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Original Research |

Hospital Report Cards for Hospital-Acquired Pressure Ulcers: How Good Are the Grades?

Jennifer A. Meddings, MD, MSc; Heidi Reichert, MA; Tim Hofer, MD, MSc; and Laurence F. McMahon Jr., MD, MPH
[+] Article, Author, and Disclosure Information

From University of Michigan Medical School, University of Michigan School of Public Health, and Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan.

Presented in part at the Society of General Internal Medicine 35th Annual Meeting, Orlando, Florida, 9–12 May 2012, and by poster presentation at the AcademyHealth 2012 Annual Research Meeting, Orlando, Florida, 24–26 June 2012.

Note: The pressure ulcer surveillance data reported on the CalHospitalCompare Web site were obtained by application, permission, and data use agreement from the executive committee of CHART.

Acknowledgment: The authors thank Andrew Hickner, MSI, for providing assistance with references and manuscript editing; Gwendolyn Blackford, BS, RHIA, for providing insight about processes used and regulations followed by hospital coders while assigning diagnosis codes; Susan Barbour, RN, MS, FNP, CWON, for providing insight into the California hospital pressure ulcer surveillance data collection process; and Nancy Stotts, RN, EdD, FAAN, for responding to several inquiries and providing references about the CALNOC data collection process for HAPUs.

Financial Support: By grant 1K08-HS019767-01 from the Agency for Healthcare Research and Quality to Dr. Meddings. The authors were also supported by award 1R01-0HS018344-01A1 to Dr. McMahon. Dr. Meddings is a recipient of the National Institutes of Health Clinical Loan Repayment Program for 2009 to 2013.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0482.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Meddings (e-mail, meddings@umich.edu). Data set: The data from the State Inpatient Databases used for this study are available by application, purchase, and data use agreement from the Healthcare Cost and Utilization Project (www.hcup-us.ahrq.gov/databases.jsp).

Corresponding Author: Jennifer A. Meddings, MD, MSc, Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800; e-mail, meddings@umich.edu.

Current Author Addresses: Dr. Meddings: Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, 2800 Plymouth Road, Building 16, Room 427W, Ann Arbor, MI 48109-2800.

Ms. Reichert: Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, 2800 Huron Parkway, NCRC Room 474C, Ann Arbor, MI 48109-2800.

Dr. Hofer: HSR&D Field Program, Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, 2800 Plymouth Road, Ann Arbor, MI 48113.

Dr. McMahon: University of Michigan Medical Center, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.

Author Contributions: Conception and design: J.A. Meddings, T. Hofer, L.F. McMahon.

Analysis and interpretation of the data: J.A. Meddings, H. Reichert, T. Hofer, L.F. McMahon.

Drafting of the article: J.A. Meddings, H. Reichert, T. Hofer.

Critical revision of the article for important intellectual content: J.A. Meddings, T. Hofer, L.F. McMahon.

Final approval of the article: J.A. Meddings, T. Hofer, L.F. McMahon.

Statistical expertise: H. Reichert, T. Hofer.

Obtaining of funding: J.A. Meddings, T. Hofer, L.F. McMahon.

Administrative, technical, or logistic support: J.A. Meddings, L.F. McMahon.

Collection and assembly of data: J.A. Meddings, H. Reichert.

Ann Intern Med. 2013;159(8): 505-513. doi:10.7326/0003-4819-159-8-201310150-00003
Text Size: A A A

Chinese translation

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.


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Appendix Figure.

The CHART grading method.

Area of detail for Figure 3. To assign a performance grade, CHART compares a hospital's lower and upper confidence limits for the pressure ulcer prevalence rate with percentile cutoffs (see Appendix Table 6). This makes it possible for hospitals with higher point estimates for their pressure ulcer prevalence rate (i.e., hospitals immediately to the left of the green line) to receive better grades than peer hospitals with lower point estimates (i.e., hospitals immediately to the right of the green line). CHART = California Hospital Assessment and Reporting Taskforce; HAPU2+ = stage II or greater hospital-acquired pressure ulcer.

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Figure 2.

HAPU2+ rates, by administrative data (top) and surveillance data (bottom).

Ten hospitals in the administrative data set reported zero cases, and 23 hospitals in the surveillance data set reported zero cases. CHART = California Hospital Assessment and Reporting Taskforce; HAPU2+ = stage II or greater hospital-acquired pressure ulcer.

* Denotes hospital that had fewer than 30 cases or was otherwise deemed by CHART as having too few cases to assign a grade.

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Figure 3.

Relative performance of hospitals according to administrative data (top) and surveillance data (bottom).

In the top graph, hospitals were ranked by their administrative HAPU2+ rates and divided into 4 performance quartiles, ranging from quartile 1 (lowest rates, best performers) to quartile 4 (highest rates, worst performers). Dark-green bars highlight the 49 worst-performing hospitals in quartile 4. In the bottom graph, the hospital performance grades were assigned by CHART using an algorithm involving rates and CIs. Because of the grading method used, surveillance rates may decrease from left to right. Further details on the CHART grading method can be found in Appendix Table 6 and the Appendix Figure. The hospital rates and performance scores are reported here without modification in ranking or scoring method from what is publicly reported on the CalHospitalCompare Web site. The 49 worst-performing hospitals by administrative data shown by dark-green bars in the top graph are the same hospitals identified by dark-green bars in the bottom graph. These worst-performing 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. Of note, 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. CHART = California Hospital Assessment and Reporting Taskforce; HAPU2+ = stage II or greater hospital-acquired pressure ulcer. * One hospital was identified as being in the worst quartile when administrative data were used but had a zero rate when surveillance data were used.

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Submit a Comment/Letter
The Fallacy of Hospital-Acquired Pressure Ulcers
Posted on October 28, 2013
Scott Bolhack
TLC HealthCare Quality Improvement Organization, Inc.
Conflict of Interest: None Declared
The medical issues with pressure ulcers in our institutionalized settings are not readily resolvable by financial penalties established by CMS. The variance between administrative versus surveillance data is only the surface of a much wider problem as noted in the editorial by Pieper and Kirsner. The patient that spends only 3-4 days on average in the hospital is not there long enough for clinicians, hospitals, or regulatory agents to see the consequences of the lack of pressure prevention, even if we knew how to categorize or measure pressure injuries. A penalty for severe skin injuries that will not manifest themselves in patients with such short lengths of stay in the hospital seems counter intuitive and illogical. A deep tissue injury incurred in the hospital may not manifest clinically for days to weeks when the patient is already in another facility or at home. In these cases, the blame and economic cost is aimed at the facilities and employees of the wrong place. Not only does the penalty never reach the intended party; the economic and legal burden falls to the wrong entity. A new approach to this issue will be needed that extends beyond the ‘penalty’ initiative by CMS. A new approach could include the Everyone-At-Risk approach where any patient admitted to the hospital is considered at risk for skin pressure issues unless they can demonstrate otherwise. This will allow for a bundling of prevention practices on all admissions to the hospital without regard to their individual risk assessment. A penalty could be given to hospitals that do not adopt this approach rather than relying on the receipt of data points never recorded or measured. We all put on our seat belts when we drive our cars regardless of whether we expect to get into an accident. Its difficult to think that a patient who requires hospitalization in the first place would not be at risk to begin with.

1. Meddings JA, Reichert H, Hofer T, McMahon LF. Hospital report cards for hospital-acquired pressure ulcers: how good are the grades? Ann Intern Med. 2013; 159:505-513.
2. Pieper B, Kirsner RS. Pressure ulcers: even the grading of facilities fails. Ann Intern Med. 2013; 159:571-572.
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