Pressure Ulcers: Administrative Data Underestimate Rates

Troy Brown, RN

October 14, 2013

The actual rates of hospital-acquired pressure ulcers (HAPUs) may be vastly higher than those reported by administrative data, according to a retrospective analysis of 2 million all-payer administrative records from 448 California hospitals and quarterly hospital-wide surveillance data from 213 hospitals.

The analysis, which relied in part on surveillance data from the Collaborative Alliance for Nursing Outcomes, suggest HAPU rates, as currently calculated, may not accurately reflect the quality of care in a hospital. Experts call for more training and better assessment.

Jennifer A. Meddings, MD, assistant professor of internal medicine at the University of Michigan Health System and an appointee for research clinical work at the Ann Arbor Veterans Affairs Medical Center in Michigan, and colleagues report their findings in an article published in the October 15 issue of the Annals of Internal Medicine.

"In October 2014, as mandated in the Patient Protection and Affordable Care Act, the quartile of hospitals with the highest risk-adjusted [hospital-acquired conditions (HAC)] rates will be penalized with a 1% pay reduction for all hospitalized Medicare recipients on the basis of a total HAC score that includes a HAPU measure generated from administrative data," the authors write.

"Decisions about hospital comparisons, payment changes, and public reporting have occurred with limited validation of the administrative data that serve as the foundation for generation of these HAC measures, including the [Agency for Healthcare Research and Quality Patient Safety Index 3] measure," they add.

Therefore, the researchers compared 2 data sets to evaluate the administrative data as a quality measure.

Using hospital-specific administrative data, they found the mean HAPU2+ rate was 0.15% (95% confidence interval [CI], 0.13% - 0.17%; range, 0% - 0.74%) of discharges for all-payers population; the rate among Medicare recipients was 0.20% (95% CI, 0.17% - 0.22%).

However, using surveillance data, they found that the mean HAPU2+ rate was more than 10-fold higher, at 2.0%(95% CI, 1.8% - 2.2%; range, 0% - 7.3%) of patients examined.

The researchers then correlated each hospital's administrative HAPU2+ rate with its surveillance HAPU2+ rate. The correlation between each hospital's administrative and surveillance HAPU2+ was low (Pearson correlation coefficient, 0.20; 95% CI, 0.06 - 0.33).

For example, when the 49 hospitals in the highest (worst) quartile for HAPU2+, based on administrative data, were scored using surveillance data, their performance grades were "superior" (3 hospitals), "above average" (14), "average"(15), and "below average" (17).

"We found little correlation between each hospital's administrative and surveillanceHAPU2+ rates. This raises concerns about the use of administrative data alone for comparing hospitals by HAPU rates for public reporting or financial penalty," the authors conclude.

"The study by Meddings and colleagues in this issue shows deficiencies in our ability to identify highly and poorly performing institutions. The causes of these reporting deficiencies are also the reasons for poor performance in preventing ulcers: lack of knowledge and a lack of attention among health care providers," write Barbara Pieper, PhD, RN, from Wayne State University in Detroit, Michigan, and Robert S. Kirsner, MD, PhD, from the University of Miami Miller School of Medicine in Miami, Florida, in an accompanying editorial.

"Content in the administrative data set depends on the accuracy of coders' interpretations of clinicians' recordings in the medical record. In addition to possible underreporting by coders, clinicians may believe a pressure ulcer need not be recorded as a separate diagnosis concurrent with the patient's other medical problems," Dr. Pieper and Dr. Kirsner explain.

Dr. Pieper and Dr. Kirsner recommend the following:

  • examine data on pressure ulcers carefully and cautiously, particularly when comparing incidence and prevalence statistics;

  • physicians must remain current regarding the identification and staging of pressure ulcers;

  • clinicians and coders must use standardized pressure ulcer terminology;

  • on hospitalization, the patient must be assessed thoroughly with documentation of pressure ulcers; and

  • researchers and clinicians must collaborate with regulatory agencies to correct methodological or statistical variations in hospital-acquired conditions.

"Meddings and colleagues challenge us to think about clinical grading in terms of pressure ulcers. All providers need to learn pressure ulcer assessment and terminology and correctly record this information no matter how many other diagnoses a patient has," Dr. Pieper and Dr. Kirsner conclude.

Three authors have received grant funding from the Agency for Healthcare Research and Quality for this work. One author has also received funding from the agency for a secondary database analysis regarding risk model development for hospital-acquired complications. The editorialists have disclosed no relevant financial relationships.

Ann Intern Med. 2013;159:505-513. Abstract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: