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Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State.

ABSTRACT: OBJECTIVES:Under "Rory's Regulations," New York State Article 28 acute care hospitals were mandated to implement sepsis protocols and report patient-level data. This study sought to determine how well cases reported under state mandate align with discharge records in a statewide administrative database. DESIGN:Observational cohort study. SETTING:First 27 months of mandated sepsis reporting (April 1, 2014, to June 30, 2016). PATIENTS:Hospitalizations with sepsis at New York State Article 28 acute care hospitals. INTERVENTION:Sepsis regulations with mandated reporting. MEASUREMENTS AND MAIN RESULTS:We compared cases reported to the New York State Department of Health Sepsis Clinical Database with discharge records in the Statewide Planning and Research Cooperative System database. We classified discharges as 1) "coded sepsis discharges"-a diagnosis code for severe sepsis or septic shock and 2) "possible sepsis discharges," using Dombrovskiy and Angus criteria. Of 111,816 sepsis cases reported to the New York State Department of Health Sepsis Clinical Database, 105,722 (94.5%) were matched to discharge records in Statewide Planning and Research Cooperative System. The percentage of coded sepsis discharges reported increased from 67.5% in the first quarter to 81.3% in the final quarter of the study period (mean, 77.7%). Accounting for unmatched cases, as many as 82.7% of coded sepsis discharges were potentially reported, whereas at least 17.3% were unreported. Compared with unreported discharges, reported discharges had higher rates of acute organ dysfunction (e.g., cardiovascular dysfunction 63.0% vs 51.8%; p < 0.001) and higher in-hospital mortality (30.2% vs 26.1%; p < 0.001). Hospital characteristics (e.g., number of beds, teaching status, volume of sepsis cases) were similar between hospitals with a higher versus lower percent of discharges reported, p values greater than 0.05 for all. Hospitals' percent of discharges reported was not correlated with risk-adjusted mortality of their submitted cases (Pearson correlation coefficient 0.11; p = 0.17). CONCLUSIONS:Approximately four of five discharges with a diagnosis code of severe sepsis or septic shock in the Statewide Planning and Research Cooperative System data were reported in the New York State Department of Health Sepsis Clinical Database. Incomplete reporting appears to be driven more by underrecognition than attempts to game the system, with minimal bias to risk-adjusted hospital performance measurement.

SUBMITTER: Prescott HC

PROVIDER: S-EPMC5899037 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State.

Prescott Hallie C HC Cope Tara M TM Gesten Foster C FC Ledneva Tatiana A TA Friedrich Marcus E ME Iwashyna Theodore J TJ Osborn Tiffany M TM Seymour Christopher W CW Levy Mitchell M MM

Critical care medicine 20180501 5

<h4>Objectives</h4>Under "Rory's Regulations," New York State Article 28 acute care hospitals were mandated to implement sepsis protocols and report patient-level data. This study sought to determine how well cases reported under state mandate align with discharge records in a statewide administrative database.<h4>Design</h4>Observational cohort study.<h4>Setting</h4>First 27 months of mandated sepsis reporting (April 1, 2014, to June 30, 2016).<h4>Patients</h4>Hospitalizations with sepsis at Ne ...[more]

PMID: 29406420

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Project description:New York state implemented the first state-level sepsis regulations in 2013. These regulations were associated with improved mortality, leading other states to consider similar steps. Our objective was to provide insight into New York state's sepsis policy making process, creating a roadmap for policymakers in other states considering similar regulations.DesignQualitative study using semistructured interviews.SettingWe recruited key stakeholders who had knowledge of the New York state sepsis regulations.SubjectsThirteen key stakeholders from three groups included four New York state policymakers and seven clinicians and hospital association leaders involved in the creation and implementation of the 2013 New York state sepsis regulations, as well as two members of patient advocacy groups engaged in sepsis advocacy.InterventionsNone.Measurements and main resultsWe used iterative, inductive thematic analysis to identify themes related to participant perceptions of the New York state sepsis policy, factors that influenced the policy's perceived successes, and opportunities for improvement. We identified several factors that facilitated success. Among these were that policymakers engaged a diverse array of stakeholders in development, allowing them to address potential barriers to implementation and create early buy-in. Policymakers also paid specific attention to the balance between the desire for comprehensive reporting and the burden of data collection, narrowly focusing on "essential" sepsis-related data elements to reduce the burden on hospitals. In addition, the regulations touched on all three major domains of sepsis quality-structure, process, and outcomes-going beyond a data collection to give hospitals tools to improve sepsis care.ConclusionsWe identified factors that distinguish the New York sepsis regulations from less successful sepsis polices at the federal level. Ultimately, lessons from New York state provide valuable guidance to policymakers and hospital officials seeking to develop and implement policies that will improve sepsis quality.

Project description:ImportanceThere is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment.ObjectiveTo compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment.Design setting and participantsThis cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned.ExposuresPlan assignment.Main outcomes and measuresPercentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment.ResultsMedicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans.Conclusions and relevanceThe results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.

Project description:ImportanceThe death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear.ObjectiveTo determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital mortality.Design, settings, and participantsStatewide cohort study conducted from April 1, 2014, to December 31, 2016, in emergency departments, inpatient units, and intensive care units across New York State. A total of 1179 patients aged 18 years and younger with sepsis and septic shock reported to the New York State Department of Health who had a sepsis protocol initiated were included.ExposuresCompletion of a 1-hour sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour.Main outcomes and measuresRisk-adjusted in-hospital mortality.ResultsOf 1179 patients with sepsis reported at 54 hospitals (mean [SD] age, 7.2 [6.2] years; male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139 (11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients (24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548 patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (odds ratio [OR], 0.59 [95% CI, 0.38 to 0.93], P = .02; predicted risk difference [RD], 4.0% [95% CI, 0.9% to 7.0%]). However, completion of each individual bundle element within 1 hour was not significantly associated with lower risk-adjusted mortality (blood culture: OR, 0.73 [95% CI, 0.51 to 1.06], P = .10; RD, 2.6% [95% CI, -0.5% to 5.7%]; antibiotics: OR, 0.78 [95% CI, 0.55 to 1.12], P = .18; RD, 2.1% [95% CI, -1.1% to 5.2%], and fluid bolus: OR, 0.88 [95% CI, 0.56 to 1.37], P = .56; RD, 1.1% [95% CI, -2.6% to 4.8%]).Conclusions and relevanceIn New York State following a mandate for sepsis care, completion of a sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour was associated with lower risk-adjusted in-hospital mortality among patients with pediatric sepsis and septic shock.

Project description:ObjectivesInitial evidence suggests that state-level regulatory mandates for sepsis quality improvement are associated with decreased sepsis mortality. However, sepsis mandates require financial investments on the part of hospitals and may lead to increased spending. We evaluated the effects of the 2013 New York State sepsis regulations on the costs of care for patients hospitalized with sepsis.DesignRetrospective cohort study using state discharge data from the U.S. Healthcare Costs and Utilization Project and a comparative interrupted time series analytic approach. Costs were calculated from admission-level charge data using hospital-specific cost-to-charge ratios.SettingGeneral, short stay, acute care hospitals in New York, and four control states: Florida, Massachusetts, Maryland, and New Jersey.PatientsAll patients hospitalized with sepsis between January 1, 2011, and September 30, 2015.InterventionsThe 2013 New York mandate that all hospitals develop and implement protocols for sepsis identification and treatment, educate staff, and report performance data to the state.Measurements and main resultsThe analysis included 1,026,664 admissions in 520 hospitals. Mean unadjusted costs per hospitalization in New York State were $42,036 ± $60,940 in the pre-regulation period and $39,719 ± $59,063 in the post-regulation period, compared with $34,642 ± $52,403 pre-regulation and $31,414 ± $48,155 post-regulation in control states. In the comparative interrupted time series analysis, the regulations were not associated with a significant difference in risk-adjusted mean cost per hospitalization (p = 0.12) or risk-adjusted mean cost per hospital day (p = 0.44). For example, in the 10th quarter after implementation of the regulations, risk-adjusted mean cost per hospitalization was $3,627 (95% CI, -$681 to $7,934) more than expected in New York State relative to control states.ConclusionsMandated protocolized sepsis care was not associated with significant changes in hospital costs in patients hospitalized with sepsis in New York State.

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Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State.

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Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State.

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