{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T03:15:40Z","timestamp":1771557340992,"version":"3.50.1"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"e1","funder":[{"DOI":"10.13039\/100000133","name":"AHRQ","doi-asserted-by":"publisher","award":["1-F32-HS023710-01"],"award-info":[{"award-number":["1-F32-HS023710-01"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]},{"name":"principal investigator\u2019s"},{"name":"David Meltzer and Robert Gibbons"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2017,4,1]]},"abstract":"<jats:p>Objective: Hospital-acquired pressure ulcers (HAPUs) have a mortality rate of 11.6%, are costly to treat, and result in Medicare reimbursement penalties. Medicare codes HAPUs according to Agency for Healthcare Research and Quality Patient-Safety Indicator 3 (PSI-03), but they are sometimes inappropriately coded. The objective is to use electronic health records to predict pressure ulcers and to identify coding issues leading to penalties.<\/jats:p>\n               <jats:p>Materials and Methods: We evaluated all hospitalized patient electronic medical records at an academic medical center data repository between 2011 and 2014. These data contained patient encounter level demographic variables, diagnoses, prescription drugs, and provider orders. HAPUs were defined by PSI-03: stages III, IV, or unstageable pressure ulcers not present on admission as a secondary diagnosis, excluding cases of paralysis. Random forests reduced data dimensionality. Multilevel logistic regression of patient encounters evaluated associations between covariates and HAPU incidence.<\/jats:p>\n               <jats:p>Results: The approach produced a sample population of 21\u2009153 patients with 1549 PSI-03 cases. The greatest odds ratio (OR) of HAPU incidence was among patients diagnosed with spinal cord injury (ICD-9 907.2: OR = 14.3; P\u2009&amp;lt;\u2009.001), and 71% of spinal cord injuries were not properly coded for paralysis, leading to a PSI-03 flag. Other high ORs included bed confinement (ICD-9 V49.84: OR\u2009=\u20093.1, P\u2009&amp;lt;\u2009.001) and provider-ordered pre-albumin lab (OR\u2009=\u20092.5, P\u2009&amp;lt;\u2009.001).<\/jats:p>\n               <jats:p>Discussion: This analysis identifies spinal cord injuries as high risk for HAPUs and as being often inappropriately coded without paralysis, leading to PSI-03 flags. The resulting statistical model can be tested to predict HAPUs during hospitalization.<\/jats:p>\n               <jats:p>Conclusion: Inappropriate coding of conditions leads to poor hospital performance measures and Medicare reimbursement penalties.<\/jats:p>","DOI":"10.1093\/jamia\/ocw118","type":"journal-article","created":{"date-parts":[[2016,8,19]],"date-time":"2016-08-19T01:50:09Z","timestamp":1471571409000},"page":"e95-e102","source":"Crossref","is-referenced-by-count":23,"title":["Using clinical data to predict high-cost performance coding issues associated with pressure ulcers: a multilevel cohort model"],"prefix":"10.1093","volume":"24","author":[{"given":"William V","family":"Padula","sequence":"first","affiliation":[{"name":"Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert D","family":"Gibbons","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Chicago, Chicago, IL, USA"},{"name":"Department of Public Health Sciences, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter J","family":"Pronovost","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD, USA"},{"name":"Department of Critical Care and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Donald","family":"Hedeker","sequence":"additional","affiliation":[{"name":"Department of Public Health Sciences, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manish K","family":"Mishra","sequence":"additional","affiliation":[{"name":"Department of Community & Family Medicine, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary Beth F","family":"Makic","sequence":"additional","affiliation":[{"name":"College of Nursing, University of Colorado, Aurora, CO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John FP","family":"Bridges","sequence":"additional","affiliation":[{"name":"Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heidi L","family":"Wald","sequence":"additional","affiliation":[{"name":"School of Medicine, University of Colorado, Aurora, CO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert J","family":"Valuck","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adam J","family":"Ginensky","sequence":"additional","affiliation":[{"name":"The Graham School, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anthony","family":"Ursitti","sequence":"additional","affiliation":[{"name":"The Graham School, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura Ruth","family":"Venable","sequence":"additional","affiliation":[{"name":"The Graham School, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ziv","family":"Epstein","sequence":"additional","affiliation":[{"name":"Pomona College, Claremont, CA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David O","family":"Meltzer","sequence":"additional","affiliation":[{"name":"Section of Hospital Medicine, University of Chicago, Chicago, IL, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2016,8,18]]},"reference":[{"issue":"6","key":"2020110612434535500_ocw118-B1","first-page":"257","article-title":"Hospital-acquired pressure ulcers at academic medical centers in the United States, 2008-2012: tracking changes since the CMS nonpayment policy","volume":"41","author":"Padula","year":"2015","journal-title":"Jt Comm J Qual Patient Saf."},{"key":"2020110612434535500_ocw118-B2","article-title":"Hospitalizations related to pressure ulcers among adults 18 years and older,","volume-title":"Healthcare Cost and Utilization Project (HCUP).","author":"Russo","year":"2006"},{"issue":"9","key":"2020110612434535500_ocw118-B3","doi-asserted-by":"crossref","first-page":"1603","DOI":"10.1111\/j.1532-5415.2012.04106.x","article-title":"Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System 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infections","volume":"298","author":"Wald","year":"2007","journal-title":"JAMA."},{"key":"2020110612434535500_ocw118-B7","article-title":"CMS to improve quality of care during hospital inpatient stays","author":"CMS Media Relations","year":"2014"},{"key":"2020110612434535500_ocw118-B8","article-title":"AHRQ quality indicators","volume-title":"Patient Safety and Quality: An Evidence-based Handbook for Nurses","author":"Farguhar","year":"2008"},{"issue":"6","key":"2020110612434535500_ocw118-B9","first-page":"246","article-title":"Comparative effectiveness of quality improvement interventions for pressure ulcer prevention in academic medical centers in the United States","volume":"41","author":"Padula","year":"2015","journal-title":"Jt Comm J Qual Patient Saf."},{"issue":"4","key":"2020110612434535500_ocw118-B10","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1097\/WON.0000000000000145","article-title":"Factors influencing adoption of hospital-acquired pressure ulcer prevention 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