What do we know about overall trends in patient safety in the USA?

Patrick S. Romano, MD MPHProfessor of Medicine and PediatricsUniversity of California, DavisCenter for Health Services Research in Primary CareJune 26, 2006

Background

Two major studies of preventable adverse events during hospitalizations, based on medical record reviews by nurses and physicians:– New York, 1984– Colorado and Utah, 1992

Patient Safety Datasources

HCUP Nationwide Inpatient Sample (AHRQ Patient Safety Indicators)

CDC National Nosocomial Infection Surveillance Program

Medicare Patient Safety Monitoring System: Adverse Events

Medical Expenditure Panel Survey: Inappropriate Medications

AHRQ’s Patient Safety Indicators (PSIs)

Designed to address the perceived need for an inexpensive surveillance system based on readily available hospitalization data (using ICD-9-CM diagnoses and procedures)

Literature review to identify potential indicators and gather data on validity from prior studies

ICD-9-CM coding consultant review Clinical expert panel review (modified Delphi rating process) Empirical analyses of nationwide rates, hospital variation, impact of

risk adjustment, and relationships among indicators

Medicare Patient Safety Monitoring System Adverse events from charts Randomly-selected, nationwide subset of inpatient

medical records of Medicare beneficiaries Data weighted to produce national estimates Sample size: about 26,000 charts

– 5,500 surgical cases– 4,000 central venous catheter insertions

National trends in extremely rare (sentinel) events HCUP 1994-2002 (solid)

0.000%

0.001%

0.002%

0.003%

0.004%

0.005%

0.006%

0.007%

0.008%

0.009%

0.010%

0.011%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Foreign body left in during procedure

Postoperative hip fracture

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in extremely rare (sentinel) eventsHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0.000%

0.002%

0.004%

0.006%

0.008%

0.010%

0.012%

0.014%

0.016%

1999 2000 2001 2002 2003 2004

Foreign body left in during procedure

Transfusion reaction

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in very rare event ratesHCUP 1994-2002 (solid)

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

0.08%

0.09%

0.10%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Anesthesia reactions and complications

Postoperative hip fracture

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in very rare event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

0.08%

0.09%

0.10%

1999 2000 2001 2002 2003 2004

Anesthesia reactions and complications

Postoperative hip fracture

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in rare catheter-related event rates HCUP 1994-2002 (solid)

0.025%

0.050%

0.075%

0.100%

0.125%

0.150%

0.175%

0.200%

0.225%

0.250%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Postoperative physiologic/metabolic derangements

Selected infections due to medical care

Iatrogenic pneumothorax

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in rare catheter-related event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0.025%

0.050%

0.075%

0.100%

0.125%

0.150%

0.175%

0.200%

0.225%

0.250%

1999 2000 2001 2002 2003 2004

Postoperative physiologic/metabolic derangements

Iatrogenic pneumothorax

Selected infections due to medical care

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in postoperative medical event rates HCUP 1994-2002 (solid)

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0.9%

1.0%

1.1%

1.2%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Postoperative respiratory failure

Postoperative sepsis

Postoperative thromboembolism

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in postoperative medical event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0.9%

1.0%

1.1%

1999 2000 2001 2002 2003 2004

Postoperative respiratory failurePostoperative sepsis

Postoperative thromboembolism

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in technical surgical event rates HCUP 1994-2002 (solid)

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

0.45%

0.50%

0.55%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Accidental puncture or laceration

Postoperative hemorrhage or hematoma

Postoperative abdominopelvic wound dehiscence

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in technical surgical event ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

0.45%

0.50%

0.55%

1999 2000 2001 2002 2003 2004

Accidental puncture or laceration

Postoperative hemorrhage or hematoma

Postoperative abdominopelvic wound dehiscence

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in pressure sore ratesHCUP 1994-2002 (solid)

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

2.4%

2.6%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Decubitus ulcer

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in pressure sore ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

2.4%

2.6%

1999 2000 2001 2002 2003 2004

Decubitus ulcer

Decubitus ulcer

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

National trends in obstetric trauma and FTR-L rates HCUP 1994-2002 (solid)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

22%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Obstetric trauma: vaginal delivery w/out instrumentation

Obstetric trauma: vaginal delivery w instrumentation

Failure to rescue

Risk-adjusted rates using version 2 PSIs on HCUPNet at http://www.hcup.ahrq.gov .

National trends in obstetric trauma and FTR-L ratesHCUP 1999-2003 (solid) vs. VA 2001-2004 (dashed)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

22%

1999 2000 2001 2002 2003 2004

Failure to rescue

Obstetric trauma: vaginal delivery w/out instrumentation

Obstetric trauma: vaginal delivery w instrumentation

Rosen et al., Med Care 2006, in press (VA PTF 2001-2004); HCUP NIS 1999-2003.

Research/Policy Question

Why are some PSIs increasing in incidence over time while others are decreasing?

Selective changes in coding practice Changes in severity of illness or underlying risk of potential

safety-related events True changes in quality due to technical improvements in

surgical or nursing technique, counterbalanced by inadequate staffing to prevent some complications

National trends in CDC’s nosocomial infection ratesNational Nosocomial Infection Surveillance Program 1998-2003

0

2

4

6

8

10

12

14

1998 1999 2000 2001 2002 2003

per

1,00

0 IC

U d

ays

CVC-associated bloodstream infections, adult ICU patients

Ventilator-associated pneumonia, adult ICU patients

National Health Care Quality Report 2005, downloadable tables

National trends in CDC’s nosocomial infection ratesNational Nosocomial Infection Surveillance Program 1998-2003

0

2

4

6

8

10

12

14

1998 1999 2000 2001 2002 2003

per 1

,000

ICU

days

CVC-associated bloodstream infections, LBW neonatal ICU patients

Ventilator-associated pneumonia, LBW neonatal ICU patients

National Health Care Quality Report 2005, downloadable tables

National trends in Medicare Patient Safety Monitoring System, 2002-2003

0

2

4

6

8

10

12

14

2002 2003

Perc

enta

ge

Total knee arthroplasty, postoperative adverse events

Total hip arthroplasty, postoperative adverse events

National Health Care Quality Report 2005, downloadable tables

National trends in Medicare Patient Safety Monitoring System, 2002-2003

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

2002 2003

Perc

enta

ge

CVC placement, insertion-related mechanical events

CVC placement, insertion site infections

CVC placement, bloodstream infections

National Health Care Quality Report 2005, downloadable tables

Inappropriate use of medications by the elderlyMedical Expenditure Panel Survey, 1996-2002

National Health Care Quality Report, 2005

JCAHO Core Measures for AMI

JCAHO Core Measures for heart failure

JCAHO Core Measures for pneumonia

Conclusions

No consistent trends across AHRQ Patient Safety Indicators:– Most technical errors are slowly decreasing– Most postoperative medical complications are increasing– Unclear whether unmeasured risk or coding changes may

explain some of these findings Nosocomial infection rates in ICUs are decreasing

– Volunteer hospitals only

Conclusions

Postoperative adverse event rates appear to be decreasing among Medicare patients:– Methodology not well described and validated– Only 2002 and 2003 data

Substantial improvements in most JCAHO core measures:– Performing to the test– Outcome measures (e.g. AMI mortality) show relatively little

change