Hospital Quality Institute

By the Numbers

FEBRUARY 2017

A monthly snapshot of progress

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

Maternal Quality Measures (CMQCC - MDC)

• 182 California hospitals currently report data to CMQCC’s Maternal Data Center as of December 31, 2016 and 61 do not report, as detailed below by region:

Region Submitting data Not yet reporting: legal complete Not engaged Total HASC 73 12 24 109 HASDIC 14 1 0 15 HC 95 10 14 119 Total 182 23 38 243

Note: There are now 243 hospitals offering maternity services because Dameron Hospital’s L&D unit closed (Hospital Council). • The latest available statewide maternal outcomes for the hospitals participating in CMQCC are shown below:

CMQCC MDC outcome Better 2014 2015 % Change 2014-2015 2015 Hospital Range NTSV C-Section rate (%) ↓ 26.1 25.6 -1.9 11.1 - 76.9 Episiotomy rate (%) ↓ 11.6 10.3 -11.2 0.0 – 57.6 VBAC rate (%) ↑ 9.4 11.3 20.2 0.0 – 45.3 Breastfeeding rate (%) ↑ 66.5 66.5 0.0 7.1 - 97.4

Note. Data are only updated once per year by CMQCC MDC; those shown above for 2015 are the latest available.

California Live Births and Fertility

• The figures below show the number of live births (left figure; a birth in which a child is born alive) and fertility rates (right figure; live births/1,000 women ages 15-44) in California overall and by mother’s age from 2010-2014. Overall live births and fertility rates in California decreased slightly from 2010-2014, particularly among women under 30, but increased among those ages 30 and older.

California Hospital Improvement Innovation Network (CalHIIN)

• Hospital Recruitment to CalHIIN: o Outreach continued to all eligible California hospitals (n=295) as well as ‘orphan’ hospitals in AZ, TX, OH, and FL. o 261 hospitals have joined CalHIIN to date, only 13 have declined participation. o 77 California hospitals have joined different HIINs (Dignity, Premier, Vizient, Solutions Pediatric).

• Onboarding to the CalHIIN database is underway this month through data release conferrals from the hospitals. • Education events are being launched addressing the topics of: Readmissions, C-Difficile Infections, and Data portal use. • Collaboration and planning meetings held with CDPH and HSAG regarding HAI reduction, and HSAG regarding Readmissions. • Consultation support to hospitals underway.

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

Sepsis

• The figure on the left below shows sepsis hospitalization rates (per 1,000 hospitalizations) and case-fatality rates (per 100 sepsis cases) in California from 2010-2015. While sepsis hospitalization rates increased in California from 2010-2015, the case fatality rates decreased during the same time period.

• The figure on the right below shows the same sepsis rates for 2015 by age (note: newborn < 28 days old). Both the sepsis hospitalization and case-fatality rates are highest among persons ages 18 and older. While the sepsis rate for newborns is not particularly high, they are much more likely to die from sepsis.

Condition-Specific and Overall Hospital Readmission

• The figure below shows readmission rates within 30 days associated with hospital treatment for specific medical conditions and overall. Progress is expressed as Rate Ratios (RR), for which lower values indicate that the California readmission rate is lower than the national rate. The RRs are adjusted for patients of varying risk across facilities.

• California hospitals overall have lower readmission rates with regard to CABG and hip/knee replacement than is the case nationally. AMI, COPD, HF, pneumonia, stroke and overall readmission rates for California are basically the same as the national rates.

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

Hospital-Acquired Infections (HAIs)

• The figure below shows hospital-acquired infection (HAI) rates for CDI, CLABSI, CAUTI, MRSA, SSI Colon Surgery, SSI Hip Replacement Surgery, SSI Abdominal Hysterectomy, and SSI Knee Replacement Surgery. Progress is expressed as Standardized Infection Ratios (SIR), for which lower values indicate that the California rate for the HAI is lower than the national baseline. The SIRs are adjusted for patients of varying risk across facilities.

• California hospitals overall have consistently outperformed the national baselines with regard to CLABSI, CAUTI, MRSA, hip replacement SSI, abdominal hysterectomy SSI, and knee replacement SSI. CDI and Colon surgery SSI remain as challenges.

CHPSO

• 1,115,668 safety event reports in the CHPSO database as of January 31, 2017. • 390 CHPSO members, including hospitals and healthcare organizations representing the western half of the United States,

from Hawaii to Texas. • As of 1/31/17, there are 2,705 CHPSO newsletter subscribers. • As of 1/31/17, there are 186 CHPSO Legal Counsel subscribers.

o CHPSO members had the opportunity to earn CEs by attending CHPSO safe tables. One safe table meeting was held in January on discharge medications and 63 attendees were present, representing 25 hospitals.

Partnership for Patient Experience (P4PEx)

Patient Satisfaction (HCAHPS) • The latest results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey of US

hospitals were released December 19, 2016. The table on the next page shows how California scores changed between the current and prior survey periods, and how California scores for the current period differ from the national average.

o California hospitals overall have lower scores on all HCAHPS measures than is the case nationwide, but the difference is particularly striking for quietness of rooms at night, for which the statewide score for California hospitals is 16.1% lower than the national average, and for always receiving timely help, for which the statewide score for California is 11.6% lower than the national average.

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

HCAHPS Measure

California National Average 201501-201512

201504-201603

% Change

Hospital Range

201504-201603

% Difference CA vs. US

Nurse Communication (NC) 75 75 0 55 - 97 80 -6.3 Doctor Communication (DC) 78 78 0 59 - 95 82 -4.9 Help Timely (HT) 62 61 -1.6 36 - 94 69 -11.6 Pain Controlled (PC) 69 68 -1.4 49 - 87 71 -4.2 Medicines Explained (ME) 61 61 0 37 - 92 65 -6.2 Clean Environment (CE) 71 71 0 48 - 92 74 -4.1 Quiet Environment (QE) 52 52 0 31 - 92 62 -16.1 Received Discharge Info (RI) 85 85 0 69 - 94 87 -2.3 Understood Discharge Info (UI) 48 48 0 28 - 70 52 -7.7 Rated Hospital 9 or 10 (9/10) 68 68 0 32 - 97 72 -5.6 Recommend Hospital (RH) 69 69 0 25 - 99 72 -4.2 Note. Data are retrieved from the CMS Hospital Compare website, which is updated quarterly with data representing the prior 4 quarters. The current HCAHPS file was updated December 19, 2016 and represents 12-months of data starting 2Q2015 and ending 1Q2016.

• The figures below put California statewide scores for each of the 11 HCAHPS measures in historical context. Since HCAHPS began, California hospitals have generally improved on all HCAHPS measures. Nonetheless, they have lagged behind national HCAHPS scores on all eleven measures. The gap between “Received” and “Understood” discharge information remains a particular problem, as does quietness of the environment at night.

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

• The chart below shows HCAHPS Summary Star Ratings for California hospitals reported on the CMS Hospital Compare website (as of the December 19, 2016 data update) by region.

• HCAHPS hospital star ratings vary considerably by region, with a higher percentage of 1 star hospitals in the HASC region, a lower percentage of 1 star hospitals in the HC region, and lower percentages of 4 star hospitals in both the HASC and HC regions.

Relation of Person and Family Engagement (PFE) Practices with Patient Satisfaction (HCAHPS)

• HQI began exploring the relationship between implementing PFE recommended practices and levels of patient satisfaction. Specifically, we compared PFE adherence at baseline for the 176 hospitals involved in CalHEN 2.0 with their end-of-year HCAHPS Top-Box scores for calendar year 2015. The differences in HCAHPS Top-Box Scores, HCAHPS Summary Star Ratings, and CMS Overall Hospital Quality Star Ratings, for hospitals that implemented each PFE recommended practice compare to those that did not are shown in the following table (statistically significant results are highlighted in yellow).

HCAHPS Measure

Planning Checklist

(PFE1)

Shift-Change Huddle (PFE2)

Dedicated PFE Staff

(PFE3)

Active PFE Committee

(PFE4)

Patients on Board (PFE5)

Nurse Communication (NC) -1.2 2.3 1.0 1.3 2.3 Doctor Communication (DC) 0.8 2.2 1.9 2.1 3.1 Help Timely (HT) -0.8 3.3 0.6 1.6 3.2 Pain Controlled (PC) -0.3 2.3 1.3 1.3 2.7 Medicines Explained (ME) -0.9 1.8 0.8 1.7 1.5 Clean Environment (CE) -2.4 0.9 0.3 0.6 1.8 Quiet Environment (QE) -1.2 4.1 1.1 0.5 0.2 Received Discharge Info (RI) -0.2 1.4 1.1 1.4 1.4 Understood Discharge Info (UI) -2.0 2.4 2.6 3.7 4.1 Rated Hospital 9 or 10 (9/10) -1.5 5.8 4.2 5.0 6.2 Recommend Hospital (RH) -0.9 6.5 5.7 6.2 7.5 HCAPS Summary Star Rating -0.1 0.4 0.3 0.4 0.5 CMS Hospital Quality Star Rating -0.1 0.1 0.1 0.1 0.0

Note. Higher positive values = better (hospital that implemented the PFE recommendation had higher HCAHPS Top-Box scores).

By the Numbers Report February 2017

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

• Some of the findings from the correlation of PFE and HCAHPS measures for CalHEN 2.0 hospitals are:

o In general, implementing PFE measures was associated with higher HCAHPS scores for most measures. o Having patient representatives on a governing board was most strongly related to higher HCAHPS scores (9

HCAHPS measures), followed by having shift-change huddles (7 measures), having an active PFE committee (6 measures), and having dedicated PFE staff (5 measures).

o Use of a pre-admission planning checklist was not found to be related positively to any HCAHPS measures; in fact it was negatively related to perceived cleanliness of the environment (use of the list was associated with lower cleanliness scores).

o Most PFE measures were not associated with the cleanliness or quietness of the environment. The only PFE measure related to quietness of the environment—which has been a persistent challenge for California hospitals— was the use of shift-change huddles.

o None of the PFE practices were associated with CMS Overall Hospital Quality Star Ratings.

HealthCare Reliability Organizing (HCRO)

• 13 hospital systems are actively engaged in the HCRO program. San Diego is in active discussion to form an education cohort collaborative.

• 12 other healthcare organizations have expressed interest in becoming a cohort in 2017 and will be sequenced according to interest and readiness.

• eLearning Management System (LMS): o 12 new LMS users were added in January. o 30 new learning modules for 8 Reliable Clinical Practices are scheduled to be launched in February. o 177 unique learners are taking or have completed HCRO Foundations; the figure below shows their progress.

Reports and General Announcements

• Federal and state Medicaid spending increased by an estimated 4.3% to $575.9 billion in fiscal year 2016, according to a new CMS report. Federal Medicaid spending alone grew by an estimated 4.5% to $363.4 billion in FY 2016, while state Medicaid spending increased by an estimated 3.8% to $212.5 billion. CMS estimated that the federal share of all Medicaid spending remained at 63% in FY 2016 (Click here for report).

• According to a report by the American Hospital Association, 1 of every 9 US jobs is supported by the hospital industry and hospitals employ 5.7 million people directly and contribute $2.8 trillion economically each year (Click here for more).

• Among the 20 US hospitals with the highest numbers of discharges only one hospital in California, Cedars-Sinai Medical Center in Los Angeles (53,087 discharges), made the top 20 (click here for the full list)

• Becker’s Hospital Review published an online article called 50 Things to Know about the Hospital Industry in 2017 that is replete with statistics and interesting facts, including the information about the numbers of hospitals of different types that is shown below. The full article is available here.

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Category Number % Registered Hospitals in the US 5,564 100.0 Community Hospitals 4,862 87.4 Nonprofit 2,845 58.5 For-profit 1,034 21.3 Government-owned 983 20.2 Rural Hospitals 1,829 37.6 Critical Access Hospitals 1,337 27.5 Academic Medical Centers ≈400 ≈8.2

• A study published in The Lancet regarding a multicenter randomized trial of using ultraviolet light in addition to standard disinfection procedures for reducing hospital-acquired infections from multidrug-resistant MRSA, vancomycin-resistant enterococci (VRE), C. difficile and Acinetobacter found that the incidence of new infections was 30% lower (relative risk [RR] 0.70, 95% CI 0.50–0.98; p=0.036) when UV was added to the standard cleaning strategies. The trial compared standard disinfection using quaternary ammonium with three other cleaning methods: quaternary ammonium followed by UV light, chlorine bleach without UV light, and bleach with UV light. Overall, the most effective strategy was using quaternary ammonium followed by UV light, which was particularly effective against transmission of MRSA, although the results varied across infectious agents. For example, using chlorine bleach instead of quaternary ammonium cut transmissions of VRE by more than half and adding UV light to the bleach regimen was even more successful, cutting VRE transmission by 64 percent. None of the cleaning methods significantly reduced the incidence of C. difficile beyond standard cleaning procedures (Click here for abstract) (click here for video).

• Updated clinical guidelines for the management of sepsis and septic shock were published in JAMA (Click here for new guidelines). In any accompanying Research Letter the case is made for CMS to add sepsis readmission as a measure of hospital performance to the Hospital Readmission Reduction Program (HRRP). Specifically, the authors analyzed the 2013 Nationwide Readmissions Database (HCUP) and found that sepsis accounted for 12.2% of readmissions, followed by 6.7% for heart failure, 5% for pneumonia, 4.6% for COPD and 1.3% for heart attack. In addition, the estimated average cost per readmission for sepsis was $10,070, compared to $9,533 for pneumonia, $9,424 for heart attack, $9,051 for heart failure and $8,417 for COPD (see table below for more information; Click here for article).

• California ranked 47th for number of hospital outpatient visits per 1,000 residents per a recent Kaiser Permanente analysis; the top 5 were: Maine, Vermont, DC, New Hampshire, and West Virginia (Click here for full list).

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W:\By The Numbers Monthly Report\HQI By the Numbers 02-2017.docx (Updated: 02/07/2017 1:00 PM) Report Inquiries: Scott Masten, Senior Biostatistician at smasten@hqinstitute.org or (916) 552-7557

• Per a study published in BMJ Quality & Safety on patient-centered readmission factors based on 1,066 readmitted patients, 91% reported understanding their discharge plan. However, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%), or issues such as inadequate discharge instructions or follow-up care (6%) (Click here for abstract).

• Of the top 10 selling drugs in 2015, 7 were so-called “orphan drugs” that are shielded from competition by the FDA for 7 years with the intention of encouraging drug companies to research and market drugs for relatively rare disorders. According to a Kaiser Permanent report the orphan drug program may now be being used to artificially inflate drug prices by getting multiple approvals over time for the same drug, thereby creating drug monopolies (Click here for full article).

• An article in The American Journal of Kidney Diseases found that bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. Specifically, patients who received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) or were dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞) had much higher odds of having these bloodstream infections. They conclude that exposing patients to reused dialyzers increases the risk for bloodstream infections, so providers should consider implementing single dialyzer use whenever possible (Click here for article).

• According to a study published in Arthritis Care and Research by Brown University researchers, the 30-, 60-, and 90-day unplanned hospital readmission rates were 5.3%, 7.2%, and 8.5% respectively, for Medicare beneficiaries with total knee replacement or total hip replacement discharged from hospitals from 2009-2011. Patients were most frequently discharged to home health (46.3%) followed by skilled nursing facility (40.9%) and inpatient rehabilitation facility (12.7%). The Charlson, Elixhauser, and the CMS Hierarchical Condition Category (HCC) models did not significantly improve prediction for post-acute discharge settings and hospital readmission for patients beyond using basic patient demographics and hospital use variables (Click here for article).

• An article published in PlosOne suggests that diabetes is an underreported cause of death on birth certificates, reducing its place among leading causes of death in the US. Specifically, the CDC estimates that 4% of deaths are due to diabetes (making it the 7th leading cause of death) and the researchers found based on two different data sources that the diabetes likely contributes to 11.5-11.8% of deaths annually, making it the third leading cause of death (Click here for article).

• A retrospective study published in Health Services Research compared hospital performance and penalties under the new (harm-based + change in input PSI measures and weights) and old (volume-based) AHRQ Patient Safety Indicator (PSI)-90 composite measure and found that although the revised measure likely has only a small impact on reporting (5% of hospitals would have changed categorization), financial penalties would have been different for up to 15% of hospitals. They conclude that the use of the harm-based weights in PSI-90 has the potential to significantly change payments under pay-for-performance programs (Click here for abstract) (click here for revised PSI-90 Fact Sheet).

• A study published in Health Affairs compared changes in HCAHPS Top-Box scores before and after the Value-Based Purchasing (VBP) program was implemented. The study found that hospital patient experience as measured by HCAHPS improved modestly from 2008-2014, that most of the improvement occurred during the pre-VBP period and then slowed down subsequent to VBP for most hospital subtypes, and concluded that financial incentives of VBP were not associated with meaningful improvement in patient experience (Click here for abstract).

• MRSA infections in VA hospitals continued to decrease in all units (87.0% ICU, 80.1% non-ICU, 80.9% spinal-cord injury, 49.4% long-term care) during the 8 years subsequent to the implementation of a MRSA Prevention Initiative per a study published in the American Journal of Infection Control (Click here for abstract) (Click here for bundle description).

• An intervention called “Intentional Rounding,” which is a structured approach whereby nurses conduct checks on patients at set times to assess and manage their fundamental care needs, was found to reduce patient falls in a neuroscience ward by 50% according to a study published in the Journal of Clinical Nursing (Click here for abstract).

• A study published in Health Affairs suggests that Medicare Advantage patients receive less intense post-acute care, but have better outcomes (e.g., lower readmissions), than Medicare Fee-For-Service patients who are treated for joint replacement, stroke, or heart failure (Click here for abstract).

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