AHRQ Quality Indicators 101: Background and Introduction to the AHRQ QIs

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AHRQ Quality Indicators 101 Background and
Introduction to the AHRQ QIs

• Mamatha Pancholi, MS, Program Officer,
• Center for Delivery, Organization, and Markets
• Jeffrey J. Geppert, JD, EdM, Research Leader,
  Battelle Memorial Institute
• September 17, 2008

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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Learning Objectives

• Purpose of this Webinar is to provide an
  introduction to the AHRQ Quality Indicators for
  persons interested in using them for public
  reporting.
• By the end of this Webinar, participants should
  be able to
• Identify and describe the five major categories
  of the QIs.
• Identify advantages and limitations of the QIs.
• Describe multiple uses of the QIs.
• Discuss significance of the National Quality
  Forums endorsement of several QIs.
• Identify the purpose and application deadline for
  the Quality Indicators Learning Institute.

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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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 Statesrepresents approximately 90
  percent of all discharges

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AHRQ Quality Indicators (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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Example Indicator Evaluation
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Structure of AHRQ QI

• 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, discharge quarter
• Numerator is the number of cases flagged with
  the outcome of interest (e.g., postoperative
  sepsis, avoidable hospitalization for asthma,
  death)
• Denominator is the population at risk (e.g.,
  pneumonia patients, elective surgical patients,
  county population from census data)
• The observed rate is numerator/denominator
• Volume counts for selected procedures

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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

• Bacterial pneumonia
• Dehydration
• Urinary tract infection
• Perforated appendix
• Low birth weight
• Angina without procedure
• Congestive heart failure

• Hypertension
• Adult asthma
• COPD
• Diabetes cx - short term
• Diabetes cx - long term
• Uncontrolled diabetes
• Lower extremity amputation

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Inpatient Quality Indicators

• Volume Indicators
• Esophageal resection
• Pancreatic resection
• AAA repair
• CABG
• Percutaneous transluminal coronary angioplasty
• Carotid endarterectomy

• Utilization Indicators
• Cesarean delivery rate
• Primary cesarean delivery rate
• VBAC rate
• VBAC rate, uncomplicated
• Laparoscopic cholecystectomy rate
• Incidental appendectomy in the elderly rate
• Bilateral cardiac catheterization rate

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Inpatient Quality Indicators (cont.)

• Mortality Indicators for Inpatient Conditions
• Acute myocardial infarction
• AMI, without transfer cases
• Congestive heart failure
• Gastrointestinal hemorrhage
• Hip fracture
• Pneumonia
• Acute stroke

• Mortality Indicators for Inpatient Procedures
• AAA repair
• CABG
• Craniotomy
• Esophageal resection
• Hip replacement
• Pancreatic resection

Two additional mortality indicators (carotid
endarterectomy and PTCA) are included in the IQI
software but are not recommended as stand-alone
measures.
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Patient Safety Indicators

• Complications of anesthesia
• Death in low mortality DRGs
• Decubitus ulcer
• Failure to rescue
• Foreign body left during procedure
• Iatrogenic pneumothorax
• Selected infections due to medical care
• Postoperative hemorrhage or hematoma
• Postoperative hip fracture
• Postoperative physiological and metabolic
  derangement
• Postoperative PE or DVT

The indicators marked with are also provided as
area-level indicators.
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Patient Safety Indicators (cont.)

• Postoperative respiratory failure
• Postoperative sepsis
• Postoperative wound dehiscence
• Technical difficulty with procedure
• Transfusion reaction
• Birth trauma injury to neonate
• Obstetric (OB) trauma cesarean delivery (w/ and
  w/o 3rd degree lacerations)
• OB trauma vaginal delivery with instrument (w/
  and w/o 3rd degree lacerations)
• OB trauma vaginal delivery without instrument
  (w/ and w/o 3rd degree lacerations)

The indicators marked with are also provided as
area-level indicators.
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Pediatric Quality Indicators

• Inpatient Indicators
• Accidental puncture and laceration
• Decubitus ulcer
• Foreign body left in after procedure
• Iatrogenic pneumothorax in neonates at risk
• Iatrogenic pneumothorax in non-neonates
• Pediatric heart surgery mortality
• Pediatric heart surgery volume
• Postoperative hemorrhage or hematoma
• Postoperative respiratory failure
• Postoperative sepsis
• Postoperative wound dehiscence due to medical
  care
• Transfusion reaction

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Pediatric Quality Indicators (Contd)

• Area-Level Indicators
• Asthma admission rate
• Diabetes short-term complication admission rate
• Gastroenteritis admission rate
• Perforated appendix admission rate
• Urinary tract infection admission rate

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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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
• Healthcare Cost Utilization Project
• Medicare Provider Analysis and Review

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Advantages (contd)

• 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, womens 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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Advantages (contd)

• 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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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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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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Recent Improvements

• Composite Measures Developed composite measures
  for the IQIs, PSIs, PQIs, and PDIs
• Risk Adjustment/Admin Data Additional risk
  adjustment methods for AHRQ QIs
• Updated Literature Reviews Completed IQIs,
  Pediatric QIs, and PSIs
• Reporting Template Tested and refined
• NQF Endorsed QIs

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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Future Vision Join Forces to Improve Data

• Use HIT to improve timeliness
• Add clinical detail for accuracy, credibility
• Condition present on admission
• Lab values
• Expand outpatient reach (e.g., emergency
  department, physician data)
• Pilot cross-site data, new data links
• New tools for expanded data
• Continue privacy data security

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Followup State Pilots to Add Clinical Detail
and Robustness

• AHRQ has funded HCUP Partner projects to add more
  clinical data to statewide administrative
  databases
• Present on Admission (POA)
• Laboratory values
• Other

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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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 Funds 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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12 States Use QIs for Public Hospital Reporting
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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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QI Reporting Template(s)

• Challenge Presentation Matters!!
• Approach Two Model Templates
• Composite scorecard
• Health topic/disease
• Report Sponsors Choose
• Overall approach
• Topics, composites, measures to report
• How scores will be calculated
• The medium to be used

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The Evidence Base

• Model reports are based on
• Literature review and analysis
• Interviews with experts
• Focus groups with different populations
• Cognitive interviews

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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QIs Submitted to the National Quality Forum (NQF)

• Submitted September 2006
• Select Individual QIs (34)
• Composite Measures (4)
• Reporting Template/Framework (2)
• Additional QIs Submitted
• Perinatal Project (3)
• Perioperative Project (3)

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NQF Endorsed QIs

• Diabetes Project
• PQI 1 - Diabetes Short-Term Com-
• plication Admission Rate and PQI 14 -
  Uncontrolled Diabetes Admission Rate
• PQI 3 - Diabetes Long-Term Complication
  Admission Rate
• PQI 16 - Rate of Lower-Extremity Amputation
  Among Patients With Diabetes
• Hospital Additional Priorities 2005-06,
  Pneumonia Mortality Supplement
• IQI 20 Inpatient Pneumonia Mortality

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NQF Endorsed QIs

• Ambulatory Care Project Phase 3
• PQIs PQI Composite
• Standards of Hospital Care Additional Priorities
  2007
• Patient Safety, Adult (8)
• Patient Safety, Pediatrics (4)
• Pediatrics (2)
• Surgery Anesthesia (11)
• Perioperative Care
• Postop PE/DVT
• Perinatal Care
• Birth Trauma Injury to Neonates
• Nosocomial Bloodstream Infections in Neonates

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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ICD-9-CM Coding Proposals

• AHRQ has proposed several coding changes to
  ICD-9-CM that were needed to enhance the accuracy
  and usefulness of some indicators
• Retinopathy of prematurity
• Necrotizing enterocolitis
• Disruption of postoperative wound
• Deep vein thrombosis
• Transfusion reaction

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Measure Harmonization

• Working with other measure developers to align
  specifications of similar measures
• JCAHO
• CMS
• Researchers

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Validation Studies

• AHRQ sponsored
• Phase I
• Simple Review
• Indepth Review
• Supplemental Review
• Phase II
• Currently Recruiting

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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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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

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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
• Contact Jennifer Cohen (cohenj_at_battelle.org)

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AHRQ QI Development

• Emergency Preparedness
• PQIs for the Medicaid Population

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Overview

• Origins
• Current Modules
• Advantages Challenges
• Recent Improvements
• Future Vision
• Uses of the AHRQ QIs
• Reporting Template
• National Quality Forum Endorsement
• Additional Activities
• QI Learning Institute

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AHRQ QI Learning Institute

• Purpose To provide a forum for discussing and
  facilitating the use of the AHRQ Quality
  Indicators (QIs) in statewide and regional
  programs that report hospital quality measures to
  the public.
• Provide opportunities for discussion and
  peer-to-peer learning through Webinars,
  conference calls, and in-person meetings
• Increase familiarity with the AHRQ QI reporting
  template and related tools.
• Target Audience Leaders (or their
  representatives, including project staff and
  consultants) who are directly involved with
  developing public reporting programs from
• State agencies/task forces,
• State hospital associations, and/or
• Coalitions

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Possible Topics of Monthly Webinars

• Selecting Measures and Sample Size
• Preparing Data for the Report
• Classifying Hospitals
• Displaying the Data
• Explaining the QIs on Your Web Site
• Creating a Consumer-Friendly Web Site
• Marketing and Promoting Your Report
• Evaluation of Public Reporting Program

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Applying for Membership

• If you are interested in becoming a member of
• the AHRQ QI Learning Institute
• Send an e-mail to QualityIndicatorsLearning_at_ahrq.
  hhs.gov with the subject heading Application
  Information for the QI Learning Institute. 
• AHRQ will respond with application details.
• Application due by September 30, 2008.

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For More Information

• Quality Indicators
• Web site http//qualityindicators.ahrq.gov/
• QI documentation and software are available
• E-mail support_at_qualityindicators.ahrq.gov
• Support Phone [phone] (voicemail)
• Staff Mamatha.Pancholi_at_ahrq.hhs.gov
• QI Learning Institute
• QI Learning Institute Web site
• http//www.ahrq.gov/qilearninginstitute/
• E-mail QualityIndicatorsLearning_at_ahrq.hhs.gov

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