what do we know about overall trends in patient safety in the usa? patrick s. romano, md mph...
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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