PEDIATRICS Vol. 122 No. 4 October 2008, pp. 903-904 (doi:10.1542/peds.2008-2172)
LETTER TO THE EDITOR |
Limitations in the Agency for Healthcare Research and Quality Pediatric Quality Indicators Result in Flawed Call for National Benchmarks: In Reply
Matthew Kronman, MDDivisions of General Pediatrics and Infectious Diseases
Children's Hospital of Philadelphia
Philadelphia, PA 19104
Matthew Hall, PhD
Child Health Corporation of America
Shawnee Mission, KS 66202
Anthony D. Slonim, MD, DrPH
Carilion Clinic Children's Hospital
Roanoke, VA 24013
Samir S. Shah, MD, MSCE
Departments of Pediatrics and Epidemiology and the Center for Clinical Epidemiology and Biostatistics
Divisions of General Pediatrics and Infectious Diseases
Children's Hospital of Philadelphia
University of Pennsylvania School of Medicine
Philadelphia, PA 19104
We thank Scanlon et al for their thoughtful letter on our recent investigation1 of the charges and lengths of stay associated with pediatric-specific quality indicators (PDIs) and commend them for their own important work2 toward validating the PDIs. Research by Scanlon et al has suggested that there is substantial variation in positive predictive value among the 11 PDIs studied.2 In some instances, specific indicators, as noted by medical chart review, were present on admission, whereas others were deemed nonpreventable. Scanlon et al have argued that "[c]hart review should become an essential and mandatory component of the development of administrative-based quality indicators along with expert opinion,"2 which is a sentiment echoed by others.3
We agree. To be broadly useful across institutions, the PDIs must be rigorously validated by using strict definitions of preventability and close examination for events being present at the time of hospital admission. Yet, there are data suggesting that even chart review may not be the gold standard for identifying adverse events; postdischarge interviews can still detect more clinically significant and probably preventable adverse events than simple chart review.4 Nonetheless, the PDIs are not ready in their current form to be used as national benchmarks and need further refining to serve as such.
However, the PDIs are by no means useless. First, absent significant changes in coding practices, coding of PDIs within individual institutions should remain internally consistent over time, allowing for their use as a tracking tool for pediatric adverse events. Second, rates of many of the adverse events captured by the PDIs that were already present on admission are still worth tracking over time within individual communities and more broadly. Even taking into account corrections for the PDIs that were present at admission and those that were not preventable using the Scanlon et al data, PDIs in the Pediatric Health Information Systems database are still associated with substantial increases in charges and lengths of stay: postoperative sepsis is associated with an additional $41 million in charges and 3700 in hospital patient-days annually.
Last, the goal of finding an effective method of tracking pediatric adverse events over time and creating national benchmarks is an important one. Although the PDIs in their current state contain limitations that make comparison across institutions difficult, adapting them to be more useful for this purpose will help institutions determine best practices that not only decrease adverse event rates but also create significant cost savings. Because the Centers for Medicare and Medicaid Services have announced that they will cease reimbursing hospitalizations during which certain adverse events occurred, determining accurate methods for identifying adverse events has become even more pressing for pediatric health care institutions.5,6
REFERENCES
- Kronman MP, Hall M, Slonim AD, Shah SS. Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children's hospitals. Pediatrics. 2008;121 (6). Available at: www.pediatrics.org/cgi/content/full/121/6/e1653
- Scanlon MC, Harris MJ II, Levy F, Sedman A. Evaluation of the Agency for Healthcare Research and Quality pediatric quality indicators. Pediatrics. 2008;121 (6). Available at: www.pediatrics.org/cgi/content/full/121/6/e1723
- Kahn MG, Todd J. Comparative quality measures: putting evidence above expediency.
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[Free Full Text] - Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?
Ann Intern Med. 2008;149
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[Abstract/Free Full Text] - Lubell J. CMS: your mistake, your problem—eight hospital-acquired conditions won't be paid for. Mod Healthc. 2007;37 (33):10 –11[Medline]
- Centers for Medicare and Medicaid Services. Details for: incorporating selected national quality forum and never events into Medicare's list of hospital-acquired conditions. Available at: www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3043&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed July 9, 2008
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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