The necessary pursuit of reducing harm in ambulatory settings: Advancing ambulatory care with AM-PPCs

Over the past 25 years, considerable advancements have been achieved in fostering accountability for the quality of care in medical practice.  Accountability is generally understood in a broader context, extending beyond the mere incidence of harm to include the capability to mitigate such harm. This perspective is exemplified by the approach taken in holding hospitals accountable for readmissions where no distinct care failure has been identified, yet patient care has not reached its optimal standard.

Recent history has witnessed a significant shift and continuous increase in the volume, intensity and diversity of procedures performed in ambulatory settings. We are also getting more integrated data to track the outcomes of these procedures. In our recent study, published in the American Journal of Medical Quality, we use Solventum’s new classification system, Solventum™ Ambulatory Potentially Preventable Complications (AM-PPC), to compare day procedure/surgery management of the wider processes of patient care during and after procedures. In the article, we demonstrate broad variation in elective surgery performance for common ambulatory procedures generally regarded as low risk, which nonetheless results in hospital admissions and emergency department visits due to complications of care.  We also shared procedure-specific average 30-day adverse event rates. 

Our findings revealed significant variability in outcomes of ambulatory procedures, with an overall complication rate averaging 2.1%. Notably, specific service lines such as urology and upper genitourinary procedures exhibited complication rates ranging broadly from 1.7% to more than 14%.

Additionally, following the removal of hip arthroplasty from the Centers for Medicare & Medicaid (CMS) inpatient-only list, procedure volumes increased dramatically — from just 683 cases in 2019 to more than 94,704 cases in 2021. This rapid growth continued in 2022, with an additional 17.4% increase, totaling 111,196 cases. 

Facility complication rates for hip arthroplasty in 2022 showed considerable variability, ranging from 0% to 7.6% with nearly a quarter (23%) of facilities experiencing rates more than 50% above the national median. These findings we present in the study offer baseline complication rates for ambulatory procedures, providing the industry with a resource to identify gaps, guide targeted improvements and enhance patient safety.

The Solventum research team that developed the classification logic guided and led by our physician experts, is similar to that used by our colleagues at U.S. News & World Report. By utilizing standardized encounter data, joined up across sequential patient encounters, the Solventum AM-PPC logic enables us to identify patterns of care that may result in avoidable patient outcomes. Although we may strive for perfection in all our endeavors, it is rarely, if ever, attained. But by identifying areas with high rates of poor outcomes, we can determine where to focus our most significant efforts. This core principle, which underscores the commitment to improvement, is integral to all Solventum quality of care tools that address potentially preventable events.

As we focus our efforts on supporting those that want to make care better, more affordable and safer by providing actionable insights into patterns of care we are consistently reminded of two things. 

First, it is essential to balance the need for access to healthcare data joined across extended periods of time with the privacy of individual patients. Privacy and transparency can often conflict. We need the health system to be transparent to understand what is effective and ineffective, to share best practices, and to mitigate poor practices and service gaps. However, this should not come at the expense of individuals' rights to anonymity. We would suggest that greater pooling of patient data is required to empower studies such as those reported in AJMQ, without compromising patient privacy, provided it is managed responsibly.

Second, in building a classification system such as Solventum AM-PPCs, it is crucial to balance various opinions to generate a result. Regular re-evaluation of these opinions is essential, and they must be either substantiated or amended accordingly. This principle applies to all the classification tools we develop. We look forward to updating the findings reported in this article over the coming years and expanding those findings to include additional data sources that cover broader aspects of population health. 

Furthermore, we will inevitably refine the classification logic to accommodate changes in practice, clinical coding guidelines, technological advancements and the challenges posed by an expanding user base. These factors will necessitate the reassessment of the logic across different versions of the model.

Classification tools, like healthcare itself, are an evolving partnership between those who deliver care and those that support its safety and efficacy. 

Furthermore, we welcome the opportunity to work together with all healthcare stakeholders with a broadened perspective on elevating the standard of care and patient safety across various care settings and population health.
 

Dana Casey is a clinical and economic research group product owner at Solventum.

Richard Fuller is director of data analysis and economics for the clinical research group at Solventum.