Quality Indicator, Physicians Differ on Preventable Admissions

Tara Haelle

February 29, 2016

The majority of hospital admissions deemed preventable using the standardized Prevention Quality Indicator (PQI) were not rated preventable by physicians at the hospital, a new study finds. Instead, the physicians found a larger, mostly distinct group of admissions were preventable, researchers report in a study published online February 18 in the Journal of General Internal Medicine.

In fact, physicians and the PQI agreed on the preventability of only 10% of overall admissions, a concordance no different than what would be expected by chance.

"The PQI cannot identify an appropriate rate for hospital admissions within a given population" for specific conditions, explain Krishna K. Patel, MD, from the Department of Internal Medicine at the Cleveland Clinic Foundation in Ohio, and colleagues. "Therefore it cannot serve as a tool to help hospitals focus their prevention efforts."

Attempts to reduce readmission rates with measurement, public reporting, sharing best practices, improving processes, and financial penalties have only slightly moved that needle, and these admissions represent a small proportion of overall preventable admissions, the authors write.

To address the healthcare costs associated with preventable hospital admissions, an estimated 9% to 36% of the 40 million annual admissions in the United States, the Centers for Medicare & Medicaid Services has begun including preventable admissions rates as a factor in its incentive and penalty programs. Because it is too labor intensive to analyze specific admissions and factors that could have prevented them, several pay-for-performance programs are using the PQI to determine preventable admissions rates. But the PQI was developed by the Agency for Healthcare Research and Quality (AHRQ) to assess population-level access to primary care across a geographical region, not as an indicator of hospital-level quality.

Therefore, the researchers compared a hospital's rate of preventable admissions using the PQI with the rate determined by physicians. For the latter, on the second day of an admission, an attending physician assessed whether any system, clinician, or patient factor in the 2 weeks before admission could have been addressed to avoid the admission. Physicians chose from a list of factors compiled by merging past research findings with a poll of 15 physicians. The physician also determined whether the primary contributing factor would be very easy, somewhat easy, somewhat difficult, or very difficult to address.

Each case was also independently reviewed by two physicians blinded to the initial physician's assessment, which showed moderate interobserver agreement (kappa = 0.43 between reviewers and attending; kappa = 0.51 between reviewers).

Among 322 consecutive admissions from December 1 through December 15, 2013, more than a third (38%) were deemed preventable by physicians, and a quarter of these were readmissions. The physicians rated 49% of readmissions preventable compared with 35% of the other admissions (P = .04); however, the preventable and nonpreventable groups had a similar intensity of contact with any physicians in the 2 weeks before admission.

The physicians deemed 44% of admissions preventable based on patient factors: 17% resulting from nonadherence, 8% resulting from mental health/substance abuse, and others resulting from poor health literacy, secondary gain from hospitalization, and poor home support. Just over a quarter (26%) of admissions were primarily a result of system factors, including ease of inpatient management exceeding that of outpatient management in 11% of overall cases and inadequate nursing facility care, lack of access to outpatient providers, and a complication from a previous admission in other cases.

In addition, 30% of preventable admissions were judged to be related to clinician factors, including too low a threshold for admission (9%), inadequate follow-up (8%), and inappropriate diagnosis or treatment (7%). For example, admissions for a localized skin rash, for a viral influenza upper respiratory infection, and for insufficient management of acute kidney injury in a previous admission made up some of the clinician-associated preventable admissions.

In contrast, the PQI identified 23% of overall admissions preventable, and 56% of these cases were not identified by the physicians as preventable. Only 9.6% of admissions were considered preventable by both the physicians and the PQI.

"AHRQ's PQI method was developed to measure the adequacy of primary care in a region and to identify outliers for internal quality review," the authors write. "It presupposes that conditions such as [chronic obstructive pulmonary disease] and heart failure exacerbations, uncontrolled diabetes, bacterial pneumonia, ruptured appendix and urinary tract infection are affected by access to high-quality ambulatory care and that lower admission rates represent better care." Yet, a wide range of possible factors might contribute to variations in rates of conditions, such as these at the hospital level that are not necessarily preventable.

The authors note that physician assessment methods identify more preventable admissions, the factors that can be addressed to prevent these, and tools for local quality improvement. However, the gains in accuracy come at the cost of not being easily standardized for comparison across hospitals.

"For healthcare providers to reduce admission rates, they must understand why preventable admissions occur: 52% of the preventable admissions in our study were considered very or somewhat easy to prevent, and these were more likely to be due to clinician factors such as inadequate follow-up, no contact between the admitting MD and primary care provider and the low threshold for admission," the authors write.

The authors have disclosed no relevant financial relationships.

J Gen Intern Med. February 18, 2016. Abstract


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