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Refinement of the HCUP Quality Indicators

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Table 1S. Provider Indicator List


Provider Level Indicator Name Type of Indicator Indicator Description Empirical Ratinga Risk Adjustment Recommended Caveats of Use From the Literature Reviewb Better Quality May Be Associated with:
AAA repair volume (#1) Volume Raw volume compared to
annual thresholds
(20, 32 procedures)
Not applicable Not applicable X Proxy
? Easily manipulated
Higher rates
Carotid endarterectomy volume (#2) Volume Raw volume compared to
annual thresholds
(50, 101 procedures)
Not applicable Not applicable X Proxy
X Easily manipulated
Higher rates
CABG volume (#3) Volume Raw volume compared to annual thresholds (100, 200 procedures) Not applicable Not applicable X Proxy
? Easily manipulated
Higher rates
Esophageal resection volume (#4) Volume Raw volume compared to
annual thresholds (6, 7 procedures)
Not applicable Not applicable X Proxy
? Easily manipulated
Higher rates
Pancreatic resection volume (#5) Volume Raw volume compared to
annual thresholds
(10, 11 procedures)
Not applicable Not applicable X Proxy
? Easily manipulated
Higher rates
Pediatric heart surgery volume (#6) Volume Raw volume compared to annual thresholds (100 procedures) Not applicable Not applicable X Proxy
? Easily manipulated
Higher rates
PTCA volume (#7) Volume Raw volume compared to annual thresholds (200, 400 procedures) Not applicable Not applicable X Proxy
? Selection bias
X Easily manipulated
Higher rates
Cesarean section rate (#8) Utilization Number of cesarean sections per 100 deliveries 17 Age adjustment, and potentially supplemental (clinical data, linked to infant record, or linked to birth record) ? Confound-
ing bias
? Unclear construct validity
? Unclear benchmark
Lower ratesc
Incidental appendectomy among elderly rate (#9) Utilization Number of incidental appendectomies per 100 abdominal surgeries 13
Smoothing recommended
Age and sex ? Unclear construct validity
? Easily manipulated
Lower rates
Bi-lateral cardiac catheterization rate (#10) Utilization Number of bilateral caths per 100 cardiac caths 25 None required ? Selection bias
? Unclear construct validity
Lower rates
VBAC rate (#11) Utilization Number of vaginal births per 100 deliveries in women with previous cesarean section 19 Age adjustment, and potentially supplemental (clinical data, linked to infant record, or linked to birth record) X Selection bias
? Confound-
ing bias
? Unclear construct validity
? Unclear benchmark
Higher ratesc
Laparoscopic cholecystectomy (#12) Utilization Number of lap. cholecystectomies per 100 cholecystectomies 20 Age and sex adjustment, and potentially supplemental clinical. X Selection bias
X Confound-
ing bias
? Unclear construct validity
X Easily manipulated
X Unclear benchmark
Higher ratesc
AMI mortality (#33) In-hospital Mortality Number of deaths per 100 discharges for AMI 5
Smoothing recommended
APR-DRG X Information bias
X Confound-
ing bias
Lower rates
CHF mortality (#34) In-hospital Mortality Number of deaths per 100 discharges for CHF 6
Smoothing recommended
APR-DRG X Selection bias
X Information bias
X Confound-
ing bias
Lower rates
GI hemorrhage mortality (#35) In-hospital Mortality Number of deaths per 100 discharges for GI hemorrhage 5
Smoothing recommended
APR-DRG X Confound-
ing bias
? Unclear construct validity
Lower rates
Hip fracture mortality (#36) In-hospital Mortality Number of deaths per 100 discharges for hip fracture 10
Smoothing recommended
APR-DRG ? Information bias
X Confound-
ing bias
? Unclear construct validity
Lower rates
Pneumonia mortality (#37) In-hospital Mortality Number of deaths per 100 discharges for pneumonia 7
Smoothing recommended
APR-DRG X Selection bias
? Information bias
X Confound-
ing bias
Lower rates
Stroke mortality (#38) In-hospital Mortality Number of deaths per 100 discharges for stroke 10
Smoothing recommended
APR-DRG X Selection bias
? Information bias
X Confound-
ing bias
Lower rates
AAA repair mortality (#39) Post-
procedural Mortality
Number of deaths per 100 AAA repairs 8
Smoothing recommended
APR-DRG, though impact may be impaired by skewed distribution. X Confound-
ing bias
? Unclear construct validity
Lower rates
CABG mortality (#40) Post-
procedural Mortality
Number of deaths per 100 CABG procedures 5
Smoothing recommended
APR-DRG ? Selection bias
X Confound-
ing bias
? Unclear construct validity
? Easily manipulated
Lower rates
Craniotomy mortality (#41) Post-
procedural Mortality
Number of deaths per 100 craniotomies 6
Smoothing recommended
APR-DRG X Confound-
ing bias
? Unclear construct validity
Lower rates
Esophageal resection mortality (#42) Post-
procedural Mortality
Number of deaths per 100 esophageal resections for cancer 8
Smoothing recommended
APR-DRG, though impact may be impaired by skewed distribution. ? Confound-
ing bias
? Unclear construct validity
Lower rates
Hip replacement mortality (#43) Post-
procedural Mortality
Number of deaths per 100 hip replacements 3
Smoothing recommended
APR-DRG ? Selection bias
? Confound-
ing bias
? Unclear construct validity
Lower rates
Pancreatic resection mortality (#44) Post-
procedural Mortality
Number of deaths per 100 pancreatic resections for cancer 5
Smoothing recommended
APR-DRG, though impact may be impaired by skewed distribution. ? Confound-
ing bias
? Unclear construct validity
Lower rates
Pediatric heart surgery mortality (#45)d Post-
procedural Mortality
Number of deaths per 100 heart surgeries in patients under age 18 years 3
Smoothing recommended
APR-DRG X Confound-
ing bias
? Unclear construct validity
   Unclear benchmark
Lower rates

a. Each indicator is rated from 0-26 on its empirical performance of precision and minimum bias with 0 indicating the lowest empirical rating (poor performance) and 26 indicating the highest performance.
b. Each indicator was evaluated for seven caveats (proxy, selection bias, information bias, confounding bias, unclear construct validity, easily manipulated, unclear benchmark). A question mark preceding the caveat means that this is a theoretical or suggested concern. A checkmark means that this is a concern that has been demonstrated.
c. For some indicators, very low or very high rates may indicate a potential quality problem. The direction listed is the direction for improvement given the current rates for these indicators.
d. Pediatric heart surgery mortality is not recommended as a stand alone indicator, because of ample evidence for confounding bias in the absence of more sophisticated risk-adjustment. It is designed only for use with the corresponding volume measure, or with risk-adjustment methods such as those described in the detailed literature review.


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