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Creating a Hybrid Database by Adding a POA Modifier and Numerical Laboratory Results to Administrative Claims Data

Michael Pine, M.D., M.B.A.
Michael Pine and Associates, Inc.
mpine@consultmpa.com

Overview

Data for Monitoring Clinical Performance

Claims Data Versus Clinical Data

diagram

Relative Ease of Data Collection

Data fall on a spectrum of type of data collection, with automated collection at one end of the spectrum, and manual collection at the other end of the spectrum.

Data fall on a spectrum of type of data collection, with automated collection at one end of the spectrum, and manual collection at the other end of the spectrum.

Manual collection: Numerical laboratory, vital signs, and other clinical data, which together are classified as clinical data.

end of diagram

Efficient Use of Clinical Data

diagram

Hemoglobin: Low analytic power, low cost to collect.
FEV1: Low analytic power, high cost to collect.
Albumin: High analytic power, low cost to collect.
Mental status: High analytic power, high cost to collect.

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Enhancing Claims Data

diagram

Creating a Hybrid Database
Claims Data are: Standard claims and Present-on-Admission.
Clinical Data are: Numerical laboratory, vital signs, and other clinical data.
Hybrid Data are: Standard claims, Present-on-Admission, and numerical laboratory.

end of diagram

Potential Benefits of Enhancing Claims Data

Comparative Performance of Alternative Databases

Inpatient Quality Indicators (Mortality)

Patient Safety Indicators (Complications)

Data Used in CLAIMS Models

Data Used in HYBRID Models

Data Used in CLINICAL Models

diagram

Bias Due to Suboptimal Risk-Adjustment

Measured performance:

Spectrum of bias:

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diagram

Bias Due to Suboptimal Data (IQIs)

Line chart of type of data (raw, claims, and hybrid) graphed by the percent of data exceeding the upper threshold for bias in standard deviations.

Data values are not shown in the chart, so percentages are listed in ranges.

Raw Data60% to 70%30% to 40%20% to 30%10% to 20%Claims Data40% to 50%20% to 30%0% to 10%0% to 10%Hybrid Data10% to 20%0% to 10%0% to 10%0% to 10%
Percent Exceeding Upper Threshold Upper Threshold for Bias in Standard Deviations
0.5 1.0 1.5 2.0

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Beginning of diagram

Bias Due to Suboptimal Data (PSIs)

Line chart of type of data (raw, claims, and hybrid) graphed by the percent of data exceeding the upper threshold for bias in standard deviations.

Data values are not shown in the chart, so percentages are listed in ranges.

Raw Data50% to 60%20% to 30%10% to 20%0% to 10%Claims Data30% to 40%10% to 20%0% to 10%0% to 10%Hybrid Data10% to 20%0% to 10%0% to 10%0% to 10%
Percent Exceeding Upper Threshold Upper Threshold for Bias in Standard Deviations
0.5 1.0 1.5 2.0

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POA Coding

New Information Derived from POA Coding

General Guidelines for POA Coding

Valid POA Codes

Rules for POA Coding (1)

Rules for POA Coding (2)

Rules for POA Coding (3)

Rules for POA Coding (4)

Rules for POA Coding (4)

POA Quality Screens

Distribution of Hospital Scores

Score Hospitals (#) Hospitals (%)
> 90% 65 39.4%
> 80% to 90% 41 24.8%
> 70% to 80% 26 15.8%
> 60% to 70% 19 11.5%
60% or lower 14 8.5%
Total Scored 165 100%
>% Unknown 22 n/a

Screening and Improvement of POA Coding

diagram

Circular diagram of process of screening and improvement of POA coding. Steps 1 through 6 repeat.

  1. POA screening
  2. Performance evaluation
  3. Process analysis
  4. Identification of opportunities for improvement
  5. Plan for improvement
  6. 1Plan for improvement

Numerical Laboratory Data

Types of Data in HYBRID IQI Models

15.6 data elements are: Standard claims and Present-on-Admission.

11.1 data elements are: Numerical laboratory.

Hybrid Data are: Standard claims, Present-on-Admission, and numerical laboratory.

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Types of Data in HYBRID PSI Models

21.8 data elements are: Standard claims and Present-on-Admission.

6.5 data elements are: Numerical laboratory.

Hybrid Data are: Standard claims, Present-on-Admission, and numerical laboratory.

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Numerical Laboratory Data

Recommended Chemistry Data

Other Recommended Lab Data

Blood Gas

Hematology

Vital Signs and Other Clinical Data

diagram

Types of Data in CLINICAL IQI Models

15.6 data elements are: Standard claims and Present-on-Admission.

11.1 data elements are: Numerical laboratory.

9.0 data elements are: Vital signs and other clinical data.

Hybrid Data are: Standard claims, Present-on-Admission, and numerical laboratory.

end diagram

Types of Data in CLINICAL PSI Models

diagram

15.6 data elements are: Standard claims and Present-on-Admission.

11.1 data elements are: Numerical laboratory.

9.0 data elements are: Vital signs and other clinical data.

Hybrid Data are: Standard claims, Present-on-Admission, and numerical laboratory.

end diagram

Vital Signs, Other Lab Data, Scores

Abstracted Key Clinical Findings

The Bottom Line

Risk-Adjusted Mortality in CABG Surgery

diagram

Chart of risk-adjusted mortality in percent for CABG surgery

Chart shows confidence interval, predicted percent risk-adjusted mortality, observed percent risk-adjusted mortality, and p-value of predicted to observed percent risk-adjusted mortality for CABG surgery by hospital. Chart does not include data values, so range of values are estimated.

Hospital Number Confidence Limit (Lower) Confidence Limit (Upper) Predicted percent risk-adjusted mortality Observed percent risk-adjusted mortality P-value of predicted to observed percent mortality
Hospital 6 1.5% to 2.0% 4.5% to 5.0% 3.0% to 3.5% 1.5% to 2.0% p = 0.001 to 0.01
Hospital 7 2.0% to 2.5% 4.0% to 4.5% 3.0% to 3.5% 2.0% to 2.5% p = 0.01 to 0.05
Hospital 18 1.0% to 1.5% 7.5% to 8.0% 4.0% to 4.5% 2.0% to 2.5% p = 0.01 to 0.05
Hospital 13 1.5% to 2.0% 5.0% to 5.5% 3.5% to 4.0% 2.5% to 3.0% p is greater than 0.05
Hospital 1 0.5% to 1.0% 5.0% to 5.5% 3.0% to 3.5% 1.5% to 2.0% p is greater than 0.05
Hospital 10 0.0% 4.0% to 4.5% 2.0% to 2.5% 1.0% to 1.5% p is greater than 0.05
Hospital 14 0.5% to 1.0% 4.5% to 5.0% 2.5% to 3.0% 2.0% to 2.5% p is greater than 0.05
Hospital 5 1.0% to 1.5% 6.5% to 7.0% 3.5% to 4.0% 3.0% to 3.5% p is greater than 0.05
Hospital 3 0.0% to 0.5% 4.5% to 5.0% 2.5% to 3.0% 2.0% to 2.5% p is greater than 0.05
Hospital 12 0.0% 3.5% to 4.0% 1.5% to 2.0% 1.5% to 2.0% p is greater than 0.05
Hospital 11 0.0% to 0.5% 4.5% to 5.0% 2.5% to 3.0% 2.5% to 3.0% p is greater than 0.05
Hospital 17 0.5% to 1.0% 4.0% to 4.5% 2.5% to 3.0% 2.5% to 3.0% p is greater than 0.05
Hospital 16 0.5% to 1.0% 5.0% to 5.5% 2.5% to 3.0% 3.0% to 3.5% p is greater than 0.05
Hospital 15 0.0% 3.0% to 3.5% 1.0% to 1.5% 2.0% to 2.5% p is greater than 0.05
Hospital 9 1.5% to 2.0% 4.0% to 4.5% 2.5% to 3.0% 3.0% to 3.5% p is greater than 0.05
Hospital 8 1.0% to 1.5% 3.5% to 4.0% 2.0% to 2.5% 2.5% to 3.0% p is greater than 0.05
Hospital 2 1.0% to 1.5% 4.5% to 5.0% 3.0% to 3.5% 3.5% to 4.0% p is greater than 0.05
Hospital 4 0.5% to 1.0% 5.5% to 6.0% 3.0% to 3.5% 4.5% to 5.0% p = 0.01 to 0.05

end of diagram

Bias in Measurement of PSIs

Line chart of observed vs predicted rates of true complications, bias due to failure to risk-adjust true complication rates, and bias due to misclassifying comorbidities as complications, graphed by the percent of data exceeding the upper threshold for bias in standard deviations.

Data values are not shown in the chart, so percentages are listed in ranges.

Percent Exceeding Upper Threshold Upper Threshold for Bias in Standard Deviations
0.5 1.0 1.5 2.0
Observed vs predicted rates of true complications 80% to 90% 60% to 70% 40% to 50% 20% to 30%
Bias due to failure to risk-adjust true complication rates 40% to 50% 10% to 20% 0% to 10% 0% to 10%
Bias due to misclassifying comorbidities as complications 40% to 50% 20% to 30% 10% to 20% 0% to 10%

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Carpe Diem!


Internet Citation: Michael Pine Presentation. Healthcare Cost and Utilization Project (HCUP). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/datainnovations/clinicaldata/MPinepresentation.jsp.
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Last modified 12/6/10