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Evaluation of Measurement of Patient Safety – AHRQ PSIs, NSQIP & New PSIs

Interesting article in BMJ Quality& Safety that asks is there a best measure of patient safety? The authors write of the strengths and weaknesses of the various patient safety measures – including AHRQ Patient Safety Indicators (PSI), National Surgery Quality Improvement Program (NSQIP) and the new set of administrative data-based PSIs developed using Canadian International Classification of Diseases (ICD)-10 coded data. Although the AHRQ PSIs were originally designed for quality improvement (QI) and surveillance, in the USA, they have been increasingly used for federal and state public reporting and pay-for-performance despite concerns about coding accuracy. Differences in complications rates across sites could therefore reflect coding and documentation differences between facilities, rather than true differences in complication rates. The new set of administrative data-based PSIs developed using Canadian International Classification of Diseases (ICD)-10 coded data may be broader in scope but appear to have similar limitations to the AHRQ ones when it comes to accuracy. The NSQIP-based system, on the other hand, has the advantage of high accuracy, as its measures are based on detailed clinical information; however, such measures are resource-intensive to collect and, due to sampling issues, only capture a small subset of post-surgical events. The authors suggest however, it is not necessary to choose one measure or set of measures over another. Having different measures of patient safety, including those using administrative data, contributes to the goal of comprehensive measurement. Patient safety improvement, say the authors, may be best served by considering the different measurement systems as complementary, which will improve the ability to capture as many safety events as possible. Such measurement systems, even when used together, are not ‘perfect’, and thus would be most useful if they had a primary focus on QI use, rather than on public reporting or financial reimbursements, potentially punitive actions that may not be equitable across hospitals. Furthermore, since they are focused only on inpatient safety events, neither the new PSIs, AHRQ PSIs or NSQIP allow us to truly capture the universe of safety events. Given that most care is now delivered in the outpatient setting, the field of patient safety measurement needs to expand to capture this setting as well. Continuing to ‘reinvent’ the wheel with development of new inpatient PSIs—that in the end have some of the same limitations as the older PSI measures—is a commendable journey, but one not likely to significantly advance the patient safety field. It is time to take the road less travelled.

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