The ACCP Provides Comment to the Centers for Medicare & Medicaid Services on COPD Outcome Measures
October 7, 2011
On behalf of the American College of Chest Physicians (ACCP), the ACCP Quality Improvement Committee (QIC) appreciates the opportunity to comment on these measures. On principle, the QIC agrees that COPD is an area of interest for performance measurement, and outcome measures are a preferable method for performance measurement. However, the QIC mentioned that they would be more interested in seeing a pulmonary function test as a performance measure, rather than 30-day readmission rates. The QIC also cited the manuscript by John E. Heffner, MD, FCCP, and colleagues titled, “COPD Performance Measures: Missing Opportunities for Improving Care” as a potential bank of needed COPD performance measures.
The QIC notes that patients who are discharged to other acute care facilities are excluded from these measures and would like to know whether or not acute care facilities include long-term acute care hospitals. The QIC is concerned that an unintended consequence might be patients discharged to long-term acute care hospitals to avoid an increased 30-day mortality rate. We would recommend that long-term acute care transfers be included. In addition, time-delineated mortality rates at 30, 60, and 90 days might be considered.
The QIC also noted that the inclusion of patients admitted with ICD-9 code 799.1 (cardiorespiratory arrest) is likely to contaminate the denominator with patients having a variety of disorders, only one of which needs to be called an exacerbation of COPD. In addition, excluding patients enrolling in hospice on the day of admission is appropriate, but it very often takes more than a day to reach consensus on that decision. Furthermore, not excluding patients who have “do not resuscitate” or “do not intubate” status is a problem. While the QIC understands the rationale behind this, when mortality is the outcome of importance, and the most potent tool available to physicians is not available for use, the QIC feels that physicians should not be responsible. The QIC recommends treating patients with a “do not resuscitate” or “do not intubate” status similar to patients enrolling in hospice. The QIC also feels that shock and sepsis should be included in the risk adjustment.
The QIC questions why certain comorbid conditions are included for risk adjustment; for example, retinal disorders, mononeuropathy, and dermatologic disorders. In addition, diagnoses that are new on admission should be included because these will clearly affect outcome.
The QIC also stated that coding methods for these airway disorders are notoriously inaccurate, unreliable, and irreproducible. While there are many coding errors for many diagnoses in medicine, the inaccuracies are much greater in the obstructive lung diseases field than for other conditions. For example, asthma, bronchiectasis, and congestive heart failure are routinely and commonly coded as COPD.
Finally, the QIC strongly urges continued evaluation, testing, and validation of the risk adjustment model, which has not been externally validated, as the measures are deployed.
