1. Session 3C: Overview of the AHRQ Quality Indicators Thursday, September 27, 2007 3:30 pm to 5:00 pm ET

2. Session Overview Research, rational and processes used to develop indicators Research, rational and processes used to develop indicators – Development Process: Neonatal, Patrick Romano – Establishing the Validity of the AHRQ QI/NQF process, Pat Zrelak Tools for the interpretation and use Tools for the interpretation and use – QI Mapping Tool, Melanie Chansky – Use of the QI’s, Jeff Geppert Information on how ICD-9 coding practices impacts the indicators Information on how ICD-9 coding practices impacts the indicators – Expectations of next release, Sheryl Davies

3. AHRQ Quality Indicators Provides a tool utilizing data collected routinely in the delivery of hospital care to: Provides a tool utilizing data collected routinely in the delivery of hospital care to: – identify potential quality concerns – identify areas that need further study and investigation – track changes over time Facilitate decision making by federal, state and local policy makers; healthcare leaders; clinicians; etc. Facilitate decision making by federal, state and local policy makers; healthcare leaders; clinicians; etc. Variety of uses Variety of uses Maximizes existing resources Maximizes existing resources

4. Structure of AHRQ QI Definitions based on Definitions based on – ICD-9-CM diagnosis and procedure codes – Often along with DRG, MDC, sex, age, procedure dates, admission type, admission source, discharge disposition Numerator is the number of cases “flagged” with the outcome of interest Numerator is the number of cases “flagged” with the outcome of interest Denominator is the population at risk Denominator is the population at risk The observed rate is numerator / denominator The observed rate is numerator / denominator Volume counts for selected procedures Volume counts for selected procedures

5. Four QI Modules Prevention Quality Indicators (PQI) Prevention Quality Indicators (PQI) – Identify “ambulatory care sensitive conditions” (ACSCs) in adult populations good outpatient care can potentially prevent the need for hospitalization good outpatient care can potentially prevent the need for hospitalization early intervention can prevent complications or more severe disease early intervention can prevent complications or more severe disease

6. Prevention Quality Indicators (PQI) Adult Asthma Adult Asthma Angina w/o Procedure Angina w/o Procedure Bacterial Pneumonia Bacterial Pneumonia Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Dehydration Dehydration Diabetes Short Term complications Diabetes Short Term complications Diabetes Long-term complications Diabetes Long-term complications Hypertension Hypertension Low Birth Weight Low Birth Weight Rate of Lower- extremity Amputation among people with diabetes Rate of Lower- extremity Amputation among people with diabetes Perforated Appendix Perforated Appendix Urinary Tract Infection Urinary Tract Infection Uncontrolled Diabetes Uncontrolled Diabetes Congestive Heart Failure Congestive Heart Failure

7. Inpatient Quality Indicators (IQI) Reflect quality of care inside hospitals Reflect quality of care inside hospitals Inpatient mortality for certain procedures and medical conditions Inpatient mortality for certain procedures and medical conditions u Mortality varies for procedure or condition across institutions u Evidence that high mortality may be associated with deficiencies in quality

8. IQI Mortality Indicators for Inpatient Procedures and Conditions Procedures Procedures – Abdominal Aortic Aneurysm – Esophageal Resection – Coronary Artery Bypass Graft – Carotid Endarterectomy – Craniotomy – Pancreatic Resection – Hip Replacement – PTCA Conditions Conditions – Acute Myocardial Infarction (AMI) – AMI, without transfer cases – Congestive Heart Failure – Acute Stroke Mortality – Gastrointestinal Hemorrhage – Hip Fracture – Pneumonia

9. IQIs Utilization of procedures Utilization of procedures – Examines procedures with varying use across hospitals – Potential overuse, underuse or misuse Indicators Indicators Bilateral Cardiac Catheterization Rate Bilateral Cardiac Catheterization Rate Cesarean Delivery Rate Cesarean Delivery Rate Incidental Appendectomy in the Elderly Rate Incidental Appendectomy in the Elderly Rate Laparoscopic Cholecystectomy Rate Laparoscopic Cholecystectomy Rate Primary Cesarean Delivery Rate Primary Cesarean Delivery Rate Vaginal birth after Cesarean Rate (VBAC) Vaginal birth after Cesarean Rate (VBAC) VBAC rate, uncomplicated VBAC rate, uncomplicated

10. IQIs Area-level Utilization Area-level Utilization – Reflect the rate of hospitalization in the area for specific procedures – Use age and gender adjusted population- based denominator Indicators Indicators Coronary artery bypass graft (CABG) rate Coronary artery bypass graft (CABG) rate Hysterectomy rate Hysterectomy rate Laminectomy or spinal fusion rate Laminectomy or spinal fusion rate PTCA area rate PTCA area rate

11. IQIs Volume of procedures Volume of procedures – Indirect measures of quality – Counts of admissions – Evidence suggesting that hospitals that perform more of an intensive, complex procedure have better outcomes Indicators Indicators Abdominal Aortic Aneurysm Repair Abdominal Aortic Aneurysm Repair Carotid Endarterectomy Carotid Endarterectomy Coronary Artery Bypass Graft Coronary Artery Bypass Graft Esophageal Resection Esophageal Resection Pancreatic Resection Pancreatic Resection Percutaneous Transluminal Coronary Percutaneous Transluminal Coronary Angioplasty (PTCA) Angioplasty (PTCA)

12. Patient Safety Indicators (PSI) Identify adverse events that patients experience as a result of exposure to the health care system Identify adverse events that patients experience as a result of exposure to the health care system These events are likely amenable to prevention by changes at the system or provider level. These events are likely amenable to prevention by changes at the system or provider level.

13. Area Level PSI Cases of potentially preventable complications that occur in given area either during hospitalization or resulting in subsequent hospitalization Cases of potentially preventable complications that occur in given area either during hospitalization or resulting in subsequent hospitalization Indicators Indicators – Accidental Puncture or Laceration – Foreign Body Left in During a Procedure – Iatrogenic Pneumothorax – Postoperative Hemorrhage and Hematoma – Postoperative Wound Dehiscence – Selected Infections Due to Medical Care – Transfusion Reaction

14. Provider-Level PSI Accidental puncture or Laceration Accidental puncture or Laceration Birth Trauma-Injury to neonate Birth Trauma-Injury to neonate Complications of anesthesia Complications of anesthesia Death in low-mortlaity DRG’s Death in low-mortlaity DRG’s Decubitus Ulcer Decubitus Ulcer Failure to Rescue Failure to Rescue Foreign body left during procedure Foreign body left during procedure Iatrogenic pneumothorax Iatrogenic pneumothorax Obstetric Trauma-Vaginal with and without instrument Obstetric Trauma-Vaginal with and without instrument Obstetric Trauma-Cesarean delivery Obstetric Trauma-Cesarean delivery Postoperative Hip Fracture Postoperative Hip Fracture Postoperative Hemorrhage and Hematoma Postoperative Hemorrhage and Hematoma Postoperative Physiological and Metabolic Derangements Postoperative Physiological and Metabolic Derangements Postoperative Pulmonary Embolism or Deep Vein Thrombosis Postoperative Pulmonary Embolism or Deep Vein Thrombosis Postoperative Sepsis Postoperative Sepsis Postoperative Wound Dehiscence Postoperative Wound Dehiscence Selected Infections Due to Medical Care Selected Infections Due to Medical Care Transfusion Reaction Transfusion Reaction  Measure of potentially preventable complication for patients who received their initial care and the patients who received their initial care and the complication of care within the same hospitalization complication of care within the same hospitalization  Include only cases where a secondary diagnosis code flags a potentially preventable complication flags a potentially preventable complication

15. Pediatric Quality Indicators (PDI) Identify potentially preventable complications tailored for the pediatric population Identify potentially preventable complications tailored for the pediatric population – Age under 18 – Not in MDC 14 (Pregnancy, Childbirth and the Puerperium) – Not in Adult Diagnostic Related Groups

16. Provider Level and Area-Level Indicators Provider Level Provider Level – Accidental Puncture and Laceration – Decubitus Ulcer – Foreign Body Left During procedure – Iatrogenic pneumothorax in neonate – and non-neonate – Pediatric heart surgery mortality – Pediatric heart surgery volume – Postoperative hemorrhage & hematoma – Postoperative respiratory failure – Postoperative sepsis – Postoperative wound dehiscence – Selected Infections due to medical care – Transfusion reaction Area Level Area Level – Asthma Admission Rate – Diabetes Short-term Complications – Gastroenteritis Admission – Perforated Appendix Admission – Urinary Tract Infection

17. AHRQ QI User Support Resources AHRQ QI User Support Resources Electronic Newsletter Electronic Newsletter QI Listserv QI Listserv www.qualityindicators.ahrq.gov/signup.htm www.qualityindicators.ahrq.gov/signup.htm QI Support Web Site QI Support Web Site www.qualityindicators.ahrq.gov www.qualityindicators.ahrq.gov Support Email Support Email support@qualityindicators.ahrq.gov support@qualityindicators.ahrq.gov Support Telephone (voicemail) Support Telephone (voicemail) (888) 512-6090 (888) 512-6090