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UNIVERSITY OF CALIFORNIA

Los Angeles

Pay-for-Performances Impact
on Overall Quality o f Care
for Acute Myocardial Infarction Patients

A dissertation submitted in partial satisfaction o f the


requirements for the degree Doctor o f Philosophy
in Health Services

by
Mikele Mariah Bunce

2007

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UMI Number: 3272270

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The dissertation o f Mikele Mariah Bunce is approved.

Charles Corbett

Paul Torrens
' ...

Robert Kaplan, Committee Chair

University o f California, Los Angeles


2007

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DEDICATION

To Donald Randy Bunce and Diana Carter Bunce


for inspiring me to go after my dreams and for believing that I could achieve them
and to Cameron Carter Bunce for his love and support.

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TABLE OF CONTENTS

Section

Page Number

I.

Introduction

II.

Background

III.

a.

Sub-Optimal Elealth Care Quality

b.

United States Reimbursement Systems for Hospitals

c.

Quality Metrics

d.

Premier Hospital Quality Incentive Demonstration

e.

Hospital Quality Alliance

f.

Scripps Health

10

Literature Review

12

a.

Process and Outcome Measures

12

b.

Acute Myocardial Infarction HospitalProcess Measures

13

c.

Pay-for-Performance

19

IV.

Hypotheses

23

V.

Conceptual Model

25

VI.

Data

26

a.

Main Analysis

26

b.

Additional Analysis

27

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VII.

Data Sources

29

VIII.

Data Elements

31

a. Dependent Variables

36

b. Predictor Variables

36

i.

Pay-for-Performance Scores

37

Patient Demographics

39

iii.

Hospital Characteristics

39

iv.

Patients Medical Condition

40

v.

Treatment

40

Patients Behavior

41

ii.

vi.
IX.

Study Design

42

X.

Statistical Methods

45

a.

Study Aim 1

45

b. Study Aim 2

47

Results

50

a. Patient Characteristics

50

b. Pay-for-Performance Process Measure Analysis

59

XI.

i.
ii.

Scripps Performance Results

59

Premier, Inc. and Scripps Health Performance

66

c. Process Outcomes Link Analysis


i.
ii.

Survival Analysis Mortality Results


Survival Analysis Times Series Mortality
Results

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70
70
72

iii.
iv.

v.
vi.

d.

Logistic Regression Mortality Results


Logistic Regression Times Series Mortality
Results
Logistic Regression Morbidity Results
Logistic Regression Times Series Morbidity
Results

Covariates Impact on Outcomes Analysis


i. Test for Proportional Hazards
ii. Covariate Survival Analysis Results

e.

XII.

Pay-for-Performance Outcomes Analysis

75
75

77
77

78
78
79
82

i. Mortality Pre and Post Intervention Results

82

ii. Morbidity Pre and Post Intervention Results

85

Discussion

86

a.

Pay-for-Performances Impact on Process Measures

86

b.

Process-Outcomes Link

94

c.

Covariates Impact on Outcomes

97

d.

Pay-for-Performances Impact on Outcomes

102

e.

Summary

104

XIII.

Limitations

106

XIV.

Attachments

114

a.

Premier Hospital Quality Incentive Demonstration

114

b.

Hospital Quality Initiative

116

c.

Conceptual Model

121

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d. Variable Coding

122

e. Covariates Frequencies Over Time

126

f.

XV.

Covariates Included in Stepwise Survival Analysis on Total


Population

134

g. Covariates Included in Time Series Stepwise Survival


Analysis

137

References

143

LISTS OF FIGURES
Figure

Page Number

I.

All Applicable P4P Measure Compliance Over Time

59

II.

Aspirin at Arrival Compliance Over Time

62

III.

Beta Blocker at Arrival Compliance Over Time

63

IV.

ACEI or ARB for LVSD Compliance Over Time

63

V.

Smoking Cessation Advice/Counseling Compliance Over Time

64

VI.

Aspirin at Discharge Compliance Over Time

64

VII.

Beta Blocker at Discharge Compliance Over Time

65

VIII.

Thrombolytic Agent Within 30 Minutes Compliance Over Time

65

IX.

PCI Within 120 Minutes Compliance Over Time

66

X.

Premier, Inc. and Scripps Health Weighted Average AMI


Process Measure Compliance Over Time

68

XI.

30-Day Mortality Rates Over Time

83

XII.

90-Day Mortality Rates Over Time

83

XIII.

180-Day Mortality Rates Over Time

84

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XIV.

30-Day Readmission Rates Over Time

86

LISTS OF TABLES
Table

Page Number

I.

Variable Sources

29

II.

Conceptual Domains, Theoretical Variables, Empirical


Variables, and Prediction on Outcomes

31

III.

Variable Frequencies for Non-Continuous Variables for


Total Patient Population

52

IV.

Variable Means for Continuous Variables for Total Patient


Population

56

V.

Means o f Age and Hospital Characteristics at Each


Observation Time Period

58

VI.

Logistic Regression Results o f Scripps Process Measure Scores


Before and After HQA

60

VII.

Premier, Inc., Scripps Health, and Other National HQA


Participants Process Measure Scores

68

VIII. Differences in Performance Measure Scores Between Scripps


Health, Premier, Inc., and Other National HQA Participants
Before and After P4P and P4R

69

IX.

Scripps Health and Premier, Inc. Performance Before and After


P4P

69

X.

Scripps Health and Premier, Inc. Performance Before and After


P4R

70

XI.

Survival Analysis Results for Regressors o f Interest in Total


Population

70

XII.

All Applicable and Recommended P4P Variable Survival


Analysis Results

71

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XIII.

Time Series Survival Analysis Results for Regressors o f Interest

73

XIV.

Alive/Dead at 30 Days Outcome Results for Regressors o f


Interest in Total Population

75

XV.

Alive/Dead at 30 Days Time Series Outcome Results for


76
Statistically Significant Regressors o f Interest in Total Population

XVI.

Readmission in 30 Days Outcome Results for Regressors o f


Interest in Total Population

77

XVII. Readmission in 30 Days Outcome Results for Statistically


Significant Regressors o f Interest in Total Population

78

XVIII. Test for Proportional Hazards Results

79

XIX.

Covariate Hazard Functions

81

XX.

Logistic Regression Results o f 30-Day Mortality Before and


After HQA

84

XXI.

Logistic Regression Results o f 90-Day Mortality Before and


After HQA

84

XXII. Logistic Regression Results o f 180-Day Mortality Before and


After HQA

ix

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85

ACKNOWLEDGEMENTS

I would like to take this opportunity to thank and acknowledge a number o f people who
helped make this research come to fruition. First and foremost, I would like to thank
my dissertation committee: Dr. Robert Kaplan, Dr. Jack Needleman, Dr. Paul Torrens,
and Dr. Charles Corbett for their guidance, patience, and motivation. I would also like
to extend thanks to Dr. Ninez Ponce and Dr. Tom Rice at the UCLA School o f Public
Health.

Scripps Health has been extremely supportive o f my research endeavors. I could not
have completed this dissertation without the encouragement and aide o f Dr. Brent
Eastman, Barbara Price, Chris Van Gorder, and Mindi Matson. The cardiologists in the
Scripps Health system were invaluable in helping create the conceptual model for this
research and in providing clinical expertise, in particular, Dr. Paul Teirstein, Dr. Eric
Topol and Dr. Paul Phillips.

My friends and family have been by my side throughout the whole process. I want to
express my thanks to them for making this journey easier along the way.

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VITA
August 9, 1977

Bom, Stanford, California

1999

B.A., Human Biology


Stanford University
Stanford, California

1999

Quality Data Coordinator


Palo Alto Medical Foundation
Palo Alto, California

1999- 2001

Cancer Center Consultant; JCAHO/PI Analyst


UCSF Medical Center
San Francisco, California

2002 - 2005

Consultant; Senior Consultant


Sinaiko Healthcare Consulting
Los Angeles, California

2003

M.P.H., Health Services


University o f California, Los Angeles
Los Angeles, California

2005 - present

Director, Quality
Scripps Health
San Diego, California

PUBLICATIONS AND PRESENTATIONS


Bunce, Mikele. Clinical Guidelines: Increased Quality of Care at the Expense o f
Clinical Autonomy? Journal o f Health Care Compliance. 2005; 7(3):50-52.
Bunce, Mikele M. Innovative Approaches Help Improve the Managed Care Trifecta.
Managed Healthcare Executive. 2005; 15(6):42-44.
Bunce, Mikele and Richard Sinaiko. HIPAA: The Next Phase. Myths and Realities of
the Electronic Transaction and Code Set Standards. Physicians Practice. 2003;
13(8):67-70.

xi

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Sinaiko, Richard E, Mikele M Bunce, Neal Eigler, Saibal Kar, Sepideh S Farivar,
Emma C Wollschlager. Drug-Eluting Stent Use May Negatively Impact the Economic
Helath o f a Hospital: A Single-Center Case Study. Supplement to Journal o f American
College o f Cardiology - Abstracts o f Original Contributions. 2004; 43(5):402A-403A.
Toloui, Omid B and Mikele M Bunce. Are Individual or Group Incentives Best?
Cardiology Practice Options. Oct 2005; 6-7.

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ABSTRACT OF THE DISSERTATION

Pay-for-Performances Impact
on Overall Quality o f Care
for Acute Myocardial Infarction Patients

by

Mikele Mariah Bunce


Doctor o f Philosophy in Health Services
University o f California, Los Angeles, 2007
Professor Robert Kaplan, Chair

Background: Pay-for-performance (P4P) is a methodology where financial incentives


are given to healthcare providers for the provision o f high quality patient care.
However, there is limited research on whether P4P programs improve patient
outcomes. Methods: Compliance with eight acute myocardial infarction (AMI) metrics
used in the Hospital Quality Alliance (HQA) precursor to the Centers for Medicare &
Medicaid Services (CMS) Values Based Purchasing (i.e., P4P) plan as well as patient
mortality were analyzed using patient level data for 3,954 patients discharged from
Scripps Health hospitals from 2003 to 2005. Three observational time periods o f six
months o f data before participation in the HQA were compared to three observational

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time periods o f six months o f data after participation in the HQA within a time series
study design. Multivariate survival analyses and logistic regressions were performed to
determine whether an improvement in process measure compliance and/or patient
mortality could be attributed to participation in the HQA. Results: Compliance with
providing all applicable P4P measures improved from 60-72% before HQA to 75-86%
after HQA. Similarly, 30-day mortality improved from 11-13% before HQA to 8-9%
after HQA. Regression discontinuity analyses with time series process measure and
outcome data identified that neither the slope nor the intercept o f performance after
participation in the HQA was statistically significantly different than before
participation in the HQA using a p-value o f 0.05. Conclusion: For a hospital system
already improving compliance with AMI process measures and patient outcomes,
participation in the HQA did not change that pattern o f improvement. One cannot
conclude that the HQA was the catalyst for improvement. However, mortality did
improve after participation in the HQA, indicating that any potential unintended
consequences o f participation in the HQA did not have a significant negative impact on
outcomes. Further research is required to determine whether other changes (e.g.,
increased staffing ratios, treatment modality used) could be attributed to the change in
performance metric compliance and the change in outcomes. Further research is also
recommended to determine whether the HQA had early or lagged effects on process
measures and outcomes not identified in this study.

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In t r o d u c t io n
According to the Institute o f M edicines report Crossing the Quality Chasm: A
New Health System for the 21st Century, health care today harms too frequently and
fails to deliver its potential benefits therefore the American health care delivery
system is in need o f fundamental change.1 Although healthcare professionals aim to
provide high quality patient care, recent reports on the staggering number o f medical
errors and the failure to deliver the best available care confirm that not only is high
quality care not always received, but poor quality care has resulted in unnecessary
deaths.2,3
The healthcare industry is no different than other industries in that it is driven
by money. In order to survive, provider organizations must be mindful o f
reimbursement. However, the dominant healthcare payment systems in the United
States (US) do not reward quality care and can often provide incentives against
providing high quality care.4
Pay-for-performance (P4P) systems were developed as a mechanism to align
financial incentives for providing high quality care. The American Medical
Association (AMA) defines pay for performance as a method o f linking pay to a
measure o f individual, group, or organizational performance, based on an appraisal
system. These types o f bonus incentive schemes are based on the idea that work
output, determined by some kind o f measuring system, varies according to effort and
that the prospect o f increased pay will motivate improved performance.5

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There are three methodologies for P4P programs: competitive bonus payment;
payment at risk; and quality tiered networks. Competitive bonus payments are
awarded to top performers in a group o f providers and bottom performers may or may
not receive less compensation. In payment at risk models, a percentage o f revenue is
withheld by the payor until a review o f quality scores is conducted. Providers who do
not meet quality targets lose the percentage at risk. In quality-tiered networks,
consumers are incented to select high quality providers by offering discounted co
payments. Consumers who prefer lower scoring hospitals on quality measures must
pay higher co-payments.6 Reimbursement is allocated based upon providers scores on
specific quality metrics as identified by the particular P4P program.
There are a few dominant P4P programs in the US for hospitals. The Premier
Hospital Quality Incentive Demonstration is a true P4P program, where top tiered
providers are paid higher reimbursement rates and bottom tiered providers are paid
lower reimbursement rates. However, the Premier Hospital Quality Incentive
Demonstration is limited to Premier, Inc. hospitals.
Another program geared towards hospitals is the Centers for Medicare &
Medicaid Services (CMS) Hospital Quality Alliance program. Section 501(b) o f the
Medicare Prescription Drug, Improvement, and Modernization Act o f 2003 (MMA)
established a financial incentive for hospitals to report on the quality o f inpatient care
they provide to patients.7 Hospitals began voluntarily reporting this data to CMS by
July 1, 2004. Every hospital in the US has the ability to participate. The Hospital
Quality Alliance pays hospitals that do not report quality data to CMS lower

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reimbursement rates than hospitals that do provide performance data. This program is
currently a pay-for-reporting reimbursement system, but is amalgamating into a payfor-performance reimbursement system over time.8
The literature suggests that if you measure something, it will improve.9,10 This
notion has also been substantiated through some o f the P4P literature. A literature
review showed that more often than not, P4P programs had their intended effect of
*

11 12 13

improving scores on the measures that dictate payment. However, literature is


sparse on whether outcomes were actually improved through these P4P programs.
Despite the proliferation o f pay-for-performance programs, they are largely
untested. 14
This researchs first aim is to determine whether P4P leads to improved
process measure scores. The second aim o f the research is to determine whether
increased process measure scores lead to improved outcomes within the context o f a
P4P program. In other words, the second study aim tries to answer the question of
whether overall quality o f care (as evidenced through outcomes) is improved while
process measure scores are improved or whether the effect o f P4P is a zero sum
game.15 In a zero sum game situation, the process measures that are rewarded through
P4P may improve but the overall quality o f care (outcomes) remains the same because
other measures affecting outcomes that are not tied to reimbursement have decreased.
It is possible for limited resources to be reallocated to the performance measures that
impact reimbursement at the potential detriment to the overall quality o f care
provided.

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This study will analyze the change in eight P4P indicators for acute myocardial
infarction (AMI) patients before and after the Hospital Quality Alliance was
implemented and will analyze correlations between these measures and AMI patient
outcomes (mortality). Data from five hospital campuses within the Scripps Health
system in San Diego, California from January 1, 2003 to December 31, 2005 was used
to conduct this research.

B ackground
Sub-Optimal Health Care Quality
The US performs more poorly than most countries in many measures o f health
care quality.16 The reports o f substandard healthcare are numerous. Haley et al
estimated that two million patients suffer hospital-acquired infections each year.17
While patients may believe that they are coming to a hospital to have their sickness
cured or managed, some patients conditions become worse in the hospital.
An article by Robert Langreth reported that three percent or more o f hospital
patients are hurt by medical errors and that one in 300 patients die from such mistakes.
Comparing this figure to the fact that in US aviation only one in five million flights
ends in a deadly accident is disturbing. Langreth further notes that 24% o f people say
they or a family member have been harmed by a medical error. The same article
reports that 90,000 people die o f hospital-acquired infections annually and that more
than half o f these deaths may be preventable. In addition, 180,000 elderly outpatients
die or are seriously injured by drug toxicity, where half o f these incidents may be

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preventable.18
According to the Institute o f M edicines report To Err is Human: Building a
Safer Health System, when extrapolated to the over 33.6 million admissions to US
hospitals in 1997, the results o f [a] study in Colorado and Utah imply that at least
44,000 Americans die each year as a result o f medical errors. The results o f the New
York Study suggest the number may be as high as 98,000. Even when using the lower
estimate, deaths due to medical errors exceed the number attributable to the 8thleading cause o f death. More people die in a given year as a result o f medical errors
than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS
(16,516).2 The 2003 National Committee for Quality Assurance (NCQA) report titled
The State o f Health Care Quality estimates that there are more than 57,000 deaths
per year attributable to failure to deliver recommended care.19 Regardless o f the exact
number of avoidable deaths, the projected numbers are astounding and provide
impetus for healthcare delivery reform.
Even if hospitals/physicians are not contributors to further illness, healthcare
professionals may not be treating patients as well as they could. McGlynn et al
determined that patients only receive 54.9% o f recommended care overall and that
quality can range from receiving 78.7% o f recommended care for patients with senile
cataracts to 10.5% o f recommended care for patients with alcohol dependence.
Specifically for heart attack patients, W oolf determined that 39% to 55% o f patients
did not receive needed medications which resulted in 37,000 avoidable deaths.21 There
are numerous studies like these that aim to quantify not only unnecessary morbidity

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and mortality but a lack o f ideal healthcare being currently provided in the US. While
researchers may not be in agreement about how wide the gap or chasm is between
current healthcare and ideal healthcare, there is little debate over the fact that a gap
does exist.

United States Reimbursement Systems for Hospitals


The past and current healthcare payment systems have created incentives to
overutilize services (e.g. FFS) and underutilize service (e.g. capitation). Current
reimbursement systems expect high quality care rather than pay for it.
Medicare reimburses hospitals on a prospective basis. Each patient case is
categorized into a diagnosis related group (DRG). One o f the important components
that determines M edicares payment rate is cost o f care as determined by hospital cost
reports. Medicare uses a cost-based reimbursement system, where theoretically higher
cost services should receive higher payment in future years. In some instances,
Medicares reimbursement system actually rewards poor care, for example, if a patient
acquires an infection during admission, reimbursement may be higher than if the
patient had not acquired a nosocomial infection.4
Another example o f M edicares reimbursement system acting as a disincentive
to provide better care is in the case o f a patient needing multiple vessel percutaneous
coronary intervention. Flospital reimbursement is higher if a patient receives one drugeluting stent at one time and then receives a second drug-eluting stent during a second
procedure at least a few days later. If the patient has both stents deployed during the

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same procedure the quality o f care for the patient is better due to a reduced risk of
complications and less recovery time, however, the staging o f stent deployment has
been determined to be one o f the negative consequences o f the low reimbursement rate
for angioplasty using drug-eluting stents.22
Fee-for-service payment methodologies reimburse higher rates for services
with higher charges. Fee-for-service reimbursement may therefore incent providers to
furnish more services than necessary to reap greater financial reward.
Capitation and case rate payments put a hospital at risk. A lump sum is
prospectively paid to a hospital for coverage o f a patients care for a certain period of
time. If the cost o f providing care to that patient is less than the payment received,
then the hospital makes a profit. If the cost o f care is greater than the payment
received, then the hospital loses money. Hence, capitation and case rate payments
result in increased profit to providers if fewer services are rendered. These
reimbursement methods can create an incentive towards underutilization o f diagnostic
and treatment services.

Quality Metrics
Organizations such as the Agency for Healthcare Research and Quality
(AHRQ) and the National Quality Forum (NQF) develop quality metrics by reviewing
evidence-based literature for clinical conditions. When there is a very high degree o f
consensus regarding metrics that positively correlate with improved clinical outcomes,
the organization develops a proposal metric. Various constituents and the general

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public (through posting on the organizations websites) are asked to give feedback
upon proposed metrics until the organization decides that the metric is ready for
finalized form or whether the metric is too controversial to use. A HRQs National
Quality Measures Clearinghouse then tracks the use o f the measure, the extent o f
measure testing that has been conducted, and the evidence for reliability/validity
testing.23
There are a variety o f categories o f quality metrics: structural measures;
process measures; outcome measures; access to care measures; and experience
measures. Most quality metrics for clinical conditions are related to process rather than
clinical outcomes. The reason that process measures are often chosen is because o f the
feasibility o f collecting process measures and because these process measures have
been deemed through evidence-based medicine to be positively correlated with
improved outcomes.

Premier Hospital Quality Incentive Demonstration


The Premier Hospital Quality Incentive Demonstration is a P4P program
between CMS and Premier, Inc. Premier, Inc. is a collaborative o f not-for-profit
hospitals across the nation, of which, a total o f 274 hospital members have chosen to
participate in the Demonstration project.
Each hospital reports inpatient performance data on 34 quality measures in the
clinical areas of heart attack, heart failure, pneumonia, coronary artery bypass graft
(CABG), and hip and knee replacements. Top performers in each clinical condition

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(top 50%) are recognized as such at the website www.cms.hhs.gov. Additionally, the
top two deciles o f performers are given a financial bonus by CMS. By the third year o f
the Demonstration, hospitals that were in the bottom two deciles o f performance in
year one receive lower reimbursement rates from CMS if their performance has not
increased from the baseline level. For more information, see Attachment I.

Hospital Quality Alliance


The Hospital Quality Alliance is a collaboration o f the CMS, the American
Hospital Association, the Federation o f American Hospitals, and the Association of
American Medical Colleges and is a component o f the larger CMS Hospital Quality
Initiative (see Attachment II). The goal o f the Hospital Quality Alliance is to improve
the quality o f care provided by the nations hospitals by measuring and publicly
reporting on that care.
The Hospital Quality Alliance is a voluntary initiative. However, hospitals that
currently choose not to participate receive a market basket minus 2.0% reimbursement
from CMS. Hospitals that do participate submit data on various process measures
which then get reported on a public website www.hospitalcompare.hhs.gov. The
public posting of scores is expected to improve the quality o f care and the ability of
consumers to make informed healthcare choices. 24 The Hospital Compare website
currently reports 21 measures across the following clinical conditions: heart attack;
heart failure; pneumonia; and surgical infection prevention. Hospitals participating in
the Hospital Quality Alliance submitted their first data by July 1, 2004 on a starter

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set o f 10 measures. The 21 measures currently posted on Hospital Compare include


the starter set and are scheduled to continue to grow over time.

Scripps Health
Scripps Health is a private, not-for-profit, community-based health care
delivery network that includes four licensed acute-care hospitals located on five
campuses in San Diego County. There is a distance o f three to 41 miles between each
campus.
Scripps was founded in 1924 by Ellen Browning Scripps. The flagship
hospital, Scripps Memorial Hospital La Jolla, has 372 licensed beds and is one o f the
countys six designated trauma centers and the only Magnet Hospital in San Diego
County. Scripps Memorial Hospital La Jollas payor mix is approximately 28%
Medicare, 3% MediCal, 60% commercial, 6% other governmental payors and self pay
(including no pay), and 3% other (including workers compensation).
Scripps Memorial Hospital Encinitas joined the Scripps Health system in 1978.
This hospital provides services to patients located in San Diegos North County and
has 140 acute-care licensed beds. Scripps Memorial Hospital Encinitass payor mix is
approximately 38% Medicare, 17% MediCal, 38% commercial, 6% other
governmental payors and self pay, and 1% other.
Scripps Green Hospital joined the Scripps Health system in 1991. Scripps
Green Hospital has 173 acute-care licensed beds. Scripps Green Hospital is unique
because it shares its campus with Scripps Clinic, which houses a large medical group,

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so all physicians who admit patients at Scripps Green Hospital are part o f the Scripps
Clinic Medical Group. Scripps Green Hospitals payor mix is approximately 54%
Medicare, 0% MediCal, 41% commercial, 3% other governmental payors and self pay,
and 2% other.
Scripps Mercy Hospital has two campuses, one in the Hillcrest area and one in
Chula Vista. The Scripps Mercy Hospital San Diego (Hillcrest) location o f Scripps
Mercy Hospital was founded in 1890 and is San Diegos oldest hospital as well as its
only Catholic medical center. It joined the Scripps system in 1995. Scripps Mercy
Hospital San Diego has 700 licensed beds. In October, 2004 Scripps Mercy Hospital
expanded to include Scripps Mercy Hospital Chula Vista which has another 183 acutecare licensed beds. Because o f its locations and charitable mission, Scripps Mercy
Hospital renders a lot o f uncompensated care as evidenced by the high percentage of
other governmental and self pay patients which includes no-pay patients. Scripps
Mercy Hospital San Diegos payor mix is approximately 31% Medicare, 22%
MediCal, 32% commercial, 12% other governmental payors and self pay, and 3%
other. Scripps Mercy Hospital Chula Vistas payor mix is approximately 39%
Medicare, 28% MediCal, 17% commercial, 16% other governmental payors and self
pay, and 0% other.
The Scripps Health system employs over 10,000 individuals, is affiliated with
over 2,600 physicians and operates 11 clinics, an ambulatory surgery center, a home
health center, and various other support services.

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L it e r a t u r e R e v ie w
Process and Outcomes Measures
Hospital performance measures began being collecting in the 1850s by
Florence Nightingale. Nightingale collected data on the number o f deaths per 1,000
sick patients before and after commencement o f sanitary improvements were
conducted. The resulting data suggest that sanitary improvements may have been the
cause o f the drastic reduction in the number o f observed deaths during that time.25
Collecting performance data gives individuals the knowledge with which to make
improvements and then monitor the success o f the improvement activities.
Some performance metrics measure outcomes, such as those used by Florence
Nightingale, and others measure process. While the goal o f performance improvement
activities is often to improve patient outcomes, if outcomes alone are measured, it may
be difficult to determine which activities should be implemented to affect a change in
outcomes. When certain processes are determined to be causal factors o f improved
outcomes, the tracking o f these process measures can more easily guide providers to
the activities on which they should focus. For example, Tu and Cameron conducted a
survey o f physicians at Ontario hospitals about whether acute myocardial infarction
report cards were useful for assessing and improving the quality o f care. Survey
respondents noted that process o f care measures such as post-infarction beta-blocker
and angiotensin-converting enzyme inhibitor use, and cardiac procedure waiting times
were the most useful data, and outcomes data (e.g. 30-day and one-year risk adjusted
AMI mortality rates) the least useful o f the many performance measures published in

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the report card.26 If process measures are indeed correlated with outcomes, then
knowing ones scores on these measures can guide improvement activities which
should result in improved outcomes.
Unfortunately, not all process measures are good predictors o f outcomes. A
study by Griffith, Knutzen, and Alexander compared structure and process measures
used by the Joint Commission on Accreditation o f Healthcare Organizations (JCAHO)
to hospital performance measures derived from Medicare. The results o f the study
indicated that JCAHOs measures were generally not correlated with outcome
measures.27
Other studies have tried to determine whether collecting hospital performance
measures improve quality o f care, however, these studies do not address outcomes.
For instance, a Williams et al article notes that after JCAHO implemented
standardized performance measures, consistent improvements in process o f care
measures for AMI, heart failure, and pneumonia were observed over a two-year
period.

Hospitals were successful in improving process measures, however, the

authors o f this study did not determine whether improved process measures scores
were correlated with improved outcomes. Improving outcomes is the intended goal of
these metrics but is often assumed rather than verified.

Acute M yocardial Infarction Hospital Process Measures


Evidence-based medicine suggests that the eight process measures for acute
myocardial infarction (AMI) used in the Hospital Quality Alliance are correlated with

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improved outcomes. According to the AHRQs National Quality Measures


Clearinghouse, each o f the eight AMI process measures may lead to reduced mortality
and morbidity, yet is underperformed or underutilized with AMI patients . 2 9

1. Percent o f patients without aspirin contraindications who received aspirin within 24


hours before or after hospital arrival and
2. Percent o f patients without aspirin contraindications who are prescribed aspirin at
hospital discharge
A number o f meta-analyses have been conducted that show that patients who
have had an AMI or who had had acute or prior vascular disease have reduced
mortality and incidence o f stroke and recurrent MI when the patient is treated with

30 , 31 , 32,33
aspirin.

The American College o f Chest Physicians recommend in their guideline for


thrombolysis and adjunctive therapy in AMI treatment, that patients with AMI/STelevated myocardial infarction (STEMI) be given aspirin at the initial healthcare
evaluation and then indefinitely thereafter . 3 4 This recommendation received a Grade
1

A which means that the magnitude o f benefits, risk, burdens, and costs is certain and

that randomized controlled trails on the subject generate consistent results.


The American College o f Cardiology/American Heart Association
(ACC/AHA) recommends that patients with STEMI receive aspirin for initial
treatment, for ongoing treatment, and for secondary prevention.

TS

All three o f these

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recommendations are rated as Class I which denotes situations in which interventions


are effective or useful based on evidence and/or consensus.
The European Society o f Cardiology also agrees that patients with AMI should
receive aspirin as noted in their recommendations regarding platelet inhibitor therapy
in patients with AM I . 3 6 They gave this recommendation a rating o f Grade 1 indicating
that it is a situation in which the benefits o f the intervention clearly outweigh the
burden, costs, and risks.

3. Percent o f patients without beta blocker contraindications who received a beta


blocker within 24 hours after hospital arrival and
4. Percent o f patients without beta blocker contraindications who are prescribed a beta
blocker at hospital discharge
There have been many meta-analyses that have concluded that patients with an
37 33 38 39

AMI who receive beta blockers have a reduced risk o f mortality.

Meta

analyses have also determined that beta-blockers are effective for the secondary
prevention of coronary events . 3 9 , 4 0
The ACC/AHA recommends with a Class I rating that patients with STEMI
receive prompt administration o f oral beta-blockers unless contraindicated. The
ACC/AHA also recommends with a Class I rating that beta-blockers should be
continued indefinitely unless contraindicated for secondary prevention management of
patients with STEMI . 3 5

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The European Society o f Cardiology agrees that patients with STEMI receive
beta-blockers for acute treatment, to prevent reinfarction, to improve survival, and for
primary prevention of sudden cardiac death . 4 1 Both recommendations for initial
treatment and secondary prevention received a Class I rating.

5. Percent o f patients with left ventricular systolic dysfunction (LVSD) and without
both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker
(ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge
Meta-analyses by Latini et al and the ACE Inhibitor Myocardial Infarction
Collaborative Group both determined that early ACEI therapy reduced 30-day
mortality compared to those who received a placebo

4 2 ,4 3

A meta-analysis by

Domanski et al also showed that ACEIs given in patients with AMI reduced mortality,
cardiovascular death, and sudden cardiac death as compared with patients who
received a placebo . 4 4
Lee et al conducted a meta-analysis which showed that for patients with highrisk AMI, the use o f ARBs compared with the use o f ACEIs made no difference in
mortality rates

45

The ACC/AHA recommends that patients with STEMI should be prescribed an


ACEI at the time o f hospital discharge for long-term management unless
contraindicated. The ACC/AHA also recommends that patients with STEMI with left
ventricular ejection fraction (LVEF) o f less than 40% or patients who have clinical or
radiological signs o f heart failure and who are intolerant o f ACEIs should be

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prescribed an ARB at the time of hospital discharge for long-term management . 3 5 Both
o f these recommendations received a Class I rating.
Similarly, the European Society o f Cardiology made the Class I
recommendation that patients with AMI beyond the first 24 hours who have left
ventricular dysfunction (defined as LVEF less than 45%) or overt heart failure should
receive an ACEI . 4 6

. Percent of patients with history o f smoking cigarettes who are given smoking

cessation advice or counseling during the hospital stay


A meta-analysis by Wilson et al determined that smoking cessation reduces
mortality in patients who have had a myocardial infarction (MI) . 4 7 Similarly, a meta
analysis by Critchley and Capewell determined that patients with coronary artery
disease (CAD) who quit smoking have a lower risk o f death as compared to patients
with CAD who continue to smoke . 4 8
A Houston et al retrospective analysis showed that compared with those who
did not receive smoking cessation counseling, smokers who did receive inpatient
counseling had lower rates o f 30-day, 60-day, and two-year mortality . 4 9 A
retrospective analysis conducted by Rea et al determined that for patients who have
had an MI, smoking was associated with an elevated risk for recurrent coronary
events . 5 0 Further, a guideline developed by the European Society o f Cardiology notes
that the most effective o f all secondary prevention measures for patients who have had
a STEMI is smoking cessation

41

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7. Percent o f patients receiving percutaneous coronary intervention (PCI) during the


hospital stay with time from hospital arrival to PCI o f 120 minutes or less
Multiple meta-analyses have showed that in patients with an AMI, primary
PCI reduces short-term mortality, reinfarction, recurrent ischemia, and stroke
compared to patients who receive thrombolysis . 5 1 , 5 2 ,5 3
Zeymer et al determined that in patients with AMI undergoing primary PCI
who have cardiogenic shock, a longer symptom onset to PCI time is associated with
increased mortality . 5 4 A nonrandomized prospective study by Cannon et al showed
that for patients with AMI undergoing primary percutaneous transluminal coronary
angioplasty (PTCA) (a form o f PCI), a door-to-balloon inflation time o f greater than
two hours is associated with increased in-hospital mortality . 5 5
Until 2007, the Hospital Quality Alliance measured compliance with PCI
within

1 2 0

minutes from hospital arrival, however, the standard has since changed to

measuring PCI within 90 minutes o f hospital arrival. Guidelines such as those


developed by the ACC/AHA recommend that patients with STEMI undergoing
primary PCI should have the procedure performed as quickly as possible, aiming for a
door-to-balloon time o f 90 minutes or less . 3 5

. Percent o f patients receiving thrombolytic therapy during the hospital stay and

having a time from hospital arrival to thrombolysis o f 30 minutes or less.


Meta-analyses conducted by Lau et al and Antman et al both show that the use
o f thrombolytic therapy is associated with a reduction in mortality for patients with

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33 39

AMI. The Fibrinolytic Therapy Trialists Collaborative Group also found a large
mortality reduction between days two to 35 for patients receiving thrombolysis . 5 6
The ACC/AHA and the European Society o f Cardiology both give Class I
recommendations for the use o f thrombolytics unless contraindicated for STEMI
patients . 3 5 ,4 1
The American College o f Chest Physicians recommends that for patients who
receive fibrinolytic therapy, the goal should be 30 minutes from hospital arrival or first
contact with the patient until administration . 3 4

Pay-for-Performance
P4P programs are relatively new in the healthcare industry, although they are
rising in number. While there is growing interest in this area, there is little published
research on P4P in health care and there are only a few studies which demonstrate that
P4P leads to improved quality o f care . 5 7 Most articles on P4P are explanatory. There
are not many research studies that show the rates o f compliance with quality indicators
before and after P4P programs. In fact, Dudely et al conducted a literature search on
performance-based payment in the healthcare industry and only identified eight
randomized controlled trials published on this topic. The eight trials o f performancebased payment were neither consistent in their design o f the independent variable (the
financial incentive offered) nor comparable in terms o f their dependent variable (the
performance indicator measured ) .

11

Dudley et al found that all o f these randomized

controlled trials were aimed to incent individual physicians, a group o f providers, or

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pharmacists. In these eight studies with a total o f ten dependent variables, six
dependent variables were positive which means that there was an effect in the
desired direction, and four were negative . 11 These studies show that there is no clear
consensus as to whether P4P is successful in achieving its desired outcomes.
A more recently published review of empirical studies on financial incentives
designed to improve healthcare by Petersen et al affirmed the Dudley et al findings
that P4P generates positive yet inconsistent desired effects. In the Petersen et al
analysis o f 17 eligible studies addressing financial incentives effect on quality o f care,
none of the studies were based on hospital performance. Five o f the six studies of
physician-level financial incentives, seven o f the nine studies o f provider group-level
financial incentives, and one o f the two studies o f the payment system-level financial
incentives found partial or positive effects on process or access measures. Four studies
suggested unintended effects o f incentives. 58
Other non-randomized controlled studies about P4P programs geared towards
physicians have shown to have some benefits. One study noted that P4P helped the
health plan Wellpoint improve immunization rates from 21% to 58% and pap smear
rates from 79% to 85%.59 A New York P4P program showed that financial incentives
for physicians coupled with other care management tools led to improved scores on
five out o f six process measures and two out o f three outcome measures . 6 0 The
Integrated Healthcare Associations P4P program for California physicians rates
physicians on three domains: clinical measures; patient experience; and information
technology (IT) adoption. Results from year two compared to year one show that 87%

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of physician groups improved their clinical measure scores by an average o f 5.3%, that
65% o f physician groups improved their patient experience average performance, and
that 34% o f physician groups who reported no IT capability in 2003 received partial or
full credit for IT adoption in 2004.

10

Year three results also showed increases in the

number o f patients receiving cervical cancer screenings, diabetes tests, and childhood
immunizations compared to year tw o . 61
There are not as many articles about how well P4P works in the hospital
setting. One such study, the Premier Hospital Quality Incentive demonstration,
showed that this P4P program accomplished its intended results. Quality o f care
improved in all o f the five clinical areas for which quality was measured. Composite
quality scores improved between the first and last quarter o f the first year o f the
demonstration: from 87% to 91% for patients with acute myocardial infarction (heart
attack); from 65 to 74% for patients with heart failure; from 69% to 79% for patients
with pneumonia; from 85% to 90% for patients with coronary artery bypass graft; and
from 85% to 90% for patients with hip and knee replacement.

13

A study in China, while structured differently than the P4P programs aimed
towards improving quality, found that P4P contributed significantly to the increase in
hospital service revenue and hospital cost recovery, which were the aims o f the
project. However, this program also showed that when the bonus system switched
from a weaker incentive to a stronger one, there was an increase in unnecessary care . 6 2
Not all reviews o f P4P programs conclude that the program has produced its
intended benefit. A study by Rosenthal, Frank, Li, and Epstein concluded that paying

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clinicians to reach a common, fixed performance target may produce little gain in
quality for the money spent and will largely reward those with higher performance at
baseline . 5 7 In an article by Sipkoff, American Medical Association Secretary John H.
Armstrong, MD took a harder stance, although it was not supported by any data,
stating that some so-called pay-for-performance initiatives are a lose-lose proposition
for patients and their doctors. The only benefit is to health plans. Done right, these
programs can improve medical care; done wrong, they can harm patients.
Furthermore, a review o f empirical literature conducted by Rosenthal and Frank
concluded that there is little evidence to support the effectiveness o f paying for quality
in healthcare . 6 4
The research that has been conducted thus far on pay-for-performance
programs for healthcare providers does address whether scores on P4P measures have
improved. However, studies that look at whether the improved scores on the P4P
process measures do indeed result in improved outcomes have been scarce. The
assumption is that based upon evidence-based literature, outcomes should improve,
but research on P4P programs has not conclusively proved that assumption to be
correct.
Fonarow et al used the ACC/AHA performance measures to test the
relationship between heart failure P4P metrics and outcomes. They found that none of
the five performance measures was significantly associated with reduced early
mortality risk and only one measure was associated with 60 to 90 day post-discharge
mortality or rehospitalization. The authors concluded that additional measures and

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better methods for identifying and validating heart failure performance measures may
be needed to improve care o f heart failure patients . 6 5
The evidence shows that improvements on the eight AMI process measures
used by the Hospital Quality Alliance should result in improved outcomes. However,
the evidence for this assumption was not gathered from P4P programs. If everything
else is held constant and process measures improve, outcomes improve according to
the literature. However, what if other factors are not held constant? Pay-forperformance models financially reward scores on certain measures. By rewarding
some quality indicators and not others, one can assume that the measures that are
rewarded may increase, but one cannot assume that the measures that are not rewarded
will remain constant. If some quality measures that are not rewarded decrease because
o f the increased emphasis and allocation o f resources on the measures that are
financially rewarded, then what effect does that decrease have on overall quality? The
question remains unanswered as to whether the net effect of P4P programs is positive
(i.e. decreased mortality/increased outcomes) or whether the net affect o f P4P
programs is constant or is correlated with worse outcomes.

H ypo th eses
Specific Aim 1 - To determine the relationship between participation in a pay-forperformance program and scores on process measures.

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While a literature review suggests that P4P programs generally result in their
intended outcomes, it is not consistently the case. My research aims to determine
whether AMI process measure scores improved due to participation in P4P programs.
Hypothesis 1 a): Process measure scores will not improve due to
participation in pay-for-performance.
Hypothesis 1 b): Process measure scores will improve due to
participation in pay-for-performance.

Specific Aim 2 - To determine whether pay-for-performance programs succeed in


improving the overall quality o f patient care as evidenced through the outcome
measure o f mortality.
While evidence-based medicine shows that improved scores on process
measures can improve patient outcomes, the data collected thus far on pay-forperformance programs only suggests that pay-for-performance programs improve
scores on process measures. My research aims to extend the analysis to whether
improved scores on process measures indeed improve clinical outcomes within the
context o f hospitals participating in pay-for-performance programs.
Pay-for-performance programs present incentives to providers to focus on the
measures that lead to increased reimbursement. There has been little research
conducted on whether unintended consequences o f P4P negatively impact patient
outcomes. My research on patient outcomes also aims to shed light on whether
focusing resources on the P4P measures results in decreased quality o f care in non-

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measured indicators which outweigh the positive benefits o f P4P programs or whether
P4P programs improve the overall quality o f care through increased attention on
performance measures. If patient mortality increases through P4P, one should
investigate the former conclusion and if patient mortality decreases through P4P, one
should investigate the latter conclusion.
Hypothesis 2 a): Pay-for-performance programs will not improve
clinical outcomes.
Hypothesis 2 b): Pay-for-performance programs will improve clinical
outcomes.

C o nceptual M odel
Both aims o f this study can be addressed through the same conceptual model.
The conceptual model is depicted in Attachment III. The conceptual model shows that
there are a number o f factors that may affect outcomes for patients with acute
myocardial infarction. There are six main factors that may contribute to mortality rates
after an AMI: increased P4P scores on process measures; patient demographics;
hospital characteristics; patients medical condition; treatment; and patient behavior.
The belief is that all six factors can have a direct effect on patient outcomes.
There are many potential interactions between the six factors contributing to
outcomes. Patient demographics can affect patient behavior, treatment, and patients
medical condition. Hospital characteristics can affect treatment and pay-forperformance process measures. A patients medical condition can affect treatment and

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patient behavior. Patient behavior can affect treatment and a patients medical
condition.
The conceptual model elucidates the fact that there are many interrelated
components affecting outcomes, which is why it is essential to hold as many o f these
factors possible constant in order to determine how increases/changes in P4P scores
alone affect patient outcomes.

D ata
M ain Analysis
Patients with acute myocardial infarctions seen at Scripps Memorial Hospital
Encinitas, Scripps Memorial Hospital La Jolla, Scripps Green Hospital, Scripps Mercy
Hospital San Diego, and Scripps Mercy Hospital Chula Vista from the time period
January 1, 2003 to December 31, 2005 are all included in this study. July 1, 2004 is
the date that the Scripps hospitals began participating in the CMS Hospital Quality
Alliance (HQ A) pay-for-reporting program, therefore, there are 18 months o f data
from before the initiative began and 18 months o f data from after the initiative started.
The total patient population is 1,924 patients before participation in the Hospital
Quality Alliance and 2,030 patients after participation began, for a total o f 3,954
patients included in the study. [Of note is the fact that data is not available from
Scripps Memorial Hospital Encinitas from January, 2003 to June, 2004. During that
timeframe Encinitas used the National Registry o f Myocardial Infarction (NRMI)
electronic application to track clinical information such as aspirin or beta blockers at

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arrival instead o f MIDAS+. The older NRMI data could not be located, therefore, it
was not included in this analysis.]
Scripps Health patient level data from its participation in the Hospital Quality
Alliance is being used. While the HQA is a pay-for-reporting (P4R) program, it is the
precursor to a P4P program beginning on October 1, 2008. While not a true P4P
program currently, since it is well known in the industry that it is moving towards a
P4P program, hospitals are trying to achieve high scores to well position themselves
for the future. Therefore, HQA data is used as an approximation for future P4P
keeping in mind that P4P results may be greater/different than that through P4R. For
example, a study by Lindenauer et al found that performance on P4P metrics improved
with both P4R and P4P programs, however, hospitals participating in P4P improved
their scores more than hospitals participating in P4R . 6 6 It is expected that directional
effects o f P4R and P4P will be the same but that the magnitude o f the impact on
process measure scores and outcomes may be different.

Additional Analysis
An additional analysis was conducted using nation-wide hospital data. For the
additional analysis, data on compliance with seven AMI indicators was used. [The
indicator for PCI within 120 minutes was excluded due to inconsistency o f data
collected, as one time period reported PTCA within 90 minutes instead o f PCI within
120 minutes.] An indicator was also added to denote an overall process measure score.
This indicator is called Weighted Average Score and was calculated by adding up

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all the numerators for the seven individual measures and dividing that number by the
sum o f all the individual measures denominators. Premier, Inc. hospitals data,
Scripps Health hospitals data, and other national Hospital Quality Alliance
participants data are included in this analysis. Observations were conducted over
various timeframes between October 1, 2002 and June 30, 2005.
Data from 10/02-9/03 (before the Premier Hospital Quality Incentive
Demonstration) was collected from the 54 Premier, Inc. hospitals participating in the
baseline data collection phase o f the Demonstration. These 54 Premier, Inc. hospitals
represent 70,860 patients. Data from five Scripps Health facilities over the same time
period representing 4,511 patients was also used. (Scripps Memorial Hospital La Jolla
data was unable to be obtained from

1 0

/ 0 2 - 1 2 / 0 2 , therefore, it was excluded from the

analysis.)
Another observation was conducted from 1/04-6/04 (after the Premier Hospital
Quality Incentive Demonstration and before the Hospital Quality Alliance). Data was
collected from 54 Premier, Inc. hospitals representing 37,422 patients for this time
frame. Data from five Scripps Health facilities over the same time period from 1/046/04 representing 2,388 patients was also collected.
One more time frame o f data was collected from 7/04-6/05 (after HQA). Data
from the same 54 Premier, Inc. hospitals representing 71,914 patients was collected as
well as data from the same five Scripps Health facilities representing 3,890 patients. In
addition, data from 4,180 other US hospitals (excluding the five Scripps Health and 54
Premier, Inc. facilities) participating in HQA representing 1,707,557 patients was

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collected for the time period 7/04-6/05. [Note that additional Premier, Inc. hospitals
joined the Premier Hospital Quality Incentive Demonstration over time. Fifty-four
hospitals participated in the program from the time o f baseline data collection and
those were the facility scores used for this analysis.]

D ata Sources
The majority o f the data used for this research is gathered from the Scripps
Health electronic data systems, MIDAS+ and TRENDSTAR. See Table 1. Scripps
Health uses MIDAS+ for quality and outcomes reporting and maintenance.
Information compiled from chart reviews for the P4P measures used in this study is
stored in the MIDAS+ system. TRENDSTAR is another electronic database which is
used by Scripps Health for primarily financial purposes. TRENDSTAR houses both
clinical and financial data. The same patients are in both the MIDAS+ and
TRENDSTAR systems.

Table 1: Variable Sources


Data Source
MIDAS+

MIDAS+ or TRENDSTAR

Variables
Alive/dead status at discharge (and post-discharge
for patients who have been readmitted)
Aspirin at Arrival
Aspirin at Discharge
Beta Blocker at Arrival
Beta Blocker at Discharge
ACEI or ARB for LVSD
Adult Smoking Cessation Advice/Counseling
PCI Received within 120 Minutes
Thrombolytic Agent Received within 30 Minutes
o f Arrival
A g e

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Social Security Death Index

Interviews / Misc. Databases

Race
Gender
Martial Status
Religion
Facility
Payor - Access to Care Proxy
Primary Care Physician - Access to Care Proxy
Coronary Artery Disease (CAD)
Prior Myocardial Infarction
Family History o f CAD
Dyslipidemia
Diabetes
Hypertension
Obesity
Depression
Smoking Status within last 12 months
Coronary Artery Bypass Graft (CABG) Surgery
Other Open Heart Surgery
Angioplasty / PCI Treatment
Thrombolysis Treatment
Other Primary Cardiac Procedures (Diagnostic or
Treatment)
No Cardiac Treatment
Readmissions within 30 days
If patient is not classified as deceased in Scripps
Health electronic records:
Date o f Death
Hospital Paid Full Time Employees (FTE) per
Adjusted Occupied Bed
Hospital Rapid Response Team Available
Hospital Chest Pain Center Available
Hospital Cardiovascular Award (as determined by
Solucient, U.S. News & World Report, etc.) during
Year o f Visit
Total Hospital Annual AMI Volume
Average Cardiologist Annual AMI Volume
Annual Hospital AMI Admissions per ICU Beds
Hospital Payor Mix
Teaching Hospital Status (as evidenced by a
Graduate Medical Education program)
Surgical Back-up Available

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The Social Security Death Index was used as one resource to determine post
discharge mortality o f patients in this study. The Social Security Death Index is
populated by the Death Master File (DMF) from the Social Security Administration
(SSA). The database currently contains over 79 million records. The latest update used
for this analysis reflects the most current information provided by the SSA for deaths
through September 30, 2006. The file is created from internal SSA records o f deceased
persons possessing social security numbers and whose deaths were reported to the
SSA. Often this was done in connection with filing for death benefits by a family
member, an attorney, a mortuary, etc. Each update o f the DMF includes corrections to
old data as well as additional names. [NOTE: If someone is missing from the list, it
may be that the benefit was never requested, an error was made on the form requesting
the benefit, or an error was made when entering the information into the SSDI . ] 6 7 The
Social Security Death Index is also used by FlealthGrades, an independent healthcare
rating company, to determine 30-day post discharge and 180-day post discharge AMI
mortality rates . 6 8

D ata E lem ents


Table 2 lists all the variables included in the model under the Empirical
Variable column and also links those variables to the theoretical variables listed in the
conceptual model (Attachment III). Table 2 describes the predicted effect on outcomes

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that each variable may have. The following section describes all variables in more
detail.

Table 2: Conceptual Domains, Theoretical Variables, Empirical Variables, and


Prediction on Outcome
C onceptual
Dom ain
Patient Outcomes
(Dependent
Variable)

Hospital Pay for


Performance Scores

Patient
Demographics

T h eoretical V ariable

E m pirical V ariable

Prediction

Survival Post AMI

D ays Survival Post


AMI
A live/D ead at 30 days

N ot applicable, outcome
o f interest

Readmissions
Aspirin at Arrival
Aspirin at Discharge
Beta Blocker at
Arrival
Beta Blocker at
Discharge
ACEI for LVSD
Smoking Cessation
A dvice
PCI R eceived within
120 Mins
Thrombolytic Agent
R eceived within 30
Mins
A ge

Readmissions within
30 days
Aspirin at Arrival
Aspirin at Discharge
Beta Blocker at
Arrival
Beta Blocker at
Discharge
ACEI for LVSD
Smoking Cessation
A dvice
PCI Received within
120 Mins
Thrombolytic Agent
Received within 30
Mins
A ge

Race

Race

Gender

Gender

A ccess to Care

Insurance Status
Primary Care
Physician (PCP)

Administration o f these
process measures will
decrease mortality^0'56

Older age is associated


with increased risk o f
mortality
Life expectancy rates are
better for whites than for
minorities so minorities
have an increased risk o f
mortality69
Unknown direction o f
effect - being male is
associated with increased
risk o f mortality70,
however, for risk o f
mortality after an AMI,
studies have shown
similar mortality rates
across gender70
Having regular access to
care is associated with
decreased risk o f
mortality71

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Status

Hospital
Characteristics

Education
Income

Data Unavailable

Marital Status

Martial Status

Religion

Religion

Facility

Facility

Nurse Staffing Ratio

Minimum Nurse
Staffing Ratio is set
based upon bed type.
Instead used Paid FTE
per Adjusted Occupied
Bed
Rapid Response Team

Response Team to
AMI in ED / Urgent
Care

Chest Pain Center

Center o f Excellence /
Award for Heart Care

Cardiovascular Care
Award Received
During Year o f Visit

Total Hospital AMI


Volume
Average Cardiologist
AMI Volum e
Level o f Technology
Available

Total Hospital AMI


Adm issions
Average Cardiologist
AMI Adm issions
N o variable included
as Scripps physicians
felt that instead o f
technology, bed level
should be measured

Lower education and


lower incom e are both
associated with increased
risk o f mortality.
Single and w idowed
individuals are associated
with increased risk o f
mortality compared to
married people72
R eligion may impact
treatment decisions and
patient behavior which
may then impact
outcom es yet direction o f
its effect is unknown
The aggregation o f the
hospital characteristics in
each facility may impact
outcomes yet direction o f
its effect is unknown
Higher nurse/staff-topatient staffing ratios may
lead to greater compliance
with performance metrics
and better patient
outcomes
Having a Rapid Response
Team or Chest Pain
Center may lead to
quicker treatment and
better com pliance with
performance metrics
B eing designated as a
Center o f E xcellence for
Heart Care may motivate
com pliance with
performance metrics to
continue to achieve
recognition for high
quality care
Having higher volumes
and more experience
treating AM I patients may
lead to better outcomes
Having more technology
available may lead to
quicker diagnosis and
performance o f process
measures

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Ratio o f AMI
A dm issions to ICU
Beds

Patients M edical
Condition

Hospital Profitability /
Payor Mix

Payor Mix

Teaching Hospital
Status

Teaching Hospital
Status

Surgical Back-Up

Surgical Back-Up

CAD

CAD

Prior MI

Prior MI

Family History o f
CAD

Family History o f
CAD

Dyslipidem ia

Dyslipidem ia

Having more beds


available may lead to
quicker treatment and
therefore better outcomes
Hospitals in better
financial positioning may
be better equipped to
provide quick and
appropriate care in
accordance with
performance metrics.
Hospitals with better
payor m ix m ay have
healthier patients who
m ay have better outcomes
Internal data from Scripps
shows that com pliance on
performance metrics is
greater for teaching
patients
Having surgical back-up
m ay lead to better
outcomes i f com plications
arise
Uncertain effect previous diagnosis o f
CAD could mean that
disease is more severe
(increased risk o f
mortality) or it could
mean that the patient has
a regular source o f care
w hich is w hy CAD was
diagnosed before the heart
attack (decreased risk o f
mortality)
A prior MI is associated
with increased risk o f
mortality73
B e lie f that fam ily history
o f CAD is associated with
increased risk o f mortality
b/c fam ily history o f CAD
is a risk factor for heart
disease74
B e lie f that dyslipidem ia is
associated with increased
risk o f mortality b/c it is
associated with
progression o f
cardiovascular disease75

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Treatment

Patient Behavior

Diabetes

Diabetes

Hypertension

Hypertension

Obesity

Obesity

Stress / Depression

Depression

Severity o f
Illness/Comorbidities

Severity o f Illness;
Risk o f Mortality
excluded as data field
not populated in 2003
Thrombolysis;
Angioplasty; CABG
Surgery; Other Open
Heart Surgery; Other
Cardiac Diagnostic or
Treatment Procedure;
N o Treatment

Thrombolysis;
Angioplasty; CABG
Surgery; Other Open
Heart Surgery; Other
Cardiac Diagnostic or
Treatment Procedure;
N o Treatment
NA

Months Since
Adm ission to Censor
Date

Diet

N o variable included

A lcohol Consumption

N o variable included

Exercise Level

N o variable included

Diabetes is associated
with increased risk o f
mortality after AM I76
B e lie f that hypertension is
associated with increased
risk o f mortality b/c it is a
risk factor for AM I77
B e lie f that obesity is
associated with increased
risk o f mortality b/c it is a
risk factor for heart
disease74
Depression is associated
with increased risk o f
mortality after AM I78
The sicker the patient (the
more com orbidities) the
higher the risk o f
mortality
More invasive treatment
(e.g. open heart surgery)
may have high o f risk o f
mortality, however, sicker
patients m ay have no
treatment or more
invasive treatment than
healthier pts
Months since admission
to censor date may impact
days survival as patients
who were admitted later
have less possible days o f
survival until censor time
than patients admitted
earlier in the 3 year time
period
B e lie f that a diet lacking
in fruits and vegetables is
associated with increased
risk o f mortality b/c it is a
risk factor for AM I79
B e lie f that no alcohol
consumption and
excessive alcohol
consumption are
associated with increased
risk o f mortality b/c they
are risk factors for heart
disease74
B e lie f that having a low
exercise level is

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Smoking Status

Smoking Status within


the past 12 months

associated with increased


risk o f mortality b/c it is a
risk factor for heart
disease74
B e lie f that being a current
smoker is associated with
increased risk o f mortality
b/c it is a risk factor for
heart disease74

Dependent Variables
There are three dependent variables: days survival, alive/dead at 30 days, and
readmissions within 30 days. Mortality/survival time was chosen as a dependent
variable because it is the most crude outcome measure for patients undergoing an
acute myocardial infarction. The days survival time is coded as a continuous variable,
while alive/dead at 30 days is coded as a binary variable.
Readmission rate is another outcome indicator. This variable was chosen
because mortality rates can be inflexible and unlikely to change despite interventions.
Readmissions may be a more elastic variable and therefore, readmissions within 30
days were also tracked. The readmission variable is coded as a binary variable.

Predictor Variables
The predictor variables for this analysis were all chosen due to their
hypothesized relationship to patient outcomes (i.e. the dependent variables). (See
Table 2.) Most o f these variables were collected through the Scripps Health electronic
systems MIDAS+ and TRENDSTAR, although the hospital characteristic variables

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were collected through interviews and other databases. For more detail about how
each variable is coded, please refer to Attachment IV.

Pay-for-Performance Scores
There are nine variables related to P4P scores which comprise the regressors of
interest. There are eight individual variables: 1) the percent o f patients without aspirin
contraindications who received aspirin within 24 hours before or after hospital arrival;
2

) the percent o f patients without aspirin contraindications who are prescribed aspirin

at hospital discharge; 3) the percent o f patients without beta blocker contraindications


who received a beta blocker within 24 hours after hospital arrival; 4) the percent of
patients without beta blocker contraindications who are prescribed a beta blocker at
hospital discharge; 5) the percent o f patients with LVSD and without both ACEI and
ARB contraindications who are prescribed an ACEI or ARB at hospital discharge; 6 )
the percent of patients with history o f smoking cigarettes within the past

1 2

months

who are given smoking cessation advice or counseling during the hospital stay; the
percent o f patients receiving PCI during the hospital stay with time from hospital
arrival to PCI o f 120 minutes or less; and 8 ) the percent of patients without
contraindications to thrombolysis receiving thrombolytic therapy during the hospital
stay and having a time from hospital arrival to thrombolysis o f 30 minutes or less and
one aggregate P4P compliance variable.
Each o f the eight individual variables is coded as a binary variable with the
option o f being non-applicable for a particular patient. Therefore, the aspirin at arrival

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indicator is coded as 1 for yes, 0 for no, and 99 for not applicable. Not applicable
codes are used in instances such as a contraindication to aspirin at arrival (e.g. aspirin
allergy, active bleeding on arrival, Coumadin/warfarin as pre-arrival medication) or
where the measure does not apply such as no thrombolysis therapy was given or the
patient is not a smoker.
In addition to the eight individual regressors o f interest, another variable titled
All Applicable P4P Measures was created to reflect patients who received all
recommended AMI process measures where applicable. The all applicable P4P
measures variable is coded as

for yes and

for no with no option o f not applicable.

The process for determination o f the pay-for-performance scores is as follows:


all patients identified to have an acute myocardial infarction through a discharge
diagnosis coded as 410.00 through 410.92 are included in the MIDAS+ AMI Core
Measure Study. Abstractors review each patient record for those individuals included
in the AMI Core Measure Study and determine whether the patient had a
contraindication to any o f the eight measures. If the patient did have a
contraindication, he/she was excluded from the denominator for the compliance score
for that particular indicator. Therefore, the denominators for the eight individual
measures are different from each other. After each patients record is reviewed for
compliance with the performance metrics, a quality assurance check is completed by
another individual internally. After data is sent from MIDAS+ to CMS for
participation in the Hospital Quality Alliance, CM S designated Quality Improvement
Organization (QIO) Lumetra, does their own quality assurance check on each

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hospitals data. If the Lumetra quality assurance review does not indicate at least 80%
congruence with the hospital data then the hospital does not receive the full Medicare
payment associated with participation in HQA. There were no instances o f data
congruence between Scripps Health facilities and Lumetra less than 80% during this
studys time frame.

Patient Demographics
There are certain patient attributes that are difficult, if near impossible, to
change. These variables categorized as Patient Demographics often have a significant
impact upon outcomes so it is important to control for as many o f these variables as
possible. The patient demographic variables included in this model are: age; race;
gender; payor and primary care physician as proxies for access to care; martial status;
and religion. Ideally, patients with the same clinical condition irrespective o f these
variables should receive the same treatment, however, the variables can impact
treatment decisions and often do affect outcomes.

Hospital Characteristics
There are certain hospital characteristics that may give patients treated in one
hospital a better chance of survival than patients treated in another hospital with
different characteristics. The following hospital characteristics may advantage patients
and are therefore included in this model: high FTE per adjusted occupied bed rates;
having a Rapid Response Team; having a Chest Pain Center; being received an award
for Excellence for Cardiovascular Care; having high hospital and average physician

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AMI volumes; having a low ratio o f AMI patients to ICU beds; having better payor
mixes; being a teaching hospital; and having surgical back-up. These variables were
collected through interviews with physicians and cardiovascular administrators at
Scripps Health and through other databases used in the Strategic Planning, Human
Resources, and Finance departments. A variable for facility was also included in the
model.

Patients Medical Condition


A patients medical condition can have a large impact upon outcomes. It goes
without saying that sicker patients have an increased risk of mortality. Sicker patients
are determined to be those with multiple comorbidities and those with many or severe
complications. There are certain comorbidities that may increase a patients risk o f
mortality due to the fact that these conditions are considered to be risk factors for heart
disease and/or AMI. The risk factors that are included as variables in this model are:
CAD; prior MI; family history o f CAD; dyslipidemia; diabetes; hypertension; obesity;
and depression. Comorbidities were determined from additional chronic illnesses, self
medical history, and family medical history that were not only documented in the
medical record but also in either the MIDAS+ or TRENDSTAR electronic system.

Treatment
The type o f treatment that a patient has may impact his/her survival. Surgeries
(CABG surgery and other open heart surgery) are invasive procedures that are
inherently more risky and may have higher rates o f inpatient mortality than less

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invasive procedures. Angioplasty and thrombolytic therapy are other common,


medically recognized treatment options for AMI patients. Patients who do not have
surgery, angioplasty, or thrombolytic therapy and who have another primary cardiac
diagnostic or treatment procedure or who have no cardiac treatment may be at higher
risk for short and long term mortality than those who have an intervention known to
improve outcomes for heart attack patients.
Months since admission to censor date is also included as an independent
variable. Potential days survival until the censor date o f October 1, 2006 is longer for
patients admitted in 2003 than for patients admitted in 2004 or 2005. The months since
admission variable was added to help control for this difference.

Patients Behavior
While Patient Demographics captures patient attributes that are inherent or
hard to change, Patients Behavior is a category o f variables that are more easily
subject to change. Perhaps the single most important patient behavior responsible for
increased morbidity and mortality is smoking status.
Smoking status is an item usually collected through Scripps Healths paper
medical record documents rather than electronically. Unfortunately, not all providers
document smoking status in a consistent fashion in the paper chart. MIDAS+ does
collect whether a patient was a smoker within the past 12 months. For feasibility and
reliability purposes, I will use this data field and categorize smokers as those who have

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smoked within the past


within the past

1 2

1 2

months and non-smokers as those who have not smoked

months.

S t u d y D e s ig n
This study has two aims: to determine the relationship between participation in
a pay-for-performance program and scores on process measures and to determine
whether pay-for-performance programs succeed in improving the overall quality of
patient care. Analyses to address both aims use the same study design: a quasiexperimental time series design.
The study design for this analysis is depicted below.
Oi O 2 O 3 X O4 O 5 06
Oi represents AMI performance metric scores from January to June, 2003, O 2 from
July to December, 2003, O 3 from January to June, 2004 O4 from July to December,
2004, O 5 from January to June, 2005, and 06 from July to December, 2005. X
represents the implementation o f the Hospital Quality Alliance and Scripps Health
participation in this precursor to a pay-for-performance program. Based upon the
outcome patterns of patients treated in the Scripps Health system during the
observations one through six, one can infer whether pay-for-performance had an effect
on the performance metric scores.
According to Campbell and Stanley, the time series design controls many
internal threats to validity including maturation, testing, regression, selection,
mortality, and interactions such as the interaction o f selection and maturation.

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80

Maturation could occur if providers were getting better at treating AMI patients over
time, however, it is unlikely maturation would occur over one time period and not the
others. Furthermore, the instrumentation for data collection did not change over this
time period, so instrumentation is not a likely threat to internal validity. However, the
time series design does not control for the effect o f history. If history is not controlled,
then one cannot rule out the rival hypothesis that a simultaneous event produced the
changed in performance metric scores rather than the pay-for-performance program.
An additional analysis was conducted to address the threat to internal validity
from history. This difference-in-differences analysis compares participants o f pay-forperformance programs. It is difficult to identify and measure performance o f control
group hospitals (i.e. hospitals that did not participate in the Hospital Quality Alliance)
as almost all hospitals nation-wide participate in the HQA. These non-participating
hospitals may be less comparable to the Scripps hospitals because they are unique
facilities such as the Naval Medical Center and the Veterans Administration.
However, there is a group o f hospitals that began a true P4P program before the HQA
began. The Premier, Inc. hospital system began participating in a pay-for-performance
program as a demonstration project with CMS. The Premier Hospital Quality
Incentive Demonstration began in 2003 whereas the Hospital Quality Alliance began
in 2004.
For the Premier, Inc. hospitals, one would expect that if P4P led to better
compliance with performance metrics, then the Premier hospitals would experience a
higher rate o f compliance with the performance metrics once they began their P4P

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program at the end of 2003 compared to before they began participating and compared
to other non-participants. When the rest o f the nation began reporting the same
performance metrics, one would expect that Premier hospitals would be minimally if
at all affected.
If data shows that the rates o f improvement in P4P scores around the middle o f
2004 were fairly small for Premier hospitals but fairly large for Scripps hospitals and
other hospitals nationwide, then one could assume that the Hospital Quality Alliance
lead to the increased scores on the P4P performance measures. Furthermore, if the
change in Premier, Inc. and Scripps Health scores from before to after participation in
the P4P/P4R program is similar, one can interpret that the intervention improved
performance on these quality indicators.
The study design for this additional analysis is represented as:
Oi
O4

O2
O5

X
X
X

O3
06
6 7

Premier, Inc.
Scripps Health
National Trends

Oi represents a composite performance weighted average score for seven AMI


measures from October, 2002 to September, 2003, O2 from

January, 2004 to June,

2004, and O 3 from July, 2004 to June, 2005 all for Premier,

Inc. hospitals. O4

represents a weighted average compliance score for October 2002 to September, 2003,
O 5 from January, 2004 to June, 2004, and 06 from July, 2004 to June, 2005 for
patients seen at Scripps Health facilities. O 7 represents the compliance score from July,
2004 to June, 2005 for other national HQA participating hospitals. The first X in the
row labeled Premier, Inc. represents the implementation o f Premier Hospital Quality

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Incentive Demonstration program which began October 1, 2003, whereas the other
three X s represent implementation o f the HQA.
This modified recurrent institutional cycle design does control for the threat of
history.

S t a t is t ic a l M e t h o d s
Study Aim 1
To test the relationship between participation in the HQA and process measure
scores, time series observations on process measure compliance were collected.
Logistic regression analyses were conducted to determine whether the slope and
intercept o f the process measure compliance scores changed pre-HQA to post-HQA.
Logistic regression is a mathematical modeling approach that can be used to describe
the relationship o f several xs [covariates] to a dichotomous dependent variable.

81

The equation for the logistic regression that was conducted is


y = po + Pifi + P2 O2 *x) + P3 X
where y is compliance with the process measure, Po is the constant/intercept, p is the
coefficient, t is a variable for time and x is a variable to denote a post-HQA score.
The logistic regression analysis was run for each of the process measures
independently with the process measure as the dependent variable. The post-HQA
variable included in the analysis was coded as 0 for a pre-HQA score and 1 for a postHQA score. The other covariate included in the analysis was a time variable which
was coded as 1, 2 or 3 for the three observations before HQA and the three

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observations after HQA. The last variable included in the analysis was an interaction
term between the post-HQA score and the time variable.
In order to test whether an internal threat to history was impacting the study
results, data from Scripps Health was compared to Premier, Inc. and other national
participants in the HQA in an additional data analysis. The absolute differences in
performance for different hospitals over the same time period and for the same
hospitals over different time periods were analyzed using t-tests to determine the
statistical significance o f the change in scores.
A similar analysis to the logistic regression to test the change in process
measures scores before and after participation in the HQA was also conducted
between Scripps Health and Premier, Inc. performance. The equation for the logistic
regression is the same
y = Po+ Plft + P2 ( / 2 *x) + P3 X
however, in the analysis between Scripps Health and Premier, Inc., y is the weighted
average process measure score, p 0 is the constant/intercept, p i - 3 are the coefficients, t
denotes pre/post intervention (either the P4P Premier Hospital Quality Incentive
Demonstration or the P4R HQA program) and x denotes a Premier, Inc. performance
score. The time variable is coded as 1 for before intervention and 2 for after
intervention. The site variable (x) is coded as 0 for Scripps Health and 1 for Premier,
Inc.
SPSS (a predictive analytic software application) was used to conduct all o f the
statistical analyses for both study aims.

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Study Aim 2
Survival analysis was used to determine pay-for-performances impact on
patient outcomes using days survival as the main outcome variable. Survival analysis
is the most appropriate statistical model to use because time is an important
component o f the outcome variable. Survival analysis is a family o f techniques
dealing with the time it takes for something to happen: a cure, a failure, an employee
leaving, a relapse, a death, and so on.
A Cox proportional hazard model was used to conduct the survival analysis.
By using a Cox proportional hazard model, no assumptions are made about the nature
or shape o f the hazard function. The model assumes that the underlying hazard rate
(rather than survival time) is a function o f the independent variables . 8 3
The equation for the Cox proportional hazard model for individual i at time t is
hi(t) = X0 (Oexp{PiXii+...+pkxik}
The baseline hazard function

(t) is the hazard for the individual when all

independent variables values are equal to zero, P is the coefficient, x is the covariate,
and h is the hazard o f death. While no assumptions are made about the shape o f the
underlying hazard function, the model equations.. .do imply two assumptions. First,
they specify a multiplicative relationship between the underlying hazard function and
the log-linear function o f the covariates. This assumption is also called the
proportionality assumption. In practical terms, it is assumed that, given two
observations with different values for the independent variables, the ratio o f the hazard
functions for those two observations does not depend on time. The second

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assumption... is that there is a log-linear relationship between the independent


variables and the underlying hazard function .

83

Significance o f interaction terms

between each covariate and a time variable were analyzed to determine whether the
proportionality assumption was valid.
The outcome variable, days survival, was calculated with a censor date o f
October 1, 2006, therefore, if a patient had not passed away before October 1, 2006,
then he/she was censored. A survival time is described as censored when there is a
follow-up time but the event has not yet occurred or is not known to have occurred . 8 4
All the covariates listed in the Empirical Variable column o f Table 2 were
included for block entry by forward stepwise selection in the survival analysis. A
probability o f 0.05 was required for stepwise entry and a probability o f 0.10 was
required for stepwise removal. A designated maximum o f 20 iterations was used in the
stepwise selection o f covariates. After covariates were added into the model, forced
entry o f one pay-for-performance metric was added so that only one o f the regressors
o f interest was in the model at one time. Hazard ratios were obtained for each
regressor o f interest on the full population o f 3,954 patients and for each six month
time period between January 1, 2003 and December 31, 2005.
In addition, an analysis with forced entry o f all covariates with no regressors o f
interest was conducted on the total patient population in order to see the effect on the
hazard function for each individual covariate including those that were consistently
excluded from the model when stepwise variable selection was employed.

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While the primary data analysis was conducted using survival analysis,
additional outcome analyses were conducted using logistic regression.
The equation for a logistic model is:
z = a+PiXi+P 2 *2 + --+Pp^p
where z equals the odds o f mortality/readmissions, a is the intercept, P is the
coefficient, and x is the independent variable. All o f the covariates included in the
survival analysis (except months since admission to censor date) were included in the
logistic regression analyses, however, the outcome variable changed to alive/dead at
30 days and readmissions within 30 days. [The months since admission to censor date
variable was included in the survival analyses to control for the fact that patients
admitted earlier than others had greater potential days o f survival until censor time
than did patients admitted at later dates. With an outcome variable o f mortality at 30
days, this control variable is no longer needed as all patients were tracked for greater
than 30 days post-discharge regardless o f their admission or discharge date.] For the
logistic regressions, forward stepwise variable selection was employed with a
probability o f 0.05 for entry, 0.10 for removal and a maximum o f 20 iterations. The
logistic regression analyses were conducted on the full model to determine whether
the process measures were significant predictors o f mortality and readmissions within
30 days. For measures that were statistically significant predictors o f mortality and/or
readmissions, time series analyses looking at the hazard functions over all six
observational time periods were also conducted.

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Further logistic regression analyses were conducted to see whether the slope
and intercept o f the 30-day, 90-day, and 180-day mortality rates changed from before
participation in the FIQA to after participation in the HQA.
The equation for this logistic regression is
y = (3o + Pih + $ 2 ^ 2 *x) + P3 X
where y is the mortality rate, Po is the constant/intercept, p 1 . 3 are the coefficients, 1 is a
variable for time and x is a variable to denote a post-HQA score.
The logistic regression analysis was run three times with 30-day, 90-day, and
180-day mortality each as the dependent variable. This analysis is similar to that
conducted on the process measure scores with the post-HQA variable coded as 0 for a
pre-HQA score and 1 for a post-HQA score, the time variable coded as 1, 2 or 3 for
the three observations before HQA and the three observations after HQA, and
inclusion o f the interaction term between the post-HQA score and the time variable.

R esults
Patient Characteristics
Refer to Table 3 for a listing o f variable frequencies for non-continuous
variables and to Table 4 for a listing o f variable means for continuous variables. For
the total patient population of AMI patients discharged from Scripps Health facilities
from January 1, 2003 to December 31, 2005, 63% were men, 67% were Caucasian,
53% were married, and 69% stated a religious affiliation. The average age o f patients
was 70 years. Thirty percent o f the patients were seen at Scripps Memorial Hospital

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La Jolla, 29% at Scripps Mercy Hospital San Diego, 18% at Scripps M ercy Hospital
Chula Vista, 17% at Scripps Green Hospital, and six percent at Scripps Memorial
Hospital Encinitas. Thirty-one percent o f patients identified a primary care provider
and 96% identified a payor.
One hundred percent o f patients had coronary artery disease, seven percent had
a previous myocardial infarction, two percent had a family history o f coronary artery
disease, 37% had dyslipidemia, 29% had diabetes, 62% had hypertension, seven
percent were obese, four percent were depressed and 18% were smokers within the
past 12 months. Again, it is important to note that the results are dependent upon
having comorbidities documented in the medical record as well as the electronic
system. The actual incidence o f comorbidities may be higher than these reported
statistics due to the fact that patients may not mention additional illnesses to their
physicians, physicians may not document all additional illnesses in the medical record,
and/or additional illnesses may be not be able to be documented through the electronic
systems as only a limited number o f diagnoses can be tracked.
Out o f the various treatment options, eight percent o f patients received CABG
surgery, one percent had other open heart surgery, 53% had a percutaneous coronary
intervention, four percent had thrombolytic therapy, 58% had another primary cardiac
diagnostic or treatment procedure (e.g., angiocardiogram, cardiac cath), and 23% had
no cardiac treatment. The percentages o f patients with different treatment options add
up to more than

1 0 0

% because some patients had more than one o f the listed

interventions/treatments.

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Hospital characteristics were also tracked. The mean number o f paid FTE per
adjusted occupied bed was 5.6, while the annual AMI admissions per ICU beds was
13.0. The mean value for annual hospital AMI admissions was 429 and the average
cardiologist AMI annual admissions was 18. Nine percent o f patients were seen in a
hospital with a Rapid Response Team and 29% o f patients were seen in a hospital with
a Chest Pain Center. Thirty-six percent o f patients were seen in a facility that received
a cardiovascular excellence award (e.g. Solucient, U.S. News & World Report) for the
year o f service that the patient was seen. Fifty percent o f patients were seen in
facilities with Graduate Medical Education programs and 76% o f patients were seen in
facilities with cardiovascular surgery back-up capabilities. The mean payor mix for
Scripps Health hospitals was 37% Medicare, 13% Medicaid, 39% commercial, 8 %
other government payors/self-pay/no pay, and 3% other payors including W orkers
Compensation.
Twenty-one percent o f total patients died before the censor date o f October 1,
2006. Ten percent o f patients died within 30 days o f admission, 12% within 90 days o f
admission, and 14% within 180 days o f admission. Five percent o f patients were
readmitted within 30 days.

Table 3: Variable Frequencies for Non-Continuous Variables for Total Patient


Population______________________________
Variable

Sex
Male
Female
Ethnicity
White

2499
1455

63%
37%

2662

67%

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African/American
Native American
Asian/Pac Islander
Other
Unknown
Marital Status
Single
Widowed
Divorced/Separated
Married
Religion
Stated Religion
No Stated Religion
Facility
Chula Vista
Encinitas
Green
La Jolla
Mercy
Identified PCP
No/Unknown
Yes
Identified Payor
No/Unknown
Yes
Censored
Yes/Alive
No/Dead
ACEI or ARB for LVSD
No
Yes
Not Applicable
Smoking Cessation Advice
No
Yes
Not Applicable
Aspirin at Arrival
No
Yes
Not Applicable
Aspirin at Discharge
No
Yes
Not Applicable
Beta Blocker at Arrival
No

126
5
434
638
89

3%
0%
11%
16%
2%

921
687
232
2114

23%
17%
6%
53%

2699
1219

69%
31%

713
249
663
1173
1156

18%
6%
17%
30%
29%

2731
1223

69%
31%

164
3790

4%
96%

3135
819

79%
21%

125
430
3399

23%
77%

157
492
3305

24%
76%

121
2449
1384

5%
95%

185
2977
792

6%
94%

205

9%

53

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Yes
Not Applicable
Beta Blocker at Discharge
No
Yes
Not Applicable
Thrombolysis w/in 30 min
No
Yes
Not Applicable
PCI w/in 120 min
No
Yes
Not Applicable
All Applicable P4P Measures
No
Yes
CABG Treatment
No
Yes
Other Open Heart Surgery
No
Yes
PCI/Angioplasty Tx
No
Yes
Thrombolysis Treatment
No
Yes
Oth Cardiac Proc (Dx or Tx)
No
Yes
No Cardiac Treatment
No
Yes
CAD
No
Yes
Prior Ml
No
Yes
Family History of CAD
No
Yes
Dyslipidemia
No

2010
1739

91%

324
2742
888

11%
89%

113
38
3803

75%
25%

237
188
3529

56%
44%

1055
2899

27%
73%

3650
304

92%
8%

3906
48

99%
1%

1849
2105

47%
53%

3787
167

96%
4%

1670
2284

42%
58%

3032
922

77%
23%

3
3951

0%
100%

3661
293

93%
7%

3871
83

98%
2%

2478

63%

54

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Yes

1476

Diabetes
No
2825
Yes
1129
Hypertension
No
1503
Yes
2451
Obesity
No
3683
Yes
271
Depression
No
3799
Yes
155
Smoker
No or Unknown
3247
Yes
707
Readmit w/in 30 days
No
3748
Yes
206
Rapid Response Team
No
3616
Yes
338
Chest Pain Center
No
2798
Yes
1156
Cardiovascular Award Yr of Visit
No
2514
1440
Yes
Teaching Hospital Status
No
1985
1969
Yes
Surgical Back-Up
No
962
Yes
2992
30-Day Mortality
3554
Alive
Dead
400
90-Day Mortality
Alive
3470
484
Dead
180-Day Mortality
Alive
3382
572
Dead

37%

71%
29%
38%
62%
93%
7%
96%
4%
82%
18%
95%
5%
91%
9%
71%
29%
64%
36%
50%
50%
24%
76%
90%
10%
88%
12%
86%
14%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Table 4: Variable Means for Continuous Variables for Total Patient Population
Variable

Age
Months Since Admission
Paid FTE/Adjusted Occupied Bed
Hospital Annual AMI Admits
Avg Annual Cardiologist AMI Admits
Annual AMI Admits / ICU Beds
Payor: % Medicare
Payor: % MediCal
Payor: % Commercial
Payor: % Other Gvmt Payors / Self Pay
Payor: % Other / Workers Comp

Mean

69.67
26.64
5.60
428.86
18.30
13.01
36.59
13.35
38.65
8.45
3.10

Some o f the patient characteristics changed over the observational time


periods. See Attachment V for a full listing o f variable frequencies at each
observational time period and Table 5 for means o f age and hospital characteristics at
each observational time period. The percent o f male patients ranged from 63% - 69%
in the time periods after participation in the HQA compared to 60% - 61% before. The
mean age o f patients ranged from 7 0 - 7 1 years during observations one through three
and ranged from 67 - 70 years during observations four through six. Observation time
period two and three (from July 1, 2003 to June 30, 2004) had a high percent o f
Asian/Pacific Islander patients (18% - 22%) compared to the other time periods where
the percent o f Asian/Pacific Islander patients ranged from five to nine. As previously
noted, AMI patients seen at Encinitas from January 1, 2003 to June 30, 2004 were not
included in the analysis, which impacted the percent o f patients seen at each Scripps
facility before compared to after participation in HQA. The total patient volume
remained similar over this time frame. Forty-five percent of patients from July 1, 2005

56

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to December 31, 2005 identified a PCP compared to a range from 27% - 34% in the
other time periods.
[Because patients from Encinitas were not included before participation in the
HQA, analyses were conducted excluding Encinitas patients after participation in
HQA to see if the results would change. The general findings remained the same
whether post-HQA Encinitas patients were included or not.]
The percent o f patients treated with PCI generally trended upward over time.
The percent o f patients with thrombolytic therapy slightly decreased over time. There
was also an increase in other primary cardiac diagnostic and treatment procedures
from before to after participation in HQA. Conversely, the percent o f patients
receiving no cardiac treatment decreased steadily from 30% during observation one to
17% in observation six.
There were small increases from before and after participation in HQA with
patients who had a family history o f CAD (one percent before to three percent after)
and patients who had dyslipidemia (30% - 35% before to 40% - 47% after).
Hospital-wide paid FTE per adjusted occupied bed increased from 5.3 in
observation one to 5.8 in observation six. Rapid Response Teams began being
deployed in 2005 and were not present until then. The percent o f patients seen in a
hospital who received a cardiovascular clinical excellence award during the year o f the
patients visit was lower in 2003 (21% - 23%) than in 2004 and 2005 (33% - 48%).
Annual hospital AMI admissions decreased in 2005 (362 - 369) compared to 2003 and

57

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2004 (444 - 464). The annual AMI admissions per ICU bed decreased in 2005 (mean
of 11) compared to a mean o f 14 in 2003 and 2004
Changes in the regressors o f interest over the time periods are detailed in
Figures 1-9. The majority o f the pay-for-performance metrics increased in compliance
over this timeframe. Process measure scores are discussed in more detail in the
Process Measure Analysis section. [Note: The denominators (i.e., n) o f the individual
regressors o f interest are different from each other during the same time periods
because o f instances where the measure is not applicable to certain patients, as
explained in the Data Elements section.]
The percent o f patients who had died before the censor date was highest for the
earlier time periods (i.e., earlier discharge dates) and lowest for the later time periods,
which is as expected. Given that the follow-up time until censoring is longer for the
patients admitted earlier, there is greater opportunity for the patients in the earlier
observation periods to be determined to be deceased. The percent o f patients who had
died within 30 days of discharge decreased from 13% in observation one to eight
percent in observation six. Similar results were seen in 90-day mortality which
decreased over the same time period from 15% to
decreased from 18% to

1 1

1 0

%, and 180-day mortality which

%.

Table 5: Means o f Age and Hospital Characteristics at Each Observation Time Period
Variables

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

Age
Paid FTE per Adj O cc Bed
Hosp Annual AMI Admits

71.03
5.33
460.38

71.75
5.52
444.23

70.09
5.48
453.49

68.78
5.71
463.94

67.43
5.73
362.15

69.52
5.84
368.94

58

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Avg Cardiologist AMI Vol


AMI Admits/ICU Beds
Payor: % Medicare
Payor: % MediCal
Payor: % Commercial
Payor: % Oth Gvmt/SIf Py
Payor: % Oth (Wrk Comp)

17.94
14.21
37.14
14.00
37.14
8.90
2.95

17.80
13.95
37.92
13.93
36.52
8.87
2.87

19.26
13.65
35.61
13.84
39.11
8.25
3.18

20.15
13.90
34.70
12.97
41.73
7.58
3.02

16.73
10.89
37.67
12.75
37.81
8.76
3.30

16.97
10.99
37.51
12.63
38.21
8.69
3.28

Pay-for-Performance Process Measure Analysis

Scripps Performance Results


Compliance with providing all the applicable AMI process measures increased
at Scripps Health over all six observations, going from 60% at observation one to

8 6

at observation six. See Figure 1. The logistic regression for patients receiving all
applicable P4P measures identified that time (beta, 0.28; p < 0.0001) and the postHQA/site (beta, 0.68; p = 0.0002) variables were statistically significant. See Table 6 .

Figure 1: All Applicable P4P Measure Compliance Over Time


All Applicable P4P Measures
100%
90%
80%
70%
60%
50%
40%
30%
20 %
10%

0%

86 %
* - 75%

2Z2%_

n=642
1/1/036/30/03

'

n=548

n=734

n=836

n=668

n=526

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

59

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Table 6: Logistic Regression Results o f Scripps Process Measure Scores Before and
After HQA________________________________________________________________
Regressor of
Interest

All Applicable P4P


Time
0.2784
Post
0.6754
Post by Time
0.0564
Constant
0.1140
Aspirin at Arrival
Time
0.0877
Post
0.0943
Post by Time
0.4691
Constant
2.5121
Aspirin at Discharge
0.1729
Time
Post
0.7039
Post by Time
0.2073
Constant
2.0316
Beta Blocker at Arrival
Time
0.1889
Post
1.5529
Post by Time
-0.2458
Constant
1.5353
Beta Blocker at Discharge
Time
0.1300
Post
0.2992
Post by Time
0.2590
1.5555
Constant
Smoking Cessation Advice
Time
0.3486
Post
0.2455
Post by Time
0.3639
Constant
0.0492
ACEI or ARB for LVSD
-0.0971
Time
Post
-0.6955
Post by Time
0.5573
Constant
1.2881
Thrombolysis w/in 30 mins
0.1698
Time
-0.8566
Post
Post by Time
0.1838
-1.1957
Constant
PCI w/in 120 minutes
Time
0.8992

S.E.

Wald

df

Sig.

Exp(B)

95% Cl Exp(B)
Lower Upper

0.0575
0.1837
0.0921
0.1240

23.411
13.514
0.3753
0.8454

1
1
1
1

0.0000
0.0002
0.5401
0.3579

1.3210
1.9648
1.0580
1.1208

1.1801
1.3707
0.8833

1.4787
2.8165
1.2673

0.1333
0.5025
0.2807
0.2794

0.4329
0.0352
2.7934
80.837

1
1
1
1

0.5106
0.8511
0.0947
0.0000

1.0917
1.0989
1.5986
12.3313

0.8406
0.4104
0.9222

1.4178
2.9426
2.7713

0.1079
0.4060
0.2168
0.2276

2.5697
3.0061
0.9142
79.657

1
1
1
1

0.1089
0.0829
0.3390
0.0000

1.1888
2.0216
1.2304
7.6264

0.9622
0.9123
0.8044

1.4687
4.4797
1.8819

0.1048
0.4324
0.2099
0.2157

3.2504
12.899
1.3705
50.645

1
1
1
1

0.0714
0.0003
0.2417
0.0000

1.2079
4.7251
0.7821
4.6425

0.9837
2.0248
0.5183

1.4834
11.027
1.1802

0.0892
0.3006
0.1559
0.1917

2.1246
0.9909
2.7594
65.844

1
1
1
1

0.1450
0.3195
0.0967
0.0000

1.1388
1.3488
1.2956
4.7376

0.9562
0.7483
0.9545

1.3563
2.4313
1.7587

0.1433
0.4720
0.2454
0.3129

5.9188
0.2706
2.1987
0.0248

1
1
1
1

0.0150
0.6029
0.1381
0.8750

1.4171
1.2783
1.4390
1.0505

1.0701
0.5069
0.8895

1.8767
3.2238
2.3280

0.1608
0.5127
0.2614
0.3441

0.3641
1.8407
4.5455
14.015

1
1
1
1

0.5462
0.1749
0.0330
0.0002

0.9075
0.4988
1.7460
3.6260

0.6621
0.1826
1.0460

1.2438
1.3624
2.9143

0.3050
1.0094
0.4901
0.6010

0.3099
0.7201
0.1406
3.9587

1
1
1
1

0.5777
0.3961
0.7077
0.0466

1.1851
0.4246
1.2018
0.3025

0.6518
0.0587
0.4598

2.1548
3.0705
3.1407

0.1952

21.220

0.0000

2.4575

1.6763

3.6029

60

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Post
Post by Time
Constant

2.3538
-0.5450
-2.6526

0.5767
0.2655
0.4468

16.658
4.2141
35.248

1 0.0000
1 0.0401
1 0.0000

10.5252
0.5799
0.0705

3.3989 32.593
0.3446 0.9756

While the all applicable P4P measure improved consistently over the six
observation time periods, the change over time in the individual AMI process
measures was not as consistent. All o f the eight individual P4P measures increased
from observation one to observation six, however, most scores fluctuated over time.
Aspirin at arrival compliance ranged from 93% - 95% before the HQA to 96% - 99%
after the HQA. Beta blocker at arrival ranged from 85% - 89% before the HQA to
94% - 96% after the HQA. ACEI or ARB for LVSD ranged from 71% - 79% before
the HQA to 74% - 87% after the HQA. Smoking cessation advice ranged from 57% 75% before the HQA to 71% - 89% after the HQA. Aspirin at discharge ranged from
90% - 94% before the HQA to 96% - 98% after the HQA. Beta blocker at discharge
ranged from 83% - 89% before the HQA to 90% - 95% after the HQA. Thrombolytic
agent within 30 minutes ranged from 24% - 37% before the HQA to 14% - 31% after
the HQA. PCI within 120 minutes ranged from 16% - 52% before the HQA to 53% 71% after the HQA. See Figures 2-9.
Analysis was conducted to determine whether compliance in these process
measures was statistically different after participation in the HQA compared to before
For four o f the AMI process measures: aspirin at arrival; aspirin at discharge; beta
blocker at discharge; and thrombolytic agent within 30 minutes, there were no
statistically significant terms o f the equation. The post-HQA variable (beta, 1.55; p =

61

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

0.0003) was statistically significant in the beta blocker at arrival equation. Time was
the only variable with a statistically significant beta/coefficient for smoking cessation
advice (beta, 0.35; p = 0.015). ACEI or ARB for LVSD had statistically significant
coefficients for the interaction term between post-HQA and time (beta, 0.56; p =
0.033). The time variable (beta, 0.90; p < 0.0001), the post-HQA variable (beta, 2.35;
p < 0.0001), and the interaction term (beta, -0.55; p = 0.04) were all statistically
significant for PCI within 120 minutes. See Table 6 .

Figure 2: Aspirin at Arrival Compliance Over Time


Aspirin at Arrival
100 %

99%
96%
94%
92%

i3%

90%
n=489

n=414

n=457

n=497

n=409

n=304

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

88%

62

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Figure 3: Beta Blocker at Arrival Compliance Over Time


!

Beta Blocker at Arrival


100%

96%

95%
90%

89%

85%
80%
75%

n=420

n=380

n=400

n=405

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

n=344
1/1/056/30/05

7/1/0512/31/05

Figure 4: ACEI or ARB for LVSD Compliance Over Time


ACEI for LVSD
90%
87%

85%
80%

79%

75%
71%

70%

*4%

65%
60%
55%
50%
1/1/036/30/03

n=89

n=94

n=106

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

n=69
1/1/056/30/05

7/1/0512/31/05

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 5: Smoking Cessation Advice/Counseling Compliance Over Time


Smoking Cessation Advice
95%
90%
85%
80%
75%
70%
65%
60%
; 55%
! 50%

89%

- 73%

57%
n=101
1/1/036/30/03

7/1/0312/31/03

71%

n=130

n=129

1/1/046/30/04

7/1/0412/31/04

n=93
1/1/056/30/05

7/1/0512/31/05

Figure 6: Aspirin at Discharge Compliance Over Time


Aspirin at Discharge
100 %

98%

98%
96%

156%

94%

94%

92%
90%
88 %
86 %

n=527

n=451

n=585

n=669

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

n=516

84%
1/1/056/30/05

7/1/0512/31/05

64

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 7: Beta Blocker at Discharge Compliance Over Time


Beta Blocker at Discharge
100%

95%
90%

90%

89%

85%

;3%

80%
75%

n=491

n=439

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

n=649

n=515

n=414

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

Figure 8: Thrombolytic Agent Within 30 Minutes Compliance Over Time


Thrombosis w/in 30 min
100%

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

28%

!4%

4%
n=38

n=30

1/1/036/30/03

7/1/0312/31/03

n=18
1/1/046/30/04

n=28
7/1/0412/31/04

n=21

n=16

1/1/056/30/05

7/1/0512/31/05

65

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 9: PCI Within 120 Minutes Compliance Over Time


PCI w/in 120 min
100%

90%
80%
70%
60%
50%
40%
30%

!6 %

52%
28%

20 %
10%

n=72

0%

1/1/036/30/03

7/1/0312/31/03

n=67
1/1/046/30/04

n=77
7/1/0412/31/04

n=68

n=58

1/1/056/30/05

7/1/0512/31/05

Premier, Inc. and Scripps Health Performance Results


The data collected in order to determine whether other events in history could
create another legitimate rival hypothesis to P4P as a causal factor for increased
performance metric scores showed that Premier, Inc. and Scripps Health scores
increased at each time interval analyzed. See Figure 10 and Table 7.
Scripps Health and Premier, Inc. hospitals started out at statistically
significantly different levels o f performance with the AMI P4P indicators as measured
by the weighted average score (absolute difference, 7.7; 95 Cl, 6 .9-8.5; p < 0.0001).
See Table 8 . After Premier hospitals began participating in the Premier Hospital
Quality Incentive Demonstration, their performance increased (absolute difference,
1.3; 95 Cl, 0.9-1.6 ; p < 0.0001) as did Scripps (absolute difference, 2.7; 95 Cl, 1.0-4.3;
p = 0.002), although Scripps did not participate in any P4P or P4R program over this

66

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

time. The process measure scores o f the two facilities were still significantly different
(absolute difference, 6.3; 95 Cl, 5.3-7.3; p < 0.0001) at the second observation from
1/04-6/04.
Between observation two (1/04-6/04) and observation three (7/04-6/05), both
health systems began participating in the HQA. From time two to time three, Premier,
Inc. improved its performance at a statistically significant level (absolute difference,
0.9; 95 Cl, 0.6-1.1; p < 0.0001) as did Scripps Health (absolute difference, 4.9; 95 Cl,
3.5-6.4; p < 0.0001), yet their performance was still statistically different from each
other (absolute difference, 2.2; 95 Cl, 1.5-2.9; p < 0.0001). [Of note for the time
period three is that the Scripps Health facilities performance was similar (i.e., not
statistically different) to that o f other HQA participants nation-wide.]
Scripps Health and Premier, Inc. had different levels o f performance during the
first observation. The ceiling o f performance is 100%, so Premier, Inc. starting at 93%
compliance with the process measures had less opportunity to improve than did
Scripps Health at 85% compliance. Because the two systems started out at different
levels o f performance, the slope and intercepts o f their levels o f performance were
tested against each other. The time variable (beta, 0.23; p = 0.002) and the Premier/site
variable (beta, 0.85; p < 0.0001) were both statistically significant in the comparison
of facility scores from observation one to observation two. See Table 9. From
observation two to observation three, the time variable (beta, 0.59; p < 0.0001), the
Premier variable (beta, 1.23 ; p < 0 .0001) and the time and site interaction variable
(beta, -0.41, p < 0.0001) were all statistically significant. See Table 10.

67

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Figure 10: Premier, Inc. and Scripps Health Weighted Average AMI Process Measure
Compliance Over Time

Weighted Average AMI Process Measure Score


100%
95 %
90 %

Premier
Scripps

85 %
80 %
75 %
10/ 02 - 9/03

1/ 04 - 6/04

7/ 04 - 6/05

Table 7: Premier, Inc., Scripps Health, and Other National HQA Participants Process
Measure Scores
1 0 /0 2 -9 /0 3
Premier, Inc.

Aspirin on Arrival
Aspirin at Discharge
ACEI or ARB for LVSD
Beta Blocker on Arrival
Beta Blocker at Discharge
Smoking Cessation Advice
Thrombolysis w/in 30 mins
Weighted Average Score

1 /0 4 -6 /0 4

7/04-6/05

%
96.4
96.8
85.5
93.3
94.4
78.3
41.8
93.1

n
(13,436)
(18,247)
(4,115)
(11,495)
(17,538)
(5,520)
(509)
(70,860)

%
95.9
96.9
82.6
92.7
95.0
90.4
47.8
94.3

n
(7,256)
(10,262)
(2,384)
(6,136)
(10,016)
(1,322)
(46)
(37,422)

%
96.1
96.8
85.0
94.3
95.8
93.6
38.5
95.2

n
(14,012)
(18,627)
(2,394)
(11,272)
(19,155)
(6,220)
(234)
(71,914)

93.6
92.0
76.6
84.0
82.9
54.1
27.6
85.3

(1,054)
(1,075)
(197)
(907)
(1,006)
(196)
(76)
(4,511)

94.4
93.0
64.3
84.5
86.3
75.0
18.2
88.0

(517)
(627)
(84)
(465)
(608)
(76)
(11)
(2,388)

97.0
96.5
83.8
93.1
91.9
78.6
20.8
93.0

(756)
(1,100)
(74)
(625)
(1,073)
(238)
(24)
(3,890)

Scripps Health

Aspirin on Arrival
Aspirin at Discharge
ACEI or ARB for LVSD
Beta Blocker on Arrival
Beta Blocker at Discharge
Smoking Cessation Advice
Thrombolysis w/in 30 mins
Weighted Average Score
Oth Nat'l HQA Participants

68

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Aspirin on Arrival
Aspirin at Discharge
ACEI or ARB for LVSD
Beta Blocker on Arrival
Beta Blocker at Discharge
Smoking Cessation Advice
Thrombolysis w/in 30 mins
Weighted Average Score

94.7
94.8
82.3
90.6
93.4
88.4
38.0
92.4

(376,314)
(406,184)
(51,869)
(316,685)
(415,266)
(129,657)
(11,582)
(1,707,557)

Table 8: Differences in Performance Measure Scores Between Scripps Health,


Premier, Inc., and Other National HQA Participants Before and After P4P and P4R

Same Hosp; Diff Time

Premier, Inc.
Premier, Inc.
Premier, Inc.
Premier, Inc.
Scripps Health
Scripps Health
Scripps Health
Scripps Health

Timeframe

Wghtd
Avg

date
10/02-9/03
1/04 - 6/04
1/04 - 6/04
7/04 - 6/05
10/02-9/03
1/04 - 6/04
1/04 - 6/04
7/04 - 6/05

%
93.1
94.3
94.3
95.2
85.3
88.0
88.0
93.0

#
(70,860)
(37,422)
(37,422)
(71,914)
(4,511)
(2,388)
(2,388)
(3,890)

10/02-9/03
10/02-9/03
1/04-6/04
1/04-6/04
7/04 - 6/05
7/04 - 6/05
7/04 - 6/05
7/04 - 6/05

93.1
85.3
94.3
88.0
95.2
93.0
93.0
92.4

(70,860)
(4,511)
(37,422)
(2,388)
(71,914)
(3,890)
(3,890)
(1,707,557)

Absolute Difference
Between Groups

95% Cl

p-value

1.3

0.9- 1.6

< 0.0001

0.9

0.6-1.1

< 0.0001

2.7

1.0-4.3

0.0022

4.9

3.5-6.4

< 0.0001

7.7

6.9 - 8.5

< 0.0001

6.3

5.3-7.3

< 0.0001

2.2

1.5 -2.9

< 0.0001

0.6

not statistically
significantly different

Same Time; Diff Hosp

Premier, Inc.
Scripps Health
Premier, Inc.
Scripps Health
Premier, Inc.
Scripps Health
Scripps Health
Oth Nat'l HQA

Table 9: Scripps Health and Premier, Inc. Performance Before and After P4P
Before P4P

S.E.

Time
0.2326 0.0758
Premier
0.8546 0.1115
Premier by Time
-0.0204 0.0804
Constant
1.5295 0.1052
Note: Time coded as 1 for 10/02-9/03 and

Wald

df

Sig.

9.4159
1 0.0022
58.731
1 0.0000
0.0641
1 0.8001
1 0.0000
211.46
2 for 1/04-6/04.

Exp(B)

1.2618
2.3504
0.9798
4.6159

95% Cl Exp(B)
Lower Upper

1.0877
1.8890
0.8370

69

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.4639
2.9246
1.1470

Table 10: Scripps Health and Premier, Inc. Performance Before and After P4R
Before P4R

S.E.

Wald

df

1
Time
0.5853 0.0889 43.379
Premier
1.2277 0.1487 68.170
1
Premier by Time
1
-0.4138 0.0933 19.687
1
Constant
1.4093 0.1408 100.23
Note: Time coded as 1 for 1/04-6/04 and 2 for 7/04-6/05.

Sig.

Exp(B)

0.0000
0.0000
0.0000
0.0000

1.7956
3.4134
0.6611
4.0931

95% Cl Exp(B)
Lower Upper

1.5086
2.5504
0.5507

2.1373
4.5683
0.7937

Process-Outcomes Link Analysis

Survival Analysis Mortality Results


The results o f the survival analysis to test whether process measures affect
outcomes are presented in Table 12. This survival analysis was conducted on the total
population o f 3,954 patients for each regressor o f interest. Three o f the regressors of
interest had a statistically significant impact on outcomes (i.e., better mortality) at a pvalue o f less than 0.05: aspirin at arrival (hazard ratio, 0.53; 95 Cl, 0.39-0.71 ; p <
0.0001); beta blocker at arrival (hazard ratio, 0,62; 95 Cl, 0.46-0.82; p = 0.0009); and
ACEI or ARB for LVSD (hazard ratio, 0.67; 95 Cl, 0.46-0.98; p = 0.04). Refer to
Attachment VI for the hazard functions o f covariates included in the full model
analysis o f each regressor o f interest.

Table 11: Survival Analysis Results for Regressors o f Interest in Total Population
Measure Name

Aspirin at Arrival
Aspirin at D/C
Beta Blocker at Arr
Beta Blocker at D/C
Smk Cess Advice
ACEI for LVSD
Thromb 30 mins
PCI 120 mins

S.E.

Wald

-0.6412
-0.2995
-0.4832
0.0090
-0.0635
-0.4013
0.8405
0.1076

0.1536
0.1576
0.1453
0.1576
0.2922
0.1934
0.4584
0.2974

17.435
3.6134
11.065
0.0033
0.0472
4.3060
3.3622
0.1308

df

1
1
1
1
1
1
1
1

Sig.

Exp(B)

95% Cl Exp(B)
Lower
Upper

0.0000
0.0573
0.0009
0.9544
0.8281
0.0380
0.0667
0.7176

0.5267
0.7412
0.6168
1.0091
0.9385
0.6695
2.3176
1.1136

0.3898
0.5442
0.4640
0.7409
0.5294
0.4583
0.9437
0.6217

70

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0.7116
1.0094
0.8200
1.3743
1.6639
0.9780
5.6915
1.9945

All Applicable P4P

0.0145

0.0828

0.0306

0.8611

1.0146

0.8627

1.1933

While not statistically significant, it is interesting to note that the all applicable
P4P variable has a positive coefficient and a hazard ratio that is greater than 1.0,
denoting that receiving all applicable P4P process measures may be predictive of
worse outcomes (higher mortality). One possible reason for this finding is that
providing thrombolytic agents for AMI treatment is no longer the standard o f care for
hospitals with catheterization laboratories (cath labs) and is now only common in rural
hospitals without high levels o f technology available. All Scripps Health hospitals
have cath labs, therefore, if the variable changed to all applicable and recommended
P4P measures rather than all applicable P4P measures, the results may change.
Indeed, the results did change when an analysis was conducted using an all
applicable and recommended P4P measure that includes seven AMI process measures
and excludes the measure for thrombolytic agent received within 30 minutes. The all
applicable and recommended P4P variable now has a negative coefficient and a hazard
ratio less than one, denoting that it is predictive o f lower mortality. However, the
results are not statistically significant. See Table 13.

Table 12: All Applicable and Recommended P4P Variable Survival Analysis Results
Measure Name

All App & Rec P4P

S.E.

Wald

df

Sig.

Exp(B)

95% Cl Exp(B)
Lower Upper

-0.1020

0.0858

1.4124

0.2347

0.9030

0.7632

1.0685

[Analyses were run using the all applicable and recommended P4P variable to
determine whether any o f the main study findings changed using this variable instead

71

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o f the all applicable P4P variable. While the percent compliance during each
observation period was slightly higher for the all applicable and recommended P4P
variable than the all applicable P4P measure, the results o f the analyses were similar in
that the rate o f improvement before participation in the HQA was not statistically
different than the rate o f improvement after participation in the HQA.]

Survival Analysis Times Series Mortality Results


A time series design was used to determine if there was any difference in the
regressors o f interests impact on outcomes over time. One would expect the impact of
an indicator such as aspirin at arrival to be consistent over time. Some o f the
regressors o f interest showed no consistently statistically significant impact on
outcomes over time. For each time period, beta blocker at discharge, smoking
cessation advice/counseling, thrombolytic agent within 30 minutes, and PCI within
120 minutes did not affect outcomes at a statistically significant level. Aspirin at
arrival was found to be a significant prediction o f lower (i.e. better) mortality for two
o f the six observation time periods (hazard ratio, 0.51; 95 Cl, 0.27-0.98; p = 0.04 for
7/03- 12/03 and hazard ratio, 0.38; 95 Cl, 0.20-0.73; p = 0.004 for 7/04-12/04).
Aspirin at discharge was also a significant prediction o f lower mortality for three
observation time periods (hazard ratio, 0.39; 95 Cl, 0.22-0.71; p = 0.002 for 1/03-6/03;
hazard ratio, 0.45; 95 Cl, 0.23-0.87; p = 0.02 for 7/04-12/04; and hazard ratio, 0.27; 95
Cl, 0.08-0.90; p = 0.03 for 1/05-6/05). Beta blocker at arrival was a predictor o f lower
mortality for one time period (hazard ratio, 0.36; 95 Cl, 0.20-0.66; p = 0.001 for 1/04-

72

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

6/04). One observation time period (1/04-6/04) showed that ACEIs or ARBs for
LVSD improved outcomes (hazard ratio, 0.46; 95 Cl, 0.21-0.99; p = 0.05). Receiving
all recommended P4P measures was a predictor o f improved outcomes for observation
four from 7/04-12/04 (hazard ratio, 0.70; 95 Cl, 0.49 - 1.00; p = 0.05). The hazard
ratios differed over time, which is likely due to the small sample size within each six
month time period. However, the direction o f the effect (e.g. negative coefficient and
hazard ratio less than 1 .0 ) was consistent for the time periods that were statistically
significant. See Table 13.

Table 13; Time Series Survival Analysis Results for Regressors o f Interest
B

SE

Wald

0.3460
0.3334
0.3194
0.3375
0.4753
0.7480

2.9681
4.0561
2.2021
8.2705
0.8613
1.1131

df

Sig.

Exp(B)

95% Cl Exp(B)
Lower
Upper

Aspirin at Arrival

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-0.5961
-0.6714
-0.4739
-0.9706
-0.4411
-0.7891

1
1
1
1
1
1

0.0849
0.0440
0.1378
0.0040
0.3534
0.2914

0.5510
0.5110
0.6225
0.3789
0.6433
0.5000

0.2796
0.2658
0.3329
0.1955
0.2534
0.1049

1.0855
0.9822
1.1642
0.7341
1.6331
1.9677

Aspirin at D/C

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

9.5270
-0.9377 0.3038
Coefficients did not converge
0.0983
-0.1060
0.3380
5.6058
-0.7991
0.3375
-1.3268
0.6218 4.5534
0.0006
10.5639 433.66

1 0.0020
0.3915
for split file so no model
1 0.7539
0.8995
1 0.0179
0.4497
1 0.0329
0.2653
1 0.9806 38710.7

0.2158
0.7102
fitted for this time
0.4637
1.7446
0.2321
0.8715
0.0784
0.8975
0.0000

Beta Blocker at Arrival

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-0.2909
-0.4630
-1.0155
-0.7180
-0.5114
12.5175

0.2717
0.3437
0.3084
0.4015
0.3921
396.34

1.1464
1.8148
10.841
3.1978
1.7012
0.0010

1
1
1
1
1
1

0.2843
0.1779
0.0010
0.0737
0.1921
0.9748

0.7476
0.6294
0.3622
0.4877
0.5996
273073

0.4389
0.3209
0.1979
0.2220
0.2781
0.0000

1.2733
1.2344
0.6630
1.0714
1.2932

Beta Blckr at D/C

Jan - June '03


July - Dec '03
Jan - June '04

0.6201
1 0.4310
0.7604
0.3845
1.5037
-0.2740
0.3479
Coefficients did not converge for split file so no model fitted for this time
0.7526
1 0.3857
1.4990
0.6006
3.7411
0.4048 0.4666

73

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July - Dec '04


Jan - June '05
July - Dec '05

-0.0740
-0.7125
-0.9228

0.3235
0.5462
0.6305

0.0523
1.7013
2.1421

1
1
1

0.8192
0.1921
0.1433

0.9287
0.4904
0.3974

0.4927
0.1681
0.1155

1.7507
1.4307
1.3675

Smk Cess Advice

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-0.9137 0.6991
1.7080
1 0.1912
1.1547
0.0733
0.0040
1 0.9494
0.9305
1 0.3347
0.5500 0.5701
0.9696
1 0.3248
0.6463 0.6564
Coefficients did not converge for split file so
Coefficients did not converge for split file so

0.4011
1.0760
1.7332
1.9085
no model
no model

0.1019
1.5786
0.1119 10.3451
0.5669
5.2984
0.5272
6.9083
fitted for this time
fitted for this time

ACEI/ARB for LVSD

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-0.1198
-0.4370
-0.7807
-0.7089
0.3678
-0.7841

0.4106
0.4163
0.3943
0.4504
1.0585
0.8175

0.0851
1.1019
3.9205
2.4768
0.1207
0.9200

1
1
1
1
1
1

0.7705
0.2938
0.0477
0.1155
0.7283
0.3375

0.8871
0.6459
0.4581
0.4922
1.4445
0.4565

0.3967
0.2856
0.2115
0.2036
0.1814
0.0920

1.9837
1.4608
0.9921
1.1900
11.5008
2.2664

Thromb w/in 30

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

0.0006
1 0.9798
0.0000
0
-11.6878 462.55
Coefficients did not converge for split file so no model fitted for this time
0.1762
0.5166
1.2308
1 0.6747
1.6764
0.1502 18.7084
0.6156
1 0.4327 191.045
5.2525 6.6947
0.0004 9.5E+07
9.0075 26.102
0.1191
1 0.7300 8163.87
0.0000 1.3E+26
Coefficients did not converge for split file, so no model fitted for this time

PCI w/in 120 mins

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

Coefficients did not converge for split file, so no model fitted for this time
Coefficients did not converge for split file, so no model fitted for this time
0.0218
1 0.8827
1.0934
0.0893 0.6056
0.3337
3.5830
Coefficients did not converge for split file, so no model fitted for this time
0.6312
0.7410
0.3856
1 0.5346
0.1477
-0.4601
2.6970
Coefficients did not converge for split file, so no model fitted for this time

All Applicable P4P

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

0.2336
-0.0105
0.0323
-0.3572
-0.0395
0.5410

0.1804
0.1981
0.1706
0.1814
0.2622
0.4222

1.6760
0.0028
0.0358
3.8772
0.0227
1.6416

1
1
1
1
1
1

0.1955
0.9576
0.8499
0.0489
0.8802
0.2001

1.2631
0.9895
1.0328
0.6996
0.9612
1.7177

0.8869
0.6712
0.7393
0.4903
0.5750
0.7508

1.7990
1.4589
1.4429
0.9984
1.6069
3.9298

Refer to Attachment VII for the hazard functions of covariates included in the
time series models for each regressor o f interest.

74

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Logistic Regression Mortality Results


In a logistic regression analysis with 30-day post-discharge mortality as the
outcome variable, aspirin at arrival (odds ratio, 0.39; 95 C l , 0.25-0.61; p < 0.0001),
aspirin at discharge (odds ratio, 0.41; 95 Cl, 0.22-0.75; p = 0.004), beta blocker at
arrival (odds ratio, 0.48; 95 Cl, 0.32-0.72; p < 0.0003), and ACEI or ARB for LVSD
(odds ratio, 0.35; 95 Cl, 0.17-0.72; p = 0.005) were all predictors o f lower patient
mortality. See Table 15.

Table 14: Alive/Dead at 30 Days Outcome Results for Regressors o f Interest in Total
Population__________________________________________________________________
Measure Name

Aspirin at Arrival
Aspirin at D/C
Beta Blocker at Arr
Beta Blocker at D/C
Smk Cess Advice
ACEI for LVSD
Thromb 30 mins
PCI 120 mins
All Applicable P4P

SE

Wald

-0.9437
-0.9013
-0.7301
-0.4739
0.6669
-1.0627
2.4802
-0.0729
0.1541

0.2287
0.3150
0.2024
0.3037
0.6756
0.3755
1.3502
0.4086
0.1293

17.020
8.1889
13.008
2.4349
0.9746
8.0083
3.3743
0.0318
1.4201

df

1
1
1
1
1
1
1
1
1

Sig.

Exp(B)

95% Cl Exp(B)
Lower Upper

0.0000
0.0042
0.0003
0.1187
0.3235
0.0047
0.0662
0.8585
0.2334

0.3892
0.4061
0.4818
0.6226
1.9483
0.3455
11.944
0.9297
1.1666

0.2486
0.2190
0.3240
0.3433
0.5183
0.1655
0.8470
0.4174
0.9054

0.6093
0.7528
0.7165
1.1290
7.3234
0.7213
168.43
2.0709
1.5032

Logistic Regression Time Series Mortality Results


The hazard functions for the statistically significant regressors o f interest in the
full model were tracked over time using logistic regression. Aspirin at arrival was a
predictor o f better outcomes during observation two (odds ratio, 0.25; 95 Cl, 0.090.70; p = 0.008). Aspirin at discharge was a predictor o f better outcomes over time
period one (odds ratio, 0.22; 95 Cl, 0.08-0.62; p = 0.004), time period four (odds ratio,
0.18; 95 Cl, 0.05-0.64; p = 0.008), and time period five (odds ratio, 0.02; 95 Cl, 0.00-

75

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

0.37; p = 0.009). During observation three (odds ratio, 0.19, 95 Cl, 0.08-0.44; p =
0.0001) and observation five (odds ratio, 0.30, 95 Cl, 0.09-0.96; p = 0.04) beta blocker
at arrival was a significant predictor o f lower mortality. ACEI or ARB for LVSD had
a statistically significant positive impact on outcomes during time period three (odds
ratio, 0.10, 95 Cl, 0.02-0.60; p = 0.01). Similar to the survival analysis looking at the
process measures impact on mortality over time, the logistic regression over each six
month time period shows a mostly consistent pattern in the direction o f the process
measures effect. See Table 16.

Table 15: Alive/Dead at 30 Days Time Series Outcome Results for Statistically
Significant Regressors of Interest in Total Population
B

S.E.

-0.8053
-1.3747
-0.8598
-0.8426
-1.1214
19.9181

0.4378
0.5216
0.4913
0.6275
0.7527
18881.9

3.3838
6.9469
3.0631
1.8034
2.2194

0.5193
0.8079
0.8459
0.6438
1.5295
14093.9

8.3715
0.8258
0.0631
7.0386
6.8014

0.4214
0.4654
0.4445
0.6881
0.5979
11224.1

1.8974
1.6993
14.3767
1.8087
4.0806

0.7463
0.8894

Wald

df

95% Cl Exp(B)
Lower
Upper

Sig.

Exp(B)

1
1
1
1
1
1

0.0658
0.0084
0.0801
0.1793
0.1363
0.9992

0.4469
0.2529
0.4232
0.4306
0.3258
4.5E+08

0.1895
0.0910
0.1616
0.1259
0.0745

1
1
1
1
1
1

0.0038
0.3635
0.8016
0.0080
0.0091
0.9990

0.2226
0.4799
0.8085
0.1812
0.0185
3.4E+07

0.0804
0.0985
0.1540
0.0513
0,0009

0.1684
0.1924
0.0001
0.1787
0.0434
0.9987

0.5597
0.5451
0.1854
0.3964
0.2988
1.1E+08

0.2451
0.2189
0.0776
0.1029
0.0926

0.0000

1
1
1
1
1
1

2.4754
0.2326

1
1

0.1156
0.6296

0.3091
0.6512

0.0716
0.1139

Aspirin at Arrival

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

0.0000

1.0541
0.7030
1.1086
1.4728
1.4246

0.0000

Aspirin at Discharge

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-1.5026
-0.7341
-0.2126
-1.7081
-3.9890
17.3388

0.0000

0.6159
2.3378
4.2436
0.6400
0.3712

0.0000

Beta Blocker at Arrival

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June '05
July - Dec '05

-0.5804
-0.6067
-1.6853
-0.9254
-1.2079
18.5513

1.2782
1.3573
0.4430
1.5269
0.9647

0.0000

ACEI/ARB for LVSD

Jan - June '03


July - Dec '03

-1.1742
-0.4290

76

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.3345
3.7221

Ja n -Ju n e '04
Ju ly -D e c '04
Ja n -Ju n e '05
Ju ly -D e c '05

-2.2266
-0.3417
-0.2003
-1.2879

0.8752
1.2451
8507.2
1.2815

6.4717
0.0753
0.0000
1.0099

1
1
1
1

0.0110
0.7837
1.0000
0.3149

0.1079
0.7105
1.8141
0.2759

0.0194
0.0619
0.0000
0.0224

0.5998
8.1543
.
3.4002

Logistic Regression Morbidity Results


Besides mortality, another indicator o f patient outcomes is readmission rates.
Using readmissions within 30 days as the outcome variable, a logistic regression
analysis identified that aspirin at discharge (odds ratio, 3.1; 95 Cl, 1.23-7.79; p = 0.02)
was a predictor o f more readmissions within 30 days o f discharge while receiving all
applicable P4P measures was a predictor o f less readmissions within 30 days (odds
ratio, 0.65; 95 Cl, 0.48-0.89; p = 0.007). See Table 17.

Table 16: Readmission in 30 Days Outcome Results for Regressors o f Interest in


Total Population
Measure Name

Aspirin at Arrival
Aspirin at Discharge
Beta Blocker at Arr
Beta Blocker at D/C
Smk Cess Advice
ACEI for LVSD
Thromb 30 mins
PCI 120 mins
All Applicable P4P

SE

Wald

0.0327
1.1306
0.5151
0.2534
0.0032
0.0799
-0.2662
-0.7717
-0.4246

0.4402
0.4705
0.4342
0.2692
0.3770
0.3718
0.6521
0.5815
0.1585

0.0055
5.7736
1.4077
0.8857
0.0001
0.0462
0.1667
1.7613
7.1765

df

1
1
1
1
1
1
1
1
1

Sig.

Exp(B)

95% Cl Exp(B)
Lower Upper

0.9408
0.0163
0.2354
0.3467
0.9933
0.8299
0.6831
0.1845
0.0074

1.0332
3.0974
1.6739
1.2883
1.0032
1.0832
0.7663
0.4622
0.6541

0.4360
1.2317
0.7147
0.7601
0.4792
0.5227
0.2135
0.1479
0.4794

2.4483
7.7895
3.9201
2.1836
2.1003
2.2447
2.7506
1.4448
0.8923

Logistic Regression Time Series Morbidity Results


Looking at the significant regressors o f interests impact on readmissions over
time shows that receiving all applicable P4P measures was a predictor o f fewer
readmissions within 30 days from 1/04-6/04 (odds ratio, 0.30; 95 Cl, 0.14-0.62; p =

77

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

0.001) and from 1/05-6/05 (odds ratio, 0.34; 95 Cl, 0.16-0.76; p = 0.008). However,
aspirin at discharge did not have a statistically significant impact on readmissions
within 30 days for any o f the six month time intervals. See Table 18.

Table 17: Readmission in 30 Days Outcome Results for Statistically Significant


Regressors of Interest in Total Population__________________________________
B

S.E.

Wald

df

Sig.

Exp(B)

95% Cl Exp(B)
Lower
Upper

All P4P Measures

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec 04
Jan - June 05
July - Dec '05

0.4005
0.2208
-1.2137
-0.4562
-1.0694
0.1403

0.3954
0.4592
0.3772
0.3353
0.4056
0.5704

1.0259
0.2313
10.355
1.8518
6.9533
0.0605

1
1
1
1
1
1

0.3111
0.6306
0.0013
0.1736
0.0084
0.8058

1.4926
1.2471
0.2971
0.6337
0.3432
1.1506

0.6876
0.5071
0.1418
0.3284
0.1550
0.3762

3.2401
3.0672
0.6222
1.2225
0.7599
3.5190

1.0412
1.0516
0.7761
1.0760
8903.7
13508.2

0.9578
2.9775
0.3320
1.1493
0.0000
0.0000

1
1
1
1
1
1

0.3278
0.0844
0.5645
0.2837
0.9984
0.9989

2.7704
6.1384
1.5639
3.1692
6.6E+0.7
1.01E+08

0.3600
0.7815
0.3417
0.3847
0
0

21.3213
48.2147
7.1588
26.1112

Aspirin at Discharge

Jan - June '03


July - Dec '03
Jan - June '04
July - Dec '04
Jan - June'05
July - Dec '05

1.0190
1.8146
0.4472
1.1535
18.0126
18.4351

Covariates Impact on Outcomes Analysis

Testfo r Proportional Hazards Results


The Cox proportional hazards model assumes that the effect o f each covariate
is the same at all points in time. If the effect o f a covariate differs with time, then the
proportional hazard assumption is violated. One can identify when the proportionality
assumption has failed if the interaction term between the variable and time has a beta
coefficient that is at least twice as large as its standard error and if the interaction term
is statistically significant (p < 0.05). Forty-five o f the 49 covariates have a non
significant interaction term between itself and time which indicates that the

78

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proportional hazards assumption has not been violated. Four variables did fail the
proportionality assumption: Asian/Pacific Islander race (beta, -0.04; p = 0.008);
identified payor (beta, 0.14; p = 0.006); thrombolysis treatment (beta, -0.06; p =
0.005); and depression (beta, 0.05; p = 0.04). These four variables may be time
dependent or may be interacting with one or more covariates and time. See Table 11.

Table 18: Test for Proportional Hazards Results


Interaction Variables

Chula Vista*time
Encinitas*time
Green*time
La Jolla*time
Mercy*time
Age*time
Female*time
Single*time
Widowed*time
Divorced/Sep*time
Married*time
White*time
African American*time
Native American*time
Asian/Pac Isbtime
Other Race*time
Unk Race*time
Stated Religion*time
Identified PCP*time
Identified Payor*time
CABG Surgery*time
Oth Open Heart*time
PCI Tx*time
Thrombolysis Tx*time
Oth Card Dx Tx*time
No Cardiac Tx*time
CAD*time
Prior Ml*time
Family Hx CAD*time
Dyslipidemia*time
Diabetes*time

SE

0.0280
0.0054
0.0022
-0.0106
-0.0004
-0.0120

0.0556
0.0317
0.0310
0.0265
0.0003
0.0084

0.0120
0.0122
0.0055

0.0122
0.0165
0.0104

-0.0083
1.7233
-0.0377
0.0046
0.0831
-0.0042
0.0071
0.1353
0.0106
-0.0216
0.0083
-0.0604
-0.0184
-0.0311
0.0882
0.0026
0.0343
0.0157
-0.0007

0.0236
5.2730
0.0143
0.0127
0.0468
0.0086
0.0083
0.0494
0.0166
0.0337
0.0109
0.0213
0.0161
0.0185
0.1661
0.0169
0.0660
0.0103
0.0085

Wald

0.6702
0.2533
0.0287
0.0049
0.1603
1.3068
2.0464
1.1549
0.9674
0.5441
0.2760
11.5778
0.1251
0.1068
6.9601
0.1322
3.1538
0.2410
0.7228
7.4856
0.4093
0.4090
0.5860
8.0281
1.3140
2.8299
0.2821
0.0246
0.2692
2.3093
0.0070

df

Sig.

4
1
1
1
1
1
1
3
1
1
1
5
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Exp(B)

0.9549
0.6148
0.8654
0.9443
0.6889
0.2530
0.1526
0.7638
0.3253
0.4607
0.5994
0.0411
0.7235
0.7438
0.0083
0.7162
0.0758
0.6235
0.3952
0.0062
0.5223
0.5225
0.4440
0.0046
0.2517
0.0925
0.5953
0.8755
0.6039
0.1286
0.9332

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.0284
1.0054
1.0022
0.9894
0.9996
0.9881
1.0121
1.0122
1.0055
0.9917
5.6027
0.9630
1.0046
1.0866
0.9958
1.0071
1.1448
1.0107
0.9787
1.0084
0.9414
0.9817
0.9694
1.0922
1.0026
1.0348
1.0158
0.9993

Hypertension*time
Obesity*time
Depression*time
Smoker*time
FTE/Occ Bed*time
Rapid Resp Trrftime
Chest Pain Ctr*time
CV Award*time
Hosp AMI VoPtime
MD AMI VoPtime
Adm/ICU Beds*time
Medicare*time
MediCaPtime
CommerciaPtime
Oth Gvmt/SP*time
Oth Pyr/WC*time
Surg Backup*time
Teaching Hosp*time

0.0108
-0.0024
0.0504
-0.0186
0.0161
-0.0275
-0.0052
-0.0310
0.0000
0.0024
-0.0038
-0.0023
-0.0042
-0.0030

-0.0018
0.0006

0.0078
0.0204
0.0245
0.0125
0.0155
0.0477
0.0239
0.0255
0.0001
0.0028
0.0049
0.0069
0.0103
0.0078

0.0269
0.0252

1.8941
0.0139
4.2307
2.2266
1.0713
0.3324
0.0475
1.4772
0.0616
0.7017
0.6010
0.1098
0.1660
0.1469

0.0047
0.0005

1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1

0.1687
0.9062
0.0397
0.1357
0.3006
0.5643
0.8274
0.2242
0.8039
0.4022
0.4382
0.7403
0.6837
0.7015

1.0109
0.9976
1.0516
0.9816
1.0162
0.9729
0.9948
0.9695
1.0000
1.0024
0.9962
0.9977
0.9958
0.9970

0.9455
0.9823

0.9982
1.0006

.
.

Covariate Survival Analysis Results


The following covariates were predictors o f lower mortality when in the full
model for survival analysis: widowed (hazard ratio, 0.80; 95 Cl, 0.64-0.99; p = 0.04);
identified a PCP (hazard ratio 0.76; 95 Cl, 0.65-0.99; p = 0.0005); CABG surgery
(hazard ratio, 0.58; 95 Cl, 0.40-0.83; p = 0.003); PCI treatment (hazard ratio, 0.48; 95
Cl, 0.39-0.59; p < 0.0001); dyslipidemia (hazard ratio, 0.42; 95 Cl, 0.34-0.50; p <
0.0001); hypertension (hazard ratio, 0.84; 95 Cl, 0.73-0.97; p - 0.02); and increased
rate o f AMI admission to ICU beds (hazard ratio, 0.64; 95 Cl, 0.42-0.98; p = 0.04).
Conversely, the following covariates were predictors o f higher (i.e., worse) mortality
when in the full model for survival analysis: Encinitas hospital (hazard ratio, 25.0; 95
Cl, 2.7-227.3; p = 0.004); Mercy hospital (hazard ratio, 13.4; 95 Cl, 2.0-89.6; p =
0.008); increased age (hazard ratio, 1.04; 95 Cl, 1.03-1.05; p < 0.0001); identified a

80

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payor (hazard ratio, 3.0; 95 Cl, 1.46-5.98; p = 0.003); thrombolysis treatment (hazard
ratio, 1.55; 95 Cl, 1.00-2.38; p = 0.05); no cardiac treatment (hazard ratio 1.68; 95 Cl,
1.17-2.40; p = 0.005); diabetes (hazard ratio, 1.17; 95 Cl, 1.00-1.37; p = 0.05); and
increased annual hospital AMI admissions (hazard ratio, 1.02; 95 Cl, 1.00-1.03; p =
0.03). See Table 14.

Table 19: Covariate Hazard Functions


Covariates

Chula Vista
Encinitas
Green
La Jolla
Mercy
Age
Female
Single
Widowed
Divorced/Separtd
Married
White
African American
Native American
Asian/Pacific Isldr
Other
Unknown
Stated Religion
Mos Since Admit
Identified PCP
Identified Payor
CABG Tx
Oth Open Heart
PCI Tx
Thrombolysis Tx
Oth Cardiac Proc
No Cardiac Tx
CAD
Prior Ml
Family Hx CAD
Dyslipidemia
Diabetes

SE

3.2170
0.3869
4.8870
2.5931
0.0377
-0.0589

1.1272
2.6798
3.2021
0.9706
0.0035
0.0782

-0.2249
0.1931
-0.0560

0.1098
0.1504
0.0959

0.0208
0.0747
0.0221
-0.0492
-0.1945
0.0552
0.0088
-0.2747
1.0844
-0.5488
0.5468
-0.7360
0.4357
0.2381
0.5158
-0.8021
-0.0971
-0.5211
-0.8797
0.1611

0.1951
1.0046
0.1227
0.1010
0.3590
0.0809
0.0114
0.0787
0.3594
0.1867
0.3021
0.1096
0.2206
0.1567
0.1831
1.0143
0.1562
0.5849
0.1002
0.0802

Wald

13.793
8.1453
0.0208
2.3292
7.1381
114.37
0.5665
8.7622
4.1984
1.6469
0.3413
0.6209
0.0114
0.0055
0.0324
0.2376
0.2934
0.4658
0.6026
12.185
9.1063
8.6410
3.2771
45.071
3.9003
2.3075
7.9356
0.6253
0.3863
0.7938
77.096
4.0369

df

4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Sig.

0.0080
0.0043
0.8852
0.1270
0.0075

0.0000
0.4516
0.0326
0.0405
0.1994
0.5591
0.9870
0.9150
0.9407
0.8572
0.6260
0.5881
0.4949
0.4376
0.0005
0.0025
0.0033
0.0703

0.0000
0.0483
0.1288
0.0048
0.4291
0.5343
0.3730
0.0000
0.0445

Exp(B)

95% Cl Exp(B)
Lower
Upper

24.954
1.4724
132.56
13.371
1.0384
0.9428

2.7395
0.0077
0.2493
1.9953
1.0313
0.8088

227.31
281.26
70482
89.598
1.0456
1.0990

0.7986
1.2130
0.9455

0.6440
0.9032
0.7835

0.9903
1.6289
1.1410

1.0210
1.0775
1.0223
0.9520
0.8233
1.0568
1.0089
0.7598
2.9578
0.5776
1.7278
0.4790
1.5460
1.2688
1.6750
0.4484
0.9075
0.5939
0.4149
1.1748

0.6966
0.1504
0.8038
0.7810
0.4073
0.9018
0.9866
0.6512
1.4624
0.4006
0.9558
0.3864
1.0033
0.9332
1.1699
0.0614
0.6681
0.1887
0.3409
1.0040

1.4965
7.7188
1.3002
1.1603
1.6640
1.2383
1.0316
0.8865
5.9822
0.8329
3.1234
0.5938
2.3823
1.7252
2.3982
3.2737
1.2326
1.8688
0.5049
1.3746

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Hypertension
-0.1721
0.0737
0.8419
5.4537
1 0.0195
0.7287
0.9727
Obesity
-0.2532
0.1918
1.7432
1 0.1867
0.7763
0.5331
1.1305
Depression
-0.3028
0.2061
1 0.1418
2.1580
0.7387
0.4932
1.1065
Smkr Past 12 Mo -0.1255
0.1243
1.0206
1 0.3124
0.8820
0.6914
1.1253
FTE/Adj Occ Bed
0.1742
0.1765
0.9736
1 0.3238
1.1903
0.8421
1.6823
Rapid Resp Tm
-0.7087
0.4351
1 0.1034
2.6528
0.4923
0.2098
1.1550
Chest Pain Ctr
0
CV Award Yr Visit -0.6358
0.3549
3.2096
1 0.0732
0.5295
0.2641
1.0616
Hosp AMI Admits
0.0071
0.0158
4.9456
1 0.0262
1.0160
1.0019
1.0303
Avg MD AMI Adm
0.0401
0.0512
0.6149
1 0.4329
1.0409
0.9416
1.1508
AMI Adm/ICU Bd
-0.4456
0.2150 4.2959
1 0.0382
0.4202
0.6405
0.9761
Medicare
-0.3454
0.3034
1.2965
1 0.2549
0.7079
0.3906
1.2830
MediCal
-0.4018
0.3715
1.1697
1 0.2795
0.6691
0.3231
1.3859
Commercial
-0.7990
0.4716 2.8700
1 0.0902
0.4498
0.1785
1.1336
Oth Gvmt/Self Py -1.0648
0.6094
3.0529
1 0.0806
0.3448
0.1044
1.1384
Oth Pyr Wrk Cmp
0
Teaching Hosp
-0.2640
0.4764
0.3070
1 0.5795
0.7680
0.3019
1.9536
Surgical Backup
0
a = Degree of freedom reduced because of constant or linearly dependent covariates
b = Constant or Linearly Dependent Covariates Chest_Pain_Center = Facility_Code(4);
Other_including_Workers_Comp = 180 + 4.979*Facility

Pay-for-Performance Outcomes Analysis

Mortality Pre and Post-Intervention Results


Thirty-day, 90-day, and 180-day mortality rates all improved from 2003 to
2005. Before participation in the HQA, 30-day mortality ranged from 11% - 13%,
while after participation in the HQA, the rate dropped between eight percent and nine
percent. Similarly, 90-day mortality went from 13% - 15% before the HQA to 10% 11% after the HQA. Sixteen to 18% o f patients died within 180 days before
participation in the HQA compared to 11% - 14% after. See Figures 11-13.

82

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 11: 30-Day Mortality Rates Over Time


30-Day Mortality Rate
20 %
18%

16%
11%

10%
8%
6%

4%
2%
0%

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

Figure 12: 90-Day Mortality Rates Over Time

90-Day Mortality Rate


20 %

18%
16%
14%

T3%

12%
10%
8%

11%
10%

6%

4%
2%
0%

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

83

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Figure 13: 180-Day Mortality Rates Over Time

180-Day Mortality Rate


20%
. 18%

18%
16%
14%

16%

.14%
12%

12%
10 %
8%
6%

11 %

4%
2%

0%
1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

1/1/056/30/05

7/1/0512/31/05

The results of the logistic regression to determine whether HQA impacted 30day, 90-day, or 180-day mortality showed that none o f the variables (time, post-HQA,
and time/post-HQA interaction) were statistically significant in any o f the three
equations. See Tables 19-21.

Table 20: Logistic Regression Results o f 30-Day Mortality Before and After HQA
30-Day Mortality

Time
Post
Post by Time
Constant

S.E.

Wald

-0.0555
-0.4796
0.0336
-1.8791

0.0830
0.2704
0.1300
0.1816

0.4465
3.1441
0.0667
107.12

df

1
1
1
1

Sig.

Exp(B)

0.5040
0.0762
0.7963

0.9461
0.6191
1.0341
0.1527

0 .0 0 0 0

95% Cl Exp(B)
Lower Upper

0.8040
0.3644
0.8015

1.1132
1.0518
1.3342

T able 21: Logistic Regression Results o f 90-Day Mortality Before and After HQA
95% Cl Exp(B)
Exp(B) Lower Upper
B
S.E.
Wald
df
Sig.
90-Day Mortality

Time
Post
Post by Time

-0.0840
-0.3131
-0.0164

0.0777
0.2457
0.1195

1.1683
1.6232
0.0189

1
1
1

0.2798
0.2027
0.8905

0.9195
0.7312
0.9837

0.7896
0.4517
0.7783

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1.0707
1.1836
1.2433

Constant

-1.6424

0.1690

94.456

0.0000

0.1935

Table 22: Logistic Regression Results o f 180-Day Mortality Before and After HQA
180-Day Mortality

Time
Post
Post by Time
Constant

S.E.

Wald

-0.0803
-0.2737
-0.0423
-1.4528

0.0725
0.2290
0.1115
0.1582

1.2255
1.4291
0.1438
84.375

df

1
1
1
1

Sig.

Exp(B)

0.2683
0.2319
0.7046
0.0000

0.9228
0.7605
0.9586
0.2339

95% Cl Exp(B)
Lower Upper

0.8005
0.4855
0.7705

1.0638
1.1913
1.1927

Morbidity Pre and Post-Intervention Results


The rate o f readmissions within 30 days decreased from seven percent in the
beginning o f 2003 to four percent at the end o f the 2005. Unlike the mortality rates,
the decline in morbidity (readmission) rates did not show a consistent improvement, as
scores fluctuated during this time. However, the results of the logistic regression
identified that neither the intercept o f the post-HQA performance nor the rate o f
readmissions post-participation in the HQA were statistically significant. This finding
was similar to the result o f the logistic regression for mortality. See Figure 14 and
Table 22.

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Figure 14: 30-Day Readmission Rates Over Time


30-Day Readmission Rate
20%

18%
16%
14%

1/1/036/30/03

7/1/0312/31/03

1/1/046/30/04

7/1/0412/31/04

7/1/0512/31/05

1/1/056/30/05

Table 22: Logistic Regression Results o f Readmission Within 30-Days Before and
After HQ A_______________________________________________________________
30-Day Readmit

Time
Post
Post by Time
Constant

S.E.

Wald

-0.1714
-0.0712
-0.0108
-2.5307

0.1201
0.3540
0.1762
0.2540

2.0362
0.0405
0.0037
99.268

df

1
1
1
1

Sig.

Exp(B)

0.1536
0.8405
0.9513
0.0000

0.8425
0.9312
0.9893
0.0796

95% Cl Exp(B)
Lower Upper

0.6657
0.4653
0.7003

1.0661
1.8636
1.3975

D is c u s s io n

Pay-for-Performances Impact on Process Measures


From 2003 to 2005, Scripps Healths performance in AMI process measures
improved substantially. Compliance with all applicable P4P measures increased from
60% to

8 6

% from observation one to observation six. Over the same period o f time,

aspirin at arrival improved from 93% to 99%. Beta blocker at arrival improved from
85% to 96%. ACEI or ARB for LVSD improved from 75% to 87%. Smoking

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cessation advice improved from 57% to 89%. Aspirin at discharge improved from
91% to 98%. Beta blocker at discharge improved from 86% to 95%. PCI within 120
minutes improved from 16% to 71%. Thrombolytic agent within 30 minutes was the
only indicator without any consistent improvement over the three years, perhaps
impacted by the infrequency o f patients receiving thrombolytic therapy. Thrombolytic
agent within 30 minute performance went from 24% in early 2003 to 31% in late
2005.
Scripps Health has improved its performance in providing all applicable P4P
measures for AMI patients consistently during all six observation time periods from
2003 to 2005. The slope, measuring the rate o f improvement, before and after
participation in the HQA did not change, indicating that the rate o f improvement did
not change after participation in the HQA. The coefficients o f the post-HQA variable
and the interaction term suggest that initiation o f participation in the HQA may have
led or contributed to a lower than expected performance in providing all applicable
P4P measures in the forth observation given the performance prior to participation in
the HQA. The post-HQA intercept noting the different level o f performance in
providing all applicable P4P measures after initiation o f the HQA was statistically
significant.
Aspirin at arrival, aspirin at discharge, beta blocker at discharge, and
thrombolytic agent received within 30 minutes did not have statistically significant
differences in performance from before participation in the HQA to after participation
in the HQA. The slope of performance with beta blocker at arrival did not change with

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participation in the HQA but its intercept for scores post-HQA did. Compliance with
providing beta blockers at arrival was at a higher level after participation in the HQA
began than would have been expected given the rate o f improvement for this indicator
before participation in the HQA. Smoking cessation advice/counseling compliance did
not change in slope or intercept, however, the changes taking place over time (from
observation one through three to observation four through six) were statistically
significant, suggesting seasonal, cyclical, or time dependent change effects present.
The slope o f performance with the ACEI or ARB for LVSD metric did change at a
statistically significant level, indicating that participation in the HQA may have
contributed to a change in improvement rate for this measure. Compliance with PCI
within 120 minutes changed dramatically from before to after participation in the
HQA. The intercept and the change in slope (i.e. the betas for the post-HQA variable
and the interaction term) indicate that participation in the HQA may have slowed the
level and rate o f improvement in compliance with PCI within 120 minutes. However,
it is important to keep in mind that there is a ceiling for performance (i.e., 100%
compliance) and sustaining the high levels o f improvement experienced before the
HQA may be unfeasible at later time periods.
In summary, the data analyses indicate that Scripps Healths improvements in
P4P process measure compliance for AMI patients cannot be attributed to its
participation in the Hospital Quality Alliance. If the HQA had made an impact on
process measure compliance, one would have expected a significant change in slope
(i.e., increased slope indicates better performance) and/or a significant change in

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intercept o f the post-HQA variable (i.e., intercept at higher value than expected due to
pre-HQA slope indicates better performance), which did not happen. In certain metrics
(e.g., all applicable P4P measures and PCI within 120 minutes), participation may
have negatively impacted the level o f performance and/or rate o f improvement in
performance, as the slope and/or intercept o f post-HQA compliance was not as high as
expected based upon pre-HQA scores. Further analysis should be conducted with a
time fit (rather than a linear model) to take into account the asymptotic nature o f
process measure performance. Should the results o f the time fit model analysis be
similar to these results, then research on potential unintended consequences o f
participation in the HQA is recommended.
Before drawing the conclusion that the HQA did not affect process measures, it
is important to note some limitations o f this analysis. The Scripps Health process
measure performance was improving before initiation o f participation in the HQA.
Anticipation of the HQA and knowledge o f the process measures the HQA would
track may have motivated improvement in compliance with the measures during this
time. Conversely, there could have been other events in history, such as new journal
articles, that led to improvement before the HQA. The reason for improvement in
scores before participation in the HQA is unknown.
The HQA could have impacted performance in indirect ways. To prepare for
the HQA and reaching high levels o f process measure compliance, there may have
been changes in staffing, documentation, and care processes. These changes could all
impact process measure scores, however, these changes could take place gradually

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before and/or after the HQA. While motivated by the HQA, these changes may not be
captured between observation three and four when participation in the HQA began. If
changes did not occur during that time period, they would not be attributed to the
HQA given the study design that was used.
Perhaps beginning to collect and monitor data on the AMI process measures
motivated improvement in scores either irrespective o f or in conjunction with
participation in the HQA. Williams et al suggest that collecting data on performance
? o

measures may be a sufficient catalyst for improvement.

However, the results o f this

study do not confirm other studies findings that P4P improves process measures.12,13
This research suggests that it may not be P4P (but perhaps collection and monitoring
o f data or publication o f new evidence-based medicine) that drives improvement. On
the other hand, it is important to do further analysis to look for early and lagged effects
o f participation in the HQA before concluding that the HQA had/has no impact on
process measure scores.
Had the results of the previous analysis shown that participation in the HQA
significantly impacted Scripps Healths process measure scores, an analysis to test
whether the internal threat o f history was present would have been conducted.
However, the null hypothesis for the first study aim held, which is that process
measures did not improve as a result o f pay-for-performance. Nevertheless, the data
that would have been used to test the internal threat o f history was useful in comparing
Scripps Health performance with that o f another hospital system, Premier, Inc., that
participated in an earlier P4P program as well as that o f other hospitals nation-wide

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participating in the HQA.


Scripps Health and Premier, Inc. started out with much different levels of
performance with the AMI process measures (absolute difference 7.7%), which
decreased over time, dropping to an absolute difference o f 6.3% in time period two
and to 2.2% in time period three after Scripps began participating in the HQA. Scripps
Healths performance from 7/04-6/05 was similar (not statistically different) to that o f
other hospitals participating in the HQA nation-wide, which suggests that Premier,
Inc. had characteristics that encouraged or made it easier to comply with the AMI
process measures than other hospitals nationally. Premier, Inc. began using a
sophisticated reporting and analytics tool to monitor and track process measure
performance before Scripps Health did. According to Stephanie Alexander, Senior
Vice President for Premier Healthcare Informatics (personal communication, 2007),
the 54 hospitals that began participating in the Premier Hospital Quality Incentive
Demonstration we required to use the Premier decision support analytic tools to
collect, monitor, and analyze their performance on the 34 measures used in the
demonstration project before the program began. This is likely a key reason for the
variation in performance levels at the first observation, However, further research into
the differences between Premier, Inc. hospitals and others nation-wide (including
Scripps) is recommended.
The test to identify whether the P4P program that Premier, Inc. participated in
changed its performance compared to Scripps Health (the control) determined that the
Premier Hospital Quality Incentive Demonstration cannot be attributed to the

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improvement in scores. The slopes of the Premier, Inc. performance in comparison to


the Scripps Health performance over the same time period were not statistically
different. The time variable and the site variable were statistically significant,
indicating that the facilities started out at different levels o f performance and that there
was significant increase in performance for both organizations from 10/02-9/03 to
1/04-6/04.
From 1/04-6/04 to 7/04-6/05, there was a statistically significant intervention
impacting Premier, Inc. and Scripps Health facilities performance on the AMI process
measures. The slopes for the two health systems performance were statistically
different from each other. The statistical significance in slopes combined with the
variable coefficients indicates that participation in the HQA had a larger impact on
Scripps Health than it did for Premier, Inc. Given that Premier, Inc. was already
participating in a P4P program and Scripps Health began participating in a public
reporting initiative for the first time, it makes sense that Premier, Inc. would not have
experienced as great an impact as Scripps Health. In addition, the time and the site
variables were statistically significant suggesting that performance started out at
statistically different levels and that both systems experienced significant increases in
scores over this time frame.
The analysis comparing Scripps Health performance to itself suggests that
participation in the HQA did not change the rate o f improvement in Scripps Healths
compliance with AMI process measures, yet the analysis comparing Scripps Health
performance to Premier, Inc. performance suggests otherwise. It is important to note

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that the time period for these analyses differs. The analysis comparing Scripps Health
to itself is a time series design looking at performance from 1/03-12/05 in six month
intervals. The analysis comparing Scripps Health to Premier, Inc. performance was
based upon scores from 1/04-6/04 compared to 7/04-6/05. In addition, the two
analyses used different metrics. The analysis comparing Scripps Health to itself used
an all applicable P4P metric as well as eight individual measures. The analysis
comparing Scripps Health to Premier, Inc. included a weighted average metric o f the
numerators and denominators o f seven individual measures. Further analysis is
recommended to determine the impact o f the HQA on process measure compliance. It
would be ideal to conduct an additional analysis comparing Scripps Health to a like
hospital system that did not participate in the HQA, yet it is unlikely that one exists.
The largest change in scores occurred for Premier, Inc. when it started
participating in its first intervention (the P4P program) and for Scripps Health when it
started participating in its only intervention (the P4R program). The larger change in
scores over the time period o f the first intervention for Premier, Inc. and the time
period o f the only intervention for Scripps Health may indicate that improvement was
occurring from 10/02-6/05 but that the initiation of public interest in the AMI process
measure scores may have increased internal emphasis on performance. While it is
tempting to draw this conclusion, given the lack o f statistical significance o f the P4P
program and the conflicting results for the statistical significance o f the P4R program,
conclusions o f this nature are unwarranted. Further analysis using a time fit or learning
model to account for the performance metric ceiling is recommended.

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Process-Outcomes Link
Although evidence-based literature suggests that compliance with the eight
AMI process measures used in this analysis should lead to improved patient outcomes
(i.e. increased probability o f survival), this study showed that not all o f the measures
were associated with a statistically significant reduction in mortality in the Scripps
Health system. A survival analysis on the full model of 3,954 patients using days
survival as the outcome variable indicated that aspirin at arrival, beta blocker at
arrival, and ACEI or ARB for LVSD were predictors o f lower mortality at a p-value <
0.05. Aspirin at arrival was associated with a 47% lower risk o f death (hazard ratio;
0.53), beta blocker at arrival was associated with a 26% lower risk o f death (hazard
ratio; 0.74), and ACEI or ARB for LVSD was associated with a 33% lower risk of
death (hazard ratio; 0.67).
Similarly, a logistic regression on the full model of patients using 30-day
mortality as the outcome variable indicated that all three of the above noted indicators
(aspirin at arrival, beta blocker at arrival, ACEI/ARB for LVSD) as well as aspirin at
discharge were all predictors o f lower mortality at a p-value <0.01. Aspirin at arrival
was associated with a 61% lower odds o f death within 30 days (odds ratio; 0.39),
aspirin at discharge was associated with a 59% lower odds o f death within 30 days
(odds ratio; 0.41), beta blocker at arrival was associated with a 52% lower odds of
death within 30 days (odds ratio; 0.48), and ACEI or ARB for LVSD was associated
with a 65% lower odds o f death within 30 days (odds ratio; 0.35).

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Further research on the P4P measures that were not associated with improved
outcomes at a statistically significant level (e.g., beta blocker at discharge, smoking
cessation advice, thrombolytic agent within 30 minutes, PCI within 120 minutes) is
recommended using a larger patient population. If analyses are conducted on a large
patient population and the results still show that these indicators are not predictors of
improved outcomes at a statistically significant level, then it may be important to
revisit the value o f including these measures in P4P programs. Although evidencebased literature identifies certain process measures as predictive o f better outcomes,
the literature also suggests that not all process measures are indeed good predictors of
outcomes.2765 If there are other indicators that are statistically significant predictors of
lower mortality, then perhaps increased attention should be focused on those
indicators rather than these four indicators.
Outcomes data for Premier, Inc. patients was not able to be obtained, however,
analyses comparing Scripps Health and Premier, Inc. process measure compliance and
patient mortality could shed further light on the relationship between the AMI P4P
indicators and patient outcomes.
While mortality is the outcome o f most interest, as it is often the primary
concern o f the patient and the healthcare provider, readmissions are a way to assess
potential morbidity. If a patient is readmitted to a hospital within 30-days, it may
indicate that the patient had a complication while recovering from earlier treatment. A
readmission may also indicate that appropriate care may not have been received at an
earlier visit, warranting a return with continued illness that is more severe and cannot

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be handled on an outpatient basis. A logistic regression on the total patient population


using readmissions within 30-days as the outcome variable identified that receiving
aspirin at discharge was associated with an increased probability o f having a
readmission within 30-days, while receiving all recommended P4P measures was
associated with a decreased probability o f having a readmission within 30-days. This
analysis shows that although receiving all applicable P4P measures is not a predictor
o f lower mortality, it may be a predictor o f lower morbidity. Patients receiving all
applicable P4P measures had a 35% lower odds o f a readmission within 30 days (odds
ratio; 0.65).
Aspirin at discharge was found to be a significant predictor o f higher morbidity
(readmissions within 30 days). This result may be confounded by the fact that the
patients who received aspirin at discharge had higher incidence o f comorbities that can
lead to disease complications. For example, there higher rates o f obesity (eight percent
o f patients with aspirin at discharge had obesity compared to three percent without)
and smokers (19% o f patients with aspirin at discharge were current smokers
compared to 14% without aspirin at discharge). There was also a large difference in
patients receiving no cardiac treatment for AMI (17% o f patients with aspirin at
discharge had no cardiac treatment compared to 40% without), which is a predictor of
higher mortality. Patients without cardiac treatment who die have no opportunity to be
readmitted, which may affect readmission rates. Further research is needed to
determine whether there are other characteristics o f patients receiving aspirin at
discharge that are associated with increased readmission rates. Confounding variables

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impacting these results may be a more likely hypothesis than concluding that
providing aspirin at discharge is indeed increasing readmission rates.

Covariates Impact on Outcomes


The test o f the proportional hazard assumption was violated for four variables:
Asian/Pacific Islander race; identified payor; thrombolysis treatment; and depression.
If we estimate a proportional hazard model when the assumption is violated for some
variable (thereby suppressing the interaction), then the coefficient we estimate for that
variable is a sort o f average effect over the range o f times observed in the data.85
Therefore, caution must be taken in making conclusions based upon these four
covariates. Asian/Pacific Islander race and depression did not have a statistically
significant impact on outcomes, while identified payor and thrombolysis treatment
were predictors of worse mortality. Thrombolytic administration is no longer the
recommended treatment for patients seen in hospitals with cath labs and was only
given to a small subset o f patients. All Scripps Health facilities have cath labs,
therefore, it is not surprising that thrombolysis treatment was associated with worse
outcomes. Patients with an identified payor had a mean age o f 70 compared to a mean
age o f 54 for those patients without an identified payor. Age may be confounding the
negative effect on outcomes that identified payor is indicating. However, it is
important to note again that no conclusions should be made based upon the
thrombolytic agent within 30 minute or the identified payor variables.

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There were other covariates that were determined to have a statistically


significant impact on outcomes that did not violate the proportional hazards
assumption. Being widowed, having an identified PCP, having CABG surgery, having
PCI surgery, having dyslipidemia, having hypertension, and having a higher
admissions per 1CU bed ratio were all predictors o f lower/better mortality. Being
treated at Scripps Memorial Hospital Encinitas or Scripps Mercy Hospital San Diego
was associated with worse outcomes than patients seen at Scripps Mercy Hospital
Chula Vista. Other predictors o f higher mortality rates were increased age, having no
cardiac treatment, having diabetes, and having higher hospital-wide annual AMI
admissions.
Being widowed was associated with a 20% lower risk o f death (hazard ratio;
0.80) than being single. This finding is interesting considering that the literature
suggests that being single and being widowed are associated with higher rates o f
mortality compared to married individuals.72 One difference in these populations that
could possibly account for some o f the difference in risk o f death was that only 9% of
widowers were current smokers compared to 28% o f single people. Additional
analysis is recommended on possible differences in widowed and single patient
populations that may impact the risk o f death.
Having an identified PCP was used as a proxy for access to care, the
assumption being that if a patient has an identified physician, then perhaps the patient
is being seen for regular preventive, well-check, and follow-up to treatment exams. As
noted in Table 2, having regular access to care is associated with decreased mortality,

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which was confirmed with this analysis. This study showed that having an identified
PCP was associated with a 24% lower risk o f death (hazard ratio; 0.76) than patients
who did not have an identified PCP.
The belief before beginning the data analysis was that PCI procedures may be
associated with better outcomes as they are less invasive (and therefore less risky) and
require less recovery time than do open heart surgeries. It is interesting that CABG
surgery, as well as PCI treatment, was associated with improved outcomes. Patients
with CABG surgery had a 42% lower risk o f death (hazard ratio; 0.58) and patients
with PCI/angioplasty had a 52% lower risk o f death (hazard ratio; 0.48) than patients
without these treatments. For more severe patients, CABG surgery may be preferable
to PCI treatment. For the patients in this study, both treatment options were shown to
be effective in reducing mortality.
The comorbidities dyslipidemia and hypertension were included in the analysis
because they are risk factors for heart disease. This analysis showed that patients who
had dyslipidemia had a 58% lower risk o f death (hazard ratio; 0.42) and patients who
had hypertension had a 16% lower risk o f death (hazard ratio; 0.84) than patients who
did not have these conditions. This finding was opposite of what was expected. One
explanation for this finding is that patients who have documented and coded illness are
likely being treated for their condition. Some individuals without documented and
coded illness may have other chronic conditions but may not be getting treatment or
having active management o f their disease. Additionally, in some cases, patients
without the specified illness may be sicker than those who do have the specified

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illness. For instance, patients with hypotension may be too sick to treat and may have
a higher risk o f death than hypertensive patients. Given that the direction o f the effect
on mortality was unexpected for patients with dyslipidemia and hypertension, further
research is recommended related to these comorbidities.
The ratio of AMI admissions per ICU beds was used as a proxy for technology.
The expectation before running the analysis was that the lower the ratio o f admissions
per ICU bed, the higher the technology available for that facility. However, the results
turned out otherwise, with higher rates o f AMI admissions per ICU bed being a
predictor o f improved patient outcomes. As the ratio o f annual AMI admission per
ICU beds increases by one (e.g., from 13.0 to 14.0), there is a 36% lower risk o f death
(hazard ratio; 0.64). Perhaps for this study, a high ratio o f AMI volume to ICU beds is
an indicator of the fact that higher levels o f volume necessitate increased throughput
and efficiency which lead to faster time to treatment. According to one interventional
cardiologist at Scripps Green Hospital, the busier his day is, the more efficient and
responsive he is to staff. Again, additional research is needed to determine whether
this is a valid rival hypothesis.
Patients seen at Scripps Memorial Hospital Encinitas had a 25% higher risk of
death (hazard ratio; 25.0) and patients seen at Scripps Mercy Hospital San Diego had a
13% higher risk o f death (hazard function; 13.4) than patients seen at Scripps Mercy
Hospital Chula Vista. [Note that the interpretation o f hazard functions is different for
categorical variables than for continuous and binary variables.] There may be
differences in the patient populations that confound and/or lead to these results. For

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instance, at Scripps Memorial Hospital Encinitas, 67% o f patients received all


recommended P4P metrics compared to 73% at Scripps Mercy Hospital Chula Vista.
At Scripps Mercy Hospital San Diego only 30% o f patients had an identified PCP
(predictive o f lower mortality) than patients at Scripps Mercy Hospital Chula Vista
where 47% had an identified PCP. Follow-up analysis on differences between these
facilities is needed to better understand their impact on outcomes.
The data from this study confirmed what is well known in the general
population, which is that older patients have increased risk o f death. In this study o f
AMI patients, for each additional year older a patient is, his/her risk o f dying is four
percent (hazard ratio; 1.04) greater that o f the previous year.
It is intuitive that patients receiving no cardiac treatment were shown to have
worse outcomes in this study as they may be too sick to treat. Standard interventions
for heart attack patients like PCI procedures and CABG surgeries are proven in
evidence-based literature to improve outcomes. However, patients may refuse
treatment, may have contraindications to treatment, or may not benefit from treatment
given the severity o f their condition. Patients in this study who received no cardiac
treatment had 68% higher risk o f death (hazard ratio; 1.68).
As noted in Table 2, other literature has shown that patients with diabetes who
have an AMI have a higher risk o f mortality. Similar to the literature on this subject,
this study confirmed that the comorbidity o f diabetes is a predictor o f increased
mortality. Patients with diabetes had a 17% higher risk o f death (hazard ratio; 1.17)
than those who did not.

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An interesting result o f this analysis was that the higher the annual AMI
admissions, the worse the outcome. Each additional annual AMI admission is
predictive o f a two percent higher risk o f death (hazard ratio; 1.02). Volume is often
used as an indicator o f high performing health care providers in recognition awards
such as the U.S. News & World Report or the Leapfrog Top 100 Hospitals list. It is
believed that the more often an organization or a clinician performs a certain service,
the better he/she/it is at it. The results o f this study indicate that higher hospital AMI
volume may be a predictor o f worse outcomes (i.e., higher mortality). The nonintuitive result illuminates the issue that annual AMI admissions is an indicator o f
disease burden only. Volume does not denote whether optimal therapy was given.
Additional analysis using the number o f CABG surgeries for patients who receive a
CABG surgery and number o f PCI procedures performed for patients who receive a
PCI, is recommended rather than the number o f patients seen irrespective o f treatment.
Should results o f follow-up analysis support this studys findings, a rival hypothesis
that if volumes increase past a certain threshold, resources may not be able to support
the increase in volume with the same high level o f service should be investigated.
Perhaps the needed beds, cardiologists, or equipment is not available in a timely
manner if volumes are higher than ideal for a certain facility.

Pay-for-Performances Impact on Outcomes


The regression discontinuity analysis did not note any significant changes in
mortality due to participation in the HQA. Thirty-day, 90-day, and 180-day mortality

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rates did improve over the time period, however, the slope and intercept o f the postHQA compared to pre-HQA time periods were not statistically significant. If the HQA
was responsible for a change in patient outcomes, one would expect the slope and/or
intercept of the performance after participation in the HQA to be different from the
performance before participation in the HQA. However, the slope and intercept did
not change at a statistically significant level, therefore, one cannot conclude that the
noted improvements in 30-day, 90-day, and 180-day mortality rates were caused by
pay-for-performance.
A trend line for readmission rates within 30 days shows a general downward
trend in readmission rates from 2003 to 2005, possibly indicating that patient
morbidity improved during this time. Again, if the HQA provided the impetus for
improvement, one would expect the slope and/or intercept o f the performance preHQA to be different from post-HQA, which was not the case. Therefore, it is not
appropriate to conclude that the HQA improved Scripps Healths readmission rate
within 30 days.
The randomized and non-randomized controlled trials on P4P suggest that the
majority o f studies/indicators analyzed achieved their desired outcome, however, some
studies also show that the desired outcomes were not achieved and that unintended
11 58

effects o f P4P may exist. This studys results indicate that in a healthcare system
that is already improving performance on process measures liked to P4P/P4R
programs and already improving mortality rates, P4P/P4R participation does not break
that pattern. While participation in the HQA may have affected process and/or

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outcomes at Scripps Health, it cannot be confirmed by this study. The null hypothesis
for the second study aim held, which is that outcomes did not improve as a results of
P4P. However, this study is able to confirm that a health system can both participate in
a P4P/P4R program and continue to improve outcomes.
Some healthcare providers argue that the P4P metrics are not indicators that
should be o f primary focus when providing patient care and that by participating in
public reporting and P4P programs, all ones time is spent documenting information
and collecting new data rather than improving care. The results o f this study challenge
the notion that participating in the HQA can be a hindrance to providing high quality
care, as Scripps was able to do both.

Summary
This is an exploratory analysis. The study results identified that Scripps Health
process measure compliance increased over the study time period, however, the
conclusion cannot be made that P4P caused the increase in performance levels over
this time. This study found that four o f the eight individual AMI process measures
were predictors o f improved outcomes at statistically significant levels. However, this
study also found that P4P was not the direct cause o f improved patient outcomes.
At the onset o f this research project, the intent was to find out whether P4P
achieved its intended effect o f improving outcomes. The literature suggests that by
complying with certain process measures, outcomes should improve. The problem
with the current literature is that it assumes that if everything else is held constant and

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process measures improve, outcomes will improve. In the actual context o f hospital
operations, there are limited resources. In order to improve process measure scores,
another activity that may also lead to improved outcomes may be overlooked or
forgotten. There is the potential to decrease or not affect outcomes by participating in
P4P if limited resources are shifted to focus on activities that are not the most
important in ensuring the best possible outcomes. This research showed that for
Scripps Health, survival did improve from 2003 to 2005. Therefore, the potential
unintended effects o f participation in the HQA did not have a significantly negative
impact on outcomes.
Further research to determine what factors led to the improved outcomes from
2003 to 2005 would be beneficial. For instance, the mean hospital paid FTE per
adjusted occupied beds variable increased over time. Further analysis could be done to
determine whether increases in staffing had a statistically significant impact on patient
mortality and if there were certain factors that led to increased staffing levels. In
addition, the percent o f patients with no cardiac treatment decreased during this time
period from 30% in early 2003 to 17% in late 2005, and having no cardiac treatment
was a statistically significant predictor o f higher mortality. Focusing on appropriate
acute care treatment options and treatment o f comorbid/chronic conditions is also
recommended.
Rosenthal and Frank said that there is little empirical evidence to support the
effectiveness o f paying for quality in healthcare.64 This study cannot support or refute
Rosenthal and Franks statement, however, it can pose additional questions and areas

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for research. For instance, other literature shows that public reporting increases
improvement beyond the collection o f data and private reporting.86 This study does not
show a significant difference in improvement rates before and after public reporting,
so does collecting data result in improvements up to a certain point and then does
public reporting/P4P drive performance to a level which is not easily achieved without
a financial and/or reputation risk to the healthcare provider? Are there process
measures that may be more indicative o f lower mortality than those currently used by
P4P and P4R programs? Can the early and lagged effects o f participation in P4R/P4P
programs be quantified so that the question o f whether it is effective to pay for quality
in healthcare be answered? The intent o f this research was to answer questions about
the value and impact o f P4P. Instead o f answering those questions, this analysis
identified additional areas o f needed investigation.

L im it a t io n s
There are a number o f limitations o f this study. The limitations span from the
study design to the data that was able to be collected. Ideally, a true experimental
study design with patients seen from hospitals nation-wide randomized into pay-forperformance and non-P4P payment methodologies would have been used. Ideally, all
the data identified in the conceptual model would have been able to be obtained and
the sample size for the patient-level data would have been similar to that which was
collected for the other nation-wide HQA participants (e.g., greater than one million) so
that one could have confidence that the sample size is large enough to elicit significant

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results. However, it is often unrealistic or unfeasible to conduct ideal studies. True


experimental study designs with randomized hospitals into P4P and non-P4P programs
have not yet been conducted and would require collaboration with payment
organizations such as insurance companies, employers, and/or the federal government.
It is also difficult to obtain large scale, national patient-level data with the patient
demographic, patient behavior, hospital characteristic, treatment, and outcome
information needed due to patient privacy rules. Given these constraints, a quasiexperimental study was conducted. Inherent in this study are limitations.
One set o f limitations are those due to the data that was able to be collected.
Scripps Health patient level data was used rather than national data. Due to
relationships with Scripps Health and an understanding of the data collected and its
organizational characteristics, it was felt that a study using Scripps Health data could
be conducted in a timely fashion, whereas, contacting hospitals nationally and
establishing cooperation and Institutional Review Board approval could take years to
complete.
Scripps Health operates five hospital campuses in San Diego County. Each
hospital campus serves different populations o f patients as evidenced through the
different locations, payor mixes and religious affiliations. While each o f the five
facilities is different from each other, there may be characteristics o f Scripps Health
(such as the performance rate o f process measures and outcomes before participation
in the HQA) that limit the ability to apply this studys findings to other hospitals.

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External validity may be compromised due to the fact that patient data has been
collected from one health system in one geographical location.
The goal o f this study is to determine how P4P affects patient outcomes,
however, this study uses scores from the Hospital Quality Alliance, which is a pay-forreporting program. Reimbursement for participation in the Hospital Quality Alliance is
the same for all participants regardless o f ones process measure scores. The fact that
payment does not reward the high performers (and potentially disadvantage the low
performers) may limit the ability to extrapolate these findings to true P4P programs.
The HQA was chosen as the intervention because most hospitals have not participated
in a true P4P program and those that have (e.g., Premier, Inc.) do not make patient
level data available to the public. Since these findings are based upon a pay-forreporting system, they may underestimate the true effect of a P4P program. If high
performing hospitals were paid more than others, it may create a larger motivation to
improve ones scores. Because Scripps Health has expected (and the expectation has
since been confirmed) that the Hospital Quality Alliance will eventually become a true
P4P program, this potential limitation may be mitigated but not eliminated.
Another potential limitation to this study is that the total patient population o f
3,954 patients may be too small to yield statistically significant results on outcomes.
Results o f analyses on the full patient population and in the time series design that are
not currently statistically significant could become statistically significant if the
patient population was larger.

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As noted in Table 2, all o f the variables that should ideally be included in this
survival analysis (per the conceptual model) were not able to be included in this study.
The following data elements were not available for inclusion in the patient-level
analyses: patients education, income, severity o f illness, diet, physical activity level,
and alcohol consumption. These variables did not exist on a standardized and
consistent basis in Scripps Health electronic systems from 2003 to 2005 and were
therefore not included in this analysis. Similarly, data from patients seen at Scripps
Memorial Hospital Encinitas from before participation in HQA were not able to be
included in this analysis as patient level data is not available from that time frame.
Even with the current data, there may be more than the ideal number o f
variables included in the model. Given that this is not a definitive analysis, this
limitation may not be o f much concern, however, further analysis should weigh the
positive and negative effects o f including all variables in the conceptual model in the
study.
Post-discharge mortality was established using the Social Security Death
Index. The SSDI does not publish cause o f death, therefore mortality rates are based
on all potential causes of death rather than just deaths related to cardiac disease. This
methodology was applied consistently for all Scripps Health AMI patients over 2003
to 2005.
Another set o f limitations exist related to the study design. As previously
mentioned, a true experimental study design which controls for all internal threats to
validity would be ideal. However, a quasi-experimental time series design was used

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for the main analyses with regression discontinuity analyses supporting the time series
results. In a time series design, the internal threat o f history is not controlled. Had the
results of the time series analyses indicated that P4P was predictive o f improved
process measure compliance and/or lower mortality, the modified recurrent
institutional cycle design would have been used to determine whether the threat o f
history was a likely threat to internal validity. While the additional analysis was not
needed, as the results o f the time series design showed that P4P did not significantly
improve process measures or outcomes, it should be noted that other events in history
could be impacting the study results. For instance, introduction o f new journal articles
and evidence-based care guidelines can impact compliance with process measures,
treatment, and subsequently patient outcomes. [Key evidence-based literature for each
o f the AMI process measures was published before this study (with other articles
published during this studys time frame), except for the cited evidence for smoking
cessation advice/counseling, which was first published in 2003.]
It is unlikely that maturation threats exist. It would be unusual for providers to
get better at treating AMI patients just between one observation time period and not
the others. Testing effects, if present, should also occur during each time period rather
than just one time period, so testing threats are likely controlled. Instrumentation is a
threat to internal validity if the intervention changes the way data is collected. There
were no significant changes in the data collection process using the Scripps Health
information systems during this time period. There may be slight variations due to
different abstractors used for process measure data collection. However, the required

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80% abstraction accuracy rate was always met, so while instrumentation could be a
threat to internal validity, it is unlikely to be a significant threat in this study.
Regression threats are controlled because regression towards the mean trends decline
over time and, therefore, would be an unlikely rival hypothesis for a change in scores
from after compared to before participation in the HQA. Selection is not a threat
because all patients selected by MIDAS+ for the AMI Focus Study based upon
diagnosis codes 410.00 - 410.92 are included in the analysis. Patients are not able to
drop out o f the study. Attrition is another unlikely threat as none o f the patients or
hospitals dropped out o f the study. Interactions such as those between selection and
maturation are also controlled with the time series design.
The time series study design, however, does not control for external threats to
validity such as interaction o f testing and the intervention and the interaction between
selection and the intervention. Similar analyses to those conducted in this study using
different patient populations is recommended in order to substantiate the external
validity o f the results o f this study.
The time series design compares data from after an intervention to before an
intervention, so the timing o f the intervention is o f key importance. The analyses to
determine whether P4P affected process measures and/or outcomes used the date of
initiation o f HQA as the intervention date. Hospitals learned about the HQA before the
implementation date, however, from subjective discussions with California hospitals
in early 2004, many were not prepared for the HQA. Most hospitals mentioned a
desire and an intent to participate but some had to scramble to sign up before the

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deadline and the majority had not been actively focused on making improvements in
these measures. When participation in the HQA began on July 1, 2004, discharges
from the fourth quarter o f 2003 were submitted to the HQA. However, October 1,
2003 was not chosen as the intervention date because hospitals did not have the
opportunity to affect care processes for patients previously discharged. Therefore, the
implementation date for July 1, 2004 (the implementation date o f the HQA) was
chosen as the intervention date. It is possible, however, for early or lagged effects to
have occurred. Efforts are being currently made at Scripps Health to improve AMI
process measure scores in anticipation o f CM S Values Based Purchasing plan. These
analyses did not specifically look for early or delayed effects o f participation in the
HQA, although they could exist.
Most o f the analyses were conducted with patient-level data from Scripps
Health. However, for the modified recurrent institutional cycle design between
Premier, Inc. and Scripps Health, a major limitation exists. Scripps Health and
Premier, Inc. are different hospital systems and may be non-equivalent. Scripps Health
is located in San Diego, California, while the Premier, Inc. hospitals are located
nation-wide. Both hospital systems have different information technology systems
used to collect patient data and process measure compliance. Differences between
performance improvement activities and the systems Board/management
prioritization o f quality improvement is unknown. Both hospital systems are similar in
that they functioned from 2003 to 2005 in a largely decentralized fashion with
different (i.e. non-standardized) care processes utilized by the different facilities

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within the system depending on the unique environment, cultures o f the patients
served, and employees. However, should the hospital systems be deemed to be non
equivalent, internal validity of the study findings from the additional analysis using
Scripps Health and Premier, Inc. data may be compromised.
Given the nature o f this research, it would be difficult to conduct a true
experimental study using a large sample size o f national patient-level data. Despite the
many limitations o f this research, the study results are interesting because they suggest
that P4P may not produce its desired results. CMS is moving towards focusing on P4P
(which it calls Values Based Purchasing) through an amalgamation o f the HQA
program into one that reimburses providers more for higher levels o f compliance on
process measures. This studys results suggests that if the goal o f CM Ss program
slated to begin in fiscal year 2009 is to improve the quality o f patient care (i.e.,
outcomes), that further research should be conducted in order to determine whether
that goal is a realistic outcome o f P4P. Perhaps other areas o f focus such as staffing
ratios and particular treatment modalities should be the focus o f a program whose
intent is to pay hospitals for better quality o f patient care. Again, this research
identifies the need for additional analysis in order to determine where to focus
provider efforts in order to improve patient care.

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Attachment I: Premier Hospital Quality Incentive Demonstration87

According the CMS Fact Sheet, The Premier Hospital Quality Incentive
Demonstration will recognize and provide financial rewards to hospitals that
demonstrate high quality performance in a number o f areas o f acute care. The
demonstration involves a CMS partnership with Premier, Inc., a nationwide
organization o f not-for-profit hospitals, and will reward participating top performing
hospitals by increasing their payment for Medicare patients. Participating hospitals
performance under the demonstration will be posted at www.cms.hhs.gov for health
care professionals.
CMS is pursuing a vision to improve the quality o f health care by expanding the
information available about quality o f care and through direct incentives to reward the
delivery o f superior quality care. Through the Premier Hospital Quality Incentive
Demonstration, CMS aims to see a significant improvement in the quality o f inpatient
care by awarding bonus payments to hospitals for high quality in several clinical areas,
and by reporting extensive quality data on the CMS web site. Premier was selected for
the demonstration because, through its database o f hospitals in the Premier Perspective
system, it has the ability to track and report quality data for 34 quality measures for
each of its hospitals. This capability to immediately provide such a broad set o f quality
data makes the Premier database operationally unique and enables a rapid test o f the
concept of incentives for high performance in several areas o f quality.
Under the demonstration, top performing hospitals will receive bonuses based on their
performance on evidence-based quality measures for inpatients with: heart attack,
heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements.
The quality measures proposed for the demonstration have an extensive record o f
validation through research, and are based on work by the Quality Improvement
Organizations (QIOs), the Joint Commission on Accreditation o f Healthcare
Organizations (JCAHO), the Agency for Healthcare Research and Quality, the
National Quality Forum (NQF), the Premier system and other CMS collaborators.
Hospitals will be scored on the quality measures related to each condition measured in
the demonstration. Composite quality scores will be calculated annually for each
demonstration hospital by rolling-up individual measures into an overall quality
score for each clinical condition. CMS will categorize the distribution o f hospital
quality scores into deciles to identify top performers for each condition.
CMS will identify hospitals in the demonstration with the highest clinical quality
performance for each o f the five clinical areas. Hospitals in the top 20% o f quality for
those clinical areas will be given a financial payment as a reward for the quality of
their care. Hospitals in the top decile o f hospitals for a given diagnosis will be

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provided a 2% bonus o f their Medicare payments for the measured condition, while
hospitals in the second decile will be paid a 1% bonus. The cost o f the bonuses to
Medicare will be about $7 million a year, or $21 million over three years.
In year three, hospitals that do not achieve performance improvements above
demonstration baseline will have adjusted payments. The demonstration baseline will
be clinical thresholds set at the year one cut-off scores for the lower 9th and 10th
decile hospitals. Hospitals will receive 1% lower DRG payment for clinical conditions
that score below the 9th decile baseline level and 2% less if they score below the 10th
decile baseline level.
Hospitals participating in Premier Hospital Quality Incentive Demonstration reported
previously collected quality data currently available in the Premier Perspective
database to provide a historical reference on these quality indicators. The data was
published at www.cms.hhs.gov in early 2004. The first year results will be reported in
2005 recognizing those hospitals with the highest quality and noting those hospitals
that received bonus awards.
Participation in the demonstration is voluntary and open to hospitals in the Premier
Perspective system as o f March 31, 2003. A total o f 274 hospitals are participating in
the demonstration. CMS will use the Premier demonstration as a pilot test o f this
concept, and may develop a request for additional proposals for this concept once we
obtain results from the evaluation o f the Premier demonstration.

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Attachment II: Hospital Quality Initiative 88


According to the Hospital Quality Initiative Overview prepared by CMS, Quality
health care is a high priority for the Bush administration, the Department o f Health
and Human Services (HHS), and the Centers for Medicare & Medicaid Services
(CMS). In November 2001, HHS announced the Quality Initiative to assure quality
health care for all Americans through accountability and public disclosure. The
Initiative is intended to (a) empower consumers with quality o f care information to
make more informed decisions about their health care, and (b) encourage providers
and clinicians to improve the quality o f health care.
The Quality Initiative was launched nationally in November 2002 for nursing homes,
and was expanded in 2003 to the nations home health care agencies and hospitals. In
2004, the Quality Initiative was further expanded to officially include kidney dialysis
facilities that provide services for patients with ESRD. This comprehensive approach
to improving healthcare quality also includes the Doctors Office Quality-Information
Technology (DOQ-IT) project.
The Hospital Quality Initiative uses a variety o f tools to help stimulate and support
improvements in the quality o f care delivered by hospitals. The intent is to help
improve hospitals quality o f care by distributing objective, easy to understand data on
hospital performance. This will encourage consumers and their physicians to discuss
and make better informed decisions on how to get the best hospital care, create
incentives for hospitals to improve care, and support public accountability.
CMS is working in conjunction with the Hospital Quality Alliance (HQA), a publicprivate collaboration on hospital measurement and reporting. This collaboration
includes the American Hospital Association, the Federation o f American Hospitals,
and the Association o f American Medical Colleges, and is supported by Agency for
Healthcare Research Quality (AHRQ), CMS and other organizations such as the
National Quality Forum, the Joint Commission on Accreditation o f Healthcare
Organizations, American Medical Association, Consumer-Purchaser Disclosure
Project, AFL-CIO, AARP and the U.S. Chamber o f Commerce. Through this
initiative, a robust, prioritized and standardized set o f hospital quality measures has
been refined for use in voluntary public reporting. As the first step, Hospital Compare,
a new website/webtool developed to publicly report valid, credible and user-friendly
information about the quality o f care delivered in the nations hospitals, debuted in
April at www.hospitalcompare.hhs.gov and www.medicare.gov.
The Hospital Quality Initiative is complex and differs in several ways from the
Nursing Home Quality Initiative and Home Health Quality Initiative. In the previous
initiatives, CMS had well-studied and validated clinical data sets and standardized
data transmission infrastructure from which to draw a number o f pertinent quality

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measures for public reporting. In contrast with the earlier initiatives, there was no
comprehensive data set on hospitals from which to develop the pertinent quality
measures, nor are hospitals mandated to submit clinical performance data to CMS.
However, section 501(b) o f the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 provided a strong incentive for eligible hospitals to submit
quality data for ten quality measures known as the starter set. The law stipulates that
a hospital that does not submit performance data for the ten quality measures will
receive a 0.4 percentage points reduction in its annual payment update from CMS for
FY 2005, 2006 and 2007.
The twenty measures currently reported on Hospital Compare include the ten starter
measures plus additional measures that many hospitals also voluntarily report. The
measures represent wide agreement from CMS, the hospital industry and public sector
stakeholders such as the Joint Commission on Accreditation o f Healthcare
Organizations (JCAHO), the National Quality Forum (NQF), and the Agency for
Healthcare Research and Quality (AHRQ).
The twenty hospital quality measures currently listed on Hospital Compare have gone
through years o f extensive testing for validity and reliability by CMS and the QIOs,
the Joint Commission on Accreditation o f Healthcare Organizations, the HQA and
researchers. The hospital quality measures are also endorsed by the National Quality
Forum, a national standards setting entity.

Measure
Aspirin at arrival
Aspirin at discharge
Beta-Blocker at arrival

Hospital Quality Measures


Condition
Acute Myocardial Infarction
(AMI)/Heart attack

Beta-Blocker at discharge
ACE Inhibitor or Angiotensin Receptor Blocker
(ARB) for left ventricular systolic dysfunction
Smoking cessation
Thrombolytic agent received within 30 minutes
o f hospital arrival
Percutaneous Coronary Intervention (PCI)
received within 120 minutes o f hospital arrival
Left ventricular function assessment
ACE Inhibitor or Angiotensin Receptor Blocker
(ARB) for left ventricular systolic dysfunction
Comprehensive discharge instructions
Smoking cessation
Initial antibiotic received within 4 hours of

Heart Failure

Pneumonia

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hospital arrival
Pneumococcal vaccination status
Blood culture performed before first antibiotic
received
Smoking cessation
Oxygenation assessment
Appropriate initial antibiotic selection
Prophylactic antibiotic received within 1 hour
prior to surgical incision
Prophylactic antibiotics discontinued within 24
hours after surgery end time

Surgical Infection Prevention

These measures were chosen because they are related to three serious medical
conditions and prevention o f surgical infections and it is possible for hospitals to
submit information on for public reporting today. Both JCAHO and CMS provide
their own processes to submit data and use data edit procedures to check data for
completeness and accuracy. In addition, the quality measures are well understood by
providers and stakeholders and can be validated by CMS with existing resources
through its QIO program. The ultimate goal o f CMS and its collaborators in the HQA
is for this set o f measures to be reported by all hospitals, and accepted by all
purchasers, oversight and accrediting entities, payers and providers. In the future,
additional quality measures will be added to Hospital Compare.
CMS, along with its sister agency AHRQ, is in the final stages developing a
standardized survey o f patient perspectives o f their hospital care, known as Hospital
CAHPS (HCAHPS). Information from this survey will be publicly reported on
Hospital Compare in the future. The survey has been tested by hospitals in Arizona,
Maryland and New York as part o f a CMS pilot project. Additional testing occurred in
Connecticut and select sites around the country. Public reporting o f standardized
measures on patients perspectives o f the quality o f hospital care will encourage
consumers and their physicians to discuss and make more informed decisions on how
to get the best hospital care, as well as increase the public accountability o f hospitals.
The Quality Initiative employs a multi-pronged approach to support, provide
incentives and drive systems and facilities - including the clinicians and professionals
working in those settings - toward superior care through:
Ongoing regulation and enforcement conducted by State survey agencies and CMS
New consumer hospital quality information on our websites,
www.hospitalcompare.hhs.gov and www.medicare.gov, and at 1-800-MEDICARE
The testing o f rewards for superior performance on certain measures o f quality
Continual, community-based quality improvement resources through the QIOs
Collaboration and partnership to leverage knowledge and resources

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CMS will continue to conduct regulation and enforcement activities to ensure that
Medicare hospitals comply with federal standards for patient health and safety and
quality o f care. The survey and certification program is a joint effort o f the federal and
state governments to ensure safety and improve the quality o f care in health care
facilities. These activities provide an important view o f the quality o f care in hospitals.
CMS and the HQA will conduct an integrated communications campaign to encourage
consumers and their physicians to discuss and make informed decisions on how to get
the best hospital care. They will encourage patients to access hospital quality
information on www.hospitalcompare.hhs.gov and www.medicare.gov or by calling 1800-MEDICARE. CMS will also direct the QIOs to promote awareness,
understanding and use o f quality measures by working with clinicians and
intermediaries including primary care physicians, community organizations, and the
media.
As part of the Hospital Quality Initiative, CMS is exploring pay-for-performance via
the Premier Hospital Quality Incentive Demonstration. Under the demonstration,
hospitals will receive bonuses based on their performance on quality measures
selected for inpatients with specific clinical conditions: heart attack, heart failure,
pneumonia, coronary artery bypass graft, and hip and knee replacements. Hospitals
will be scored on the quality measures related to each condition measured. Composite
scores will be calculated annually for each demonstration hospital. Separate scores
will be calculated for each clinical condition by rolling up individual measures into
an overall score.
CMS will categorize the distribution o f hospital scores into deciles to identify top
performers for each condition. For each condition, all o f the hospitals in the top 50%
will be reported as top performers. Those hospitals in the top 20% will be recognized
and given a financial bonus. By the end o f the demonstration, it is anticipated that
participating hospitals will show improvement from performance in year one. In year
three, hospitals will receive lower payments if they score below clinical baselines set
in the first year for the bottom 20% o f hospitals.
The QIOs will continue to work with hospitals to improve performance on the
hospital-reported measures and to develop and implement continuous quality
improvement programs. The QIOs have worked with physicians, hospitals, and other
providers on improvement activities for the past 20 years and have seen providers
achieve a 10-20% relative improvement in performance. For the past three years, the
QIOs have been working with hospitals to improve performance on most o f the starter
set of 10 hospital quality measures. During this period, performance on these measures
has improved across the country. As part o f this initiative, the QIOs are also working
with community, health care and business organizations, and with the local media to

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provide quality information to the public and encourage hospitals to use the
information to improve care.
To be effective, the Hospital Quality Initiative must truly be a collaborative effort with
hospitals and their associations, physicians, other clinicians, federal and state agencies,
QIOs, independent health care quality organizations, private purchasers, accrediting
organizations, and consumer advocates. The initiative is designed to improve
communication among all parties to positively impact quality o f care. By collaborating
to expand knowledge and resources, all partners can achieve greater and immediate
improvements in the quality o f hospital care. The HQA, mentioned earlier, is a prime
example o f a cooperative effort in the Hospital Quality Initiative.

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Attachment III: Conceptual Model

Regressor of Interest
Increased P 4P scores

Patient B ehavior
* Diet (Fruits/Veggies)
* Failure to Drink Any Alcohol

* Aspirin at Arrival
* Aspirin at Discharge
* Beta Blocker at Arrival
* Beta Blocker at Discharge
* ACEI or ARB for LVSD

* Exercise Level
* Smoking Status

* Smoking Cessation Advice


* PCI Received w/in 120 Mins
* Thrombolytic Agent Received
w /in 30 Minutes o f Arrival
T reatm ent
* Thrombolysis
* Angioplasty
* CABG
* Other Open Heart Surgery

Outcome

P atien t D em ographics

Days Survival;
R eadm issions in
30 D ays

* A ge
* Race
* Gender

* Other Cardiac Diagnostic and


Treatment Services

* A ccess to Care
* Education

* N o Treatment

* Income
* Marital Status
* Religion
P atient's M edical C ondition

H ospital C haracteristics /

* CAD
* Prior MI
* Family Hx o f CAD

W orking Environm ent


* Staffing Ratios
* Response Team to AMI in ED

* Dyslipidemia

* Center o f Excellence for Heart Care

* Diabetes
* Hypertension
* Obesity
* Stress / Depression

* Hospital / M D AMI Volume


* Technology Available

* Severity o f Illness / Comorbidities

* Hospital Wealth / Payor Mix


* Teaching Hospital Status
* Surgical Back-up

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Attachment IV: Variable Coding


Outcome

Regressor of
Interest

Survival Post AMI

continuous variable

Alive/Dead at 30 Days
Readmissions

Readmissions within 30 Days

Dead = 1; Alive = 0
Readmission = 1; N ot = 0

Aspirin at Arrival

Aspirin at Arrival

Yes = 1; No = 0; NA = 99

Aspirin at Discharge
Beta Blocker at Arrival

Aspirin at Discharge

Yes = 1; No = 0; NA = 99

Beta Blocker at Arrival


Beta Blocker at Discharge

Yes = 1; No = 0; NA = 99
Yes = 1; No = 0; NA = 99
Yes = 1; No = 0; NA = 99

Adult Smoking Cessation Advice

ACEI for LVSD


Smoking Cessation Advice

PCI Received w/in 120 mins of


Arrival

PCI Received within 120 Mins of


Arrival

Beta Blocker at Discharge


ACEI or ARB for LVSD

Patient
Demographics

Days Survival Post AMI

Yes = 1; No = 0; NA = 99
Yes = 1; No = 0; NA = 99

Thrombolytic Agent Received w/in Thrombolytic Agent Received w/in


30 mins o f Arrival
30 Mins o f Arrival

Yes = 1; No = 0; NA = 99

All Applicable P4P measures

Yes = 1; No = 0

Age
Race

All Applicable P4P measures


Age
Race

categorical variable
White = 1 (excluded);
African American = 2; 3 =
Native American; 4 =
Asian/Pacific Islander; 5 =
Other; 6 = Unknown

Gender

Gender

Female = 1; Male = 0

continuous variable

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Patient
Demographics
(cont'd)

Insurance Status (Payor)

Insurance Listed = 1; No or
Unknown = 0

PCP Status

Insurance Listed = 1; No or
Unknown = 0

Education

Data Unavailable

NA

Income

Data Unavailable

NA

Martial Status

Martial Status

categorical variable

Access to Care

Single = 1 (excluded);
Widowed = 2;
Divorced/Separated = 3;
Married = 4
Religion

Religion

Stated Religion = 1; N ot = 0

Facility

categorical variable
Chula Vista = 1 (excluded);
Encinitas = 2; Green = 3; La
Jolla = 4; Mercy San Diego =
5

Staffing Ratios

Paid FTE per Adjusted Occupied


Bed

continuous variable

Response Team to AMI in ED /


Urgent Care

Rapid Response Team


Chest Pain Center

Yes = 1; No = 0

Hospital
Facility
Characteristics

Center o f Excellence for Heart Care Center of Excellence for


Cardiovascular Care

Yes = 1; No = 0
Yes = 1; No = 0

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Hospital
AMI Volume
Characteristics
(cont'd)
AMI Volume (cont'd)

Patient's
Medical
Condition

Total Hospital AMI Annual


Admissions

continuous variable

Average Cardiologist AMI Annual


Admissions

continuous variable

Technology Available

Ratio o f AMI Admissions to ICU


Beds

continuous variable

Hospital Wealth / Payor Mix

Payor Mix: % Medicare; % Medical; all continuous variables


% Commercial; % Other
Governmental & Self Pay; % Other

Teaching Hospital Status


Surgical Back-Up
CAD

Teaching Hospital Status

Prior MI

Prior MI

Yes = 1; No = 0
Yes = 1; No = 0

Family History o f CAD

Family History of CAD

Yes = 1; No = 0

High LDL / Low HDL Levels

Dyslipidemia

Yes = 1; No = 0

Diabetes
Hypertension

Diabetes
Hypertension

Yes = 1; No = 0

Obesity

Obesity
Depression

Stress / Depression

Treatment

Surgical Back-Up Present


CAD

Yes = 1; No = 0
Yes = 1; No = 0

Yes = 1; No = 0
Yes = 1; No = 0
Yes = 1; No = 0

Severity of Illness / Risk of


Mortality

Inconsistent Data

NA

Thrombolysis

Thrombolysis

Thrombolysis = 1; Not = 0

Angioplasty

Angioplasty

Angioplasty = 1; N ot = 0

CABG

CABG

CA BG = 1; Not = 0

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Treatment
(cont'd)

Patient
Behavior

Other Open Heart Surgery


Other Cardiac Diagnostic or
Treatment Procedure

Other Open Heart Surgery

Other Surgery = 1; Not = 0

Other Cardiac Diagnostic or


Treatment Procedure

Other Cardiac Dx or Tx = 1;
N ot = 0

No Treatment
Months Since Admission

No Treatment

No Treatment = 1; Not = 0

Months Since Admission

continuous variable

Diet (Fruits / Veggies)

No variable included
No variable included

NA

Failure to Drink any Alcohol


Exercise Level
Smoking Status

to

U i

No variable included
Smoking Status within the past 12
months

NA
NA
Yes = 1; No or Unknown = 0

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Attachment V: Covariate Frequencies Over Time


Observation 1

Observation 2

Observation 3

Observation 4

Observation 5

7/1/03-12/31/03
%
n

1/1/04-6/30/04
%
n

Total Patients

1/1/03-6/30/03
n
%
100%
642

7/1/04-12/31/04
n
%
l()U"
836

1/1/05-6/30/05
n
%
100%
668

Sex
Male
Female

391
251

Age
<50
50-59
60-69
70-79
80+

56
87
121
171
203

548

100%

734

100%

61%
39%

331
217

60%
40%

441
293

60%
40%

529
307

63%
37%

442
226

9%
14%
19%
27%
32%

30
79
109
156
174

5%
14%
20%
28%
32%

70
112
144
202

10%
15%
20%
28%
28%

82
139
185
221
209

10%
17%
22%
26%
25%

206

Observation 6
7/1/05-12/31/05
%
n
526

100%

66%
34%

365
161

69%
31%

75
123
151
175
148

11%
18%
22%
26%
22%

44
91
113
116
162

8%
17%
21%
22%
31%

Ethnicity
White
African American
Native American
Asian/Pac Islander
Other
Unknown

480
8
2
42
109
1

75%
1%
0%
7%
17%
0%

311
18
1
120
97
1

57%
3%
0%
22%
18%
0%

434
36
1
131
132
0

59%
5%
0%
18%
18%
0%

531
22
1
73
199
10

64%
3%
0%
9%
24%
1%

495
25
0
40
99
9

74%
4%
0%
6%
15%
1%

411
17
0
28
2
68

78%
3%
0%
5%
0%
13%

Marital Status
Single
Widowed
Divorced/Separted
Married

134
125
34
349

21%
19%
5%
54%

111
121
36
280

20%
22%
7%
51%

188
133
47
366

26%
18%
6%
50%

199
132
44
461

24%
16%
5%
55%

165
108
41
354

25%
16%
6%
53%

124
68
30
304

24%
13%
6%
58%

Religion
Stated Religion

442

69%

377

69%

511

70%

606

72%

437

65%

326

67%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

N o Stated Religion

Observation 1
1/1/03-6/30/03
n
%
200
31%

Observation 2
7 /1 /0 3 -1 : 5 1 03
O
n
\-\

31%

Observation 3
1/1/04-6/30/04
0/
n
/o
223
30%

Observation 4
7/1/04-12/31/04
n
%
2 R)
28%

Observation 5
1/1/05-6/30/05

Observation 6
7/1/05-12/31/05
O.

n
231

%
35%

n
164

/o
33%

Facility
Chula Vista
Encinitas
Green
La Jolla
Mercy

139
0
127
148
228

22%
0%
20%
23%
36%

124
0
123
113
188

23%
0%
22%
21%
34%

160
0
122
233
219

22%
0%
17%
32%
30%

138
104
96
315
183

17%
12%
11%
38%
22%

81
81
112
196
198

12%
12%
17%
29%
30%

71
64
83
168
140

13%
12%
16%
32%
27%

PCP
No/Unknown
Yes

469
173

73%
l_ 27%

364
184

66%
34%

515
219

70%
30%

608
228

73%
27%

486
182

73%
27%

289
237

55%
45%

Payor
No/Unknown
Yes

23
619

4%
96%

26
522

5%
95%

23
711

3%
97%

38
798

5%
95%

28
640

4%
96%

26
500

5%
95%

Censored
Y es/Alive
No/Dead

451
191

70%
30%

411
137

75%
25%

551
183

75%
25%

682
154

82%
18%

576
92

86%
14%

464
62

88%
12%

ACEI for LVSD


No
Y es
N ot Applicable

:
28
85
529

Smoking Cessation A dvice


No
43
Y es
58
N ot Applicable
541

25%
75%

19
70
459

21%
79%

27
67
640

29%
71%

28
78
730

26%
74%

14
70
584

17%
83%

9
60
457

13%
87%

43%
57%

18
53
477

25%
75%

35
95
604

27%
73%

37
92
707

29%
71%

14
111
543

11%
89%

10
83
433

11%
89%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Observation 1
1/1/03-6/30/03
0/
n
/o

Observation 2
7/1/03-12/31/03
O
A
/Q
n

Aspirin at Arrival
No
Yes
N ot Applicable

36
453
153

7%
93%

22
392
134

5%
95%

Aspirin at Discharge
No
Yes
N ot Applicable

48
479
115

9%
91%

47
404
97

10%
90%

64
356
222

15%
85%

48
332
168

71
420
151

14%
86%

N ot Applicable

29
9
604

PCI w/in 120 min


No
Yes
N ot Applicable

70
13
559

Beta Blocker at Arrival


No
Y es
N ot Applicable

Observation 3
1/1/04-6/30/04
n
%

Observation 4
7/1/04-12/31/04
n
%

Observation 5
1/1/05-6/30/05
n
%

Observation 6
7/1/05-12/31/05
%
n

Beta Blocker at Discharge


No
Y es
N ot Applicable
Thrombolytic w/in 30 min
No
Yes

29

6%
94%

20
477
339

4%
96%

10
399
259

2%
98%

4
300
222

1%
99%

38
547
149

6%
94%

27
642
167

4%
96%

18
498
152

3%
97%

7
407
112

2%
98%

13%
87%

44
356
334

11%
89%

16
389
431

4%
96%

22
322
324

6%
94%

11

4%
96%

73
366
109

17%
83%

64
494
176

11%
89%

64
585
187

10%
90%

31
484
153

6%
94%

21
393
112

5%
95%

76%
24%

19
11
518

63%
37%

13
5
716

72%
28%

23
5
808

82%
18%

18
3
647

86%
14%

11
5
510

69%
31%

84%
16%

52
20
476

72%
28%

32

48%
52%

36
41
759

47%
53%

30
38
600

44%
56%

17
41
468

29%
71%

j
;

428
277

35
667

255
260

Observation 2
7/1/03-12/31/03
n
%

Observation 3
1/1/04-6/30/04
0/1
n
/o

Observation 4
7/1/04-12/31/04
n
%
p...............

Observation 5
1/1/05-6/30/05
n
%

Observation 6
7/1/05-12/31/05
n

185
363

34%
66%

205
529

28%
72%

205
631

25%
75%

126
542

19%
81%

75
451

86%

14%

CABG Surgery
No
Yes

591
51

92%
8%

518
30

95%
5%

689
45

94%
6%

758
78

91%
9%

614
54

92%
8%

480
46

91%
9%

Other Open Heart Surgery


No
Yes

637
5

99%
1%

539
9

98%
2%

728
6

99%
1%

824
12

99%
1%

658
10

99%
1%

520
6

99%
1%

PCI/Angioplasty Tx
No
Yes

370
272

58%
42%

286
262

52%
48%

361
373

49%
51%

369
467

44%
56%

256
412

38%
62%

207
319

39%
61%

Thrombosis Treatment
No
Yes

607
35

95%
5%

513
35

94%
6%

713
21

97%
3%

806
30

96%
4%

643
25

96%
4%

505
21

96%
4%

Other Prim. Cardiac Proc. (dx or tx)


No
322
50%
Yes
320
50%

272
276

50%
50%

358
376

49%
51%

323
513

39%
61%

215
453

32%
68%

o
00

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Observation 1
1/1/03-6/30/03
n
/o
A ll Applicable P4P Measures
No
259
40%
Yes
60%
383
!

346

34%
66%

N o Cardiac Tx
No
Yes

391
157

71%
29%

522
212

71%
29%

657
179

79%
21%

575
93

86%
14%

437
89

83%
17%

0%
100%

2
524

0%
100%

450
192

70%
30%

1
CAD
No
Yes

1
641

0%
100%

0
548

0%
100%

0
734

0%
100%

0
836

0%
100%

0
668

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Observation 1
1/1/03-6/30/03
Q/
11
/O
Prior MI
No
Yes
Family History o f CAD
No
Yes

604
38

94%
6%

Observation 2
7/1/03-12/31/03
O
a
/O
a

507
41

93%
7%

Observation 3
1/1/04-6/30/04
n
%
682
52

Observation 4
7/1/04-12/31/04
n
%

93%
7%

767
69

92%
8%

Observation 5
1/1/05-6/30/05
n
%
622
46

93%
7%

479
47

91%
9%

i
i

Observation 6
7/1/05-12/31/05
n
%

635
7

99%
1%

543
5

99%
1%

724
10

99%
1%

809
27

97%
3%

650
18

97%
3%

510
16

97%
3%

Dyslipidemia
No
Yes

452
190

70%
30%

377
171

69%
31%

480
254

65%
35%

501
335

60%
40%

391
277

59%
41%

277
249

53%
47%

Diabetes
No
Yes

445
197

69%
31%

399
149

73%
27%

525
209

72%
28%

605
231

72%
28%

482
186

72%
28%

369
157

70%
30%

252
390

39%
61%

205
343

37%
63%

282
452

38%
62%

319
517

38%
62%

260
r 408

39%
61%

185
341

35%
65%

Hypertension
No
Yes

---------Obesity
No
Yes

599
43

93%
7%

507
41

93%
7%

687
47

........

94%
6%

782
54

94%
6%

616
52

92%
8%

492
34

94%
6%

Depression
No
Yes

617
25

96%
4%

522
26

95%
5%

708
26

96%
4%

802
34

96%
4%

646
22

97%
3%

504
22

96%
4%

Smoker
N o or Unknown
Yes

533
109

83%
17%

474
74

86%
14%

592
142

81%
19%

688
148

82%
18%

535
133

80%
20%

425
101

81%
19%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Observation 1
1/1/03-6/30/03
n
%
Readmit w/in 30 days
No
Yes

Observation 2
7/1/03-12/31/03
(1/0
n

Observation 3
1/1/04-6/30/04
0/'
u

Observation 4
7/1/04-12/31/04
n

Observation 5
1/1/05-6/30/05
0'I)
ii

Observation 6
7/1/05-12/31/05
0/
n
/o

599
43

93%
7%

524
24

96%
4%

698
36

95%
5%

788
48

94%
6%

634
34

95%
5%

505
21

96%
4%

Paid FTE per Adj Occ Bed


4 .5 - 4 .9
131
5 .0 - 5 .4
211
5 .5 - 5 .9
258
6.0 - 6.4
42
6.5+
0

20%
33%
40%
7%
0%

64
196
182
106
0

12%
36%
33%
19%
0%

110
278

15%
38%

266
80
0

36%
11%
0%

27
223
372
149
65

3%
27%
44%
18%
8%

14
146
386
70
52

2%
22%
58%
10%
8%

12
53
350
28
r 83

2%
10%
67%
5%
16%

Rapid Response Team


No
Y es

642
0

100%
0%

548
0

100%
0%

734
0

100%
0%

836
0

100%
0%

470
198

70%
30%

386
140

73%
27%

Chest Pain Center


No
Yes

414
228

64%
36%

360
188

66%
34%

515
219

70%
30%

653
183

78%
22%

470
198

70%
30%

386
140

73%
27%

CV Award During Yr o f Visit


494
No
148
Yes

77%

435
113

79%
21%

393
341

54%

23%

46%

557
279

67%
33%

360
308

54%
46%

275
251

52%
48%

0%
41%
36%
0%
23%

0
247
188
0
113

0%
45%
34%
0%
21%

0
282
159
233
0

0
338
183
315
0

0%
40%
22%
38%
0%

274
198
0
196
0

41%
30%
0%
29%
0%

218
140
0
168
0

41%
27%
0%
32%
0%

Annual AMI Admissions


<200
200 - 399
400 - 599
600 - 800
800+

0
266
228
0
148

0%
42%
24%
35%
0%

Annual AMI Admits/ICU Beds


1
< 10
10-14
493
15-19
0
20+
148
Payor: % Medicare
<30
3 0 -3 9
On
I
o

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Observation 1
1/1/03-6/30/03
n
%
A vg Cardiologist AMI Admits
0
< 10
0%
494
77%
1 0 -2 0
2 0 -3 0
148
23%

50+
Payor: % MediCal
0
1-9
10-19
20+

148
367
0
127

Observation 2
7/1/03-12/31/03
%
n

Observation 3
1/1/04-6/30/04
n
%

Observation 5
1/1/05-6/30/05
%
n

Observation 6
7/1/05-12/31/05
f). i)
n

0
435
113

0%
79%
21%

o
501
233

0%
68%
32%

0
521
315

0%
62%
38%

81
391
196

12%
59%
29%

71
287
168

13%
55%
32%

0%
77%
0%
23%

0
435
0
113

0%
79%
0%
21%

122
379
233 ^
0

17%
52%
32%
0%

96
425
315
0

11%
51%
38%
0%

274
198
196
0

41%
30%
29%
0%

218
140
168
0

41%
27%
32%

23%
57%
0%
20%

113
312
0
123

21%
57%
0%
22%

233
379
0
122

32%
52%
0%
17%

315
425
0
96

38%
51%
0%
11%

0
556
0
112

0%
83%
0%
17%

0
443
0
83

0%
89%
0%
11%

17%
32%
0%
52%

96
315
104
321

11%
38%
12%
38%

112
196
0
360

17%
29%
0%
54%

83
168
0
h 275

16%
32%
0%
52%

0%

j
127
148
0
367

20%
23%
i 0%
57%

123
113
0
312

22%
H 21%
0%
57%

122
233
0
379

-------Payor: % Commercial
<20
20-39
40-59
60+

Observation 4
7/1/04-12/31/04
%
n

139
228
127
148

22%
36%
20%
23%

--------124
188
123
113

23%
r 34%
22%
21%

160
219
122
233

j 22%
30%
17%
32%

________ j. ...... .

--------

1 - --..

138
287
96
315

17%
34%
11%
38%

81
279
112
196

12%
42%
17%
29%

71
204
83
168

13%
39%
16%
32%

96

11%

112

17%

83

16%

!
Payor: % Oth Gvm t/Self Pay
<5
127

20%

123

22%

122

17%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

5-9
10-14
15+

Observation 1
1/1/03-6/30/03
n
fl
148
23%
228
36%
139
22%

Observation 2
7/1/03-12/31/03
n
o
1 11
21%
188
34%
124
23%

Observation 3
1/1/04-6/30/04
n
h
2''3
32%
379
52%
0
0%

Observation 4
7/1/04-12/31/04
n
%
419
50%
321
38%
0
0%

Observation 5
1/1/05-6/30/05
n
%
100
29%
360
54%
0
0%

Observation 6
7/1/05-12/31/05
n
%
H>S
32%
275
52%
0
0%

Payor: % Oth Incl Wrk Comp


<5
642

100%

548

100%

734

100%

836

100%

668

100%

526

100%

Teaching Hospital Status


No
Yes
,

45%
55%

237
311

43%
57%

393
341

54%
46%

557
279

67%
33%

279
389

42%
58%

232
294

44%
56%

287
355

U>

Surgical Back-up
No
Y es

139
503

22%
78%

124
424

23%
77%

160 J
574

22%
78%

242
594

29%
71%

r~506

24%
76%

135
391

26%
74%

30-Day Mortality
Alive
Dead

561
81

87%
13%

482
66

88% ^
12%

650
84

89%
11% ^

766
70

92%
8%

611
57

91%
1 9%

484
42

92%
8%

85%
15%

473
75

86%
14%

637
97

87%
13%

741
95

89%
11%

599
69

I 9o% n
10%

476
50

90%
10%

721
115

86%
14%

589
79

88%
12%

467
59

89%
11%

90-Day Mortality
Alive
Dead

162

544
98

1
180-Day Mortality
Alive
Dead

|
527
115

82%
18%

,4 5 9
I- 89

84%
16%

619
115

84%
16%

Attachment VI: Covariates Included in Stepwise Survival Analysis on Total


Population
R esults o f M odel w ith A spirin at A rrival
Measure Name
Chula Vista
Encinitas
Green
La Jolla
Mercy
A ge
Single

SE

-0.1210
0.0448
-0.6455
0.1140
0.0394

0.1797
0.1706
0.1442
0.1084
0.0038

W idowed
Divorced/Separated
Married
Identified PCP
Identified Payor
PCI Tx
Dyslipidemia
Depression
Aspirin at Arrival

-0.2831
0.1965
-0.0301
-0.3535
1.5366
-0.7567
-0.9383
-0.5344
-0.6412

0.1285
0.1725
0.1101
0.0933
0.5049
0.1123
0.1238
0.2717
0.1536

Measure Name
Chula Vista
Encinitas
Green
La Jolla
Mercy
A ge
Female
Identified Payor
PCI Tx
N o Cardiac Tx
Dyslipidem ia
Diabetes
Rapid Resp Team
M D AMI Volume
Aspirin at Discharge

11
-0.0290
-0.2023
-2.5615
0.2351
0.0399
-0.2616
2.5948
-0.6575
0.4475
-0.6225
0.3941
-0.8133
0.1045
-0.2995

SE
0.2276
0.2245
0.5275
0.1464
0.0045
0.1011
1.0032
0.1359
0.1382
0.1213
0.1022
0.2741
0.0338
0.1576

Wald
33.8999
0.4537
0.0690
20.0331
1.1075
106.6588
9.4984
4.8578
1.2970
0.0746
14.3548
9.2615
45.4293
57.4167
3.8702
17.4353

df
4
1
1
1
1
1

if
Wald
48.9382
0.0163
0.8124
23.5792
2.5786
77.3883
6.6947
6.6895
23.4197
10.4904
26.3342
14.8755
8.8022
9.5323
3.6134

1
1
1
1
1
1
1
1
1

Sig0.0000
0.5006
0.7927
0.0000
0.2926
0.0000
0.0233
0.0275
0.2548
0.7848
0.0002
0.0023
0.0000
0.0000
0.0492
0.0000

df
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1

sig .
0.0000
0.8984
0.3674
0.0000
0.1083
0.0000
0.0097
0.0097
0.0000
0.0012
0.0000
0.0001
0.0030
0.0020
0.0573

df
4
1

Sig.
0.0000

i
Measure Name
Chula Vista
Encinitas

11
-0.2397

SI.
0.2339

Wald
37.1830
1.0501

0.3055

L\p(IJ)

, 95.(), u Cl hxp(B)
Lower
Lpper

0.8860
1.0458
0.5244
1.1208
1.0402

0.6230
0.7486
0.3953
0.9063
1.0324

1.2600
1.4610
0.6957
1.3860
1.0480

0.7534
1.2171
0.9704
0.7022
4.6486
0.4692
0.3913
0.5860
0.5267

0.5857
0.8679
0.7821
0.5848
1.7280
0.3765
0.3070
0.3441
0.3898

0.9691
1.7069
1.2040
0.8431
12.506
0.5847
0.4988
0.9980
0.7116

F.xp(B)
0.9714
0.8168
0.0772
1.2651
1.0407
0.7698
13.3937
0.5181
1.5644
0.5366
1.4830
0.4434
1.1101
0.7412

95.0.;, c i r.xpdD
Lower
tipper
0.6218
0.5261
0.0274
0.9495
1.0315
0.6314
1.8747
0.3970
1.1933
0.4231
1.2139
0.2591
1.0389
0.5442

1.5174
1.2682
0.2170
1.6856
1.0499
0.9385
95.689
0.6762
2.0510
0.6806
1.8118
0.7588
1.1862
1.0094

! 95 .o no ( i i:. \p (ii)
1 xptHJ I Lower
Lpper
0.7869

0.4975

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.2445

Green
La Jolla
Mercy
A ge
Single
W idowed
Divorced/Separated
Married
Identified PCP
Identified Payor
PCI Tx
Dyslipidem ia
Depression
Beta Blocker at Arr

Measure Name
Chula Vista
Encinitas
Green
La Jolla
Mercy
Age
Female
Identified PCP
Identified Payor
PCI Tx
N o Cardiac Tx

0.1535
-0.7041
0.2000
0.0366

0.1920
0.1685
0.1200
0.0042

-0.2491
0.2986
-0.0065
-0.3104
1.7034
-0.9497
-0.8586
-0.6319
-0.4832

0.1441
0.1871
0.1233
0.1046
0.5823
0.1270
0.1318
0.3065
0.1453

SE

0.6391
17.4664
2.7769
7 7.4819
8.9227
2.9869
2.5478
0.0028
8.8048
8.5576
55.9470
42.4619
4.2489
11.0646

1
1
1
1
1
1
1
1
1

0.4240
0.0000
0.0956
0.0000
0.0303
0.0839
0.1104
0.9576
0.0030
0.0034
0.0000
0.0000
0.0393
0.0009

df
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Sig,
0.0000
0.6282
0.7467
0.0000
0.0635
0.0000
0.0153
0.0153
0.0077
0.0000
0.0010
0.0000
0.0001
0.0020
0.0228
0.9544

ExpiB)

df

Sig.
0.0000
0.9661
0.0001
0.0034
0.8281

Exp(B)
1.0535
382995
3.6120
2.2555
0.9385

95.0% Cl E.xp(B)
Lower
Upper
1.1)297
1.0779
0.0000 7E+262
1.9143
6.8151
1.3096
3.8845
0.5294
1.6639

Sig. : i \ p ( B )
0.0061
1.0220

95.0% Cl I xp(B)
Lower
Upper
1.0062
1.0380

Dyslipidem ia
Diabetes
Rapid Resp Team
M D AMI Volume
Beta Blocker at D/C

-0.1194
-0.0740
-2.1889
0.2782
0.0382
-0.2533
-0.2637
2.6716
-0.7571
0.4565
-0.6441
0.4209
-0.8450
0.0773
0.0090

0.2466
0.2291
0.5303
0.1499
0.0046
0.1044
0.1087
1.0032
0.1392
0.1389
0.1232
0.1050
0.2740
0.0340
0.1576

Wald
41.8478
0.2345
0.1043
17.0356
3.4435
67.7096
5.8835
5.8852
7.0912
29.5849
10.7993
27.3284
16.0642
9.5150
5.1842
0.0033

Measure Name
Age
Identified Payor
N o Cardiac Tx
CV Award Yr Visit
Smk C ess A dvice

B
0.0522
12.8558
1.2843
0.8133
-0.0635

SE
0.0117
302.21
0.3239
0.2774
0.2922

Wald
19.9919
0.0018
15.7179
8.5984
0.0472

1
1
1

1
1
1
1
1

1.1659
0.4945
1.2214
1.0373

0.8002
0.3555
0.9654
1.0289

0.6880
1.5453
1.0458

0.7795
1.3479
0.9935
0.7332
5.4924
0.3869
0.4238
0.5316
0.6168

0.5877
0.9342
0.7802
0.5972
1.7544
0.3016
0.3273
0.2915
0.4640

1.0340
1.9448
1.2651
0.9000
17.195
0.4962
0.5486
0.9694
0.8200

0.8875
0.9287
0.1120
1.3208
1.0389
0.7762
0.7682
14.4624
0.4690
1.5786
0.5251
1.5234
0.4295
1.0804
1.0091

1
Measure Name
Age

B
0.0218

SE
0.0079

Wald
7.5207

df

1.6988

95.0% Cl Lxp(B)
Lower
Upper
0.5474
0.5927
0.0396
0.9845
1.0295
0.6325
0.6208
2.0243
0.3571
1.2023
0.4125
1.2400
0.2511
1.0108
0.7409

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.4389
1.4551
0.3168
1.7719
1.0484
0.9525
0.9506
103.32
0.6161
2.0725
0.6686
1.8716
0.7348
1.1547
1.3743

Identified Payor
N o Cardiac Tx
Dyslipidem ia
ACEI for LVSD

11.6020
0.5439
-0.8687
-0.4013

Measure Name
Age
PCI Tx
M D AMI Volume
Thromb 30 mins

B
0.0764
-2.3551
0.0969
0.8405

Measure Name
Age
Identified PCP
Oth Open Heart Surg
Oth Cardiac Dx Tx
N o Cardiac Tx
Dyslipidemia
PCI 120 mins

B
0.0496
-0.8192
1.5377
1.1058
2.6608
-1.4195
0.1076

Measure Name
Chula Vista
Encinitas
Green
La Jolla
Mercy
Age
Single
W idowed
Divorced/Separated
Married
Identified PCP
Identified Payor
CABG Tx
PCI Tx
N o Cardiac Tx
Dyslipidemia
Diabetes
Hypertension
Rapid Resp Team
Payor: Medicare
A ll Applicable P4P

158.40
0.1846
0.2414
0.1934

si-:

0.0054
8.6767
12.9457
4.3060

1
1
1
1

0.9416
0.0032
0.0003
0.0380

109316
1.7227
0.4195
0.6695

0.0000
1.1996
0.2613
0.4583

95.01 ii Cl l.\p (B )
Lower
Upper
1.0409
1.1193
0.0252
0.3578
1.0138
1.1973
0.9437
5.6915

7E+139
2.4738
0.6733
0.9780

0.0185
0.6772
0.0424
0.4584

Wald
17.02 ' 1
12.0943
5.2141
3.3622

df .
1
1
1
1

Sig0.0000
0.0005
0.0224
0.0667

l:\p (B )
1 1)794
0.0949
1.1018
2.3176

SE
0.0123
0.4137
0.7456
0.3820
0.7943
0.4442
0.2974

Wald
16.2400
3.9203
4.2537
8.3787
11.2211
10.2107
0.1308

df

Sig.
0.0001
0.0477
0.0392
0.0038
0.0008
0.0014
0.7176

l'\p (B )
1.0508
0.4408
4.6538
3.0218
14.3070
0.2418
1.1136

95.0% Cl l \p(.B)
Lower
Upper
1.0258
1.0765
0.1959
0.9918
1.0794
20.065
1.4291
6.3892
3.0160
67.867
0.1012
0.5776
0.6217
1.9945

Wald
50.7085
1.1117
3.2234
0.3673
9.5586
136.3460
9.2243
4.3471
1.5895
0.0916
14.2395
9.5697
7.2617
55.8814
7.1935
82.7575
4.4570
7.5856
7.3004
4.3516
0.0306

df
4
1
1
1
1
1

Sig.
0.0000
0.2917
0.0726
0.5445
0.0020
0.0000
0.0265
0.0371
0.2074
0.7622
0.0002
0.0020
0.0070
0.0000
0.0073
0.0000
0.0348
0.0059
0.0069
0.0370
0.8611

h \p (B )

9 5 .0 " .,Cl INpfBj


Lower
Upper

SE

0.1937
-0.9376
0.2066
0.8249
0.0387

0.1837
0.5222
0.3410
0.2668
0.0033

-0.2237
0.1878
-0.0281
-0.2923
1.1090
-0.4582
-0.7810
0.2632
-0.9066
0.1668
-0.2001
-0.4787
0.0688
0.0145

0.1073
0.1490
0.0928
0.0775
0.3585
0.1700
0.1045
0.0981
0.0997
0.0790
0.0727
0.1772
0.0330
0.0828

1
1
1
1
1
1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1

1.2137
0.3916
1.2295
2.2817
1.0394

0.8467
0.1407
0.6303
1.3525
1.0327

1.7397
1.0898
2.3986
3.8492
1.0462

0.7995
1.2066
0.9723
0.7465
3.0315
0.6324
0.4580
1.3011
0.4039
1.1815
0.8186
0.6196
1.0712
1.0146

0.6479
0.9011
0.8106
0.6414
1.5014
0.4532
0.3732
1.0734
0.3322
1.0120
0.7099
0.4378
1.0042
0.8627

0.9867
1.6158
1.1663
0.8689
6.1209
0.8825
0.5620
1.5770
0.4910
1.3793
0.9439
0.8768
1.1427
1.1933

136

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Attachment VII: Covariates Included in Stepwise Survival Analysis with Times Serie
Model

Measure Name
Jan - June '03
A ge
Single
W idowed
Divorced/Sep.
Married
PCI
Dyslipidem ia
FTE/Occ Bed
AMI V ol/ICU Bed
July - D ec '03
Age
PCI
Dyslipidem ia
MD AMI V ol
Jan - June '04
Age
Dyslipidem ia
MD AMI V ol
Payor
CABG
July - D ec '04
Age
PCI
Dyslipidem ia
Diabetes
Chest Pain Ctr
Jan - June '05
Age
PCI
Dyslipidem ia
CABG
PCP
Oth Open Heart
Obesity
| July - D ec '05
Dyslipidem ia
Oth Open Heart
Religious
N o Cardiac Tx

SE

0.0505

0.0080

-0.1343
0.9478
-0.0694
-0.5725
-0.6977
0.5784
-0.0906

Wald

df

Siu.

i 95.0% Cl IAp<B)
l.xpl B)

Lower

Upper

1
3
1
1
1
1
1
1
1

0.0000
0.0447
0.6119
0.0175
0.7686
0.0141
0.0061
0.0212
0.0038

1.0518

1.0355

1.0685

0.2647
0.3991
0.2357
0.2332
0.2543
0.2509
0.0313

39.8887
8.0661
0.2575
5.6408
0.0865
6.0280
7.5297
5.3135
8.3835

0.8743
2.5800
0.9330
0.5641
0.4977
1.7832
0.9134

0.5204
1.1801
0.5878
0.3572
0.3024
1.0905
0.8591

1.4689
5.6402
1.4810
0.8909
0.8193
2.9159
0.9712

0.0318
-0.8266
-1.0204
-0.0829

0.0091
0.2769
0.3156
0.0256

12.3088
8.9131
10.4551
10.5325

1
1
1
1

0.0005
0.0028
0.0012
0.0012

1.0323
0.4375
0.3605
0.9204

1.0141
0.2543
0.1942
0.8755

1.0508
0.7528
0.6691
0.9677

0.0328
-0.8441
-0.0510
11.7195
0.8636

0.0075
0.2523
0.0162
163.119
0.3362

18.9996
11.1895
9.9234
0.0052
6.5977

1
1
1
1
1

0.0000
0.0008
0.0016
0.9427
0.0102

1.0334
0.4300
0.9503
122945.2
2.3717

1.0182
0.2622
0.9206
0.0000
1.2271

1.0488
0.7050
0.9809
9E+143
4.5840

0.0384
-1.1742
-1.1427
0.5383
0.5835

0.0082
0.2564
0.3027
0.2302
0.2149

22.0170
20.9696
14.2534
5.4678
7.3711

1
1
1
1
1

0.0000
0.0000
0.0002
0.0194
0.0066

1.0392
0.3091
0.3190
1.7130
1.7923

1.0226
0.1870
0.1762
1.0910
1.1762

1.0560
0.5109
0.5773
2.6897
2.7312

0.0464
-0.8223
-1.0248
-5.4559
-0.7182
4.5779
-12.9575

0.0098
0.2745
0.3476
1.4727
0.3023
1.0738
333.47

22.5312
8.9734
8.6919
13.7240
5.6443
18.1760
0.0015

1
1
1
1
1
1
1

0.0000
0.0027
0.0032
0.0002
0.0175
0.0000
0.9690

1.0474
0.4394
0.3589
0.0043
0.4876
97.3080
0.0000

1.0276
0.2566
0.1816
0.0002
0.2696
11.8617
0.0000

1.0677
0.7526
0.7093
0.0766
0.8819
798.273
2E+278

-1.4689
2.8566
1.2051
1.3818

0.4867
1.0553
0.5319
0.3471

9.1098
7.3274
5.1337
15.8512

1
1
1
1

0.0025
0.0068
0.0235
0.0001

0.2302
17.4014
3.3372
3.9821

0.0887
2.1995
1.1766
2.0169

0.5975
137.671
9.4651
7.8622

137

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Significant C ovariates in A spirin at D ischarge M odel


95.0v. Cl I \p (B )
Measure Name
Jan - June '03
Age
PCI
Dyslipidem ia
Diabetes
Chest Pain Ctr
Hosp AM I Admits
Jan - June '04
Age
Dyslipidem ia
CABG
M D AMI Vol

SE

0.0543
-0.4380
-0.7086
0.6023
0.6442
-0.0040

0.0087
0.2220
0.2478
0.1964
0.2211
0.0008

0.0452
-0.5834
0.8608
-0.1141

0.0086
0.2363
0.3428
0.0216

Wald
39.4572
3.8943
8.1765
9.4020
8.4853
24.4023
27.8069
6.0971
6.3055
27.9946
6.7995

df

SI.

Wald

I \p (B )

l.uwcr

I 'ppcr

1
1
1
1
1
1

0.0000
0.0484
0.0042
0.0022
0.0036
0.0000

1.05581
0.6453
0.4924
1.8262
1.9044
0.9961

1.0381
0.4177
0.3029
1.2427
1.2346
0.9945,

1.0739
0.9970
0.8002
2.6838
2.9376
0.9976

1
1
1
1

0.0000
0.0135
0.0120
0.0000
0.0091

1.0462
0.5580
2.3650
0.8921
0.8559

1.0288
0.3512
1.2079
0.8552
0.7614

1.0639
0.8866
4.6304
0.9307
0.9621

0.0001
0.0029
0.0416
0.0016
0.1458
0.2024
0.2824
0.2362
0.0742

1.0345
0.4656
0.6040
0.9403

1.0166
0.2817
0.3719
0.9050

1.0527
0.7697
0.9809
0.9771

0.6696
1.5254
0.7286
0.6573

0.3614
0.7064
0.4315
0.4146

1.2406
3.2939
1.2303
1.0420

0.0006
0.0199
0.0181
0.0676

1.0650
0.3104
2.5103
2.4413

1.0273
0.1159
1.1701
0.9375

1.1041
0.8309
5.3852
6.3577

1.0160
0.0398

1.1005
0.3689

0.4716
0.5722
2.3087
0.0494

9.6220
11.2904
153.131
2.9048

M os Since Admit
-0.1557
0.0597
1
July - D ec '04
Age
0.0339
0.0089
14.5106
1
-0.7643
0.2564
1
PCI
8.8848
-0.5042
Dyslipidem ia
0.2474
4.1526
1
MD AMI V ol
-0.0615
0.0195
9.9108
1
Single
5.3835
-0.4011
0.3147
1.6250
1
Widowed
Divorced/Separtd
0.4222
0.3928
1.1555
1
1.4034
1
Married
-0.3166
0.2673
Oth Cardiac D x/Tx
-0.4196
0.2351
3.1865
1
Jan - June '05
0.0630
0.0184
1
A ge
11.7497
0.5024
1
-1.1700
5.4226
PCI
0.9204
0.3894
Diabetes
5.5857
1
N o Cardiac Tx
0.8925
3.3406
1
0.4883
July - D ec '05
Age
0.0558
0.0204
7.4977
1
-2.1102
13.8082
1
PCI
0.5679
White
10.6060
4
African American
0.7562
0.7693
0.9663
1
Native American
0.9328
1
0.7608
1.5033
1
Asian/Pacific Isl
2.9340
1.0701
7.5177
Other
-0.9704
1.0392
0.8720
1
a = Degree o f freedom reduced because o f constant or linearly

Measure Name
Jan - June '03
Age
PCI
Dyslipidem ia

Sin.

df

0.0062
1.0574
0.0002
0.1212
0.0314
2.1302
0.3256
0.2202
2.5416
18.8024
0.0061
0.3504
0.3789
dependent covariates

Sig-

| 95.0% Cl l-\p(U>
1 '
1 Ipper
. INp(B) j Lower
|

0.0535
-0.6887
-0.9782

0.0087
0.2727
0.3019

38.1785
6.3802
10.4962

1
1
1

0.0000
0.0115
0.0012

1.0550
0.5022
0.3760

1.0372
0.2943
0.2081

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.0730
0.8570
0.6795

CD

>
cro

Hosp AM I Admits
July - D ec. '03
PCI
Dyslipidem ia
Single
W idowed
Divorced/Separtd
Married
PCI
Prior M l
M D AM I Admits
Jan - June '04
Age
PCI
Dyslipidem ia
Payor
CABG
AMI V ol/IC U Bed
July - D ec. '04
Age
PCI
Dyslipidem ia
Chest Pain Ctr
Jan - June '05
A ge
PCI
Dyslipidem ia
CABG
Oth Open Heart
July - Dec. '05
Oth Open Heart
N o Cardiac Tx

-0.0018

0.0005

14.1942

0.0002

0.9982

0 .9972

0.9991

0.0457
-1.0924
-0.8866

0.0106
0.2987
0.3373

1
1
1

-0.8424
0.6804
0.4372
-0.9102
-1.4522
-0.0748

0.3901
0.4396
0.3019
0.2624
0.7290
0.0264

18.6928
13.3734
6.9094
16.5009
4.6622
2.3959
2.0973
12.0356
3.9683
8.0004

1
1
1
1
1
1

0.0003
0.0086
0.0009
0.0308
0.1217
0.1476
0.0005
0.0464
0.0047

0.0000

1.0468
0.3354
0.4120

1.0253
0.1868
0.2127

1.0687
0.6023
0.7981

0.4307
1.9748
1.5483
0.4024
0.2341
0.9280

0.2005
0.8343
0.8569
0.2406
0.0561
0.8811

0.9252
4.6742

0.0208
-0.8080
-0.6462
11.8731
0.8169
-0.1674

0.0081
0.2453
0.2613
178.479
0.3558
0.0485

6.5930
10.8525
6.1161
0.0044
5.2720
11.9217

1
1
1
1
1
1

0.0102
1.0210
0.0010
0.4457
0.0134
0.5240
0.9470 143361.2
0.0217
2.2636
0.0006
0.8459

1.0049
0.2756
0.3140
0.0000
1.1270
0.7692

1.0373
0.7209
0.8745
1E+157
4.5463
0.9302

0.0339
-1.2278
-0.6807
0.8264

0.0090
0.2952
0.3052
0.2330

14.2293
17.2981
4.9733
12.5856

1
1
1
1

0.0002
0.0000
0.0257
0.0004

1.0344
0.2929
0.5063
2.2852

1.0164
0.1643
0.2783
1.4475

1.0528
0.5225
0.9209
3.6075

0.0424
-0.9294
-0.9419
-16.4216
4.8938

0.0111
0.3180
0.3750
257.908
1.1078

14.6253
8.5392
6.3094
0.0041
19.5168

1
1
1
1
1

0.0001
0.0035
0.0120
0.9492
0.0000

1.0434
0.3948
0.3899
0.0000
133.4662

1.0209
0.2117
0.1870
0.0000
15.2210

1.0663
0.7364
0.8131
3E+212
1170.3

3.5584
1.7844

1.0569
0.3606

11.3359
24.4914

1
1

0.0008
0.0000

35.1061
5.9562

4.4235
2.9380

278.609
12.0751

1
Measure Name
Jan - June '03
A ge
N o Cardiac Tx
Dyslipidem ia
Diabetes
CV Award Yr Visit
Jan - June '04
A ge
CABG
M D AMI Admits
July - D ec. '04

|
SE

'
Wald

[
df

Sig.

' I. xpfB )

2.7978
0.6730
0.9769
0.9773

' 95.0% Cl ExplB)


:
Lower
Upper

0.0500
0.6518
-1.0429
0.6407
-1.8926

0.0089
0.2097
0.2641
0.2122
0.4411

31.3390
9.6655
15.5900
9.1142
18.4049

1
1
1
1
1

0.0000
0.0019
0.0001
0.0025
0.0000

1.0513
1.9190
0.3524
1.8977
0.1507

1.0331
1.2724
0.2100
1.2520
0.0635

1.0699
2.8942
0.5914
2.8766
0.3577

0.0447
0.9472
-0.1130

0.0088
0.3397
0.0237

25.6835
7.7766
22.6504

1
1
1

0.0000
0.0053
0.0000

1.0457
2.5785
0.8931

1.0278
1.3251
0.8525

1.0640
5.0176
0.9357

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Age
MD AM I Admits
PCI
Jan - June '05
Age
N o Cardiac Tx
PCI
July - D ec. '05
N o Cardiac Tx

Measure Name
Jan - June '03
Age
| July - D ec. '03
Depression
Jan - June 04
CABG
Oth Cardiac D x/Tx
AMI V ol/IC U Bed
July - D ec. '04
Age
Chula Vista
Encinitas
Green
La Jolla
Mercy
Oth Open Heart
Hypertension
Mos Since Admit

Measure Name
Jul\ - Dec '03
Dyslipidem ia
Jan - June '04
Oth Cardiac D x/Tx
Paid FTE/Occ Bed
July - D ec '04
Dyslipidem ia
Oth Cardiac D x/Tx
Jan - June '05
Age
N o Cardiac Tx
a = Constant or Linearly

0.0386
-0.0758
-0.8372

0.0089
0.0206
0.2454

18.6717
13.4932
11.6383

1
1
1

0.0000
0.0002
0.0006

1.0394
0.9270
0.4329

1.0213
0.8902
0.2676

1.0577
0.9652
0.7003

0.0541
0.8051
-1.0489

0.0163
0.4509
0.4544

11.0878
3.1874
5.3291

1
1
1

0.0009
0.0742
0.0210

1.0556
2.2368
0.3503

1.0225
0.9243
0.1438

1.0898
5.4134
0.8535

2.2814

0.4526

25.4048

0.0000

9.7900

4 .0319

23.7716

Sh

Wald

df

Siu.

L.\p( B)

95.0% Cl INplU)
Lower
Upper

0.0766

0.0260

8.6970

0.0032

1.0797

2.4378

0.9145

7.1058

0.0077

11.4474

1.9190
-1.3918
-0.5172

0.8415
0.5511
0.1267

5.1999
6.3796
16.6729

1
1
1

0.0226
0.0115
0.0000

6.8140
0.2486
0.5962

1.3094
0.0844
0.4651

35.4586
0.7321
0.7642

0.1327

0.0320

0.0000
0.0147
0.0025
0.0125
0.0024
0.0007
0.0138
0.0284
0.0006

1.0725

1.2159

1.1751
1.1405
1.1058
1.2503
1.4727
0.6620
0.2077

1
4
1
1
1
1
1
1
1

1.1420

-3.5539
-2.8503
-3.3590
-4.2626
3.6262
1.4512
0.7132

17.1989
12.3933
9.1473
6.2453
9.2275
11.6238
6.0628
4.8062
11.7891

0.0286
0.0578
0.0348
0.0141
37.5707
4.2683
2.0405

0.0029
0.0062
0.0040
0.0012
2.0954
1.1663
1.3581

0.2863
0.5407
0.3037
0.1633
673.634
15.6215
3.0657

SE

Wald

E\p( B)

1.0260

1.13611

|
1.9067 1 68.72841

95.0% Cl l .xp(B)
Lower
Upper

df

...Sig- ..

0.0243

0.2968

0.1031

0.8540

-1.2148

0.5393

5.0738

-1.4614
0.9935

0.4071
0.4541

12.8884
4.7869

1
1

0.0003
0.0287

0.2319
2.7008

0.1044
1.1091

0.5150
6.5769

-1.6722
-1.0289

0.7450
0.4378

5.0376
5.5221

1
1

0.0248
0.0188

0.1878
0.3574

0.0436
0.1515

0.8090
0.8430

0.0808
0.0342
5.5895
1
0.0181
1.0842
1.0139
1.1594
1.2595
0.6344
1
0.0471
1.0163 12.2166
3.9419
3.5236
Dependent Covariates F a c ility C o d e (l) = 0 ; O th e rO p e n H e a rtS u rg e ry =

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

0 ; CAD - 1 ; Family Hx CAD = 0 ; Rapid_Response_Team = 0

Measure Name
Jan - June '03
A ge
Jan - June '04
Age
July - D ec '04

SE

Wald

0.0836

0.0490

2.9096

0.1020

0.0407

6.2954

df

Sig.

L \p (B )

| 95.0% Cl l:\p (B )
Lower
Upper

0.0881

1.0872

0.9876

1.1969

0.0121

1.1074

1.0226

1.1993

0.2354
1
Age
0.3957
2.8250
0.0928
1.4855
0.9364
2.3565
Diabetes
1
9.9209
8.4119
1.3909
0.2382 20350.57
0.0014 2.9E+11
a = Constant or Linearly Dependent Covariates Facility Code( 1) = 0 ; Facility C ode(2) = 0 ; R a ce(l)
= 0 ; Race(4) = 0 ; Other Open Heart Surgery = 0 ; N o Cardiac Tx = 0 ; CAD = 1 ; Prior MI = 0
; Rapid Response Team = 0
b = Constant or Linearly Dependent Covariates Facility_Code(2) = 0 ; Race(4) = 0 ; CABG = 0 ;
Other Open Heart Surgery = 0 ; N o Cardiac Tx = 0 ; CAD = 1 ; Family Hx CAD = 0

Measure Name
Jan - June '05
Age

Measure Name
Jan - June '03
Age
Payor
CABG
PCI
Dyslipidem ia
Diabetes
FTE/Occ Bed
CV Award
July - D ec '03
Age
Payor
PCI
Dyslipidemia
CV Award
PCP
Jan - June '04
Age
Payor
PCI
Dyslipidemia

mm

SE

0.0758

0.0315

5.8122

i
SE

Wald

Wald

, df
1

df

Sig.
0.0159

Sin.

0.0000

0.1597
0.2264
0.2620

31.9357
0.0070
6.1230
17.9007
17.9846
4.6426
4.0755
5.6400

1
1
1
1
1
1
1
1

0.0337
11.5852
-1.0454
-0.9363
-1.0210
-0.6360

0.0079
161.289
0.2176
0.2664
0.3075
0.1926

18.2644
0.0052
23.0773
12.3549
11.0276
10.9050

1
1
1
1
1
1

0.0000

0.0365
11.8038
-0.4487
-0.8713

0.0063
164.896
0.1822
0.2045

33.6451
0.0051
6.0677
18.1546

1
1
1
1

0.0000

0.0371
11.5906
-0.9255
-0.7964
-0.8964
0.3441
0.4571
-0.6223

0.0066
138.818
0.3740
0.1882
0.2114

0.9335
0.0133

0.0000
0.0000
0.0312
0.0435
0.0176

0.9427

0.0000
0.0004
0.0009
0.0010

0.9429
0.0138

0.0000

. L \p (B )
1.0788

95.0,, Cl L \p(B )
Lower
Upper
1.0143

1.1474

95.0'.,. Cl EAplB)
INpiB) | lam er
Upper
1.0378
108080.5
0.3963
0.4509
0.4080
1.4107
1.5795
0.5367
1.0343
107492.8
0.3515
0.3921
0.3602
0.5294
1.0372
133758.6
0.6384
0.4184

1.0245

0.0000
0.1904
0.3118
0.2696
1.0316
1.0134
0.3211
1.0184

0.0000
0.2295
0.2326
0.1972
0.3629
1.0245

0.0000
0.4468
0.2803

141

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

1.0512
2E+123
0.8250
0.6521
0.6175
1.9292
2.4617
0.8970
1.0504
2E+142
0.5385
0.6608
0.6581
0.7722
1.0501
3E+145
0.9124
0.6247

MD AMI Vol
July - D ec '04
Age
PCI
Dyslipidemia
Diabetes
PCP
MD AMI V ol
Religious
Jan - June '05
Age
CABG
PCI
Dyslipidemia
PCP
Oth Open Hrt
Hypertension
July - D ec '05
Age
PCI
Dyslipidemia
Thrombosis

-0.0456

0.0139

10.7542

0.0010

0.9554

0.9297

0.9818

0.0407
-1.0476
-0.8596
0.4099
-0.4957
-0.0556
-0.3793

0.0068
0.1977
0.2068
0.1790
0.1829
0.0154
0.1731

36.0978
28.0693
17.2810
5.2455
7.3493
13.0036
4.7988

1
1
1
1
1
1
1

0.0000
0.0000
0.0000
0.0220
0.0067
0.0003
0.0285

1.0415
0.3508
0.4233
1.5066
0.6091
0.9459
0.6843

1.0278
0.2381
0.2823
1.0609
0.4256
0.9177
0.4874

1.0554
0.5168
0.6349
2.1395
0.8717
0.9749
0.9609

0.0499
-5.4805
-1.0113
-1.1324
-0.6556
4.7810
-0.6189

0.0083
1.2485
0.2357
0.3074
0.2704
1.0373
0.2145

35.9481
19.2685
18.4052
13.5697
5.8791
21.2448
8.3263

1
1
1
1
1
1
1

0.0000
0.0000
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1.0512
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14.6131
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1
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0.0001
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0.0019

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1.9162

1.0652
0.5030
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17.6393

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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