Medical staff and coders need to work together to improve care

During the past six months, the Agency for Healthcare Research and Quality (AHRQ) has increased its number of inpatient quality indicators (IQI) and patient safety indicators (PSI). Indicators targeted for 2010 include death among surgical patients with treatable serious complications, accidental puncture and laceration, and mortality rates for patients with heart failure, stroke, hip fracture, and abdominal aortic aneurysm repair.  

These additional indicators translate into a burden for hospitals. Outcomes are defined by International Classification of Diseases (ICD) codes from hospital discharge diagnoses, not abstracted data. AHRQ is researching whether these codes accurately reflect patient’s clinical conditions.

AHRQ, as the research arm of CMS, has done its homework and funded research to explore increased length of stay and increased costs of complications related to medical care. In research the AHRQ presented in September 2008, discharge ICD codes for deep vein thrombosis (DVT) as a complication of a medical or surgical hospitalization were only 30% and 60% accurate, respectively. However, when present-on-admission (POA) data was excluded, the accuracy increased to 79% and 83%. (Note: Only 1,000 charts were abstracted between the medical and surgical DVTs.)

CMS has been working with the medical coding organizations to improve coding accuracy, and thus POA data have evolved as a meaningful method to identify hospital-acquired conditions.

What does this mean for physicians and providers involved in hospital-based quality care? I see two themes: First, physicians will need to work with coders to develop improved clinical accuracy from the abstracted data. Run reports to find out what your complication rates are per AHRQ PSI ICD definitions to find out how your hospital might compare on a public scorecard. 

Currently, surgical site infections and central line blood stream infections are tracked through coded data, and if the data does not accurately reflect these complications, when public reporting emerges, hospitals can be hurt. Work with your coders when they code major infections, complications, decubitus ulcers, and DVTs to prevent inaccuracies in coding.

Second, quality leaders need to examine systems of care as they investigate IQIs and mortality data. We all know that teams of specialists care for complex patients, so investigating the mortality data for post-operative conditions involves more than looking at surgical skill. To see optimal patient outcomes, post-operative care requires support from the nursing department, pharmacy, respiratory care, etc. In addition, for diseases like heart failure, standardizing care around evidence-based guidelines will help improve patient outcomes. If hospitals want the competitive edge around value-based purchasing and public reporting, quality leaders must dive into the data and analyze systems of care to identify opportunities for improvement.

Carlotta Rinke, MD, FACP, MBA
Assistant vice president of quality and patient safety
Alexian Brothers Medical Center