100034 MOUNT SINAI MEDICAL CENTER

100034 MOUNT SINAI MEDICAL CENTER

4300 ALTON RD Miami Beach, FL 33140-2948

Overall Hospital Performance State Wide

Total Hospitalizations: 26,978 2,765,069

* Total Adult Hospitalizations: 18,674 2,255,089

* Total Pediatric Hospitalizations: 2 32,562

Risk Adjusted Average Length of Stay: 4.7 days 4.6 days

* 15-day Overall Readmission Rate: 7.17 % (Higher than Expected) 6.11 %

*Time period for readmission data.

Performance by Medical Condition or Procedure

Adults

Bones and Joints Average Length of Stay (days) Charges

Condition or Procedure Hospitalizations Obs Exp Risk Adj Low High

Back Problems 153 4.6 3.6 4.9 22,987 46,065

State Wide 18,879 3.8 27,726 65,060

Disc Surgery 139 5.7 5.0 5.4 55,620 85,561

State Wide 7,834 4.7 60,205 129,074

Femur Fracture Surgical Repair 126 7.5 6.0 7.0 57,291 93,658

State Wide 19,606 5.5 66,993 138,754

Fracture of Pelvis or Dislocation of Hip 41 6.0 3.8 6.1 24,951 50,092

State Wide 3,492 3.8 22,370 51,178

Hip Replacement 164 4.3 3.3 4.0 53,642 72,659

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AHRQ Quality Indicators version 4.2

3M™ APR™ DRG Classification System version 31

Florida Agency For Health Care Administration

State Wide 42,438 3.0 64,252 124,523

Knee Replacement 291 3.1 2.2 3.3 49,438 57,445

State Wide 38,778 2.4 64,098 126,684

Leg Amputation 24 13.6 11.9 12.4 77,064 174,934

State Wide 4,895 10.9 68,115 169,410

Shoulder, Upper Arm & Forearm Procedures 87 3.3 2.7 3.3 43,972 61,702

State Wide 17,567 2.7 72,175 139,684

Spinal Fusion 211 5.5 4.3 5.2 71,017 150,444

State Wide 27,782 4.0 108,241 227,915

Tibia / Fibula Fracture Repair 39 7.1 4.6 8.1 53,508 82,159

State Wide 11,944 5.3 68,634 149,260

Brain and Nervous System Average Length of Stay (days) Charges


Craniotomy (brain surgery) 108 15.7 9.9 14.0 137,129 277,815

State Wide 10,435 8.9 98,846 259,650

Stroke 383 5.7 5.2 5.2 39,061 90,063

State Wide 43,670 4.7 37,432 98,172

Transient Cerebral Ischemia 96 2.4 2.2 2.4 31,523 47,510

State Wide 10,005 2.2 30,527 66,048

Cancer Average Length of Stay (days) Charges


Acute Leukemia 23 11.4 14.1 11.3 30,697 111,769

State Wide 1,801 13.9 42,948 266,814

Bone Marrow Transplant 0 0.0 0.0 0.0

State Wide 1,057 22.9 230,901 590,446

Brain Cancer 35 4.3 5.3 4.2 19,192 50,249

State Wide 3,644 5.2 27,487 78,511

Chemotherapy 21 7.1 5.8 7.3 23,284 91,344

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State Wide 6,229 6.0 28,404 91,329

Digestive System Cancer 102 5.0 5.6 4.9 13,876 57,567

State Wide 5,594 5.5 31,160 87,017

Female Reproductive Cancer 14 5.9 6.1 4.5 14,498 61,187

State Wide 1,417 4.7 25,322 72,386

Kidney / Ureter Removal 115 3.6 5.0 3.3 44,947 67,040

State Wide 3,220 4.6 64,867 143,635

Leukemia / Lymphoma, Non-Surgical 95 5.9 7.1 5.5 29,124 83,380

State Wide 6,350 6.5 30,239 106,107

Leukemia / Lymphoma, Surgical 33 8.0 10.1 8.1 58,931 121,581

State Wide 2,563 10.2 57,972 188,195

Liver / Pancreatic Cancer 53 4.8 5.3 4.4 26,739 70,548

State Wide 4,890 4.9 31,127 84,697

Lung Cancer 93 4.1 5.4 4.2 15,448 69,621

State Wide 7,096 5.6 34,132 95,197

Mastectomy 57 2.5 2.2 2.7 63,238 98,680

State Wide 1,392 2.4 65,022 168,438

Diabetes/ Endocrinology/ Metabolism Average Length of Stay (days) Charges


Diabetes 125 3.3 3.4 3.1 18,206 37,480

State Wide 28,759 3.2 20,010 49,154

General Medical Information Average Length of Stay (days) Charges


Acute Pancreatitis 132 3.5 3.8 3.3 21,432 41,449

State Wide 19,870 3.6 23,566 54,570

Cellulitis 242 3.2 3.6 3.4 16,445 33,720

State Wide 36,608 3.7 18,968 46,684

Convulsions (Seizures) 83 2.9 3.3 3.1 20,495 40,874

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State Wide 19,536 3.4 25,157 62,652

Diverticulosis / Diverticulitis 207 3.5 3.5 3.4 23,111 40,914

State Wide 22,119 3.4 23,136 52,663

Gastrointestinal Hemorrhage 249 3.7 3.8 3.6 26,972 49,749

State Wide 36,578 3.7 28,944 68,101

Hypovolemia (Low Blood Volume) 114 3.7 3.7 3.5 23,176 44,226

State Wide 10,648 3.4 20,554 51,095

Inflammatory Bowel Disease 67 4.3 3.6 4.5 24,863 45,644

State Wide 7,148 3.8 24,544 57,218

Migraine & Other Headaches 61 3.0 2.3 3.2 24,917 48,041

State Wide 5,421 2.4 25,736 58,043

Non-Bacterial Gastroenteritis, Nausea & Vomiting 124 3.0 3.0 2.8 22,598 39,057

State Wide 21,130 2.8 23,513 51,421

Renal Failure 280 4.2 4.4 4.1 23,049 49,057

State Wide 47,119 4.3 22,274 61,279

Septicemia (blood poisoning) 923 6.6 6.1 6.4 32,397 83,937

State Wide 134,198 6.0 34,725 98,265

Sickle Cell Disease 31 3.8 4.7 3.8 20,629 40,505

State Wide 8,837 4.7 19,729 48,173

Syncope (fainting) 110 2.6 2.4 2.8 20,152 42,470

State Wide 15,701 2.6 25,701 58,999

Urinary Stones 101 1.9 2.0 1.9 27,307 37,346

State Wide 8,335 2.0 24,768 57,624

Urinary Tract Infection 331 3.7 3.7 3.6 22,111 40,766

State Wide 44,084 3.6 22,385 51,664

Heart and Circulatory System Average Length of Stay (days) Charges


Angina Pectoris & Coronary Atherosclerosis 207 2.0 2.0 2.0 17,349 34,250

State Wide 12,352 2.0 20,441 47,111

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Angioplasty 860 4.5 4.0 4.2 79,462 131,003

State Wide 50,941 3.7 91,677 199,729

Cardiac Catheterization 392 5.0 4.2 4.8 42,302 79,036

State Wide 30,137 4.0 47,728 102,578

Cardiac Defibrillator & Heart Assist Anomaly 86 9.1 7.5 10.0 131,891 250,498

State Wide 6,071 8.2 190,156 392,955

Cardiac Pacemaker Implant 106 5.2 4.1 5.2 58,724 88,729

State Wide 8,913 4.2 73,059 139,478

Cardiac Valve Procedures without Cardiac Catheterization 157 9.0 8.9 9.0 128,348 199,226

State Wide 4,408 8.9 183,737 374,338

Chest Pain 123 1.8 1.6 1.9 16,051 30,527

State Wide 11,587 1.6 21,494 45,258

Coronary Bypass Surgery 170 9.1 9.1 9.8 120,603 187,919

State Wide 14,286 9.8 180,133 399,850

Heart Attack 259 3.7 3.4 3.9 33,040 60,560

State Wide 23,058 3.6 33,481 82,390

Heart Failure 681 4.9 4.7 4.9 27,695 56,147

State Wide 84,902 4.7 25,795 65,637

High Blood Pressure 216 3.1 2.8 2.9 22,217 46,795

State Wide 16,772 2.6 22,601 51,373

Irregular Heartbeat 343 3.2 3.0 3.1 21,317 43,762

State Wide 46,238 2.9 19,411 47,642

Major Thoracic & Abdominal Vascular Procedures 67 8.0 8.0 8.3 92,336 178,034

State Wide 3,661 8.3 106,168 276,193

Peripheral Vascular Disease (PVD) 160 4.0 3.7 4.2 21,416 48,673

State Wide 15,547 3.9 21,865 62,070

Pulmonary Edema & Respiratory Failure 96 4.2 5.0 4.1 7,253 65,210

State Wide 29,700 4.9 30,652 84,428

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Lungs Average Length of Stay (days) Charges


Asthma 99 4.0 3.1 4.1 22,485 40,059

State Wide 9,376 3.2 22,178 50,587

Chronic Obstructive Pulmonary Disease, COPD 283 4.2 4.0 4.2 24,355 50,444

State Wide 45,830 4.0 24,507 57,744

Lung and Chest Procedures 429 5.2 6.0 6.9 59,535 98,095

State Wide 11,532 7.9 72,034 183,672

Pneumonia 359 4.6 4.3 4.6 24,039 57,609

State Wide 44,807 4.3 25,491 63,472

Pneumonitis, Aspiration 146 6.8 6.2 7.2 28,893 76,881

State Wide 17,060 6.6 34,766 97,161

Surgery Average Length of Stay (days) Charges


Appendectomy 172 2.4 2.5 2.5 39,307 53,750

State Wide 9,406 2.6 45,959 94,912

Arteriovenostomy (renal dialysis) 9 10.6 8.1 10.4 88,498 127,012

State Wide 708 7.9 67,045 156,226

Gall Bladder Removal 5 2.8 5.4 3.4 30,048 63,211

State Wide 1,207 6.6 72,096 174,112

Heart and/or Lung Transplant 0 0.0 0.0 0.0

State Wide 413 38.8 572,046 1,254,911

Hernia Repair 43 5.0 4.2 5.3 38,738 78,247

State Wide 5,591 4.4 55,782 126,084

Inguinal, Femoral & Umbilical Hernia Procedures 27 3.3 3.1 3.7 38,816 58,834

State Wide 2,692 3.5 47,126 108,943

Kidney/Pancreas Transplant 0 0.0 0.0 0.0

State Wide 1,488 7.0 191,621 321,639

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Laparoscopic Gall Bladder Removal 267 3.5 3.5 3.7 44,680 69,413

State Wide 22,876 3.6 54,018 116,733

Liver Transplant 0 0.0 0.0 0.0

State Wide 607 20.6 293,633 697,816

Major Small & Large Bowel Procedures 218 7.8 7.6 8.2 61,558 127,395

State Wide 25,054 8.0 76,013 185,964

Major Stomach, Esophageal & Duodenal Procedures 99 4.6 5.4 6.5 47,483 98,161

State Wide 5,354 7.6 72,554 189,740

Minor Small & Large Bowel Procedures 38 5.6 5.2 6.3 40,631 77,665

State Wide 5,887 5.9 43,824 116,391

Obesity Procedures 39 2.0 1.6 2.1 42,315 49,318

State Wide 10,998 1.7 50,762 118,386

Peritoneal Adhesiolysis 19 7.1 8.0 7.1 57,377 109,799

State Wide 2,188 7.9 60,752 150,623

Radical Prostatectomy 54 1.5 1.8 1.6 34,366 41,342

State Wide 2,068 2.0 71,741 115,590

Thyroid, Parathyroid & Thyroglossal Procedures 26 3.0 3.0 2.7 43,110 65,619

State Wide 1,654 2.6 59,948 106,004

Transurethral Prostatectomy 22 3.5 3.8 3.3 31,941 54,514

State Wide 1,834 3.6 38,134 87,152

Urethral & Transurethral Procedures 68 3.4 3.4 3.1 35,206 55,147

State Wide 7,298 3.1 41,954 89,846

Women's Health / Deliveries Average Length of Stay (days) Charges


Cesarean Section Delivery 923 3.2 3.1 3.4 21,288 27,495

State Wide 78,785 3.3 26,107 49,148

Hysterectomies and Other Uterine & Adnexa Procedures 51 2.5 2.2 3.1 29,320 46,249

State Wide 13,900 2.7 43,887 96,861

Vaginal Delivery 1,607 2.5 2.4 2.5 15,877 25,489

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State Wide 125,102 2.4 13,853 27,497

Deliveries and Newborns

Newborns Average Length of Stay (days) Charges


Baby with Complications 1,491 4.1 4.7 6.9 4,255 9,525

State Wide 79,283 7.8 4,716 30,858

Normal Baby 1,159 2.0 2.1 2.0 4,064 5,034

State Wide 138,977 2.1 3,051 5,795

Pediatrics

Pediatrics Average Length of Stay (days) Charges


Appendectomy - Ages 1-17 years 4 0.8 1.7 0.8 29,992 36,909

State Wide 5,070 1.7 24,654 41,434

Asthma - Ages 2-17 years 1 1.0 1.8 1.1

State Wide 15,526 2.0 8,012 18,018

Brain Surgery - Ages 0-17 years 0 0.0 0.0 0.0

State Wide 3,463 7.5 44,463 141,052

Bronchiolitis and RSV Pneumonia - Ages 0-4 years 0 0.0 0.0 0.0

State Wide 16,539 2.8 7,624 18,936

Cancer Care - Ages 0-17 years 8 6.8 3.0 12.8 34,823 39,507

State Wide 8,678 5.6 17,168 60,198

Cellulitis - Ages 0-17 years 2 2.5 2.5 2.7 12,954 12,954

State Wide 12,076 2.7 7,842 19,221

Convulsions (Seizures) - Ages 0-4 years 0 0.0 0.0 0.0

State Wide 6,596 2.8 9,894 26,734

Convulsions (Seizures) - Ages 5-17 years 0 0.0 0.0 0.0

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State Wide 7,185 2.4 10,334 28,563

Diabetes - Ages 6-17 years 0 0.0 0.0 0.0

State Wide 2,392 2.3 10,496 23,858

Fever and Infectious Illness - Ages 0-17 years 2 1.5 2.0 1.8 16,981 16,981

State Wide 22,646 2.3 7,671 16,822

Gastroenteritis - Ages 3 months - 4 years 0 0.0 0.0 0.0

State Wide 5,781 2.1 6,379 13,383

Gastroenteritis - Ages 5-17 years 0 0.0 0.0 0.0

State Wide 3,600 2.0 7,432 18,229

Pneumonia, Other - Ages 2-17 years 1 5.0 2.8 5.2

State Wide 12,890 2.9 10,333 24,530

Sickle Cell Disease - Ages 1-17 years 0 0.0 0.0 0.0

State Wide 5,228 3.8 9,849 25,412

Spinal Fusion - Ages 5-17 years 0 0.0 0.0 0.0

State Wide 2,552 5.5 148,887 293,154

Urinary Tract Infections - Ages 3 months to 17 years 0 0.0 0.0 0.0

State Wide 5,113 3.1 9,375 20,379

Viral Meningitis - Ages 0-17 years 0 0.0 0.0 0.0

State Wide 1,361 2.7 10,076 20,113

AHRQ Pediatric Quality Measures

Quality Measure Lower

Confidence

Upper

Confidence

Numerator Denominator Observed Volume Observed Rate Risk Adj Rate Expected Rate Interval Interval

Accidental Puncture or Laceration As Expected 1 5,030 5,030 0.02% 0.03% %0.04 0.00 % %0.13

State Wide 117 589,632 589,632 0.02% 0.02% 0.01% 0.03%

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Pediatric Heart Surgery Mortality 0 0 0 0.00%

Not Rated

0.00% %0.00 0.00 % %0.00

State Wide 95 3,540 3,540 2.68% 3.08% 2.40% 3.75%

Pediatric Heart Surgery Volume 0 0 0 0.00%

Not Rated

0.00% %0.00 0.00 % %0.00

State Wide 3,851 0 0 0.00% 0.00% 0.00% 0.00%

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AHRQ Mortality Rates

Mortality for Inpatient Procedures

Quality Indicator Denominator Numerator Observed Rate Risk Adjusted Rate

Lower

Conf

Interval

Upper

Conf

Interval

Abdominal Aortic Aneurysm Repair Mortality Rate 36 1 2.78 % 2.11% As Expected 0.00% 7.90 %

State Wide 2,869 113 3.94 % 2.43 %

Carotid Endarterectomy Mortality Rate 39 0 0.00 % 0.00% As Expected 0.00% 2.24 %

State Wide 7,170 22 0.31 % 0.24 %

Coronary Artery Bypass Graft Mortality Rate 235 4 1.70 % 0.49% As Expected 0.00 % 1.61 %

State Wide 15,134 413 2.73 % 0.83 %

Craniotomy Mortality Rate (Surgical opening of the

skull)

State Wide

189

10,840

7

603

3.70 %

5.56 %

7.06% As Expected

10.74 %

2.29 % 11.83 %

Esophageal Resection Mortality Rate (Surgical

Removal of the Throat)

State Wide

5

382

0

27

0.00 %

7.07 %

0.00% Not Rated

2.29 %

0.00 % 11.01 %

Hip Replacement Mortality Rate 113 0 0.00 % 0.00% As Expected 0.00% 0.42 %

State Wide 23,592 18 0.08 % 0.03 %

Pancreatic Resection Mortality Rate (Surgical

Removal of the Pancreas)

State Wide

9

621

0

22

0.00 %

3.54 %

0.00% As Expected

1.39 %

0.00% 7.33 %

Percutaneous Transluminal Coronary Angioplasty

Mortality Rate

State Wide

711

38,441

12

971

1.69 %

2.53 %

1.11%

1.80%

Lower than

Expected

0.42 % 1.80 %

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Mortality for Inpatient Conditions

Quality Indicator Denominator Numerator Observed Rate Risk Adjusted Rate

Lower

Conf

Interval

Upper

Conf

Interval

Acute Myocardial Infarction Mortality Rate (Heart

Attack)

State Wide

581

43,815

27

2,146

4.65 %

4.90 %

3.77% As Expected

4.04 %

1.94% 5.60 %

Acute Myocardial Infarction Mortality Rate (Heart

Attack), Without Transfer Cases

State Wide

480

40,301

24

1,955

5.00 %

4.85 %

4.26% As Expected

4.21 %

2.13% 6.39 %

Acute Stroke Mortality Rate 315 19 6.03 % 6.93% As Expected 3.39% 10.47 %

State Wide 44,151 2,728 6.18 % 7.15 %

Congestive Heart Failure (CHF) Mortality Rate 693 30 4.33 % 2.84% As Expected 1.75% 3.92 %

State Wide 78,661 1,940 2.47 % 1.78 %

Gastrointestinal (GI) Hemorrhage Mortality Rate 368 5 1.36 % 1.17% As Expected 0.00 % 2.61 %

State Wide 41,223 702 1.70 % 1.49 %

Hip Fracture Mortality Rate 171 3 1.75 % 1.42% As Expected 0.00% 3.68 %

State Wide 21,956 378 1.72 % 1.39 %

Pneumonia Mortality Rate 451 19 4.21 % 2.82% As Expected 1.35% 4.29 %

State Wide 56,654 1,536 2.71 % 2.04 %

Complication/Infection Rates

* AHRQ Patient Safety Indicators

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Patient Safety Indicator

latrogenic pneumothorax

State Wide

Denominator

17,299

1,974,190

Numerator

10

506

Observed Rate

0.06 %

%0.03

Risk Adjusted Rate

0.13 % Higher than

Expected

0.06 %

Lower

Conf

Interval

0.08 %

Upper

Conf

Interval 0.18 %

Postoperative hip fracture

State Wide

3,860

285,566

0

13

0.00

0.00

%

%

0.00 %

0.00 %

As Expected 0.00 % 0.04 %

Postoperative pulmonary embolism or deep vein

thrombosis

State Wide

5,686

523,956

27

2,540

0.47

0.48

%

%

0.32 %

0.39 %


Pressure ulcer (bed or pressure sore)

State Wide

7,495

606,061

11

466

0.15

0.08

%

%

0.47 %

0.24 %


* Methodology utilizes Present on Admission (POA)

Readmissions by Medical Condition or Procedure

Adults

Bones and Joints

Condition or Procedure

Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Back Problems

State Wide

8

841

115

15,581

6.96 %

5.40 %

5.41% 6.94% As Expected

Disc Surgery

State Wide

5

380

100

6,752

5.00 %

5.63 %


Femur Fracture Surgical Repair

State Wide

6

849

96

17,232

6.25 %

4.93 %


Fracture of Pelvis or Dislocation of Hip

State Wide

1

120

30

3,092

3.33 %

3.88 %


Hip Replacement 2 134 1.49 % 3.14% 1.42% As Expected

State Wide 1,150 38,479 2.99 %

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Knee Replacement

State Wide

1

804

219

37,743

0.46 %

2.13 %


Leg Amputation

State Wide

4

377

23

4,415

17.39 %

8.54 %


Shoulder, Upper Arm & Forearm Procedures

State Wide

3

404

78

15,378

3.85 %

2.63 %


Spinal Fusion

State Wide

3

1,101

121

24,895

2.48 %

4.42 %


Tibia / Fibula Fracture Repair

State Wide

1

367

30

10,183

3.33 %

3.60 %


Brain and Nervous System


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Craniotomy (brain surgery)

State Wide

4

408

37

5,584

10.81 %

7.31 %


Stroke

State Wide

15

1,863

233

34,124

6.44 %

5.46 %


Transient Cerebral Ischemia

State Wide

1

334

76

8,859

1.32 %

3.77 %


Cancer


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Digestive System Cancer

State Wide

0

43

22

1,388

0.00 %

3.10 %


Female Reproductive Cancer

State Wide

1

14

2

477

50.00 %

2.94 %

2.21% 66.49% Not Rated

Kidney / Ureter Removal 6 63 9.52 % 5.00% 10.61% As Expected

State Wide 132 2,371 5.57 %

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Leukemia / Lymphoma, Non-Surgical

State Wide

0

19

7

830

0.00 %

2.29 %


Leukemia / Lymphoma, Surgical

State Wide

1

13

7

520

14.29 %

2.50 %

2.39% 14.94% Higher than Expected

Liver / Pancreatic Cancer

State Wide

2

57

9

1,203

22.22 %

4.74 %


Lung Cancer

State Wide

0

78

11

2,156

0.00 %

3.62 %


Mastectomy

State Wide

1

36

32

1,013

3.13 %

3.55 %


Diabetes/ Endocrinology/ Metabolism


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Diabetes

State Wide

7

1,691

63

21,351

11.11 %

7.92 %


General Medical Information


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Acute Pancreatitis

State Wide

5

1,196

78

15,518

6.41 %

7.71 %


Cellulitis

State Wide

7

1,544

180

29,161

3.89 %

5.29 %


Convulsions (Seizures)

State Wide

8

851

40

14,108

20.00 %

6.03 %


Diverticulosis / Diverticulitis

State Wide

10

1,004

161

19,302

6.21 %

5.20 %


Gastrointestinal Hemorrhage 6 157 3.82 % 7.52% 3.73% As Expected

State Wide 2,006 27,329 7.34 %

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Hypovolemia (Low Blood Volume)

State Wide

1

483

69

7,449

1.45 %

6.48 %


Inflammatory Bowel Disease

State Wide

4

450

38

5,693

10.53 %

7.90 %

7.15% 11.64 % As Expected

Migraine & Other Headaches

State Wide

1

185

43

4,360

2.33 %

4.24 %


Non-Bacterial Gastroenteritis, Nausea & Vomiting

State Wide

4

903

90

16,768

4.44 %

5.39 %


Renal Failure

State Wide

21

2,848

195

34,458

10.77 %

8.27 %


Septicemia (blood poisoning)

State Wide

39

6,576

480

90,013

8.13 %

7.31 %


Sickle Cell Disease

State Wide

2

976

15

5,840

13.33 %

16.71 %


Syncope (fainting)

State Wide

3

539

68

12,592

4.41 %

4.28 %


Urinary Stones

State Wide

3

227

73

6,975

4.11 %

3.25 %


Urinary Tract Infection

State Wide

12

2,064

223

35,981

5.38 %

5.74 %


Heart and Circulatory System


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Angina Pectoris & Coronary Atherosclerosis

State Wide

15

694

131

9,624

11.45 %

7.21 %


Angioplasty

State Wide

51

3,009

642

43,770

7.94 %

6.87 %


Cardiac Catheterization 9 267 3.37 % 5.41% 3.40% As Expected

State Wide 1,379 25,273 5.46 %

Page 16 of 22

11/19/2020




Cardiac Defibrillator & Heart Assist Anomaly

State Wide

8

456

60

4,822

13.33 %

9.46 %


Cardiac Pacemaker Implant

State Wide

5

458

74

8,107

6.76 %

5.65 %


Cardiac Valve Procedures without Cardiac

Catheterization

State Wide

10

324

116

3,815

8.62 %

8.49 %


Chest Pain

State Wide

6

424

68

9,396

8.82 %

4.51 %


Coronary Bypass Surgery

State Wide

6

1,016

120

12,460

5.00 %

8.15 %


Heart Attack

State Wide

16

1,273

148

15,689

10.81 %

8.11 %


Heart Failure

State Wide

49

6,612

441

60,902

11.11 %

10.86 %

10.49% 11.50 % As Expected

High Blood Pressure

State Wide

7

727

146

13,811

4.79 %

5.26 %


Irregular Heartbeat

State Wide

26

2,483

241

38,426

10.79 %

6.46 %


Major Thoracic & Abdominal Vascular Procedures

State Wide

6

318

51

2,885

11.76 %

11.02 %


Peripheral Vascular Disease (PVD)

State Wide

9

613

87

10,857

10.34 %

5.65 %


Pulmonary Edema & Respiratory Failure

State Wide

3

1,872

28

19,918

10.71 %

9.40 %


Lungs


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Asthma 1 79 1.27 % 5.06% 1.37% As Expected

State Wide 438 8,008 5.47 %

Page 17 of 22

11/19/2020




Chronic Obstructive Pulmonary Disease, COPD 14 198 7.07 % 8.90% 6.81 % As Expected

State Wide 3,199 37,294 8.58 %

Lung and Chest Procedures 15 184 8.15 % 5.27% 10.74 % As Expected

State Wide 553 7,964 6.94 %

Pneumonia 13 203 6.40 % 6.55% 6.29 % As Expected

State Wide 2,187 33,983 6.44 %

Pneumonitis, Aspiration 6 96 6.25 % 8.58% 6.08 % As Expected

State Wide 925 11,076 8.35 %

Surgery


Readmissions /

Numerator

Population at

Risk /

Denominator

Observed

Readmission

Rate

Expected

Readmission

Rate

Risk Adjusted

Readmission

Rate

Appendectomy

State Wide

6

296

97

7,871

6.19 %

3.76 %


Arteriovenostomy (renal dialysis)

State Wide

0

64

6

632

0.00 %

10.13 %


Gall Bladder Removal

State Wide

0

90

5

1,090

0.00 %

8.26 %

6.76% 0.00% Not Rated

Hernia Repair

State Wide

3

352

51

4,999

5.88 %

7.04 %


Inguinal, Femoral & Umbilical Hernia Procedures

State Wide

1

95

19

2,340

5.26 %

4.06 %


Laparoscopic Gall Bladder Removal

State Wide

3

942

173

20,374

1.73 %

4.62 %


Major Small & Large Bowel Procedures

State Wide

11

1,684

110

19,318

10.00 %

8.72 %


Major Stomach, Esophageal & Duodenal

Procedures

State Wide

4

369

69

4,122

5.80 %

8.95 %


Minor Small & Large Bowel Procedures 2 28 7.14 % 8.68% 7.29% As Expected

State Wide 437 4,935 8.86 %

Page 18 of 22

11/19/2020




Obesity Procedures 2 44 4.55 % 2.00% 5.61% As Expected

State Wide 244 9,876 2.47 %

Peritoneal Adhesiolysis 4 11 36.36 % 7.70% 40.88% Higher than Expected

State Wide 164 1,894 8.66 %

Radical Prostatectomy 0 25 0.00 % 2.56% 0.00% As Expected

State Wide 41 1,447 2.83 %

Thyroid, Parathyroid & Thyroglossal Procedures 0 17 0.00 % 3.27% 0.00% As Expected

State Wide 46 1,198 3.84 %

Transurethral Prostatectomy 1 18 5.56 % 7.08% 5.11 % As Expected

State Wide 104 1,596 6.52 %

Urethral & Transurethral Procedures 5 44 11.36 % 5.43% 11.93 % As Expected

State Wide 362 6,347 5.70 %

Women's Health / Deliveries Population at Observed Expected

Risk Adjusted

Readmission

Readmissions / Risk / Readmission Readmission Rate

Condition or Procedure Numerator Denominator Rate Rate

Hysterectomies and Other Uterine & Adnexa 2 40 5.00 % 3.04% 5.66% As Expected

Procedures

State Wide 407 11,826 3.44 %

Pediatrics

Pediatrics Population at Observed Expected

Risk Adjusted

Readmission

Readmissions / Risk / Readmission Readmission Rate

Condition or Procedure Numerator Denominator Rate Rate

Appendectomy - Ages 1-17 years 0 1 0.00 % 2.01% 0.00% Not Rated

State Wide 61 2,914 2.09 %

Asthma - Ages 2-17 years 0 1 0.00 % 1.20% 0.00% Not Rated

State Wide 159 9,865 1.61 %

Pneumonia, Other - Ages 2-17 years 0 1 0.00 % 1.79% 0.00% Not Rated

Page 19 of 22

11/19/2020




State Wide 153 7,449 2.05 %

Page 20 of 22

11/19/2020




Cases by Physician

Total hip replacement

LicNo

ME46349

Name

Amaya Wilfredo P

ME62590 Lavernia Carlos J

ME104875 Saenz CesarL

ME66812 Umlas Marc E

Cases

5

2

11

27

Total knee replacement

LicNo

ME46349

Name

Amaya Wilfredo P

ME62590 Lavernia Carlos J

ME104875 Saenz CesarL

Cases

51

8

91

Page 21 of 22

11/19/2020




20ME66812 Umlas Marc E

Page 22 of 22

11/19/2020




Documents

100034 MOUNT SINAI MEDICAL CENTER