hospital data to improve the quality of care and patient safety in … · 2015. 5. 22. · hospital...
TRANSCRIPT
Hospital data to improve the
quality of care and patient
safety in oncology
Symposium
QUALITY AND SAFETY IN ONCOLOGY NURSING: INTERNATIONAL PERSPECTIVES
Dr Jean-Marie Januel, PhD, MPH, RN
MER 1, IUFRS, CHUV - UNIL
© JM Januel, 2015
Summary
To show the importance of routine data in measuring patient safety in hospital
To describe the current state of the project to develop Patient Safety Indicators (PSI) at international level
o Example of the PSI for postoperative pulmonary embolism and deep vein thrombosis
Top establish the interest of PSI and their perspectives to evaluate care in oncology
© JM Januel, 2015
From the Antiquity to the end of Middle-age
o Contemplative medicine in reference to the « Malade
imaginaire » from Molière1
Claude Bernard (1813-1878)
o Physiological medicine and principles
of interventional medicine
o Increasing of iatrogenic risks
1 Shuster E. Lancet 1998; 351: 974-977.
From contemplative medicine…
… to interventional medicine
© JM Januel, 2015
QUALITY
Fair
Efficiency
Safe
Efficient
Timeless
Content of the quality of care
Patient
centered
Crossing the Quality Chasm, IOM. 2001
© JM Januel, 2015
5
Care ability not to be iatrogenic (not to be
harmful, not causing complications).
To take measures to prevent the occurrence of
hospital adverse events associated with care
(HAE)
Or to reduce hospitalization consequences in
terms of complications
Patient safety
© JM Januel, 2015
6
Epidemiology of HAE
10% of hospitalizations
43% avoidable
International and ubiquitary issue
o AE occurrence : 3% to 19%1
o Variations due to the definition used to
identify AE mainly
1 De Vries, et al. Qual Saf Health Care 2008;17:216-223
© JM Januel, 2015
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Scale of risks according usual exposures in the life
* De Vries, et al. Qual Saf Health Care 2008;17:216-223
Cancer incidence (total
population)
HAE (10% of
hospitalizations)
Transfusion accident
Incidence of road injury
Aircraft accident
(incidence per fly)
Chemical industry accident
10-6 10-5 10-4 10-3 10-2 10-1
Ultra safe Risky Unsafe
© JM Januel, 2015
Limits of ad hoc study
Need of important resources (prevalence survey)
Cannot be repeated with high frequency
Small sample size
Dependant of quality of patient record /
agreement across observers to identify outcomes
using chart review
To use hospital routine data ?
© JM Januel, 2015
Example of indicators based on hospital
routine data
To use administrative data (diagnostic codes
based on the international classification of
diseases, ICD) to identify HAE potentially
associated to health care (= outcome indicators)
Indirect measurement of a selection of HAE
© JM Januel, 2015
1 PSI = 1 HAE
Algorithm of diagnostic codes
PSI algorithm
Codes for secondary diagnoses (SD)
corresponding to HAE clinical definition
At risk population defined using DRG codes,
diagnosis codes, and/or procedure codes
PSI =
McDonald K, Romano P, et al. AHRQ Publication No. 02-0038 .
Rockville, MD: Agency for Healthcare Research and Quality. 2002.
© JM Januel, 2015
Precision of PSI measurement
(criterion validity)
Heterogeneous PPV according to PSI
Chronology in assessing HAE (code for
« present on admission »)
Version of the ICD that is used in countries
Others factors that contribute to quality of
coding for ICD data
© JM Januel, 2015
Robustness of PSI measurement
(reliability)
0
5
10
15
20
25
30
[18-40[ [40-65[ [65-75[ [75-85[ >= 85 ans
PS
I /1
000 s
tays
PSI 12 - Categories of age
2005 H
2006 H
2005 F
2006 F
0
20
40
60
80
100
120
1 [2-4[ [4-8[ [8-15[ [15-22[ [22-29[ >= 29
PS
I /1
000 s
tays
PSI 12 - Lenght of stay(days)
2005
2006
Januel J.M. et al. Série Sources et Méthodes. Ministère de la Santé,
DREES, Etudes & Recherches, 2011.
© JM Januel, 2015
Citations of « PSI » in PubMed
0
10
20
30
40
50
Fré
qu
en
ce
, N
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Année
© JM Januel, 2015
PSI as a standard to assess health system
performance
In USA, Canada, Australia (program at national
level)
France: ongoing development of the PSI 12
(postoperative pulmonary embolism and deep
vein thrombosis) in patients undergoing hip /
knee arthroplasty (by the end of 2015)
© JM Januel, 2015
AHRQ
IMeCCHI
OECD
- First project
- 20 PSI (ICD-9-CM)
International Methodology Consortium for
Coded Health Information
- An independent consortium
- Subgroup on PSI (CA, CH, F, GER, AUS, USA)
- Adaptation of 15 PSI from ICD-9-CM to ICD-10
- HCQI Project
- A sélection of PSI
- ICD-9-CM / ICD-10
- International comparisons
Januel et al. Rev Epidemiol Sante Publique 2011
International comparisons based on PSI
© JM Januel, 2015
PSI Interest for international
comparisons
Performance of health systems
o Comparisons (benchmarking)
o To learn “from others”
To show differences
o Health system organization
o Practices of coding
o Healthcare practices
© JM Januel, 2015
International comparisons of the PSI 12
(postoperative pulmonary embolism [PE] /
deep vein thrombosis [DVT])
To propose a new approach to perform
comparative study using an evidence based-
benchmark (corresponding to the state of art
practices in healthcare)
To develop and to test a such approach to
HAE that occur in postoperative (example based
on postoperative PE/DVT)
© JM Januel, 2015
To establish an external benchmark to be used as a
reference value for comparisons (evidence based
practice)
To compare the rate of PE/DVT that occurs in
hospitalized patients undergoing hip replacement using
hospital routine data (PSI measurement) across several
countries
To explore potential factors that could explain
differences between countries (as confounding factors
in comparisons interpretation = potential bias)
A three steps study
© JM Januel, 2015
To choose a clinical benchmark
= Evidence-Based Practice
Hip arthroplasty
% (95% CI) I² P
Total LMWH (Observational + RCT) 0.58 (0.35-0.81) 51.8% 0.001
LMWH (Observational) 0.83 (0.19-1.48) 67.3% 0.230
LMWH (RCT) 0.51 (0.26-0.76) 45.4% 0.010
Direct inhibitor of IIa/Xa factors (EC) 0.31 (0.03-0.59) 32.8% 0.070
Indirect inhibitor of IIa/Xa factors (EC) 0.68 (0.26-0.97) 0.0% 0.380
TOTAL 0.53 (0.35-0.70) 49.4% <0.001
Januel et al. JAMA 2012
© JM Januel, 2015
Hospitalized patients (≥ 18 yrs) undergoing hip arthroplasty
5 countries (Switzerland, France, Canada, New-Zealand,
the U.S. State of the California)
Patient Safety Indicator (PSI) 12 to measure postoperative
PE/DVT (= venous thromboembolism, VTE)
A priori confounding factors (stratification)
o Length of stay
o Number of coding secondary diagnoses
o Procedure codes for ultrasound that was used to screen DVT
systematically
A cross-sectional study
© JM Januel, 2015
PSI algorithm to identify postoperative PE/DVT 1,2
1 Januel JM, et al. Rev Epidemiol Sante Publique 2011; 59: 341-350.
2 OECD Health Technical Report. N°19. DELSA/ELSA/WD/http 2008.
NUMERATOR DENOMINATOR Procedure codes
N° PSI Inclusions Inclusions Exclusions Exclusions
12 Postoperative
PE / DVT
Secondary
diagnoses of
PE / DVT
Procedure codes
for total or partial
hip prosthesis
18 yrs
Principal
diagnosis of
PE/DVT
MDC 14
Stent in the
cava vena
(recurrent PE)
© JM Januel, 2015
Hospital length of stay (LOS)
© JM Januel, 2015
Hospital length of stay (LOS)
© JM Januel, 2015
Hospital length of stay (LOS)
© JM Januel, 2015
Number of coded secondary diagnoses
0.00
0.01
0.02
0.03
0.04
0.05
Ob
se
rved
pro
ba
bili
ty o
f V
TE
3 4 5 6 7 8 9 10=<2 11+
Number of Second Diagnoses Coding Fields
Switzerland France Canada New-Zealand California-US
© JM Januel, 2015
Number of coded secondary diagnoses
© JM Januel, 2015
Q1 Q2 Q3 Q4
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Obse
rved
eve
nt o
ccure
nce r
ate
, %
VTE DVT (only) PE (only) DVT+PE
Type of thromboembolic events stratified by quartile (Q) for systematic ultrasound
DVT and Procedure codes of ultrasound (France)
© JM Januel, 2015
Quartiles
1 2 3 4
Proportion of stay with ultrasound by hospital, Median 0 1.43 5.35 46.25
[IQR, 25th – 75th percentiles] [0 – 0] [1.95 – 2.02] [3.85 – 7.41] [18.18 – 85.55]
% of stays with PE/DVT 0.88 0.68 0.94 2.55
(95% CI) (0.76 – 1.00) (0.58 – 0.77) (0.84 – 1.04) (2.31 – 2.79)
Volume of hip arthroplasty by hospital, Median 82 155 137 140
[IQR, 25th – 75th percentiles] [40 – 140] [97 – 228] [74 – 228] [72 – 238]
Type of hospital
Public hospital and assimilated, n (%) 503 (42.70) 269 (22.84) 277 (23.51) 129 (10.95)
For profit private hospital, n (%) 354 (24.65) 181 (12.60) 377 (26.25) 524 (36.49)
LOS, Median 13.18 12.31 12.02 11.73
[IQR, 25th – 75th percentiles] [10.97 – 15.75] [10.34 – 14.36] [10.97 – 15.75] [10.97 – 15.75]
Number of secondary diagnoses, Median 2.41 2.35 2.31 2.56
[IQR, 25th – 75th percentiles] [2.31 – 2.51] [2.23 – 2.47] [2.21 – 2.40] [2.45 – 2.67]
Factors associated to ultrasound coded
© JM Januel, 2015
PSI as standard metrics
At international level
o Standard (for comparisons)
o Comparability, factors to explain differences
potentially…
At national level
o Improving healthcare quality remains the
fundamental and principal objective
o Complementarily between PSI and ad hoc
study (± electronically patient records)
© JM Januel, 2015
N° Patient Safety Indicators (PSI) de la AHRQ (CIM-9-CM) IMeCCHI OECD
1. Complications of anesthesia X X
2. Lower DRG mortality - -
3. Decubitus ulcer X X
4. Failure to rescue - -
5. Body left during procedure X X
6. Iatrogenic pneumothorax X X
7. Central venous catheter bloodstream infection X X
8. Postoperative hip fracture X X
9. Postoperative hemorrhage or hematoma - -
10. Postoperative physiological and metabolic disorders X -
11. Postoperative respiratory failure - X
12. Postoperative pulmonary embolism and deep vein thrombosis X X
13. Postoperative septis X X
14. Abdominal-pelvic surgical wound dehiscence - -
15. Technical difficulty - laceration or accidentally puncture during care X X
16. Transfusion reaction X X
17. Birth Trauma - trauma in newborn X X
18. Obstetric trauma during a vaginal delivery (with instrument) X X
19. Obstetric trauma during a vaginal delivery (without instrument) X X
20. Obstetric trauma during a cesarean X X
© JM Januel, 2015
Interest and perspectives in oncology
PSI = HAE with avoidable criteria
o Oncology patients are excluded of some
AHRQ PSI (denominator)
To refine interesting PSI for oncology care
o Also include patients with cancer in the
denominator
o To develop new PSI (specific)
