EVALUATION OF THE QUALITY OF PRESENT-ON-ADMISSION CODING

Score Grade Hospitals (#)Hospitals

(%)

>95% A 31 16.6%

>90% to 95% B 34 18.2%

>80% to 90% C 41 21.9%

>70% to 80% D 26 13.9%

>70% or lower F 55 29.4%

Total Scored 187 100%

POA Screening Results for Sample Hospital Scores for High-Risk Medical Conditions

Screen Score

Range*

Chronic medical conditions 1 1 to 6

Acute and chronic components 1 1 to

2High prevalence of hospital-acquired 2 1 to

4High mortality when hospital-acquired 3 1 to

5

* 1 = Best Result

POA Screening Results for Sample Hospital Scores for Elective Surgical Procedures

Screen Score

Range*

Chronic medical conditions 1 1 to 6

Acute and chronic components 1 1 to

2

Relative contraindications 3 1 to 5

Routine cases with long postop LOS 2 1 to

2

* 1 = Best Result

POA Screening Results for Sample Hospital Scores for Labor and Delivery

Screen Score

Range*

Chronic medical conditions 1 1 to 6

Pre-labor obstetrical conditions 3 1 to

6Inconsistent coding of delivery 1 1 to

4Inconsistent coding of complications 1 1 to

5

* 1 = Best Result

POA Screening Results for Sample HospitalScores for General Screens and Aggregate Performance

Screen Score

Range*

Miscoded exempt codes 1 1 to 5

Miscoded non-exempt codes 2 1 to 6

Miscoded principal diagnoses 3 1 to 6

* 1 = Best Result

Overall Performance Score

Grade

All 15 screens 83.5% C

Distribution of Hospital Total Scores

Score Grade Hospitals (#) Hospitals (%)

>95% A 31 16.6%

>90% to 95% B 34 18.2%

>80% to 90% C 41 21.9%

>70% to 80% D 26 13.9%

>70% or lower F 55 29.4%

Total Scored 187 100%

COMPARISON OF RISK-ADJUSTED CLINICAL PERFORMANCE

Hospital

L

Hospital

K

Hospital

J

Hospital

I

Hospital

H

Hospital

G

Hospital

F

Hospital

E

Hospital

D

Hospital

C

Hospital

B

Hospital

A

0%

2%

4%

6%

8%

10%

12%

14%

Mortality in Percent

Observed and Predicted Hospital Mortality Rates

Congestive Heart Failure

Hos-pital L

Hos-pital

K

Hos-pital J

Hos-pital I

Hos-pital

H

Hos-pital

G

Hos-pital F

Hos-pital E

Hos-pital

D

Hos-pital C

Hos-pital

B

Hos-pital

A

0%

2%

4%

6%

8%

10%

12%

AVG P > 0.05 P = 0.01 to 0.05 Observed Predicted

Mortality in Percent

Observed and Predicted Hospital Adverse Outcome Rates

Congestive Heart Failure

Hos-pital

K

Hos-pital J

Hos-pital I

Hos-pital

H

Hos-pital

G

Hos-pital F

Hos-pital E

Hos-pital

D

Hos-pital C

Hos-pital

B

Hos-pital

A

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

AVG P > 0.05 P = 0.01 to 0.05 Observed Predicted

Adverse Outcome Rate in Percent

Hospital CostCongestive Heart Failure

A B C D E F G H I J K L M N O P Q R S T-$1,250

-$1,000

-$750

-$500

-$250

$0

$250

$500

$750

$1,000

$1,250

Total Cost Routine CostHOSPITAL

Ob

serv

ed

min

us P

red

icte

d C

ost

($)

Adverse Outcomes and Hospital CostsCongestive Heart Failure

$4 $6 $8 $10 $12 $140%

8%

16%

24%

32%

40%

Suboptimal Performance Reference Standard

Total Hospital Cost (thousands $)

% A

dvers

e O

utc

om

e R

ate 13.82

%$6,62

9

7.99%$5,59

6

Observed and Predicted 30-Day Readmission Rate

Congestive Heart Failure

Hos-pital

K

Hos-pital J

Hos-pital I

Hos-pital

H

Hos-pital

G

Hos-pital F

Hos-pital E

Hos-pital

D

Hos-pital C

Hos-pital

B

Hos-pital

A

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

AVG P > 0.05 P = 0.01 to 0.05 Observed Predicted

Adverse Outcome Rate in Percent

DISTRIBUTION OF ADVERSE OUTCOMES

Low Risk Moderate Risk

High Risk0%5%

10%15%20%25%30%35%40%45%

Observed

Advers

e O

utc

om

e R

ate

(%

)

Distribution of Adverse OutcomesCongestive Heart Failure

Low Risk Moderate Risk High Risk0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Observed Predicted

Ad

vers

e O

utc

om

e R

ate

(%

)

Chi-square = 1.85N.S.

Asymmetrical Relationships of Observed and Predicted Outcomes Provide Insights about

Clinical Effectiveness

Overall Results

Less Success

with High Risk

Balanced

Less Success with Low

RiskSuperior

Average

Suboptimal

Effect of Risk on Performance

Superior Practice with

Low Risk Cases

Superior Practice

Across All Risk Groups

Superior Practice with

High Risk Cases

Special Problems with High Risk Cases

Suboptimal Practice

Across All Risk Groups

Special Problems

with Low Risk Cases

Potential Problems with High Risk Cases

No Particular Strengths or Weaknesses

Potential Problems

with Low Risk Cases

DYNAMIC PERSPECTIVE USING CONTROL CHARTS

1/9

1/15

1/18

1/25

1/31

2/12

2/13

2/21

2/26

3/3

3/13

3/21

4/3

4/8

4/22

5/13

6/5

7/3

7/16

7/26

8/20

10/4

10/29

11/26

12/10

12/30

0%

2%

4%

6%

8%

10%

12%

Date of Last Event in Interval

Sta

nd

ard

ized

Ad

vers

e

Ou

tco

me R

ate

Mortality RateCongestive Heart Failure

1/9

1/15

1/18

1/25

1/31

2/12

2/13

2/21

2/26

3/3

3/13

3/21

4/3

4/8

4/22

5/13

6/5

7/3

7/16

7/26

8/20

10/4

10/29

11/26

12/10

12/30

0%

2%

4%

6%

8%

10%

12%

Avg 1 SD 2 SD 3 SD

Last Date in Interval

Sta

nd

ard

ized

Ad

vers

e O

utc

om

e

Rate

(%

)

Adverse Outcome RateCongestive Heart Failure

1/11

1/19

1/26

1/30

2/19

2/27

3/4

3/21

3/31

4/7

4/20

4/26

5/12

5/24

6/3

6/19

6/29

7/23

8/1

8/12

8/22

8/31

9/11

9/22

9/29

10/9

10/17

10/24

11/1

11/13

11/21

11/29

12/6

12/8

12/18

12/25

0%

5%

10%

15%

20%

25%

30%

35%

Avg 1 SD 2 SD 3 SD

Last Date in Interval

Sta

nd

ard

ized

Ad

vers

e O

utc

om

e

Rate

(%

)

Routine CostCongestive Heart Failure

1/8

1/16

1/24

2/1

2/9

2/17

2/25

3/5

3/13

3/21

3/29

4/6

4/14

4/22

4/30

5/8

5/16

5/24

6/1

6/9

6/17

6/25

7/3

7/11

7/19

7/27

8/4

8/12

8/20

8/28

9/5

9/13

9/21

9/29

10/7

10/15

10/23

10/31

11/8

11/16

11/24

12/2

12/10

12/18

12/26

$3

$4

$5

$6

$7

$8

Avg 1 SD 2 SD 3 SD

Last Date in Interval

Sta

nd

ard

ized

Cost

in $

1,0

00

ASSESSMENT OF COMPARATIVE COST-EFFECTIVENESS

Outcome(Best Providers)

Input(Not A or C)

Input(B† only in high

risk)

Comparison

Outcome(Worst

Providers)

Conclusion(Best Practice = Awith B† only in high

risk)

Cost-Effective

Ineffective

Risk Stratification

Comparative

Effectiveness

Comparative

Effectiveness

Traditional Comparative Effectiveness Analyses

Congestive Heart Failure (First Line Therapy)

Input A(+ Diuretics)

Input A†

(++ Diuretics)

Comparative

Effectiveness

Conclusion(Best Practice =

A+B† +C)

Input B†

(+ Vasodilators)

Input B(No

Vasodilators)

Comparative

EffectivenessInput C

(No Pressors)Input C†

(+ Pressors)

Superior

Inferior

Patient-Centered Comparative Cost-Effectiveness Analysis

Congestive Heart Failure (First Line Therapy)

Outcome(Best Providers)

Comparative

Effectiveness

Input(Not A† or C†)

Input(B† only in high

risk)

Comparison

Outcome(Worst

Providers)

Conclusion(Best Practice = Awith B† only in high

risk)

Cost-Effective

Ineffective

Risk Stratification