Hospital report cards for hospital-acquired pressure ulcers: how good are the grades?

Abstract

Background: Value-based purchasing programs use administrative data to compare hospitals by rates of hospital-acquired pressure ulcers (HAPUs) for public reporting and financial penalties. However, validation of these data is lacking.

Objective: To assess the validity of the administrative data used to generate HAPU rates by comparing the rates generated from these data with those generated from surveillance data.

Design: Retrospective analysis of 2 million all-payer administrative records from 448 California hospitals and quarterly hospitalwide surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes (as publicly reported on the CalHospitalCompare Web site).

Setting: 196 acute care hospitals with at least 6 months of available administrative and surveillance data.

Patients: Nonobstetric adults discharged in 2009.

Measurements: Hospital-specific HAPU rates were computed as the percentage of discharged adults (from administrative data) or examined adults (from surveillance data) with at least 1 stage II or greater HAPU (HAPU2+). Categorization of hospital performance based on administrative data was compared with the grade assigned when surveillance data were used.

Results: When administrative data were used, the mean hospital-specific HAPU2+ rate was 0.15% (95% CI, 0.13% to 0.17%); when surveillance data were used, the rate was 2.0% (CI, 1.8% to 2.2%). Among the 49 hospitals with HAPU2+ rates in the highest (worst) quartile from administrative data, use of the surveillance data set resulted in performance grades of "superior" for 3 of these hospitals, "above average" for 14, "average" for 15, and "below average" for 17.

Limitation: Data are from 1 state and 1 year.

Conclusion: Hospital performance scores generated from HAPU2+ rates varied considerably according to whether administrative or surveillance data were used, suggesting that administrative data may not be appropriate for comparing hospitals.

Primary funding source: Agency for Healthcare Research and Quality.

Figure 1

Study Flow Diagram

Figure 2

Hospital rates of hospital-acquired pressure ulcers (stages II and above), by administrative data and surveillance data CHART: California Hospital Assessment and Reporting Taskforce

Figure 3

Relative performance of hospitals according to administrative data (top) and surveillance data (bottom) (Top) Hospitals were ranked by their administrative HAPU2+ rates and divided into 4 performance quartiles, ranging from quartile 1 (lower rates, “best performers”) to quartile 4 (highest rates, “worst performers”). Black bars highlight the 49 “worst performer” hospitals in quartile 4. (Bottom) The grades assigned by the surveillance dataset to the same 49 “worst performer” hospitals by administrative data are shown by black bars again. These “worst performer” hospitals by administrative data rates were assigned grades over the entire performance spectrum, including several in the “Superior” and “Above Average” categories. Only 17 (35%) of 49 hospitals in the worst quartile by administrative data were graded as “Below Average” by surveillance data. Note that 5 hospitals did not receive a performance grade by the surveillance method because they had insufficient data. These 5 hospitals are excluded from the bottom graph. The surveillance rates may decrease from left to right as a result of the grading method, as explained in Appendix Table 6 and Appendix Figure. *1 hospital was identified as being among the worst quartile by administrative data but had a zero rate by surveillance data.