Miscellaneous

Validity of Selected Patient Safety Indicators: Opportunities and Concerns

Kaafarani HMA, Borzecki AM, Itani KMF, et al (Tufts Univ School of Medicine, Boston, MA; Boston Univ School of Medicine, MA; et al) J Am Coll Surg 212:924–934, 2011^§

Abstract

Background

The Agency for Healthcare Research and Quality (AHRQ) recently designed the Patient Safety Indicators (PSIs) to detect potential safety-related adverse events. The National Quality Forum has endorsed several of these ICD-9-CM-based indicators as quality-of-care measures. We examined the positive predictive value (PPV) of 3 surgical PSIs: postoperative pulmonary embolus and deep vein thrombosis (pPE/DVT), iatrogenic pneumothorax (iPTX), and accidental puncture and laceration (APL).

Study Design

We applied the AHRQ PSI software (v.3.1a) to fiscal year 2003 to 2007 Veterans Health Administration (VA) administrative data to identify (flag) patients suspected of having a pPE/DVT, iPTX, or APL. Two trained nurse abstractors reviewed a sample of 336 flagged medical records (112 records per PSI) using a standardized instrument. Inter-rater reliability was assessed.

Results

Of 2,343,088 admissions, 6,080 were flagged for pPE/DVT (0.26%), 1,402 for iPTX (0.06%), and 7,203 for APL (0.31%). For pPE/DVT, the PPV was 43% (95% CI, 34% to 53%); 21% of cases had inaccurate coding (eg, arterial not venous thrombosis); and 36% featured thromboembolism present on admission or preoperatively. For iPTX, the PPV was 73% (95% CI, 64% to 81%); 18% had inaccurate coding (eg, spontaneous pneumothorax), and 9% were pneumothoraces present on admission. For APL, the PPV was 85% (95% CI, 77% to 91%); 10% of cases had coding inaccuracies and 5% indicated injuries present on admission. However, 27% of true APLs were minor injuries requiring no surgical repair (eg, small serosal bowel tear). Inter-rater reliability was >90% for all 3 PSIs.

Conclusions

Until coding revisions are implemented, these PSIs, especially pPE/DVT, should be used primarily for screening and case-finding. Their utility for public reporting and pay-for-performance needs to be reassessed (Figs 2–4).

Figure 2 Positive predictive value and analysis of false positives of postoperative pulmonary embolus or deep vein thrombosis (pPE/DVT). Numbers might not add to totals due to rounding. The percentages reported in the figure refer to the percentage of the total number of cases; those reported in the text of the manuscript refer to the percentage of the false positive cases only. (Reprinted from Journal of American College of Surgeons, Kaafarani HMA, Borzecki AM, Itani KMF, et al. Validity of selected patient safety indicators: opportunities and concerns. J Am Coll Surg. 2011;212:924–934. Copyright 2011, with permission from the American College of Surgeons.)

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