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Guiding Principles
 

Guiding Principles

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    Guiding Principles Guiding Principles Presentation Transcript

    • OSHPD Public Reporting Program Zhongmin Li, Ph.D. UCD K-30 Methods in Clinical Research July 26, 2006
    • Overview
      • What is OSHPD?
      • What is CCORP?
      • How the CABG report cards were produced?
    • What is the Office of Statewide Health Planning and Development (OSHPD)?
      • Facilities Development
        • Seismic safety
        • Code compliance
      • Cal-Mortgage
        • Facility financing
      • Workforce and Community Development
        • Health professions training
        • Nursing initiative
      • Healthcare data
        • PDD, utilization, financial
        • Inpatient, ED and ASC
      • Healthcare Quality and Analysis Division
        • Hospital outcome reports – (HOC)
        • Data dissemination - HIRC
    • Healthcare Outcomes Center (HOC)
      • 2 Programs within HOC:
        • Clinical Data (Heart bypass surgery & ICU outcomes)
        • Patient Discharge Data (heart attack, pneumonia)
      • 12 professional/administrative staff with 3 Senior Ph.D.-level research scientists
      • Contracts with University of California researchers
    • OSHPD’s Outcome Programs
      • Coronary Artery Bypass Graft (CABG) Surgery (2006 – hospitals and surgeons)
      • Intensive Care Outcomes (Final study and recc.-2005)
      • Acute Myocardial Infarction (2002)
      • Community-Acquired Pneumonia (2004)
      • Maternal Outcomes (2006)
      • Hip Fracture surgery (2006)
      Studies Using Clinical Data Studies Using Patient Discharge Data Gold = Reports that have been or will shortly be released
    • OSHPD Reports and Report Cards
    • What is the California CABG Outcomes Reporting Program (CCORP)?
      • Started as voluntary program in 1995 by OSHPD & PBGH
      • Mandatory data reporting for all Coronary Artery Bypass Graft ( CABG ) surgery
      • Risk-adjusted operative mortality reported publicly reported for:
        • Hospitals (annually starting 2003 data)
        • Surgeons (bi-annually starting 2003-04 data)
      • A Clinical Advisory Panel of heart surgeons, consumers, cardiologists, and university researchers
    • What is CCORP (Cont’d)?
      • Clinical risk-adjustment to account for differences in patient severity of illness (case-mix)
      • Yearly patient medical records audit to ensure data integrity
      • First data year: Jan-Dec 2003, received from 121 hospitals
      • Approximately 300 California surgeons
      • UCDMC has been participating since 1997
    • Rationale for CCORP
      • Senate Bill 680 (Figueroa, Statutes of 2001)
      • CABG is one of the most expensive hospital surgeries and ranks among top 10 procedures for volume and mortality rate
      • Limitations of the voluntary OSHPD/PBGH program
      • Comparative quality information informs:
        • Consumer choice
        • Healthcare purchasing
        • Quality improvement by physicians and hospitals
      • Salience of surgeon-level outcomes
    • CCORP Clinical Advisory Panel (CAP) Members
      • Robert Brook, M.D. (Chair) RAND and UCLA
      • Andrew Bindman, M.D. UCSF and S.F. General
      • Ralph Brindis, M.D. Kaiser Northern California
      • Cheryl Damberg, Ph.D. Pacific Business Group on Health
      • Timothy Denton, M.D. Cedars Sinai
      • Coyness Ennix, M.D. Alta Bates Medical Center
      • Keith Flachsbart, M.D. Kaiser San Francisco
      • Fred Grover, M.D. University of Colorado, STS
      • James MacMillan, M.D. Valley Heart Surgeons, Modesto
    • Unadjusted Isolated CABG Inpatient Mortality Rates for CA and Other States (1996-2004) NOTE: MA = 30-day mortality
    • Hospital Distribution of Unadjusted In-Hospital Mortality Rate: Avg. = 2.4% (2003)
    • Hospital Distribution of Risk Adjusted Operative Mortality: Avg. = 2.9% (2003)
    • CCORP 2003 Hospital Performance Ratings for Operative Mortality 2003 CCORP public report was released in March 2006 http://www.oshpd.state.ca.us Total 121 100.0% Significantly Better 4 3.3% No Difference 113 93.4% Significantly Worse 4 3.3% No. of Hospitals Percent
    • How CABG Report Cards Were Produced?
      • Data Collection
      • Source
      • Data elements (59; not exact same as STS)
      • Hospital reporting tools
      • Acceptance criteria
      • Deadline and Extension
      • OSHPD staff support
        • Data abstraction manual
        • Training of coders
    • How CABG Public Report Was Produced (Cont’d)?
      • Data Cleaning and Validation
      • Data quality report (DQR)
      • Data Linkage/discrepancy report (DDR)
      • On-site data audit
        • Audit strategy
        • Sample selection
      • “ As good as you can get”?
    • Risk Adjustment
      • Central to the report cards
      • Why Isolated CABGs only
      • Inpatient vs. operative mortality
      • Risk model
        • Development
        • Validation
        • Testing (c-statistics; calibration)
        • CAP approval
      • Identification of quality outliers
        • 95%CI
        • Exact Poisson Probability
    • Major Risk Factors
      • Demographic (Age/Gender/Race/BMI)
      • Operative status
      • Pre-operative comobidities (Creatinine/Dialysis/Diabetes/CVD/PVD/CLD/Hypertension/Hepatic failure, etc.)
      • Cardiac (Arrhythmia type/MI timing/CHF/Shock)
      • Previous intervention (Prior CABG/PCI)
      • Hemodynamic status (EF/Left main/# of diseased vessels/Mitral insufficiency)
    • Risk Adjustment Model
      • Expected rate = Intercept + X*B, where
        • B-Coefficients estimated on CCORP data using logistic regression (PROC LOGISTIC in SAS)
        • X includes age, gender and each of risk factors
      • Risk-adjusted rate=
      • Observed rate*
      • (Population rate/Expected rate)
      • Alternative formula:
      • Risk-adjusted rate=
      • Population rate*
      • (Observed rate/Expected rate)
    • Risk Adjustment Example
      • Risk adjustment “adjusts” the observed rate of Hospital A to account for differences between the case-mix of Hospital A and the reference population
      • The larger the difference between the rate was expected for Hospital A and the population rate, the larger the adjustment
      • If a hospital has the same case-mix as the reference population, then no adjustment is made
    • Risk Adjustment Example
      • Population rate > Hospital A Expected rate
        • Hospital A has a less severe case-mix than the population
        • “ adjustment factor” is >1
        • Risk Adjusted rate is higher then observed rate
        • If hospital A had the same case-mix as the population, we would expect their observed rate to be higher
    • Risk Adjustment Example
      • Population rate < Hospital A Expected rate
        • Hospital A has a more severe case-mix than the population
        • “ adjustment factor” is <1
        • Risk Adjusted rate is lower then observed rate
        • If hospital A had the same case-mix as the population, we would expect their observed rate to be lower
    • Report Review and Appeal Process
      • Prior to public release:
      • Hospital review (60-day)
      • Surgeon review (30-day)
      • Surgeon can appeal for
        • Flawed data
        • Flawed risk adjustment
      • 1 st surgeon level report: Winter 2006
    • What’s Next for CCORP?: NQF National Voluntary Cardiac Surgical Measures
      • Gold = currently collected by CCORP or will be collected in 2006
      • 1. Participation in a systematic database for cardiac surgery
      • 2. Surgical volume for isolated CABG surgery, valve surgery, and CABG + valve surgery
      • 3. Timing of antibiotic administration for cardiac surgery patients
      • 4. Selection of antibiotic administration for cardiac surgery patients
      • 5. Pre-operative beta blockade
      • 6. Use of internal mammary artery
      • 7. Duration of prophylaxis for cardiac surgery patients
      • 8. Prolonged intubation
      • 9. Deep sternal wound infection rate
      • 10. Stroke/cerebrovascular accident
      • 11. Post-operative renal insufficiency
    • NQF National Voluntary Cardiac Surgical Measures (Cont’d)
      • 12. Surgical re-exploration
      • 13. Anti-platelet medications at discharge
      • 14. Beta blockade at discharge
      • 15. Anti-lipid treatment at discharge
      • 16. Risk-adjusted inpatient operative mortality for CABG
      • 17. Risk-adjusted operative mortality for CABG
      • 18. Risk-adjusted operative mortality for AVR
      • 19. Risk-adjusted operative mortality for MVR
      • 20. Risk-adjusted operative mortality for MVR+CABG
      • 21. Risk-adjusted operative mortality for AVR+CABG
    • IMA Usage Rates as a Reportable Process Measure of Quality
      • Internal Mammary Artery Graft
      • “ Standard” conduit for CABGs
      • Supported by extensive clinical trials and research
      • Priority research area of performance - NQF
      • Process of Care element - STS
      • Reported by “Leap Frog” Group
      • IMA data and clinical info. available - CCORP
    • Hospital Variation in Left Internal Mammary Artery (LIMA) Use: CCORP 2003
      • Percent LIMA Use*
      • <60 -
      • 60-74 -
      • 75-84 -
      • 85-94 -
      •  95 -
      • Avg. LIMA Use: 89.1% -
      • * Rates are after exclusions for certain patient subgroups
      • Number of Hospitals (%)
      • 1 (1%)
      • 11 (9%)
      • 17 (14%)
      • 48 (40%)
      • 44 (36%)
      • 121 total hospitals
      • *UCDMC - 92.5%
    • CPB Used vs. OPCABG
      • Operative Mortality
      • Off Pump CABGs
      • 9,025 (22.3%) 2.17%
      • On Pump CABGs
      • 31,380 (77.7%) 3.36%
      • UCDMC - < 2%
    • How Are Hospital CABG Report Results Used?
      • Hospital tiered networks: Blue Cross Cardiac “Centers of Expertise” and Blue Shield “Cardiac Quality Initiative”
      • Private Healthcare data providers such as Subimo
      • Purchaser coalitions such as Leapfrog, PBGH (Healthscope consumer website)
      • Public Access through OSHPD website:
      • http://www.oshpd.state.ca.us/HQAD/Outcomes/index.htm
      • CHART
      • Hospital Promotion
    • Questions
      • OSHPD web site ( www.oshpd.ca.gov )
      • Contact HIRC at (916) 322-2814 to obtain copy of the report