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Session 3: AHRQ Quality Indicators

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On December 4, 2008, Melanie Chansky gave a presentation about the AHRQ Quality Indicators at the Using Administrative Data to Answer State Policy Questions Intensive Workshop. Please select the following link to access the slides: (PowerPoint® File, 1.5 MB; PDF file, 280 KB, PDF Help).

Slides: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48


Slide 1: The AHRQ Quality Indicators

Melanie Chansky, MAA, Research Scientist
Battelle Memorial Institute
December 4, 2008

On the top of the slide are the logos for the Department of Health & Human Services and the AHRQ logo. The Department of Health & Human Services logo is an artistic image of an eagle with the outlined profile of faces. The AHRQ logo reads, "AHRQ - Agency for Healthcare Research and Quality: Advancing Excellence in Health Care, www.ahrq.gov."

This presentation uses a template with a blue background and a header with the AHRQ and Department of Health & Human Services logos on the left.

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Slide 2: Overview (The QIs and QI Modules Highlighted)

  1. The QIs and QI Modules
  2. NQF-Approved Measures
  3. Public Reporting
  4. Validation Efforts
  5. QI Tools

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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.

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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.

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Slide 5: Example Indicator Evaluation

Graphic illustration of how quality indicators are evaluated. It shows a flowchart with different colored boxes and ovals with text. The first text box is rectangular with the words "Literature Review User Data." There is an arrow from the first box to a blue oval with the "Initial Empirical Analyses and Definition." From the blue oval there is an arrow pointing to a burgundy rectangular box labeled "Panel Evaluation." This box has an arrow pointing to another blue oval with the words "Further Empirical Analyses Refined Def." inside. This oval points to a yellow rectangular box labeled "Further Review? Final Definition."

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Slide 6: Current QI Modules

Diagram of current QI modules illustrated with different circles with text inside. The circles are labeled:

  • Inpatient QIs
    Mortality Utilization Volume
  • Neonatal QIs
  • Pediatric QIs
  • Patient Safety QIs
    Complications
    Unexpected Death
  • Prevention QIs (Area Level)
    Avoidable Hospitalizations/Other Avoidable Conditions

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Slide 7: Prevention Quality Indicators

  • The original QI module (released 2001).
  • Focus on quality of care for ambulatory care-sensitive conditions.

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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.

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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.

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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

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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

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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

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Slide 13: Patient Safety Indicators

  • Third set of QIs (released 2003).
  • Focus on potential adverse events occurring during hospitalization.

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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 Wound 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

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Slide 15: List of PSIs (cont'd.)

Area-Level:

  • Foreign Body Left in During Procedure
  • Iatrogenic Pneumothorax
  • Selected Infections Due to Medical Care
  • Postoperative Wound Dehiscence in Abdominopelvic Surgical Patients
  • Accidental Puncture and Laceration
  • Transfusion Reaction
  • Postoperative Hemorrhage or Hematoma

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Slide 16: Pediatric Quality Indicators

  • Fourth set of QIs (released 2006).
  • Measures similar to other modules, but focus on pediatric population.

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Slide 17: List of PDIs

Hospital-Level:

  • Accidental Puncture or Laceration
  • Complications of anesthesia
  • 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 Wound Dehiscence
  • Selected Infections Due to Medical Care
  • Transfusion Reaction

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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

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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

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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.

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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.

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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.

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Slide 23: Overview (NQF-Approved Measures highlighted)

  1. The QIs and QI Modules
  2. NQF-Approved Measures
  3. Public Reporting
  4. Validation Efforts
  5. QI Tools

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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).

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Slide 25: National Quality Forum Endorsement: IQI Labels

 

IQI Label IQI Label
IQI #01 Esophageal Resection Volume IQI #16 CHF Mortality
IQI #02 Pancreatic Resection Volume IQI #17 Acute Stroke Mortality
IQI #04 Abdominal Aortic Aneurysm (AAA) Repair Volume IQI #19 Hip Fracture Mortality
IQI #08 Esophageal Resection Mortality IQI #20 Pneumonia Mortality
IQI #09 Pancreatic Resection Mortality IQI #24 Incidental Appendectomy in the Elderly
IQI #11 Abdominal Aortic Aneurysm (AAA) Repair Mortality IQI #25 Bilateral Catheterization

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Slide 26: National Quality Forum Endorsement (continued)

 

PSI Label PSI Label
PSI #02 Death in Low Mortality DRGs PSI #12 Postoperative DVT or PE
PSI #04 Death Among Surgical Inpatients With Treatable Serious Complications PSI #14 Postoperative Wound Dehiscence
PSI #05 Foreign Body PSI #15 Accidental Puncture or Laceration
PSI #06 Iatrogenic Pneumothorax PSI #16 Transfusion Reaction

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Slide 27: National Quality Forum Endorsement (continued)

 

PDI Label PDI Label
PDI #01 Accidental Puncture or Laceration PDI #07 Pediatric Heart Surgery Volume
PDI #02 Decubitus Ulcer PDI #11 Postoperative Wound Dehiscence
PDI #03 Foreign Body PDI #13 Transfusion Reaction
PDI #05 Iatrogenic Pneumothorax NQI* #02 Blood Stream Infection in Neonates*
PDI #06 Pediatric Heart Surgery Mortality    

* NQI- Neonate Quality Indicator, Endorsement pending

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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.

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Slide 29: Overview (Public Reporting highlighted)

  1. The QIs and QI Modules
  2. NQF-Approved Measures
  3. Public Reporting
  4. Validation Efforts
  5. QI Tools

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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

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Slide 31: 12 States Use QIs for Public Hospital Reporting

Map of the United States with the 12 States highlighted:

  • Oregon
  • Utah
  • Colorado
  • Texas
  • Florida
  • Kentucky
  • Massachusetts
  • Ohio
  • Vermont
  • New York
  • Wisconsin (parts of state)
  • Iowa

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Slide 32: Overview (Validation Efforts highlighted)

  1. The QIs and QI Modules
  2. NQF-Approved Measures
  3. Public Reporting
  4. Validation Efforts
  5. QI Tools

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Slide 33: Validation Studies

AHRQ sponsored

  • Phase I:
    • Simple Review
    • In-depth Review
    • Supplemental Review
  • Phase II:
    • Currently Recruiting

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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.

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Slide 35: Validation Pilot, Phase I (continued)

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.

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Slide 36: 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.

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Slide 37: Other Validation Studies

University HealthSystem Consortium — Patient Safety Indicators

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Slide 38: Overview (QI Tools highlighted)

  1. The QIs and QI Modules
  2. NQF-Approved Measures
  3. Public Reporting
  4. Validation Efforts
  5. QI Tools

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Slide 39: Windows Quality Indicators Software (WinQI)

  • Allows users to run AHRQ QI analysis with data they provide.
  • Current users: federal government, state government, hospital associations, individual hospitals, researchers.
  • Software enables calculation of QI rates as well as generation of reports.

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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.

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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.

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Slide 42: Sample Map for PQI 14, Uncontrolled Diabetes Admission

A sample map showing uncontrolled diabetes admission (2001, PQI14) for the State of California. The map is color-coded by the RA rate per 10,000 people. The legend highlights "Data Quintiles. Green is the lowest 20%, or lowest rates. Red is the highest 20%, or highest rates." One county is magnified showing it has one of the highest rates.

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Slide 43: Excel Spreadsheet Produced by PHC, with Cost Savings Estimate

Screen shot of an Excel spreadsheet showing the uncontrolled diabetes admission rates per county in California produced by PHC with cost savings estimate. The spreadsheet highlights data for one county and indicates that the County Risk-Adjusted Rate is significantly higher than the state rate.

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Slide 44: Sample Map for PQI 14, Population Data Added

A sample map for PQI 14 for the State of California, with population data added. Population data are broken into three groups. Stick figures superimposed on map to represent relative population size for persons age 18 and over. The smallest figure is for 55 to 143, the next is for 145 to 224, and the largest is for 231 to 445. The RA rate per 10,000 people is shown in five color-coded categories. For example, the lowest rate, 0.02 to 0.36, is coded green.

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Slide 45: For More Information...

Quality Indicators:

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Slide 46: Presenter Contact Info

Melanie Chansky, Battelle
Phone: 703-248-1659
Email: chanskym@battelle.org

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Slide 47: Questions?

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Slide 48: Thank You!

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