The initial results of the study involved the development of financial data concerning Potentially Preventable Complications. The financial analysis included administrative charge data from the states of California and Maryland analyzed by the 3M Health Information Services staff. It also included a brief, summary analysis of actual cost data from the Syracuse hospitals evaluated by the Hospital Executive Council. These two analyses, based on different data sets and indicators, were intended to provide estimates concerning the impact of inpatient complications on hospital costs.
Analysis of the charge data involved editing of information submitted by hospitals. Patient data that were incomplete, or based on a discharge status of transferred to another acute care facility or expired were excluded. It has been estimated that these data involved a maximum of 6 percent of the records from each state. The resulting information from the California Office of Statewide Health Planning and Development was based on fiscal year 2008 (July 2007 - June 2008) and included 235 hospitals. The resulting information from the Maryland Health Services and Cost Review Commission was based on fiscal year 2008 (October 2005 - September 2006) and included 43 hospitals [24
The information from Maryland included uniform categories of financial data that made it possible to estimate costs accurately from charge data. The California charge data did not include this level of structure and were evaluated using a charge to cost ratio of 1.264. A regression model was applied to both data sets to estimate average costs per patient by Potentially Preventable Complications. Examples of incremental costs added to patient expenses for PPCs with the highest frequencies in both states are identified in Table [24
Estimated Potentially Preventable Complications Cost Based on Hospital Charge Data States of California and Maryland
The data in Table indicate that the mean incremental costs per Potentially Preventable Complication were similar. It was notable that different data bases and need for separate statistical methods produced estimated incremental costs that did not vary greatly. At the patient level, the estimated impact of these costs was substantial. The incremental costs of the complications for these categories ranged from $4,950 to $25,401 in California and from $3,910 to $16,709 in Maryland [24
]. These data included results from the study, rather than a separate analysis.
In the development of their demonstration program concerning Potentially Preventable Complications, the Hospital Executive Council and the Syracuse hospitals also produced estimates of the impact of these outcomes on hospital costs. Like the evaluations involving the California and Maryland data, these comparisons were based on inpatient populations with the same APR DRGs and severity of illness levels that experienced the PPCs and patients with the same risk characteristics who did not experience the PPCs. The Syracuse comparisons, however, were based on actual cost data from the hospitals. Through this stratification, to the extent possible, the differences in costs identified resulted from the complications involved, rather than variations in diagnoses and severity of illness of the populations.
Examples of the cost analyses from three of the Syracuse hospitals are summarized in Table . They include discharges, total costs, and mean costs per discharge for selected PPCs during the period before implementation of the demonstration program. The comparisons were based on patients with and without each PPC who were assigned to the same All Patients Refined Diagnosis Related Groups and severity of illness levels within these APR DRGs.
Hospital Inpatient Cost Comparisons Patients With and Without Selected Complications Syracuse Hospitals January - June 2008
The comparisons of actual costs from the Syracuse hospitals, like those from California and Maryland, suggested the substantial impact of complications on expenses for hospital inpatients. For patients with urinary tract infection, clostridium difficile colitis, and decubitus ulcer at Community-General Hospital, mean costs for patients with the complication were more than double those for the same at risk populations without it. For patients with urinary tract infection at Crouse Hospital, pneumonia at St. Joseph's Hospital Health Center, and decubitus ulcer as a PPC at both hospitals, expenses were several times those for at risk groups without the complications. A portion of this may have resulted from surgery patients and those with higher severity of illness at those hospitals. These comparisons were developed based on actual hospital costs, stratified to include patients with and without the PPC that were assigned to the same All Patients Refined Diagnosis Related Groups and severity of illness
A review of drivers of these costs at St. Joseph's Hospital Health Center and Crouse Hospital suggested that increased expenses for nursing, pharmaceuticals, and diagnostic testing were most responsible. These expenses were based on the cost of these resources related to lengths of stay at the hospital. Substantially longer stays for patients with the PPCs accounted for higher use of resources by this group. The analysis did not include separate analysis of the drugs consumed or the procedures associated with the adverse events.
Evaluation of the impact of Potentially Preventable Complications involved the use of severity adjusted benchmark data. Initial use of this information was based on California inpatient data for 2005 and 2006. Severity adjusted benchmarks from this source for medical and surgical inpatients at Crouse Hospital and St. Joseph's Hospital Health Center in Syracuse during 2008 are summarized in Table .
Benchmark Rates of Major Potentially Preventable Complications Medical/Surgical PPCs January - September 2008 Annualized
In addition to containing hospital benchmark data, this information comprised a summary of the incidence of major Potentially Preventable Complications in California, the largest inpatient state database in the United States. The data indicate that the highest complication rates per 1,000 hospital discharges were 7.04 - 10.20 for Urinary Tract Infections, 7.71 - 7.72 for Accidental Punctures, and 5.22 - 8.73 for Pneumonia and Other Lung Infections.
Data related to Potentially Preventable Complications in the Syracuse hospitals also involved early evaluation of programs for managing these outcomes that were implemented between October 2008 and March 2009. These comparisons involved data for January-June 2008, the period immediately prior to implementation of the projects, and January-March and April-June 2009, the most recent period for which coded inpatient data were available for the hospitals. This information is summarized in Table .
Potentially Preventable Complications Programs Implemented Between October - December 2008 Syracuse Hospitals January - June 2008, January - June 2009
This information demonstrated that, within these time frames, complication rates had declined slightly for three of the initiatives. These included decubitus ulcer, and post hemorrhage/acute anemia at St. Joseph's Hospital Health Center and pulmonary embolism at Crouse Hospital. For these projects, differences between hospital and severity adjusted benchmark rates fell from significant to nonsignificant levels. The rate for urinary tract infection at Community-General Hospital declined from nonsignificantly higher to nonsignificantly lower than the benchmark. These declines resulted from before and after comparisons, rather than the use of control groups. In the participating hospitals, it was not possible to develop control groups within the scope of the study.
These comparisons also demonstrated that differences between hospital and severity adjusted PPC rates increased for urinary tract infection and decubitus ulcer at Crouse Hospital and for clostridium difficile colitis at Community-General Hospital. Only the increase for urinary tract infection reached a significant level. These declines resulted from before and after comparisons, rather than the use of control groups.
These data suggested that, based on the average cost differences identified in Table , the financial impact of managing complications could be considerable. This point was based on simple calculations of the impact of changes in complications at the Syracuse hospitals during the period of the study, rather than a specific analysis. For example, declines in PPC rates at St. Joseph's Hospital Health Center between January-June 2008 and January-March 2009 reduced the first quarter costs for patients at risk of pneumonia by $386,707.50 and for those at risk of decubitus ulcer by $134,422.5. These expenses would translate into annualized savings of $1,546,830 for pneumonia and $537,690 for decubitus ulcer. For Crouse Hospital, the decline in complication rates produced a first quarter savings of $20,218. For Community-General Hospital, the decline in complications for urinary tract infections produced a savings $90,940.
The demonstration project in Syracuse will generate additional information concerning the impact of clinical interventions on a range of inpatient complications within urban, general hospitals. It is projected to conclude at the end of 2010.