State of the State: Hospital Performance in Pennsylvania October 2015 1
Measuring Hospital Performance Progress in Pennsylvania: Process Measures 2
PA Hospital Performance: Process Measures We examined the latest year-over-year (YOY) changes in the Center for Medicare and Medicaid Services (CMS) and Joint Commission (JC) process measures aggregated on www.pahealthcarequality.org. 16 process measures (14 CMS and 2 JC Measures) reported on the PHCQA website were examined from 2006 to 2014. 3 Heart Attack Measures* 2 Heart Failure Measures* 3 Pneumonia Measures* 7 Surgical Care Measures* 1 Prevention Measure* We used rates and averages to compare performance data. The PA rate is calculated using a volume-based, weighted-average of hospitals in Pennsylvania. The PA average is calculated using an institution-based, non-weighted average of hospitals in Pennsylvania. * See glossary for detailed list 3
Process Measures Data: Overall Findings Pennsylvania hospital performance improved from July 2013 June 2014. Pennsylvania performance improvements were consistent with improvements nationally over the same time period. Pennsylvania Hospitals generally performed above average compared to other hospitals across the country. 4
YOY Comparison of the Years Ending June 2013 and June 2014 Process measure scores for PA hospitals improved across the board. PA rates increased in 14 of the 16 measures, with only 2 measures remaining stagnant. The standard deviations for PA hospitals decreased for 15 out of 16 process measures, indicating an overall improvement in consistency. PA hospital performance improvements were similar to nationwide hospital performance improvements. National rates and top ten percentiles either increased or remained the same for the majority of process measures. 5
Process Measures in Charts and Graphs 6
YOY Comparison of PA Rates: Process Measures 100% 98% 96% 94% 92% 90% 88% 86% The SCIP-INF-10 rate was the only measure that saw a decrease. PA Rate Q3 2012 - Q2 2013 PA Rate Q3 2013 - Q2 2014 7
PA Rate 3-Year Trends: 2012 2014 100% 98% 96% 94% 92% 90% 88% All process measures have improved over the past three years. Q3 2011 - Q2 2012 Q3 2012 - Q2 2013 Q3 2013 - Q2 2014 8
Q3 2013 Q2 2014 Process Measures PA Rate vs. National Rate 100% 96% 92% 88% 84% 80% PA Rate US Rate As of June 2014, PA rates exceeded national rates for 13 of the 16 process measures. 9
Q3 2013 Q2 2014 Process Measures PA Averages vs. PA Rates 100% 96% 92% 88% 84% 80% PA Rate PA Average All PA rates are higher than the corresponding PA averages, suggesting hospitals with larger patient volumes perform slightly better on average than hospitals caring for fewer patients. 10
Percentage of PA Hospitals Achieving 100% Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% The number of PA hospitals that achieved 100% compliance has increased for every measure. Across all measures, the mean number of PA hospitals achieving 100% has increased from 22% in 2012 to 40% in 2014 (represented in graph as Overall Mean ). Q3 2011 - Q2 2012 Q3 2012 - Q2 2013 Q3 2013 - Q2 2014 11
CMS HCAHPS Measures 12
Measuring Progress in PA Hospital Performance: HCAHPS Patient Experience Measures We reviewed the latest year-over-year (YOY) score changes in the 10 CMS HCAHPS Measures reported on the PHCQA website: H-COMP-1: Nurse Communication H-COMP-2: Doctor Communication H-COMP-3: Responsiveness of Hospital Staff H-COMP-4: Pain Well Controlled H-COMP-5: Medicine Explained by Staff H-COMP-6: Discharge Information H-CLEAN-HSP: Room and Bathroom Kept Clean H-QUIET-HSP: Room Quiet at Night H-HSP-RATING: Hospital Rating H-RECMND: Hospital Recommendation Only the scores of the top tier answer categories were evaluated. We also examined correlations among HCAHPS measure scores. 13
YOY HCAHPS Data Comparisons between July 2012 June 2013 & July 2013 June 2014 PA hospital HCAHPS scores for the year running up to Q2 2014 are similar to the national average. The PA average was within 2% of the national average for 9 of the 10 measures. PA HCAHPS scores increased for 9 of the 10 measures since the previously reported year. Increases were small, with no measure improving by more than 1.75%. The one measure to decline, H-COMP-4, decreased by only 0.09%. Changes in HCAHPS scores for hospitals nationwide were also modest. US averages increased or stayed the same for all HCAHPS measures. None of the US averages increased by more than 2 percentage points. 14
Q3 2013 Q2 2014 HCAHPS PA Average vs. National Average 100% 90% 80% 70% 60% 50% 40% 30% PA Average US Average 20% 10% 0% Only H-COMP-1 and H-COMP-6 exceeded the national average. Overall, PA hospitals performed about as well as the national average for all measures, except H-QUIET-HSP which under performed. 15
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% YOY Comparison of PA Averages: HCAHPS Q3 2012 - Q2 2013 Q3 2013 - Q2 2014 Although 9 out of the 10 HCAHPS measures have improved since the previous year, the increases were very modest. Only H-QUIET-HSP improved by more than 1%. 16
5-Year Comparison of PA HCAHPS Data 100% 90% 80% 70% 60% 50% 40% 30% Q3 2009 - Q2 2010 Q3 2010 - Q2 2011 Q3 2011 - Q2 2012 Q3 2012 - Q2 2013 Q3 2013 - Q2 2014 20% 10% 0% Overall, HCAHPS ratings have slowly and steadily improved each year. Across all measures, performance has improved by an average of about 4% between 2010 and 2014, increasing by an average of 0.8% each year. 17
14% Percentage of PA Hospitals in the Top Tenth Percentile Nationwide 12% 10% 8% 6% Q3 2009 - Q2 2010 Q3 2010 - Q2 2011 Q3 2011 - Q2 2012 Q3 2012 - Q2 2013 Q3 2013 - Q2 2014 4% 2% 0% At the end of Q2 2014, at least 10% of PA hospitals scored in the top 10 th percentile nationwide for H-COMP-4 and H-CLEAN-HSP. While the percentage of PA hospitals in the top 10 th percentile nationwide as of Q2 2014 increased from the previous year for 4 measures, this percentage decreased for 6 of the measures. 18
Q3 2013 Q2 2014 HCAHPS Data Correlations H-COMP-1 H-COMP-2 H-COMP-3 H-COMP-4 H-COMP-5 H-COMP-6 H-CLEAN-HSP H-QUIET-HSP H-HSP-RATING H-RECMND H-COMP-1 1 Correlation Key H-COMP-2 0.760 1 = Very Strong Correlation (0.7 0.999) H-COMP-3 0.711 0.593 1 = Strong Correlation (0.5 0.699) H-COMP-4 0.870 0.741 0.517 1 = Medium Correlation (0.2 0.499) H-COMP-5 0.876 0.792 0.660 0.788 1 H-COMP-6 0.709 0.584 0.290 0.774 0.624 1 H-CLEAN-HSP 0.494 0.437 0.681 0.340 0.491 0.204 1 H-QUIET-HSP 0.493 0.403 0.628 0.351 0.548 0.211 0.544 1 H-HSP-RATING 0.889 0.695 0.622 0.802 0.813 0.711 0.456 0.501 1 H-RECMND 0.710 0.531 0.583 0.549 0.645 0.457 0.380 0.484 0.884 1 Hospital Ratings are very strongly correlated with H-COMP-1: Nurse Communication (r = 0.889) H-COMP-4: Pain Well Controlled (r = 0.802) H-COMP-5: Medicine Explained by Staff (r = 0.813) H-COMP-6: Clear Discharge Instructions (r = 0.711) Patients are more likely to recommend a hospital to a friend if they think their nurse communicated well with them (r = 0.710) and they rated their experience a 9 or 10 (r = 0.884). Nurse communication has a stronger impact on patient evaluations of hospital experience than doctor communication. 19
All Average HCAHPS Scores Based on Location and Setting Large Urban (Phil & Pitt) Urban Rural West Central Northeast Southeast # of Hospitals 161 66 51 44 61 31 30 39 H-COMP-1 79.62% 79.09% 80.04% 79.93% 79.75% 80.45% 79.97% 78.49% H-COMP-2 80.10% 79.02% 80.67% 81.07% 81.30% 80.29% 80.37% 77.87% H-COMP-3 67.90% 66.46% 68.98% 68.82% 67.95% 69.32% 68.30% 66.39% H-COMP-4 70.36% 69.29% 71.49% 70.66% 70.57% 71.42% 71.20% 68.54% H-COMP-5 63.27% 62.39% 63.16% 64.71% 63.49% 63.65% 64.13% 61.95% H-COMP-6 86.29% 85.41% 87.43% 86.27% 87.02% 87.26% 86.07% 84.54% H-CLEAN-HSP 73.78% 70.40% 75.51% 76.84% 73.54% 77.19% 74.97% 70.51% H-QUIET-HSP 55.41% 54.88% 57.06% 54.30% 54.41% 55.65% 56.47% 55.97% H-HSP-RATING 69.28% 68.68% 71.32% 67.82% 68.74% 71.29% 69.47% 68.29% H-RECMND 69.54% 70.12% 72.29% 65.48% 68.13% 70.77% 69.80% 70.56% Urban hospitals outperformed Large Urban hospitals in all 10 measures and Rural hospitals in 7 measures. Patients who receive care at Urban hospitals are the most likely to recommend and highly rate their hospital. Central Pennsylvania hospitals had higher scores in 7 of 10 measures than those located in other regions of Pennsylvania. 20
High Volume vs. Low Volume Hospitals All Bottom Quartile (<2,500 Discharged Patients) Top Quartile (>14,000 Discharged Patients) # of Hospitals 161 46 36 H-COMP-1 79.62% 81.87% 78.91% H-COMP-2 80.10% 83.52% 78.72% H-COMP-3 67.90% 74.04% 64.39% H-COMP-4 70.36% 72.13% 69.10% H-COMP-5 63.27% 67.17% 61.67% H-COMP-6 86.29% 86.61% 86.45% H-CLEAN-HSP 73.78% 80.63% 68.68% H-QUIET-HSP 55.41% 61.52% 51.40% H-HSP-RATING 69.28% 73.00% 68.88% H-RECMND 69.54% 72.61% 72.06% Low volume hospitals score higher than the PA average for every measure. High volume hospitals score lower than the PA average for 8 of 10 measures. 21
Teaching vs. Non-Teaching Hospitals All Teaching Non-Teaching # of Hospitals 161 82 79 H-COMP-1 79.62% 78.83% 80.01% H-COMP-2 80.10% 79.37% 80.63% H-COMP-3 67.90% 65.63% 69.82% H-COMP-4 70.36% 69.66% 70.70% H-COMP-5 63.27% 62.23% 64.06% H-COMP-6 86.29% 86.29% 86.16% H-CLEAN-HSP 73.78% 71.26% 76.07% H-QUIET-HSP 55.41% 53.56% 56.74% H-HSP-RATING 69.28% 68.39% 69.51% H-RECMND 69.54% 68.98% 69.33% Non-teaching hospitals scored higher than teaching hospitals for 9 of the 10 HCAHPS measures. 22
All Process Measures 8-Year Trend Analysis 23
PA Hospital Non-Weighted Averages Performance Measure 2007 2008 2009 2010 2011 2012 2013 2014 Improvement from 2007-2014 Heart Attack Measures Aspirin Prescribed at Discharge (AMI-2) 92.8% 94.2% 95.8% 95.2% 96.3% 97.2% 96.9% 99.2% 6.9% PCI within 90 Minutes of Arrival (AMI-8a) 57.5% 73.0% 80.5% 84.7% 89.4% 91.2% 94.6% 95.7% 66.4% Statin prescribed at discharge (AMI-10) N/A N/A N/A N/A N/A 92.2% 93.2% 96.6% 4.8% Heart Failure Measures Patients Given Discharge Instructions (HF-1) 68.0% 76.6% 81.8% 87.5% 89.1% 91.8% 93.5% 94.9% 39.6% ACE Inhibitor or ARB for LVSD (HF-3) 82.8% 87.7% 90.1% 93.1% 93.2% 94.2% 94.8% 96.2% 16.2% Pneumonia Measures Blood Culture within First 24 hours (ICU) (PN-3a) N/A 91.6% 95.3% 96.3% 97.3% 97.0% 97.8% 98.1% 7.1% Initial Antibiotic Selection (PN-6) 87.4% 88.3% 90.1% 95.5% 93.9% 94.1% 95.2% 96.2% 10.1% Initial Antibiotic Selection for Non-ICU Patients (PN-6b) N/A 92.4% 94.7% 95.1% 96.3% 96.4% 97.2% 97.3% 5.3% 24
PA Hospital Non-Weighted Averages Performance Measure 2007 2008 2009 2010 2011 2012 2013 2014 Improvement from 2007-2014 Surgical Care Measures Beta Blocker during the Perioperative Period (SCIP-CARD-2) Prophylactic Antibiotic within 1 hour of incision (SCIP-INF-1) N/A N/A 90.3% 89.8% 93.5% 95.2% 96.6% 97.7% 8.2% 82.9% 87.4% 91.7% 94.6% 96.3% 97.0% 98.2% 98.9% 19.3% Appropriate Antibiotic (SCIP-INF-2) N/A 94.7% 96.8% 95.9% 97.6% 97.6% 98.2% 98.4% 3.9% Prophylactic Antibiotic Discontinued within 24 hours (SCIP-INF-3) Urinary Catheter Removal within Two Days of Surgery (SCIP-INF-9) Surgery Patients with Perioperative Temperature Management (SCIP-INF-10) VTE Received within 24 Hours of Surgery (SCIP-VTE-2) 76.0% 85.3% 90.4% 92.5% 95.1% 96.9% 97.4% 97.8% 28.7% N/A N/A N/A 90.5% 92.9% 94.7% 96.6% 98.0% 8.3% N/A N/A N/A N/A N/A 99.3% 99.5% 99.7% 0.4% 89.3% 81.4% 90.4% 92.2% 95.4% 97.0% 97.7% 99.0% 10.9% 25
Pennsylvania Rates Performance Measure 2007 2008 2009 2010 2011 2012 2013 2014 Improvement from 2007-2014 Heart Attack Measures Aspirin Prescribed at Discharge (AMI-2) 97.5% 97.9% 98.6% 98.9% 99.2% 99.4% 99.4% 99.5% 2.1% PCI within 90 Minutes of Arrival (AMI-8a) 62.5% 76.9% 84.1% 88.2% 92.2% 93.1% 96.2% 96.2% 53.9% Statin prescribed at discharge (AMI-10) N/A N/A N/A N/A N/A 97.9% 98.5% 98.9% 1.0% Heart Failure Measures Patients Given Discharge Instructions (HF-1) 73.6% 81.1% 86.4% 90.3% 92.2% 94.7% 95.6% 96.3% 30.8% ACE Inhibitor or ARB for LVSD (HF-3) 86.8% 91.8% 93.9% 94.8% 95.6% 96.9% 97.2% 97.8% 12.7% Pneumonia Measures Blood Culture within First 24 hours (ICU) (PN-3a) N/A 93.2% 95.8% 97.0% 97.9% 98.0% 98.2% 98.4% 5.6% Initial Antibiotic Selection (PN-6) 88.4% 89.8% 91.5% 93.2% 94.9% 95.8% 96.2% 96.6% 9.3% Initial Antibiotic Selection for Non-ICU Patients (PN-6b) N/A 93.0% 94.8% 95.5% 96.4% 96.9% 97.2% 97.4% 4.7% 26
Pennsylvania Rates Performance Measure 2007 2008 2009 2010 2011 2012 2013 2014 Improvement from 2007-2014 Surgical Care Measures Beta Blocker during the Perioperative Period (SCIP-CARD-2) Prophylactic Antibiotic within 1 hour of incision (SCIP-INF-1) N/A N/A 91.3% 93.6% 96.0% 97.6% 98.3% 98.7% 8.1% 87.6% 91.8% 95.9% 97.3% 98.2% 98.7% 99.1% 99.3% 13.4% Appropriate Antibiotic (SCIP-INF-2) N/A 96.1% 97.8% 97.6% 98.3% 98.7% 99.2% 99.2% 3.2% Prophylactic Antibiotic Discontinued within 24 hours (SCIP-INF-3) Urinary Catheter Removal within Two Days of Surgery (SCIP-INF-9) Surgery Patients with Perioperative Temperature Management (SCIP-INF-10) VTE Received within 24 Hours of Surgery (SCIP-VTE-2) 80.1% 89.3% 93.3% 95.2% 96.9% 98.3% 98.4% 98.7% 23.2% N/A N/A N/A 94.5% 94.9% 96.9% 98.2% 99.0% 4.8% N/A N/A N/A N/A N/A 99.8% 99.8% 99.8% 0.0% 83.8% 90.7% 93.7% 95.5% 97.1% 98.4% 98.7% 99.4% 18.6% 27
CMS Emergency Department Measures 28
Emergency Department Measures Emergency Department (ED) measures display how timely and effective the care in a hospital s emergency department is delivered. Measures which show ED timeliness of care are displayed as an average in minutes, and thus may not reflect daily fluctuations of ED care. A lower score is better. ED measures are based on a limited sample each quarter and do not reflect the score of all ED patients. 29
Minutes 3-Year Comparison of PA Averages: ED Measures 300 250 200 150 100 Q2 2012 Q2 2013 Q2 2014 50 0 ED-1b ED-2b OP-18 OP-20 OP-21 Performance has gradually improved each year for OP-20 and OP-21. PA hospital performance has remained relatively stable over the last three years for ED-1b, ED-2b, and OP-18. 30
Minutes Q2 2014 ED Measures PA Average vs. US Average 300 250 200 150 PA Average US Average 100 50 0 ED-1b ED-2b OP-18 OP-20 OP-21 Pennsylvania performs better than the national average for ED-1b and OP-18. 31
CMS Outcome Measures 32
Trend Analysis: CMS Outcome Measures We compared readmission and mortality performance over the past 8 years. The measures in this section evaluate outcomes during the 30-day period after discharge. Data for these measures are rolled-up three years. A lower score is better. The only mortality measure that has shown consistent improvement is the 30-Day Heart Attack Mortality measure. Improvements in Heart Failure and Pneumonia process measure scores over the years have not necessarily translated into lower mortality rates. While Pennsylvania hospitals performed better than US hospitals on average for all mortality measures, readmission rates in Pennsylvania are almost identical to the national rates. Over the past 8 years, readmission rates have decreased for all measures. 33
18% 16% 14% 12% 10% 8% 6% 4% 2% 0% YOY Comparison of PA Mortality Rates Heart Attack Heart Failure Pneumonia 2007-2010 2008-2011 2009-2012 2010-2013 2011-2014 Pennsylvania heart attack mortality rates have steadily decreased over the overlapping 5-year analysis periods. Heart Failure mortality performance has slightly worsened since the initial reporting period. 34
2011 2014 Mortality Rates: PA vs. US 16% 14% 12% 10% 8% PA Rate US Rate 6% 4% 2% 0% Heart Attack Heart Failure Pneumonia Pennsylvania mortality rates are slightly better than national mortality rates. 35
YOY Comparison of PA Readmission Rates 30% 25% 20% 15% 10% 5% 0% Heart Attack Heart Failure Pneumonia 2007-2010 2008-2011 2009-2012 2010-2013 2011-2014 Pennsylvania readmission rates have decreased for all measures during the overlapping 5-year analysis periods. 36
2011 2014 Readmission Rates: PA vs. US 25% 20% 15% 10% PA Rate US Rate 5% 0% Heart Attack Heart Failure Pneumonia Pennsylvania and national readmission rates are almost identical. 37
Pennsylvania Outcome Measures Trend Analysis Performance Measure 2006-2009 2007-2010 2008-2011 2009-2012 2010-2013 2011-2014 Improvement Readmission Measures Heart Attack 20.1% 19.9% 19.7% 18.3% 17.8% 17.2% 14.4% Heart Failure 25.0% 25.0% 25.0% 23.1% 22.6% 21.9% 12.4% Pneumonia 18.5% 18.5% 18.6% 17.7% 17.3% 16.9% 8.6% Mortality Measures Heart Attack 15.9% 15.6% 15.2% 14.3% 14.3% 13.7% 13.8% Heart Failure 10.7% 10.9% 11.2% 11.2% 11.4% 11.3% -5.6% Pneumonia 11.2% 11.6% 11.9% 11.5% 11.5% 11.1% 0.9% 38
Glossary of Measure Abbreviations 39
Glossary of Measure Abbreviations Heart Attack Measures AMI-2: aspirin prescribed at discharge AMI-8a: PCI given within 90 minutes of arrival AMI-10: statin prescribed at discharge Heart Failure Measures Pneumonia Measures PN-3a (JC): blood cultures for pneumonia patients in intensive care units PN-6: pneumonia patients given the most appropriate initial antibiotic(s) PN-6b (JC): initial antibiotic selection for CAP in immunocompetent non ICU patients HF-1: heart failure patients given discharge instructions HF-3: ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) 40
Glossary of Measure Abbreviations Surgical Care Measures SCIP-CARD-2: surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery SCIP-INF-1: surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection SCIP-INF-2: surgery patients who were given the right kind of antibiotic to help prevent infection SCIP-INF-3: surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) SCIP-INF-9: surgery patients whose urinary catheters were removed on the first or second day after surgery SCIP-INF-10: surgery patients with perioperative temperature management SCIP-VTE-2: patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery 41
Glossary of Measure Abbreviations HCAHPS Measures H-COMP-1: nurses always communicated well H-COMP-2: doctors always communicated well H-COMP-3: patients always received help as soon as they wanted H-COMP-4: pain was always well controlled H-COMP-5: staff always explained medicines before giving them to patients H-COMP-6: patients were given information about what to do during their recovery at home H-CLEAN-HSP: rooms and bathrooms were always clean H-QUIET-HSP: rooms were always quiet at night H-HSP-RATING: patients who rated their hospital experience overall a 9 or 10 out of 10 H-RECMND: patients who would definitely recommend the hospital to family and friends Emergency Department (ED) Measures ED-1b: time from ED arrival to ED departure for admitted patients ED-2b: time from admit decision to departure time from the ED for admitted patients OP-18: median time from ED arrival to ED departure for discharged ED patients OP-20: door to diagnostic evaluation by a qualified medical professional OP-21: median time to pain management for long bone fracture Prevention Measure IMM-2: percent of acute care hospitalized patients age 6 months or older screened for seasonal influenza immunization status or vaccinated prior to discharge 42