0 hospital quality incentive demonstration (hqid) key facts three year demo (2003-2006); extended...

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Hospital Quality Incentive Demonstration (HQID)Key Facts

• Three year demo (2003-2006); extended for three additional years through Oct. 2009• 225 hospitals in 37 states• Quality measures

– First 3 years: 33 nationally recognized measures in five clinical conditions:• Heart attack (Acute myocardial infarction (AMI))• Heart bypass surgery (Coronary artery bypass graft (CABG))• Heart failure (HF)• Community acquired pneumonia (PN)• Hip and knee replacement surgery (Hip/Knee)

– Second three years: 41 nationally recognized measures in multiple clinical conditions

• Financial incentives

– First three years: Top 2 deciles in each condition rewarded; Penalties for hospitals still in the bottom 2 deciles in each condition (set in year 2)

– Second three years: Awards paid for threshold attainment, most improvement, and top performer; similar penalty methodology

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Dramatic and Sustained Improvement

Avg. improvement across all 5 clinical areas for

median CQS (24 quarters)

18.8%

Clinical Area

Improvement (percentage points)

Heart Attack 9.4%

Heart Bypass 12.9%

Pneumonia 25.5%

Heart Failure 32.8%

Hip & Knee 13.4%

CMS Value-based Purchasing DemonstrationComposite Quality Score

CMS/Premier HQID Project Participants Composite Quality Score:

Trend of Quarterly Median (5th Decile) by Clinical Focus AreaOctober 1, 2003 - September 30, 2009 (Years 1, 2, 3, & 4 Final Data; Year 5 & 6 Preliminary Data)

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Heart Attack Heart BypassSurgery

Pneumonia Heart Failure Hip and Knee SCIP Stroke

Clinical Focus Area

4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07

1Q08 2Q08 3Q08 4Q08 1Q09 2q09 3q09

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More Patients are Reliably Receiving Evidenced-based Care

Evidence-based Care ImprovementsAvg. improvement from

4Q03 to 3Q09 in all clinical areas(24 quarters)

55.7%

Clinical Area

Improvement(percentage points)

Heart Attack 26.0%

Heart Bypass

59.4%

Pneumonia 68.1%

Heart Failure

58.1%

Hip & Knee 66.7%

Ap

pro

pria

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are

Sco

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CMS/Premier HQID Project Participants Appropriate Care Score: Trend of Quarterly Median (5th Decile) by Clinical Focus Area

October 1, 2003 - June 30, 2009 (Year 1, 2, 3, and 4 Final Data; Year 5 and 6 Preliminary)

0%

10%

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100%

Heart Attack Heart BypassSurgery

Pneumonia Heart Failure Hip and Knee SCIP Stroke

Clinical Focus Area4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07

1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09

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Improvement Across All VBP demo Participants

Heart Failure CMS HQID Quality Score Threshold Changes by Year

Pneumonia CMS Quality Score Threshold Changes by Year

CABG CMS Quality Score Threshold Changes by Year

• Quality improvement across all hospitals • Variation in hospital performance decreased

Heart Failure Composite Quality Score Decile Threshold ChangeCMS/Premier Hospital Quality Demonstration Project

October 1, 2003 - September 30, 2009Year 1, 2, 3, and 4 Final Data; Year 5 and 6 Preliminary Results

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10%

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70%

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110%

Year 1 (N=259) Year 2 (N=250) Year 3 (N=241) Year 4 (N=224) Year 5 Prelim (N=221) Year 6 Prelim (N=214)

Project Year

Decil

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hre

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Pneumonia Composite Quality Score Decile Threshold ChangeCMS/Premier Hospital Quality Demonstration Project


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Coronary Artery Bypass Graft Composite Quality Score Decile Threshold ChangeCMS/Premier Hospital Quality Demonstration Project


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1st1st 1st

65%

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105%


Project Year

Decil

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5

Improvement and Savings Over Three Years

Avg. cost improvement per patient across all clinical areas

$1,063

If all hospitals in the nation were to achieve this improvement, the estimated cost savings would be greater than $4.5 billion annually with estimated 70,000 lives saved per year

Avg. improvement in mortality across four clinical areas

1.87%

Clinical Area Improvement

Heart Attack $1,599

Heart Bypass Surgery

$1,579

Pneumonia $811

Heart Failure $1,181

Hip Replacement $744

Knee Replacement $463

Clinical Area Starting Score

Ending Score

Improve-ment

Heart Attack 8.86% 6.59% 2.27%

Heart Bypass Surgery

2.51% 1.55% 0.95%

Pneumonia 9.28% 6.89% 2.39%

Heart Failure 4.84% 2.99% 1.86%

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Relationship between hospital type and performance

• No relationship between hospital performance and urban/rural or bed size status

• Relationship between safety-net status and performance: – Safety net hospitals (11.75% DSH) initially started out with lower

quality scores as a group. – While safety-net hospitals improved performance, as a group, they

tended to cluster below the median. – However, safety-net hospital were equally represented in the top

20% by the third year. – Therefore, we found no statistically significant disparity for top

performance in the third year for safety-net hospitals.

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Widely Accepted Clinical Indicators Used in CMS VBP demonstration(Measures added for Years 4&5 = Red text)Outcomes measures (7) = Bold italicized textComposite score an average of all measures for each condition

Acute myocardial infarction (AMI)1. Aspirin at arrival2. Aspirin prescribed at discharge3. ACEI/ARB for LVSD4. Smoking cessation advice/counseling5. Beta blocker prescribed at discharge6. Beta blocker at arrival7. Thrombolytic received within 30 minutes of hospital arrival8. PCI received within 90 minutes of hospital arrival9. Inpatient mortality rate

Coronary artery bypass graft (CABG)10. Aspirin prescribed at discharge11. CABG using internal mammary artery (Test)12. Prophylactic antibiotic received within one hour prior to surgical incision13. Prophylactic antibiotic selection for surgical patients14. Prophylactic antibiotics discontinued within 24/48 hours after surgery end15. Patients with controlled 6 A.M. Postoperative Blood Glucose16. Inpatient mortality rate17. Post operative hemorrhage or hematoma18. Post operative physiologic and metabolic derangement

Hip and knee replacement19. Prophylactic antibiotic received within one hour prior to surgical incision20. Prophylactic antibiotic selection for surgical patients21. Prophylactic antibiotics discontinued within 24 hours after surgery end time22. Post operative hemorrhage or hematoma23. Post operative physiologic and metabolic derangement6. Readmission within 30 days to any acute care facility7. Surgery patients with recommended VTE prophylaxis ordered 8. Surgery patients who received appropriate VTE prophylaxis within 24 hours

prior to surgery up to 24 hours after surgery end time

Heart failure (HF)1. Left Ventricular Systolic (LVS) assessment2. Detailed discharge instructions3. ACEI or ARB for LVSD4. Smoking cessation advice/counseling

Pneumonia (PN)5. Percentage of patients who received an oxygenation assessment within 24 hours prior to

or after hospital arrival6. Initial antibiotic selection for Community Acquired Pneumonia7. Blood culture collected prior to first antibiotic administration8. Influenza screening/vaccination9. Pneumococcal screening/vaccination10. Antibiotic timing, percentage of pneumonia patients who received first dose of antibiotics

within four/six hours after hospital arrival11. Smoking cessation advice/counseling

Surgical Care Improvement Project (SCIP) (year 5 & 6)12. Prophylactic antibiotic received within 1 hour prior to surgical incision13. Prophylactic antibiotic selection for surgical patients 14. Prophylactic antibiotics discontinued within 24 hours after surgery end15. Patients with controlled 6 A.M. Postoperative Blood Glucose16. Surgical Patients with Hair Removal17. Colorectal Surgery Patients with Normothermia18. Surgery patients with recommended VTE prophylaxis ordered 19. Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to

surgery up to 24 hours after surgery end time 20. Surgery patients on Beta-Blocker Therapy who Receive Beta-Blocker during Perioperative

Period

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A composite of 19 measures shared in common between HQID and Hospital Compare shows P4P hospitals performing above the nation as a whole

In Broader Comparison, Hospitals in VBP Demonstration Excel

National Leaders in Quality Performance

• VBP demonstration participants avg. 6.5% higher than Non-Participants in first

3 ½ years of demo

• Avg. improvement for HQID participants = 7.8%

• Avg. improvement for Non-participants = 5.6%

New England Journal of Medicine publication by

Lindenauer et al. (February 2007) found that hospitals engaged in P4P achieved quality scores 2.6 to 4.1 percentage points above

other hospitals due solely to the impact of P4P incentives.

HQID hospitals have higher quality ratings* than national hospitals overall *CMS process score

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Example: Reliable Care Improves Readmissions, Mortality, Cost and Length of Stay Outcomes

11.0%

6.2%

1.6%

0.0%

5.0%

10.0%

15.0%

Low - 0% -49%

Medium -50% - 74%

High - 75% -100%

Mortality rate of heart bypass surgery patients (%)

Patient Process Measure

Mor

talit

y R

ate

Data show lower mortality rates for heart bypass surgery patients receiving better care

11.3%

6.5%

3.9%

0.0%

5.0%

10.0%

15.0%

Low - 0% -49%

Medium -50% - 74%

High - 75% -100%

Heart bypass surgery patients with complications(%)


Com

plic

atio

ns

Data indicate fewer complications are associated with better care

15.7%

12.4% 12.6%

0.0%

5.0%

10.0%

15.0%

20.0%

Low - 0% -49%

Medium -50% - 74%

High - 75% -100%

Mortality rate of heart bypass surgery patients (%)


Pat

ient

Rea

dmis

sion

s (%

)

Data indicate fewer readmissions are associated with better care

11.2%9.7%

13.5%

0.0%

5.0%

10.0%

15.0%

Low - 0% -49%

Medium -50% - 74%

High - 75% -100%


Ave

rage

LO

S (

days

)

Data show fewer hospital days associated with patients receiving better care

Average LOS for heart bypass surgery patients

0 hospital quality incentive demonstration (hqid) key facts three year demo (2003-2006); extended...

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