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Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's
Garth H Utter1, Joanne Cuny, Pradeep Sama
1Department of Surgery, University of California, Davis, Medical Center, Sacramento, CA, USA. garth.utter@ucdmc.ucdavis.edu
Insights
Patient Safety Indicator 11 (PSI 11) for postoperative respiratory failure has a high positive predictive value (PPV). However, it often includes non-preventable cases, suggesting areas for improvement in its application.
Area of Science:
- Healthcare Quality and Safety
- Medical Informatics
- Surgical Outcomes Research
Background:
- The US Agency for Healthcare Research and Quality developed Patient Safety Indicator (PSI) 11 to identify postoperative respiratory failure after elective surgery using ICD-9-CM codes.
- The indicator's accuracy in detecting true positive cases of respiratory failure requires validation.
Purpose of the Study:
- To determine the positive predictive value (PPV) of Patient Safety Indicator (PSI) 11 for postoperative respiratory failure.
- To identify factors contributing to false positive and true positive classifications of PSI 11.
Main Methods:
- A retrospective cross-sectional study was conducted across 18 academic medical centers.
- Medical records of 609 cases meeting PSI 11 criteria were reviewed by trained abstractors.
- The PPV was calculated, and descriptive analyses were performed on identified cases.
Main Results:
- Of 609 cases, 90.5% met technical criteria, and 83.2% were true postoperative respiratory failure cases.
- Common reasons for false positives included nonelective hospitalization and prolonged intubation.
- True positive cases frequently involved comorbidities (50%) and resulted in death (23%).
Conclusions:
- PSI 11 demonstrates a relatively high PPV for detecting postoperative respiratory failure.
- The indicator's current form does not exclusively identify preventable cases.
- Excluding nonelective hospitalizations or specific procedures may enhance PPV; modifying diagnosis code criteria could increase PPV but reduce detection rates.
Background:
Patient Safety Indicator (PSI) 11, or postoperative respiratory failure, was developed by the US Agency for Healthcare Research and Quality to detect incident cases of respiratory failure after elective operations through use of ICD-9-CM diagnosis and procedure codes. We sought to determine the positive predictive value (PPV) of this indicator.
Study Design:
We conducted a retrospective cross-sectional study, sampling consecutive cases that met PSI 11 criteria from 18 geographically diverse academic medical centers on or before June 30, 2007. Trained abstractors from each center reviewed medical records using a standard instrument. We assessed the PPV of the indicator (with 95% CI adjusted for clustering within centers) and conducted descriptive analyses of the cases.
Results:
Of 609 cases that met PSI 11 criteria, 551 (90.5%; 95% CI, 86.5-94.4%) satisfied the technical criteria of the indicator and 507 (83.2%; 95% CI, 77.2-89.3%) represented true cases of postoperative respiratory failure from a clinical standpoint. The most frequent reasons for being falsely positive were nonelective hospitalization, prolonged intubation for airway protection, and insufficient evidence to support a diagnosis of acute respiratory failure. Fifty percent of true-positive cases involved substantial baseline comorbidities, and 23% resulted in death.
Conclusions:
Although PSI 11 predicts true postoperative respiratory failure with relatively high frequency, the indicator does not limit detection to preventable cases. The PPV of PSI 11 might be increased by excluding cases with a principal diagnosis suggestive of a nonelective hospitalization and those with head or neck procedures. Removing the diagnosis code criterion from the indicator might also increase PPV, but would decrease the number of true positive cases detected by 20%.
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