1_AttachmentJ-10.doc

Section J, Attachment 10 Appendix A – Details on Measures

Contents:

1. Measures – I-1,2,3,4,6

2. Measure – I- 5

3. Measures - O-1a and O-1b

4. Measure —O-2

5. Measure -- O-3

6. Measure -- O-4

7. Measure – O-5a, b, and c

8. Measure-- O-6

9. The Proportion of Transitions Table (basis of Measures I-1, 2, 3, 4, 6 and O-3) (with example)

1. Measures – I-1,2,3,4,6

For measures I-1, I-2, I-3, I-4, and I-6 (and O-3, which is listed separately below), the QIO will report the relevant rate for each provider that they listed in the area, along with a justification for their estimate. The QIO will enter these six rates, by provider, monthly throughout the project. The rate for each measure for each provider will be multiplied by the proportion of transitions represented by that provider in the Table of Proportions of Transitions (in #9 below) to yield the proportion of transitions involved in that measure. For each measure, those rates by provider will be summed to yield the proportion of transitions affected by the local project. An example of this calculation for I-1 and I-6 are given in the example presented in #9 below.

One patient transition may have been affected by more than one intervention; thus, the reporting of rates for each provider by the QIO will have to take account of the overlap and avoid double-counting transitions. The process for doing this will be included in the justification for the estimate of the provider table supplied monthly by the QIO.

An “intervention” reported here consists of an aim, a working group guiding the intervention, an intervention strategy, and a measurement strategy. An “intervention” in this meaning does not include activities limited to planning. Complex interventions and monitors may be reported as one coherent project or as split in meaningful ways, as preferred by the QIO and approved by the GTL; that choice will not affect the key monitors of progress as given below.

The Specific Measures:

I-1 Description: Percentage of patient care transitions (FFS Medicare) in the specified geographic area that are attributable to providers who agree to participate.

The rate at which providers are coming to meetings, agreeing in writing (including by Email), or otherwise participating in decision-making or intervention implementation. This is meant to be as inclusive as possible, and the rate may fall as well as rising from month to month (e.g., when a provider institution decides to withdraw from the project or new management stops participating). In general, the presence of a representative of a provider “at the table” will indicate 100% participation for the transitions represented by that provider. However, non-institutional providers will have to have their rate of participation estimated, and institutional providers might have different branches or other reasons why a particular representative reflects only part of their population.

I-2 Description: Percentage of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses hospital/community system wide processes. (Task 2.2.a).

I-3 Description: Percentage of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses AMI, CHF, or pneumonia.(Task 2.2.b)

I-4: Description: Percentage of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses specific reasons for readmission (Task 2.2.c)

I-6. Description: Percentage of patient care transitions (FFS Medicare) in the specified geographic area to which implemented and measured (as in I-5) interventions apply.

2. Measure – I- 5

Description: Percentage of implemented interventions in the specific geographic area that are measured. Calculated by dividing the sum of the interventions implemented for which measures are being collected, by the total number of interventions tallied. This ratio should always be as close to 1 as possible, since interventions without measurement are unlikely to provide insight.

3. Measures O-1a and O-1b

Description: Percentage of patients over 65 years who rate hospital performance meeting HCAHPS performance standard for medication management (O-1a) or discharge planning (O-1b) Method:

1. Existing data collection has each hospital completing 300 surveys per year, collecting the surveys quarterly.

2. After each quarter, construct rolling annual sets of H-CAHPS reports on the four data elements for all targeted hospitals in each project site (from the list submitted by the QIO) and for comparison sites.

3. Combine all targeted hospitals and split out the respondents age 65 or older.

4. Using the same approach as the two nationally reported measures, calculate the two measures from the survey questions 16 and 17 (for medication management) and 18 and 19 (for discharge planning).

5. Report rolling measures from the preceding year, quarterly, for each target community and each comparison community (as well as the publicly reported national and state reports on all hospitals’ data, annually).

4. Measure —O-2 Description: Percentage of patients discharged from an “acute care” hospital to a community setting and readmitted within 30 days who are seen by a physician between discharge and readmission.

Numerator: Medicare FFS beneficiaries discharged alive from “acute care” hospital who are readmitted within 30 days and for whom a physician (including nurse practitioner or physician assistant) claim was submitted for services in the time between discharge and readmission.

Denominator: Medicare FFS beneficiaries discharged alive from acute care hospital who are readmitted within 30 days.

Data Sources:

1. Medicare claims for the specified geographic areas for codes listed below.

List of E&M codes

New patient, office – 99201- 99205

Established patient, office – 99211- 99215

Consultations, office or outpatient – 99241 – 99245

Nursing facility, new or established – 99304 – 99310, 99315-99316, 99318

Domiciliary and assisted living – new – 99324 – 99328

Domiciliary and assisted living – established – 99334- 99337 and 99339-40

Home care – new – 99341- 99345

Home care – established – 99347 – 99350

Exclusions:

1. Claim for dates of service for institutional post acute care in the time between discharge and readmission.

2. Claim for hospice or home care in the time between discharge and readmission.

5. Measure -- O-3

The QIOs will report narrative and time series reports, using the SQUIRE guidelines for reporting (see Appendix) and will estimate the rate of implementation of improvements, by provider, using the method described for the Interim Reports, #2 above.

Description: Percentage of patient care transitions (FFS Medicare), in the specified geographic area, for which implemented and measured interventions show improvement.

Method: In addition to the narrative and time-series reports, the QIO will report the proportion of transitions affected by interventions that showed improvement in quality, by provider. This report follows the method of the interim measures, using the Table of Proportions of Transitions, including being summed to an overall rate at which improvements affect transitions in the community. This rate will be reported quarterly.

6. Measure -- O-4 Description: Percentage of patients from the specified geographic area re-hospitalized within 30 days of discharge from an acute care hospital.

“Acute care” hospitals will not include critical access hospitals for the purposes of this measure.

Data source:

· Claims for beneficiaries hospitalized in the target area for each project (and for the comparison sites) (defined by ZIP codes),

· 1 quarter + 1 month of claims Frequency of calculation: Quarterly for the 30 day measure.

Denominator: Each QIO will specify a population by ZIP Code of residence in the enrollment file (see specifications and exclusions below). The only exclusions from among beneficiaries in traditional Medicare at the time of hospitalization are for enrollees discharged dead, or discharged to another acute care hospital (and admitted to that other hospital on the same day).

Numerator: From those in the denominator, the number of Medicare beneficiaries who were readmitted at least once within 30 days of discharge from their initial hospital stay within the target period.

7. Measure -- O- 6

Description: Percentage of patient transitions within the specified geographic area for which a CARE instrument was used.

Data Sources:

1. CARE instrument data from OIS.

2. Proportions of transitions table.

8. Measures – O-5a, b, and c.

Using the methods established for the national reporting, except the readmission rates will be calculated quarterly without adjustment for purposes of tracking change, and annually for purposes of public reporting.

9. The Proportion of Transitions Table (basis of Measures I-1, 2, 3, 4, 6 and O-3) (with example) Data:

From Medicare claims:

· Beneficiary Zip code of residence at the time of hospital discharge

· Admission and Discharge dates for “acute care” (IPPS) hospitalizations in 2007 (initially, then repeated annually) with follow-up through January 2008 (initially, then repeated annually).

· Calculated by August 2008 (and annually in 2009, 2010)

· Admission and discharge dates for all SNF, IRF, LTAC, psychiatric hospitals, and critical access hospitals for the same time periods.

Procedure:

1. For the ZIP codes specified by each QIO, pull all hospitalizations in 2007.

2. Exclude discharges dead.

3. Test for whether there is a new hospitalization on the same day as the initial hospital discharge. If so, discard the initial hospitalization and count only the ensuing hospitalization

4. For each beneficiary discharged alive in 2007, pull all other institutional use (admission and discharge date) for each beneficiary.

5. Assign 2 variables for each of the 30 days after the initial discharge: the day after discharge and the Medicare provider number where the beneficiary resides on that day. If the beneficiary is not residing in any of the target settings, then assign a neutral provider number (I will use “9” in the example below). This will yield a table with days 0 through 30 and provider numbers for each. Day 0 will have the provider number of the index hospital doing the discharge. If the patient is in two facilities on the same day (by having a discharge date and an admission date that match, then assign the patient to the admission setting for that day. This yields tables like the following:

Example #1 - For a patient who only has a hospital discharge from hospital #1

Bene ID # xxx-xx-xxxxx

Example #2 - For a patient who only has a readmission to hospital #2, on the 10th day

Bene ID # xxx-xx-xxxxx

Example #3 - For that patient, who is discharged from hospital #2 a few days later, resetting the clock. This time, the person uses an SNF, #3, from day 5 through day 12 but is not readmitted to a hospital

Bene ID # xxx-xx-xxxxx

Example #4 - For a patient who goes direct from hospital #1 to an IRF (#4) for four more days, then to SNF (#5) for all of the rest of the month

Bene ID # xxx-xx-xxxxx

6. If the patient is readmitted to an “acute care” hospital within 30 days, truncate the table on the day of readmission, and count the new admission as a new start date for the 30 day follow-up.

7. Test for whether each beneficiary’s table has changes in provider number and create a list in which the provider number on the day before a change is listed as “sender” and the provider number on the day after a change is listed as “receiver.”

For the examples above –

Example #1 yields one transition in which #1 is a sender and “9” is a receiver

Example #2 yields two transitions, one in which #1 is a sender and “9” is a receiver, and one in which “9” is a sender and #2 is a receiver

Example #3 yields three transitions, one in which #1 is a sender and “9” is a receiver, one in which “9” is a sender and #3 is a receiver, and one in which #3 is a sender and “9” is a receiver

Example #4 yields two transitions, one in which #1 is a sender and #4 is a receiver, one in which #4 is a sender and #5 is a receiver.

Thus, if these were all hospitalizations, the tally would be

8. The sum of transitions on the list is the number of transitions.

9. The number of parties to transitions is double the number of transitions.

10. Tally the number of times each provider number is a sender or a receiver.

11. (Report the entire table to the QIO).

12. Match the provider number with the list that the QIO provided in order to create the institutional list in the Table: Proportions of Transitions Attributable to Each Institutional Provider. So, in this example, if provider #4 and # 5 are not in the QIO list, then the table above becomes

The following steps are needed in order to estimate the proportion of non-institutional providers that are not in the target area.

13. The proportion of institutional providers that are “out of area” = 1 – [N of times that a targeted institution is party to transitions/ total N of times that an institution is party to transitions]

14. The proportion of non-institutional providers presumed to be “out of area” is assumed to be the same as the proportion of institutional providers that are “out of area,” as in #13.

15. Multiply the number of times that the “9” (or other neutral provider code) is party to transitions by the proportion of non-institutional providers that are “out of area” (#14) to get the number of transitions attributable to non-institutional providers “out of area.”

16. Subtract the product in #15 from the number of times that the “9” is party to transitions in order to obtain the non-institutional providers that are “in area.”

17. Fill in the last two lines of the Table with the numbers obtained in #15 and #16.

An empty final table and the further calculation of the simple example above follow:

(Other area hospitals)…

(Other “post acute care” institutions)

And for the example above, the table would be the first and last columns in this table

Appendix B – SQUIRE guidelines for reporting intervention trials.

SQUIRE Guidelines

(Standards for QUality Improvement Reporting Excellence)

Version 2.6 – 12/1/07 – used with permission – will amend to match final published version

· These guidelines are intended to provide a framework for writing and publishing reports of studies that formally assess the nature and effectiveness of interventions carried out to improve the quality and safety of care. (Guidelines for informal reports of experiences with QI interventions can be found at: [URL for QSHC/BMJ QI reporting guidelines])

· Although each major section (i.e., Introduction, Methods, Results, and Discussion) of published reports of original studies generally contains at least some information about all the numbered items included in the corresponding guideline section, some information about individual items from one section (for example, the Introduction) is often also needed in other sections (for example, the Discussion).

Front matter

What did you do to help with finding, indexing, and scanning your report?

Introduction

Why did you undertake the intervention, and why did you decide to study it?

3. Background

Knowledge

· Provides a brief, balanced summary of current knowledge of care problem being addressed, and characteristics of organizations in which it occurs

· Specifies who (champions, supporters) and what (events, observations) triggered the decision to make changes, and why now (timing)

· Indicates the factors contributing to choice of the specific improvement intervention (e.g., analysis of causes of the dysfunction; prior studies of relevant improvement strategies)

5. Intended improvement

· Describes the specific aim (changes/improvements in care processes and patient outcomes) of the proposed intervention

9. Planning the intervention

· Characterizes in detail how the intervention was initially planned: i.e., what was to be done (initial steps; functions to be accomplished by those steps; how tests of change would be used to modify the intervention), and by whom (intended roles, qualifications, and training of staff)

10. Planning the study

· Outlines plans made for assessing how well the intervention was implemented (dose or intensity of exposure)

· Describes the mechanisms (theories) by which intervention components were expected to cause changes, and approaches planned for testing whether those mechanisms were effective

· Identifies the experimental or quasi-experimental design chosen for measuring impact of the intervention on primary and secondary outcomes, if applicable

· Explains efforts planned for implementing the essential aspects of chosen study design, as described in appropriate study design publication guidelines (see, for example, www.equator-network.org)

· Describes specific plans made for maximizing internal and external validity

11. Methods of evaluation

· Describes instruments (qualitative, quantitative, or mixed) used to assess a) effectiveness of implementation, b) contributions of intervention components and context factors to effectiveness of the intervention, and c) primary and secondary outcomes

· Reports efforts to validate and test reliability of assessment instruments

· Explains methods used to assure data quality (e.g., blinding, repeating measurements and data extraction; training in data collection)

· Aligns unit of analysis with level at which the intervention was applied (if applicable)

· Specifies degree of variability expected in implementation, change expected in primary outcome (effect size), and ability of study design (including size) to detect such effects

· Describes analytic methods used to demonstrate effects of time as a variable (e.g., statistical process control)

· Characterizes relevant elements of setting or settings (e.g., geography, physical resources, organizational culture, history of change efforts), and structures and patterns of care (e.g., staffing, leadership) that provided context for the intervention

· Explains the actual course of the intervention (e.g., sequence of steps, events or phases; type and number of participants at key points), preferably using a time-line diagram or flow chart

· Documents degree of success in implementing intervention components

· Describes how and why the initial plan evolved, and the most important lessons learned from that evolution, particularly the effects of internal feedback from tests of change (reflexiveness)

b) Changes in processes of care and patient outcomes associated with the intervention

· Presents data on changes observed in the care delivery process

· Presents data on changes observed in measures of patient outcome (e.g., morbidity, mortality, function, patient/staff satisfaction, service utilization, cost, care disparities)

· Presents evidence on strength of the association between observed changes in outcomes and intervention components and context factors

· Includes summary of missing data for intervention and outcomes

15. Relation to other evidence

· Compares and contrasts study results with relevant findings of others, drawing on broad and balanced review of the literature; use of a summary table may be helpful in building on existing evidence

· Explores factors affecting generalizability (external validity), particularly features of local settings and implementation of the intervention

· Addresses likelihood that observed gains may weaken over time, and describes plans, if any, for monitoring and maintaining improvement; explicitly states if such planning was not done

· Reviews efforts made to minimize and adjust for study limitations

· Assesses the effect of study limitations on interpretation and application of results

· Draws inferences consistent with the strength of the data about causal mechanisms and size of observed changes, paying particular attention to components of the intervention and context factors that helped determine the intervention’s effectiveness (or lack thereof)

· Suggests steps that might be modified to improve future performance

· Reviews issues of opportunity cost and actual financial cost of the intervention

· Suggests implications of this report for further studies of improvement interventions

Appendix C: Databases and Analytic Methods to support interventions.

This material is supplemental to the section in the SOW concerning databases and analytic methods that are available to the QIO to use in supporting interventions. (Task 2.4)

· Appendix C- 1 – Variables proposed to include in the claims databases

· Appendix C – 2 – Sample of analyses with existing SAS code, by hospital

· Appendix C- 3 – Samples of claims sequence for individual patients

· Appendix C-4 Timeline of periods of data generation and resulting reports Appendix C- 1 – Variables (for each claim) in the databases supplied tc "Print " \f C \l 1 tc "Data Set CLAIMS.VARIABLE_LISTING " \f C \l 2Obs

NAME

Appendix C – 2 – Sample of analyses with existing SAS code, by hospital (fictitious hospitals)

Statistics from Index Hospitalization at Participant Hospital

PRIMARY DISCHARGE DIAGNOSIS:

ADMISSION TYPE:

DISCHARGE DISPOSITION:

Statistics from Admissions to Target Hospital Post Index Hospitalization

READMISSION RATIO = (total #readm in specified days from index dsg date) / (total #pts alive within specified time):

NUMBER OF READMISSIONS = (total #pts readm specifed # of times) / (total #pts alive at 180 days from index dsg):

Statistics from Physician Office Visits Post Index Hospitalization

Time to Event Statistics

NUMBER OF DAYS BETWEEN DISCHARGE DATE OF INDEX

HOSPITALIZATION AND…

Appendix C- 3 – Samples of claims sequence for individual patients (note these are fictitious patients) theseare are fictitious patients)

VALUE Project Claims-based Electronic Medical Record Recorded Claims July 1, 2005 through December 31, 2006

CASE ID: Jane Doe AGE: 87 SEX: Male RACE: XX DEATH DT: XX STATE: XX

INDEX EVENT DATE: XXXXXXXXXXX INDEX EVENT: Earliest 2005q3 Inp AMI, HF, or PN as Prin Discharge Dx CARE COST: $211,785

Service MD Days Fr Event Payment

Type Place Spec. Start End Amount Diagnoses HCPCS/CPT4 Procedures ICD9 Procedures

HSP Hospce 118 128 $1,541 ALZHEIMER*S DISEASE

HSP Hospce 88 117 $4,203 ALZHEIMER*S DISEASE

HSP Hospce 57 87 $4,343 ALZHEIMER*S DISEASE

HSP Hospce 27 56 $4,049 ALZHEIMER*S DISEASE

HSP Hospce 0 26 $3,644 ALZHEIMER*S DISEASE

INP Inp -7 0 $47,931 PNEUMONIA, ORGANISM NOS ENTRAL INFUS NUTRIT SUB

RETENTION URINE NOS VENOUS CATH NEC

CONVULSIONS NEC

DVRTCLO COLON W/O HMRHG

PERIPH VASCULAR DIS NOS

HYPERTENSION NOS

DMII WO CMP NT ST UNCNTR

THRUSH

INT INF CLSTRDIUM DFCILE

medical Off Neurol -17 -17 $66 ALZHEIMER*S DISEASE Office/outpatient visit, est

OTP Otp -25 -16 $385 CONVULSIONS NEC Wheelchair mngement training

72887 Therapeutic activities

Therapeutic exercises

Pt evaluation medical Off Podiat -31 -31 $31 FX MEDIAL MALLEOLUS-CLOS Office/outpatient visit, est

EDEMA

70714 medical Off Podiat -64 -64 $42 FX MEDIAL MALLEOLUS-CLOS Office/outpatient visit, est

EDEMA

SNF SNF -65 -49 $5,505 CONVULSIONS NEC CB103

PERIPH VASCULAR DIS NOS

HYPERTENSION NOS

ALZHEIMER*S DISEASE

DMII WO CMP NT ST UNCNTR

OTP Otp -94 -94 $5,151 FX MEDIAL MALLEOLUS-CLOS Emergency dept visit

HX-VEN THROMBOSIS/EMBOLS Extremity study

BONE & CARTILAGE DIS NOS Injection (IV)

URIN TRACT INFECTION NOS Antibiotic sensitivity, MIC

HYPERTENSION NOS Urine culture, colony count

ALZHEIMER*S DISEASE 87077

29410 Automated hemogram

HYPOSMOLALITY Urinalysis nonauto w/o scope

DMII WO CMP NT ST UNCNTR Urinalysis, auto, w/scope

See data set for more detail

SNF SNF -96 -66 $13,771 CONVULSIONS NEC RMB02

PERIPH VASCULAR DIS NOS CB103

HYPERTENSION NOS

ALZHEIMER*S DISEASE

DMII WO CMP NT ST UNCNTR

medical Off Neurol -107 -107 $42 EPIL PAR CONT W INTR EPI Office/outpatient visit, est

SNF SNF -126 -97 $14,604 CONVULSIONS NEC RVB11

PERIPH VASCULAR DIS NOS RVB07

HYPERTENSION NOS RMB02

ALZHEIMER*S DISEASE

DMII WO CMP NT ST UNCNTR

SNF SNF -135 -127 $4,908 CONVULSIONS NEC RVB11

PERIPH VASCULAR DIS NOS

HYPERTENSION NOS

ALZHEIMER*S DISEASE

DMII WO CMP NT ST UNCNTR

INP Inp -138 -135 $11,552 PART EPIL W/O INTR EPIL

HX-CIRCULATORY DIS NEC

CONGESTIVE HEART FAILURE

HYPERTENSION NOS

ALZHEIMER*S DISEASE

HYPOPOTASSEMIA

HYPOSMOLALITY

DIS MAGNESIUM METABOLISM

DMII WO CMP NT ST UNCNTR

HHA Home -176 -141 $5,440 PHYSICAL THERAPY NEC HCGM1

ENCNTR OCCUPATNAL THRPY G0155

CONVULSIONS NEC G0154

72887 G0152

LATE EFFECT CV DIS NOS G0151

DMII WO CMP NT ST UNCNTR

OTP Otp -185 -179 $432 ABNORMALITY OF GAIT Therapeutic activities

MALAISE AND FATIGUE NEC Gait training therapy

Therapeutic exercises

Pt evaluation

SNF SNF -199 -186 $17,999 REHABILITATION PROC NEC RHC01

HX-CIRCULATORY DIS NEC

CONVULSIONS NEC

70703

URIN TRACT INFECTION NOS

PNEUMONIA, ORGANISM NOS

ALZHEIMER*S DISEASE

29410

DMII WO CMP NT ST UNCNTR

INP Inp -207 -199 $33,465 7837 COLONOSCOPY

ACCIDENT IN PLACE NOS SM BOWEL ENDOSCOPY NEC

CONVULSIONS NEC

URIN TRACT INFECTION NOS

BLOOD IN STOOL

AGRANULOCYTOSIS

HYPOVOLEMIA

DMII WO CMP NT ST UNCNTR

E. COLI INFECT NOS

medical Off GP/IM -211 -211 $0 CHEST PAIN NOS Office/outpatient visit, est

78321

MALAISE AND FATIGUE NEC

HYPERTENSION NOS

HHA Home -245 -232 $1,400 PHYSICAL THERAPY NEC HCGJ1

ABNORMALITY OF GAIT G0151

MALAISE AND FATIGUE NEC

CONVULSIONS NEC

PAIN IN THORACIC SPINE

SNF SNF -253 -246 $8,923 REHABILITATION PROC NEC RHA01

HX-CIRCULATORY DIS NEC

DEBILITY NOS

CONVULSIONS NEC

FOOD/VOMIT PNEUMONITIS

HYPERTENSION NOS

ALZHEIMER*S DISEASE

29410

DMII WO CMP NT ST UNCNTR

INP Inp -255 -253 $17,586 CONVULSIONS NEC

HX-CIRCULATORY DIS NEC

URINARY INCONTINENCE NOS

FOOD/VOMIT PNEUMONITIS

HYPERTENSION NOS

ALZHEIMER*S DISEASE

29410

DMII WO CMP NT ST UNCNTR

medical Off GP/IM -273 -273 $65 DMII UNSPF UNCNTRLD Office/outpatient visit, est

V0481

CONVULSIONS NEC

HYPERTENSION NOS

medical Off Neurol -284 -284 $65 ALZHEIMER*S DISEASE Office/outpatient visit, est medical Off GP/IM -304 -304 $65 EDEMA Office/outpatient visit, est

CONVULSIONS NEC

STOMACH FUNCTION DIS NEC

HYPERTENSION NOS

OTP Otp -309 -309 $3,591 MALAISE AND FATIGUE NEC Emergency dept visit

STATUS AMPUT FOOT Electrocardiogram, tracing

HX-CIRCULATORY DIS NEC Urine culture, colony count

CONVULSIONS NEC Automated hemogram

HYPERTENSION NOS Glucose blood test

ALZHEIMER*S DISEASE Urinalysis nonauto w/o scope

DMII WO CMP NT ST UNCNTR Urinalysis, auto, w/scope

80053

Chest x-ray

See data set for more detail medical Off GP/IM -325 -325 $65 DMII UNSPF UNCNTRLD Office/outpatient visit, est

EDEMA

CONVULSIONS NEC

medical Off GP/IM -339 -339 $65 DMII UNSPF UNCNTRLD Office/outpatient visit, est

EDEMA

CONVULSIONS NEC

HYPERTENSION NOS

OTP Otp -379 -379 $772 CONVULSIONS NEC Electroencephalogram (EEG) medical Off GP/IM -393 -393 $65 DMII UNSPF UNCNTRLD Office/outpatient visit, est

MALAISE AND FATIGUE NEC

RHINITIS DUE TO POLLEN

VALUE Project Claims-based Electronic Medical Record Recorded Claims July 1, 2005 through December 31, 2006

CASE ID: John Doe STATE: XX AGE: 68 SEX: Male

RACE: XX DEATH DT: XX

INDEX EVENT DATE: XXXXXXX

INDEX EVENT: Earliest 2005q3 Inp AMI, HF, or PN as Prin D/C Dx CARE COST: $1,259,813

Service MD Days Fr Event Payment

Type Place Spec. Start End Amount Diagnoses HCPCS/CPT4 Procedures ICD9 Procedures

SNF SNF 344 345 $1,012 FX NECK OF FEMUR NOS-OPN RML05

EDEMA

78099

GASTROINTEST HEMORR NOS

ACUTE PANCREATITIS

STOMACH FUNCTION DIS NOS

CHR AIRWAY OBSTRUCT NEC

ANXIETY STATE NOS

ANEMIA NOS

INP Inp 337 344 $26,533 28529 PACKED CELL TRANSFUSION

INF MCRG RSTN PNCLLINS SM BOWEL ENDOSCOPY NEC

OTHER POSTOP INFECTION VENOUS CATH NEC

CHRONIC PANCREATITIS

DIAPHRAGMATIC HERNIA

CHR AIRWAY OBSTRUCT NEC

CONGESTIVE HEART FAILURE

ORGANIC BRAIN SYND NOS

STAPHYLOCOCCUS AUREUS

SNF SNF 325 337 $8,800 FX NECK OF FEMUR NOS-OPN RML35

POSTTRAUM WND INFEC NEC

78099

GASTROINTEST HEMORR NOS

STOMACH FUNCTION DIS NOS

HYPERTENSION NOS

ANXIETY STATE NOS

ANEMIA NOS

INP Inp 322 325 $29,007 INTERTROCHANTERIC FX-CL PACKED CELL TRANSFUSION

FX BASE FEMORAL NCK-CLOS CLOSED RED-INT FIX FEMUR

SKIN DISORDERS NEC

PULMONARY COLLAPSE

CHR AIRWAY OBSTRUCT NEC

HYPOTENSION NOS

VENOUS THROMBOSIS NEC

HEART DISEASE NOS

ANEMIA NOS

OTP Otp 278 282 $17,299 52100 Leukocyte poor blood, unit

ESOPHAGEAL REFLUX G0378

CHRONIC PERIODONTITIS Non-covered item or service

CHR AIRWAY OBSTRUCT NEC Pulmonary service/procedure

42830 Measure blood oxygen level

CONGESTIVE HEART FAILURE Aerosol or vapor inhalations

HYPERTENSION NOS Airway inhalation treatment

TOBACCO USE DISORDER Electrocardiogram, tracing

ANEMIA NOS Compatibility test

See data set for more detail

OTP Otp 229 254 $1,293 CHR AIRWAY OBSTRUCT NEC Self care mngment training

78099 Therapeutic activities

STOMACH FUNCTION DIS NOS Gait training therapy

PNEUMONIA, ORGANISM NOS Therapeutic exercises

ACUTE PHARYNGITIS Therapeutic exercises

HYPOTENSION NOS Ot evaluation

CHR PULMON HEART DIS NEC Pt evaluation

INP Inp 211 226 $135,425 SEPTICEMIA NOS CONT MECH VENT < 96 HRS

ACUTE RESPIRATRY FAILURE ENTRAL INFUS NUTRIT SUB

PULMONARY COLLAPSE INSERT ENDOTRACHEAL TUBE

FOOD/VOMIT PNEUMONITIS CONT POS AIRWAY PRESSURE

OBS CHR BRNC W ACT EXA CONTR PULMON ARTERIOGRAM

42830 VENOUS CATH NEC

27651

MIXED ACID-BASE BAL DIS

PROTEIN-CAL MALNUTR NOS

OTP Otp 177 177 $1,607 ABDMNAL PAIN EPIGASTRIC Fentanyl citrate injeciton

INTESTINAL BYPASS STATUS Upper gi endoscopy,diagnosis

HEARING LOSS NOS

BLINDNESS, ONE EYE

OTP Otp 113 113 $383 HEADACHE Emergency dept visit

ABDMNAL PAIN UNSPCF SITE

OTP Otp 90 90 $55 BRAIN INJURY NEC Office/outpatient visit, est

SNF SNF 43 54 $4,604 PEPTIC ULCER NOS RVA11

BRAIN INJURY NEC RMA07

78099

72887

CHR AIRWAY OBSTRUCT NEC

PNEUMONIA, ORGANISM NOS

SNF SNF 35 42 $4,611 PEPTIC ULCER NOS RVA11

BRAIN INJURY NEC

78099

CHR AIRWAY OBSTRUCT NEC

PNEUMONIA, ORGANISM NOS

INP Inp 16 35 $191,473 CHR DUODEN ULCER W HEM CONT MECH VENT 96+ HRS

SURG COMP-DIGESTV SYSTEM INSERT ENDOTRACHEAL TUBE

PANCREAT CYST/PSEUDOCYST CHOLECYSTECTOMY

CHRONIC PANCREATITIS ENTEROSTOMY NEC

PARALYTIC ILEUS GASTROENTEROSTOMY NEC

POST TRAUM PULM INSUFFIC TRUNCAL VAGOTOMY

CHR AIRWAY OBSTRUCT NEC

PNEUMONIA, ORGANISM NOS

PROTEIN-CAL MALNUTR NOS

INP Inp 0 16 $40,591 CHR DUODEN ULC NOS-OBSTR

CONVULSIONS NEC

ACQ PYLORIC STENOSIS

CHR AIRWAY OBSTRUCT NEC

ANEMIA NOS

PROTEIN-CAL MALNUTR NOS

INP Inp -18 0 $165,201 PNEUMONIA, ORGANISM NOS CONT MECH VENT 96+ HRS

99591 ENTRAL INFUS NUTRIT SUB

SPLEEN HEMATOMA-CLOSED INSERT ENDOTRACHEAL TUBE

FX MULT RIBS NOS-CLOSED OTHER LOCAL DESTRUC SKIN

78552 NONEXCIS DEBRIDEMENT WND

CHR DUODEN ULC NOS-OBSTR VENOUS CATH NEC

ACUTE RESPIRATRY FAILURE

PROTEIN-CAL MALNUTR NOS

SEPTICEMIA NOS

OTP Otp -24 -23 $499 HEADACHE Emergency dept visit

ABDMNAL PAIN EPIGASTRIC Automated hemogram

HHA Home -28 -27 $125 LUMBAGO HCHJ1

CHR AIRWAY OBSTRUCT NEC G0154

OTP Otp -29 -29 $4,159 MYALGIA AND MYOSITIS NOS Emergency dept visit

V462 Electrocardiogram, tracing

EMPHYSEMA NEC Injection (IV)

MONONEURITIS NOS IV infusion therapy, 1 hour

TOBACCO USE DISORDER Automated hemogram

Assay CK (CPK)

Urinalysis, auto, w/scope

80053

Chest x-ray

CAT scan of head or brain

INP Inp -44 -42 $20,408 CHR STOMACH ULC W HEM PACKED CELL TRANSFUSION

LT EFF INTRACRANIAL INJ SM BOWEL ENDOSCOPY NEC

CONVULSIONS NEC VENOUS CATH NEC

EMPHYSEMA NEC

HYPOTENSION NEC

CONGESTIVE HEART FAILURE

HYPERTENSION NOS

CHR BLOOD LOSS ANEMIA

PROTEIN-CAL MALNUTR NOS

OTP Otp -44 -44 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

LONG-TERM USE MEDS NEC

OTP Otp -48 -48 $1,170 HYPOPOTASSEMIA Emergency dept visit

BONE & CARTILAGE DIS NOS Thromboplastin time, partial

MYALGIA AND MYOSITIS NOS Prothrombin time

CONGESTIVE HEART FAILURE Automated hemogram

ANEMIA NOS 80053

OTP Otp -65 -65 $166 HEADACHE Emergency dept visit

V462

CHRONIC PANCREATITIS

CHR AIRWAY OBSTRUCT NEC

CONGESTIVE HEART FAILURE

TOBACCO USE DISORDER

OTP Otp -70 -70 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

LONG-TERM USE MEDS NEC

OTP Otp -86 -86 $6,885 WRIST DROP Emergency dept visit

LONG-TERM USE ANTICOAGUL Electrocardiogram, tracing

V462 Thromboplastin time, partial

EMPHYSEMA NEC Prothrombin time

CONGESTIVE HEART FAILURE Automated hemogram

TOBACCO USE DISORDER 80048

3d/holograph reconstr add-on

Magnetic image, neck spine

Chest x-ray

See data set for more detail

OTP Otp -91 -91 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est medical Off GP/IM -97 -97 $89 REHABILITATION PROC NEC G0181

V5423

42833

HHA Home -100 -68 $2,624 DEBILITY NOS HBGL1

HEAD INJURY NOS G0156

HEADACHE G0154

G0152

G0151

SNF SNF -110 -102 $4,977 PNEUMONIA, ORGANISM NOS RMB07

SHOCK W/O TRAUMA NEC RHB35

MUSCSKEL SYMPT LIMB NEC

GASTROINTEST HEMORR NOS

CHR AIRWAY OBSTRUCT NEC

HEARING LOSS NOS

SNF SNF -117 -111 $6,252 PNEUMONIA, ORGANISM NOS RHB35

SHOCK W/O TRAUMA NEC

MUSCSKEL SYMPT LIMB NEC

GASTROINTEST HEMORR NOS

CHR AIRWAY OBSTRUCT NEC

HEARING LOSS NOS

INP Inp -137 -117 $117,510 PNEUMONIA, ORGANISM NOS CONTR PULMON ARTERIOGRAM

SHOCK W/O TRAUMA NEC EGD WITH CLOSED BIOPSY

CELLULITIS OF LEG EGD WITH CLOSED BIOPSY

ACUTE RENAL FAILURE NOS ENDOSC CONTROL GAST HEM

CHR DUODEN ULCER W HEM ENDOSC CONTROL GAST HEM

PULMONARY COLLAPSE VENOUS CATH NEC

OBS CHR BRNC W ACT EXA

AC POSTHEMORRHAG ANEMIA

HYPOVOLEMIA

INP Inp -147 -143 $15,787 CONGESTIVE HEART FAILURE

PRSNL HST PEPTIC ULCR DS

LT EFF INTRACRANIAL INJ

70710

OBS CHR BRNC W ACT EXA

CHR PULMON HEART DIS NOS

BRAIN CONDITION NOS

HYPOPOTASSEMIA

PROTEIN-CAL MALNUTR NOS

OTP Otp -156 -156 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

ASPHYXIA

OTP Otp -163 -163 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

LONG-TERM USE MEDS NEC

ASPHYXIA

OTP Otp -182 -182 $85 78321 Office/outpatient visit, est

LONG-TERM USE MEDS NEC

56400

CONGESTIVE HEART FAILURE

SNF SNF -200 -189 $7,285 ACUTE PANCREATITIS RHB07

MUSCSKEL SYMPT LIMB NEC

GASTROINTEST HEMORR NOS

ACUTE RESPIRATRY FAILURE

OBS CHR BRNC W ACT EXA

SNF SNF -216 -201 $10,337 ACUTE PANCREATITIS RHB11

INF MCRG RSTN PNCLLINS RHB07

MUSCSKEL SYMPT LIMB NEC

GASTROINTEST HEMORR NOS

ESOPHAGEAL REFLUX

ACUTE RESPIRATRY FAILURE

OBS CHR BRNC W ACT EXA

AC POSTHEMORRHAG ANEMIA

INP Inp -230 -216 $105,505 CHR DUODEN ULCER W HEM SERUM TRANSFUSION NEC

PARALYTIC ILEUS PACKED CELL TRANSFUSION

AC VASC INSUFF INTESTINE CONT MECH VENT < 96 HRS

ACUTE RESPIRATRY FAILURE INSERT ENDOTRACHEAL TUBE

PULMONARY COLLAPSE SM BOWEL ENDOSCOPY NEC

PLEURAL EFFUSION NOS VENOUS CATH NEC

OBS CHR BRNC W ACT EXA

AC POSTHEMORRHAG ANEMIA

CANDIDAL ESOPHAGITIS

OTP Otp -230 -230 $565 HEMATEMESIS A0429

DIARRHEA A0425

SNF SNF -231 -230 $169 ACUTE PANCREATITIS SE207

ANEMIA NOS

OTP Otp -242 -242 $2,439 CHRONIC PANCREATITIS Fentanyl citrate injeciton

V462 Emergency dept visit

CHR AIRWAY OBSTRUCT NEC Injection (IV)

HYPOVOLEMIA Automated hemogram

Assay lipase

Urinalysis, auto, w/o scope

80053

Chest x-ray

36556

SNF SNF -246 -232 $10,836 ACUTE PANCREATITIS SE311

ANEMIA NOS SE207

INP Inp -267 -246 $51,107 CHRONIC PANCREATITIS

LT EFF INTRACRANIAL INJ

PLEURAL EFFUSION NOS

EMPYEMA W/O FISTULA

CHR AIRWAY OBSTRUCT NEC

ANEMIA NOS

PROTEIN-CAL MALNUTR NOS

DMII WO CMP NT ST UNCNTR

HYPOTHYROIDISM NOS

INP Inp -281 -267 $121,697 CHRONIC PANCREATITIS PERCU ABDOMINAL DRAINAGE

PANCREAT CYST/PSEUDOCYST VENOUS CATH NEC

PLEURAL EFFUSION NOS INSERT INTERCOSTAL CATH

OBS CHR BRNC W ACT EXA

CHR PULMON HEART DIS NOS

PARAPLEGIA NOS

ANEMIA NOS

PROTEIN-CAL MALNUTR NOS

HYPOTHYROIDISM NOS

SNF SNF -292 -282 $5,944 CELLULITIS, SITE NEC RVB01

CHR AIRWAY OBSTRUCT NEC

SNF SNF -293 -293 $854 CELLULITIS, SITE NEC RHB01

CHR AIRWAY OBSTRUCT NEC

INP Inp -310 -293 $100,033 PLEURAL EFFUS NEC NOT TB PARENT INFUS NUTRIT SUB

RESPIRATORY ABNORM NEC NONEXCIS DEBRIDEMENT WND

CELLULITIS OF LEG VENOUS CATH NEC

PANCREAT CYST/PSEUDOCYST THORACENTESIS

CHRONIC PANCREATITIS INSERT INTERCOSTAL CATH

PULMONARY COLLAPSE

OBS CHR BRNC W ACT EXA

HYPERTENSION NOS

TOBACCO USE DISORDER

SNF SNF -322 -311 $4,405 CELLULITIS NOS RHC01

REHABILITATION PROC NEC Therapeutic activities

MALAISE AND FATIGUE NEC Therapeutic activities

ACUTE PANCREATITIS Ot evaluation

CHR AIRWAY OBSTRUCT NEC Ot evaluation

VENOUS INSUFFICIENCY NOS

TOBACCO USE DISORDER

ANEMIA NOS

PROTEIN-CAL MALNUTR NOS

INP Inp -326 -322 $26,314 CELLULITIS OF LEG EXC WOUND DEBRIDEMENT

70719 VENOUS CATH NEC

ACUTE RENAL FAILURE NOS

CHR AIRWAY OBSTRUCT NEC

CONGESTIVE HEART FAILURE

COAGULAT DEFECT NEC/NOS

HYPOVOLEMIA

HYPOSMOLALITY

PROTEIN-CAL MALNUTR NOS

OTP Otp -329 -329 $85 BURN NOS Office/outpatient visit, est

CHR AIRWAY OBSTRUCT NEC

CONGESTIVE HEART FAILURE

OTP Otp -336 -336 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

TRAUMATIC SUBDURAL HEM

CHR AIRWAY OBSTRUCT NEC

OTP Otp -338 -338 $690 ABDMNAL PAIN UNSPCF SITE CAT scan of abdomen medical Off Gastr -342 -342 $42 PANCREAT CYST/PSEUDOCYST Office/outpatient visit, est

OTP Otp -359 -359 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

LONG-TERM USE MEDS NEC

78099

CHR AIRWAY OBSTRUCT NEC

OTP Otp -366 -366 $55 EDEMA Office/outpatient visit, est

OTP Otp -373 -373 $85 CONGESTIVE HEART FAILURE Office/outpatient visit, est

TRAUM SUBARACHNOID HEM

ASPHYXIA

CHR AIRWAY OBSTRUCT NEC

VALUE Project Claims-based Electronic Medical Record Recorded Claims July 1, 2005 through December 31, 2006

CASE ID: James Doe AGE: 72 SEX: Male RACE: XX DEATH DT: n/a STATE: XX

INDEX EVENT DATE: XXX INDEX EVENT: Earliest 2005q3 Inp AMI, HF, or PN as Prin Discharge Dx CARE COST: $116,913

Service MD Days Fr Event Payment

Type Place Spec. Start End Amount Diagnoses HCPCS/CPT4 Procedures ICD9 Procedures medical Off Other 315 315 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 302 302 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 287 287 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 273 273 $12 ALLERGIC RHINITIS NOS Office/outpatient visit, est

ASTHMA W/O STATUS ASTHM Immunotherapy, one injection medical Off GP/IM 258 258 $42 CVA Office/outpatient visit, est medical Off Other 253 253 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 245 245 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection

OTP Otp 233 233 $3,300 V7651 Colon ca scrn barium enema

INT HEMORRHOID W/O COMPL

medical Off Other 233 233 $182 ALLERGIC RHINITIS NOS Antigen therapy services medical Off GP/IM 231 231 $0 ROUTINE MEDICAL EXAM Preventive visit,new,65 & ove medical Off Other 231 231 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 217 217 $42 RHINITIS DUE TO POLLEN Office/outpatient visit, est

ASTHMA W/O STATUS ASTHM Immunotherapy, one injection medical Off Other 208 208 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 205 205 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 196 196 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 190 190 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 187 187 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 175 175 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 169 169 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 159 159 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 153 153 $1 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 147 147 $0 ALLERGIC RHINI