By T. Brian Callister, MD

This article appeared originally in the spring, 2010 issue of Continuum, the quarterly journal of the Acute Long Term Hospital Association and is reprinted with permission.

Establishing specific benchmarks for patient outcomes is a complex and difficult process. However, it is widely accepted as a necessity within the medical community in order to attempt to show “quality” in patient care and “value” for the healthcare dollar. Benchmarking outcomes has recently come into the spotlight of the mainstream media and has also become a focus of legislators, regulators, and third party payers. The recent article in the New England Journal of Medicine that demonstrated a 19.6% thirty day hospital re-admit rate for Medicare beneficiaries has become a frequently cited rallying call for improvements in inpatient quality as well as a call for a wholesale re-evaluation of what defines an appropriate discharge.1

Long Term Acute Care Hospitals (LTACH) have been tracking such “quality” measures for many years (as Short Term Acute Care Hospitals have done), but such tracking has only been performed by individual hospitals or hospital chains. There has been no industry wide consensus on outcome measures for LTACHs – a fact that has not gone unnoticed by regulators and payers alike.

Finally, this month will mark the beginning of industry wide tracking of six specific outcome measures for LTACHs with ALTHA membership. The LTACH Outcome Benchmark Project is by no means a flawless set of perfect quality measures, and it certainly does not represent the last word on measuring quality. However, it is a necessary beginning of a process to analyze, evaluate, and understand specific outcome measures that may assist us in defining the “value” that LTACHs bring to the continuum. In order to understand the potential benefits and pitfalls of this project, it is important to understand the history of its development.

The ALTHA Clinical Committee, under the guidance of Dr. Sean Muldoon, Chief Medical Officer for Kindred Healthcare, began wrestling with the idea of industry wide outcome measures almost a decade ago. For several years, the clinicians on the committee struggled to agree on the definitions themselves. Measures as seemingly simple as ventilator wean rates became battle grounds for inclusion and exclusion criteria. In addition, executive management fears of data sharing severely limited the clinicians’ collective ability to evaluate the real worth of many of the proposed parameters. In fact, these same issues continue to cause some anxiety and concern moving forward. Fortunately, the Clinical Committee has devised a safe mechanism for data submission that should alleviate much of the fear about data sharing among ALTHA members.

The substance of the project – answering the question of whether or not the particular measures chosen will indeed help us to show value in LTACH care – will not be known until we actually begin to see some results. However, it is comforting to know that many of the clinicians on the Clinical Committee remain confident, based on their own companies’ internal tracking over many years, that it is very likely that at least some of the outcome measures chosen will indeed provide some proof of the added value that LTACHs bring to the continuum.

Certainly, some of the measures will prove to be much better markers of quality than others, but the committee wanted to begin the process with a broad stroke of measures. Some of the measures are very simple but potentially not as useful (such as “crude mortality”) as others that are more complex and difficult to measure yet may indeed be the best markers of quality (such as “unplanned short term acute transfer rate”). As we move forward with data gathering and results analysis, we may indeed decide to stop tracking certain measures or to add new measures. Obviously, these decisions will depend on the usefulness of each individual outcome marker with regard to validity, ease of data gathering, and the perception by the Clinical Committee of whether or not a given measure is actually providing a valuable insight on quality.

The initial outcome benchmarks to be tracked are:

  • Crude mortality
  • Ventilator weaning
  • Nosocomial pressure ulcer (Incidence)
  • Catheter-related bloodstream infection rate
  • Readmits back to the LTACH
  • Unplanned short-term acute care transfer rate

The data submission will be performed by one designated clinical officer from each ALTHA member company or hospital. The designated submitter will be verified by an independent third party initially and on an ongoing basis. Data will be submitted quarterly and will be collated and reported out to ALTHA as aggregate data only. No individual hospital, company, or geographic data will be reported. In addition, participating hospitals will be required to sign an agreement that prohibits their use of the aggregate results for advertising or any other purpose.

The project is a joint research project of the ALTHA Clinical Committee and GostinStrategic (an independent third party administrator). No ALTHA member or employee may access any of the submission data, and ALTHA will only receive the six final aggregate results each quarter. Finally, participation in the project is limited to ALTHA member hospitals and is strictly voluntary.

The Long Term Acute Care Hospital Outcome Benchmark Project that is launched this month is a necessary first step in our attempt to provide meaningful data that will assist us in our effort to prove that the quality of LTACH care adds significant value for our patients and for society. With the enthusiastic support of our ALTHA Clinical Committee, this quality benchmark project, almost a decade in planning, has finally become a reality. Now we are ready to take the next step – a step that will require the aggressive support of all of our member hospitals. Please join me in thanking the ALTHA Clinical Committee for their hard work and dedication in moving this project forward, and please encourage and insure that your hospital participates in this critical endeavor.

For more information on participating in the LTACH outcome benchmarking project, please contact Stephanie Donolli at stephanie.donolli@altha.org or 703-518-9900.

REFERENCES
1 Jencks, S. et.al, Rehospitalizations among Patients in the
Medicare Fee-For Service Program. N Engl J Med 2009;360:
1418-1428