Exploring Excess Mortality in the Ventilator Population Using Clinical Advisor

1. Exploring Excess Mortality in the Ventilator Population Using Clinical Advisor Richard Bankowitz, MD Rosemary Berg September 11, 2008

2. 2 Session Objectives At the end of the session, the participant will be able to: Review drivers of mortality in the ventilator population Explore use of Clinical Advisor in understanding clinical processes driving excess mortality

3. 3 Wide Variation of QUEST Charter Members that are at or Below the Mortality Threshold

4. 4 Top 10 Mortality APR-DRGs for QUEST Members

5. 5 Excess Mortality Analysis ProcessIdentifying Patient Groups A method for identifying aggregate excess mortality was presented by Richard Bankowitz, M.D. and Eugene Kroch, Ph.D. on April 24, 2008 Exploring QUEST Mortality is available on the Performance Improvement Portal This session will address drilling into patient groups already identified, such as by APR-DRG, listed on page 2 of the the Baseline Mortality Drill Down Report. Finding Mortality and Cost of Care Targets with Clinical Advisor, presented at QUEST Collaborative II, is available on the Performance Improvement Portal (PIP) Drilling into Mortality Target Areas (Septicemia and Heart Failure) with Clinical Advisor, presented July 8, 2008 is posted on the PIP

6. 6 Approximating the QUEST Mortality Measurein Clinical Advisor The QUEST Mortality Cheat Sheet is available on the Performance Improvement Portal Only patients with patient type Acute Inpatient (08) are included. From the CA prompt Patient Type/Standard Patient Type include Inpatient. Patients with these discharge status codes are excluded from the QUEST mortality measure: 2 = Discharged/Transferred to Other Facility 43 = Discharged/Transferred to Federal Hospital 61 = Discharged/Transferred to Swing Bed 66 = Discharged/Transferred to a CAH From the CA prompt Patient Visits/Discharge Status, exclude the codes listed above. Note: Some patients may not have enough data to run the CareScience analytics; case counts may vary

7. 7 Exploring Drivers of Mortality Goal Explore in-patient mortality by finding ACTIONABLE clusters – i.e., patient cohorts in which mortality rates might be improved with an intervention (Part of a PDCA cycle) Common cause – systemic problems Special cause – isolated but important causes Definition Excess Deaths = Total deaths in excess of predicted by the risk adjustment model = (actual % - expected %) * N patients Excess Deaths can be “negative” in this definition Therefore sum of all non-negative Excess Deaths over all patient subsets will be greater than hospital-wide results (hospital-wide obs – hospital-wide exp) * Total Discharges In other words, there are always pockets of opportunity Approach Use Clinical Advisor to determine excess death by categories Admission Source, Age, Principal Dx, APR-DRG or DRG, severity, other

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9. 9 Approaching Drivers of Mortality *Illustrative Examples of Potential Secondary Drivers Goal Explore in-patient mortality by finding ACTIONABLE clusters – IE patient cohorts in which mortality rates might be improved with an intervention (Part of a PDCA cycle) Common cause – systemic problems Special cause – isolated but important causes Definition Excess Deaths = Total deaths in excess of predicted by the risk adjustment model = (obs % - exp %) * N patients Excess Deaths can be “negative” in this definition Therefore sum of all non-negative Excess Deaths over all patient subsets will be greater than hospital-wide results (hospital-wide obs – hospital-wide exp) * Total Discharges In other words, there are always pockets of opportunity Approach Use CA or QM to determine excess death by categories Admission Source, Age, Principal Dx, APR-DRG or DRG, severity, other Goal Explore in-patient mortality by finding ACTIONABLE clusters – IE patient cohorts in which mortality rates might be improved with an intervention (Part of a PDCA cycle) Common cause – systemic problems Special cause – isolated but important causes Definition Excess Deaths = Total deaths in excess of predicted by the risk adjustment model = (obs % - exp %) * N patients Excess Deaths can be “negative” in this definition Therefore sum of all non-negative Excess Deaths over all patient subsets will be greater than hospital-wide results (hospital-wide obs – hospital-wide exp) * Total Discharges In other words, there are always pockets of opportunity Approach Use CA or QM to determine excess death by categories Admission Source, Age, Principal Dx, APR-DRG or DRG, severity, other

10. 10 Ventilator Mortality Drivers Identified in the Literature Early weaning from ventilator Minimize ICU days VTE prophylaxis Stress ulcer prophylaxis Management of high risk secondary diagnoses Acidosis Coronary insufficiency, heart failure Septic shock Extrapulmonary organ failure Protection from barotrauma (e.g., pneumothorax) Prevention of Ventilator-associated pneumonia Use of intensivists

11. 11 Many Ways to Define the Ventilator Population

12. Ventilator-related Excess Mortality APR-DRG 130 Respiratory Diagnosis with Mechanical Ventilation 96+ hours

13. 13 Analysis on Subsequent Slides Includes: APR DRG 130: Respiratory Diagnosis with Mechanical Ventilation 96+ hours with population exclusions to approximate the CareScience mortality model. QUEST Baseline period: July 1, 2006 – June 30, 2007, unless otherwise noted Hospital of interest is a QUEST Charter Member Hospital with excess mortality in APR DRG 130 Top performing peer group of 15 QUEST hospitals with low CareScience O/E mortality ratios in APR DRG 130 (Custom peer group)

14. 14 QUEST Mortality Drill Down Reports Mortality Trend Mortality by Day of Hospital Stay Mortality by APR-DRG Risk of Mortality Subclass Mortality by Detailed Age Grouping Mortality by Secondary Diagnosis Mortality and Palliative Care Coding Mortality and Ventilator Duration Resource Use Comparisons Non-invasive ventilation ICU duration VTE Prophylaxis Stress Ulcer Prophylaxis Treatment of Secondary Diagnoses Patient Safety Indicators

15. 15 Hospital of Interest Mortality OpportunitiesQUEST Baseline Report

16. 16 Mortality TrendAPR-DRG 130 Respiratory Diagnosis with Mechanical Ventilation 96+ hours

17. 17 Mortality by Day of Hospital StayAPR-DRG 130 Respiratory Diagnosis with Mechanical Ventilation 96+ hours

18. 18 Mortality RateComparison to Top Performer Peers

19. 19 Mortality Rate by Risk of MortalityComparison to Top Performer Peers

20. 20 Mortality Rate by Age GroupComparison to Top Performer Peers

21. 21 Mortality Rate by Secondary DiagnosisComparison to Top Performer Peers

22. 22 Mortality and Palliative Care CodingComparison to Top Performer Peers

23. 23 Ventilator DurationHospital of Interest

24. 24 Use of Non-invasive VentilationComparison to Top Performer Peers

25. 25 Use of ICU Resources and ALOSComparison to Top Performer Peers

26. 26 Use of VTE Prophylaxis Comparison to Top Performer Peers

27. 27 Use of Stress Ulcer Prophylaxis Comparison to Top Performer Peers

28. 28 Ventilator Patients with CHFUse of ACE Inhibitors and Beta Blockers Comparison to Top Performer Peers

29. 29 Patient Safety Indicator AnalysisComparison to Top Performer Peers

30. 30 Other Areas for ConsiderationAPR-DRG 130 Respiratory Diagnosis with Mechanical Ventilation 96+ hours Similarities between hospital of interest and top performer peers: Mortality by Severity of Illness (most patients in severity 3 & 4) Principal diagnosis distribution (60% acute respiratory failure) Other procedures distribution (few other procedures; this is a medically managed population) Antibiotic use Other areas to explore? Extrapulmonary organ failure VAP Severe sepsis Sedation use Intensivist use

31. 31 Mortality Analysis Summary Look for excess mortality in risk-adjusted populations Identify the potential drivers of mortality in the identified population. Look for differences in comparison with peers and those who expired vs. those who lived. Let the data take you to your next clinical hypothesis and test. Always verify your hypotheses and analysis with clinicians closest to the process.

32. 32 Resources on the Performance Improvement Portal Ventilator Associated Pneumonia advice category Protocols for: Ventilation Weaning Sedation vacation Mortality measurement, tools, results Share your successes, ask questions of Collaborative Members

33. QUESTIONS?