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Session 1: Administrative Data and HCUP Tools

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On December 4, 2008, Claudia Steiner gave a presentation about Administrative Data and HCUP Tools at the Using Administrative Data to Answer State Policy Questions Intensive Workshop. This is the text version of the event's slide presentation. Please select the following link to access the slides: (PowerPoint® File, 5.9 MB).

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 | 49 | 50 | 51 | 52 | 53 | 54 | 55 | 56 | 57 | 58


Slide 1: Administrative Data and HCUP Tools: Healthcare Cost and Utilization Project

Using Administrative Data to Answer Policy Questions
December 4-5, 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 and the HCUP logo on the right.

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Slide 2: Introductions

Claudia Steiner, MD, MPH
Research Medical Officer
Agency for Healthcare Research and Quality

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Slide 3: AHRQ - Agency within DHHS

The U.S. Department of Health and Human Services is composed of ATSDR, NIH, SAMHSA, IHS, HRSA, AHRQ, AOA, FDA, CMS, CDC, and ACF. HCUP can be found within AHRQ.

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Slide 4: The HCUP Partnership: A Voluntary Federal-State-Private Sector Collaboration

This slide contains a map of the United States, indicating the level of HCUP participation of each state. A total of 40 states participate in HCUP and provide 90 percent of all discharges.

Nonparticipant states: AK, NM, ID, MT, ND, LA, MS, AL, PA, DE
Partner states providing inpatient data only: WA, OR, NV, WY, TX, AR, IL, WV, VA, RI
Partner states providing inpatient and ambulatory surgery data: CO, OK, MI, KY, NC
Partner states providing inpatient and emergency department data: HI, AZ, MA
Partner states providing inpatient, ambulatory surgery, and emergency department data: CA, UT, SD, NE, KS, MN, IA, MO, WI, IN, OH, TN, SC, GA, FL, MD, NJ, NY, CT, VT, NH, ME

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Slide 5: Current HCUP Partners

  1. Arizona Department of Health Services
  2. Arkansas Department of Health
  3. California Office of Statewide Health Planning & Development
  4. Colorado Hospital Association
  5. Connecticut Integrated Health Information (Chime, Inc.)
  6. Florida Agency for Health Care Administration
  7. Georgia Hospital Association
  8. Hawaii Health Information Corporation
  9. Illinois Department of Public Health
  10. Indiana Hospital & Health Association
  11. Iowa Hospital Association
  12. Kansas Hospital Association

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Slide 6: Current HCUP Partners (continued)

  1. Kentucky Cabinet for Health and Family Services
  2. Maine Health Data Organization
  3. Maryland Health Services Host Review Commission
  4. Massachusetts Division of Health Care Finance and Policy
  5. Michigan Health & Hospital Association
  6. Minnesota Hospital Association
  7. Missouri Hospital Industry Data Institute
  8. Nebraska Hospital Association
  9. Nevada Division of Health Care Financing and Policy, Department of Health and Human Services
  10. New Hampshire Department of Health & Human Services
  11. New Jersey Department of Health and Senior Services

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Slide 7: Current HCUP Partners (continued)

  1. New York State Department of Health
  2. North Carolina Department of Health and Human Services
  3. Ohio Hospital Association
  4. Oklahoma Health Care Information Center for Health Statistics
  5. Oregon Association of Hospitals and Health Systems
  6. Rhode Island Department of Health
  7. South Carolina State Budget & Control Board
  8. South Dakota Association of Health Care Organizations
  9. Tennessee Hospital Association

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Slide 8: Current HCUP Partners (continued)

  1. Texas Department of State Health Services
  2. Utah Department of Health
  3. Vermont Association of Hospitals and Health Systems
  4. Virginia Health Information
  5. Washington State Department of Health
  6. West Virginia Health Care Authority
  7. Wisconsin Department of Health and Family Services
  8. Wyoming Hospital Association

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Slide 9: HCUP Is a Family of Databases, Tools, and Products

HCUP is composed of HCUP databases, Software tools, Research publications, User support, and EQUIPS. This slide contains images corresponding to the components of HCUP.

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Slide 10: Administrative Data

This slide contains an image of a technician writing on a clipboard.

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Slide 11: The Foundation of Administrative Data is Billing Data

This slide contains Billing UB-04 Form. The top third contains demographic data and the bottom two-thirds contains diagnoses, procedures, and charges.

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Slide 12: The Flow of Inpatient Admissions

There are two perspectives on this slide, the patient perspective and the data perspective. The patient perspective starts with a scheduled admission or a transfer from the Emergency department, which leads to reception, admission, administration of care, and discharge. From the data perspective, the patient record is generated from reception, admission, and administration of care, which leads to a discharge summary and a medical coder. The record is then transferred to the billing department. The billing department then generates the bill.

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Slide 13: From Patient to Data

This slide is a visualization of how hospital administrative data are entered into HCUP databases. There are images corresponding to the following steps:

  1. Patient enters hospital
  2. Billing record created
  3. Hospital sends billing data and any additional data elements to Data Organizations
  4. States store data in varying formats
  5. AHRQ standardizes data to create uniform HCUP databases

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Slide 14: General File Structure for Hospital Administrative Data

Range of file sizes

  • ~ 55,000 to 4.0 million records, depending on state

Core set of variables

  • Generally available across most states

State-specific variables

  • Vary by state
  • Allow specific analyses to be done
    • Patient race/ethnicity — to examine disparities
    • Encrypted patient identifier — to examine readmissions

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Slide 15: What Core Data Elements Are Included in Administrative Data?

This slide contains the image of UB-04 billing form. The following information can be found on this form:

  • Patient demographics (age, sex)
  • Diagnoses & procedures (ICD-9-CM, DRG)
  • Expected payer
  • Length of stay
  • Patient disposition
  • Admission source & type
  • Dates of admission and discharge
  • Hospital identifiers

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Slide 16: What are Some State-Specific Data Elements?

  • Race/Ethnicity
  • Patient county
  • Patient ZIP Code
  • Severity of illness
  • Birthweight
  • Procedure date (days from admission)
  • Primary payer details
  • Secondary payer
  • Detailed charges
  • Patient identifiers, encrypted
  • Physician identifiers, encrypted
  • Physician specialty

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Slide 17: Example: Payer Detail Varies by State

This slide contains a chart comparing HCUP standards to data from States. A red circle highlights an example. In the HCUP standard, the description is Private insurance and the value is 3. Conversely, the submitted data from the state has three different descriptions (Blue Cross and Blue Shield, Other Insurance Company/Self Insured, and HMO-PPO) and four different values (B, I/S, H).

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Slide 18: Hospital Billing Data Have Benefits and Limitations

Benefits

  • Large sample size
  • Uniformity of coding
  • Routine, regular collection
  • Ease of access
  • All-payer
  • Available at local, state, regional, national level

Limitations

  • Differences in coding across hospitals
  • No data on individuals outside of hospital system
  • May not show complete episode of care
  • May not include all hospitals
  • Lack revenue information
  • Sparse clinical details

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Slide 19: Accessing Data

Your own state data organization can provide:

  • Most recent data
  • Data elements not released outside government
    • e.g., patient identifiers, physician identifiers, linkage variables

To compare your data with other states:

  • Obtain HCUP-formatted, uniform files through HCUP Central Distributor
  • Obtain other states' data directly from other states
  • Can access summary statistics through HCUPnet

National benchmarks

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Slide 20: Obtain HCUP Data - Two Methods

On this slide, there are two screenshots of the HCUP database. The top image is of the HCUP Central Distributor, www.hcup-us.ahrq.gov/tech_assist/centdist.jsp. The bottom image is a list of HCUP Partner States, http://www.hcup-us.ahrq.gov/partners.jsp.

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Slide 21: States Releasing SID through HCUP Central Distributor

1990-2007*

  • Arizona
  • Arkansas
  • California**
  • Colorado
  • Florida
  • Hawaii
  • Iowa
  • Kentucky
  • Maryland
  • Massachusetts
  • Michigan
  • Nebraska
  • Nevada
  • New Jersey
  • New York
  • North Carolina
  • Oregon
  • Rhode Island
  • South Carolina
  • Utah
  • Vermont
  • Washington
  • West Virginia
  • Wisconsin

* Not all states participate in all years.
** Special application process.

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Slide 22: Nationwide Inpatient Sample (NIS)

This slide contains an image of a health care worker adjusting an IV.

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Slide 23: What Is the Nationwide Inpatient Sample (NIS)?

This slide contains an image of the United States. Superimposed is a box with the following text: State Inpatient Databases (SID), Comprehensive hospital discharge data from States. This leads to Nationwide Inpatient Sample (NIS).

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Slide 24: Purpose of the NIS

  • Allows national and regional studies of inpatient hospital utilization and charges — generates national estimates
  • Not recommended for state-level analyses

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Slide 25: Statewide Data Systems Participating in NIS

This slide contains a chart listing the data year certain states began participating in NIS.

Data Year # of States States
1988 8 CA, CO, FL, IA, IL, MA, NJ, WA
1989-1992 11 +AZ, PA, WI
1993-1994 17 +CT, KS, MD, NY, OR, SC
1995-1996 19 +MO, TN
1997-1998 22 +HI, UT, GA
1999 24 +ME, VA
2000 28 +KY, NC, TX, WV
2001 33 +MI, MN, NE, RI, VT
2002 35 +NV, OH, SD (AZ not available)
2003 37 +AZ, IN, NH (ME not available)
2004 37 +AR (PA not available)
2005 37 +OK (VA not available)
2006 38 +VA

There are a total of 38 states participating in NIS.

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Slide 26: The NIS Can Be Used for Many Purposes

  • Use of and charges for hospital services
  • Medical practice variation
  • Medical treatment effectiveness
  • Quality of care and patient safety
  • Impact of health policy changes
  • Diffusion of medical technology

Provides national and regional benchmarks to compare your own experience.

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Slide 27: Coming Soon... National Emergency Department Sample (NEDS)

This slide contains an image of an ambulance.

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Slide 28: Software Tools for Use with Administrative Data

This slide contains an image of a medical professional holding a newborn.

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Slide 29: HCUP Software Tools

This slide lists the 15 HCUP-related software tools:

  1. Clinical Classification System (CCS)
    1. ICD-9-CM CCS
    2. ICD-10 CCS
    3. CPT CCS
    4. Mental Health CCS
  2. Comorbidity Software
  3. Chronic Condition Indicators
  4. Procedure Classes
  5. Cost-to-Charge Ratios
  6. HCUPnet
  7. Hospital Market Structure (HMS) Flags
  8. Utilization Flags
  9. Quality Indicators
    1. Prevention QIs
    2. Inpatient QIs
    3. Patient Safety QIs
    4. Pediatric QIs

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Slide 30: Most AHRQ HCUP Tools Can Be Applied to Any Administrative Database

On the left of the slide, there are 3-dimensional discs denoting SID, NIS, KID, SASD, SEDD, and Other Administrative Databases. A bracket encompassing these images points to the following list:

  • CCS Tools
  • Comorbidity
  • Procedure classes
  • Chronic Condition Indicator
  • AHRQ QIs

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Slide 31: Most AHRQ HCUP Tools Aid to Summarize Data

On the left of the slide, there are 3-dimensional discs denoting SID, NIS, KID, SASD, SEDD, and Other Administrative Databases. The bracket encompassing these images points to the following list:

  • CCS Tools
    • ICD-9-CM CCS
    • ICD-10 CCS
    • CPT CCS
    • MH CCS
  • Procedure Classes
  • Chronic Condition Indicator

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Slide 32: Most Tools Based On Medical Coding Classifications

  • ICD-9-CM
  • CPT
  • HCPCS
  • DRGs
  • MDC
  • CCS

On the right side of the slide are cover images of the 2006 ICD-9-CM, the 2006 CPT, and the 2006 HCPCS.

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Slide 33: Multiple Coding Systems

Individual Codes

  • ICD-9-CM
  • CPT
  • HCPCS

Groupers

  • DRGs
  • MDC
  • CCS

Which coding system is appropriate for your policy analysis?

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Slide 34: ICD-9-CM

  • ICD-9-CM Diagnosis Codes
  • ICD-9-CM Procedure Codes
  • Included in both inpatient and outpatient databases

On the right is the cover image of the 2006 ICD-9-CM.

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Slide 35: Common Procedural Coding System - CPT & HCPCS

  • CPT
  • HCPCS
  • Local Codes

An image of the 2006 CPT is located on the left side of the slide and the 2006 HCPCS is located on the right side of the slide.

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Slide 36: Clinical Classifications Software (CCS)

This slide contains a visual of ICD-9-CM Diagnosis Codes (12,600 Diagnosis Codes and 3,500 Procedure Codes) being converted into Clinical Classifications.

The CCS collapses ICD-9-CM codes into a smaller number of clinically meaningful categories that can be more useful for presenting descriptive statistics than are individual ICD-9-CM codes.

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Slide 37: CCS for ICD-9-CM

This slide contains the diagram showing how CCS groups ICD-9-CM codes into clinically meaningful categories.
A combination of CCS for ICD-9-CM, your data, and ICD-9-CM codes lead to CCS Codes such as CCS 2 (Septicemia) and CCS 6 (Hepatitis).

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Slide 38: Most AHRQ HCUP Tools Aid to Summarize Data

On the left of the slide, there are 3-dimensional discs denoting SID, NIS, KID, SASD, SEDD, and Other Administrative Databases. A bracket encompassing these images points to the following list:

  • CCS Tools
    • ICD-9-CM CCS
    • ICD-10 CCS
    • CPT CCS
    • MH CCS
  • Procedure Classes
  • Chronic Condition Indicator

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Slide 39: Kansas - 2006

This slide contains a chart ranking ICD-9-CM based on total discharges in Kansas in 2006.

Rank ICD-9-CM diagnosis code and name Total number
of discharges
1. V30.00 Single Lb In-Hosp W/O Cs 27,705
2. V30.01 Single Lb In-Hosp W Cs 11,266
3. 486 Pneumonia, Organism Nos 10,417
4. 428.0 Chf Nos (after Oct 1, 2002) 7,536
5. 414.01 Crnry Athrscl Natve Vssl 6,615
6. 654.21 Prev C-Delivery-Delivrd 4,888
7. 276.51 Dehydration 4,100
8. 786.59 Chest Pain Nec 4,057
9. 715.36 Loc Osteoarth Nos-L/Leg 3,949
10. 664.11 Del W 2 Deg Lacerat-Del 3,610

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Slide 40: Colorado - 2006

Rank order of CCS principal diagnosis category

This slide contains a chart ranking CCS principal diagnosis based on total discharges in Colorado in 2006.

Rank CCS principal diagnosis category and name Total number
of discharges
1. 218 Liveborn 66,845
2. 193 Trauma to perineum and vulva 17,261
3. 195 Other complications of birth, puerperium affecting management of the mother 13,733
4. 203 Osteoarthritis 13,178
5. 122 Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 12,922
6. 205 Spondylosis, intervertebral disc disorders, other back problems 9,639
7. 108 Congestive heart failure, nonhypertensive 8,042
8. 237 Complication of device, implant or graft 7,885
9. 101 Coronary atherosclerosis 7,879
10. 69 Affective disorders 7,311

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Slide 41: U.S. - 2006

This slide contains a chart ranking CCS principal diagnosis based on total discharges in the U.S. in 2006.

Rank CCS principal diagnosis category and name Total number
of discharges
1. 218 Liveborn 4,288,954
2. 122 Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 1,218,467
3. 101 Coronary atherosclerosis 1,198,274
4. 108 Congestive heart failure, nonhypertensive 1,098,573
5. 102 Nonspecific chest pain 856,948
6. 193 Trauma to perineum and vulva 817,848
7. 195 Other complications of birth, puerperium affecting management of the mother 767,357
8. 106 Cardiac dysrhythmias 749,182
9. 203 Osteoarthritis 735,087
10. 100 Acute myocardial infarction 675,121

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Slide 42: North Carolina - 2000-2006

This slide contains a line graph entitled: Total number of discharges CCS principal diagnosis category 203, Osteoarthritis. Below are the corresponding dates and number of discharges on the graph:

2000: 11,630
2001: 13,337
2002: 14,658
2003: 16,088
2004: 18,967
2005: 21,083
2006: 22,007

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Slide 43: Procedure Classes

ICD-9-CM Procedure codes

  • Minor Diagnostic
  • Minor Therapeutic
  • Major Diagnostic
  • Major Therapeutic

Groups ICD-9-CM Codes into One of Four Categories to Distinguish Between Diagnostic/Therapeutic Procedures

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Slide 44: Procedure Classes (continued)

Cardiac Procedures

  • Minor Diagnostic
    • Electrocardiogram (ICD-9-CM: 8952)
  • Minor Therapeutic
    • Pacemaker (ICD-9-CM: 3778)
  • Major Diagnostic
    • Pericardial Biopsy (ICD-9-CM: 3724)
  • Major Therapeutic
    • CABG (ICD-9-CM: 3610)

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Slide 45: Chronic/Non-Chronic Indicator

ICD-9-CM Diagnosis codes

  • Chronic
  • Non-Chronic

Groups ICD-9-CM Diagnosis Codes into Chronic or Non-Chronic Categories

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Slide 46: Chronic/Non-Chronic Indicator (continued)

  • Chronic
    • Diabetes (ICD-9-CM 25000)
  • Non-Chronic
    • Food Poisoning (ICD-9-CM 0059)

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Slide 47: Probability of Readmission, 6 HCUP SID, 2002

This slide contains a chart of data listing various illness categories with unlabeled data.

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Slide 48: Comorbidity Software*

This slide contains a visual representation of the elements of Comorbidity software. A combination of ICD-9-CM Codes and DRGs on Administrative Data are the basis of Comorbidity software, which offers 30 comorbidity classifications.

The Comorbidity Software is based on the ICD-9-CM coding scheme. This software creates about 30 variables that identify major comorbidities.
* Elixhauser A, et al. Medical Care, Jan. 1998.

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Slide 49: Appends Indicator Flags for Each Comorbidity to Records

  • Congestive heart failure
  • Valvular disease
  • Pulmonary circulation disorders
  • Peripheral vascular disorders
  • Hypertension (uncomplicated and complicated)
  • Paralysis
  • Other neurological disorders
  • Chronic pulmonary disease
  • Diabetes without chronic complications
  • Diabetes with chronic complications
  • Hypothyroidism
  • Renal failure
  • Liver disease
  • Chronic peptic ulcer disease

30 flags are created and appended to each record.
Examples:
The flag for Congestive Heart Failure is CM_CHF= 0 or 1
The flag for Valvular disease is CM_VALVE = 0 or 1

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Slide 50: Appends Indicator Flags for Each Comorbidity

  • HIV and AIDS
  • Lymphoma
  • Metastatic cancer
  • Solid tumor without metastasis
  • Rheumatoid arthritis/collagen vascular diseases
  • Coagulation deficiency
  • Obesity
  • Weight loss
  • Fluid and electrolyte disorders
  • Blood loss anemia
  • Deficiency anemia
  • Alcohol abuse
  • Drug Abuse
  • Psychoses
  • Depression

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Slide 51: Utilization Flags

Reveals additional information about use of health care services.
This slide also contains a visual showing that a combination of Utilization Flag software, your data, ICD-9-CM codes, and UB-92 codes are used in departments such as the emergency room, chest x-ray/CT scan, and the intensive care unit.

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Slide 52: 30 Utilization Flags

On the left of this slide, there is an image of a chart listing Utilization Flags in specific categories. The box next to the image contains the following text: ICD-9-CM codes are not available for all services — there is some concern that some diagnostic procedures may be under-reported.

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Slide 53: HCUPnet - On-line Query System

This slide contains an image of surgeons working on a patient.

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Slide 54: HCUPnet: Quick, Free Access to HCUP Data

  • Free, interactive online query system
  • Users generate tables of outcomes by diagnoses and procedures
  • Data can be cross-classified by patient and hospital characteristics
  • Includes national, regional, and state data (for states that choose to participate)
http://hcup.ahrq.gov/hcupnet

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Slide 55: HCUPnet Can Answer a Variety of Questions

  • What percentage of hospitalizations for children are uninsured, by state?
  • What are the most expensive conditions treated in U.S. hospitals?
  • What is the trend in admissions for depression?
  • Will there be sufficient cases to do my analysis?
  • How do my estimates compare with HCUPnet (validation)?

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Slide 56: HCUPnet Demonstration

This slide contains a screenshot of the HCUPnet homepage.

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Slide 57: HCUP User Support Website

  • Find detailed information on HCUP databases, tools, and products
  • Access HCUPnet
  • Find comprehensive listing of HCUP-related publications, database reports, and fact books
  • Access technical assistance
    http://www.hcup-us.ahrq.gov

A screenshot of the home page of the HCUP User Support Website is located on the right of the slide.

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Slide 58: Using HCUP Technical Assistance

Active Technical Assistance

  • Responds to inquiries about HCUP data, products, and tools
  • Collects user feedback and suggestions for improvement

E-mail: hcup@ahrq.gov
Phone: (866) 290-HCUP

Image includes a photo of a technical assistance provider at the computer.

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