Annual Reports

10th SOW Annual Report of QIO Case Review Information
United States Virgin Islands
Virgin Islands Medical Institute, Inc.

I. Total # of Reviews – Provide the total number of reviews the QIO performed in CRIS by the associated review type.

Review Type	# of Reviews	Percent of Reviews (%)
Coding Validation (120 - HWDRG)	0	0%
Coding Validation (All Other Selection Reasons)	0	0%
Quality of Care Review (101 through 104 -Beneficiary Complaint)	1	50%
Quality of Care Review (All Other Selection Reasons)	0	0%
Utilization (158 - FI/MAC Referral for Readmission Review)	0	0%
Utilization (All Other Selection Reasons)	1	50%
Notice of Non-coverage (105 through 108 - Admission and Preadmission)	0	0%
Notice of Non-coverage (118 - BIPA)	0	0%
Notice of Non-coverage (117 - Grijalva)	0	0%
Notice of Non-coverage (121 through 124 -Weichardt)	0	0%
Notice of Non-coverage (111-Request for QIO Concurrence)	0	0%
EMTALA 5 Day	0	0%
EMTALA 60 Day	0	0%
Total	2

 

II. Top 10 Principal Medical Diagnoses – Provide the top 10 principal medical diagnoses for inpatient claims billed for Medicare beneficiaries.

Top 10 Medical Diagnoses	# of Beneficiaries	Percent of Beneficiaries (%)
1. 486 - PNEUMONIA, ORGANISM NOS	86	20.05%
2. 43491 - CRBL ART OCL NOS W INFRC	62	14.45%
3. 4280 - CHF NOS	60	13.99%
4. 5990 - URIN TRACT INFECTION NOS	40	9.32%
5. 25080 - DMII OTH NT ST UNCNTRLD	37	8.62%
6. 41401 - CRNRY ATHRSCL NATVE VSSL	36	8.39%
7. 71516 - LOC PRIM OSTEOART-L/LEG	31	7.23%
8. 27651 - DEHYDRATION	29	6.76%
9. 0389 - SEPTICEMIA NOS	24	5.59%
10. 2859 - ANEMIA NOS	24	5.59%
Total	429	100.00%

 

III. Provider Reviews Geographics – Provide the count and percent by Rural vs. Urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review.

Geographical Area	# of Providers	Percent of Providers (%)
Rural	1	100%
Urban	0	0%
Unknown	0	0%
Total	1	100%

 

IV. Provider Reviews Settings – Provide the count and percent by Setting for Health Service Providers (HSPs) associated with a completed QIO review.

Setting	# of Providers	Percent of Providers (%)
0 - Acute Care Unit of an Inpatient Facility	1	100%
1 - Distinct Psychiatric Facility	0	0%
2 - Distinct Rehabilitation Facility	0	0%
3 - Distinct Skilled Nursing Facility	0	0%
5 - Clinic	0	0%
6 - Distinct Dialysis Center Facility	0	0%
7 - Dialysis Center Unit of Inpatient Facility	0	0%
8 - Independent Based RHC	0	0%
9 - Provider Based RHC	0	0%
C - Free Standing Ambulatory Surgery Center	0	0%
G - End Stage Renal Disease Unit	0	0%
H - Home Health Agency	0	0%
N - Critical Access Hospital	0	0%
O - Setting does not fit into any other existing setting code	0	0%
Q - Long Term Care Facility	0	0%
R - Hospice	3	0%
S - Psychiatric Unit of an Inpatient Facility	0	0%
T - Rehabilitation Unit of an Inpatient Facility	0	0%
U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals	0	0%
Y - Federally Qualified Health Centers	0	0%
Z - Swing Bed Designation for Critical Access Hospitals	0	0%
Other	0	0%
Total	1	100.00%

 

A. Quality of Care Concerns Confirmed – Provide the number of concerns by Quality of Care PRAF Category Code and the number that were confirmed at highest level of review, for completed quality of care reviews.

 

B. Serious Reportable Events on Quality of Care Reviews - Provide the number of Quality Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns. Indicate the number and percent of those QIAs that are associated with quality of care concerns you deemed to fall into the category of “Serious Reportable Events”.

 

C. Confirmed Quality of Care Concerns with Associated Interventions – Provide the number of Initial Quality Improvement Activities initiated, by Activity Type, for reviews with one or more confirmed Quality of Care concerns. Provide the percent of total activities that each comprises.

Initial Quality Improvement Activity	# of Interventions (QIAs) with this Initial Quality Improvement Activity	Percent of Interventions (QIAs) with this Initial Quality Improvement Activity
1 - Send educational/alternative approach letter	0	0%
2 - Perform intensified review	0	0%
3 - Require continuing education	0	0%
4 - Request/review policy/procedure	0	0%
5 - Request development of QIP	0	0%
6 - Accept provider-initiated QIP	0	0%
7 - Conduct informal meeting or teleconference	0	0%
8 - Refer to licensing board	0	0%
9 - Initiate sanction activity	0	0%
10 - Other	0	0%
Total	0	0%

 

D. Discharge/Service Termination – Provide discharge location of beneficiaries linked to discharge/service termination reviews for Selection Reasons 111 (Request for QIO Concurrence) and 121 – 124 (Weichardt Selection Reasons). Note: Data represents discharge/service termination reviews from 8/1/2011 – 4/30/2012, 8/1/2012 – 4/30/2013 and 8/1/2013 – 2/28/2014 for the first, second and third annual reports respectively. A shortened data timeframe is necessary to allow for maturity of claims data which is the source of “Discharge Status” for these cases.

Discharge Status	# of Beneficiaries	Percent of Beneficiaries (%)
01 - Discharged to home or self care (routine discharge)	1	100%
02 - Discharged/transferred to another short-term general hospital for inpatient care	0	0%
03 - Discharged/transferred to skilled nursing facility (SNF)	0	0%
04 - Discharged/transferred to intermediate care facility (ICF)	0	0%
05 - Discharged/transferred to another type of institution (including distinct parts)	0	0%
06 - Discharged/transferred to home under care of organized home health service organization	0	0%
07 - Left against medical advice or discontinued care	0	0%
09 – Admitted as an inpatient to this hospital	0	0%
20 – Expired (or did not recover – Christian Science patient)	0	0%
21 – Discharged/transferred to court/law enforcement	0	0%
30 – Still a patient	0	0%
40 - Expired at home (Hospice claims only)	0	0%
41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free standing Hospice)	0	0%
42 - Expired – place unknown (Hospice claims only)	0	0%
43 - Discharged/transferred to a Federal hospital	0	0%
50 - Hospice - home	0	0%
51 - Hospice - medical facility	0	0%
61 - Discharged/transferred within this institution to a hospital-based Medicare approved swing bed	0	0%
62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital	0	0%
63 - Discharged/transferred to a long term care hospital	0	0%
64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare	0	0%
65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital	0	0%
66 - Discharged/transferred to a Critical Access Hospital	0	0%
70 - Discharged/transferred to another type of health care institution not defined elsewhere in code list	0	0%
Other	0	0%
Total	1	100%

 

E. Beneficiary Demographics – Provide the number of beneficiaries for whom a case review activity was started, by demographic category, and the percent of beneficiaries each category represents.

Demographics	# of Beneficiaries	Percent of Beneficiaries (%)
Sex/Gender
Female	4	100%
Male	0	0%
Unknown	0	0%
Total	4	100%
Race
Asian	0	0%
Black	2	50%
Hispanic	1	25%
North American Native	0	0%
Other	0	0%
Unknown	0	0%
White	1	25%
Total	4	100%

 

F. Quality of Care Reviews and Concerns by Intervention Type - Using a QIA started within the reporting period for the current year’s report, please provide a short description as to the type of intervention(s)/QIA(s) employed, per C.6 Technical Assistance requirements in the Contract, for three diverse or different quality categories (C1-99). Intervention/QIA types may include, but are not limited to: Educational or Alternative Approach to Care letter; Continuing Education; Assistance in Developing Policy & Procedure; Modification to Existing Policy & Procedure; Formal Quality Improvement Plan and/or Corrective Action Plan. Note: If the QIO does not have three diverse or different quality categories, please indicate such on the report.

There is no QIA started during the reporting period

 

Description 1 – Type of Intervention for Quality Category C <1-99>
Quality Category: C02 – Apparently did not make appropriate diagnosis and or assessments

 

Description 2 – Type of Intervention for Quality Category C <1-99>
Quality Category: C11- Apparently did not demonstrate that the patient was ready for discharge

 

Description 3 – Type of Intervention for Quality Category C <1-99>
Quality Category: C15 - Apparently did not effectively coordinate across disciplines

 

Example from Description <1, 2 or 3>: How Interventions Determined/Best Practices
Description #1

G. Evidence Used in Decision-Making - Drawing upon your QIO’s case review practices, please describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for Medical Necessity/Utilization Review and Appeals. Provide a brief statement of rationale for how the specific evidence/standards of care were chosen. The types of evidence/standards of care may include, but are not limited to, Local Coverage Determinations (LCD), Medicare Conditions Coverage, Medicare Conditions of Participation and National Coverage Determinations (NCD).

For QoC, describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for the specific list of diagnostic categories provided in the table.
Note: The list is from other 10^th SoW initiatives in which QIOs are involved. If there are any categories for which you did not conduct a QoC review during the reporting period, denote that in the table.

Review Type	Diagnostic Categories	Evidence/ Standards of Care Used	Rationale for Evidence/Standard of Care Selected
Quality of Care	Pneumonia	Guide to the elimination of Ventilator-Associated Pneumonia. An APIC Guide 2009.   CDC Guidelines for Prevention of Nosocomial Pneumonia.   ORDI; Evidence-Based Guidelines for Selected and Previously Considered Hospital Acquired Conditions. January 5, 2011	Relevance to case under review. Expert status in the field.
	Heart Failure	No QoC during this period	No QoC during this period
	Acute Myocardial Infarction	No QoC during this period	No QoC during this period
	Pressure Ulcers	NPUAP Guidelines	Relevance to case under review. Expert status in the field.
	Urinary Tract Infection	Evidence-Based Guidelines for Selected and Previously Considered Hospital Acquired Conditions. January 5, 2011	Relevance to case under review. Expert status in the field.
	Sepsis	No QoC during this period	No QoC during this period
	Adverse Drug Events	No QoC during this period.	No QoC during this period
	Falls	No QoC during this period	No QoC during this period
	Patient Trauma	No QoC during this period	No QoC during this period
	Surgical complications	No QoC during this period	No QoC during this period
Medical Necessity/Utilization Review		McKesson (Interqual) Milliman	Two recognized MN or UR software programs available to the QIO at the time of review.
Appeals		Local Coverage Determination (LCD's) Guielines   Medicare Conditions of Participation   Medicare Claims Processing Manual   Medicare Benefit Policy Manual   Chapter   Palliative Perfomance Scale   Functinoal Assessment Scale   Karnofsky Score Performance Status	Guidelines used for Hospice admission and contuinued stay. Commonly utilized standards/regulations.

 

Please provide three brief examples/case studies where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc. Identify the evidence based criteria used to support review decisions on those cases and what influenced the selection of that criteria. Documentation should be two paragraphs or less per example/case study.

 

Example/Case Study 1

Linkage to:  C7.1 Reducing Healthcare-Associated Infections(HAI)

 Criteria:

Guide to the Elimination of Ventilator-Associated Pneumonia. An APIC Guide 2009. 

 CDC. Guideline for Prevention of Nosocomial Pneumonia.

 CDC. Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009

The concerns for the case were associated with ventilator associated pneumonia, catheter associated urinary tract infection, and hospital acquired MRSA bacteremia.

The physician reviewers concluded that although the patient experienced nosocomial infections, the evidence did not show that these events were preventable.  The determination was based on documentation of regular performance of evidence based strategies to prevent these infections including but not limited to insertion of devices using aseptic techniques, (chlorhexidene) oral care, elevation of head of bed, and daily assessment of extubation potential. Additionally accepted indications for urinary catheterization were present and documented. Additionally, the reviewers also considered the presence of risk factors, to include poor nutritional status, co-morbidities, prolonged hospitalization with intubation, and critically ill condition, in making the determination of whether infection events were preventable. These criteria were selected based on their inclusion in best practice guidelines for HAI prevention.  

Example/Case Study 2

Linkage to:  C7.2 Reduce Health Care Acquire Conditions in Nursing Homes.

Criteria:

European Pressure Ulcer Advisory Panel and National Pressure Ulcer

Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009

The concern for the case was associated with hospital acquired pressure ulcers.

 

The physician reviewers concluded that although the patient experienced pressure ulcers, the evidence did not show that these events were preventable.  The determination was based on documentation of regular performance of evidence based strategies including but not limited to documented frequent patient repositioning, skin care, use of special mattress surfaces and multiple linen changes in the same day for pressure ulcer prevention. Additionally, the reviewers also considered the presence of risk factors, to include poor nutritional status, co-morbidities, prolonged bedbound status, and critically ill condition, in making the determination of whether this event was preventable. 

 

Example/Case Study 3

Linkage to:  C7.3 Reducing Adverse Drug Events

Criteria:

 

ACR-SIR practice guideline for the performance of inferior vena cava (IVC) filter placement for the prevention of pulmonary embolism. [online publication]. Reston (VA): American College of Radiology (ACR); 2010.

Inferior Vena Cava Filters for Prevention of Pulmonary Embolism, from the ACCP Guidelines, 9th Ed. 2012.

The concerns for this case were associated with use of an anticoagulant for acute pulmonary embolism (PE) and administration of a medication that the patient was allergic to.

 

The patient received treatment for the acute PE with an anticoagulant. This treatment was discontinued, approximately one month later when the patient developed gastrointestinal bleeding.  As a result, lower extremity sequential intermittent compression devices were used for deep venous thrombosis prophylaxis.  Also, the patient was treated with an antibiotic for an infection and had an allergic response.  Though the patient had a history of allergy to this medication, this information was provided after medication administration and occurrence of the adverse drug reaction (ADR).

 

The physician reviewers concluded that the indication and dosing schedule for the anticoagulant were appropriate. In addition the actions taken after development of the ADR were consistent with guidelines for PE treatment.  The reviewers also concluded that the antibiotic selection was appropriate given the absence of allergy history; the identification of the ADR and discontinuation of the medication were consistent with best practices. Subsequent education provided to the family about ways to avoid reoccurrence was also found to be appropriate. 

H. Effectiveness of QIAs - Please provide an analysis of how the findings in tables B, C and F can be used to support the effectiveness of QIAs conducted as part of the BFCC Aim. The QIO should provide a narrative analysis on the information provided and recommendations for how the information could be used to make a positive impact on the work done in other 10SOW Aims.

Narrative Analysis:

There is not QIA starrted during the reporting period.