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The AHRQ approach to evaluating and selecting quality indicators Patrick Romano

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The AHRQ approach to evaluating and selecting quality indicators  Patrick Romano Powered By Docstoc
					The AHRQ approach to evaluating
and selecting quality indicators
based on administrative data
 Patrick S. Romano, MD MPH
 Professor of Medicine and Pediatrics
 UC Davis Center for Health Services Research in
 Primary Care, Sacramento CA USA
 Administrative Data in Health Research:
 An International Symposium
 Calgary, Alberta
 June 17, 2005
AHRQ Quality Indicators
Current project team
    Kathryn McDonald, M.M., Stanford, Principal Investigator
    Patrick Romano, M.D., M.P.H, Co-Investigator, UC Davis
    Jeffrey Geppert, J.D., Ed.M., Lead Analyst, Battelle
    Sheryl Davies, M.A., Project Manager, Stanford
    Corinna Haberland, M.D., M.S., Pediatrics Researcher, Stanford
    Douglas Payne, M.D., UC Davis
    Banafsheh Sadeghi, M.D., Ph.D. student, UC Davis
    Mark Gritz, PhD, Battelle, Principal Investigator
    Greg Hubert, Battelle, Project Manager
    Mamatha Pancholi, AHRQ

    Plus many other contributors to development of indicators, especially:
    Mark McClellan, M.D., Ph.D., Stanford (now CMS)
    Kaveh Shojania, M.D., UCSF (now University of Ottawa)
    Bradford Duncan, M.D., M.S., Stanford (now PAMC)
    Anne Elixhauser, Ph.D., AHRQ
    Denise Remus, Ph.D., R.N., Previous AHRQ (now Premier)
Acknowledgments
 Funded by AHRQ
 Contract No. 290-97-0013
 Support of Quality Indicators Contract No. 290-02-
   0007

 Data used for analyses:
 Nationwide Inpatient Sample (NIS), 1995-2000.
   Healthcare Cost and Utilization Project (HCUP),
   Agency for Healthcare Research and Quality
 State Inpatient Databases (SID), 1997 (19 states).
   Healthcare Cost and Utilization Project (HCUP),
   Agency for Healthcare Research and Quality
Acknowledgments
  We gratefully acknowledge the data organizations in participating
   states that contributed data to HCUP and that we used in this
   study: the Arizona Department of Health Services; California
   Office of Statewide Health and Development; Colorado Health and
   Hospital Association; CHIME, Inc. (Connecticut); Florida Agency
   for Health Care Administration; Georgia Hospital Association;
   Hawaii Health Information Corporation; Illinois Health Care Cost
   Containment Council; Iowa Hospital Association; Kansas Hospital
   Association; Maryland Health Services Cost Review Commission;
   Massachusetts Division of Health Care Finance and Policy;
   Missouri Hospital Industry Data Institute; New Jersey Department
   of Health and Senior Services; New York State Department of
   Health; Oregon Association of Hospitals and Health Systems;
   Pennsylvania Health Care Cost Containment Council; South
   Carolina State Budget and Control Board; Tennessee Hospital
   Association; Utah Department of Health; Washington State
   Department of Health; and Wisconsin Department of Health and
   Family Service.
Topics for this morning

    Background
    Development of indicators
    Refinement of indicators
    Ongoing validation and future work
Goals
  Develop quality indicators using hospital
   administrative data (ICD-9-CM)
  Disseminate indicators via web site
   www.qualityindicators.ahrq.gov
  Provide technical support to users of the
   indicators
  Continue to improve indicators
  Add new indicators and modules
Administrative data and
quality improvement
 Obstacles                      Opportunities
   Lack of information on         Coding practices improving
    processes of care and          Data availability improving
    physiologic measures of         (e.g., less truncation)
    severity                       More specific codes added
   Lack of information on          annually, ICD-10-CM
    timing (comorbidities vs.      Large data sets improve
    adverse events)                 precision
   Coding errors cause bias       Comprehensive: all
   Truncation of secondary         hospitals
    diagnoses causes bias          Quality screening feasible;
   Heterogeneous severity          link with internal process
    within single code              data
AHRQ Quality Indicators
Project timeline
 EPC Project             SQI-I       SQI-II




  1999                  2002                  2005

       Evidence-based Practice Center (EPC)
       Support for Quality Indicators I (SQI-I)
       Support for Quality Indicators II (SQI-II)
Continuous improvement
of AHRQ QIs
                                                 Ongoing
 Development              Refinement
                                                 Validation


 33 HCUP QIs       User            Research        New
                  Evidence         Evidence      Research

76+ AHRQ QIs                        Published    Empirical
               Support    Work
   34 IQIs      Hotline   Groups    Literature
                                                  Clinical
   16 PQIs                                        Coding
                  Comparative        Quality
   26 PSIs         Reporting       Improvement    Other
                                                 Measures
  #? PedQIs
Indicator set development:
The big picture
     SOURCES

     Literature


                  Candidate
     Actual Use                Evaluation
                  Indicators



      Concept


                                Selection
Current QI modules
 Prevention Quality      Ambulatory care
  Indicators (PQI)         sensitive conditions

                          Mortality following
 Inpatient Quality        procedures
  Indicators (IQI)        Mortality for medical
                           conditions
                          Utilization of procedures
                          Volume of procedures

 Patient Safety          Postoperative
                           complications
  Indicators (PSI)
                          Iatrogenic conditions
Structure of indicators
  Definitions based on
     ICD-9-CM diagnosis and procedure codes
     Inclusion/exclusion criteria based upon DRG, MDC,
      sex, age, procedure dates, admission type
  Numerator = number of cases “flagged” with
   the complication or situation of interest
     e.g., Postop sepsis, avoidable hospitalization for
      asthma, death
  Denominator = number of patients considered
   to be at risk for that complication or situation
     e.g. elective surgical patients, county population
      from census data
  Indicator “rate” = numerator/denominator
 Indicator development:
 General process
 Literature review
    To identify quality concepts and potential indicators
    To find previous work on indicator validity

 ICD-9-CM coding review
    To ensure proper definition (correspondence between clinical concept and
     coding practice)

 Clinical panel reviews
    To refine indicator definition and risk groupings
    To establish face validity when minimal literature

 Empirical analyses
    To explore alternative definitions
    To assess nationwide rates, hospital variation, relationships among indicators
    To develop appropriate methods to account for differences in underlying risk
PSI objectives
 Considerable interest in medical errors
 Few tools exist for studying epidemiology of
  patient safety in the population
 Researchers, policy analysts, and public health
  agencies need passive surveillance systems that
  do not require electronic medical records, costly
  chart reviews, or incident reporting
 Providers need screening tools to identify
  potential problems and target QI activities
 Routinely collected administrative data may
  provide a mechanism for surveillance/screening
Literature review to find
candidate PSI indicators
 MEDLINE/EMBASE search guided by medical
  librarians at Stanford and NCPCRD (UK)
   Few examples described in peer reviewed journals
 Iezzoni et al.’s Complications Screening Program
  (CSP)
 Miller et al.’s Patient Safety Indicators
 Review of ICD-9-CM code book
 Codes from above sources were grouped into
  clinically coherent indicators with appropriate
  denominators
Literature review:
Coding and construct validity
 Validation studies of Iezzoni et al.’s CSP
   At least one of three validation studies (coders, nurses,
    or physicians) confirmed PPV at least 75%
   Nurse-identified process-of-care failures were more
    prevalent among flagged cases than among unflagged
    controls
 Other studies of coding validity
 Construct validity
   Explicit processes of care (e.g., medications)
   Implicit process of care
   Nurse staffing or skill mix; physician skill mix
Summary of construct validity
evidence from literature
Indicator                                                  Explicit process   Implicit process   Staffing
Complications of anesthesia
Death in low mortality DRGs                                                          +
Decubitus ulcer                                                                                     ±
Failure to rescue                                                                                  ++
Foreign body left during procedure
Iatrogenic pneumothorax
Selected infections due to medical care
Postoperative hip fracture                                        +                  +
Postoperative hemorrhage or hematoma                              ±                  +
Postoperative physiologic/metabolic derangements                                                    –-
Postoperative respiratory failure                                 ±                  +              ±
Postoperative thromboembolism                                     +                  +              ±
Postoperative sepsis                                                                                –-
Accidental puncture or laceration
Transfusion reaction
Postoperative abdominopelvic wound dehiscence
Birth trauma
Obstetric trauma – vaginal birth with instrumentation
Obstetric trauma – vaginal birth without instrumentation
Obstetric trauma – cesarean birth
ICD-9-CM coding consultant review

 All definitions were reviewed by an expert
  coding consultant from the American Health
  Information Management Association, with
  special attention to prior coding guidelines
 Central staff of ICD-9-CM were queried as
  necessary
 Definitions were refined as appropriate
Clinical panel review
 Intended to establish consensual validity
 Modified RAND/UCLA Appropriateness Method
 Physicians of various specialties/subspecialties, nurses,
  other specialized professionals (e.g., midwife, pharmacist)
 Potential indicators were rated by 8 multispecialty panels;
  surgical indicators were also rated by 3 surgical panels
 All panelists rated all assigned indicators (1-9) on:
    Overall usefulness
    Likelihood of identifying the occurrence of an adverse event
     or complication (i.e., not present at admission)
    Likelihood of being preventable (i.e., not an expected result
     of underlying conditions)
    Likelihood of being due to medical error or negligence (i.e.,
     not just lack of ideal or perfect care)
    Likelihood of being clearly charted in the medical record
    Extent to which indicator is subject to bias due to case mix
Evaluation framework
                Medical error and complications continuum

Medical error                                               Nonpreventable
                                                             Complications


 Pre-conference ratings and comments/suggestions
 Individual ratings returned to panelists with
  distribution of ratings and other panelists’
  comments/suggestions
 Telephone conference call moderated by PI and
  attended by note-taker, focusing on high-variability
  items and panelists’ suggestions (90-120 mins)
 Suggestions adopted only by consensus
 Post-conference ratings and comments/
  suggestions
    Example reviews
    Multispecialty panels
                         Postop Pneumonia                 Decubitus Ulcer
   Overall rating                          (5)                               (8)

   Not present on                                  (7)                       (8)
    admission

   Preventability (4)                 (4)                                    (8)

   Due to medical              (2)                                           (8)
    error (2)

   Charting by                                   (6)                       (7)
    physicians (6)

   Not biased (3)                    (3)                                   (7)
Final selection of indicators

  Retained indicators for which “overall
   usefulness” rating was “Acceptable” or
   “Acceptable-” :
    Median score 7-9
    Definite or indeterminate agreement
  Excluded indicators rated “Unclear,”
   “Unclear-,” or “Unacceptable”:
    Median score <7, OR
    At least 2 panelists rated the indicator in each of the
     extreme 3-point ranges
Candidate PSIs reviewed

  48 indicators reviewed in total
    37 reviewed by multispecialty panel
    15 of those reviewed by surgical panel
  20 “accepted” based on face validity
    2 dropped due to operational concerns
  17 “experimental” or promising indicators
  11 rejected
“Accepted” PSIs
Selected postoperative
   complications                          Other
 Postoperative thromboembolism            Complications of anesthesia
 Postoperative respiratory failure        Death in low mortality DRGs
 Postoperative sepsis                     Failure to rescue
 Postoperative physiologic and            Transfusion reaction
   metabolic derangements
 Postoperative abdominopelvic
   wound dehiscence                       Obstetric trauma and birth
                                            trauma
 Postoperative hip fracture
                                           Birth trauma – injury to neonate
 Postoperative hemorrhage or
   hematoma                                Obstetric trauma – vaginal
                                            delivery with instrument
Selected technical adverse events
                                           Obstetric trauma – vaginal
 Decubitus ulcer                           delivery without instrument
 Selected infections due to medical       Obstetric trauma – cesarean
   care                                     section delivery
Technical difficulty with procedures
 Iatrogenic pneumothorax
 Accidental puncture or laceration
 Foreign body left in during procedure
“Experimental” PSIs
   Aspiration pneumonia
   CABG after PTCA
   Decubitus ulcer in high risk patients
   In-hospital fractures possibly related to falls
   Intraoperative nerve compression injuries
   Malignant hyperthermia
   Postoperative acute myocardial infarction
   Postoperative iatrogenic complications – cardiac system
   Postoperative iatrogenic complications – nervous system
   Reopening of surgical site
   Suture of laceration
   Obstetric wound complications- cesarean section
   Obstetric wound complications- vaginal delivery
   Other obstetric complications
   Postpartum urinary tract infection
   Third or fourth degree obstetric laceration (JCAHO)
   Uterine rupture
 Estimated cases in 2000 (NIS)
 Romano et al., Health Affairs 2003
                                            Frequency ± Rate per
Indicator                                        95% CI   100

Postoperative septicemia                   14,055 ± 1060    1.091
Postoperative thromboembolism              75,811 ± 4,156   0.919
Postoperative respiratory failure            12,842 ± 938   0.359
Postoperative physiologic or metabolic        4,003 ± 419   0.089
derangement
Decubitus ulcer                          201,459 ± 10,104   2.130
Infection due to medical care              54,490 ± 2,658   0.193
Postoperative hip fracture                    5,207 ± 327   0.080
Accidental puncture or laceration          89,348 ± 5,669   0.324
Iatrogenic pneumothorax                    19,397 ± 1,025   0.067
Postoperative hemorrhage/hematoma            17,014 ± 968   0.206
 Impact of patient safety events in 2000
 (Zhan and Miller, JAMA 2003)
                                          Excess LOS      Excess
Indicator                                      (days)   charge ($)
Postoperative septicemia                         10.9     $57,700
Postoperative thromboembolism                     5.4      21,700
Postoperative respiratory failure                 9.1      53,500
Postoperative physiologic or metabolic            8.9      54,800
derangement
Decubitus ulcer                                   4.0      10,800
Selected infections due to medical care           9.6      38,700
Postoperative hip fracture                        5.2      13,400
Accidental puncture or laceration                 1.3       8,300
Iatrogenic pneumothorax                           4.4      17,300
Postoperative hemorrhage/hematoma                 3.9      21,400
  Estimated cases in 2000 (NIS)
  Romano et al., Health Affairs 2003
                                                  Frequency ± Rate per
Indicator                                              95% CI   100
Birth trauma                                     27,035 ± 5,674   0.667
Obstetric trauma –cesarean                          5,523 ± 597   0.593
Obstetric trauma - vaginal without             249,243 ± 12,570   8.659
instrumentation
Obstetric trauma - vaginal w instrumentation     60,622 ± 3,104   24.408
Failure to rescue                               267,541 ± 5,056   17.424
Postoperative abdominopelvic wound                  3,858 ± 289   0.193
dehiscence
Transfusion reaction                                   138 ± 49   0.0004
Complications of anesthesia                         5,305 ± 455   0.056
Death in low mortality DRGs                         5,912 ± 433   0.043
Foreign body left during procedure                  2,710 ± 204   0.008
  Impact of patient safety events in 2000
  (Zhan and Miller, JAMA 2003)
                                               Excess LOS       Excess
Indicator                                           (days)    charge ($)

Birth trauma                                     -0.1 (NS)     300 (NS)
Obstetric trauma –cesarean                             0.4        2,700
Obstetric trauma - vaginal without                    0.05     -100 (NS)
instrumentation

Obstetric trauma - vaginal w instrumentation          0.07          220

Postoperative abdominopelvic wound                     9.4       40,300
dehiscence
Transfusion reaction                              3.4 (NS)   18,900 (NS)
Complications of anesthesia                       0.2 (NS)        1,600
Foreign body left during procedure                     2.1       13,300
     Standard deviation of hospital
     effects: 1997 SID
    0.1                                                                           Postop hemorr/hemat
                                                                                  Postop physio/metab
   0.09
                                                                                  Selected infection
   0.08                                                                           Iatrogenic PTX
                                                                                  Anesth complications
   0.07                                                                           Postop AP wound dehis
                                                                                  Postop hip fracture
   0.06
                                                                                  Accid puncture/lac
   0.05                                                                           Postop resp failure
                                                                                  Postop DVT/PE
   0.04                                                                           Death low mort DRGs
                                                                                  Ob trauma –cesarean
   0.03                                                                           Postop sepsis
   0.02                                                                           Decubitus ulcer
                                                                                  Birth trauma
   0.01                                                                           Ob trauma - vag w/out
                                                                                  Failure to rescue
      0                                                                           Ob trauma - vag forc/vac
PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
     Signal standard deviation of
     hospital effects: 1997 SID
    0.1                                                                           Postop hemorr/hemat
                                                                                  Postop physio/metab
   0.09                                                                           Selected infection
                                                                                  Iatrogenic PTX
   0.08
                                                                                  Postop hip fracture
   0.07                                                                           Anesth complications
                                                                                  Postop AP wound dehis
   0.06                                                                           Postop resp failure
   0.05                                                                           Accid puncture/lac
                                                                                  Death low mort DRGs
   0.04                                                                           Ob trauma –cesarean
                                                                                  Postop DVT/PE
   0.03
                                                                                  Postop sepsis
   0.02                                                                           Decubitus ulcer
                                                                                  Birth trauma
   0.01                                                                           Ob trauma - vag w/out
                                                                                  Failure to rescue
      0
                                                                                  Ob trauma - vag forc/vac
PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
     Year-to-year correlation of hospital
     effects: 1996-97 Florida SID
   0.8                                                                            Postop hemorr/hemat
                                                                                  Postop physio/metab
   0.7                                                                            Selected infection
                                                                                  Iatrogenic PTX
   0.6                                                                            Postop hip fracture
                                                                                  Anesth complications
   0.5                                                                            Postop AP wound dehis
                                                                                  Postop resp failure
   0.4                                                                            Accid puncture/lac
                                                                                  Death low mort DRGs
   0.3                                                                            Ob trauma –cesarean
                                                                                  Postop DVT/PE

   0.2                                                                            Postop sepsis
                                                                                  Decubitus ulcer

   0.1                                                                            Birth trauma
                                                                                  Ob trauma - vag w/out
                                                                                  Failure to rescue
     0
                                                                                  Ob trauma - vag forc/vac
PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
Risk adjustment methods

  Must use only administrative data
  APR-DRGs and other canned packages
   may adjust for complications
  Final model
    DRGs (complication DRGs aggregated)
    Modified Comorbidity Index based on list
     developed by Elixhauser et al.
    Age, Sex, Age-Sex interactions
Hospital level variation:
Impact of bias, 1997 SID (summary)
       High Bias              Medium Bias                    Low Bias
Failure to rescue        Postop respiratory failure   Postop abdominopelvic
(44% change 2 deciles)   (11%)                        wound dehiscence (4%)
Accidental puncture or                                Obstetric trauma –
laceration (24%)         Postop hip fracture (8%)     cesarean birth (2%)
                         Iatrogenic pneumothorax      Postop hemorrhage or
Decubitus ulcer (26%)    (14%)                        hematoma (4%)

Postop thromboembolism   Postop physio/metabolic      Complications of
(14%)                    derangement (5%)             anesthesia (<1%)
                         Obstetric trauma – vaginal   Obstetric trauma – vaginal
Death in low mortality   birth with instrumentation   birth without
DRGs (13%)               (5%)                         Instrumentation (<1%)
                         Selected infections due to
Postop sepsis (11%)      medical care (10%)           Birth trauma (0%)
      PSIs loading on “general
      complications” (factor 1)
     0.7
     0.6
     0.5
     0.4
                                                                                                            Factor 1
     0.3
     0.2
     0.1
                                                                                                            Factor 2
     0.0




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PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
     PSIs loading on “perioperative
     complications” (factor 2)
    0.5

    0.4

    0.3

    0.2                                                                                     Factor 1

    0.1

    0.0
            Postop resp    Postop sepsis      Decubitus        Postop           Accid       Factor 2
   -0.1         fail                            ulcer       physio/metab     puncture/lac

   -0.2

   -0.3

   -0.4

   -0.5
PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
     PSIs loading on neither factor
     (<1% variance explained)
     0.5

     0.4

     0.3

     0.2                                                                          Factor 1

     0.1

     0.0
                       Foreign body left                    Postop wound dehis    Factor 2
     -0.1

     -0.2

     -0.3

     -0.4

     -0.5

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm
Indicator refinement:
Keeping measures current

 Regular ICD-9-CM    New evidence from
  and DRG coding       published sources
  updates              or user suggestions
   Examples            Examples
Indicator refinement
Coding updates
  Decubitus ulcer
    Added new codes for defining site of decubiti
  Postoperative wound dehiscence
    Due to procedure reassignment, added code for
     “Other gastric procedures” previously excluded.
  Craniotomy mortality
    Due to DRG restructuring, added exclusion for
     head trauma and new DRGs
Indicator refinement
Literature review
  Cesarean section – trend in tracking mode
   of delivery is to focus on women without
   strong indications for C/S (e.g., breech,
   prior cesarean), so ACOG-compatible
   version was implemented.
  Pediatric heart surgery – new definition
   developed by initial developer, excluding
   non-invasive procedures
  Failure to rescue – theoretical revisions
   suggested by initial developer (under
   review)
Indicator refinement
General user suggestions
  CHF, Angina and Hypertension –
   implemented consistent definition for
   “heart surgery” exclusions.
  AMI mortality – new indicator version
   excludes transfers (matching JCAHO).
  Using patient zip code instead of hospital
   zip codes for area level indicators.
Hosp A
Hosp B
Hosp C


Hosp D
Hosp E


Hosp F


Hosp G
Control charts trending reports on IQIs
        AHRQ Inpatient Quality Indicator                                                                                   AHRQ Inpatient Quality Indicator
        Observed Mortality 1999-Q2 2002                                                                                    Observed Mortality 1999-Q2 2002
                       Acute MI Mortality                                                                                                     CHF Mortality




                                                                  Observed Mortality Rate
 .14                                                                                                                 .08
 .12
 .10                                                                                                                 .06
                                                                 Acute MI Mortality                                                                                                       CHF Mortality
 .08
                                                                 UCL                                                 .04
 .06                                                                                                                                                                                      UCL

 .04                                                             Center = .0919                                      .02                                                                  Center = .0487
 .02
0.00                                                             LCL                                                0.00                                                                  LCL
           AP 199


           O 99


           AP 200


           O 00


           AP 200


           O 00


           AP 200




                                                                                                                              AP 199


                                                                                                                              O 99


                                                                                                                              AP 200


                                                                                                                              O 00


                                                                                                                              AP 200


                                                                                                                              O 00


                                                                                                                              AP 200
           JA


           J U 19


           J A 19


           J U 20


           J A 20


           J U 20


           J A 20




                                                                                                                              JA


                                                                                                                              J U 19


                                                                                                                              J A 19


                                                                                                                              J U 20


                                                                                                                              J A 20


                                                                                                                              J U 20


                                                                                                                              J A 20
             C




             C




             C




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              N 99


              L 00


              N 00


              L 01


              N 01




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                                                                                                                                 L 99


                                                                                                                                 N 99


                                                                                                                                 L 00


                                                                                                                                 N 00


                                                                                                                                 L 01


                                                                                                                                 N 01
              R 9




              R 0




              R 1




              R 2




                                                                                                                                 R 9




                                                                                                                                 R 0




                                                                                                                                 R 1




                                                                                                                                 R 2
              T 9




              T 0




              T 1




                                                                                                                                  T 9




                                                                                                                                  T 0




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                1




                2




                2




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                                                                                                                                   2




                                                                                                                                   2
                20




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                  02




                                                                                                                                     02
                                      2001 THCIC Observed Rate:.1006                                                                                      2001 THCIC Observed Rate: .0497
        DFWHC Data Initiative                                                                                              DFWHC Data Initiative

        January 2003                                                                                                       January 2003




        AHRQ Inpatient Quality Indicator                                                                                   AHRQ Inpatient Quality Indicator

        Observed Mortality 1999-Q2 2002                                                                                    Observed Utilization 1999-Q2 2002
                          CABG Mortality                                                                                                           VBAC
  .07                                                                                                                 .3

  .06
  .05                                                                                                                                                                                        VBAC
                                                                                    CABG Mortality                    .2
                                                                                                 Utilization Rate




  .04
  .03                                                                               UCL                                                                                                      UCL
                                                                                                                      .1
  .02                                                                               Center = .0371                                                                                           Center = .1866
  .01
 0.00                                                                               LCL                              0.0                                                                     LCL
            AP 199


            O 99



            AP 00


            O 00


            AP 200


            O 00


            AP 200
            JA


            JU 19


            JA 19



            JU 20


            JA 20


            JU 20


            JA 20




                                                                                                                              AP 99



                                                                                                                              O 99



                                                                                                                              AP 200



                                                                                                                              O 00



                                                                                                                              AP 200



                                                                                                                              O 00



                                                                                                                              AP 00
                                                                                                                              JA



                                                                                                                              J U 19



                                                                                                                              J A 19



                                                                                                                              J U 20



                                                                                                                              J A 20



                                                                                                                              J U 20



                                                                                                                              J A 20
             C




             C




             C




                                                                                                                                C




                                                                                                                                C




                                                                                                                                C
              N


              L 99


              N 99



              L 00


              N 00


              L 01


              N 01
               R 9




               R 0




               R 1




               R 2




                                                                                                                                 N



                                                                                                                                 L 99



                                                                                                                                 N



                                                                                                                                 L 00



                                                                                                                                 N 00



                                                                                                                                 L 01



                                                                                                                                 N 01
               T 9




               T 0




               T 1




                                                                                                                                 R 9




                                                                                                                                 R 0




                                                                                                                                 R 1




                                                                                                                                 R 2
                                                                                                                                  T




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                                                                                                                                  T
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                2




                2
                2




                20




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                                                                                                                                    20
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                                                                                                                                      02
                                                                                                                                       99
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                                                                                                                                        0




                                                                                                                                        1
        DFWHC Data Initiative         2001 THCI C Observed Rate: .0386                                                                                        2001 THCI C Observed Rate: .1506
                                                                                                                           DFWHC Data Initiative
        January 2003                                                                                                       January 2003
                                                      AHRQ Prevention Quality Indicators
                                    Congestive Heart Failure Admission Rate - 2000
                                                                                                                 2000                                       Rates per 100,000 Population
                                                                                                                                 Numerator    Denominator                  Risk       Confidence           Stat.
                                                                                                          County                 (Outcome)    (Population) Observed Adjusted         Interval (95%)        Sig.
                                                                                                          State of Texas               60,879    14,959,865       406.9       470.2
                                                                                                          BOSQUE                           36        13,086       275.1         0.0         ( 0.0, 0.0 )
                                                                                                          CAMP                             64         8,578       746.1       608.6 ( 444.0, 773.2 )        o
                                                                                                          COLLIN                          617       357,255       172.7       376.4 ( 356.3, 396.5 )        +
                                                                                                          COMANCHE                         37        10,638       347.8        54.6      ( 10.2, 99.0 )     +
                                                                                                          COOKE                            47        26,342       178.4        82.4    ( 47.7, 117.1 )      +
                                                                                                          DALLAS                        5,705     1,620,396       352.1       479.7 ( 469.1, 490.3 )        o
                                                                                                          DELTA                            48         3,997     1,201.0       983.5 ( 677.6, 1289.4 )       -
                                                                                                          DENTON                          736       315,985       232.9       453.4 ( 430.0, 476.8 )        o
                                                                                                          EASTLAND                         52        13,855       375.3        80.6    ( 33.3, 127.9 )      +
                                                                                                          ELLIS                           332        78,059       425.3       482.0 ( 433.4, 530.6 )        o
                                                                                                          ERATH                           105        24,316       431.8       358.7 ( 283.6, 433.8 )        +
                                                                                                          FANNIN                          170        23,947       709.9       565.0 ( 470.1, 659.9 )        o
                                                                                                          FRANKLIN                         56         7,173       780.7       580.6 ( 404.8, 756.4 )        o
                                                                                                          GRAYSON                         611        82,867       737.3       631.6 ( 577.7, 685.5 )        -
                                                                                                          HAMILTON                         22         6,340       347.0         0.0         ( 0.0, 0.0 )
                                                                                                          HENDERSON                       386        56,268       686.0       547.2 ( 486.2, 608.2 )        -
                                                                                                          HILL                            221        24,181       913.9       734.0 ( 626.4, 841.6 )        -
                                                                                                          HOOD                            151        31,504       479.3       362.5 ( 296.1, 428.9 )        +
                                                                                                          HOPKINS                          36        23,595       152.6        39.3      ( 14.0, 64.6 )     +
                                                                                                          HUNT                            365        56,718       643.5       616.2 ( 551.8, 680.6 )        -
                                                                                                          JACK                              4         6,414        62.4         0.0         ( 0.0, 0.0 )
                                                                                                          JOHNSON                         511        91,560       558.1       597.6 ( 547.7, 647.5 )         -
                                                                                                          KAUFMAN                         365        51,311       711.4       730.0 ( 656.3, 803.7 )         -
                                                                                                          LAMAR                           299        36,064       829.1       707.1 ( 620.6, 793.6 )         -
                                                                                                          MONTAGUE                         20        14,472       138.2         0.0         ( 0.0, 0.0 )
                                                                                                          MORRIS                           53         9,700       546.4       349.8 ( 232.3, 467.3 )        +
                                                                                                          NAVARRO                         175        32,900       531.9       418.6 ( 348.8, 488.4 )        o
Risk Adjusted Rates per              Named counties without shading have a Risk Adjusted rate of zero.    PALO PINTO                       22        20,021       109.9         0.0         ( 0.0, 0.0 )
100,000 Population                                                                                        PARKER                          142        64,836       219.0       257.3 ( 218.3, 296.3 )        +
                                                                                                          RAINS                            52         6,933       750.1       633.8 ( 447.0, 820.6 )        o
        1 to 117.0                                                                                        ROCKWALL                         61        31,548       193.4       288.5 ( 229.3, 347.7 )        +
                                                                                                          SOMERVELL                         9         4,734       190.1        97.8      ( 8.8, 186.8 )     +
        117.1 to 283.2                    08 Congestive Heart Failure Admission Rate                      STEPHENS                         13         7,201       180.5         0.0         ( 0.0, 0.0 )
                                          Congestive heart failure (CHF) can be controlled in an          TARRANT                       3,364     1,055,074       318.8       438.1 ( 425.5, 450.7 )        +
        283.3 to 399.2                                                                                    TITUS                            85        19,891       427.3       380.3 ( 294.8, 465.8 )        +
                                          outpatient setting for the most part; however, the disease is
                                          a chronic progressive disorder for which some                   VAN ZANDT                       185        36,462       507.4       358.8 ( 297.4, 420.2 )        +
        399.3 to 565.2                                                                                    WISE                             40        35,620       112.3       134.8    ( 96.7, 172.9 )      +
                                          hospitalizations are appropriate.
                                                                                                          WOOD                            270        28,545       945.9       705.7 ( 608.6, 802.8 )        -
       > 565.2                                                                                            YOUNG                            25        13,364       187.1         0.0         ( 0.0, 0.0 )
       DI Hospitals                                                                                       Texas Hospital Inpatient Discharge Public Use Date File, FY2000. Texas Health Care Information
                                                                                                          Council, Austin, Texas. December, 2001.

                                                                                                          + = County’s RA rate significantly lower than State RA rate
                                                                                                          - = County’s RA rate significantly higher
                                                                                                          o = No statistical difference


© 2003, Dallas-Fort Worth Hospital Council - Data Initiative                                                                                                   For Hospital Internal Use Only - January, 2003
A case study of obstetric trauma
Dallas-Fort Worth Hospital Council
                             1999     1999     1999      1999      1999      1999      1999              1999            S ta t
P a rticipa ting H ospita ls N um     Den      Obs       R iskAdj E xp       LoCI      H iCI              CI             S ig
State of Texas (THCIC PUDF)*      831   305519      2.72      2.72      2.72      2.44       3.00
Hosp   A                            6     3255      1.84       1.82      2.75     -0.91       4.55 ( 0.00, 4.55 )          o
Hosp   B                            3     1324      2.27       2.27      2.72     -2.00       6.54 ( 0.00, 6.54 )          o
Hosp   C                           55     1815    30.30       30.28      2.72    26.63       33.94 ( 26.63, 33.94 )         -
Hosp   D                            1     1427      0.70       0.66      2.89     -3.47       4.79 ( 0.00, 4.79 )          o
                             2000     2000     2000      2000       2000      2000      2000            2000             S ta t
P a rticipa ting H ospita ls N um     Den      Obs       R iskAdj E xp        LoCI      H iCI             CI             S ig
State of Texas (THCIC PUDF)*      831   326095      2.55       2.55      2.55      2.28       2.82
Hosp   A                            3     3303      0.91       0.90      2.58     -1.81       3.61 ( 0.00, 3.61 )          o
Hosp   B                            2     1604      1.25       1.27      2.51     -2.61       5.14 ( 0.00, 5.14 )          o
Hosp   C                           45     1752    25.68       25.66      2.55    21.94       29.38 ( 21.94, 29.38 )         -
Hosp   D                            2     1484      1.35       1.36      2.54     -2.68       5.39 ( 0.00, 5.39 )          o
                             2001     2001     2001      2001       2001      2001      2001            2001             S ta t
P a rticipa ting H ospita ls N um     Den      Obs       R iskAdj E xp        LoCI      H iCI             CI             S ig
State of Texas (THCIC PUDF)*      763   333101      2.29       2.29      2.29      2.02       2.56
Hosp   A                            8      3099      2.58       2.58      2.29     -0.21       5.37 ( 0.00,    5.37 )      o
Hosp   B                            4      1553      2.58       2.58      2.29     -1.37       6.53 ( 0.00,    6.53 )      o
Hosp   C                           53      1915     27.68      27.66      2.29     24.11      31.22 ( 24.11,   31.22 )     -
Hosp   D                            1      1618      0.62       0.59      2.40     -3.29       4.46 ( 0.00,    4.46 )      o
Confusion about coding
Birth Trauma―Injury to Neonate
Numerator:
        Discharges with ICD-9-CM codes for birth trauma in any diagnosis field per 1,000 liveborn births.

Birth Trauma
ICD-9-CM diagnosis codes:
7670    Subdural and cerebral hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
7673    Injuries to skeleton (excludes clavicle)
7674    Injury to spine and spinal cord               Code Index under “Molding, head”
7677    Other cranial and peripheral nerve injuries
7678    Other specified birth trauma                  lists 767.3
7679    Birth trauma, unspecified




                             ICD-9-CM Coding Manual Definition
767.3 Other Injuries To Skeleton Due To Birth Trauma
Fracture of: long bones, skull
767.4 Injury To Spine And Spinal Cord Due To Birth Trauma
{Dislocation} {Fracture} {Laceration} {Rupture} of spine or spinal cord due to birth trauma
Input from review of medical records
PSI                Issue
Postoperative      Documentation states that the denominator excludes all surgical
pulmonary          cases with a secondary procedure code of 38.7 (Insertion of vena
embolism (PE) or   cava filter) when performed on the day of or prior to the principal
deep vein          procedure. In some surgical cases, 38.7 was the only surgical
thrombosis (DVT)   procedure (so not secondary). That code drove the DRG to be a
                   surgical case. The denominator should exclude cases with 38.7 as
                   the only surgical (major operating room) procedure.
Post Operative Hip This measure seems to include fractures that occurred prior to
Fracture           admission. Example: the patient experiences a TIA or Stroke, fell,
                   fractured hip, and was admitted for surgical repair. The Fx Hip was
                   coded in the secondary diagnosis category, but did not occur in the
                   facility. Additionally, some were transfers from other facilities.
Iatrogenic         Iatrogenic Pneumothorax appears to be very coder dependent.
Pneumothorax       Some patients who have stiff lungs with scarring, undergo
                   therapeutic thoracentesis, and some air is left in the scarred area
                   (but no collapse), are coded as pneumothoraces.
Post Operative     There may be an issue with this indicator related to coding blood
Hemorrhage or      loss during vs. after surgery as a hemorrhage.
Hematoma
Decubitus Ulcer    This indicator is designed to exclude patients transferred from Long
                   Term Care. Some hospitals admit these patients through the ED;
                   they receive an admit code of ED instead of transfer from LTC and
                   are not excluded from the population.
Ongoing validation through use

                      Data          Quality
                      Problem       Problem

                         Quality Indicator
                         Triggers Concern
                     (Health System Symptom)

     Differential diagnosis           Treatment
     Data issue?                      Correct data
     Health care quality              Implement quality
     deficiency?                      improvements
     Indicator limitation?            Revise indicator definitions
User activity (2002-current)
 Web Site Statistics
   75,000+ Unique computers
   19,000 Repeat visits
   145,000 File downloads (software and documentation,
    user guides, technical reports)
   IQIs and PSIs more popular than PQIs
 Hotline
   1,200 User support requests answered
   25% from Hospitals, 15% Hospital Associations
   40% related to PSIs
Measurement soup:
Need for more research
 Many indicators touted to identify possible quality
  concerns at any level – consumer, provider, state,
  nation
 AHRQ QIs as screening tool: What exactly does
  this mean? When is this tool cost-effective?
   Sequence of “tests” – where do AHRQ QIs fit?
   Which indicators are more valid under what
    circumstances?
   When is it worth moving straight to an improvement
    effort versus conducting supplementary data analyses?
 Real litmus test for measures… evidence of
  quality improvement
More information on AHRQ QIs
   E-mail: support@qualityindicators.ahrq.gov
   Website: http://qualityindicators.ahrq.gov
   QI documentation and software available on website
   Listserve sign-up available on website
   Support is conducted under contract by Battelle
    Memorial Institute, Stanford University and
    University of California at Davis
   Research collaborations: psromano@ucdavis.edu
 PQI Rates
    PQI                                                           Per 100,000                Area SD
    DIABETES SHORT TRM COMPLICATION                                   46.7                     35.3
    PERFORATED APPENDIX                                          32.5 (per 100)                16
    DIABETES LONG TERM COMPLICATION                                  112.6                    67.6
    PEDIATRIC ASTHMA                                                  164.6                   182.5
    CHRONIC OBSTRUCTIVE PULMONARY
       DISEASE                                                        344.3                   277.7
    PEDIATRIC GASTROENTERITIS                                         112.3                   137.8
    HYPERTENSION                                                      50.2                    49.3
    CONGESTIVE HEART FAILURE                                          502.8                   250.8
    LOW BIRTH WEIGHT                                              6.0 (per 100)                3.8
    DEHYDRATION                                                       174.9                   131.2
    BACTERIAL PNEUMONIA                                               503.9                   306.8
    URINARY INFECTION                                                 158.5                   97.7
    ANGINA                                                            82.3                    78.0
    DIABETES UNCONTROLLED                                              27.2                   33.9
    ADULT ASTHMA                                                       98.4                   79.2
    LOWER EXTREMITY AMPUTATION                                         37.5                   28.2

Source: SID, 2002. AHRQ Prevention Quality Indicators SAS Software Version 2.1 Revision 4.
  IQI Rates
IQI                                                                        Per 100           Provider SD
IN-HOSP MORT ESOPHAGEAL RESECTION                                           13.29               29.76
IN-HOSP MORT PANCREATIC RESECTION                                            9.39               23.19
IN-HOSP MORT PEDIATRIC HEART SURG                                            7.04               19.44
IN-HOSP MORT AAA REPAIR                                                     17.11               23.84
IN-HOSP MORT CABG                                                            3.70               3.84
IN-HOSP MORT CRANIOTOMY                                                      9.30               11.73
IN-HOSP MORT HIP REPLACEMENT                                                 0.48               3.24
IN-HOSP MORT AMI                                                            15.30               14.69
IN-HOSP MORT CHF                                                             5.54               8.33
IN-HOSP MORT STROKE                                                         11.03               10.31
IN-HOSP MORT GI HEMORRHAGE                                                   3.40               6.67
IN-HOSP MORT HIP FRACTURE                                                    3.96               8.17
IN-HOSP MORT PNEUMONIA                                                       8.02               6.38
CESAREAN SECTION DELIVERY                                                   23.28               8.90
PRIMARY CESAREAN SECTION                                                    14.44               7.24
VAGINAL BIRTH AFTER C-SECTION                                               16.32               12.38
LAPAROSCOPIC CHOLECYSTECTOMY                                                74.22               19.16
INCIDENTAL APPENDECTOMY                                                      2.66               4.60
BI-LATERAL CATHETERIZATION                                                   9.49               13.35

Source: SID, 2002. AHRQ Inpatient Quality Indicators SAS Software Version 2.1, Revision 4.
 PSI Rates
 PSI                                                                      Per 1000            Provider SD
 Complications Of Anesthesia                                                0.72                 1.77
 Death In Low Mortality Drgs                                                3.03                 25.05
 Decubitus Ulcer                                                            27.61                37.23
 Failure To Rescue                                                         110.82                91.49
 Foreign Body Left In During Proc                                           0.06                 0.22
 Iatrogenic Pneumothorax                                                    0.60                 1.83
 Infection Due To Medical Care                                              2.25                 7.71
 Postoperative Hip Fracture                                                 0.85                 16.89
 Postoperative Hemorrhage Or Hematoma                                       2.14                 16.84
 Postoperative Physio Metabol Derangmnt                                     1.28                 18.18
 Postoperative Respiratory Failure                                          5.89                 33.94
 Postoperative PE Or DVT                                                    9.11                 29.85
 Postoperative Sepsis                                                       16.79                50.25
 Postoperative Wound Dehiscence                                             1.87                 4.34
 Accidental Puncture/Laceration                                             2.22                 2.68
 Transfusion Reaction                                                       0.005                0.055
 Birth Trauma                                                               6.13                 21.66
 Ob Trauma - Vaginal with Instrument                                       200.13               138.28
 Ob Trauma - Vaginal without Instrument                                     78.32                63.85
 Ob Trauma – Cesarean Delivery                                              5.01                 14.10

Source: SID, 2002. AHRQ Inpatient Quality Indicators SAS Software Version 2.1, Revision 3a.

				
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