Introduction: Neurosurgical data from administrative databases is becoming the normative assessment of physician quality and efficiency. Mortality observed to expected (O:E) index rates are common metrics used by hospitals, insurers and health care policy makers to evaluate the quality of health care. The validity of reports derived from an administrative database is directly related to the accuracy of clinical, socio-economic and coding data assigned at the time of admission and discharge; often with little physician oversight. The data fidelity is key to accurately creating a quality metrics report and is the basis of this study.
Methods: Attending neurologists, neurosurgeons, chart documentation specialist’s and utilizing the UHC Clinical Database for 2011 performed a retrospective review of mortality cases for a neurosciences institute. Standard UHC algorithms were used to calculate the O: E mortality rates. Cases chosen for audit were then stratified to those with a low expected mortality rate of 0.5. Patient charts were reviewed to assess for admission source accuracy, admission diagnosis accuracy, and coding completeness and accuracy given the clinical course of the patient.
Results: A total of twenty patient’s charts that expired with a low expected mortality were reviewed. Of these twenty charts only two (10%) reflected complete accuracy in coding and documentation given the clinical course of the patient. Factors affecting the O: E calculation included erroneous coding of the primary diagnosis, inconsistent coding of patient DNR/hospice/palliative care state, inadequacies with UHC algorithms, and poor physician documentation preventing correct clinical coding by coding staff. Pre-Review the overall O: E rate of this cohort of patients was 1.22 while post-review O: E rates of the same cohort improved to 0.83 an improvement of approximately 33%.
Conclusions: Inaccurate data entry used in calculating patient and clinical outcomes can lead to high error rates when large databases are used to assess physician quality measures. Physicians need to take an active role in their clinical data, both in terms of correct charting and data monitoring. The goal of quality reporting is ultimately to help physicians improve patient care.
Patient Care: Accurate coding and documentation will reflect severity of illness and care provided to patients. Enabling the creation of standards of care and help identify possible gaps in care.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of accurate coding and documentation to determine quality and accurate patient outcomes 2) Discuss among individual institutions the importance of Chart documentation specialists 3) Identify an effective plan to audit and identify coding errors.
References: UHC, formed in 1984 and located in Chicago, Illinois, is an alliance of 119 academic medical centers and 293 of their affiliated hospitals representing the nation's leading academic medical centers.