Improving Identification of Postoperative Respiratory Failure Missed by the Patient Safety Indicator Algorithm

Abstract

The Patient Safety Indicator postoperative respiratory failure (PRF) flags cases using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for acute respiratory failure or mechanical ventilation/intubation. The authors examined how frequently PRF missed events and ways to improve event identification. A total of 125 high-risk unflagged cases were selected based on predicted probability and presence of clinically relevant codes. False-negative (FN) proportion and associated reasons were determined through chart review, and likelihood ratios (LRs) of associated codes were calculated. In all, 27% of elective cases were FNs; 55% of FNs lacked ventilation/intubation codes. “Respiratory arrest,” 799.1, had the highest LR (5.4) but occurred in only 8% of FNs. All other individual diagnostic or procedure codes had relatively low LRs (≤3.1), despite occurring in up to 36% of FNs. Among high-risk cases, the PRF algorithm often missed events. Improved ventilation/intubation coding will have more of an impact on case identification than adding ICD-9-CM codes to the algorithm.

Keywords

postoperative respiratory failure patient safety adverse events quality of care quality indicators

Get full access to this article

View all access options for this article.

References

McDonald

Romano

Geppert

Davies

Duncan

Shojana

. Measures of Patient Safety Based on Hospital Administrative Data: The Patient Safety Indicators. Rockville, MD: Agency for Health Care Research and Quality; 2002. Technical Review 5. AHRQ Pub. No. 02-0038.

National Quality Forum. NQF endorsed standards: PSI. http://www.qualityforum.org/QPS/QPSTool.aspx. Accessed August 27, 2012.

Centers for Medicare and Medicaid Services. Fiscal year 2009 quality measure reporting for 2010 payment update. http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalRHQDAPU200808.pdf. Accessed March 1, 2012.

QualityNet. Hospital inpatient quality reporting (IQR) program measures. http://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1228889673856&blobheader=multipart%2Foctetstream&blobheadername1=Content-Disposition&blobheadervalue1=attachment%3Bfilename%3DMeasComprsn_CY2012_010912.pdf&blobcol=urldata&blobtable=MungoBlobs. Accessed October 27, 2012.

Agency for Healthcare Research and Quality. AHRQ Quality Indicators: Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Version 3.0a.

Rosen

Rivard

Zhao

. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Med Care. 2005;43:873-884.

Zhan

Miller

. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874.

Rosen

Itani

KMF

Cevasco

. Validating the patient safety indicators (PSIs) in the Veterans Health Administration: do they accurately identify true safety events? Med Care. 2012;50:74-85.

Romano

Mull

Rivard

. Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data. Health Serv Res. 2009;44:182-204.

10.

Borzecki

Cevasco

Mull

Shin

Itani

Rosen

. Improving the identification of postoperative wound dehiscence missed by the patient safety indicator algorithm. Am J Surg. In press.

11.

Utter

Cuny

Sama

. Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality’s patient safety indicator? J Am Coll Surg. 2010;211:347-354.

12.

Borzecki

Kaafarani

Utter

. How valid is the AHRQ patient safety indicator “postoperative respiratory failure”? J Am Coll Surg. 2011;212:935-945.

13.

US Department of Health and Human Services. Hospital Compare. http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home. Accessed July 15, 2012.

14.

Centers for Medicare and Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates. Fed Regist. 2012;77:53258-53746.

15.

VA Information Resource Center. VIReC Research User Guide: FY2006 VHA Medical SAS Inpatient Datasets. http://www.virec.research.va.gov/RUGs/MedSAS-Archive/IP/RUG-MedSAS-IP-FY06-ER.pdf. Accessed November 21, 2012.

16.

Rivard

Elwy

Loveland

. Applying Patient Safety Indicators (PSIs) Across Healthcare Systems: Achieving Data Comparability. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 005-0021-CD.

17.

Veterans Health Administration. VistAWeb Technical Manual, version 8.0. http://www.va.gov/vdl/documents/Clinical/VistaWeb/webv_1_13_tm.pdf. Accessed October 27, 2012.

18.

Agency for Healthcare Research and Quality. Patient safety indicators: technical specifications. http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V31/psi_technical_specs_v31.pdf. Accessed October 26, 2012.

19.

HCUP. Comorbidity Software, version 3.7. http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp. Accessed October 26, 2012.

20.

Deeks

Altman

. Diagnostic tests 4: likelihood ratios. BMJ. 2004;329:168-169.

21.

Utter

Cuny

Strater

Silver

Hossli

Romano

. Variation in academic medical centers’ coding practices for postoperative respiratory complications: implications for the AHRQ postoperative respiratory failure patient safety indicator. Med Care. 2012;50:792-800.