Quality Transparency Dashboard | Public Reporting | UC Davis Health

Measure Period: 01/01/2023 - 12/31/2023

Central line-associated blood stream infection (CLABSI): A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. (Lower is better).

Limitations: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.

Measure Period: 07/01/2023 - 01/31/2024

Colorectal surgical-site infection (Colon SSI): An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. (Lower is better).

Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.

Reference Measure Period: 01/01/2023 - 12/31/2023

Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean birth rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers.

Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant. NTSV rates also do not take into account maternal factors such as obesity, diabetes, or lack of prenatal care that are associated with higher Cesarean section rates.

Measure and Reference Period: 07/01/2023 - 06/30/2024

All Cause Inpatient Mortality Index: The mortality index is the ratio of observed to expected inpatient mortality, also referred to as the O/E Ratio. An O/E ratio above 1.0 indicates an observed mortality higher than the Vizient Expected Value. The expected mortality for a population is predicted by the 2021 Vizient MS-DRG based mortality risk model, in this case specifically reflecting Academic Medical Centers.

Data from The Vizient Clinical Data Base/Resource Manager™ is used by permission of VIZIENT, all rights reserved. This tool is an analytic platform for performance improvement populated by hundreds of health systems and community hospitals nationwide, including nearly all academic medical centers. It includes comparative benchmarks such as demographic, mortality, length of stay, complication rates, readmission rates, diagnosis, procedure, resource utilization and other information.

Limitations: Risk adjustment models use administrative coding data, which may not reflect all mortality risk factors.

Measure and Reference Period: 01/01/2023 - 12/31/2023

Sepsis mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival.

Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.

Measure and Reference Period: 01/01/2023 - 10/31/2023

30-day Readmission – Hospital-wide All-Cause 30-day Unplanned Readmission Rate: The percentage of patients who were unexpectedly readmitted within 30 days of discharge from the hospital for any reason. Lower values indicate that fewer cases were unexpectedly readmitted after discharge.

Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the readmission rate. However, not all relevant risk factors are included (e.g., trauma, emergency procedures).

Reference Measure Period: 01/01/2023 - 12/31/2023

Surgical Clipping of Intracranial Aneurysms: Surgical clipping is a procedure used to treat unruptured and ruptured brain aneurysms.The mortality index is the ratio of observed to expected mortality, also referred to as the O/E Ratio. An O/E ratio above 1.0 indicates an observed mortality higher than the Vizient Expected Value. Case Mix Index (CMI) is the average relative DRG weight of a hospital’s inpatient discharges, calculated by summing the MS-DRG weight for each discharge and dividing the total by the number of discharges. The CMI reflects the diversity, clinical complexity, and resource needs of all the patients in the hospital. A higher CMI indicates a more complex and resource-intensive case load.

Data from The Vizient Clinical Data Base/Resource Manager™ is used by permission of VIZIENT, all rights reserved. This tool is an analytic platform for performance improvement populated by hundreds of health systems and community hospitals nationwide, including nearly all academic medical centers. It includes comparative benchmarks such as demographic, mortality, length of stay, complication rates, readmission rates, diagnosis, procedure, resource utilization and other information.

Reference Measure Period: 01/01/2023 - 12/31/2023

Endovascular Coiling of Intracranial Aneurysms: Endovascular coiling is a procedure used to treat unruptured and ruptured brain aneurysms. The mortality index is the ratio of observed to expected mortality, also referred to as the O/E Ratio. An O/E ratio above 1.0 indicates an observed mortality higher than the Vizient Expected Value. Case Mix Index (CMI) is the average relative DRG weight of a hospital’s inpatient discharges, calculated by summing the MS-DRG weight for each discharge and dividing the total by the number of discharges. The CMI reflects the diversity, clinical complexity, and resource needs of all the patients in the hospital. A higher CMI indicates a more complex and resource-intensive case load.

Data from The Vizient Clinical Data Base/Resource Manager™ is used by permission of VIZIENT, all rights reserved. This tool is an analytic platform for performance improvement populated by hundreds of health systems and community hospitals nationwide, including nearly all academic medical centers. It includes comparative benchmarks such as demographic, mortality, length of stay, complication rates, readmission rates, diagnosis, procedure, resource utilization and other information.

Reference Measure Period: 01/01/2023 - 12/31/2023

Ischemic Stroke Treatment

Door to treatment with intravenous thrombolytic time is defined as patients arriving to the Emergency Department with stroke symptoms who meet the criteria to receive intravenous thrombolytics to dissolve a blood clot in the brain. Lower times are better.

Door to groin puncture time is defined as the initiation of endovascular treatment for ischemic stroke patients arriving to the Emergency Department with who meet the criteria to receive endovascular stroke treatment. Lower times are better.