Outcome Case Methodology

On risk-adjusted analyses (both 3M™ and CareScience Analytics versions), there are two values for cases: Total Cases and Outcome Cases.

Total Cases

This is the number of cases in the population that match the selections at the prompts. These cases qualified for the analysis.

Outcome Cases

This is the number of inpatient cases that qualified for risk adjustment.

Outcome Cases are the Total Cases minus the cases that did not qualify for risk adjustment. As a result, the number of Outcome Cases may be smaller than the number of Total Cases.

To qualify for risk-adjustment, the case:

  • Must include the information required to risk-adjust such as age, discharge status, gender, etc.
  • Must not include the exclusionary criteria specific to each outcome.

Information Utilized for Risk-Adjustment

The following required data elements are verified during the standard data validation process that all data goes through before being accepted by QualityAdvisor. For both the 3M™ and CareScience Analytics versions of the risk-adjusted analyses, a case must have valid values for these data elements to be included in the Outcome Cases.

*Indicates a data element that may be derived (if no specific data is sent) based on other submitted data elements.

**Indicates a data element not required for risk adjustment; however, if submitted to Premier, will be used for risk-adjustment

  • Admission Type
  • Admission Date
  • Date of Birth
  • Discharge Date
  • Discharge Status
  • Full ICD diagnosis and procedure coding set (principal and secondary)
    • Principal Diagnosis
    • Secondary Diagnosis**
    • Present on Admission (POA) accompanying Secondary Diagnosis
    • Procedures**
    • Procedure Dates accompanying Procedures
  • Gender
  • Length of Stay
  • Point of Origin (Admission Source)
  • Race (can be assigned to "unknown")**
  • Standard Primary Payer (Premier-mapped)/Payor Class*
  • Zip Code (If not provided, the system uses the facility’s zip code.)

Outcome Case Exclusion Criteria

Each outcome has exclusionary criteria that are specific to that outcome:

  • Charge
  • Cost
  • Complications
  • LOS
  • Mortality
  • Readmissions (CareScience Analytics only)

The exclusionary criteria for each outcome apply only to that outcome. For example, a patient that is transferred to another facility would be excluded from the outcome cases for mortality and readmissions but not be excluded from the outcome cases for charge, cost, LOS, or complications.

Outpatients are always excluded from the outcome cases.

The following table describes the exclusionary criteria for each outcome.

Outcome

Cases are eliminated from this outcome if…

Mortality*

The patient was transferred out of the facility with one of the following discharge statuses:

  • 02 - Discharged/Transferred to Other Facility
  • 05 - Discharged/Transferred to Cancer Center or Children's Hospital
  • 43 - Discharged/Transferred to Federal Hospital
  • 66 - Discharged/Transferred to a Critical Access Hospital (CAH)
  • 82 - Discharged/Transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 85 - Discharged/Transferred to a Designated Cancer Center or Children's Hospital with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 88 - Discharged/Transferred to a federal health care facility with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 94 - Discharged/Transferred to a Critical Access Hospital (CAH) with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)

Note: Patients transferred to another facility are disqualified for risk-adjustment because their status is undetermined.

LOS*

The CareScience Analytics Expected LOS is greater than the 99th percentile for each of the 291 disease strata in the Perspective data distribution.

Note: Cases with an Expected LOS below the 1st percentile are not excluded because patients can be reasonably admitted for one day.

Charge*

The CareScience Analytics Expected Charge is less than the 1st percentile or greater than the 99th percentile for each of the 291 disease strata in the Perspective data distribution.

Cost*

The CareScience Analytics Expected Cost is less than the 1st percentile or greater than the 99th percentile for each of the 291 disease strata in the Perspective data distribution.

Complications

There are no exclusionary criteria specific to the complications outcomes. Cases are excluded only if they do not have the information required to risk-adjust.

Readmissions (CareScience Analytics version only)

The patient:

  • Had a Patient Type other than Inpatient (08)
  • Expired
  • Was transferred out of the facility
  • Left against medical advice (AMA)

Patients with one of the following discharge statuses:

  • 02 - Discharged/Transferred to Other Facility
  • 05 - Discharged/Transferred to Cancer Center or Children's Hospital
  • 7 - Left Against Medical Advice or Discontinued Care
  • 20 - Expired
  • 40 - Expired at Home (For Medicare and Trivare claims for Hospice)
  • 41 - Expired in Medical Facility
  • 42 - Expired, Place Unknown (For Hospice)
  • 43 - Discharged/Transferred to Federal Hospital
  • 66 - Discharged/Transferred to a Critical Access Hospital (CAH)
  • 82 - Discharged/Transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 85 - Discharged/Transferred to a Designated Cancer Center or Children's Hospital with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 88 - Discharged/Transferred to a federal health care facility with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)
  • 94 - Discharged/Transferred to a Critical Access Hospital (CAH) with a planned acute care hospital inpatient readmission (effective 10/1/2013 discharges)

It is important to note that the Outcomes Cases metric includes only patients with the Patient Type of Inpatient (08); all other Patient Types are excluded. This is the only risk-adjusted outcome where the Outcomes Cases metric is restricted to one Patient Type.

Note: Patients transferred to another facility are disqualified for risk-adjustment because their status is undetermined.

*Exclusions Based on Expected Values – LOS, Cost, and Charge

In general, it is rare that Mortality, LOS, Cost, and Charge outcomes have Expected values this far outside the normal range. These out of range outlier values are excluded from outcome cases because they would have disproportionate influence on the average of the expected value.

Outcome Cases on Both Versions of the Analyses

Outcome Cases are calculated the same way in both the CareScience Analytics and 3M™ versions of the risk-adjusted analyses. Once an outcome case is identified, the same case will appear on both the CareScience Analytics and 3M™ versions of the analysis.

The following graphics show a Mortality Comparison with Attending Practitioner placed on the rows for the same facility for the same timeframe in the 3M™ version and then the CareScience Analytics version. Note that the number of Total

Cases and, more importantly, the number of Outcome Cases is the same on both analyses.

Mortality Comparison - 3M™ Version

Mortality Comparison - CareScience Analytics Version

On risk-adjusted analyses, the Observed, Expected, Variation, O/E, and Statistical Significance values are based on the Outcome Cases not the Total Cases.