Data Collection and Usage

This page describes the Quality, Volume and Facility data contained in each Hospital Profile.

Quality Data

Three kinds of quality data are presented on this site: Recommended Care, Composite Scores and Outcomes Measures.

Recommended Care

The information shown on this Web site comes from hospitals that voluntarily submit data to the Quality Improvement Organization (QIO) Clinical Warehouse, the national data repository for private healthcare data. The QIO Clinical Warehouse validates the information, provides feedback to the hospitals, and makes data available to the public through the Centers for Medicare & Medicaid Services (CMS).

Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 establishes a financial incentive for all hospitals to report quality of care information voluntarily as a public service. In order to receive this incentive payment, hospitals must submit data for certain specific quality measures relating to heart attacks, heart failure, and pneumonia.

Scores for each measure are calculated by dividing the number of cases where recommended care was provided (the numerator) by the total number of eligible cases (the denominator) per reporting period. This Web site currently shows details only for measures involving at least 25 eligible cases. However, any measure with at least one eligible case is counted and is reflected in the composite scores. Patients for whom the recommended treatment was not appropriate are not counted in the denominator.

More information on these measures is available from QualityNet Exchange.

Composite Scores

Each set of Recommended Care measures pertains to a specific condition, namely Heart Attack, Heart Failure, Pneumonia or Surgical Infection. In each set, some measures are required for hospitals participating in the Hospital Quality Alliance, while others are voluntary. These are signified on the site by a (r) or (v) respectively. For Heart Attack, Heart Failure and Pneumonia, the composite or overall score is calculated using the following methodology:

For all hospitals reporting, sum the number of patients who received care under a required measure (numerator) and sum the number of patients who were eligible for care under a required measure (denominator). This takes into consideration any contraindications.
Divide the numerator by the denominator.
Report the composite score to one decimal place.

Note: For Surgical Infection we used the two voluntary measures. All hospitals reporting surgical infection report both measures.

Outcome Measures

Outcome data is derived from the annual reports published by the New York State Department of Health Cardiac Services Program. These reports contain risk-adjusted mortality rates for isolated coronary artery bypass graft surgeries, valve surgeries, percutaneous coronary interventions, and pediatric congenital surgeries in New York State.

This site publishes the number of mortalities compared to the total number of procedures, as well as an indicator of each hospital's relation to the statewide average rate for each procedure.

Volume Data

Volume data refer to the number of times a certain procedure was performed. To display the volume of procedures performed by each hospital, we sorted the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database by National Center for Health Statistics (ICD-9) codes and, using the Agency for Healthcare Research and Quality Clinical Classifications Software, created a three-level data set of procedures. All procedures have been included. Procedure volume is available on a rolling year, showing all data for the most recently available four calendar quarters.

Facility Data

Facility data, including number of beds and services available, come from the operating certificate for each hospital. Each hospital is invited to review information for accuracy and timeliness, and may also submit details such as Web site address, telephone number and other pertinent information.