Congestive Heart Failure (CHF) ECR® Playbook Contents

Methodology
1. Clinical Guidelines. The following clinical guidelines were used in the development of the ECR:
2. ECR Definition Summary. This document presents a brief summary of key ECR definitions (e.g. types of models developed, trigger codes, episode period, exclusions, etc.). It is intended to be a quick reference for key definitions, which are described fully in the Chronic Medical ECR Dataset Instructions.
3. Chronic Medical ECR Dataset Instructions. This document contains instructions for constructing the ECR datasets, which are used for the typical and potentially avoidable complications (PAC) analyses. This document was formerly referred to as the “Analysis Plan”.
4. Statistical Analysis Plan. The Statistical Analysis Plan describes the statistical analysis methods used to develop the typical regression model. This model can be used to estimate severity-adjusted costs for typical care.
5. All Codes. This workbook contains code definitions (using ICD-9-CM codes, HCPCS, etc.) for the episode triggers, the risk factor variables (“RF” variables), comorbidities (“M”), procedures (“P”), and PAC variables (“PAC”). It does not contain pharmacy variables, which are in the Pharmacy All Codes file (listed below). The Chronic Medical ECR Dataset Instructions refer to code definitions in the All Codes workbook.
6. Pharmacy All Codes. This workbook lists the pharmacy variables and, for each, whether claims with the pharmacy variable should be deleted or should be considered typical or PAC. The Chronic Medical ECR Dataset Instructions refer to the Pharmacy All Codes workbook.
Summary Results.
1. Decision Tree. This tree diagram shows an outline of the decisions made during the process of constructing episodes. The number of episodes and costs for selected steps in the process are presented.
2. Data flow. This workbook presents the following summary data:
  - Complete Data Flow. This table shows patient counts, claim counts, and cost statistics for selected steps from the Chronic Medical ECR Dataset Instructions.
  - Data Flow Overview. This table shows patient counts and cost statistics for the relevant, typical, and PAC services. The results are broken down further by stay, professional, and pharmacy. This table is also presented in the PAC Allowance Workbook.
  - Episode Allocation Graph. This graph shows the number of episodes in the typical and PAC groups and the overlap of the groups.
  - Dollar Allocation Graphs. These graphs show how total costs are distributed by the typical and PAC groups.
3. Demographics. This file shows demographic data (age, gender) for relevant episodes.
4. Predictor Frequencies. This document shows the frequency of each predictor (e.g. comorbidities, procedures, etc.) in the full typical sample
Analysis

PAC Allowance. This workbook shows the PAC allowance and ECR price calculations as well as the information used to do those calculations:
- Data Flow Overview. This table shows patient counts and cost statistics for relevant, typical, and PAC services. The results are broken down further by stay, professional, and pharmacy. This table also appears in the Data Flow workbook.
- Core Services Pricing. This table shows the core set of services and quantity of services that are recommended by Clinical Practice Guidelines or expert opinion. The table also shows the total price for the core set of services. This price is used to determine the underuse adjustment.
- Severity-Adjusted Price. This table shows the computation of the severity-adjusted base price of ECR for typical care. Prices for three hypothetical patients are shown. These prices are used in the Construction of the ECR (see tab entitled “PAC Allowance” in this workbook). The final regression model (from the Typical Analysis Results workbook) is used to do the calculations.
- PAC Allowance Computation & ECR Construction. This table shows how to calculate the PAC allowance, make adjustments for underuse and care coordination, calculate the margin and, together with the severity-adjusted base price of the ECR, helps determine the total ECR price in three hypothetical patient scenarios.
- Payer Savings Graph. This graph shows how typical and PAC dollars can be redistributed to reduce PAC costs within Prometheus.
PAC Diagnoses. This workbook shows PAC costs overall and by diagnosis.
- PAC Costs Overview. This table shows the percentage of relevant costs that are PACs and how PAC costs are distributed by professional, stay, and pharmacy.
- PAC Professional Costs by Diagnosis. This section shows the number of occurrences and associated costs of PAC diagnoses on PAC professional claims. All diagnoses displayed are potentially actionable.
- PAC Stay Costs by Principal Diagnosis. This worksheet presents the number of stays and associated costs of the principal diagnoses of PAC stays. All diagnoses displayed are potentially actionable.
Typical Analysis Results. This workbook contains the results of analyzing the typical episodes. The data are presented on the trimmed typical sample (described in the Statistical Analysis Plan).
- Allowed Amount. This page shows descriptive statistics (mean, standard deviation, etc.) for allowed amount.
- Age Distribution. This page shows descriptive statistics (mean, standard deviation, etc.) for age.
- Ln(Allow) vs. Age. This page contains a graph of allowed amount on the natural log scale vs. age. The graph shows whether allowed amount increases or decreases with age, and also whether age should be modeled as a linear, quadratic or some other type of variable.
- Comorbidities, etc. These graphs show the distribution of the number of comorbidities, procedures, and medications per episode.
- t tests. To determine whether there was a significant difference in allowed amount by each predictor variable, t tests were done. Descriptive statistics (count, percent, mean, standard deviation) for allowed amount by each risk factor variable are shown in addition to the t test results.
- Final Model fit. This spreadsheet shows the adjusted R-square and the number of episodes used for the final model.
- Final Model. This page shows the final severity-adjusted model used to predict costs of typical episodes. All predictors in the final model and their regression coefficients, standard errors, and p-values are shown.
- ECR Price Calculator. This worksheet allows the user to compute severity-adjusted base prices for typical care for hypothetical patients. The user can select desired comorbidity, procedure, and pharmacy variables (if included in the model). The worksheet uses the Final Model to do the calculations. Instructions are provided at the bottom of the worksheet.
Length of Stay Analysis. This workbook contains statistics on length of stay and stays per episodes for relevant episodes.

References

a - Kopecky S, Festin R, Smars P, Fareed MT, Ojha A, Raikar S, Macklem MJ, Breeding JE,
Straka R, Turner A, Fredrickson P, Landin AM. ICSI health care guideline: heart failure in adults. Institute for Clinical Systems Improvement, August 2007, 10th edition.

b - Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/failure//index.pdf.

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