OVERVIEW

http://www.qualityindicators.ahrq.gov/

The Quality Indicators displayed on this webpage were produced using the software developed by the Agency for Healthcare Research and Quality (AHRQ). Much of the wording used to describe these indicators is extracted from the AHRQ documentation.

 

Quality Indicators (QIs)

QIs measure the quality of healthcare that a patient receives. There are four types of indicators:

Prevention QIs identify hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.  Download PQI Module.

Inpatient QIs reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures. Download IQI Module.

Patient Safety Indicators also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.  Download PSI Module.

Pediatric QIs both reflect quality of care inside hospitals and identify potentially avoidable hospitalizations among children. Download PedQI Module.

 

Purpose

The purpose of these indicators is to show hospitals, doctors, health officials and the public where there is room for improvement. They are not meant to be used as fuel to criticize the quality of care at a facility. QIs are an approximation. They do take into account the age and gender as well as the severity of the ailment that the patient has, but they cannot account for all extraneous factors. For example, possibly a critical piece of equipment went off line, or a patient wasn’t cooperative, or didn’t follow a doctor’s instructions, the outcome may be poor, but this may not be a true reflection on the hospitals quality of care. This should be kept in mind when reviewing QI rates.

This webpage provides volume and rates for a number of Quality Indicators. It essentially makes a judgment call, “Is a facility doing better or worse than expected?” An average rating signifies that a facility has a rate that is within plus or minus 5% (.95 - 1.05) of the expected value. If a facility has an observed rate that is 6% above that expected value rather than 5%, they move from average to “Worse than expected”. This is only a 1% difference. Again, QIs are an approximation. “Better” may not mean great, and “Worse” may not mean terrible.

TIERS AND TYPES

To assist in potential improvements, all of the AHRQ QIs have been and continue to be reviewed by the National Quality Forum (NQF) (http://www.qualityforum.org/). A recent increase in the accuracy of the QIs occurred with the addition of Present on Admission (POA) in administrative data. Though the value of every indicator is reviewed, not all QIs are of equal standing. The NQF has created a rating system. This system places many of the indicators within a tier (1-4). This webpage does not display indicators for hospital comparisons below tier 2. Some indicators have not been given a tier. These will only be displayed at the state or regional level. When listed, their tier will be displayed as NA.

Tier 1

a) Public Reporting – Very good for reporting and accountability

b) Reliable – Strongly evidence based. Good for comparative reporting

c) Endorsed – Endorsed by NQF

 

Tier 2

a) Public Reporting – acceptable

b) Reliable – Moderately evidence based. Acceptable for comparative reporting

c) Endorsed – Not endorsed by NQF

 

Tier 3

a) Public Reporting – not acceptable

b) Reliable – Serious gaps in evidence base. Not acceptable for comparative reporting

c) Endorsed – Not endorsed by NQF

 

Tier 4

a) Public Reporting – not acceptable

b) Reliability – Substantial gaps in evidence base. Not acceptable for comparative reporting

c) Endorsed – Not endorsed by NQF

 

Details on every indicator can be found in the user guides at the following link http://www.qualityindicators.ahrq.gov/downloads.htm. First click on the download page for the type of indicator you are interested in. These can be found near the top left of the page.

After you’ve clicked on one of these, go to the bottom of the page and select guide. E.g. The user guides will explain the methodology and coding used for each indicator. They will also discuss their strengths, weaknesses, limitations and other details.

Below are lists of all indicators and their respective tiers.

Inpatient Quality Indicators: These indicators reflect quality of care inside hospitals and include inpatient mortality; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures is associated with lower mortality.

 

 

 Prevention Quality Indicators: These indicators consist of “ambulatory care sensitive conditions,” hospital admissions that evidence suggests could have been avoided through high-quality outpatient care or that reflect conditions that could be less severe, if treated early and appropriately. This website will only display these indicators at the state and regional levels.

 

 

Strengths and Limitations in Using the PQIs: In the AHRQ document pqi_guide_v31.doc, page 14, the strengths and limitations of the PQIs are discussed in detail. (This document can be found at the bottom of the web page http://www.qualityindicators.ahrq.gov/pqi_download.htm).

 

According to AHRQ, the PQIs are a valuable tool for identifying potential quality problems in outpatient care that help to set the direction for more in-depth investigation. The PQIs will allow comparisons across States, regions, and local communities over time. The following table displays the limitations of the PQIs. These limitations should be taken into account when evaluating the data presented on this Transparency website.

 

 

a

Notes under Literature Review Findings: Proxy – Indicator does not directly measure patient outcomes but an aspect of care that is associated with the outcome; thus, it is best used with other indicators that measure similar aspects of care. Confounding bias – Patient characteristics may substantially affect the performance of the indicator; risk adjustment is recommended. Unclear construct – There is uncertainty or poor correlation with widely accepted process measures. Easily manipulated – Use of the indicator may create perverse incentives to improve performance on the indicator without truly improving quality of care. Unclear benchmark – The “correct rate” has not been established for the indicator; national, regional, or peer group averages may be the best benchmark available. ? – The concern is theoretical or suggested, but no specific evidence was found in the literature. – Indicates that the concern has been demonstrated in the literature.

b

Uncontrolled diabetes is designed to be combined with diabetes short-term complications

 

 

 

 

Patient Safety Indicators: These indicators focus on potentially preventable instances of complications and other ailments or complications resulting from exposure to the health care system.

 

Pediatric Quality Indicators: This module, available in February, 2006, contains indicators that apply to the special characteristics of the pediatric population.

 

 

 

FIELDS AND FORMATS

Fields

 

Cases

The Cases are the number of outcomes of interest. This may be the volume of a particular procedure(s) or it may be the number of deaths, depending on the Indicator viewed.

Population

Population at risk: The number of discharges of those that had particular procedures (the procedures are normally found within the indicator name). This population is usually limited to certain age ranges and has certain exclusions depending on the indicator.

Observed Rate

The observed rate is the number of Cases divided by the Population at risk. For example, if the indicator were <Acute Stroke Mortality Rate (IQI 17)>, and there were 100 cases to 1,000 population (100/1000 = 0.1), observed mortality rate would be 10%.

Risk Adjusted Rate

This value may initially seem counterintuitive, but as the overall severity of the patients goes up, the Risk Adjusted Rate goes down in comparison to the Observed Rate. Essentially, what this field is saying is, “If you have very sick patients, you’ll be provided leeway on your Quality Rates.”

Severity

The AHRQ software used to create the indicators creates standard population rates for each indicator. It also creates expected rates based on the severity of the patient mix. Expected rates are Observed Rates adjusted for risk. If the expected rate is higher than the population rate, then the severity is high (and vice versa).

Persistence

The “Persist” column lets the user know if the rates shown are an anomaly or expected to continue into the future. A “Yes” signifies that the displayed rates will continue unless the quality of care changes.

Formats

Notice that the hospital names are hyperlinks. If you click on these you will be directed to the hospital home page, or another page that they have requested. If you see a , clicking on it will provide context information. For example, if the symbol is after a hospital name, for a particular quality indicator, clicking on this symbol will provide additional information for the indicator rates for that particular hospital.

If you see the words “Previous” and “Next”, this signifies that there are additional pages to view.