The AHRQ Quality Indicators
Melanie Chansky, MAA, Research Scientist
Battelle Memorial Institute
December 4, 2008
The Department of Health & Human Services and the AHRQ logos are located above the title of the presentation. Throughout the rest of the presentation, the Department of Health & Human Services and the AHRQ logos are located in the upper left corner.
Slide 2
Overview
- The QIs and QI Modules
- NQF-Approved Measures
- Public Reporting
- Validation Efforts
- QI Tools
1. The QIs and QI Modules is highlighted on this slide.
Slide 3
Quality Indicators & HCUP
• HCUP: Partnership among States, industry, and AHRQ
• Uniform database for cross-State studies; includes clinical, demographic, and resource use information
• Represents all inpatient discharge data from participating States-represents approximately 90 percent of all discharges
Slide 4
Background on the QIs
• Developed through contract with UCSF-Stanford Evidence-based Practice Center
• Use existing hospital discharge data, based on readily available data elements
• Incorporate a range of severity adjustment methods, including APR-DRGs and comorbidity groupings
• Current modules: Prevention, Inpatient, Patient Safety, Pediatric and Neonatal
Slide 5
Example Indicator Evaluation
This slide contains a visual explanation of defining and evaluating a quality indicator. Literature review and user data is the basis for initial empirical analyses and definition, which leads to the panel evaluation. After the panel evaluation, further empirical analysis is conducted and the definition is redefined, leading to additional review and establishment of a final definition.
Slide 6
Current QI Modules
Current QI Modules are:
• Inpatient QIs
• Mortality Utilization Volume
• Pediatric QIs
• Prevention QIs (area level)
• Avoidable Hospitalizations
• Other Avoidable Conditions
• Neonatal QIs
• Patient Safety QIs
• Complications
• Unexpected Death
Slide 7
Prevention Quality Indicators
• The original QI module (released 2001)
• Focus on quality of care for ambulatory care-sensitive conditions
Slide 8
List of PQIs
• Diabetes, short-term complications
• Perforated Appendix
• Diabetes, long-term complications
• Chronic Obstructive Pulmonary Disease
• Hypertension
• Congestive Heart Failure
• Low Birth Weight
• Dehydration
• Bacterial Pneumonia
• Urinary Infections
• Angina without Procedure
• Uncontrolled Diabetes
• Adult Asthma
• Lower Extremity Amputations among Patients with Diabetes
Slide 9
Inpatient Quality Indicators
• Second set of QIs (released 2002)
• Focus on quality of care inside hospitals
• Includes measures of inpatient mortality, utilization, and volume
Slide 10
List of IQIs
Mortality Rates for Medical Conditions:
• Acute Myocardial Infarction
• AMI, without transfer cases
• Congestive Heart Failure
• Stroke
• Gastrointestinal Hemorrhage
• Hip Fracture
• Pneumonia
Mortality Rates for Surgical Procedures:
• Esophageal Resection
• Pancreatic Resection
• Abdominal Aortic Aneurysm Repair
• Coronary Artery Bypass Graft
• Percutaneous Transluminal Coronary Angioplasty (PTCA)
• Carotid Endarterectomy
• Craniotomy
• Hip Replacement
Slide 11
List of IQIs (cont'd.)
Hospital-Level Procedure Utilization Rates:
• Cesarean Section Delivery
• Primary Cesarean Delivery
• Vaginal Birth After Cesarean (VBAC), uncomplicated
• VBAC, all
• Laparoscopic cholecystectomy
• Incidental Appendectomy in the elderly
• Bi-lateral cardiac catheterization
Area-Level Utilization Rates:
• Coronary Artery Bypass Graft
• PTCA
• Hysterectomy
• Laminectomy or spinal fusion
Slide 12
List of IQIs (cont'd.)
Volume of Procedures:
• Esophageal Resection
• Pancreatic Resection
• Abdominal Aortic Aneurysm Repair
• Coronary Artery Bypass Graft
• PTCA
• Carotid endarterectomy
Slide 13
Patient Safety Indicators
• Third set of QIs (released 2003)
• Focus on potential adverse events occurring during hospitalization
Slide 14
List of PSIs
Hospital-Level:
• Complications of anesthesia
• Death in Low Mortality DRGs
• Decubitus Ulcer
• Failure to Rescue
• Foreign Body Left in During Procedure
• Iatrogenic Pneumothorax
• Selected Infections Due to Medical Care
• Postoperative Hip Fracture
• Postoperative Hemorrhage or Hematoma
• Postoperative Physiologic or Metabolic Derangements
• Postoperative Respiratory Failure
• Postoperative Pulmonary Embolism or Deep Vein Thrombosis
• Postoperative Sepsis
• Postoperative Would Dehiscence in Abdominopelvic Surgical Patients
• Accidental Puncture or Laceration
• Transfusion Reaction
• Birth Trauma - Injury to Neonate
• Obstetric Trauma - Vaginal Delivery with Instrument
• Obstetric Trauma - Vaginal Delivery Without Instrument
• Obstetric Trauma - Cesarean Delivery
Slide 15
List of PSIs (cont'd.)
Area-Level:
• Foreign Body Left in During Procedure
• Iatrogenic Pneumothorax
• Selected Infections Due to Medical Care
• Postoperative Would Dehiscence in Abdominopelvic Surgical Patients
• Accidental Puncture and Laceration
• Transfusion Reaction
• Postoperative Hemorrhage or Hematoma
Slide 16
Pediatric Quality Indicators
• Fourth set of QIs (released 2006)
• Measures similar to other modules, but focus on pediatric population
Slide 17
List of PDIs
Hospital-Level:
• Accidental Puncture or Laceration
• Decubitus Ulcer
• Foreign Body Left in During Procedure
• Iatrogenic Pneumothorax in Neonates at Risk
• Iatrogenic Pneomothorax in Non-Neonates
• Pediatric Heart Surgery Mortality
• Pediatric Heart Surgery Volume
• Postoperative Hemorrhage or Hematoma
• Postoperative Respiratory Failure
• Postoperative Sepsis
• Postoperative Would Dehiscence
• Selected Infections Due to Medical Care
• Transfusion Reaction
Slide 18
List of PDIs (cont'd.)
Area-Level:
• Asthma Admission Rate
• Diabetes Short-Term Complications Rate
• Gastroenteritis Admission Rate
• Perforated Appendix Admission Rate
• Urinary Tract Infection Admission Rate
Slide 19
Advantages
Public Access
• All development documentation and details on each indicator available on Web site www.qualityindicators.ahrq.gov
• Software available to download at no cost
• Standardized indicator definitions
• Can be used with any administrative data: HCUP, MEDPAR,* State data sets, payer data, hospital internal data
• Hospitals can replicate data
*Medicare Provider Analysis and Review
Slide 20
Advantages (cont'd)
Scope
• Over 100 individual measures
• Each measure can be stratified by other variables including patient race, age, sex, provider, geographic region
• Include priority populations and areas: Child health, women's health (pregnancy and child-birth), diabetes, hypertension, ischemic heart disease, stroke, asthma, patient safety, preventive care
• Focus on acute care but do cross over to community and outpatient care delivery settings
Slide 21
Advantages (cont'd)
• Harmonization of measures
• Indicator maintenance, updates
• Tools and technical assistance
• National benchmarks
• National Healthcare Quality Report
• National Healthcare Disparities Report
• HCUPnet
Slide 22
Current Limitations & Challenges
• Outcomes data less actionable than processes
• Lack clinical detail
• Risk adjustment challenges
• Accuracy hinges on accuracy of documentation and coding
• Data potentially subject to gaming
• Time lag
Slide 23
Overview
- The QIs and QI Modules
- NQF-Approved Measures
- Public Reporting
- Validation Efforts
- QI Tools
2. NQF-Approved Measures is highlighted on this slide.
Slide 24
National Quality Forum Endorsement
• Suitable for comparative reporting and quality improvement
• Evaluated for importance, scientific acceptability, usability, and feasibility
• An effort to harmonize and standardize measures among developers
• AHRQ Quality Indicators
• 14 Prevention Quality Indicators (PQIs)
• 12 Inpatient Quality Indicators (IQIs)
• 8 Patient Safety Indicators (PSIs)
• 9 Pediatric Quality Indicators (PDIs)
Slide 25
National Quality Forum Endorsement
This slide contains a chart listing several Inpatient Quality Indicator (IQI) numbers and their corresponding label.
IQI #01: Esophageal Resection Volume
IQI #02: Pancreatic Resection Volume
IQI #04: Abdominal Aortic Aneurysm (AAA) Repair Volume
IQI #08: Esophageal Resection Mortality
IQI #09: Pancreatic Resection Mortality
IQI #11: Abdominal Aortic Aneurysm (AAA) Repair Mortality
IQI #16: CHF Mortality
IQI #17: Acute Stroke Mortality
IQI #19: Hip Fracture Mortality
IQI #20: Pneumonia Mortality
IQI #24: Incidental Appendectomy in the Elderly
IQI #25: Bilateral Catheterization
Slide 26
National Quality Forum Endorsement
This slide contains a chart listing Patient Safety Indicator (PSI) numbers and their corresponding label.
PSI #02: Death in Low Mortality DRGs
PSI #04: Death Among Surgical Inpatients With Treatable Serious Complications
PSI #05: Foreign Body
PSI #06: Iatrogenic Pneumothorax
PSI #12: Postoperative DVT or PE
PSI #14: Postoperative Wound Dehiscence
PSI #15: Accidental Puncture or Laceration
PSI #16: Transfusion Reaction
Slide 27
National Quality Forum Endorsement
This slide contains a chart listing Pediatric Quality Indicator (PDI) numbers and their corresponding label.
PDI #01: Accidental Puncture or Laceration
PDI #02: Decubitus Ulcer
PDI #03: Foreign Body
PDI #05: Iatrogenic Pneumothorax
PDI #06: Pediatric Heart Surgery Mortality
PDI #07: Pediatric Heart Surgery Volume
PDI #11: Postoperative Wound Dehiscence
PDI #13: Transfusion Reaction
NQI* #02: Blood Stream Infection in Neonates*
*NQI- Neonate Quality Indicator
*Endorsement pending
Slide 28
Composite Measures
• Inpatient Quality Indicators
• Mortality for Selected Procedures
• Mortality for Selected Conditions
• Patient Safety Indicators
• Overall Safety
• Pediatric Quality Indicators
• Overall Safety
• Volume-Outcome
• Resection, AAA repair, pediatric heart
Slide 29
Overview
- The QIs and QI Modules
- NQF-Approved Measures
- Public Reporting
- Validation Efforts
- QI Tools
3. Public Reporting is highlighted on this slide.
Slide 30
General Uses of the AHRQ QIs
• Hospital Quality Improvement - Internal and External
- Individual hospitals and health care systems
- Hospital association member-only reports
• National, State, and Regional Reporting
- National Healthcare Quality/Disparities Reports
- Commonwealth Fund's Health Performance Initiative
• Pay-for-Performance by Hospital
- CMS/Premier Demo
- Anthem of Virginia
• Hospital Profiling
- Blue Cross/Blue Shield of Illinois
• Comparative Public Reporting
Slide 31
12 States Use QIs for Public Hospital Reporting
This slide contains a map of the continental United States with the Oregon, Utah, Colorado, Texas, Iowa, Wisconsin (parts of the state), Ohio, Kentucky, Florida, New York, Vermont, and Massachusetts highlighted in orange, to indicate the states that use QIs for public hospital reporting.
Slide 32
Overview
- The QIs and QI Modules
- NQF-Approved Measures
- Public Reporting
- Validation Efforts
- QI Tools
4. Validation Efforts is highlighted on this slide.
Slide 33
Validation Studies
AHRQ sponsored
• Phase I
• Simple Review
• In-depth Review
• Supplemental Review
• Phase II
• Currently Recruiting
Slide 34
Validation Pilot, Phase I
Pilot Objectives:
• Gather evidence on the scientific acceptability of the PSIs
• Medical record reviews, data analysis, clinical panels, evidence reviews
• Consolidate the evidence base
• Improve guidance on the interpretation and use of the data
• Evaluate potential refinements to the specifications
Slide 35
Validation Pilot, Phase I
Conclusions
• The five evaluated PSIs have variable PPVs, which should be considered in selecting indicators for public reporting and pay-for-performance
• Pilot-tested a mechanism for supporting ongoing validation work, which can be applied to estimate sensitivity in Phase II
Slide 36
Validation Pilot, Phase II
Validation Pilot, Phase II
• Pending OMB review
• Estimate sensitivity (false negatives) in addition to PPV (false positives)
• 16 organizations have indicated an interest in participating in Phase II
• Encourage hospitals in HCUP partner States to participate
Slide 37
Other Validation Studies
• University HealthSystem Consortium - Patient Safety Indicators
Slide 38
Overview
- The QIs and QI Modules
- NQF-Approved Measures
- Public Reporting
- Validation Efforts
- QI Tools
5. QI Tools is highlighted on the slide.
Slide 39
Windows Quality Indicators Software (WinQI)
• Allows users to run AHRQ QI analysis with data they provide
• Current users: federal govt., state govt.,hospital associations, individual hospitals, researchers
• Software enables calculation of QI rates as well as generation of reports
Slide 40
Preventable Hospitalization Costs: A County-Level Mapping Tool
The PHC mapping tool is a QI software application designed to help organizations to:
• Better understand geographical patterns of potentially preventable hospital admission rates for selected health problems.
• Allocate resources more effectively by calculating potential cost savings if admission rates are reduced.
Slide 41
Main Functions of the PHC Mapping Tool
• Creation of maps that show the rates of hospital admission for selected health problems on a county-by-county basis.
• Calculation of potential cost savings that may occur if the number of hospital admissions for selected health problems in each county is reduced.
• Ability to place additional information about local populations onto maps to indicate the number of persons who are at greatest risk for those health problems in each county.
Slide 42
Sample Map for PQI 14, Uncontrolled Diabetes Admission
This slide contains a multi-color county-level map of California, showing uncontrolled diabetes admission in 2001 (PQI 14). The scale of the map is highlighted with the following explanation: Data Quintiles. Green is the lowest 20%, or lowest rates. Red is the highest 20%, or highest rates. The specific rate of readmission (per 10,000 people) is superimposed on the county in the map.
Slide 43
Excel Spreadsheet Produced by PHC, with Cost Savings Estimate
This slide contains a screen shot of the excel spreadsheet produced by the Preventable Hospitalization Cost mapping tool of the map on the previous slide. In this table, it is noted that the Inyo county risk-adjusted rate for PQI 14 is significantly higher than the State's. The last column estimates cost savings given a 10 percent reduction in the numerator.
Slide 44
Sample Map for PQI 14, Population Data Added
This slide contains the same multi-color county-level map of California, showing uncontrolled diabetes admission in 2001 (PQI 14), as slide 42. The only difference is the addition of population data, which is 'broken into three groups. Stick figures superimposed on map to represent relative population size' for persons over age 18.
Slide 45
For More Information.
Quality Indicators:
• Web site: http://qualityindicators.ahrq.gov/
• QI documentation and software are available
• E-mail: support@qualityindicators.ahrq.gov
• Support Phone: (888) 512-6090 (voicemail)
• Staff: Mamatha.Pancholi@ahrq.hhs.gov
Slide 46
Presenter Contact Info
Melanie Chansky, Battelle
Phone: 703-248-1659
Email: chanskym@battelle.org
Slide 47
Questions?
Slide 48
Thank You!
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