title: Performance Measures in Neurosurgical Patient Care: Differing Applications of Patient Safety Indicators.
abstract: BACKGROUND
  Patient Safety Indicators (PSIs) are administratively coded identifiers of potentially preventable adverse events. These indicators are used for multiple purposes, including benchmarking and quality improvement efforts. Baseline PSI evaluation in high-risk surgeries is fundamental to both purposes.
  
  
  OBJECTIVE
  Determine PSI rates and their impact on other outcomes in patients undergoing cranial neurosurgery compared with other surgeries.
  
  
  METHODS
  The Agency for Healthcare Research and Quality (AHRQ) PSI software was used to flag adverse events and determine risk-adjusted rates (RAR). Regression models were built to assess the association between PSIs and important patient outcomes.
  
  
  METHODS
  We identified cranial neurosurgeries based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in California, Florida, New York, Arkansas, and Mississippi State Inpatient Databases, AHRQ, 2010-2011.
  
  
  METHODS
  PSI development, 30-day all-cause readmission, length of stay, hospital costs, and inpatient mortality.
  
  
  RESULTS
  A total of 48,424 neurosurgical patients were identified. Procedure indication was strongly associated with PSI development. The neurosurgical population had significantly higher RAR of most PSIs evaluated compared with other surgical patients. Development of a PSI was strongly associated with increased length of stay and hospital cost and, in certain PSIs, increased inpatient mortality and 30-day readmission.
  
  
  CONCLUSIONS
  In this population-based study, certain accountability measures proposed for use as value-based payment modifiers show higher RAR in neurosurgery patients compared with other surgical patients and were subsequently associated with poor outcomes. Our results indicate that for quality improvement efforts, the current AHRQ risk-adjustment models should be viewed in clinically meaningful stratified subgroups: for profiling and pay-for-performance applications, additional factors should be included in the risk-adjustment models. Further evaluation of PSIs in additional high-risk surgeries is needed to better inform the use of these metrics.
authors.affiliation: *Medical School, Stanford School of Medicine †Stanford Center for Health Policy/Center for Primary Care and Outcomes Research ‡Department of Neurosurgery, Stanford School of Medicine, Stanford University §Department of Surgery, Stanford School of Medicine, Stanford, CA.
authors.forename: Nuriel
authors.initials: N
authors.lastname: Moghavem
authors.forename: Kathryn
authors.initials: K
authors.lastname: McDonald
authors.forename: John K
authors.initials: JK
authors.lastname: Ratliff
authors.forename: Tina
authors.initials: T
authors.lastname: Hernandez-Boussard
mesh_terms: D001131:Arkansas; D019985:Benchmarking; D002140:California; D005431:Florida; D017721:Hospital Costs; D017052:Hospital Mortality; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D008922:Mississippi; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D009518:New York; D010359:Patient Readmission / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000592:standards / Q000706:statistics & numerical data*; D018570:Risk Assessment / Q000706:statistics & numerical data; D012886:Skull / Q000601:surgery; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000706:statistics & numerical data; D014481:United States; D016270:United States Agency for Healthcare Research and Quality / Q000592:standards