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Prescott HC, Kadel RP, Eyman JR, Freyberg R, Quarrick M, Brewer D, Hasselbeck R. Risk-Adjusting Mortality in the Nationwide Veterans Affairs Healthcare System. J Gen Intern Med 2022; 37:3877-3884. [PMID: 35028862 PMCID: PMC9640507 DOI: 10.1007/s11606-021-07377-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND The US Veterans Affairs (VA) healthcare system began reporting risk-adjusted mortality for intensive care (ICU) admissions in 2005. However, while the VA's mortality model has been updated and adapted for risk-adjustment of all inpatient hospitalizations, recent model performance has not been published. We sought to assess the current performance of VA's 4 standardized mortality models: acute care 30-day mortality (acute care SMR-30); ICU 30-day mortality (ICU SMR-30); acute care in-hospital mortality (acute care SMR); and ICU in-hospital mortality (ICU SMR). METHODS Retrospective cohort study with split derivation and validation samples. Standardized mortality models were fit using derivation data, with coefficients applied to the validation sample. Nationwide VA hospitalizations that met model inclusion criteria during fiscal years 2017-2018(derivation) and 2019 (validation) were included. Model performance was evaluated using c-statistics to assess discrimination and comparison of observed versus predicted deaths to assess calibration. RESULTS Among 1,143,351 hospitalizations eligible for the acute care SMR-30 during 2017-2019, in-hospital mortality was 1.8%, and 30-day mortality was 4.3%. C-statistics for the SMR models in validation data were 0.870 (acute care SMR-30); 0.864 (ICU SMR-30); 0.914 (acute care SMR); and 0.887 (ICU SMR). There were 16,036 deaths (4.29% mortality) in the SMR-30 validation cohort versus 17,458 predicted deaths (4.67%), reflecting 0.38% over-prediction. Across deciles of predicted risk, the absolute difference in observed versus predicted percent mortality was a mean of 0.38%, with a maximum error of 1.81% seen in the highest-risk decile. CONCLUSIONS AND RELEVANCE The VA's SMR models, which incorporate patient physiology on presentation, are highly predictive and demonstrate good calibration both overall and across risk deciles. The current SMR models perform similarly to the initial ICU SMR model, indicating appropriate adaption and re-calibration.
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Affiliation(s)
- Hallie C Prescott
- VA Center for Clinical Management Research, Ann Arbor, MI, USA. .,University of Michigan, Department of Medicine, Ann Arbor, MI, USA.
| | - Rajendra P Kadel
- VA Center for Strategic Analytics and Reporting, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
| | - Julie R Eyman
- VA Center for Strategic Analytics and Reporting, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
| | - Ron Freyberg
- VA Center for Strategic Analytics and Reporting, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
| | - Matthew Quarrick
- VA Center for Strategic Analytics and Reporting, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
| | - David Brewer
- VA Center for Strategic Analytics and Reporting, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
| | - Rachael Hasselbeck
- VA Inpatient Evaluation Center, Department of Veterans Affairs, Veterans Health Administration, 810 Vermont Ave. NW Room 668, Washington, DC, 20420, USA
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McGrath BM, Takamine L, Hogan CK, Hofer TP, Rosen AK, Sussman JB, Wiitala WL, Ryan AM, Prescott HC. Interpretability, credibility, and usability of hospital-specific template matching versus regression-based hospital performance assessments; a multiple methods study. BMC Health Serv Res 2022; 22:739. [PMID: 35659234 PMCID: PMC9166576 DOI: 10.1186/s12913-022-08124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Hospital-specific template matching (HS-TM) is a newer method of hospital performance assessment. OBJECTIVE To assess the interpretability, credibility, and usability of HS-TM-based vs. regression-based performance assessments. RESEARCH DESIGN We surveyed hospital leaders (January-May 2021) and completed follow-up semi-structured interviews. Surveys included four hypothetical performance assessment vignettes, with method (HS-TM, regression) and hospital mortality randomized. SUBJECTS Nationwide Veterans Affairs Chiefs of Staff, Medicine, and Hospital Medicine. MEASURES Correct interpretation; self-rated confidence in interpretation; and self-rated trust in assessment (via survey). Concerns about credibility and main uses (via thematic analysis of interview transcripts). RESULTS In total, 84 participants completed 295 survey vignettes. Respondents correctly interpreted 81.8% HS-TM vs. 56.5% regression assessments, p < 0.001. Respondents "trusted the results" for 70.9% HS-TM vs. 58.2% regression assessments, p = 0.03. Nine concerns about credibility were identified: inadequate capture of case-mix and/or illness severity; inability to account for specialized programs (e.g., transplant center); comparison to geographically disparate hospitals; equating mortality with quality; lack of criterion standards; low power; comparison to dissimilar hospitals; generation of rankings; and lack of transparency. Five concerns were equally relevant to both methods, one more pertinent to HS-TM, and three more pertinent to regression. Assessments were mainly used to trigger further quality evaluation (a "check oil light") and motivate behavior change. CONCLUSIONS HS-TM-based performance assessments were more interpretable and more credible to VA hospital leaders than regression-based assessments. However, leaders had a similar set of concerns related to credibility for both methods and felt both were best used as a screen for further evaluation.
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Affiliation(s)
- Brenda M. McGrath
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Linda Takamine
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Cainnear K. Hogan
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Timothy P. Hofer
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Amy K. Rosen
- grid.410370.10000 0004 4657 1992VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Surgery, Boston University School of Medicine, Boston, MA USA
| | - Jeremy B. Sussman
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Wyndy L. Wiitala
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Andrew M. Ryan
- grid.214458.e0000000086837370Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Hallie C. Prescott
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
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Cohen CC, Barnes H, Buerhaus PI, Martsolf GR, Clarke SP, Donelan K, Tubbs-Cooley HL. Top priorities for the next decade of nursing health services research. Nurs Outlook 2020; 69:265-275. [PMID: 33386144 DOI: 10.1016/j.outlook.2020.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/28/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.
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Affiliation(s)
| | - Hilary Barnes
- University of Delaware, School of Nursing, Newark, DE
| | - Peter I Buerhaus
- Center for Interdisciplinary Health Workforce Studies, Montana State University College of Nursing, Bozeman, MT
| | - Grant R Martsolf
- University of Pittsburgh School of Nursing, Department of Acute and Tertiary Care, RAND Corporation, Pittsburgh, PA
| | - Sean P Clarke
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Karen Donelan
- Health Policy Research Center, The Mongan Institute, Survey Research and Implementation Unit, Harvard Medical School, Boston, MA
| | - Heather L Tubbs-Cooley
- Martha S. Pitzer Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus, OH
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Palevsky PM. Measuring Up. J Am Soc Nephrol 2020; 31:454-455. [DOI: 10.1681/asn.2019111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Pronovost PJ, Armstrong CM, Demski R, Peterson RR, Rothman PB. Next level of board accountability in health care quality. J Health Organ Manag 2018; 32:2-8. [PMID: 29508668 DOI: 10.1108/jhom-09-2017-0238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety. Design/methodology/approach Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes. Findings The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model. Originality/value This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors' knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.
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Affiliation(s)
- Peter J Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Bloomberg School of Public Health, Johns Hopkins University , Baltimore, Maryland, USA
| | | | - Renee Demski
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA.,The Johns Hopkins Hospital and Johns Hopkins Health System, Baltimore, Maryland, USA
| | - Ronald R Peterson
- Johns Hopkins Medicine, Baltimore, Maryland, USA.,Johns Hopkins Health System, Baltimore, Maryland, USA
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