) Readmission Rate 0.39 (0.12, 0.65) 0.43 (0.07, 0.79) Heart Failure 27
Mortality Rate -0.02 (-0.28, 0.24) 0.44 (0.07, 0.80) Readmission Rate 0.66 (0.34, 0.98) 0.86 (0.40, 1.32) Pneumonia Mortality Rate 0.40 (0.06, 0.73) 0.14 (-0.32, 0.61) Readmission Rate 0.55 (0.29, 0.80) 0.07 (-0.28, 0.42) Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Note: If MSA contained only a singly safety net hospital, this hospital was used to determine cardiovascular revascularization capacity. If MSA contained more than one safety net hospital, cardiovascular revascularization capacity was determined using the majority of patients who obtained care at a safety net hospital within the MSA. 28
Appendix Exhibit A8: Mean absolute within-msa percentage differences between safety net and non-safety net hospital 30-day all-cause risk-standardized mortality and readmission rates for urban hospitals located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital that hospitalized fee-forservice Medicare beneficiaries for acute myocardial infarction, heart failure, and pneumonia from 2006-2008, stratified by hospital condition-specific volume of the safety net hospital(s). Within-MSA Mean Risk-Standardized Rate Percentage Difference (95% Confidence Interval) Safety net hospital* condition-specific volume average Safety net hospital* condition-specific volume < average Acute Myocardial Infarction Mortality Rate -0.02 (-0.51, 0.47) 1.11 (0.69, 1.52) Readmission Rate -0.21 (-0.57, 0.14) 0.64 (0.33, 0.95) Heart Failure Mortality Rate -0.19 (-0.57, 0.20) 0.21 (-0.06, 0.47) 29
Readmission Rate 0.55 (0.13, 0.98) 0.88 (0.52, 1.25) Pneumonia Mortality Rate 0.29 (-0.18, 0.77) 0.42 (0.06, 0.79) Readmission Rate 0.49 (0.11, 0.86) 0.53 (0.25, 0.81) Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Notes: * If MSA contained only a singly safety net hospital, this hospital was used to determine condition-specific volume. If MSA contained more than one safety net hospital, condition-specific volume was determined using the majority of patients who obtained care at a safety net hospital within the MSA. Average condition-specific volume was 250 for acute myocardial infarction analyses, 450 for heart failure analyses, and 375 for pneumonia analyses. 30
Appendix Exhibit A9: Mean absolute within-msa percentage differences between safety net and non-safety net hospital 30-day all-cause risk-standardized mortality and readmission rates for urban hospitals located within a metropolitan statistical area (MSA) that contained at least one safety net and non-safety net hospital that hospitalized fee-forservice Medicare beneficiaries for acute myocardial infarction, heart failure, and pneumonia from 2006-2008, stratified by hospital bed size of the safety net hospital(s). Within-MSA Mean Risk-Standardized Rate Percentage Difference (95% Confidence Interval) Safety net hospital* bed size average Safety net hospital* bed size < average Acute Myocardial Infarction Mortality Rate 0.55 (0.10, 1.01) 0.74 (0.34, 1.13) Readmission Rate 0.35 (0.01, 0.68) 0.31 (0.02, 0.61) Heart Failure Mortality Rate 0.05 (-0.26, 0.36) 0.06 (-0.22, 0.35) Readmission Rate 0.79 (0.42, 1.16) 0.85 (0.45, 1.26) Pneumonia 31
Mortality Rate 0.67 (0.30, 1.03) 0.01 (-0.36, 0.38) Readmission Rate 0.56 (0.28, 0.84) 0.34 (0.04, 0.64) Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Notes: * If MSA contained only a singly safety net hospital, this hospital was used to determine bed size. If MSA contained more than one safety net hospital, bed size was determined using the majority of patients who obtained care at a safety net hospital within the MSA. Average bed size was 325 for acute myocardial infarction analyses, 300 for heart failure and pneumonia analyses. 32
Appendix Exhibit A10: Histogram frequency distributions for safety net and non-safety net hospital 30-day risk-standardized readmission rates for patients admitted for acute myocardial infarction (A), heart failure (B), and pneumonia (C), 2006-2008. A. B. C. 33
Source: Authors analysis of the Centers for Medicare and Medicaid Services Standard Analytic Files and Enrollment Database, used in conjunction with the American Hospital Association Annual Survey. Note: Because there were substantially greater numbers of non-safety net hospitals than safety net hospitals, rather than plot the RSRR distributions using number of hospitals along the y axis, we used density, or the number of hospitals per unit of area, with the unit of area set at 1 for each distribution. 34