COLORADO HOSPITAL REPORT CARD

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Implementation Plan of House Bill 06-1278

Prepared by Colorado Hospital Association Hospital Report Card Implementation Committee May 15, 2007

TABLE OF CONTENTS COLORADO HOSPITAL REPORT CARD I. II. III. A. B. C. D. E. F. IV. A. B. V. VI. VII. A. B. VIII. A. B. C. D. IX. X. XI. XII. A. B. C. D. E. F. Preamble.............................................................................................................................3 Purpose of the Plan ..........................................................................................................3 Structure............................................................................................................................ 4 Colorado Department of Public Health and Environment (CDPHE)............................ 4 Colorado Hospital Association (CHA) ..............................................................................5 Hospital Report Card Implementation Committee .........................................................5 Performance & Quality Coalition .....................................................................................6 Communications Work Group......................................................................................... 6 Focus Groups and Consumers ......................................................................................... 6 Process for Selection of Measures ................................................................................ 7 Process for Submission of New Measures ...................................................................... 8 Process for Inclusion of New Measures...........................................................................9 Process for Data Analysis ............................................................................................... 9 Process for Annual Release of Data.............................................................................. 9 Phase I (2007) .................................................................................................................10 Implementation Timelines ..............................................................................................10 Phase I Measures............................................................................................................... 11 Phase II..............................................................................................................................13 Balanced Scorecard Approach ..........................................................................................13 Efficiency of Care.............................................................................................................. 14 Hospital-Acquired Infection Measures ............................................................................15 Pediatric Measures ............................................................................................................15 Annual Evaluation of Effectiveness .............................................................................16 Barriers to Implementation ..........................................................................................16 Continuous Efforts to Improve Care ........................................................................... 17 Appendix .......................................................................................................................... 18 Measure Definitions (reported by county) ...................................................................... 18 Measure Definitions (reported by individual hospitals) ............................................... 24 Hospital Report Card Implementation Committee (current as of 5.15.07)....................31 Performance & Quality Coalition (current as of 5.15.07)................................................33 List of Common Acronyms............................................................................................. 34 Relevant Links for Inclusion on Report Card Website...................................................35

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I.

Preamble The Colorado Hospital Report Card has the primary purpose of ensuring that statewide hospital data and clinical outcomes are made available to the general public in a clear and usable manner. The public disclosure of this data will be made available on an internet website in a manner that not only allows consumers to conduct an interactive search to compare information from specific hospitals, but will also provide appropriate guidance on how to use and understand the data. The Colorado Hospital Report Card will utilize standardized quality and clinical outcome measures that are endorsed by national organizations, with established standards to measure the performance of healthcare providers and hospitals.

II.

Purpose of the Plan A key objective of the Colorado Hospital Report Card is to uphold a statewide commitment to hospital quality improvement, accountability and transparency. The purpose of this implementation plan is to provide a framework for the execution of House Bill 06-1278, created in a collaborative process that includes the participation of the Colorado Department of Public Health and Environment, Colorado Hospitals, consumers and other stakeholder organizations. This framework is inclusive of key elements such as a participation structure, flow of responsibility, distinct processes for selection of measures, data analysis and data release, proposed content for the two phases defined in the implementation plan and a plan for annual review of effectiveness. Although the long term goal of the report card is for it to be inclusive of measures that are applicable to all demographics and diverse communities, there are some measures that may not be appropriate to use for direct comparison of some hospitals given the nature of the patient population, size of hospital or frequency and number of procedures. Appropriate consideration for applicable measures will be given to all types of

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hospitals throughout the state to ensure a process of accountability for hospital practices and development of quality improvement initiatives for best delivery of healthcare in Colorado.

III.

Structure The organizational chart and accompanying description of each party defines the flow of responsibility for the implementation plan of the Colorado Hospital Report Card.

Colorado Department of Public Health and Environment Colorado Hospital Association Performance & Quality Coalition Hospital Report Card Implementation Committee Focus Groups and Consumers

Communications Work Group

A. Colorado Department of Public Health and Environment (CDPHE) The Colorado Department of Public Health and Environment (CDPHE) has a key responsibility to monitor the development and implementation of the Colorado Hospital Report Card. A CDPHE employee is represented on both the Performance & Quality Coalition and Hospital Report Card Implementation Committee. CDPHE and the Colorado Hospital Association will collaborate on all major processes of the Colorado Hospital Report Card
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including approving a framework, executing the implementation plan, monitoring progress and the development of future work.

B. Colorado Hospital Association (CHA) The Colorado Hospital Association (CHA) has the responsibility of ensuring that the final plan submitted to CDPHE on or before April 15, 2007 meets all of the required elements as stipulated by House Bill 06-1278. CHA also is responsible for ensuring that the final plan is implemented as proposed by this document.

C. Hospital Report Card Implementation Committee The Hospital Report Card Implementation Committee is responsible for identifying and recommending the primary elements of the Colorado Hospital Report Card, as well as evaluating the overall effectiveness of the report card and implementation plan on an ongoing basis. The consideration of measures for the report card will rely on a process using a defined set of criteria outlined in section I.V. to select measures for inclusion in the implementation plan as well as for future iterations of the Colorado Hospital Report Card. The Hospital Report Card Implementation Committee is also responsible for ensuring that the selection of measures, data analysis and data release meets the defined processes as outlined in this implementation plan. The Hospital Report Card Implementation Committee is composed of a broad membership from the healthcare community including representatives of hospitals, quality improvement organizations, CDPHE, payers, purchasers and the business community (see appendix C).

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D. Performance & Quality Coalition The Performance & Quality Coalition is responsible for facilitating the development and long term progress of the Colorado Hospital Report Card by acting in an advisory capacity to the Hospital Report Card Implementation Committee. The Performance & Quality Coalition is composed of a broad membership from the healthcare community including representatives of hospitals, quality improvement organizations, CDPHE, payers, purchasers and the business community (see appendix D).

E. Communications Work Group The Communications Work Group is responsible for ensuring that the Colorado Hospital Report Card is released to targeted audiences. The Communications Work Group will facilitate the ongoing release of new data to hospitals and consumer groups and serve as the point of contact for any media inquiries that pertain to the Colorado Hospital Report Card. This work group will ensure that the general public and other audiences have knowledge of comparative hospital quality information and that this information is in a functional format such that it is understandable and usable.

F. Focus Groups and Consumers Various focus groups will be organized by the CHA Communications Director in coordination with CDPHE and the Communications Work Group to solicit feedback on the website design and overall usability of the Colorado Hospital Report Card. Focus groups will be surveyed prior to the first official data release as well as on a continued basis to evaluate the ongoing effectiveness of the report card. Current suggested focus groups include: consumers, hospitals, physicians, purchasers and media. Particular focus will be placed

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on surveying consumers as they are the targeted population for the utilization of the report card.

IV.

Process for Selection of Measures The consideration and selection of measures for inclusion in the Colorado Hospital Report Card will be defined by a rigorous process to ensure consistency and continued applicability. The consideration and selection of new or modified measures will be an ongoing process. The flow of consideration and subsequent approval for new or modified measures is defined below:

Colorado Department of Public Health and Environment Final approval authority of new or modified measures Colorado Hospital Association Board Endorses measure selection for presentation to CDPHE Performance & Quality Coalition Acts in an advisory capacity for selection of new measures Hospital Report Card Implementation Committee Recommends measures based on defined criteria

As a general rule, only measures that have met certain criteria will be considered for inclusion in the Colorado Hospital Report Card. This criteria has been defined by quality improvement experts and other related professionals to ensure that the Colorado Hospital Report Card meets the objectives and goals set forth by the implementation plan.

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The defined criteria established by the Hospital Report Card Implementation Committee include: • • • • • • The collection of data and definition of measures must be consistent and unambiguous across all Colorado hospitals. The measures and accompanying definition must be understandable and usable to the public. The measures must be reliable (consistent) and valid (precise, logical). The measures must have statistical significance when used for comparison of hospitals. The measures must be actionable by hospitals and/or medical staff. The measures must be endorsed by quality standard groups (e.g. National Quality Forum, National Association of Children’s Hospitals and Related Institutions). • The measures must be applicable to current public health and healthcare goals for quality improvement.

All parties defined in the flow chart have a responsibility of ensuring that both the selection criteria and current designated measures meet the changing needs of consumers and are applicable to the current needs and concerns of public health.

A. Process for Submission of New Measures Interested parties will have an opportunity to propose measures for possible inclusion in the Colorado Hospital Report Card. Requests for consideration may be submitted to the Hospital Report Card Implementation Committee provided that they are inclusive of a brief explanation of the proposed measure and a short justification for the purpose and need of such an inclusion. A list

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of all proposed measures will be maintained and included in an annual report to CDPHE.

B. Process for Inclusion of New Measures New measures will be considered for inclusion in the Colorado Hospital Report Card by the Hospital Report Card Implementation Committee on an ongoing basis. The Hospital Report Card Implementation Committee will evaluate proposed measures based on the criteria outlined in section I.V. The Implementation Committee will also utilize the recommendations of quality improvement experts and other stakeholder entities. Recommendations for new or modified measures will be shared with the Performance & Quality Coalition for review and comment. Selected measures by the Hospital Report Card Implementation Committee will then be presented to the CHA Board for review and endorsement. The final approval authority of new or modified measures rests with CDPHE.

V.

Process for Data Analysis Data that specifically pertains to measures selected for inclusion in the Colorado Hospital Report Card will be collected from all Colorado hospitals on an annual basis. Data from the most recent three year period will be collected and analyzed by CHA. The integrity of the data will be evaluated prior to the official release on the public website. Statewide or other geographic trends will also be evaluated as part of the data analysis. Valid trends that are identified will be shared with hospitals in an effort to facilitate improvement in specific areas of healthcare.

VI.

Process for Annual Release of Data The annual release of data to the general public will be facilitated by the CHA Communications Director and Communications Work Group. It is essential that

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the process of releasing annual data is such that it ensures that this information is easily accessible, readily available and widely publicized. The release of annual data to all Colorado hospitals will occur prior to the official release of data and results to the public as stipulated by House Bill 06-1278. This data will be given to all Colorado hospitals one month prior to the public release to provide an opportunity for thorough review and comment from all hospitals.

VII.

Phase I (2007) A. Implementation Timelines • April 15, 2007 Submit a plan to the executive director of CDPHE and report on the status of implementation of House Bill 06-1278. • May 1, 2007 Begin the detailed development of the website. Initiate the communications plan. • May 15, 2007 Submit a final plan and report on the status of implementation to the Governor, the President of the Senate and the Speaker of the House of Representatives. Provide copies of the implementation plan to all members of the general assembly and made the plan available to the public on an internet website. • • June 2007 – September 2007 Engage focus groups and stakeholders. September 15, 2007 Make the Colorado Hospital Report Card available to every hospital in the state to ensure that each hospital has the opportunity to evaluate the data and submit comments.

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October 15, 2007 Submit the Colorado Hospital Report Card plan to the executive director of CDPHE for approval of the public disclosure of data.

November 30, 2007 Publish the Colorado Hospital Report Card to the general public as stipulated by House Bill 06-1278.

B. Phase I Measures Data that will be used in the Colorado Hospital Report Card is collected and compiled by the Colorado Hospital Association on an ongoing basis from all acute care hospitals in Colorado. Phase I of the Hospital Report Card will be inclusive of data from 2004, 2005 and 2006.

1. Agency for Healthcare Research and Quality (AHRQ) Risk-Adjusted Mortality Rate Quality Measures a. Condition Measures • • • • • • • • • • • Acute Myocardial Infarction (AMI) Congestive Heart Failure (CHF) Gastrointestinal Hemorrhage (GI bleed) Hip Fracture Pneumonia Stroke

b. Procedure Measures Carotid Endarterectomy (CEA) Coronary Artery Bypass Graft (CABG) Craniotomy Hip Replacement Percutaneous Transluminal Coronary Angioplasty (PTCA)
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2. AHRQ Volume Measures • • • • Abdominal Aortic Aneurysm Repair (AAA) Carotid Endarterectomy (CEA) Coronary Artery Bypass Graft (CABG) Percutaneous Transluminal Coronary Angioplasty (PTCA)

3. AHRQ Prevention Quality Measures a. These prevention quality measures represent hospital admission rates (by patient’s county of residence) for the following ambulatory care-sensitive conditions: • • • • • • • • • • • • • • Amputations, lower extremity, diabetic patients Angina, without procedure Appendicitis, perforated Asthma, adult Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Dehydration Diabetes, long-term complications Diabetes, short-term complications Diabetes, uncontrolled Hypertension Low Birth Weight Pneumonia Urinary Tract Infections (UTI)

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4. Other Quality Measures a. AHRQ Patient Safety Measures • • • Decubitus Ulcer Rate Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) Rate, postoperative Sepsis Rate, postoperative

b. Hospital-Acquired Infection Measures c. Pediatric Measures

VIII. Phase II A. Balanced Scorecard Approach The long term goal for the Colorado Hospital Report Card is for it to be comprised of a comprehensive set of measures that address various aspects of quality improvement. The Hospital Report Card Implementation Committee has identified possible areas of focus for the next phase of the report card, however other areas that have not yet been identified in this implementation plan can be considered for inclusion in future iterations of the report card provided they meet the criteria outlined in section I.V. and speak to the balanced scorecard approach of this implementation plan.

1. Clinical Quality • • • • AHRQ Quality Measures AHRQ Prevention Measures

2. Patient Safety AHRQ Patient Safety Measures Hospital-Acquired Infection Measures (as reported by Colorado hospitals)

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3. Patient Satisfaction • U.S. Department of Health and Human Services (HHS) Hospital Consumer Assessment of Health Providers and Systems Survey (HCAHPS) Measures 4. Best Practices • • • Centers for Medicare & Medicaid Services (CMS) Core Measures / HHS Hospital Compare IHI 100,000 Lives Campaign IHI 5 Million Lives Campaign

5. Efficiency of Care

B. Efficiency of Care As it pertains to the Colorado Hospital Report Card, efficiency of care will be defined as a measure of quality of care in combination with healthcare resource use. Currently, measures that are used to evaluate efficiency rely on proxies for measuring efficiency and costs of care such as hospital charges and average length of stay. It has not been demonstrated that these proxies accurately reflect resource use, especially given the consideration of various confounders that may influence outcomes.

The Hospital Report Card Implementation Committee and CDPHE will evaluate emerging efficiency and cost measures as they are developed. Many organizations, including AHRQ, CHA and the Colorado Foundation for Medical Care (CFMC), are conducting research to examine potential cost measures including cost to charge ratios, hospital payment rates and hospital readmission rates. Validated efficiency and cost measures will be considered for inclusion in the Colorado Hospital Report Card as they are developed and may be included in future iterations of the report card provided that they meet

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the defined selection criteria set forth in section I.V. and have been endorsed by recognized quality standard groups as valid and reliable measures.

C. Hospital-Acquired Infection Measures Hospital-acquired infection rates are important measures for inclusion on the Colorado Hospital Report Card. Legislation was recently passed in Colorado that mandates reporting of hospital-acquired infections to the Centers for Disease Control and CDPHE. An infection advisory committee has been appointed and will meet on a regular basis to determine which infection rates will be reported for certain medical procedures. Although a separate report will be generated by the Health Facility-Acquired Infection Advisory Committee, it is the goal of the Colorado Hospital Report Card to have these infection measures included in the report card and disseminated in a manner that is meaningful to the public. Hospital-acquired infection measures will be included in future iterations of the report card as they become available through CDPHE.

D. Pediatric Measures Current pediatric quality measures, such as those published by AHRQ, have a significant risk of misinforming the public since these measures are mostly an assessment of rare events. The incidence rate of rare event measures have the potential to be aversely biased in institutions caring for high-risk individuals, which may result in unintentional misinformation to the general public about health quality measures in these specific hospitals.

The Hospital Report Card Implementation Committee and CDPHE will consider new pediatric quality measures as they are developed and validated. Pediatric quality measures that successfully detect bias and are designed to

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appropriately adjust risk will be considered for inclusion in the Colorado Hospital Report Card on an annual basis provided they meet the defined criteria set forth in section I.V. and are recognized by quality standard groups as valid and reliable measures.

IX.

Annual Evaluation of Effectiveness The Hospital Report Card Implementation Committee is responsible for the ongoing evaluation of the Colorado Hospital Report Card. This committee will establish a formal process for an annual review of the Colorado Hospital Report Card and implementation plan. The annual review will largely involve evaluating the ongoing effectiveness of the Colorado Hospital Report Card as well as the implementation plan to ensure that the established elements adequately address the long term goal of the report card. The assessment of the Colorado Hospital Report Card will involve the review of quality improvement measures and evaluation of the public website used for reporting the data. New measures will be considered and selected for inclusion to meet the changing needs of the consumers and current included measures will be reviewed to ensure their ongoing applicability. The website will also be assessed annually for consumer usability. Focus groups will be engaged on a regular basis to facilitate this process and provide outside perspective and opinion. Lastly, potential barriers for best implementation of the Colorado Hospital Report Card will be assessed regularly by the Implementation Committee. Annual reports will be submitted to CDPHE.

X.

Barriers to Implementation At the time of presentation of the implementation plan to the Governor, the President of the Senate and the Speaker of the House of Representatives, the Hospital Report Card Implementation Committee has not identified any barriers that may hinder the implementation of House Bill 06-1278.

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XI.

Continuous Efforts to Improve Care CDPHE and CHA are committed to the continuous improvement of healthcare quality and patient safety improvements. CDPHE and CHA will continue to collaborate with various outside entities to ensure that new quality improvement efforts and best practice opportunities are reviewed on an annual basis.

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XII.

Appendix A. Measure Definitions (reported by county) 1. Amputation Admission Rate, lower extremity, diabetic patients (AHRQ Prevention Quality Measure) • Description - Diabetes is a major risk factor for lower-extremity amputation, which can be caused by infection, neuropathy and microvascular disease. Rate Calculation - Calculated as number of admissions for lowerextremity amputation among patients with diabetes per 100,000 population. Justification - Proper and continued treatment and glucose control may reduce the incidence of lower-extremity amputation and lower rates represent better quality care.

2. Angina Admission Rate, without procedure (AHRQ Prevention Quality Measure) • Description - Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. This discomfort, known as angina, can feel like uncomfortable pressure, squeezing, fullness or pain. Both stable and unstable angina are symptoms of potential coronary artery disease. Effective management of coronary disease reduces the occurrence of major cardiac events such as heart attacks and may also reduce admission rates for angina. Rate Calculation - Calculated as number of admissions for angina without procedure per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for angina (without procedure) and lower rates represent better quality care.

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3. Appendicitis Admission Rate, perforated (AHRQ Prevention Quality Measure) • Description - Perforated appendix may occur when appropriate treatment for acute appendicitis is delayed for a number of reasons, including problems with access to care, failure by the patient to interpret symptoms as important, misdiagnosis and other delays in obtaining surgery. Rate Calculation - Calculated as the number of admissions for perforated appendix as a share of all admissions for appendicitis within an area. Justification - Timely diagnosis and treatment may reduce the incidence of perforated appendix and lower rates represent better quality care.

4. Asthma Admission Rate, adult (AHRQ Prevention Quality Measure) • Definition - Asthma is a disease that affects the lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness and nighttime or early morning coughing. Asthma is one of the most common reasons for hospital admission and emergency room care. Rate Calculation - Calculated as number of admissions for asthma in adults per 100,000 population. Justification - Proper outpatient treatment may reduce the incidence or exacerbation of asthma requiring hospitalization and lower rates represent better quality care.

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5. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate (AHRQ Prevention Quality Measure) • Definition - Chronic obstructive pulmonary disease (COPD) comprises three primary diseases that cause respiratory dysfunction - asthma, emphysema, and chronic bronchitis - each with distinct etiologies, treatments and outcomes. This measure examines emphysema and bronchitis only; asthma is discussed separately.

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Rate Calculation - Calculated as number of admissions for COPD per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for COPD and lower rates represent better quality care.

6. Congestive Heart Failure (CHF) Admission Rate (AHRQ Prevention Quality Measure) • Description - Congestive heart failure (CHF) can be controlled in an outpatient setting for the most part; however, the disease is a chronic progressive disorder for which some hospitalizations are appropriate. Rate Calculation - Calculated as number of admissions for CHF per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for CHF and lower rates represent better quality care.

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7. Dehydration Admission Rate (AHRQ Prevention Quality Measure) • Description - Dehydration is a serious acute condition that occurs in frail patients and patients with other underlying illnesses following insufficient attention and support for fluid intake. Rate Calculation - Calculated as number of admissions for dehydration per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for dehydration and lower rates represent better quality care.

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8. Diabetes Admission Rate, long-term complications (AHRQ Prevention Quality Measure) • Description - Long-term complications of diabetes mellitus include renal, eye, neurological and circulatory disorders. Long term complications occur at some time in the majority of patients with diabetes to some degree. Diabetes can be associated with serious complications and premature death.

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Rate Calculation - Calculated as number of admissions for diabetes (long term complications) per 100,000 population. Justification - Proper outpatient treatment and adherence to prescribed care may reduce the incidence of diabetic long term complications and lower rates represent better quality care.

9. Diabetes Admission Rate, short-term complications (AHRQ Prevention Quality Measure) • Description - Short term complications of diabetes mellitus include diabetic ketoacidosis, hyperosmolarity and coma. These lifethreatening emergencies arise when a patient experiences an excess of glucose (hyperglycemia) or insulin (hypoglycemia). Rate Calculation - Calculated as number of admissions for diabetes (short term complications) per 100,000 population. Justification - Proper outpatient treatment and adherence to prescribed care may reduce the incidence of diabetic short term complications and lower rates represent better quality care.

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10. Diabetes Admission Rate, uncontrolled (AHRQ Prevention Quality Measure) • Description - Uncontrolled diabetes should be used in conjunction with short term complications of diabetes, which include diabetic ketoacidosis, hyperosmolarity and coma. Rate Calculation - Calculated as number of admissions for uncontrolled diabetes per 100,000 population. Justification - Proper outpatient treatment and adherence to prescribed care may reduce the incidence of uncontrolled diabetes and lower rates represent better quality care.

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11. Hypertension Admission Rate (AHRQ Prevention Quality Measure) • Description - Hypertension is a chronic condition that is often controllable in an outpatient setting with appropriate use of drug therapy. Hypertension, also known as high blood pressure, is a
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medical condition in which there is narrowed room in the arteries, thereby causing difficulty in blood flow. The complications associated with hypertension increase the risk of heart attack, heart failure, stroke and kidney failure. • • Rate Calculation - Calculated as number of admissions for hypertension in adults per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for hypertension and lower rates represent better quality care.

12. Low Birth Weight Admission Rate (AHRQ Prevention Quality Measure) • Description - Low birth weight infants are classified as those infants born weighing 5 pounds, 8 ounces or less (under 2,500 grams). Low birth weight is a significant health problem, contributing to infant mortality and long term developmental problems. Rate Calculation - Calculated as the number of low birth weights as a share of all births in an area. Justification - Proper preventive care may reduce incidence of low birth weight and lower rates represent better quality care.

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13. Pneumonia Admission Rate, Bacterial (AHRQ Prevention Quality Measure) • Description - Bacterial pneumonia is a relatively common acute condition, treatable for the most part with antibiotics. If left untreated in susceptible individuals, such as the elderly, pneumonia can lead to death. Rate Calculation - Calculated as number of admissions for bacterial pneumonia per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for bacterial pneumonia in non-susceptible individuals and lower rates represent better quality care.

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14. Urinary Tract Infection (UTI) Admission Rate (AHRQ Prevention Quality Measure) • Description - Urinary tract infection is a common acute condition that can, for the most part, be treated with antibiotics in an outpatient setting. However, this condition can progress to more clinically significant infections, such as pyelonephritis, in vulnerable individuals with inadequate treatment. Rate Calculation - Calculated as number of admissions for urinary infection per 100,000 population. Justification - Proper outpatient treatment may reduce admissions for urinary infection and lower rates represent better quality care.

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B. Measure Definitions (reported by individual hospitals) 1. Abdominal Aortic Aneurysm Repair (AAA) (AHRQ Volume Measure) • Description - Abdominal aortic aneurysm (AAA) repair is a relatively rare procedure that requires proficiency with the use of complex equipment; technical errors may lead to clinically significant complications, such as arrhythmias, acute myocardial infarction, colonic ischemia and death. Volume Calculation - Raw volume of provider-level AAA repair. Justification - Higher volumes have been associated with better outcomes which represent better quality.

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2. Acute Myocardial Infarction (AMI) (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • Description - An acute myocardial infarction (heart attack) can result when blood supply to the heart muscle is cut off. Cells in the heart muscle do not receive enough oxygen and begin to die. The more time that passes without treatment to restore blood flow, the greater the damage to the heart. Rate Calculation - Calculated as the number of deaths per 100 discharges for AMI. Justification - Timely and effective treatments for acute myocardial infarction (AMI), which are essential for patient survival, include appropriate use of thrombolytic therapy and revascularization.

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3. Carotid Endarterectomy (CEA) (AHRQ Risk-Adjusted Mortality Rate, Procedure Measure) • Definition - Carotid endarterectomy is a surgical procedure that removes fatty buildup of plaque from the carotid artery. This procedure has been widely used as a way to reduce stroke risk. Rate Calculation - Calculated as number of deaths per 100 CEAs

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Justification - Carotid endarterectomy (CEA) is a fairly common procedure that requires proficiency with the use of complex equipment; technical errors may lead to clinically significant complications, such as abrupt carotid occlusion with or without stroke, myocardial infarction and death.

4. Carotid Endarterectomy (CEA) (AHRQ Volume Measure) • • • Definition - See CEA Risk-Adjusted Mortality Rate, Procedure Measure Volume Calculation - Raw volume of provider-level CEA Justification - Higher volumes have been associated with better outcomes, which represent better quality.

5. Congestive Heart Failure (CHF) (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • Description - Congestive heart failure (CHF), or heart failure, is a condition in which the heart cannot pump enough blood to the body's other organs. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Swelling (edema) often results. Rate Calculation - Calculated as the number of deaths per 100 discharges for CHF. Justification - Congestive heart failure (CHF) is a progressive, chronic disease with substantial short term mortality, which varies from provider to provider.

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6. Coronary Artery Bypass Graft (CABG) (AHRQ Risk-Adjusted Mortality Rate, Procedure Measure) • Description - This procedure treats blocked heart arteries by creating new passages for blood to flow to your heart muscle. It works by taking arteries or veins from other parts of your body, called grafts, and using them to reroute the blood around the clogged artery. Rate Calculation - Calculated as number of deaths per 100 CABG procedures
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Justification - Coronary artery bypass graft (CABG) requires proficiency with the use of complex equipment; technical errors may lead to clinically significant complications, such as myocardial infarction, stroke and death.

7. Coronary Artery Bypass Graft (CABG) (AHRQ Volume Measure) • • • Definition - See CABG Risk-Adjusted Mortality Rate, Procedure Measure Volume Calculation - Raw volume of provider-level CABG. Justification - Higher volumes have been associated with better outcomes, which represent better quality.

8. Craniotomy Mortality (AHRQ Risk-Adjusted Mortality Rate, Procedure Measure) • Description - A craniotomy is an operation, or surgery, on the brain. The surgeon makes an opening in the skull so that a brain operation can be performed. A craniotomy may be done in any area of the skull and may be almost any size. Rate Calculation - Calculated as number of deaths per 100 craniotomies Justification - Craniotomy for the treatment of subarachnoid hemorrhage or cerebral aneurysm entails substantially high postoperative mortality rates.

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9. Decubitus Ulcer Rate (AHRQ Patient Safety Measure) • Description - A decubitus ulcer, also called a pressure ulcer, is an area of skin that breaks down when one position is held for too long without weight shiftment. This can occur in individuals that use wheelchairs or are bedridden, even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area and the affected tissue dies.

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Rate Calculation - Decubitus ulcer rate is calculated using cases of decubitus ulcer per 1,000 discharges with a length of stay of four or more days. Justification - A decubitus ulcer starts as reddened skin but can get progressively worse, forming a blister, then an open sore, and finally a crater. Damage can occur to tissues below the skin such as muscle, tendon, joint and bone.

10. Deep Vein Thrombosis (DVT) Rate, postoperative (AHRQ Patient Safety Measure) • Description - Deep vein thrombosis (DVT) refers to the formation of a thrombus (blood clot) within a deep vein, commonly in the thigh or calf. Rate Calculation - Deep vein thrombosis rate is calculated as cases of DVT per 1000 surgical discharges with an operating room procedure. Justification - If the thrombus partially or completely blocks the flow of blood through the vein, blood begins to pool and build-up below the site, likely causing chronic swelling and pain. A thrombus can also break free and travel through the veins reaching the lungs. Once in the lungs it is called a pulmonary embolism (PE), which is a potentially fatal condition that can kill within hours.

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11. Gastrointestinal Hemorrhage (GI bleed) (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • Description - Gastrointestinal bleeding refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the large bowel. The degree of bleeding can range from nearly undetectable to acute, massive and life-threatening. Rate Calculation - Calculated as the number of deaths per 100 discharges for GI hemorrhage. Justification - Gastrointestinal (GI) hemorrhage may lead to death when uncontrolled; the ability to manage severely ill patients with comorbidities may influence the mortality rate.

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12. Hip Fracture (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • • • Description - If more pressure is put on a bone than it can stand, it will split or break. A break of any size is called a fracture. Rate Calculation - Calculated as the number of deaths per 100 discharges for hip fracture. Justification - Hip fractures, which are a common cause of morbidity and functional decline among elderly persons, are associated with a significant increase in the subsequent risk of mortality.

13. Hip Replacement (AHRQ Risk-Adjusted Mortality Rate, Procedure Measure) • Description - Total hip arthroplasty (without hip fracture) is an elective procedure performed to improve function and relieve pain among patients with chronic osteoarthritis, rheumatoid arthritis, or other degenerative processes involving the hip joint. Rate Calculation - Calculated as number of deaths per 100 hip replacements. Justification - Better processes of care may reduce mortality for hip replacement, which represents better quality care.

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14. Percutaneous Transluminal Coronary Angioplasty (PTCA) (AHRQ Risk-Adjusted Mortality Rate, Procedure Measure) • Description - Percutaneous transluminal coronary angioplasty (PTCA) is performed on patients with coronary artery disease. PTCA involves threading a catheter (or balloon-tipped tube) from an artery in the groin to a trouble spot in an artery of the heart. The balloon is inflated so that the narrowed coronary artery can widen and allow blood to flow more easily. No ideal rate for PTCA has been established. Rate Calculation - Calculated as the number of deaths per 100 PTCAs

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Justification - Percutaneous transluminal coronary angioplasty (PTCA) is a relatively common procedure that requires proficiency with the use of complex equipment; technical errors may lead to clinically significant complications.

15. Percutaneous Transluminal Coronary Angioplasty (PTCA) (AHRQ Volume Measure) • • • Description - See PTCA Risk-Adjusted Mortality Rate, Procedure Measure Volume Calculation - Raw volume of PTCA. Justification - Higher volumes have been associated with better outcomes, which represent better quality.

16. Pneumonia (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • Description - Invasive disease caused by Streptococcus pneumoniae (pneumococcus) frequently manifests as bacteremia (bloodstream infections), pneumonia or meningitis. Antibiotic resistance has become an increasing problem among isolates of S. pneumoniae. Rate Calculation - Calculated as the number of deaths per 100 discharges for pneumonia. Justification - Treatment with appropriate antibiotics may reduce mortality from pneumonia, which is a leading cause of death in the United States.

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17. Pneumonia Infection Rate, ventilator-associated (IHI Measure) • Description - Ventilator-associated pneumonia (VAP) is defined as nosocomial pneumonia in a patient on mechanical ventilator support (by endotracheal tube or tracheostomy) for greater than or equal to 48 hours.

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18. Pulmonary Embolism (PE) Rate, postoperative (AHRQ Patient Safety Measure) • • • Definition - A pulmonary embolus (PE) is a blockage of an artery in the lungs caused by fat, air, clumped tumor cells or a blood clot. Rate Calculation - Pulmonary embolism rate is calculated as cases of PE per 1000 surgical discharges with an operating room procedure. Justification - Pulmonary embolus can cause severe injury or even death.

19. Sepsis Rate, postoperative (AHRQ Patient Safety Measure) • • Definition - Sepsis is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. Rate Calculation - Sepsis rate is calculated as cases of sepsis per 1000 elective surgery patients with an operating room procedure and a length of stay of four days or more. Justification - Sepsis is often life-threatening, especially in people with a weakened immune system or other medical illnesses.

20. Stroke (AHRQ Risk-Adjusted Mortality Rate, Condition Measure) • Description - A stroke can occur when the blood supply to part of the brain is blocked or when a blood vessel in the brain bursts, causing damage to a part of the brain. Rate Calculation - Calculated as the number of deaths per 100 discharges for stroke. Justification - Quality treatment for acute stroke must be timely and efficient to prevent potentially fatal brain tissue death, and patients may not present until after the fragile window of time has passed.

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C. Hospital Report Card Implementation Committee (current as of 5.15.07)

Donna Kusuda (chair) VP, Quality Improvement & Patient Safety HCA/HealthONE Scott Anderson Vice President of Professional Activities Colorado Hospital Association Crystal Berumen Project Director, Patient Safety Initiatives Colorado Hospital Association Lisa Camplese VP, Clinical Quality and Care Coordination Centura Health Cathy Dill Director of Quality Management Estes Park Medical Center Gail Finley-Rarey Chief of Acute, Primary, Community-based Service and Occurrence Reporting Section, Health Facilities and EMS Division Colorado Department of Public Health and Environment Teresa Fisher Patient Safety Specialist The Children’s Hospital Donna Marshall Executive Director Colorado Business Group on Health Elaine Massie Director of Quality Improvement / Risk Management Platte Valley Medical Center Kendra Moldenhauer Manager, Patient Safety and Quality Denver Health

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Janet Pogar Director of Contracting Anthem Blue Cross Danielle Seymour Quality Decision Support Exempla Healthcare Judy Sikes Director of Accreditation / Medical Staff Services Parkview Medical Center Kristin Stocker Coordinator of Regulatory Affairs University of Colorado Hospital Mack Thomas Director, Performance Management Centura Health Debbie Welle-Powell Vice President, Payer Strategies & Legislative Affairs Exempla Healthcare Judy Zuccone Director of Quality Services Yampa Valley Medical Center

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D. Performance & Quality Coalition (current as of 5.15.07)
• • • • • • • • • • • • • • • • • •

Anthem Blue Cross Banner Health Colorado Department of Public Health and Environment COPIC Insurance Centers for Medicare and Medicaid Services Centura Health Colorado Association of Health Plans Colorado Business Group on Health Colorado Foundation for Medical Care Colorado Health Institute Colorado Hospital Association Colorado Medical Society Exempla Healthcare HCA/HealthONE Physician Health Partners Platte Valley Medical Center United Healthcare University of Colorado Hospital

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E. List of Common Acronyms
• • • • •

AHRQ, Agency for Healthcare Research and Quality CDPHE, Colorado Department of Public Health and Environment CHA, Colorado Hospital Association CMS, Centers for Medicare and Medicaid Services HCAHPS, Hospital Consumer Assessment of Health Providers and Systems Survey

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HHS, U.S. Department of Health and Human Services IHI, Institute for Healthcare Improvement

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F. Relevant Links for Inclusion on Report Card Website

Agency for Healthcare Research and Quality (AHRQ), www.qualitymeasures.ahrq.gov

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Centers for Disease Control (CDC), www.cdc.gov Centers for Medicaid and Medicare (CMS), www.cms.hhs.gov Institute for Healthcare Improvement (IHI), www.ihi.org The Joint Commission (JCAHO), www.jointcommission.org

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