Guiding Principles

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Guiding Principles

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

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