AmendedRFPSection J-10 Attach.doc

Section J, Attachment J-10, Appendix A: Details on Measures (Revised 2/18/2008)

Section:

1. Details on Evaluation Measures, incl. Proportion of Transitions Table

2. Example of Power Calculation

3. Databases from claims and their uses, with data elements

4. Timeframe for Evaluation of Measures

5. Measures to Monitor Adverse Effects

6. Analytic Tools from the VALUE project

6.a. Medical Record from Claims

6.b. Hospital (or community) Practice Pattern

7. Timeline of periods of data generation and resulting reports

8. Management of Reports

9. Overview of CARE instrument and plans

10. Screen shots of Internet Platform as of January 2008

11. Sites proposed for the CARE demonstration

12. The SQUIRE Guidelines

Section 1: Details on Evaluation Measures, incl. Proportion of Transitions Table

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 and O-6, which are listed separately below), the QIO will report the relevant rate for each provider that the Theme QIO listed in the area, along with a justification for their estimate. The Theme 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. The Proportion of Transitions measure will be calculated annually. 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. The explanation will be reviewed by the Support 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.

(O-3 and O-6 also use the Proportion of Transitions Table, but they are listed separately below.)

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 65 years old and older who rate hospital performance as meeting HCAHPS performance standard for communication about medicines (O-1a) or discharge information (O-1b)

For O-1a, Communication about medicines

16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

Never(1

Sometimes(2

Usually(3

Always(4

17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

1 Never

Sometimes(2

Usually(3

Always(4 For O-1b, Discharge information

19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

Yes(1

No(2

20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Yes(1

No(2

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 (see explanatory section immediately following this list); calculate the two measures from the survey questions 16 and 17 (for communication about medicines) and 19 and 20 (for discharge information).

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).

How will composites be computed? How will missing data be handled? (Explanation and example from HCAHPS specifications)

There are seven domain-level composites included in the HCAHPS measure: communication with doctors, communication with nurses, responsiveness of hospital staff, pain control, communication about medicines, cleanliness and quiet of the hospital environment, and discharge information. The basic approach to the production of composite scores is described below.

Communication with doctors

This composite is produced by combining responses to three questions that ask:

· “During this hospital stay, how often did doctors listen carefully to you?”

· “During this hospital stay, how often did doctors explain things in a way you could understand?”

· “During this hospital stay, how often did doctors treat you with courtesy and respect?”

Respondents could answer “never,” “sometimes,” “usually,” or “always” to each. The basic steps in calculating a hospital’s composite score follow:

Step 1 – Calculate the proportion of cases in each response category for each question

P11 = Proportion of respondents who said “never” to the first question

P12 = Proportion of respondents who said “sometimes” to the first question

P13 = Proportion of respondents who said “usually” to the first question

P14 = Proportion of respondents who said “always” to the first question

Follow the same steps for calculating the proportion of cases in a response category to obtain proportions for the second question:

P21 = Proportion of respondents who said “never” to the second question

P22 = Proportion of respondents who said “sometimes” to the second question

P23 = Proportion of respondents who said “usually” to the second question

P24 = Proportion of respondents who said “always” to the second question

Follow the same steps for calculating the proportion of cases in a response category to obtain proportions for the third question:

P31 = Proportion of respondents who said “never” to the third question

P32 = Proportion of respondents who said “sometimes” to the third question

P33 = Proportion of respondents who said “usually” to the third question

P34 = Proportion of respondents who said “always” to the third question

Step 2 – Combine responses from the three questions to form the composite

Calculate the average proportion responding to each category across the three questions in the composite

PC1 = Composite proportion who said “never” = (P11+P21+P31) / 3

PC2 = Composite proportion who said “sometimes” = (P12+P22+P32) / 3

PC3 = Composite proportion who said “usually” = (P13+P23+P33) / 3

PC4 = Composite proportion who said “always” = (P14+P24+P34) / 3

A hospital’s score on the “doctor communication” composite is the proportion of cases in each response category.

If data are missing for any of the questions included in the composite, the respondent would not be included in the calculation of the proportion of respondents answering each of the response categories for that question.

HCAHPS public reporting will use the combination of “never” and “sometimes” as the main publicly reported rate, and the Care Transitions Theme will follow that precedent. So the “Communication about Medications” will be (P11+P21+P31 +P12+P22+P32) / 6 and the “Discharge information” will be (proportion with “No” on Question 19 + proportion with “No” on Question 20)/2)

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 E) 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; 2 quarters + 1 month of claims

Frequency of calculation: Quarterly for test of trend, Semi-annually for evaluation 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.

Method: The Theme QIO will report the proportion of transitions for which at least the upstream provider used the CARE instrument, so that it was available to the downstream provider. The rate follows the method of the interim measures, using the Table of Proportions of Transitions, including being summed to an overall rate at which CARE was employed in transitions in the community. This rate will be reported quarterly.

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. The evaluation measure will be the annual, risk-adjusted rate, but the quarterly (unadjusted) rates will be used for monitoring and the Support QIO will assess them with tests of trend.

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

Section 2: Example of a Power Calculation to Determine Population Size:

To determine the minimum sample size needed at an 80% likelihood of detecting a difference:

--the "unit of analysis" is a discharge --the measure is the percent of discharges resulting in re-hospitalization within 30 days (a discharge gets a code of 1 if there is a re-hospitalization within 30 days and a code of 0 if there is not)

--there are two samples (baseline and for the 28 month evaluation) --PROVIDED THAT the baseline rehospitalization rate is 20% (approximately the national average) --AND PROVIDED THAT THE PROPOSAL AIMS TO DETECT a drop in rehospitalization rate of 2 percentage points or more (from 20% to 18% or lower) --the alpha level (Probability of incorrectly rejecting the null hypothesis that there is no difference in the percentage values) is .05.

Using the "two samples test" version for percentages of the statistical power calculator found at: http://www.dssresearch.com/toolkit/spcalc/power_p2.asp The minimum sample sizes needed would be:

4800 discharges (at baseline and at 28 months) (live, fee-for-service, Medicare beneficiaries)

For a semi-annual rate of 4800 discharges, at the national rate of about 350 discharges per 1000 Medicare beneficiaries per year (from Dartmouth Atlas, 2003 data, www.dartmouthatlas.org ), the population would have to have about

4800 discharges x (1000 Medicare beneficiaries/175 discharges) = 27,400 Medicare beneficiaries.

If about 15 % of the populations are Medicare beneficiaries, then the total population is

27,400 Medicare beneficiaries x (100 total population/15 Medicare beneficiaries) = 183,000 total population

Each partner community and comparison community will have to have their actual rates applied for this calculation.

Section 3: Databases from claims and their uses. (Provisional – subject to change during development)

Guiding intervention (descriptive analyses) and monitoring adverse effect (180 – day re-hospitalization)

Initial List of Variables (for each claim) in the Part A and Part B databases supplied will be settled by the Support QIO, building from the experience in VALUE and from consultation with the Theme QIOs

Section 4: Timeframe for 28-Month Evaluation of Measures

Measure

Number

Section 5: Measures to Monitor Adverse Effects

180-day Rehospitalization

Description: Percentage of patients from the specified geographic area re-hospitalized within 180 days of discharge from an acute care hospital.

1. Numerator: Number of hospital live discharges of patients from the specified geographic area that were re-admitted within 180 days.

2. Denominator: Number of hospital live discharges of patients from the specified geographic area.

3. Data Source:

Medicare Part A claims

4. Exclusions:

Transfers to another acute care hospital

Specific Diagnosis Discharge, Mortality within 30 days.

Description: Specific Diagnosis Discharge/All-Condition 30 – day Readmission Rates (3 measures)

1. Measure: 30-day all-cause risk standardized mortality rates following HF, AMI and Pneumonia hospitalizations

2. Population/Index Hospitalizations: Discharges for Medicare fee-for-service beneficiaries age 65 or over admitted to the hospital with a principal ICD-9-CM discharge diagnosis of HF, AMI or Pneumonia and discharged alive.

iii.

Risk Standardized Mortality Rates:

P (predicted)

= ------------------------- * National Rate

E (expected)

Numerator: The number of deaths predicted by the hierarchical model among a hospital’s patients, given the patients’ risk factors and the hospital-specific effect

Denominator: The expected mortality among that hospital’s patients given the patients’ risk factors and the average of all hospital-specific effects in the nation

National Rate:

Number of 30-day mortalities in the nation

Number of discharges in the nation iv.

Data Source: Medicare administrative data including hospital inpatient and outpatient claims, physician practice claims and Medicare Enrollment Data Base file.

Section 6: Analytic Tools from the VALUE project

Section 6.a. Medical Record from Claims– Samples of claims sequence for individual patients (note: fictitious patients)

These 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 RHINITIS NOS Immunotherapy, one injection medical Off Other 141 141 $0 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 135 135 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 126 126 $12 ALLERGIC RHINITIS NOS Office/outpatient visit, est

ASTHMA W/O STATUS ASTHM Immunotherapy, one injection medical Off Other 114 117 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 105 105 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 100 100 $12 ALLERGIC RHINITIS NOS Immunotherapy, one injection medical Off Other 92 92 $12 ALLERGIC RHINITIS NOS Office/outpatient visit, est

Immunotherapy, one injection