Established Child Health Care Quality Measures
AHRQ Quality Indicators
Contents
The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) can provide information on the quality of hospital care and the adequacy of outpatient and other health care services in an area. They are produced using readily available hospital administrative data. Although they are not definitive measures, AHRQ QIs are a screening tool to help identify areas of clinical and community health care appropriate for further, more in-depth analysis.
[Note: AHRQ QIs were formerly called HCUP QIs. HCUP refers to the Healthcare Cost and Utilization Project, a Federal-State-industry partnership sponsored by AHRQ.]
AHRQ QIs help identify:
- Potentially preventable complications such as infections due to medical care.
- Adverse outcomes such as in-hospital mortality.
- Potentially problematic utilization rates for specific inpatient procedures thought to be over-, under-, or misused.
- Potential problems with outpatient and other health care in an area, generally a metropolitan statistical area (MSA) or county, as reflected in rates of hospitalization for ambulatory-care-sensitive conditions.
AHRQ QIs are based on readily available hospital discharge administrative data. Policymakers and other users can often get hospital administrative data from their State government or from hospitals. AHRQ QIs, which include 6 specific pediatric and neonatal indicators and 36 QIs that include the pediatric population, were refined through an AHRQ contract with the University of California at San Francisco-Stanford University Evidence-based Practice Center (UCSF-Stanford EPC).
AHRQ QIs fall into three modules called:
- Prevention Quality Indicators (PQIs).
- Inpatient Quality Indicators (IQIs).
- Patient Safety Indicators (PSIs).
UCSF-Stanford EPC researchers were asked to assess the original QIs,
refine and enhance them, and develop additional QIs as appropriate. They
conducted a literature search, interviewed technical experts and QI users,
assessed alternative risk adjustment strategies, and evaluated existing
and potential QIs using a variety of statistical techniques. Existing
and potential QIs were evaluated for:
- Face validity (making sense logically and clinically).
- Precision.
- Minimum bias.
- Construct validity (correlation with other measures of the same aspects
of care).
- Potential to foster real quality improvement.
- Actual application.
Example: Hospital discharge data for a given condition, e.g., pediatric
asthma, can be analyzed to identify outlier rates significantly above
or below the average by:
- Age group.
- Discharge status (routine, to another institution, to home health
care, etc.).
- Race and ethnicity (if available in the data).
- Geographic area (rural, urban).
If hospitals serving a particular program or population exhibit unusual
patterns, more focused analysis can follow.
Online Resources:
The complete report of the UCSF-Stanford EPC technical review, Refinement of the AHRQ Quality Indicators, is available at: http://www.ahrq.gov/clinic/tp/hcupqitp.htm.
AHRQ QI software includes specifications that allow users to produce comparative statistics and examine trends over time. Go to: http://www.qualityindicators.ahrq.gov
Pediatric Quality Indicators
The Pediatric Quality Indicators (PDIs) are a set of measures that can be used with hospital inpatient discharge data to provide a perspective on the quality of pediatric healthcare. For more information on PDIs, go to: http://www.qualityindicators.ahrq.gov/pdi_overview.htm
To download PDI software, a users guide, and technical specifications, go to: http://www.qualityindicators.ahrq.gov/pdi_download.htm
Child-Specific QIs
There are seven AHRQ QIs specific to children:
The Pediatric Asthma Admission Rate QI
The pediatric asthma admission rate PQI describes the admission rate for pediatric asthma per 100,000 population of children under age 18, excluding newborns and other neonates, within a geographic area such as an MSA or county.
This is an ambulatory-care-sensitive indicator. It is not a measure of hospital quality, but instead reflects the quality of outpatient and other health care services in the area.
There is no clear benchmark describing a preferred or appropriate level of pediatric asthma admissions. This QI can be used alone or in conjunction with other ambulatory-care-sensitive indicators. When using this QI, it is important to pay attention to high or low values that might bias the rate.
Online Resource: Consult pages 313-17 in the UCSF-Stanford EPC report for a more detailed analysis. To download the report, go to: http://www.ahrq.gov/clinic/tp/hcupqitp.htm
The Pediatric Gastroenteritis Admission Rate QI
The pediatric gastroenteritis admission rate PQI describes the admission rate for dehydration per 100,000 population of children under age 18, excluding newborns and other neonates, within a geographic area such as an MSA or county.
This is an ambulatory-care-sensitive indicator. It is not a measure of hospital quality, but instead reflects the quality of outpatient and other health care services in the area.
There is no clear benchmark describing a preferred or appropriate level of pediatric gastroenteritis admissions. This QI is best used in conjunction with other ambulatory-care-sensitive indicators such as the pediatric asthma admission rate QI or the low birth weight QI.
Online Resource: Consult pages 318-21 in the UCSF-Stanford EPC report for a more detailed analysis. To download the report, go to: http://www.ahrq.gov/clinic/tp/hcupqitp.htm
The Low Birth Weight QI
The low birth weight PQI describes the number of births below 2500 grams per 100 births in a geographic area such as an MSA or county.
This is an ambulatory-care-sensitive indicator. It is not a measure of hospital quality, but instead reflects the quality of outpatient and other health care services in the area.
Lower rates of low-weight births are preferable to higher ones. It is known that numerous factors outside of the health care system impact the low birth weight rate, but appropriate risk-adjusting mechanisms are not presently available. This QI should not be used alone, but can be used in conjunction with other ambulatory-care-sensitive QIs such as the pediatric asthma admission rate QI or the pediatric gastroenteritis admission rate QI.
Online Resource: Consult pages 309-12 in the UCSF-Stanford EPC report for a more detailed analysis. To download the report, go to: http://www.ahrq.gov/clinic/tp/hcupqitp.htm
The Pediatric Heart Surgery Volume QI
The pediatric heart surgery volume IQI describes the rate of discharge at a hospital for pediatric heart surgeries performed on children under age 18, excluding newborns and other neonates.
This is a volume indicator. Current evidence shows that a higher volume of such surgeries at a hospital may be associated with better outcomes. Volume measures are not direct measures of quality, however, and the relationship between volume and outcome may change as technology changes or providers become more experienced. The pediatric heart surgery volume QI should be used in conjunction with other measures, such as the pediatric heart surgery mortality QI.
Online Resource: Consult pages 206-9 in the UCSF-Stanford EPC report for a more detailed analysis.
To download the report, go to: http://www.ahrq.gov/clinic/tp/hcupqitp.htm
The Pediatric Heart Surgery Mortality QI
The pediatric heart surgery mortality IQI describes the number of deaths at a hospital following pediatric heart surgery per 100 pediatric heart surgeries performed on children under age 18, excluding newborns and other neonates.
This is a mortality indicator. Risk adjustment beyond that possible on the basis of administrative data is desirable. Lower rates are clearly preferred. This QI is not recommended as a stand-alone indicator. Use of this QI in conjunction with the pediatric heart surgery volume QI may offer a more comprehensive perspective.
Online Resource: Consult pages 373-6 in the UCSF-Stanford EPC report for a more detailed analysis. To download the report, go to: http://www.ahrq.gov/clinic/tp/hcupqitp.htm
The Birth Trauma PSI
The birth trauma PSI identifies cases of birth trauma per 1,000 liveborn births in a hospital.
This is a patient safety indicator intended to flag preventable complications of full-term deliveries. The measure excludes preterm deliveries since birth trauma for these patients may be less preventable than for full-term infants.
Risk adjustment beyond that possible using only administrative data is desirable. While not a definitive measure of quality, this measure can be used to identify potential opportunities for improvement.
Online Resource: Consult page 55 in the Guide to Patient Safety Indicators. Go to: http://www.qualityindicators.ahrq.gov/psi_download.htm
Other QIs That Can Be Used for Children
AHRQ QIs can be applied to a child population as well. These include:
- Dehydration Admission Rate.
- Bacterial Pneumonia Admission Rate.
- Urinary Infection Admission Rate.
- Perforated Appendix Admission Rate.
- Diabetes Complications Admission Rate.
Online Resource: For a complete list of AHRQ QIs with relevance to children, go to:
http://www.ahrq.gov/chtoolbx/QIchild.htm
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Availability
The QI software, currently in SAS and SPSS programming language, is in the public domain and is available free of charge. Rates can be produced for individual hospitals or geographic regions and compared with State or other averages. Go to Data Sources for a discussion of available data sources to assist in your analyses.
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Users
AHRQ QI users include:
- State purchasers.
- Academic researchers.
- Peer review organizations.
- State data organizations.
- State hospital associations.
- Health care providers.
- Business coalitions.
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Comparisons and Trends
AHRQ QIs are designed to provide initial feedback about clinical areas appropriate for further, more in-depth analysis. Many of the indicators measure areas in which variables are at work and where patient risk factors may play a large part. The measures should be viewed as screens to identify potential problem areas for further examination.
AHRQ QIs can be used:
- For quality improvement.
- To compare and trend performance over time.
They are not designed to:
- Assist in program management decisions.
- Provide definitive quality assessments.
- Make purchasing decisions.
- Provide information for public reporting on individual hospitals.
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Service Delivery and Units of Analysis
Because AHRQ QIs use hospital discharge rates drawn from hospital administrative data, they typically are not specific to any particular service delivery system, such as managed care organizations, primary-care case management programs, and fee-for-service delivery programs. AHRQ QIs can be used for statewide, regional, or local analysis if data from the relevant hospitals are available. More detailed analyses may be possible using State Medicaid claims data.
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Length-of-Enrollment Requirements
Length-of-enrollment requirements do not apply to AHRQ QIs.
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Data Sources
HCUPnet includes the largest collection of longitudinal hospital care data in the United States and can be used to calculate AHRQ QIs.
Online Resource: For more information on HCUPnet, go to: http://hcupnet.ahrq.gov/
These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcome of treatment at the national, State, and local levels. Three databases have specific relevance to children.
- The HCUP Kids' Inpatient Database (KID) is a unique longitudinal database of hospital inpatient pediatric discharges. Researchers and policymakers use the KID to analyze hospital utilization, charges, and outcomes for children across the United States. The KID's large sample size enables analyses of rare conditions, such as congenital anomalies, as well as uncommon treatments, such as organ transplantation.
The KID is currently available for the years 1997 and 2000 and contains clinical and nonclinical information on all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. Discharge weights are provided for calculating national estimates. Access to the KID is available through the HCUP Central Distributor and is open to users who sign a data use agreement. Uses are limited to research and aggregate statistical reporting.
Online Resource: For more information on the HCUP Kids' Inpatient Database, go to: http://www.hcup-us.ahrq.gov/kidoverview.jsp
- The HCUP State Inpatient Databases (SID) are a powerful set of longitudinal hospital inpatient databases. Researchers and policymakers use the SID to investigate questions unique to one State; to compare data from two or more States; to conduct market area variation analyses; and to identify State-specific trends in inpatient care utilization, access, charges, and outcomes.
The SID are composed of annual State-specific files that share a common structure and common data elements, subjected to a common set of edits. The SID contain a core set of clinical and nonclinical information on all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. The uniform format of the SID helps facilitate cross-State comparisons. Access to the SID from participating States is available through the HCUP Central Distributor. Uses are limited to research and aggregate statistical reporting.
Online Resource: For more information on the HCUP State Inpatient Databases, go to: http://www.hcup-us.ahrq.gov/sidoverview.jsp
- The HCUP Nationwide Inpatient Sample (NIS) is a unique and powerful database of hospital inpatient stays. It is the largest all-payer inpatient care database in the United States, containing data from more than 7 million hospital stays and approximately 1,000 hospitals. Researchers and policymakers use the NIS to identify, track, and analyze trends in health care utilization, access, charges, quality, and outcomes in the United States. It is ideal for developing national estimates and for research that requires a large sample size, such as rare conditions, uncommon treatments, and special patient populations.
The NIS contains clinical and nonclinical information on all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. Discharge weights are provided for calculating national estimates. Access to the NIS is available through the HCUP Central Distributor and is open to users who sign a data use agreement. Uses are limited to research and aggregate statistical reporting.
Online Resource: For more information on the HCUP Nationwide Inpatient Sample, go to:
http://www.hcup-us.ahrq.gov/nisoverview.jsp
The KID, NIS, and SID databases can be used to explore age-specific analyses. The KID is specific to children. All neonates and children are also included in the SID and NIS.
AHRQ QIs can be calculated using HCUP or any similar hospital administrative or claims data. The QI documentation provides details on data format and other data requirements of the QI software.
Online Resources:
For more information on HCUP, go to:
http://www.ahrq.gov/data/hcup/
For more information on AHRQ QIs, go to:
http://www.qualityindicators.ahrq.gov
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Development Process
HCUP is a Federal-State-industry health data partnership sponsored by AHRQ. Researchers at AHRQ developed the original HCUP QIs using the HCUP databases. The refined AHRQ QIs were developed through an AHRQ contract with the University of California at San Francisco-Stanford University Evidence-based Practice Center.
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Criteria Used
Criteria used in developing the original HCUP QIs included:
- Use of readily available, standardized, inexpensive data (hospital discharge data).
- Development of a format allowing organizations to use their own data or other locally available data.
- Preference for simple rather than more complex methodology wherever possible.
- Building on measures already in use.
The refined AHRQ QIs were enhanced by:
- Adding QIs, including additional pediatric QIs.
- Providing population-based denominators when appropriate.
- Addressing issues of risk adjustment.
- Providing methods to help stabilize low-frequency indicators.
Online Resources:
For more information on the development and uses of the QIs, see:
Johantgen M, Elixhauser A, Ball J, et al. Quality indicators using hospital discharge data: State and national applications. Jt Comm J Qual Improv 1998 Feb;88-105.
Abstract available on PubMed®:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9547683&dopt=Abstract
For more information on the refined QIs, see:
Davies S, Geppert J, McClellan M, et al. Refinement of the HCUP Quality Indicators. Technical Review 4. (Prepared by the UCSF-Stanford Evidence-based Practice Center). AHRQ Publication No. 01-0035. Rockville (MD): Agency for Healthcare Research and Quality. May 2001.
Go to: http://www.qualityindicators.ahrq.gov/downloads.htm
For more information on the Patient Safety Indicators, see:
McDonald K, Romano P, Geppert J, et al. Measures of Patient Safety Based on Hospital Administrative Data—The Patient Safety Indicators. Technical Review 5 (Prepared by the University of California San Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 02-0038. Rockville (MD): Agency for Healthcare Research and Quality. August 2002.
Go to: http://www.qualityindicators.ahrq.gov/psi_download.htm
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More Information and User Support
E-mail support@qualityindicators.ahrq.gov for more information about AHRQ QIs and for user support.
Online Resource: QI information, including software in a downloadable format, is available on the AHRQ QI Web site. Go to: http://www.qualityindicators.ahrq.gov
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Overview / CAHPS® / HEDIS® / Title V / CAHMI-PHDS / CAHMI-YAHCS
State Report Examples / Mental Health Quality Measures
Internet Citation:
Child Health Care Quality Toolbox: Established Child Health Care Quality Measures—AHRQ Quality Indicators. August 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chtoolbx/measure3.htm
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