Agency For Healthcare Research And Quality Patient Safety Indicators Research Articles

Improvement in Patient Safety May Precede Policy Changes: Trends in Patient Safety Indicators in the United States, 2000-2013.

Quality and safety improvement are global priorities. In the last two decades, the United States has introduced several payment reforms to improve patient safety. The Agency for Healthcare Research and Quality (AHRQ) developed tools to identify preventable inpatient adverse events using administrative data, patient safety indicators (PSIs). The aim of this study was to assess changes in national patient safety trends that corresponded to U.S. pay-for-performance reforms. This is a retrospective, longitudinal analysis to estimate temporal changes in 13 AHRQ's PSIs. National inpatient sample from the AHRQ and estimates were weighted to represent a national sample. We analyzed PSI trends, Center for Medicaid and Medicare Services payment policy changes, and Inpatient Prospective Payment System regulations and notices between 2000 and 2013. Of the 13 PSIs studied, 10 had an overall decrease in rates and 3 had an increase. Joinpoint analysis showed that 12 of 13 PSIs had decreasing or stable trends in the last 5 years of the study. Central-line blood stream infections had the greatest annual decrease (-31.1 annual percent change between 2006 and 2013), whereas postoperative respiratory failure had the smallest decrease (-3.5 annual percent change between 2005 and 2013). With the exception of postoperative hip fracture, significant decreases in trends preceded federal payment reform initiatives. National in-hospital patient safety has significantly improved between 2000 and 2015, as measured by PSIs. In this study, improvements in PSI trends often proceeded policies targeting patient safety events, suggesting that intense public discourses targeting patient safety may drive national policy reforms and that these improved trends may be sustained by the Center for Medicare and Medicaid Services policies that followed.

Impact of Patient Safety Indicators on readmission after abdominal aortic surgery

Patient safety is a critical component of health-care quality and measures created by the Agency for Healthcare Research and Quality (AHRQ) to identify hospitalizations with potentially preventable adverse events. This analysis evaluated whether Patient Safety Indicator (PSI) events after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) were associated with increased risk of readmission. Patients undergoing elective repair of nonruptured AAA from 2009 to 2012 were selected in the Medicare Provider Analysis and Review files using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To identify PSI events, we used the AHRQ PSI International Classification of Diseases, Ninth Revision, Clinical Modification numerator codes. Chi-square test, multivariable logistic regression analysis, nonparametric Wilcoxon rank sum test, and Kaplan-Meier survival analysis were used for statistics. A total of 66,923 patients undergoing elective AAA repair were evaluated: (1) 9,315 with OSR and (2) 57,608 with EVAR. The most frequent PSI events after OSR versus EVAR were postoperative respiratory failure (PSI, 11; 17.7% vs 1.8%; P<.0001); perioperative hemorrhage/hematoma (PSI, 9; 3.6% vs 2.6%; P<.0001); postoperative sepsis (PSI, 13; 3.5% vs 0.4%; P<.0001); accidental puncture or laceration (PSI, 15; 2.1% vs 0.6%; P<.0001); and postoperative acute kidney injury requiring dialysis (PSI, 10; 1.4% vs 0.2%; P<.0001). The overall 30-day readmission rate was 10.5%. The occurrence of any PSI event overall significantly increased 30-day readmission compared with no event cases (odds ratio [OR]=1.71; 95% confidence interval [CI], 1.57-1.86). Likelihood of 30-day readmission was greater for postoperative acute kidney injury requiring dialysis (OR=1.66; 95% CI, 1.28-2.15), postoperative respiratory failure (OR=1.36; 95% CI, 1.22-1.52), perioperative hemorrhage (OR=1.34; 95% CI, 1.18-1.52), and postoperative pressure ulcer (OR = 2.88; 95% CI, 1.99-4.17). Occurrence of any PSI event was associated with an increased total hospital and intensive care unit length of stay and total hospital charges (all P<.001). In conclusion, AHRQ PSI events may be used to identify patients at the greatest risk for readmission after AAA repair. The risk for 30-day readmission was 71% higher when a PSI event occurred and was not associated with the type of repair. Minimizing preventable PSI events may be beneficial to reducing hospital readmissions after open and endovascular AAA repair and to improving hospital resource utilization.

Tailoring an educational program on the AHRQ Patient Safety Indicators to meet stakeholder needs: lessons learned in the VA

BackgroundGiven that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders’ needs. In this paper, we share what we learned from this program development process.MethodsOur study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders’ educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders’ needs/interests. A post-program survey evaluated program participants’ perceptions about the PSI educational program.ResultsInterview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed—three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive.ConclusionsConducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders’ needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.

Assessing Estimates of Patient Safety Derived From Coded Data.

The Agency for Healthcare Research and Quality (AHRQ) developed Patient Safety Indicators (PSI) with the goal of detecting and preventing adverse events using administrative data. Use of PSIs to measure safety and quality of care raises questions since they rely heavily on coded data. The goal of this paper is to review literature on AHRQ PSIs, specifically their accuracy in detecting adverse events, and how recent coding changes affect the accuracy of these estimates. The Healthcare Utilization Project (HCUP) National Inpatient Sample (NIS) contains data on more than seven million hospital stays yearly. Trending these estimates over time indicate there has been a decrease in rates for the majority of PSIs, with Accidental Puncture or Laceration, Central Venous Catheter Blood Stream Infections, Iatrogenic Pneumothorax, and Deaths from complications decreasing significantly each year from 2008-2012. Birth Trauma, Retained Foreign Bodies, Post-op Sepsis and Post-Op Respiratory Failure PSIs show no improvement from 2008-2012. A literature review on accuracy of PSIs and the affect of the Present on Admission (POA) indicator on PSI estimates reveals mixed results. PSIs serve as a useful tool in identifying problem areas in quality of care but should be used cautiously in determining hospital performance.

Feasibility of administrative data for studying complications after hip fracture surgery

PurposeThere is limited information in administrative databases on the occurrence of serious but treatable complications after hip fracture surgery. This study sought to determine the feasibility of identifying the occurrence...

Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery

The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) is a clinically-derived, validated tool to track outcomes in surgery. The Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are a set of computer algorithms run on administrative data to identify adverse events. The purpose of this study is to compare complications following orthopedic surgery identified by ACS-NSQIP and AHRQ-PSI. Patients between 2010 and 2012 who underwent orthopedic procedures (arthroplasty, spine, trauma, foot and ankle, hand, and upper extremity) at our tertiary-care, academic institution were identified (n= 3,374). Identification of inpatient adverse events by AHRQ-PSI in the cohort was compared with 30-day events identified by ACS-NSQIP. Adverse events common to both AHRQ-PSI and ACS-NSQIP were infection, sepsis, venous thromboembolism, bleeding, respiratory failure, wound disruption, and renal failure. Concordance between AHRQ-PSI and ACS-NSQIP for identifying adverse events was examined. A total of 729 adverse events (21.6%) were identified in the cohort using ACS-NSQIP methodology and 35 adverse events (1.0%) were found using AHRQ-PSI. Only 12 events were identified by both methodologies. The most common complication was bleeding in ACS-NSQIP (18.1%) and respiratory failure in AHRQ-PSI (0.53%). The overlap was highest for venous thromboembolic events. There was no overlap in adverse events for 5 of the 7 categories of adverse events. A large discrepancy was observed between adverse events reported in ACS-NSQIP and AHRQ-PSI. A large percentage of clinically important adverse events identified in ACS-NSQIP were missed in AHRQ-PSI algorithms. The ability of AHRQ-PSI for detecting adverse events varied widely with ACS-NSQIP. AHRQ-PSI algorithms currently are insufficient to assess the quality of orthopedic surgery.

Hospital-Level Factors Related to 30-Day Readmission Rates.

This study investigates the relationship between inpatient quality of care as measured by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicator (PSI) composite and all-cause, hospital-wide, 30-day readmission rates. Discharge data from 4 statewide databases were analyzed. Linear, repeated-measures regressions were performed to predict hospital-level 30-day readmission rates. The mean readmission rate was 12.9%, and the mean PSI composite ratio was 0.95 among 524 hospitals with 2592 observations. In the hospital-level analysis, the risk-adjusted AHRQ PSI composite was not significantly associated with hospital 30-day readmission rate after controlling for hospital-level characteristics, patient case mix, and sociodemographics. Inpatient quality of care appears to have less influence on hospital readmission rates than do clinical and socioeconomic factors. However, these results suggest that a patient safety composite measure that includes postdischarge complications would provide more information to assist hospitals and communities in understanding the association between quality of care and readmission rates.

Improved Coding of Postoperative Deep Vein Thrombosis and Pulmonary Embolism in Administrative Data (AHRQ Patient Safety Indicator 12) After Introduction of New ICD-9-CM Diagnosis Codes

Symptomatic venous thromboembolism is a common postoperative complication. The Agency for Healthcare Research and Quality (AHRQ) has developed a Patient Safety Indicator 12 to assist hospitals, payers, and other stakeholders to identify patients who experienced this complication. To determine whether newly created and recently redefined ICD-9-CM codes improved the criterion validity of Patient Safety Indicator 12, based on new samples of records dated after October 2009. Two sources of data were used: (1) UHC retrospective case-control study of risk factors for acute symptomatic venous thromboembolism occurring within 90 days after total knee arthroplasty in teaching hospitals; (2) chart abstraction data by volunteer hospitals participating in the Validation Pilot Project of the AHRQ. In the UHC sample, the positive predictive value (PPV) was 99% (125/126) and the negative predictive value was 99.4% (460/463). In the AHRQ sample, the overall PPV was 81% (126/156). The PPV based on both samples shows substantial improvement compared with the previously reported PPVs of 43%-48%, suggesting that changes in ICD-9-CM code architecture and better coding guidance can improve the usefulness of coded data.

Anesthesia complications as a childbirth patient safety indicator.

The Agency for Healthcare Research and Quality (AHRQ) has established multiple sets of indicators for quality monitoring and improvement. One such set is the patient safety indicators (PSIs), which focuses on potentially preventable hospital complications after surgeries, procedures, and childbirth. Our objective in this study was to determine the prevalence of childbirth-related anesthesia complications by method of delivery and to evaluate the variation in complication rates across hospitals using the AHRQ PSI methodology and a modification specific to childbirth with the goal of determining the relevance of tracking anesthesia complications as a potential PSI for childbirth. The technical specifications of the experimental Anesthesia Complication Quality Indicator, one of the PSI defined by AHRQ, were modified to create a childbirth-specific indicator that included all childbirth admissions (vaginal and cesarean deliveries) and complications from general and neuraxial anesthesia/analgesia. Using California hospital discharge data, we calculated hospital-specific rates, adjusting for age, race/ethnicity, and pregnancy complications. A total of 508,842 deliveries occurred in 254 hospitals in California in 2009. Hospitals with <200 annual deliveries (N = 12) were excluded from analyses. Among 242 hospitals, the rate of anesthesia complications was 0.13% for the standard AHRQ study population (adult surgical admissions, which included cesarean deliveries). The childbirth-specific rate of anesthesia complications was 0.31%. When stratified by method of delivery, complication rates were 0.49% for cesarean delivery and 0.22% for vaginal delivery (P < 0.0001). The unadjusted mean (SD) was 0.34% (0.34%), with range (0%-2.46%). The rates of 13 hospitals (including their 95% confidence limits) remained in the upper quartile as outliers, with adjusted rates from 0.52% to 2.13%. Rates of childbirth-related anesthesia complications may provide an opportunity to identify hospitals with extreme rates that may provide insights into systematic ways to improve patient safety.

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for Targeting Nursing Quality Improvement

Quantifying the critical impact nurses have on the prevention and early recognition of potential complications and adverse events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI), is becoming increasingly important. In this paper, we describe how the AHRQ PSI may be used to identify nursing-specific opportunities to improve care based on data from the national AHRQ PSI validation pilot project.

Establishing standard performance measures for adult brain tumor patients: a nationwide inpatient sample database study

The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services (CMS) hospital acquired conditions (HACs) are used to evaluate the safety and quality of health care. We determined the incidence rates of PSIs and HACs among brain tumor patients in the Nationwide Inpatient Sample database (NIS). We queried the NIS for all hospitalizations involving a brain tumor. We determined the incidence rates of various PSIs and HACs among these patients by searching the hospital records for codes in the International Classification of Diseases, 9th Revision indicating each PSI or HAC. Among the 501 908 hospitalizations involving a brain tumor in the NIS, there were 102 046 occurrences of an AHRQ PSI, with 16% of patients experiencing one or more AHRQ PSI. Among brain tumor patients treated without surgery, 17.2% experienced ≥ 1 PSI. Among brain tumor patients treated with surgery, 9.8% experienced ≥ 1 PSI. The most common PSIs were postoperative respiratory failure, deep vein thrombosis, and sepsis. The total number of HACs associated with brain tumor patients was 13 778, with 2.63% of patients experiencing ≥1 HAC. Among brain tumor patients treated without surgery, 3.0% experienced ≥ 1 HAC. Among brain tumor patients treated with surgery, 7.4% experienced ≥ 1 HAC. The most common HACs were falls and trauma and pressure ulcers. Increasing comorbidity score was associated with increased likelihood of almost all PSIs and HACs. These data may be used to determine individual institutional improvements or success by comparison.

AHRQ Patient Safety Indicators: Time to Include Hemorrhage and Infection During Childbirth

Many Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) partially or completely exclude pregnant women. Both postoperative hemorrhage or hematoma (PSI 9; hemorrhage), and Postoperative Sepsis (PSI 13; infection) appear to be adaptable to pregnancy hospitalizations. Using the 2009 California Patient Discharge Dataset (N [total] = 508,842), the hemorrhage and infection PSIs were examined for their potential to include pregnant women in gynecological, antepartum, postpartum, and delivery subpopulations. The statewide and hospital-level indicator rates were calculated using hierarchical models adjusted for case mix. Only the delivery population had sufficient cases for hospital-level analysis. Both PSIs required major changes to the technical specifications because of pregnancy-specific codes and coding practices. Nevertheless, these revised indicators identified substantial morbidity that varied widely across hospitals. The hemorrhage indicator rate was 2.50% (95% confidence interval [CI], 2.45-2.54) for all deliveries, compared with 0.26% (95% CI, 0.25-0.27) in the AHRQ population and 0.18% (95% CI, 0.15-0.21) for nonpregnant women of reproductive age. Adjusted hospital rates averaged 2.52%, with a midquartile range of 1.16% to 3.09% Although infection rates were lower for all deliveries than for the AHRQ population (0.18% versus 1.20%), they were highly associated with cesarean versus vaginal birth (0.43% versus 0.05%) and ranged from 0% to 1.15% across hospitals. Although codes and coding practices for pregnancy hospitalizations differ from those used for nonpregnant adults, hospital-level measures of childbirth-associated hemorrhage and infection are feasible, vary widely, and demonstrate considerable opportunity for improvement.

Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: a quasi-experimental study

BackgroundVenous thromboembolism (VTE) causes morbidity and mortality in hospitalized patients, and regulators and payors are encouraging the use of systems to prevent them. Here, we examine the effect of a computerized clinical decision support (CDS) intervention implemented across a multi-hospital academic health system on VTE prophylaxis and events.MethodsThe study included 223,062 inpatients admitted between April 2007 and May 2010, and used administrative and clinical data. The intervention was integrated into a commercial electronic health record (EHR) in an admission orderset used for all admissions. Three time periods were examined: baseline (period 1), and the time after implementation of the first CDS intervention (period 2) and a second iteration (period 3). Providers were prompted to accept or decline prophylaxis based on patient risk. Time series analyses examined the impact of the intervention on VTE prophylaxis during time periods two and three compared to baseline, and a simple pre-post design examined impact on VTE events and bleeds secondary to anticoagulation. VTE prophylaxis and events were also examined in a prespecified surgical subset of our population meeting the public reporting criteria defined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI).ResultsUnadjusted analyses suggested that “recommended”, “any”, and “pharmacologic” prophylaxis increased from baseline to the last study period (27.1% to 51.9%, 56.7% to 78.1%, and 42.0% to 54.4% respectively; p < 0.01 for all comparisons). Results were significant across all hospitals and the health system overall. Interrupted time series analyses suggested that our intervention increased the use of “recommended” and “any” prophylaxis by 7.9% and 9.6% respectively from baseline to time period 2 (p < 0.01 for both comparisons); and 6.6% and 9.6% respectively from baseline to the combined time periods 2 and 3 (p < 0.01 for both comparisons). There were no significant changes in “pharmacologic” prophylaxis in the adjusted model. The overall percent of patients with VTE increased from baseline to the last study period (2.0% to 2.2%; p = 0.03), but an analysis excluding patients with VTE “present on admission” (POA) demonstrated no difference in events (1.3% to 1.3%; p = 0.80). Overall bleeds did not significantly change. An analysis examining VTE prophylaxis and events in a surgical subset of patients defined by the AHRQ PSI demonstrated increased “recommended”, “any”, and “pharmacologic” prophylaxis from baseline to the last study period (32.3% to 60.0%, 62.8% to 85.7%, and 47.9% to 63.3% respectively; p < 0.01 for all comparisons) as well as reduced VTE events (2.2% to 1.7%; p < 0.01).ConclusionsThe CDS intervention was associated with an increase in “recommended” and “any” VTE prophylaxis across the multi-hospital academic health system. The intervention was also associated with increased VTE rates in the overall study population, but a subanalysis using only admissions with appropriate POA documentation suggested no change in VTE rates, and a prespecified analysis of a surgical subset of our sample as defined by the AHRQ PSI for public reporting purposes suggested reduced VTE. This intervention was created in a commonly used commercial EHR and is scalable across institutions with similar systems.

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Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications

Patients with psychotic disorders often experience poorer health outcomes, but whether they experience increased risks of medical errors/patient safety events is less clear. A single state-level US study found acute care inpatients with schizophrenia were at higher risk of incurring some of the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs). We examined a nationwide sample of US Veteran's Health Administration (VHA) acute care inpatients to determine the rates observed among patients with psychotic disorders for a larger set of PSIs. Retrospective cohort analysis using administrative data. and Veterans with (n = 50 328) and without (n = 1 812 897) psychotic disorders (schizophrenia/schizoaffective disorder and other psychoses) admitted for acute care to US VHA hospitals during fiscal years 2003-06. and PSI rates were calculated using AHRQ's PSI software. Patients with psychotic disorders had significantly higher rates of postoperative respiratory failure, postoperative wound dehiscence and decubitus ulcer than those without psychotic disorders, although postoperative respiratory failures rates were not significantly higher among patients specifically diagnosed with schizophrenia. Patients with psychotic disorders had significantly lower rates of accidental puncture/laceration, foreign body left in during procedure and failure to rescue. However, the odds of failure to rescue were not significantly lower among surgical patients (the current focus of this PSI). Acute care inpatient veterans with psychotic disorders experienced higher rates of several PSIs, but lower rates of others. Whether lower rates of certain PSIs reflect better or worse care for this population is uncertain.

A Varying Patient Safety Profile Between Black and Nonblack Adults With Decreased Estimated GFR

Chronic kidney disease is a high-risk condition for a variety of adverse safety events, yet little is known about differential rates of safety events across racial groups with decreased kidney function. We sought to examine the incidence of an array of disease-specific adverse safety events in black versus nonblack patients with decreased estimated glomerular filtration rate (eGFR). Retrospective observational study of a national US Veterans Affairs cohort. Veterans with eGFR <60 mL/min/1.73 m(2) and one or more hospitalization during federal fiscal year 2005 (n = 70,154). Self-reported race/ethnicity dichotomized as black or nonblack. Hospital discharge coding for Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), laboratory records for detection of hyperkalemia and hypoglycemia, and pharmacy records to determine dosing of 4 selected medications. Relationship between race and disease-specific patient safety events. Black veterans were more likely than nonblack veterans to experience one type of safety event (33% vs 32%, respectively) and multiple types of safety events (32% vs 23%, respectively; both P < 0.001). After adjustment, black veterans were 11% and 36% more likely to have at least one episode of hyperkalemia and hypoglycemia, respectively, than nonblack veterans, but were 14% less likely to experience a medication error (all P < 0.001). There was no association between the occurrence of AHRQ PSIs and race after adjustment. Use of administrative data has a risk of imprecision in coding; Veterans Affairs cohort may limit generalizability. Black veterans with decreased eGFR are more likely to experience a broad array of safety events than nonblacks with decreased eGFR, with a preponderance of metabolic disturbances rather than medication errors or AHRQ PSIs. The differential safety phenotype in blacks versus nonblacks may have implications for preventive strategies to improve patient safety in an integrated health care system.

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for Targeting Nursing Quality Improvement

Quantifying the critical impact nurses have on the prevention and early recognition of potential complications and adverse events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI), is becoming increasingly important. In this paper, we describe how the AHRQ PSI may be used to identify nursing-specific opportunities to improve care based on data from the national AHRQ PSI validation pilot project.

Validating the Patient Safety Indicators in the Veterans Health Administration

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) use administrative data to detect potentially preventable in-hospital adverse events. However, few studies have determined how accurately the PSIs identify true safety events. We examined the criterion validity, specifically the positive predictive value (PPV), of 12 selected PSIs using clinical data abstracted from the Veterans Health Administration (VA) electronic medical record as the gold standard. We identified PSI-flagged cases from 28 representative hospitals by applying the AHRQ PSI software (v.3.1a) to VA fiscal year 2003 to 2007 administrative data. Trained nurse-abstractors used standardized abstraction tools to review a random sample of flagged medical records (112 records per PSI) for the presence of true adverse events. Interrater reliability was assessed. We evaluated PPVs and associated 95% confidence intervals of each PSI and examined false positive (FP) cases to determine why they were incorrectly flagged and gain insight into how each PSI might be improved. PPVs ranged from 28% (95% CI, 15%-43%) for Postoperative Hip Fracture to 87% (95% CI, 79%-92%) for Postoperative Wound Dehiscence. Common reasons for FPs included conditions that were present on admission (POA), coding errors, and lack of coding specificity. PSIs with the lowest PPVs had the highest proportion of FPs owing to POA. Overall, PPVs were moderate for most of the PSIs. Implementing POA codes and using more specific ICD-9-CM codes would improve their validity. Our results suggest that additional coding improvements are needed before the PSIs evaluated herein are used for hospital reporting or pay for performance.

How best to measure surgical quality? comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution

Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance.

34 INCIDENCE OF PATIENT SAFETY INDICATORS (PSIS) FOR THREE MINIMALLY INVASIVE UROLOGIC SURGERIES: A FORMAL ANALYSIS OF THE NATIONAL INPATIENT SAMPLE (NIS)

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes1 Apr 201134 INCIDENCE OF PATIENT SAFETY INDICATORS (PSIS) FOR THREE MINIMALLY INVASIVE UROLOGIC SURGERIES: A FORMAL ANALYSIS OF THE NATIONAL INPATIENT SAMPLE (NIS) Elias Hyams, Zhaoyong Feng, Bruce Trock, and Brian Matlaga Elias HyamsElias Hyams Baltimore, MD More articles by this author , Zhaoyong FengZhaoyong Feng Baltimore, MD More articles by this author , Bruce TrockBruce Trock Baltimore, MD More articles by this author , and Brian MatlagaBrian Matlaga Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.097AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patient safety has become a central issue in healthcare quality; the development of Patient Safety Indicators (PSI) by the Agency for Healthcare Research and Quality (AHRQ) has brought new opportunities for patient safety research using administrative data. PSIs are designed to identify potentially preventable adverse events that compromise patient safety. At present, our understanding of PSIs in patients undergoing urologic surgery is limited, particularly with regard to minimally invasive surgeries. We examined the prevalence of PSIs in patients undergoing commonly performed laparoscopic/endourologic procedures: laparoscopic nephrectomy (LN), laparoscopic prostatectomy (LP), and percutaneous nephrolithotomy (PNL). METHODS We examined the 2008 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project, which contains discharge data from 1,056 hospitals in 42 states. Subjects were identified by ICD-9 coding: LN (5552, 5553 or 5554 with 5421 or 5451), LP (1742 with 605), and PNL (5504, and 5503 with 5521). PSIs were identified with AHRQ's proprietary software. Descriptive analyses were performed. RESULTS See Table 1 for PSI incidence among the 3 procedures. Subjects undergoing LP were significantly older than those undergoing LN or PNL. Mortality was significantly higher in LN (0.6%) compared with PNL (0%) and LP (0%) (p=0.0002). PSI PCNL(2179) N(2048) RP(2253) p-value Death in low mortality DRGs L0(0%) 0(0) 0(0) p=ns Pressure Ulcer 5(0.2) 4(0.2) 0(0) p=0.03(PCNL vs. RP) Death among Surgical Inpatients 0(0) 6(0.3) 0(0) p=0.01(LN vs. PCNL and RP) Foreign body left during procedure 1(0.05) 1(0.05) 0(0) p=ns Iatrogenic pneumothorax 4(0.18) 1(0.05) 0(0) p=ns Central Venous Catheter-related Bloodstream Infections 0(0) 0(0) 0(0) p=ns Postoperative hip fracture 0(0) 1(0.05) 0(0) p=ns Postoperative hemorrhage or hematoma 3(0.14) 5(0.24) 3(0.13) p=ns Postoperative physiologic and metabolic derangements 1(0.05) 6(0.29) 1(0.04) p=ns Postoperative respiratory failure 10(0.46) 13(0.63) 2(0.09) p=0.02(PCNL vs. RP); p=0.003(LN vs. RP) Postoperative pulmonary embolism or deep vein thrombosis 10(0.46) 13(0.63) 3(0.13) p=0.01(LNvs.RP) Postoperative sepsis 15(0.69) 1(0.05) 0(0) p=0.0006(PCNL vs. LN); p=0.0001(PCNLvs.RP) Postoperative wound dehiscence 0(0) 1(0.05) 0(0) p=ns Accidental puncture or laceration 19(0.87) 51(2.49) 13(0.58) p=0.0001(PCNLvs.LNandLP) Transfusion reaction 0(0) 0(0) 0(0) p=ns CONCLUSIONS The prevalence of PSIs among patients undergoing minimally invasive urologic surgeries is low. As patient safety continues to be an issue of importance in evaluating the quality of medical care, these data question the relevance of the AHRQ PSIs in assessing quality of care for urologic patients. Future efforts to identify more meaningful indicators of care quality for minimally invasive urologic surgery are welcome, as the urologic community continues to focus on the preventability of adverse events. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e13-e14 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elias Hyams Baltimore, MD More articles by this author Zhaoyong Feng Baltimore, MD More articles by this author Bruce Trock Baltimore, MD More articles by this author Brian Matlaga Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...