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Administrative Data Based Tools for Pediatric and Neonatal Health
Services and Outcomes Research:Risk-Adjustment
Corinna A. Haberland, MD, MSStanford University
Child Health Services Research MeetingJune 26, 2010
Introduction
• For any comparative use of AHRQ Quality Indicators (QIs), adjusting for underlying health status is crucial
• Paucity of methods available for pediatric measures
• Developed methods for both Pediatric QIs (PDIs) and Neonatal QIs (NQIs)
Pediatric QIs – Risk Adjustment -Development
• For the hospital level AHRQ PDIs – developed a method to adjust for four factors
• Reason for Admission – using DRGs
• Age and Gender
• Comorbidities – developed de novo
• Indicator specific categories
Pediatric QIs – Risk Adjustment -Development
• Comorbidity adjustment - Clinical Classification Software (CCS)1 & 2001-2003 State Inpatient Data2
– Clinical Review – CCS categories selected out
– Empirical Analysis – Statistics Generated – Present on admission (POA)
– Relative risks
– Bias estimators
– Clinical list and Empirical list compared - matching CCS categories were placed on an initial risk-adjustment list
– List reviewed clinically again – appropriate CCS groupings added
1 Clinical Classifications Software (CCS) for ICD-9-CM, http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp2 2001-2003 State Inpatient Data, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.
Pediatric QIs – Risk Adjustment -Current Application
• Adjustment regression model includes:
Pediatric QIs – Risk Adjustment -Current Application
• Adjustment regression model includes:
– Reason for admission – DRGs
Pediatric QIs – Risk Adjustment -Current Application
• Adjustment regression model includes:
– Reason for admission – DRGs
– Age & Gender
Pediatric QIs – Risk Adjustment -Current Application
• Adjustment regression model includes:
– Reason for admission – DRGs
– Age & Gender
– Comorbidities
Pediatric QIs – Risk Adjustment -Current Application
• Comorbidity Adjustment - Using Present on Admission (POA) data:
• Determines whether the record has POA data
• Identifies covariates
• Calculate predicted value for covariate– When POA data are available – able to use actual comorbidity
values
– When POA not available – covariate values generated using comorbidity values and a POA propensity score
Pediatric QIs – Risk Adjustment -Current Application
• Adjustment regression model includes:
– Reason for admission – DRGs
– Age & Gender
– Comorbidities
– Indicator specific risk categories
Pediatric QIs – Risk Adjustment –Results
Non-Children’s Hospitals – Overall Rates0
.00
04
76
0.00
1162
0.00
0100
0.0
41
18
0
0.00
1586
0.0
08
93
5
0.0
15
26
9
0.00
1037
0.0
01
15
0
0.00
0536
0.00
1021
0.00
0101
0.0
41
91
1
0.00
1707
0.01
0285
0.01
5062
0.00
1057
0.0
01
12
1
0.000000
0.005000
0.010000
0.015000
0.020000
0.025000
0.030000
0.035000
0.040000
0.045000A
cc P
un
c &
Lac
Pre
ss U
lce
r
Iatr
o P
ne
um
o
Pe
d H
rt S
urg
Mo
rt
Po
st-o
p H
em
o /
He
ma
Po
st-o
p R
esp
Fai
l
Po
st-o
p S
ep
sis
Po
st-o
p W
ou
nd
Deh
is
Cat
h R
ela
Blo
od
Infe
c
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Overall Rates
0.00
1102
0.00
1549
0.00
0146
0.04
1615
0.00
1842
0.01
4956
0.01
4011
0.00
1317
0.00
3861
0.0
00
54
0
0.00
1213
0.0
00
13
6
0.04
1009
0.0
01
77
2
0.0
11
88
2
0.0
12
71
4
0.00
1369
0.00
1917
0.000000
0.005000
0.010000
0.015000
0.020000
0.025000
0.030000
0.035000
0.040000
0.045000
Acc
Pu
nc
& L
ac
Pre
ss U
lce
r
Iatr
o P
ne
um
o
Pe
d H
rt S
urg
Mo
rt
Po
st-o
p H
em
o /
He
ma
Po
st-o
p R
esp
Fai
l
Po
st-o
p S
ep
sis
Po
st-o
p W
ou
nd
Deh
is
Cat
h R
ela
Blo
od
Infe
c
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Non-Children’s vs. Children’s Hospitals – Ratios0
.43
2
0.75
0.6
85
0.99
0.86
1
0.5
97
1.09
0.7
88
0.2
98
0.99
4
0.8
42
0.74
5
1.02
2
0.9
63
0.86
6
1.18
5
0.7
72
0.5
85
0.000
0.200
0.400
0.600
0.800
1.000
1.200
1.400
Acc
Pu
nc
& L
ac
Pre
ss U
lce
r
Iatr
o P
ne
um
o
Pe
d H
rt S
urg
Mo
rt
Po
st-o
p H
em
o /
He
ma
Po
st-o
p R
esp
Fai
l
Po
st-o
p S
ep
sis
Po
st-o
p W
ou
nd
Deh
is
Cat
h R
ela
Blo
od
Infe
c
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Rates by Hospital Volume
Accidental Puncture & Laceration
0.00
0248
2
0.00
0278
9
0.00
0371
2
0.0
00
62
18
0.00
1055
5
0.0
00
53
06
0.0
00
48
03
0.00
0548
6
0.0
00
51
52
0.00
0583
8
0
0.0002
0.0004
0.0006
0.0008
0.001
0.0012
Q1 Q2 Q3 Q4 Q5
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Rates by Hospital Volume
Heart Surgery Mortality0
.04
0.08
0.0
35
01
26
0.0
43
41
68
0.0
40
78
52
0.20
3991
8
0.0
43
31
05
0.0
46
57
34
0.04
4536
0.0
40
10
13
0
0.05
0.1
0.15
0.2
0.25
Q1 Q2 Q3 Q4 Q5
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Rates by Hospital Volume
Catheter Related Bloodstream Infections
0.0
00
28
89
0.0
00
38
27
0.00
0795
2
0.0
01
83
57
0.00
3375
7
0.00
0274
3
0.0
00
59
71 0.
0011
437 0
.00
17
03
5
0.00
1959
7
0
0.0005
0.001
0.0015
0.002
0.0025
0.003
0.0035
0.004
Q1 Q2 Q3 Q4 Q5
Observed
Risk Adjusted
Neonatal QIs – Risk Adjustment -Development
• Preliminary RA model included:
– Birthweight
– Gender
– Multiple Gestation
– Congenital Anomalies
• Groupings derived by Phibbs, et al.1
• By organ system
• Based on mortality rates
1 Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in
very-low-birth-weight infants. New England Journal of Medicine. 2007;356(21):2165-2175 & Supplement.
Neonatal QIs – Risk Adjustment -Current Application
• Current RA model includes:
– Gender
– Outborn / Inborn status
– Birthweight
– Gestational Age
– Congenital Anomalies Groupings
Neonatal QIs – Risk Adjustment -Results
0.00
0797 0.
0018
72
0.0
03
60
8
0.00
5920
0.00
6442
0.00
0915
0.00
3076
0.0
05
14
2
0.00
7081
0.0
08
70
0
0.00
1785
0.0
02
22
6
0.00
2742
0.00
2892
0.00
3171
0.0
01
85
3
0.00
2815
0.0
02
98
1
0.0
03
31
8
0.00
3102
0.000000
0.001000
0.002000
0.003000
0.004000
0.005000
0.006000
0.007000
0.008000
0.009000
0.010000
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
LBW VLBW
Observed
Risk Adjusted
Neonatal Mortality
Neonatal QIs – Risk Adjustment -Results
0.0
03
87
8
0.01
2051
0.0
14
68
2 0.0
18
32
7 0.0
22
15
0
0.0
06
18
9
0.01
4530
0.0
14
96
9
0.02
0306
0.0
25
18
9
0.00
7429
0.01
5681
0.0
16
84
0
0.01
9363 0.
0226
23
0.0
09
53
7
0.01
7542
0.01
6270
0.0
21
22
4 0.02
5604
0.000000
0.005000
0.010000
0.015000
0.020000
0.025000
0.030000
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
LBW VLBW
Observed
Risk Adjusted
Neonatal Blood Stream Infections
Conclusions
• Risk adjustment methods for both QI sets:
– Account for important clinical variations in patients
– Attenuate differences in children’s & non-children’s hospital, and between volume quintile rates
– Will better allow for comparisons of quality outcomes
Additional Slides
Statistic Description Strict Threshold Loose Threshold
SID rate and RRObserved rate and relative risk for CCS category in
2000-2003 SID.
NY and CA SID rate and RRObserved rate and relative risk for CCS category in
2000-2003 New York and California data only.
Rate and RR given
complication
Observed rate and relative risk, using NY and CA
data, including only patients whose CCS triggering
code was NOT POA
Rate and RR given
comorbidity RR (POA)
Observed rate and relative risk, using NY and CA
data, including only patients whose CCS triggering
code was POA
RR > 2 RR > 2
% CCSPercent of indicator denominator represented by
the CCS.% CCS > 1 % % CCS > 1%
% POA Percent of the CCS that is present on admission. % POA > 85% % POA > 85%
Estimator Bias (EB)Measure of bias due to unknown POA status.
Ranges from 0 (no bias) to 1 (high bias).EB ≤ 0.2 EB ≤ 0.3
Comparison Bias (CB)Measure of bias using corrected RR and frequency
of CCS / POACB ≤ 0.015 CB ≤ 0.03
*Each statistic was calculated for each CCS that appeared as a codiagnosis for each indicator.
Diagnostic Risk Group ICD-9 Diagnosis Codes N (1998-2000) and
(% of all coded risks)
Gastrointestinal
Abdominal wall defect 756.70, 756.79 986 (0.054)
Tracheoesophageal fistula 750.3, 750.4 365 (0.020)
Small bowel or upper GI
anomalies
(1) Anomalies NOS
including pyloric
stenosis
(2)
(3) Volvulus or Intestinal
Fixation Problem
750.5, 750.7, 750.8, 750.9,
751.1, 751.5, 751.8, 751.9
751.5
560.2, 751.4
745 (0.040)
903 (0.049)
224 (0.012)
Meckel’s Syndrome 751.0 67 (0.004)
Large Bowel
(1) Atresia, etc.
(2) Hirschprung’s
(3) Meconium obstruction
751.2
751.3
771.1
647 (0.035)
214 (0.012)
1479 (0.080)
Liver, bile duct, pancreas –
(1) Biliary Atresia or
Pancreatic Anomaly
(2) Bile, liver, pancreas
751,61, 751.7
751.60, 751.69
100(0.005)
246 (0.013)
Genitourinary
Renal
(1) Agenesis
(2) Polycystic
(3) Other cystic
(4) Other anomalies
753.0
753.12, 753.14, 753.15
753.10, 753.19
753.3, 753.4
434 (0.024)
294 (0.016)
244 (0.013)
430 (0.023)
Obstructions
(1) High Obstruction
(2) Low Obstruction
(3) Prune Belly, etc.
753.21, 753.22, 753.23
753.6, 753.7, 753.8, 753.9,
753.20
756.71
2154 (0.117)
450 (0.024)
28 (0.002)
CNS
Spina bifida, etc.
(1) Spina bifida
(2) Encephalocele
741.00, 741.01, 741.02,
741.03, 741.90, 741.91,
741.92, 741.93, 742.59
742.0
441 (0.024)
86 (0.005)
Brain
(1)
(2)
(3)
742.1, 742.4
742.2, 742.3
742.8, 742.9
1080 (0.059)
757 (0.041)
252 (0.014)
Pulmonary
CDH 519.4, 553.3, 748.9, 750.6,
756.6
588 (0.032)
Airway 748.3, 748.9 933 (0.051)
Cyst, etc.
(1)
(2)
748.4, 748.60
748.69, 748.8
435 (0.024)
126 (0.007)
Cardiovascular
Aortic valve 746.3, 746.4, 424.1 216 (0.012)
Aortic arch
(1)
(2)
747.10, 747.21, 747.29
747.11, 747.22, 746.81
436 (0.024)
135 (0.007)
HLHS 746.7 321 (0.017)
Endocardial fibroelastosis 425.3 149 (0.008)
Mitral valve
(1) Stenosis
(2) Other mitral
746.5
424.0, 746.6, 746.84
42 (0.002)
436 (0.024)
Transpositions 745.10, 745.19, 745.12 360 (0.020)
Coronary/Myocard 746.85, 425.1 105 (0.006)
Common RV, etc. 745.3, 745.11, 745.0 450 (0.024)
Pulmonary valve – tricuspid
(1)
(2)
746.01, 746.83, 746.2
746.09, 745.2, 746.1
325 (0.018)
693 (0.038)
Cushion, etc. 745.60, 745.61, 745.69 346 (0.019)
Pulmonary veins, etc. 746.82, 747.41, 747.42 177 (0.010)
Great vein 747.40, 747.49 94 (0.005)
Skeletal 756.50, 756.51, 756.55,
756.59
115 (0.006)
Chromosomal Syndromes
(1)
(2)
(3) Conjoined twins
758.3, 758.5, 758.89, 758.9,
759.89, 759.9
759.7
759.4
1484 (0.081)
107 (0.006)
15 (0.001)
Other
(1) Non-immune hydrops
(2) Hamartoses
(3) Congenital anemia
778.0
759.6
776.5
385 (0.021)
34 (0.002)
1846 (0.100)
From: Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH.
Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.
New England Journal of Medicine. 2007;356(21):2165-2175 & Supplement.
Current NQI RA Congenital Anomalies Groupings
Diagnostic Risk Group
1. Gastrointestinal
756.70
756.79
Anomaly of abdominal wall, unspecified
Other congenital anomalies of abdominal wall
750.3
750.4
Tracheoesophageal fistula, esophageal atresia and stenosis
Other specified anomalies of esophagus
750.5
750.7
750.8
750.9
751.1
751.5
751.8
751.9
751.5
560.2
751.4
Congenital hypertrophic pyloric stenosis
Other specified anomalies of stomach
Other specified anomalies of upper alimentary tract
Unspecified anomaly of upper alimentary tract
Atresia and stenosis of small intestine
Other anomalies of intestine
Other specified anomalies of digestive system
Unspecified anomaly of digestive system
Other anomalies of intestine
Volvulus
Anomalies of intestinal fixation
751.0 Meckel's diverticulum
751.2
751.3
771.1
Atresia and stenosis of large intestine, rectum, and anal canal
Hirschsprung's disease and other congenital functional disorders of colon
Congenital cytomegalovirus infection
751.61
751.7
751.60
751.69
Biliary atresia
Anomalies of pancreas
Unspecified anomaly of gallbladder, bile ducts, and liver
Other anomalies of gallbladder, bile ducts, and liver
2. Genitourinary
753.0
753.12
753.14
753.15
753.10
753.19
753.3
Renal agenesis and dysgenesis
Polycystic kidney, unspecified type
Polycystic kidney, autosomal recessive
Renal dysplasia
Cystic kidney disease, unspecified
Other specified cystic kidney disease
Other specified anomalies of kidney
Current NQI RA Congenital Anomalies Groupings
3. CNS
741.00
741.01
741.02
741.03
741.90
741.91
741.92
741.93
742.59
742.0
With hydrocephalusm, unspecified region
With hydrocephalusm, cervical region
With hydrocephalusm, dorsal (thoracic) region
With hydrocephalusm, lumbar region
Without mention of hydrocephalus, unspecified region
Without mention of hydrocephalus, cervical region
Without mention of hydrocephalus, dorsal (thoracic) region
Without mention of hydrocephalus, lumbar region
Other specified anomalies of spinal cord, Other
Encephalocele
742.1
742.4
742.2
742.3
742.8
742.9
Microcephalus
Other specified anomalies of brain
Reduction deformities of brain
Congenital hydrocephalus
Other specified anomalies of nervous system
Unspecified anomaly of brain, spinal cord, and nervous system
4. Pulmonary
519.4
553.3
748.9
750.6
756.6
Disorders of diaphragm
Diaphragmatic hernia
Unspecified anomaly of respiratory system
Congenital hiatus hernia
Anomalies of diaphragm
748.3
748.9
Other anomalies of larynx, trachea, and bronchus
Unspecified anomaly of respiratory system
748.4
748.60
748.69
748.8
Congenital cystic lung
Other anomalies of lung, anomaly of lung, unspecified
Other anomalies of lung, other
Other specified anomalies of respiratory system
Current NQI RA Congenital Anomalies Groupings
5. Cardiovascular
746.3
746.4
424.1
Congenital stenosis of aortic valve
Congenital insufficiency of aortic valve
Aortic valve disorders
747.10
747.21
747.29
747.11
747.22
746.81
Coarctation of aorta (preductal) (postductal)
Other anomalies of aorta, anomalies of aortic arch
Other anomalies of aorta, other
Interruption of aortic arch
Other anomalies of aorta, atresia and stenosis of aorta
Subaortic stenosis
746.7 Hypoplastic left heart syndrome
425.3 Endocardial fibroelastosis
746.5
424.0
746.6
746.84
Congenital mitral stenosis
Mitral valve disorders
Congenital mitral insufficiency
Obstructive anomalies of heart, NEC
745.10
745.19
745.12
Complete transposition of great vessels
Transposition of great vessels, other
Corrected transposition of great vessels
746.85
425.1
Coronary artery anomaly
Hypertrophic obstructive cardiomyopathy
745.3
745.11
745.0
Common ventricle
Double outlet right ventricle
Common truncus
746.01
746.83
746.2
746.09
745.2
746.1
Atresia, congenital
Infundibular pulmonic stenosis
Ebstein's anomaly
Anomalies of pulmonary valve, other
Tetralogy of Fallot
Tricuspid atresia and stenosis, congenital
745.60
745.61
745.69
Endocardial cushion defect, unspecified type
Ostium primum defect
Endocardial cushion defects, other
Current NQI RA Congenital Anomalies Groupings
6. Skeletal
756.50
756.51
756.55
756.59
Osteodystrophy, unspecified
Osteogenesis imperfecta
Chondroectodermal dysplasia
Osteodystrophies, other
7. Chromosomal Syndromes
758.3
758.5
758.89
758.9
759.89
759.9
759.7
759.4
Autosomal deletion syndromes
Other conditions due to autosomal anomalies
Other conditions due to chromosome anomalies, other
Conditions due to anomaly of unspecified chromosome
Other specified anomalies, other
Congenital anomaly, unspecified
Multiple congenital anomalies, so described
Conjoined twins
8. Other
778.0
759.6
776.5
Hydrops fetalis not due to isoimmunization
Other hamartoses, NEC
Congenital anemia
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Rates by Hospital Volume
Pressure Ulcer
0.0
02
21
6
0.00
0292
0.00
0245
0.0
01
67
5
0.0
02
28
0
0.0
00
05
2
0.0
00
05
1
0.00
1886
0.000000
0.000500
0.001000
0.001500
0.002000
0.002500
Q1 Q2 Q3 Q4
Observed
Risk Adjusted
Pediatric QIs – Risk Adjustment –Results
Children’s Hospitals – Rates by Hospital Volume
Post-Op Hemorrhage & Hematoma