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Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

ABSTRACT: BACKGROUND:Most U.S. hospitals publicly report 30-day risk-standardized mortality rates for pneumonia. Rates exclude severe cases, which may be assigned a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. By assigning sepsis and respiratory failure codes more liberally, hospitals might improve their reported performance. OBJECTIVE:To examine the effect of the definition of pneumonia on hospital mortality rates. DESIGN:Cross-sectional study. SETTING:329 U.S. hospitals. PATIENTS:Adults hospitalized for pneumonia (as a principal diagnosis or secondary diagnosis paired with a principal diagnosis of sepsis or respiratory failure) between 2007 and 2010. MEASUREMENTS:Proportion of patients with pneumonia coded with a principal diagnosis of sepsis or respiratory failure and risk-standardized mortality rates excluding versus including a principal diagnosis of sepsis or respiratory failure. RESULTS:When the definition of pneumonia was limited to patients with a principal diagnosis of pneumonia, the risk-standardized mortality rate was significantly better than the mean in 4.3% of hospitals and significantly worse in 6.4%. When the definition was broadened to include patients with a principal diagnosis of sepsis or respiratory failure, this rate was better than the mean in 11.9% of hospitals and worse in 22.8% and the outlier status of 28.3% of hospitals changed. Among hospitals in the highest quintile of proportion of patients coded with a principal diagnosis of sepsis or respiratory failure, outlier status under the broader definition improved in 7.6% and worsened in 40.9%. Among those in the lowest quintile, 20.0% improved and none worsened. LIMITATION:Only inpatient mortality was studied. CONCLUSION:Variation in use of the principal diagnosis of sepsis or respiratory failure may bias efforts to compare hospital performance regarding pneumonia outcomes. PRIMARY FUNDING SOURCE:Agency for Healthcare Research and Quality.

SUBMITTER: Rothberg MB

PROVIDER: S-EPMC6946057 | biostudies-literature | 2014 Mar

REPOSITORIES: biostudies-literature

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Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

Rothberg Michael B MB Pekow Penelope S PS Priya Aruna A Lindenauer Peter K PK

Annals of internal medicine 20140301 6

<h4>Background</h4>Most U.S. hospitals publicly report 30-day risk-standardized mortality rates for pneumonia. Rates exclude severe cases, which may be assigned a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. By assigning sepsis and respiratory failure codes more liberally, hospitals might improve their reported performance.<h4>Objective</h4>To examine the effect of the definition of pneumonia on hospital mortality rates.<h4>Design</h4>Cross-section ...[more]

PMID: 24723078

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Project description:Risk-standardized 30-day mortality and hospital readmission rates for pneumonia are increasingly being tied to hospital reimbursement to incentivize the delivery of high-quality care. Such measures may be susceptible to gaming by recoding patients with pneumonia to a primary diagnosis of sepsis or respiratory failure. We sought to determine the degree to which hospitals can game mortality or readmission measures and change their rankings by recoding patients with pneumonia.Simulated experimental study of 2,906 U.S. acute care hospitals with at least 25 admissions for pneumonia using 2009 Medicare data.Elderly (age ? 65 yr) Medicare fee-for-service beneficiaries hospitalized with pneumonia. Patients eligible for recoding to sepsis or respiratory failure were those with a principal International Classification of Diseases, 9th Edition, Clinical Modification, discharge code for pneumonia and secondary codes for respiratory failure or acute organ dysfunction.None.We measured the number of hospitals that improved their pneumonia mortality or readmission rates after recoding eligible patients. When a sample of 100 hospitals with pneumonia mortality rates above the 50th percentile recoded all eligible patients to sepsis or respiratory failure, 90 hospitals (95% CI, 84-95) improved their mortality rate (mean improvement, 1.09%; 95% CI, 0.94-1.28%) and 41 hospitals dropped below the 50th percentile (95% CI, 33-52). When a sample of 100 hospitals with pneumonia readmission rates above the 50th percentile recoded all eligible patients, 66 hospitals (95% CI, 54-75) improved their readmission rate (mean improvement, 0.34%; 95% CI, 0.19-0.45%) and 15 hospitals (95% CI, 9-22) dropped below the 50th percentile.Hospitals can improve apparent pneumonia mortality and readmission rates by recoding pneumonia patients. Centers for Medicare and Medicaid Services should consider changes to their methods used to calculate hospital-level pneumonia outcome measures to make them less susceptible to gaming.

Project description:Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs.To identify hospital strategies that were associated with lower RSMRs.Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs.Acute care hospitals with an annualized AMI volume of at least 25 patients.Patients hospitalized with AMI between 1 January 2008 and 31 December 2009.Hospital performance improvement strategies, characteristics, and 30-day RSMRs.In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies.The cross-sectional design demonstrates statistical associations but cannot establish causal relationships.Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.

Project description:ObjectiveTo examine the association of hospital volume (a marker of quality of care) with hospital readmission rates.DesignRetrospective cross-sectional study.Setting4651 US acute care hospitals.Study data6,916,644 adult discharges, excluding patients receiving psychiatric or medical cancer treatment.Main outcome measuresWe used Medicare fee-for-service data from 1 July 2011 to 30 June 2012 to calculate observed-to-expected, unplanned, 30 day, standardized readmission rates for hospitals and for specialty cohorts medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. We assessed the association of hospital volume by quintiles with 30 day, standardized readmission rates, with and without adjustment for hospital characteristics (safety net status, teaching status, geographic region, urban/rural status, nurse to bed ratio, ownership, and cardiac procedure capability. We also examined associations with the composite outcome of 30 day, standardized readmission or mortality rates.ResultsMean 30 day, standardized readmission rate among the fifth of hospitals with the lowest volume was 14.7 (standard deviation 5.3) compared with 15.9 (1.7) among the fifth of hospitals with the highest volume (P<0.001). We observed the same pattern of lower readmission rates in the lowest versus highest volume hospitals in the specialty cohorts for medicine (16.6 v 17.4, P<0.001), cardiorespiratory (18.5 v 20.5, P<0.001), and neurology (13.2 v 14.0, p=0.01) cohorts; the cardiovascular cohort, however, had an inverse association (14.6 v 13.7, P<0.001). These associations remained after adjustment for hospital characteristics except in the cardiovascular cohort, which became non-significant, and the surgery/gynecology cohort, in which the lowest volume fifth of hospitals had significantly higher standardized readmission rates than the highest volume fifth (difference 0.63 percentage points (95% confidence interval 0.10 to 1.17), P=0.02). Mean 30 day, standardized mortality or readmission rate was not significantly different between highest and lowest volume fifths (20.4 v 20.2, P=0.19) and was highest in the middle fifth of hospitals (range 20.6-20.8).ConclusionsStandardized readmission rates are lowest in the lowest volume hospitals-opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications.

Project description:ImportanceThe Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings.ObjectiveTo identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty.Design, setting, and participantsThis cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis.ExposuresPresent-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions.Main outcomes and measuresHospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no).ResultsIncluded in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.3 [95% CI, 15.1-15.5] vs 15.9 [95% CI, 15.7-16.0]; P < .001). A 1% absolute increase in risk-adjusted hospital-level DNR prevalence was associated with greater odds of avoiding HRRP financial penalty (odds ratio, 1.06; 95% CI, 1.04-1.08; P < .001).Conclusions and relevanceThis cross-sectional study found that the lack of adjustment in CMS 30-day RSMR and RSRR models for POA DNR status of hospitalized patients may be associated with biased readmission penalization and hospital-level performance.

Dataset Information

Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

Publications

Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

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