The Joint Commission Journal on Quality and Patient Safety Letters to the Editor
Adverse Outcome Index
W
e are responding to “Accuracy of the Adverse Outcome Index: An Obstetrical Quality Measure,” by Foglia et al.1 As members of the team of developers of the Adverse Outcome Index (AOI), we appreciate the authors’ thoughtful analysis and statement that the AOI is useful as “one of many tools in [a hospital’s] quality arsenal.”1(p. 376) We continue to work on refinement of the indicator algorithms as we prepare for transition to ICD-10 coding.2 The National Perinatal Information Center/Quality Analytic Services (NPIC/QAS) encourages hospitals to conduct concurrent chart review to verify the accuracy of the AOI data. NPIC/QAS has more than 30 years of expertise in using the administrative data set for the AOI. The value of these data links directly to the accuracy of provider documentation and subsequent coding, which have improved significantly. With supplemental data, NPIC/ QAS is able to link mother and newborns to provide even more clarity regarding outcomes. The use of the industrywide standard “green” (that is, readily available data that were collected for one purpose but that can be used for other purposes) administrative data set for the AOI increases the efficiency and cost-effectiveness of this tool compared to chart abstraction. As the authors document, the AOI was useful in identifying term NICU admission, uterine rupture, birth trauma, and 3rd and 4th degree lacerations. The additional measures of maternal ICU admission and APGAR 5 < 7 should improve with more standardized use of electronic fetal monitoring and training for coders. Accurate coding of maternal ICU admission represents a potential increase in revenue, a secondary benefit. The recommendation made by Foglia et al. to review birth trauma codes should be considered. They also suggest possible revision of “this discrete-level indicator [“admission of a term infant to NICU bed”] to a severity ordinal scale with a cutoff threshold to include only the most severe admission diagnoses to the NICU. . . .”1(p. 373) However, the AOI is not intended to identify the most “severe” admissions to NICU level, which is considered appropriate care. Rather it is intended to identify term infants with mild or benign complications or who require just “observation” who are admitted to a NICU bed (per-charge coding in
the data set), which results in separation from the mother and associated breastfeeding challenges, exposure to infections, and overall anxiety for the family—a true adverse event. Foglia et al. also question the use of perineal lacerations as a quality metric and suggest that higher rates of lacerations could unduly influence the AOI values. Although it is true that index is strongly influenced by perineal lacerations, we would point to the other two composite metrics3—the Weighted Adverse Outcome Score and the Severity Index, which put the severity of lacerations (that is, severity weight of 5 versus 750 for maternal death) in perspective. We agree that the AOI would be strengthened if risk adjusted for patient case mix. However, because there are no nationally recognized algorithms for case mix adjustment, we continue to consider options and are happy to work to make this a more robust index. Although the AOI is not perfect, it remains a useful tool to inform clinicians about where to spend limited quality improvement resources. J
The Authors Reply: We thank Mann et al. for their interest in
We appreciate the modification by Mann et al. regarding the contribution of perineal lacerations, as reflected in two composite indexes3—the Weighted Adverse Outcome Score and the Severity Index. In November 2015, the American Congress of Obstetricians and Gynecologists (ACOG) made a recommendation to abandon the use of perineal lacerations as a quality outcome measure because of a lack of consistent definitions of lacerations, the presence of nonmodifiable risk factors, and a concern that its continued use could lead to a decrease in the use of operative vaginal delivery and a consequent increase in cesarean delivery to avoid a perineal laceration.4 We believe that this recommendation reinforces our stance regarding
our article “Accuracy of the Adverse Outcome Index: An Obstetrical Quality Measure.”1 We appreciate the planning that went into developing the AOI, and note that one of us [P.E.N.] was involved in developing the AOI for a study that evaluated obstetrics team training and its effects on clinical outcomes.2 We completely agree that a NICU admission, for any indication, is an adverse event for every family. However, we would suggest that the severity of the illness for which an infant is admitted, and the length of the admission, both have an impact on the familial stress imposed by this adverse event.
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October 2016
Susan Mann, MD, is Assistant Professor, Part-Time, Harvard Medical School, Boston; Director, Team Training and Simulation Obstetrics/ Gynecology Department, Beth Israel Deaconess Medical Center, Boston; and President, QualBridge Institute, Boston. Stephen Pratt, MD, is Chief, Division of Quality and Safety, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center. Janet Muri, MBA, is President, and Donna Caldwell, PhD, is Vice President, National Perinatal Information Center, Inc., Providence, Rhode Island. Please address correspondence to Susan Mann,
[email protected].
References
1. Foglia LM, et al. Accuracy of the Adverse Outcome Index: An obstetrical quality measure. Jt Comm J Qual Patient Saf. 2015;41:370–377. 2. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). (Updated: Aug 22, 2016.) Accessed Sep 15, 2016. http://www.cdc.gov/nchs/icd/icd10cm.htm. 3. Mann S, et al. Assessing quality in obstetrical care: Development of standardized measures. Jt Comm J Qual Patient Saf. 2006;32:497–505.
Volume 42 Number 10
Copyright 2016 The Joint Commission