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Adverse Patient Safety Events: Costs of Readmissions and Patient Outcomes Following Discharge Didem...
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Transcript of Adverse Patient Safety Events: Costs of Readmissions and Patient Outcomes Following Discharge Didem...
Adverse Patient Safety Events: Costs of Adverse Patient Safety Events: Costs of Readmissions and Patient Outcomes Following Readmissions and Patient Outcomes Following
DischargeDischarge
Didem M. Bernard, Ph.D.Didem M. Bernard, Ph.D.
William E. Encinosa, Ph.D.William E. Encinosa, Ph.D.
Patient Safety EventsPatient Safety Events
IoM estimated that between 44,000 and 98,000 people die in IoM estimated that between 44,000 and 98,000 people die in hospitals each year as a result of medical errorshospitals each year as a result of medical errors
Medical errors is the eighth leading cause of death in the U.S.Medical errors is the eighth leading cause of death in the U.S.
IoM recommended at least a 50% reduction in medical errors IoM recommended at least a 50% reduction in medical errors over 5 yearsover 5 years
BackgroundBackground
Medical injuries during hospitalizations lead to excess Medical injuries during hospitalizations lead to excess length of stay, charges and mortality (Zhan and Miller, length of stay, charges and mortality (Zhan and Miller, 2003)2003)
Whether adverse patient safety events have a significant Whether adverse patient safety events have a significant impact on patient outcomes and costs following impact on patient outcomes and costs following discharge is less cleardischarge is less clear
Research QuestionsResearch Questions
Do adverse patient safety events during Do adverse patient safety events during hospitalizations have an effect on patient hospitalizations have an effect on patient outcomes following discharge?outcomes following discharge?
Are there long-term costs associated with Are there long-term costs associated with potentially preventable adverse medical events?potentially preventable adverse medical events?
Patient Safety IndicatorsPatient Safety Indicators
We use the AHRQ Patient Safety Indicators (PSI) developed by the We use the AHRQ Patient Safety Indicators (PSI) developed by the UCSF- Stanford Evidence-Based Practice Center (EPC) and UC-UCSF- Stanford Evidence-Based Practice Center (EPC) and UC-Davis (2003).Davis (2003).
EPC selected 14 indicators among 63 complication indicators usingEPC selected 14 indicators among 63 complication indicators using– Indicator validity results from the literatureIndicator validity results from the literature– Empirical analyses of the precision and reliability of the Empirical analyses of the precision and reliability of the
candidate PSIscandidate PSIs– Review of potential indicators by 11 clinical panelsReview of potential indicators by 11 clinical panels
Patient Safety IndicatorsPatient Safety Indicators
1 Anesthesia Complications *
2 Accidental Puncture or Laceration During Procedure
3 Foreign Body Left In During Procedure*
4 Hemorrhage or Hematoma
5 Wound Dehiscence
6 Infection Due to Medical Care
7 Pulmonary Embolism and Deep Vein Thrombosis
* Labeled as medical errors
Patient Safety Indicators (cont.)Patient Safety Indicators (cont.)
8 Iatrogenic Pneumothorax*
9 Acute Respiratory Failure
10 Sepsis
11 Physiologic and Metabolic Derangements
12 Transfusion Reaction
13 Hip Fracture*
14 Decubitus Ulcer*
* Labeled as medical errors
Data Data
2002 California Hospital Discharge Data
AHRQ Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID)
Hospital Inpatient Cost to Charge Ratios
Area Wage Index (CMS)
Number of Hospitals: 349
Analytic Sample and MethodsAnalytic Sample and Methods
Major Surgery Discharges (17<age<65)Major Surgery Discharges (17<age<65)
From February 1, 2002 to November 30, 2002From February 1, 2002 to November 30, 2002
Index admission: A major surgery admission with no hospitalizations Index admission: A major surgery admission with no hospitalizations in a 30 day window prior to the admission date (N=602,361)in a 30 day window prior to the admission date (N=602,361)
Readmission: Any hospitalization within 30 days of initial dischargeReadmission: Any hospitalization within 30 days of initial discharge
Patient OutcomesPatient Outcomes
Probability of readmissionsProbability of readmissions
Probability of death during index admission Probability of death during index admission
Probability of death during any readmission within 30 Probability of death during any readmission within 30 days of initial dischargedays of initial discharge
Costs of Adverse Patient Safety EventsCosts of Adverse Patient Safety Events
Index admission costsIndex admission costs
Costs of readmissionsCosts of readmissions
Total costs for index admissions and readmissions Total costs for index admissions and readmissions within 30 days following dischargewithin 30 days following discharge
Basic Model: Hospital CostsBasic Model: Hospital Costs
i=personi=persony= cost of hospitalization*y= cost of hospitalization*PSI= (0,1) indicator equals 1 if patient has at least onePSI= (0,1) indicator equals 1 if patient has at least oneadverse patient safety eventadverse patient safety eventx=control variablesx=control variables
* * Index admission, readmission or total hospital costsIndex admission, readmission or total hospital costs
Basic Model: Patient OutcomesBasic Model: Patient Outcomes
i=personi=persony=(0,1) indicator equals 1 if patient is readmitted within y=(0,1) indicator equals 1 if patient is readmitted within
30 days of discharge*30 days of discharge*PSI= (0,1) indicator equals 1 if patient has at least onePSI= (0,1) indicator equals 1 if patient has at least oneadverse patient safety eventadverse patient safety eventx=control variablesx=control variables
* y=(0,1) indicator equals 1if patient dies during hospitalization* y=(0,1) indicator equals 1if patient dies during hospitalization
Control VariablesControl Variables
Patient: age, sex, race/ethnicity, transfer admission, Patient: age, sex, race/ethnicity, transfer admission, emergency admission, 30 chronic conditions, MDC, emergency admission, 30 chronic conditions, MDC, zipcode level median household incomezipcode level median household income
Hospital: teaching status, ownership type, bedsizeHospital: teaching status, ownership type, bedsize
Market: Health Service Area dummiesMarket: Health Service Area dummies
Patient OutcomesPatient Outcomes
PSI=0PSI=0 PSI=1PSI=1
Live dischargeLive discharge 84.55%84.55% 63.03%63.03%
Death during Death during index admissionindex admission 0.86%0.86% 5.97%5.97%
ReadmissionReadmission 14.14%14.14% 28.32%28.32%
Death during Death during readmissionreadmission 0.46%0.46% 2.68%2.68%
NN 583,836583,836 18,889 18,889
Average CostsAverage Costs
Index Index HospitalizationHospitalization ReadmissionReadmission Total CostsTotal Costs
PSI=0PSI=0 $12,579$12,579 $17,927 $17,927 $15,198$15,198
PSI=1PSI=1 $31,096$31,096 $33,445$33,445 $41,510$41,510
DifferenceDifference 147%147% 87%87% 173%173%
EstimationEstimation
Costs: GLM (Generalized Liner Method) log-link with Gamma Costs: GLM (Generalized Liner Method) log-link with Gamma distribution (Manning and Mullahy, 2001) distribution (Manning and Mullahy, 2001)
Patient Outcomes: Logit regressionsPatient Outcomes: Logit regressions
Simulation results: Simulation results: A : Predicted costs/outcomes with PSI=1A : Predicted costs/outcomes with PSI=1B : Predicted costs/outcomes with PSI=0B : Predicted costs/outcomes with PSI=0(A – B) : Predicted costs/outcomes due to adverse patient safety events(A – B) : Predicted costs/outcomes due to adverse patient safety events
Simulation Results: OutcomesSimulation Results: Outcomes
Death Death during index during index hospitalizationhospitalization
Death during Death during readmissionreadmission
Death within Death within 30 days of 30 days of dischargedischarge
PSI=0PSI=0 0.92%0.92% 3.4% 3.4% 1.4%1.4%
PSI=1PSI=1 1.96%1.96% 5.2%5.2% 2.8%2.8%
% Difference% Difference 1.04%*1.04%* 1.8%*1.8%* 1.4%*1.4%*
* Significantly different from zero at the 99% level
Simulation Results: Outcomes (cont.)Simulation Results: Outcomes (cont.)
Probability of Probability of
readmissionreadmission
PSI=0PSI=0 15.1%15.1%
PSI=1PSI=1 20.1%20.1%
DifferenceDifference 5.0%*5.0%*
* Significantly different from zero at the 99% level
Simulation Results: CostsSimulation Results: Costs
Index Index HospitalizationHospitalization ReadmissionReadmission Total CostsTotal Costs
PSI=0PSI=0 $12,801$12,801 $18,264 $18,264 $15,618$15,618
PSI=1PSI=1 $21,190$21,190 $26,198$26,198 $26,607$26,607
PSI COSTPSI COST
$8,388*$8,388*
(232)(232)
$7,933*$7,933*
(529)(529)
$10,989*$10,989*
(284)(284)
% Difference% Difference 65.5%65.5% 43.4%43.4% 70.4%70.4%* Significantly different from zero at the 99% level
SummarySummary
Excess costs and adverse outcomes of adverse patient safety Excess costs and adverse outcomes of adverse patient safety events are not limited to the initial hospitalization events are not limited to the initial hospitalization
Adverse patient safety events during hospitalizations lead toAdverse patient safety events during hospitalizations lead to– Higher probability of readmissionsHigher probability of readmissions– Higher probability of in-hospital death following dischargeHigher probability of in-hospital death following discharge– Higher inpatient costs following dischargeHigher inpatient costs following discharge
Policy ImplicationsPolicy Implications
A reduction in adverse patient safety eventsA reduction in adverse patient safety events
will not only improve quality of care but also will not only improve quality of care but also reduce long-term health care costsreduce long-term health care costs