RFP_AHRQ-16-10013_-_Attachment_F_-_Four_Sample_MPSMS_Algorithms_Showing_Intermediate_Data.pdf

Attachment F

Four sample MPSMS Algorithms showing intermediate data.

Medicare Patient Safety Monitoring System Annual Data Report: 2013 Findings Hospital Discharges January 2013 to December 2013

12/2014 2014 MPSMS Annual Report of 2013 Data: Measure Algorithm

Catheter-Associated Urinary Tract Infection (CAUTI) 17,952 Hospital Discharges

218 patients had a Catheter-Associated Urinary Tract Infection (CAUTI)

Yes

518 cases

7,324 cases…………………….Denominator No

Yes

16,455 cases No

No

Yes

Yes Indwelling catheter in place or on Straight Catheter Regime prior to arrival

UTI diagnosis on arrival

296 cases excluded

1,201 cases excluded

No

Physician diagnosis of UTI on either the date of the catheterization, before the catheterization date, or unable to determine the date

8,837 cases excluded

218/7,324 = 2.98% of patients did not have an indwelling catheter in place on arrival, were not on a straight catheter regime prior to arrival, had no evidence of a UTI prior to the insertion of the catheter, and experienced a UTI during the hospital stay.

Indwelling catheter placed or straight catheterization performed during stay

294 cases excluded

7,618 cases

17,656 cases

Yes

No 7,097 cases excluded

No

Yes

Physician ordered antibiotics to treat the

UTI

9 cases excluded

227 cases

Physician diagnosed UTI

Noel.Eldridge Cross-Out

12/2014 2014 MPSMS Annual Report of 2013 Data: Measure Algorithm

Adverse Events Associated with Warfarin 17,952 Hospital Discharges

1,863 cases

Yes 3,108 cases

Yes

127 patients had at least one adverse event

No

No 190 cases

217 cases

1,672 cases

1,419 cases

1,634 cases

1,846 cases

Yes 2,518 cases……………………………Denominator

Yes 131 cases

90 cases

No 357 cases

No 5 cases

No

No No No

Yes 104 cases

Vitamin K or fresh frozen plasma given

Yes 405 cases

INR ≥ 4.0

but < 6.0

There was documentation that the patient experienced one or more of the following adverse events two days before or two days after the INR; two days before or two days after the abrupt stop/hold of the warfarin; or two days before or two days after administration of Vitamin K, fresh frozen plasma, or a transfusion (unrelated to a surgical procedure). Incidences of adverse events that occurred on the date of arrival were not counted.

9 Cardiac arrest/emergency measures to sustain life 18 Gastrointestinal bleeding 8 Genitourinary bleeding 134 Hematocrit drops of 3 points (> 48 hrs. post admission) 0 Intracranial bleed (subdural hematoma) 5 New hematoma 4 Pulmonary bleeding 14 Other types of bleeding 12 Death

INR > 1.5

590 cases excluded

Abrupt cessation/hold of warfarin

105 cases excluded

INR ≥ 6.0

INR during stay

655 cases excluded

17 cases

Transfusion (Absent a surgical procedure)

Patient received warfarin during hospital stay

1,631 cases excluded

14,844 cases excluded

127/2,518 = 5.04% of patients who received warfarin during the hospital stay and had an INR documented during the hospital stay experienced an adverse event.

Note:

Patient(s) may have experienced more than one adverse event during the hospital stay. Thus, the number of adverse events is greater than the number of patients who had at least one adverse event.

12/2014 2014 MPSMS Annual Report of 2013 Data: Measure Algorithm

No

Postoperative Venous Thromboembolic Events (VTE)

5,044 Surgical Cases………………. Denominator

25 patients had at least one postoperative PE/DVT during the hospital stay1

25/5,044 = 0.50% of surgery cases experienced at least one DVT/PE during the hospital stay.

Yes 16 cases

Yes 9 cases

Yes 15 cases

Yes 19 cases

No

No No Deep Vein Thrombosis (DVT) diagnosed post procedure

DVT confirmed by diagnostic study:

• Duplex or Doppler ultrasonogram

• Contrast venogram

• Contrast CT scan

• Impedance plethysmogram (IPG)

• Magnetic Resonance venogram (MR)

OR

In the absence of the above tests, physician documentation of a positive test finding

5,029 cases excluded

Pulmonary Embolus (PE) diagnosed post procedure

PE confirmed by diagnostic study:

• High probability V/Q scan

• Pulmonary angiogram

• MR angiogram of pulmonary arteries

• Chest CT scan /CT angiogram of the chest

• Moderate probability V/Q scan AND one of the following:

o Duplex US of lower extremities o Lower extremity venogram o Impedance plethysmogram

(IPG)

o Magnetic Resonance venogram

(MR)

5,025 cases excluded

3 cases excluded

6 cases excluded

1Note:

If a case had both a DVT and PE, it was counted only once in the adverse event total as a PE.

12/2014 2014 MPSMS Annual Report of 2013 Data: Measure Algorithm

Hospital-Acquired Pressure Ulcers (HAPU) 17,952 Hospital Discharges……..…. Denominator

Region Anatomical Region 1 915 Coccyx/Sacrum 2 552 Hip and Buttock

92 Left 106 Right 299 Both 55 Location Unspecified

3 260 Heel 64 Right 70 Left 121 Both 5 Location Unspecified

4 71 Ankle 27 Right 25 Left 18 Both 1 Location Unspecified

5 40 Elbow 17 Right 14 Left 9 Both 0 Location Unspecified

Region Anatomical Region 1 51 Coccyx/Sacrum 2 68 Hip and Buttock

12 Left 21 Right 32 Both 3 Location Unspecified

3 57 Heel 19 Right 12 Left 25 Both 1 Location Unspecified

4 13 Ankle 4 Right 4 Left 4 Both 1 Location Unspecified

5 7 Elbow 3 Right 0 Left 4 Both 0 Location Unspecified

Region Anatomical Region 1 324 Coccyx/Sacrum 2 242 Hip and Buttock

30 Left 36 Right 142 Both 34 Location Unspecified

3 96 Heel 24 Right 19 Left 50 Both 3 Location Unspecified

4 17 Ankle 7 Right 6 Left 3 Both 1 Location Unspecified

5 12 Elbow 5 Right 3 Left 4 Both 0 Location Unspecified

Location 1 cases

No 157 cases

Yes

1,307 cases

Location 3

No

No

536 cases

Pressure ulcer on admission

Pressure ulcer noted during hospital stay

Location 3

Location 1

Pressure ulcer noted during hospital stay

Location 2 1,145 cases excluded

5 cases excluded

693 patients developed one or more pressure ulcers during the hospital stay

693/17,952= 3.86% of hospitalized patients developed at least one new pressure ulcer during the stay.

16,109 cases excluded

Pressure ulcer in same location as a pressure ulcer noted on admission

Location 2

16,645 cases