Identifying Process Variations Via Risk-Adjusted Outcome

Outcomes assessment as a means to improve patient care processes in the Military Health Services System is important, yet many obstacles block its accomplishment. Use of the easily obtainable indicators of crude morbidity, mortality, and resource consumption is inappropriate. Risk-adjustment of outcomes is necessary to account for the differences in patient severity of illness and other patient specific characteristics to ensure the comparability of these outcome measures. Comparison of actual versus predicted outcome rates via risk-adjustment modeling is being utilized in the civilian sector as a screening mechanism to identify quality of care and resource consumption outliers for the purposes of appropriately directing scarce quality improvement process review resources where they might be most needed. Outliers with lower than actual versus expected negative outcomes could be reviewed to see what they are doing right, while those with higher than expected negative outcomes could be reviewed to determine areas for improvement. Risk-adjustment modeling of outcomes (RAMO) is being utilized at the federal, state, and civilian institutional level. No Department of Defense utilization of risk-adjustment of provider outcome has been identified. RAMO has been used in statewide and regional studies to screen providers performing the high risk, high volume, high cost procedure of Coronary Artery Bypass Graft Surgery (CABGS). Although these studies have identified outliers with greater than expected mortality, the quality of care investigations which have followed have focused on institution and surgeon characteristics, ignoring the impact of post-operative nursing and physician care processes on patient outcome. The purpose of this study is to assess the validity of using risk-adjusted mortality as a screening mechanism to identify variations in provider practices impacting on CABG patient quality of care in Department of Defense (DOD) hospitals. It will utilize a DOD database to risk-adjust CABG patient mortality to identify medical centers having potential positive and negative CABG patient care process variations. The identified DOD medical centers will then undergo an in-depth review of their post-operative patient care processes, specifically focusing on nurse and physician hemodynamic and organizational practices. The study will utilize a case control design to assess input, process, and outcome variables of the CABG patient care process at 3 DOD medical centers with higher than suspected CABG mortality (the cases) and 3 DOD medical centers with lower than expected mortality (the controls). A combination of chart audit, observation of provider hemodynamic assessment and intervention practices, and provider hemodynamic knowledge and organizational process assessment questionnaires will be utilized for the in-depth process reviews. Data will be analyzed utilizing descriptive statistics.