Inpatient quality analysis zooms in on acute MI

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An analysis of inpatient complications placed acute MI and pulmonary embolism as top targets for potential quality measures that payers might consider to reduce variation in care and costs. The two conditions were among the top 10 conditions likely to affect mortality, length of stay, cost and reimbursement.

The Centers for Medicare & Medicaid Services (CMS) identified conditions such pressure ulcers and central venous catheter-related blood stream infections as avoidable hospital-acquired complications that harm patients and add to healthcare costs. As part of its efforts to improve quality and lower costs, CMS will begin withholding 1 percent in payment to poor performing hospitals in fiscal year 2015.

But some of the conditions identified by CMS are narrow because they rarely occur and consequently they don’t adequately reflect a hospital’s quality of care, according to Premier, a healthcare analytics company. Using 5.5 million de-identified ICD-9 discharge abstracts from 2013, Premier developed a measure methodology with the goal of widening the pool and expanding opportunities to reduce variability and the incidence of harmful and costly events.   

The analysis focused on secondary diagnoses of conditions that weren’t present at admission and were not a common comorbidity of the initial diagnosis. They focused on high-impact conditions: those that significantly increased inpatient mortality; that increased cost by 20 percent or more; and increased length of stay by 18 percent or more.

All in all, they found 86 high-impact potential inpatient complications. Of those, 22 were significantly associated with mortality, with cardiac arrest having the greatest increased risk at 41 percent. The increased risk for pulmonary embolism was 4.6 percent and for complications of an acute MI, 5.6 percent.

The list of potential inpatient complications associated with longer length of stay totaled 49, including acute MI, pulmonary embolism and complications of a cardiac device or graft. Their increases were 1.49 days, 2.67 days and 1.75 days.   

Acute MI and pulmonary embolism made the list for potential increased costs, which were affected by frequency and marginal costs. Acute MI, for instance, had a total cost of $110 million ($5,290 marginal cost and 20,016 patients). Total costs for pulmonary embolism and was $44 million ($5,070 marginal cost and 8,757 patients).

Pulmonary embolism is one of only two conditions on the CMS list of hospital-acquired complication targets to also make the cut as a high-impact complication, according to the Premier analysis. The other condition was sepsis. The CMS methodology captured only 9 percent of harmful occurrences, 12 percent of total days added and 13 percent of total costs compared with Premier.

Aligning their list with federal policies with reimbursement implications, the Premier analysts suggested 10 top potential inpatient complications, including acute MI and pulmonary embolism.

“Although we cannot say with certainty the incidence of these PICs [potential inpatient complications] that might indeed be prevented, the list provides a starting point for facilities to begin addressing the three important outcomes measures of mortality, cost and length of stay,” they wrote. “Some conditions may be secondary to other more proximal events, respiratory failure secondary to pneumonia for example, but if the PICs identified here can be significantly reduced, we anticipate dramatic changes in outcomes.”

As a next step, they plan to group complications in causal chains to fine tune the list to complications that can be addressed and prevented. They want to adapt the findings to ICD-10 for a broader set of quality measures.