The Game Is Not Over at Halftime

September 2015

It is football time in America and fans are everywhere. Even some of the youngest fans know the rules for keeping score and that the game must run to completion before the victors and the vanquished are decided. The scoreboard is always visible to the players and the fans, and no one accepts victory or defeat based upon the halftime score.

If only knowing the score in healthcare were as easy as it is in football.  In measuring the outcomes of hospital care, we don’t even know the scores for our own teams. The metrics for scoring points or for incurring penalties are generally obscured. Despite the triumphant pronouncements of hospitals’ marketing departments, objective measures that compare results to a regional or national benchmark remain relatively uncommon.

One reason for this is that the traditional set of measures are often outdated and opaque.  For example, inpatient deaths have been a traditional measure—but low mortality rates, inadequate risk adjustment, declining lengths of inpatient stay, and a shift in care to the outpatient setting have diminished the usefulness of this outcome. While inpatient complications (e.g., surgical site infection) have been used as a metric for outcomes of care, the absence of standardized definitions and the variability of surveillance to detect events have obscured the reliability of this measure also. The self-reporting of complications is somewhat analogous to the Chicago Bears having the final say on their point total.

Moreover, complications are commonly evaluated only at the conclusion of the hospitalization.  This despite the fact that the majority of major complications resulting in readmissions, emergency department visits, and even post-discharge deaths occur after discharge. Just as the football game is not over at halftime, the evaluation of outcomes of care cannot be performed at the end of hospitalization.

MPA Healthcare Solutions takes an approach that is both fair and effective.  We measure the outcomes of care through the whole continuum of inpatient hospitalization and for 90-days following discharge. To cover the complete spectrum, the four outcomes of care include inpatient mortality rates, prolonged inpatient length of stay, 90-day post-discharge deaths, and 90-day readmissions following discharge. Risk adjustment addresses the differences in the profile of patients that are managed in a given institution. A fifth metric, 90-day emergency department visits without readmission (including observation stays), will be added soon. When all five adverse outcome measures are integrated, hospitals can identify their risk-adjusted performances relative to national benchmarks. Care redesign initiatives can be implemented, and objective metrics will identify improvements achieved.

As bundled payment programs of Medicare and other payers unfold during the coming months and years, adverse outcomes of care will no longer result in increased hospital revenue. Instead, adverse outcomes will eat into hospitals’ margins and threaten their potential solvency.  Now is the time for a “goal line” stand to improve care by knowing the outcomes score in all four quarters of the game. Rallying to a higher level requires that everyone on the team knows the final score.

Donald Fry

Donald E. Fry, M.D. is Executive Vice President for Clinical Outcomes Management at MPA Healthcare Solutions, Adjunct Professor of Surgery at Northwestern University, and Professor Emeritus of Surgery at the University of New Mexico School of Medicine. At MPA Healthcare Solutions, Dr. Fry provides clinical leadership in analyzing and evaluating clinical performance, guiding quality improvement, and creating incentives for coordinated, cost-effective care.

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