2017 Data - New Jersey

Inpatient Quality Indicators

Technical Report

Hospital Performance Dashboard

A Supplement to the Hospital Performance Report

2017 Data

Health Care Quality Assessment

Office of Population Health New Jersey Department of Health

* For inquiries, contact Markos Ezra, PhD, by phone at (800) 418-1397 or by email at Markos.Ezra@doh.state.nj.us.

i

Executive Summary

The Office of Health Care Quality Assessment (HCQA) of the New Jersey Department of Health assesses health care quality using qualitative and quantitative data reported by hospitals to support performance monitoring related to patient care and safety. Specifically, HCQA produces consumer reports on cardiac surgery, hospital performance, and hospital quality indicators; reviews confidential reports and root-cause analyses of reportable medical errors; and maintains several databases to support licensure requirements. In order to enhance information that the Department provides to the public regarding quality of hospital care, HCQA staff apply statistical tools developed by the Federal Agency for Healthcare Research and Quality (AHRQ) to the New Jersey hospital discharge data commonly known as Uniform Billing (UB) data. This report presents findings resulting from the application of a statistical tool known as the Inpatient Quality Indicator (IQI) module to the 2017 New Jersey hospital discharge data.

Inpatient Quality Indicators (IQIs) are a set of measures developed at the national level by the Agency for Health Care Research and Quality (AHRQ) to provide a perspective on the quality of patient care given by hospitals. Quality of care is measured using: 1) inhospital mortality for certain procedures and medical conditions; 2) utilization of procedures for which there are questions of overuse, underuse, or misuse; and 3) volume of procedures for which there is some evidence that a higher volume of procedures is associated with lower mortality. AHRQ spent years of research and analysis to define these indicators as measures of healthcare quality.

Since 2009, the Department has been reporting on heart attack, heart failure, pneumonia and stroke mortality levels as part of the `Outcome of Care Measurers'. These indicators were recommended by the "The Governor's Commission on Rationalizing Health Care Resources" to create the `Hospital Performance Dashboard' as a supplement to the Hospital Performance Report.

The data in this report present mortality during hospitalization in each of the 71 licensed hospitals currently operating in the state. For each of the four selected IQIs, risk-adjusted rates are provided along with confidence intervals to help make a statistical assessment of patient care in the hospital. Statewide and national estimates are also provided to help compare hospital performance to the state or to the national rates.

Comparison of a hospital's rate to the statewide rate (presented in the top row of each of the IQIs tables) is one way to assess how well that hospital performed among its peers in the state. A hospital's peers could be defined at many levels (e.g., teaching hospitals, urban hospitals, suburban hospitals, etc.). It is suggested that a hospital's performance be assessed by looking at its performance across the four IQIs estimates presented in the tables.

ii

The 2017 New Jersey data shows that there are substantial variations in risk-adjusted rates of outcome by hospital. Some hospitals exhibit significantly higher risk-adjusted rates than the corresponding statewide rates while others have significantly lower rates than the statewide rates.

Some Highlights

? Statewide, in 2017, there were a total of 904 in-hospital deaths due to ACUTE MYOCARDIAL INFARCTION ? AMI for a risk-adjusted mortality rate of 11.02 per 100 discharges (for patients ages 18 years and older) with a principal ICD-10-CM diagnosis code for AMI. Table 1 shows the distribution of these heart attack (AMI) deaths by hospital.

? Overall, there were 1,019 deaths from HEART FAILURE during hospitalization in 2017, for a risk-adjusted mortality rate of 3.55 per 100 discharges (for patients ages 18 years and older), with a principal ICD-10-CM diagnosis code for heart failure. Table 2 shows the distribution of these Heart Failure deaths by hospital.

? Statewide, there were 397 in-hospital deaths from PNEUMONIA in 2017, for a riskadjusted rate of 3.74 per 100 discharges (for patients ages 18 years and older) with a principal ICD-10-CM diagnosis code for pneumonia. Hospital-specific rates for this indicator ranged from a low of 0.0 to a high of 10.13 per 100 discharges with pneumonia.

? Statewide, there were 1,207 ACUTE STROKE in-hospital deaths in 2017, for a risk-adjusted rate of 5.93 per 100 discharges (for patients ages 18 years and older) and with a principal ICD-10-CM diagnosis code for subarachnoid hemorrhage or intracerebral hemorrhage or ischemic stroke. Hospital-specific rates for this indicator ranged from a low of 0.0 to a high of 11.53 per 100 patients with stroke diagnosis. Table 4 shows the distribution of these total acute stroke deaths by hospital, while Tables 4.A, 4.B and 4.C present the breakdown of these deaths by SUBARACHNOID HEMORRHAGE STROKE, INTRACEREBRAL HEMORRHAGIC STROKE, and ISCHEMIC HEMORRHAGIC STROKE, by hospital.

? Compared to the national estimates, New Jersey appeared to have rates that are higher than the national average for 3 of the 4 indicators that are selected for the Hospital Performance Dashboard.

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References:

Updated Technical Specifications for each of the 4 IQIs presented in this report can be accessed on the AHRQ site below:

? 019.aspx

Detailed explanation about IQIs and their interpretations can be found on: ?

iv

Table 1: IN-HOSPITAL MORTALITY RATES FOR ACUTE MYOCARDIAL INFARCTION - AMI (Deaths per 100 conditions)

(Indicator Recommended for Hospital Performance Dashboard)

Hospital

# of Deaths

Risk-

# of Observed Expected Adjusted

Patients Rate

Rate

Rate

95% Confidence

Interval

LL - UL

National

28,927 567,685

5.1

NA

NA

NA - NA

Statewide

904 15,613

5.8

Atlantic City Medical Center-City Campus

3

63

4.8

Atlantic City Medical Center-Mainland Campus

33

729

4.5

Bayshore Community Hospital

10

122

8.2

Bergen Regional Medical Center

1

12

8.3

Cape Regional Medical Center Inc

5

48

10.4

Capital Health Medical Center - Hopewell

6

82

7.3

Capital Health Regional Medical Center - Fuld

9

35

25.7

Carepoint Health - Bayonne Medical Center

10

181

5.5

Carepoint Health - Christ Hospital

14

140

10.0

Carepoint Health - Hoboken University MC

1

33

3.0

CentraState Medical Center

7

45

15.6

Chilton Memorial Center

10

136

7.4

Clara Maass Medical Center

12

246

4.9

Community Medical Center

30

517

5.8

Cooper Hospital/University Medical Center

17

598

2.8

Deborah Heart and Lung Center

7

405

1.7

East Orange General Hospital

0

35

0.0

Englewood Hospital and Medical Center

13

361

3.6

Hackensack Meridian Health Pascack Valley MC

0

11

0.0

Hackensack University Medical Center

46

825

5.6

HackensackUMC - Mountainside

13

151

8.6

Hackettstown Community Hospital

4

28

14.3

Holy Name Medical Center

18

219

8.2

Hudson Regional Hospital

0

8

0.0

Hunterdon Medical Center

4

59

6.8

Inspira Medical Center - Elmer

0

20

0.0

Inspira Medical Center - Woodbury

9

151

6.0

Inspira Medical Centers, Inc

13

164

7.9

Jefferson Cherry Hill Hospital

6

33

18.2

Jefferson Stratford Hospital

4

30

13.3

Jefferson Washington Township Hospital

5

73

6.8

Jersey City Medical Center

15

302

5.0

Jersey Shore University Medical Center

46

1,034

4.4

JFK Medical CTR - Anthony M. Yelensics Community

13

341

3.8

Lourdes Medical Center of Burlington Cty.

2

46

4.3

Monmouth Medical Center

6

78

7.7

Monmouth Medical Center - Southern Campus

6

24

25.0

Morristown Medical Center

32

1,071

3.0

Newark Beth Israel Medical Center

31

433

7.2

Newton Medical Center

3

65

4.6

Ocean Medical Center - Brick Division

15

200

7.5

2.7

11.0

10.6 - 11.5

2.3

10.3

2.6 - 18.1

2.1

11.2

8.8 - 13.6

3.1

13.5

8.7 - 18.2

1.6

27.0 ^

4.3 - 49.7

4.0

13.1

6.6 - 19.6

2.9

13.0

7.0 - 19.0

2.3

57.4 ** 46.9 - 67.8

2.9

9.7

5.7 - 13.8

3.2

15.8 ** 11.5 - 20.2

2.1

7.5

0.0 - 19.4

3.3

24.3 ** 16.8 - 31.8

2.8

13.2

8.5 - 17.9

2.3

10.8

6.9 - 14.7

2.7

11.0

8.5 - 13.5

4.1

3.5 *

1.8 - 5.3

2.0

4.4 *

1.1 - 7.6

2.4

0.0 *

0.0 - 10.4

2.7

6.8 *

3.9 - 9.7

5.7

0.0 *^

0.0 - 10.8

2.2

12.7

10.6 - 14.9

4.8

9.1

5.9 - 12.3

3.2

22.8 ** 12.9 - 32.6

2.0

20.6 ** 16.1 - 25.0

1.2

0.0 ^

0.0 - 31.7

2.5

13.6

6.0 - 21.2

4.1

0.0 *^

0.0 - 10.0

2.0

15.1

9.6 - 20.6

2.7

14.7

10.4 - 19.0

4.9

18.7 ** 11.9 - 25.6

2.1

32.4 ** 20.1 - 44.8

5.8

6.0 *

1.8 - 10.3

2.4

10.5

7.1 - 13.9

2.0

11.6

9.5 - 13.7

1.9

10.0

6.4 - 13.7

3.7

6.0

0.0 - 13.0

3.3

11.7

6.1 - 17.4

3.9

32.9 **^ 23.4 - 42.4

2.9

5.3 *

3.6 - 6.9

3.0

12.3

9.8 - 14.9

4.2

5.6 *

0.2 - 10.9

3.7

10.3

7.0 - 13.6

Table 1: IN-HOSPITAL MORTALITY RATES FOR ACUTE MYOCARDIAL INFARCTION - AMI (Deaths per 100 conditions)

(Indicator Recommended for Hospital Performance Dashboard)

Hospital

# of Deaths

Risk-

# of Observed Expected Adjusted

Patients Rate

Rate

Rate

95% Confidence

Interval

LL - UL

National

28,927 567,685

5.1

NA

NA

NA - NA

Statewide Our Lady of Lourdes Medical Center Overlook Medical Center Palisades Medical Center Penn Medicine Princeton Medical Center Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center-Perth Amboy Riverview Medical Center RWJ University Hospital RWJ University Hospital at Hamilton RWJ University Hospital at Rahway RWJ University Hospital Somerset Saint Clare's Hospital Saint Clare's Hospital/Denville Campus Saint Michael's Medical Center Saint Peter's University Hospital Shore Memorial Hospital Southern Ocean County Hospital St. Barnabas Medical Center St. Francis Medical Center-Trenton St. Joseph's Hospital and Medical Center St. Joseph's Wayne St. Luke' Warren Hospital St. Mary's General Hospital The Memorial Hospital of Salem County Trinitas Hospital University Hospital Valley Hospital Virtua-Memorial Hospital Burlington Cty. Virtua-West Jersey Hospital Marlton Virtua-West Jersey Hospital Voorhees

904 15,613

5.8

50

1,055

4.7

22

300

7.3

14

93

15.1

8

78

10.3

4

51

7.8

12

204

5.9

6

163

3.7

79

871

9.1

7

77

9.1

21

121

17.4

22

356

6.2

3

31

9.7

6

140

4.3

6

188

3.2

4

63

6.3

3

18

16.7

5

64

7.8

12

305

3.9

12

344

3.5

36

561

6.4

6

53

11.3

0

13

0.0

3

104

2.9

4

21

19.0

12

132

9.1

12

156

7.7

33

441

7.5

7

127

5.5

13

264

4.9

3

64

4.7

2.7

11.0

10.6 - 11.5

2.4

10.1

8.3 - 12.0

3.0

12.3

9.3 - 15.3

2.5

30.6 ** 24.3 - 36.9

2.7

19.7 ** 13.1 - 26.2

3.3

11.9

4.9 - 19.0

2.9

10.5

6.8 - 14.2

2.4

7.8

3.1 - 12.5

2.6

17.8 ** 15.9 - 19.7

3.1

14.8

9.0 - 20.7

2.5

35.7 ** 30.5 - 41.0

2.5

12.8

9.6 - 16.0

5.6

8.7

2.2 - 15.3

2.5

8.7

3.8 - 13.7

3.7

4.4 *

0.9 - 7.8

6.8

4.7 *

0.5 - 8.9

3.7

23.1 **^ 12.0 - 34.2

4.8

8.3

3.2 - 13.4

2.7

7.5 *

4.3 - 10.7

1.9

9.3

5.6 - 13.0

2.8

11.8

9.4 - 14.1

2.7

21.8 ** 13.7 - 29.8

1.3

0.0 ^

0.0 - 24.2

2.3

6.4

0.4 - 12.5

2.2

45.0 **^ 30.4 - 59.5

2.5

18.3 ** 13.3 - 23.4

3.3

11.9

7.9 - 15.8

2.6

14.5 ** 11.9 - 17.2

2.6

10.8

5.8 - 15.8

2.2

11.4

7.6 - 15.3

2.1

11.5

3.2 - 19.8

Source: National numbers are derived from 2016 National Inpatient Sample (NIS) Data using the AHRQ SAS Software, Version 2019 while New Jersey's are calculated from the 2017 NJ UB Data using the same software version.

^ = Rate is based on a denominator less than 30 and should be taken with caution.

* = Statistically significantly below state average, ** = Statistically significantly above state average.

Expected rate is the rate the hospital would have if it had the same case-mix (e.g., age, gender, DRG, and comorbidity categories) as the reference or statewide population. If the observed rate is higher than the expected rate (i.e., the ratio of observed to expected is greater than 1.0), it suggests that the hospital performed worse than the reference population on that indicator.

Table 2: IN-HOSPITAL MORTALITY RATES FOR HEART FAILURE (Deaths per 100 conditions) (Indicator Recommended for Hospital Performance Dashboard)

Hospital

National

Statewide Atlantic City Medical Center-City Campus Atlantic City Medical Center-Mainland Campus Bayshore Community Hospital Bergen Regional Medical Center Cape Regional Medical Center Inc Capital Health Medical Center - Hopewell Capital Health Regional Medical Center - Fuld Carepoint Health - Bayonne Medical Center Carepoint Health - Christ Hospital Carepoint Health - Hoboken University Medical Center CentraState Medical Center Chilton Memorial Center Clara Maass Medical Center Community Medical Center Cooper Hospital/University Medical Center Deborah Heart and Lung Center East Orange General Hospital Englewood Hospital and Medical Center Hackensack Meridian Health Pascack Valley MC Hackensack University Medical Center HackensackUMC - Mountainside Hackettstown Community Hospital Holy Name Medical Center Hudson Regional Hospital Hunterdon Medical Center Inspira Medical Center - Elmer Inspira Medical Center - Woodbury Inspira Medical Centers, Inc Jefferson Cherry Hill Hospital Jefferson Stratford Hospital Jefferson Washington Township Hospital Jersey City Medical Center Jersey Shore University Medical Center JFK Medical CTR - Anthony M. Yelensics Community Lourdes Medical Center of Burlington Cty. Monmouth Medical Center Monmouth Medical Center - Southern Campus Morristown Medical Center Newark Beth Israel Medical Center Newton Medical Center Ocean Medical Center - Brick Division Our Lady of Lourdes Medical Center

# of Deaths

# of Patients

Risk-

Observed Expected Adjusted

Rate

Rate

Rate

95% Confidence Interval

LL - UL

27,643 987,464

2.8

NA

NA

NA - NA

1,019 8

20 13

3 8 10 1 10 5 4 33 15 20 47 15 11 1 21 10 38 17 6 13 2 5 4 14 26 4 3 21 9 30 17 2 4 9 40 32 10 21 15

32,041 251 666 366 39 388 280 227 280 331 134 511 337 649

1,085 769 493 209 569 109 944 409 244 585 32 259 178 405 787 159 257 590 492 989 646 223 274 227

1,071 968 310 772 576

3.2

2.5

3.6

3.4 - 3.7

3.2

2.1

4.2

1.9 - 6.5

3.0

2.6

3.2

1.9 - 4.5

3.6

2.6

3.8

2.1 - 5.6

7.7

2.3

9.5 **

3.8 - 15.2

2.1

2.5

2.3

0.6 - 4.1

3.6

2.4

4.2

2.1 - 6.3

0.4

1.9

0.6 *

0.0 - 3.2

3.6

2.1

4.9

2.6 - 7.1

1.5

1.9

2.2

0.1 - 4.4

3.0

2.1

3.9

0.7 - 7.1

6.5

2.6

6.9 **

5.5 - 8.4

4.5

2.9

4.2

2.5 - 5.9

3.1

2.2

4.0

2.5 - 5.4

4.3

2.6

4.7 **

3.7 - 5.7

2.0

2.6

2.1 *

0.9 - 3.3

2.2

3.5

1.8 *

0.5 - 3.1

0.5

1.7

0.8

0.0 - 3.6

3.7

2.6

3.9

2.6 - 5.3

9.2

3.4

7.5 **

4.8 - 10.2

4.0

2.6

4.4

3.3 - 5.5

4.2

2.8

4.1

2.6 - 5.7

2.5

2.5

2.7

0.6 - 4.9

2.2

2.4

2.6

1.2 - 4.0

6.3

2.1

8.3

1.7 - 14.9

1.9

2.6

2.0

0.0 - 4.1

2.2

2.1

3.1

0.2 - 5.9

3.5

2.6

3.7

2.0 - 5.3

3.3

2.1

4.4

3.1 - 5.7

2.5

2.6

2.8

0.1 - 5.4

1.2

2.4

1.4 *

0.0 - 3.5

3.6

2.4

4.1

2.7 - 5.5

1.8

1.7

3.0

1.1 - 4.9

3.0

2.8

3.1

2.1 - 4.1

2.6

2.3

3.2

1.8 - 4.6

0.9

2.2

1.1

0.0 - 3.6

1.5

2.7

1.5 *

0.0 - 3.5

4.0

2.6

4.3

2.1 - 6.6

3.7

3.0

3.5

2.6 - 4.5

3.3

1.9

5.0 **

3.7 - 6.3

3.2

2.8

3.2

1.4 - 5.0

2.7

2.8

2.7

1.6 - 3.9

2.6

2.6

2.9

1.5 - 4.2

Table 2: IN-HOSPITAL MORTALITY RATES FOR HEART FAILURE (Deaths per 100 conditions) (Indicator Recommended for Hospital Performance Dashboard)

Hospital

National

Statewide Overlook Medical Center Palisades Medical Center Penn Medicine Princeton Medical Center Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center-Perth Amboy Riverview Medical Center RWJ University Hospital RWJ University Hospital at Hamilton RWJ University Hospital at Rahway RWJ University Hospital Somerset Saint Clare's Hospital Saint Clare's Hospital/Denville Campus Saint Michael's Medical Center Saint Peter's University Hospital Shore Memorial Hospital Southern Ocean County Hospital St. Barnabas Medical Center St. Francis Medical Center-Trenton St. Joseph's Hospital and Medical Center St. Joseph's Wayne St. Luke' Warren Hospital St. Mary's General Hospital The Memorial Hospital of Salem County Trinitas Hospital University Hospital Valley Hospital Virtua-Memorial Hospital Burlington Cty. Virtua-West Jersey Hospital Marlton Virtua-West Jersey Hospital Voorhees

# of Deaths

# of Patients

Risk-

Observed Expected Adjusted

Rate

Rate

Rate

95% Confidence Interval

LL - UL

27,643 987,464

2.8

NA

NA

NA - NA

1,019 37 13 15 11 1 12 55 10 20 25 1 5 3 7 6 8 24 5 24 11 5 1 6 14 12 45 10 14 22

32,041 733 272 396 298 290 368

1,122 467 429 601 184 300 400 297 320 367 870 208 912 212 235 278 191 459 317 830 641 372 582

3.2

2.5

3.6

3.4 - 3.7

5.0

3.1

4.6

3.5 - 5.7

4.8

2.7

5.0

3.0 - 6.9

3.8

2.5

4.2

2.5 - 5.9

3.7

2.4

4.2

2.2 - 6.2

0.3

2.3

0.4 *

0.0 - 2.5

3.3

2.8

3.2

1.6 - 4.8

4.9

2.5

5.4 **

4.4 - 6.4

2.1

2.4

2.5

0.9 - 4.1

4.7

2.4

5.5 **

3.9 - 7.2

4.2

2.6

4.5

3.2 - 5.9

0.5

2.5

0.6 *

0.0 - 3.1

1.7

2.8

1.7 *

0.0 - 3.5

0.8

2.2

1.0 *

0.0 - 2.8

2.4

2.5

2.6

0.7 - 4.6

1.9

2.2

2.4

0.4 - 4.4

2.2

3.0

2.0

0.4 - 3.6

2.8

2.5

3.1

2.0 - 4.3

2.4

2.1

3.2

0.6 - 5.7

2.6

2.2

3.3

2.1 - 4.5

5.2

2.4

6.1 **

3.7 - 8.5

2.1

2.7

2.2

0.1 - 4.3

0.4

2.3

0.4

0.0 - 2.6

3.1

2.1

4.2

1.5 - 6.9

3.1

1.9

4.5

2.7 - 6.3

3.8

1.9

5.5

3.3 - 7.7

5.4

3.3

4.6

3.6 - 5.6

1.6

2.3

1.9 *

0.5 - 3.3

3.8

2.9

3.7

3.8

2.6

4.1

2.0 - 5.3 2.7 - 5.5

Source: National numbers are derived from 2016 National Inpatient Sample (NIS) Data using the AHRQ SAS Software, Version 2019 while New Jersey's are calculated from the 2017 NJ UB Data using the same software version.

^ = Rate is based on a denominator less than 30 and should be taken with caution.

* = Statistically significantly below state average, ** = Statistically significantly above state average.

Expected rate is the rate the hospital would have if it had the same case-mix (e.g., age, gender, DRG, and comorbidity categories) as the reference or statewide population. If the observed rate is higher than the expected rate (i.e., the ratio of observed to expected is greater than 1.0), it suggests that the hospital performed worse than the reference population on that indicator.

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