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How is an ecr Created?

The PROMETHEUS Payment design team convened in a series of meetings with practicing physicians who had been organized in Clinical Working Groups focused on cancer, cardiac, chronic, orthopedic, and preventive care. Their task was to select a starter set of clinical conditions around which ECRs could be constructed. For each condition, the following would have to be done:

  • Selecting clinical practice guidelines;
  • Analyzing the guidelines to determine the natural boundaries of the ECR;
  • Providing an estimate of the scope of services of the ECR, including the total units of service and the types of providers responsible for delivering those services as outlined in the guidelines;
  • Establishing a reasonable set of performance measures to be used to evaluate clinical performance of providers delivering services included in the ECR;
  • Identifying routine complications that are prevalent for patients who do not receive optimal care;
  • Participating in and supervising the data modeling of the ECR to determine the extent to which the results were valid; and
  • Creating estimates for the warranted variation of services that should be added to the base.

Starting with the conditions of AMI, hip replacement, knee replacement, and diabetes, the objective was to analyze a large claims database in order to determine the amount of unexplainable variation in total costs of care that could be reasonably attributed to complications under the control of providers. There are typical sets of services that one expects to observe in the care of a patient at any given time. However there are also non-typical services that occur as a result of quality "defects." This variation is said to be due to services associated with PACs.

As the data modeling started to yield outputs, it became clear that the current coding practices in hospitals and physician offices allowed the identification of claims and events within a claim that were associated with PACs.

To develop the definition of a PAC, the design team collaborated with organizations throughout the country with whom they interfaced continuously throughout the development of the methodology. These organizations include the Institute of Medicine, CMS, and AHRQ, all from which specific definitions of PACs were taken.

A Robert Wood Johnson Foundation grant allowed the team to continue to model an increasing number of ECRs, stabilizing the rules and models. At each step they used a circle of clinical advisers to inform the models and validate the findings. In addition, their field work in four pilot sites provided them an opportunity to work directly with physicians and hospitals to get input in and feedback on our definitions of PACs.

As the team continued to review the outputs from modeling ECRs, and refining the models themselves, they created a categorization of PACs by type of ECR.  Importantly, the core concept of measuring PACs is to have a patient-centric measurement, not a provider-specific measurement. We have therefore defined three categories of PACs:

  • Related to the index condition or stay – for example, an ED visit for keto-acidosis by a diabetic patient, or a repeat MI within 30 days of discharge for a patient hospitalized with an AMI.
  • Related to the patient's co-morbidities – for example, an ED visit for pneumonia in a diabetic patient, or diabetic coma of a patient hospitalized for a joint replacement.
  • Related to patient safety failures – for example, an adverse drug event for a patient with COPD, or a post-operative wound infection.

These categories of PACs are found in the different types of ECRs, with a further delineation based on the primary site of the PACs:

  • Acute Medical Conditions
    • inpatient-based PACs, and
    • readmissions within 30 days of discharge for the same and related reasons as the initial admission.
  • Inpatient and Outpatient Procedures – similar to acute medical events, procedures can lead to two types of potentially avoidable complications; in August 2009 we published a paper that summarizes the definitions of PACs for hip and knee replacements.
    • those that occur during the procedure (or during the stay for inpatient procedures) and
    • those that occur post-discharge.
  • Chronic Conditions – generally, any hospitalization related to the patient's core chronic condition or any co-morbidity is considered a potentially avoidable complication, unless that hospitalization is considered to be a typical service for a patient with that condition.

To-date, the team has used ECR analytics in over a dozen different databases of national and regional health plans and employers. The team has discovered a great consistency in the nature, frequency and costs associated with PACs. More importantly, they have found that when physicians and hospitals understand that (a) the goal is not zero defects but an improvement from current performance levels, and (b) the payment model will reward reduction in PACs, the objections to the definitions of PACs disappear.