Inpatient Quality Indicator Rates in Select Veteran Populations

Borzecki AM, Loveland S, Chew PW, Loya PM, Rosen AK. Inpatient Quality Indicator Rates in Select Veteran Populations. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL.

Related HSR&D Project(s)

• SDP 06-005 – Translating the AHRQ Quality Indicators to VA

Research Objectives Select patient populations with chronic conditions, such as serious mental illness (SMI) or spinal cord injuries (SCI), may be at high risk of adverse healthcare outcomes. Because of this concern, the Veterans Health Administration (VA) has implemented several initiatives to improve care of these patients. These include: establishing registries to identify and track special patient groups, establishment of condition-specific research centers under the Quality Enhancement and Research Initiative (QUERI), and separate tracking of a limited number of national performance measures in chronic disease populations. However, additional quality measures such as AHRQ's Inpatient Quality Indicators (IQIs), which are easily generated from administrative data, may be useful to provide a more comprehensive picture of care received by such patients and identify populations at particularly high risk of poor outcomes. The IQIs screen for potential inpatient quality problems by measuring: a)mortality rates from specific procedures and conditions where high mortality may be associated with poorer care, and b)utilization rates of procedures where concerns exist about over-/under-, or misuse. As part of a larger IQI study, we identified high-priority special populations and determined their IQI rates. Study Design We convened a panel of key VA stakeholders who helped prioritize both IQIs and special populations for further study. We then derived risk-adjusted rates (adjusted for age, gender, comorbidities and illness severity using APR-DRGs) for selected populations: diabetes, SMI, spinal cord injured (SCI), HIV, and stroke patients, using FY2004-2007 VA inpatient files and the AHRQ IQI software (v3.1). Rates were compared to the remaining VA population. Study Population All FY04-07 admissions of veterans with diagnoses of diabetes, SMI, SCI, HIV, or stroke. Principal Findings Of 2.3 million admissions, the subpopulation breakdown was as follows: diabetes 34%, SMI 13%, SCI 2%, HIV 1%, and stroke 6%. Diabetes and stroke patients were older than the remaining VA population (65.5+/-11.6 and 69.0+/-11.5 vs 61.7+/-14.3 years; p < 0.05); SMI, SCI and HIV subjects were younger (respective mean ages 57.5+/-13.8, 59.3+/-12.9, 51.4+/-8.8; p < 0.05). SMI patients had higher mortality rates from several medical conditions, including acute myocardial infarction (AMI), heart failure, stroke, and pneumonia than the non-SMI population (e.g., for AMI, risk-adjusted rates were 9.7+/-2.4 vs 7.4+/-2.8, per 100 AMI admissions; p < 0.05). There was a trend toward higher mortality for SCI subjects across the same conditions but differences weren't significant presumably due to low numbers. No consistent trends were seen among the other cohorts, or with respect to procedure-related mortality or utilization indicators. Conclusions SMI patients are at higher mortality risk from various medical conditions compared to the general VA population. This increased vulnerability may be due to numerous factors, such as delayed admission or inattention to medical problems. Implications for Policy, Practice or Delivery Further research is needed to understand reasons for the higher mortality risk in SMI patients, determine whether similar trends exist outside the VA, and develop quality improvement initiatives that will decrease the mortality risk of these patients. The IQIs appear useful in the VA for tracking and monitoring quality of care problems that occur in the inpatient setting, and for highlighting subpopulations that may be at increased risk of adverse outcomes.