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Modeling Coding Intensity of Procedures in a U.S. Population-Based Hip/Knee Arthroplasty Inpatient Cohort Adjusting for Patient- and Facility-Level Characteristics.

ABSTRACT: Variations in procedure coding intensity, defined as excess coding of procedures versus industry (instead of clinical) standards, can result in differentials in quality of care for patients and have additional implications for facilities and payors. The literature regarding coding intensity of procedures is limited, with a need for risk-adjusted methods that help identify over- and under-coding using commonly available data, such as administrative claims. Risk-adjusted metrics are needed for quality control and enhancement. We propose a two-step approach to risk adjustment, using a zero-inflated Poisson model, applied to a hip-knee arthroplasty cohort discharged during 2019 (n = 313,477) for patient-level risk adjustment, and a potential additional layer for adjustment based on facility-level characteristics, when desired. A 21.41% reduction in root-mean-square error was achieved upon risk adjustment for patient-level factors alone. Furthermore, we identified facilities that over- and under-code versus industry coding expectations, adjusting for both patient-level and facility-level factors. Excess coding intensity was found to vary across multiple levels: (1) geographically across U.S. Census regional divisions; (2) temporally with marked seasonal components; (3) by facility, with some facilities largely departing from industry standards, even after adjusting for both patient- and facility-level characteristics. Our proposed method is simple to implement, generalizable, it can be used across cohorts with different sets of information available, and it is not limited by the accessibility and sparsity of electronic health records. By identifying potential over- and under-coding of procedures, quality control personnel can explore and assess internal needs for enhancements in their health delivery services and monitor subsequent quality improvements.

SUBMITTER: Rios NG

PROVIDER: S-EPMC9332158 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceThe Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice.ObjectiveTo investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics.Design, setting, and participantsFiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017.ExposuresAnnual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment.Main outcomes and measuresThe HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined.ResultsAmong 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity.Conclusions and relevanceThis study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

Dataset Information

Modeling Coding Intensity of Procedures in a U.S. Population-Based Hip/Knee Arthroplasty Inpatient Cohort Adjusting for Patient- and Facility-Level Characteristics.

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