Overview IMECCHI’s patient

safety indicator projects

Hude QuanAssociate Professor

University of Calgary

Outlines

• Administrative data for studying patient

safety

• Administrative data definition

• Piloting the method

• Validation study

• Next step

Organization for Economic

Co-operation and Development

Five priority areas selected by OECD countries.

– patient safety

– mental health care

– cardiac care

– diabetes care

– primary care and prevention.

Purpose of OECD

• To raise questions about quality of

health care across countries

• Initial attention

• Patient centeredness

• To be representative of the main

disease and risk groups

ICD-9-CM PSI

http://www.ahrq.gov/

PSI 1: Complications of Anesthesia PSI 2: Death in Low-mortality

PSI 3: Decubitus Ulcer PSI 4: Failure to Rescue

PSI 5: Foreign Body Left During Procedure PSI 6: Iatrogenic Pneumothorax

PSI 7: Selected Infections Due to Medical Care PSI 8: Postoperative Hip Fracture

PSI 9: Postoperative Haemorrhage or Haematoma PSI 10: Postoperative Physiologic and

Metabolic Derangement

PSI 11: Posterative Respiratory Failure PSI 12: Postoperative Pulmonary Embolism or

Deep Vein Thrombosis

PSI 13: Postoperative Sepsis PSI 14: Postoperative Wound Dehiscence

PSI 15: Accidental Puncture or Laceration PSI 16: Transfusion Reaction

PSI 17: Birth Trauma―Injury to Neonate PSI 18: Obstetric Trauma―Vaginal Delivery

with Instrument

PSI 19: Obstetric Trauma―Vaginal Delivery

without Instrument PSI 20: Obstetric Trauma―Cesarean Delivery

Complications of Anesthesia (PSI 1)

Numerator:ICD-9-CM diagnosis codes in any secondary diagnosis field:

E8763 ENDOTRACHEAL TUBE WRONGLY PLACE DURING ANESTHETIC

PROCEDURE

E9381 HALOTHANE

E9382 OTHER GASEOUS ANESTHETICS

E9383 INTRAVENOUS ANESTHETICS

E9384 OTHER AND UNSPECIFIED GENERAL ANESTHETICS

E9385 SURFACE AND INFILTRATION ANESTHETICS

E9386 PERIPHERAL NERVE AND PLEXUS BLOCKING ANESTHETICS

E9387 SPINAL ANESTHETICS

E9389 OTHER AND UNSPECIFIED LOCAL ANESTHETICS

9681 HALOTHANE

9682 OTHER GASEOUS ANESTHETICS

9683 INTRAVENOUS ANESTHETICS

9684 OTHER AND UNSPECIFIED GENERAL ANESTHETICS

9687 SPINAL ANESTHETICS

E8551 ACCIDENTAL POISONING, OTHER NERVOUS SYSTEM DEPRESSANTS

Complications of Anesthesia (PSI 1)

Denominator:

• All surgical discharges

• Age 18 years and older

• DRG - MDC 14 (pregnancy, childbirth, and puerperium)

• Operating room procedure.

Complications of Anesthesia (PSI 1)

Requirements:

1. Secondary Diagnosis Codes

2. DRG

3. Procedure Codes

4. Operating room procedure indicator.

PSI 1 Rate = Numerator/Denominator * 100%

Realities – Variations

• Country specific ICD versions

• Diagnosis related grouping (DRG)

• Primary/Most Responsible Diagnosis

• Procedure Classification

• Validity

Canadian SituationDisease Classification

ICD-9

ICD-9-CM

ICD-10-CA

Procedure ClassificationICD-9-CM

Canadian Classification of Procedure

Disease GroupingDiagnosis-Related Group (DRG)

Developed by 3M and classified about 500 groups

Case Mix Groups (CMG)

Developed by CIHI. Groups have to be statistically

homogeneous with respect to length of hospital stay.

Need to harmonize AHRQ PSI

administrative data definition

between ICD-9-CM and ICD-10

Process

• Step 1: Code Search

-- 2569 ICD-10 codes

• Step 2: Rating rating

-- 1775 codes consensus

-- 794 codes with disagreement

-- 2541 additional codes

• Step 3: Face to face meeting

Discussed and rated a total of 3335 codes

Advances in Patient Safety

Title: Adaptation of AHRQ Patient Safety Indicators for

Use in ICD-10 Administrative Data by an

International Consortium

Hude Quan, Saskia Drösler, Vijaya Sundararajan, Eugene Wen,

Bernard Burnand, Chantal Marie Couris, Patricia Halfon, Jean-Marie

Januel, Edward Kelley, Niek Klazinga, Jean-Christophe Luthi, Lori

Moskal, Eric Pradat, Patrick S. Romano, Jennie Shepheard,

Lawrence So, Lalitha Sundaresan, Linda Tournay-Lewis, Béatrice

Trombert-Paviot, Greg Webster, William A. Ghali, for the IMECCHI

Investigators

http://www.chaps.ucalgary.ca/sas.htm

ICD-10-WHO PSI Codes

Applications

A set of algorithms for the AHRQ PSIs using

ICD-10-WHO diagnoses has been

developed and structured in close relation

to the AHRQ PSI documentation.

This work supports international applications

in ICD-9-CM and ICD-10 data.

Australia, Canada, Germany, Spain, Sweden, UK, US

Conclusions

This pilot study reveals that AHRQ Patient Safety Indicators

can be applied to international hospital data. However, the

analyses suggest that certain indicators may be too

unreliable for international comparisons. Data quality varies

across countries; undercoding may be a systematic problem

in some countries. Efforts at international harmonization of

hospital discharge data sets as well as improved accuracy

of documentation should facilitate future comparative

analyses of routine databases.

PSI positive inpatient

records

Data

Chart Review

Validation EffortsIn Canada, US, France

Medical Care, 2009

How Valid is the ICD-9-CM Based AHRQ

Patient Safety Indicator for Postoperative

Venous Thromboembolism?

Positive predictive value:

56% anytime during hospitalization

47% after operation

Conclusion:

“Current PSI 12 criteria do not accurately identify

patients with acute postoperative lower extremity

DVT or PE. Modification of the ICD-9-CM codes and

implementation of "present on admission" flags

should improve the predictive value for clinically

important VTE events.”

Annuals of Surgery, 2009

Positive Predictive Value of the AHRQ

Accidental Puncture or Laceration

Patient Safety Indicator

Positive predictive value: 91%

Conclusion:

“ Although PSI 15 is highly predictive of APL from a coding

perspective, the indicator is less predictive of APL that

could be considered clinically important. A significant

proportion of cases represent relatively inconsequential

injuries or injuries for which the risk may have been

acceptable relative to the goals of the procedure.”

Administrative dataHospital discharge data

Dx1 Dxtype1, Dx1 Dxtype1,,, Dx16 Dxtype16

M

1

2

2 = Post-admit comorbidity - A diagnosis or

condition that arises post-admission and

satisfies the requirements for determining

comorbidity.

WHO

Family of

International Classifications

… building blocks of health information …

International Classification of

Patient Safety and Quality of Care

Hude Quan

hquan@ucalgary.ca

www.IMECCHI.org