Proportion of Patients with Pneumonia that have a Potentially Avoidable Complication (during the episode time window)

Brief Description of Measure: Percent of adult population aged 18+ years with Community Acquired Pneumonia who are followed for one-month, and have one or more potentially avoidable complication (PAC) during the episode time window. Please reference the attached document labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls, in the tab labeled PACS I-9 & I-10 for a list of code definitions of PACs relevant to pneumonia.

Community Acquired Pneumonia may be managed in an inpatient setting, where the patient is admitted to a hospital within 1-3 days of onset of symptoms, or in milder cases, patients may be hospitalized a little later in the course of illness, or never at all where management could be solely in an outpatient setting. In any of these circumstances, potentially avoidable complications (PACs) may occur during the index stay, in the post-discharge period; or in patients who were never hospitalized, PACs may occur any time during the episode time window. Readmissions due to pneumonia or due to any related diagnosis are also considered as PACs.

We define PACs as one of two types:
(1) Type 1 PACs - PACs directly related to the index condition: Patients are considered to have a type 1 PAC if they develop one or more complication directly related to pneumonia or its management. Examples of these PACs are respiratory insufficiency, other lung complications, fluid electrolyte acid base problems, sepsis, respiratory failure etc.
(2) Type 2 PACs - PACs suggesting Patient Safety Failures: Patients are considered to have a type 2 PAC, if they develop any of the complications related to patient safety failures such as phlebitis, deep vein thrombosis, pressure sores or for any of the CMS-defined hospital acquired conditions (HACs).

PACs are counted as a dichotomous (yes/no) outcome. If a patient had one or more PAC in any of the above settings, they get counted as a “yes” or a 1. The enclosed workbook labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls serves as an example. The tab labeled PAC overview gives the percent of pneumonia episodes that have a PAC and the tab labeled “PAC drill down” gives the types of PACs and their frequencies in pneumonia episodes within this dataset.

The information is based on a two-year claims database from a large regional commercial insurer. The database had 3,258,706 covered lives and $25.9 billion in “allowed amounts” for claims costs. The database is an administrative claims database with medical as well as pharmacy claims.