June 22, Leah Binder President and CEO The Leapfrog Group 1660 L Street, N.W., Suite 308 Washington, D.C Dear Ms.
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1 Richard J. Umbdenstock President and Chief Executive Officer Liberty Place, Suite Seventh Street, NW Washington, DC (202) Phone Leah Binder President and CEO The Leapfrog Group 1660 L Street, N.W., Suite 308 Washington, D.C Dear Ms. Binder: On June 5, The Leapfrog Group publicly released a safety scorecard assessing the safety of more than 2,600 American hospitals. Its stated purpose was to provide a single letter grade for safety that patients could use to guide their decisions regarding where to receive hospital care. On behalf of the American Hospital Association s (AHA) more than 5,000 member hospitals and health systems, I wish to express disappointment that the scorecard s assessment was neither fair nor accurate. The AHA has worked to make credible and reliable information on hospital quality and safety available to the public so that patients can make informed health choices. We are proud that the hospital field feels strongly that the communities we serve deserve information on our strengths and weaknesses so that patients can make informed choices about where they wish to receive care. Our members have not shied away from this kind of transparency, even when their scores were not as good as they would have expected. All that they have asked is for assurance that the measures are truly important to the quality or safety of a patient s care and that the data are collected and analyzed fairly and accurately. That is why we are raising concerns about the scorecard and whether it meets these important goals. I am writing to highlight several methodological shortcomings in the survey, which we believe include an unfair bias toward responding to the survey, the use of unreliable measures, significant variation in the weights applied to measures for different groups of hospitals, and significant errors in the data. The attachment outlines these problems in detail. We point these out so that you and your colleagues might understand why we are critical of the scorecard, and why we believe no one should use it to guide their choice of hospitals, unless and until, a more accurate assessment method is used.
2 Page 2 of 5 We believe the issues we raise about the survey methodology and choice of measures call into question whether the scorecard meets the criteria The Leapfrog Group has established and, therefore, whether it is tool on which patients can rely. While we respect the organization s goals, we have long advocated for, and made considerable effort in collaboration with federal agencies and other organizations toward, developing a single, reliable set of reporting measures to assess hospital quality and safety. We urge The Leapfrog Group to review its survey in light of our concerns and these important goals. If you would like to discuss these concerns further, please feel free to call me or Nancy Foster, AHA vice president for quality and patient safety policy, at (202) Sincerely, Rich Umbdenstock President and CEO Enclosure
3 Page 3 of 5 AHA DETAILED COMMENTS ON THE LEAPFROG GROUP S HOSPITAL SURVEY METHODOLOGICAL ISSUES The Leapfrog Group s hospital safety scorecard intends to give a hospital a single score for efforts to ensure the safety of patients by rolling together data that principally come from some of the measures published by the Centers for Medicare & Medicaid Services (CMS) and from The Leapfrog Group s own survey. The data published by CMS and used in the scorecard assess hospitals performance on some steps meant to protect surgical patients from complications and some rare and potentially serious complications of care. The Leapfrog Group s survey also is intended to assess hospitals compliance with processes or procedures believed to improve patient safety. Bias toward The Leapfrog Group s Survey Chief among our concerns is that the methodology The Leapfrog Group uses appears to favor its own survey over other similarly reliable sources of information. Specifically, for two of the scored questions (presence of a computerized provider order-entry (CPOE) system and intensivists in the intensive care unit (ICU)), those who provide information by responding directly to The Leapfrog Group s survey can earn up to 100 points for a fully compliant system, while those whose responses are derived from secondary data can earn a maximum of only 15 points. This is surprising because the secondary data sources used are at least as reliable as the primary data source. For example, the secondary data source for the CPOE question is the American Hospital Association s (AHA) Health Information Technology annual survey, which is funded by the Office of the National Coordinator for Health Information Technology (ONC). This survey has a large, nationally representative response rate and provides great detail on hospitals adoption and use of health information technology, including CPOE. Therefore, it is unclear why The Leapfrog Group would give so little weight to an answer to a similar question in the AHA survey. The Leapfrog Group makes the same surprising scoring distinction for the question on intensivists. Here the secondary source from which the information can be derived is the AHA s Annual Survey (AHA survey). While not identical to The Leapfrog Group s survey, the AHA survey asks each responding hospital to indicate whether it uses intensivists in the hospital, how many full-time equivalent (FTE) intensivists it has in each ICU, and whether it runs closed units, meaning only intensivists are authorized to care for patients in the ICU. The AHA survey questions give every appearance of being sufficient to answer the question of whether all ICU patients are managed by intensivists exclusively, which is precisely what The Leapfrog Group s survey endeavors to do. Yet, once again, The Leapfrog Group allows a maximum of 15 points if the information is derived from this secondary source, whereas information derived directly from its own survey can earn more than six times that amount.
4 Page 4 of 5 By assigning vastly different point scores to similar information derived from reliable secondary sources, we are concerned that the scorecard can lead patients to inappropriate conclusions. For example, the Yale New Haven Hospital has had a complete CPOE system since 1994 and was one of the pioneers in embedding its CPOE into a fully functional electronic health record (EHR) system, which has been in place for several years. It has 137 FTE intensivists on staff, and intensivists exclusively manage all of the ICU patients, except in the cardiac care unit, where cardiologists specially trained in the management of critical patients are in charge. Yale New Haven Hospital s data from the two surveys administered by the AHA clearly demonstrate this, but because the data are derived from secondary sources, the hospital received only 30 of the potential 200 points on The Leapfrog Group s assessment. For Yale New Haven Hospital and many others, this difference in points meant it was awarded a C by The Leapfrog Group when we believe it rightfully should have received an A. Use of Unreliable Measures The Leapfrog Group uses 15 process or structural measures, including the two structural measures discussed above. Another eight measures are derived from self-reported data on The Leapfrog Group s survey. We are concerned these measures have not been sufficiently tested to confirm their reliability. One test of whether a measure has sufficient reliability, validity and importance to be used as a national standard for performance is to have the measure reviewed by the National Quality Forum (NQF); The Leapfrog Group s survey has not been put to such a test. To the best of our knowledge, it has not been assessed for its reliability and validity by any independent organization. We have similar concerns about most of the 11 outcome measures used by The Leapfrog Group; nine are proposed for retirement from the Hospital Compare website in 2014 because studies have shown them to be unreliable. In the case of the Hospital-Acquired Conditions (HAC) measures, the multi-stakeholder group known as the Measure Applications Partnership (MAP) recommended that they be removed after hearing how the data source, the denominators, and the lack of risk adjustment where warranted made these performance rates inappropriate for use in hospital-to-hospital comparisons. Despite this, The Leapfrog Group s methodology gives these measures higher weights than the demonstrably more reliable measures assessing prevention of surgical complications. Another concern with The Leapfrog Group s methodology is the significant variation in the weights assigned to measures when data are missing. About 40 percent of hospitals responded to The Leapfrog Group s survey questions. If a hospital did not respond to the survey, eight of the structural/process measures were eliminated from the calculation of the hospital s grade. That means that half of a hospital s grade was calculated on the remaining seven measures, and if the hospital did not supply data to the AHA for the surveys that are The Leapfrog Group s secondary data source, half of the grade rested on just the five process measures that assess whether the hospital follows steps to prevent surgical complications. In describing the methodology, The Leapfrog Group indicates that the weights vary only slightly when data are not reported, but in reality as noted in the table below, the weights vary significantly. We believe this means hospitals grades are being calculated based on disparate weighting systems, and the results are not comparable.
5 Page 5 of 5 Measure Measures Weighted Differently for Different Groups of Hospitals Weight if All Questions Answered Weight if Leapfrog Survey Not Completed Antibiotic received within hour prior to surgery Antibiotic selection Antibiotic discontinued Timely removal of urinary catheter Appropriate VTE prophylaxis Weight if Leapfrog and AHA Surveys Not Completed Significant Errors in the Data We also believe that significant mistakes in data handling by The Leapfrog Group have resulted in misleading information being publicly displayed. Unfortunately, we do not have the same underlying data that The Leapfrog Group used, so we cannot conduct a validation of its scoring, but we are hearing from enough of our members about significant data issues that we are concerned about the manipulation of the data. For example, we know of at least one specialty hospital that was given a score when the survey s stated methodology should have excluded the hospital based on its specialty status. And in a quick check of the display, we were able to identify a number of hospitals that likely should have qualified for a score, but weren t included. We have heard from several other hospitals that have discovered that data that were reported to The Leapfrog Group or on Hospital Compare have somehow not been included in the calculation of this scorecard.
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