Quality Indicator Overview

• What information or materials can be obtained through the AHRQ Quality Indicators website?
• How do I interpret the output or specific cases?
• Is benchmark information available?
• How are the AHRQ Quality Indicators revised and how do I learn more about them?
• Will AHRQ create Quality Indicators for each type of surgery or specific condition?
• What if I have concerns about the coding approach taken to assign the ICD-9-CM codes?
• What is the status of the QI conversion to ICD-10-CM/PCS?
• How do I learn about quality measures other than the QI?

The Agency for Healthcare Research and Quality (AHRQ) conducts many research tasks, of which the Quality Indicators (QIs) are only one. Information about AHRQ's other projects can be found through their main website: www.ahrq.gov. AHRQ develops Quality Indicators to provide health care decision makers with tools to assess their data. The AHRQ Quality Indicators website supplies the Quality Indicators software and supporting documentation for ONLY the quality indicators: Prevention Quality Indicators, Patient Safety Indicators, Inpatient Quality Indicators, and Pediatric Quality Indicators. The AHRQ Quality Indicators do not provide:

• Data
  • To obtain data you will likely have to go through your hospital, state or, possibly, HCUP Reports on hospitals
  • If you have a published report based on the AHRQ Quality Indicators, then you will need to contact the author of the report to determine the method for generating the report
  • HCUP may have reports and rates available
• Reports on users of the software
• Care guidelines or advice on how to improve rates or use the software output
• Individual trainings.

Currently, the AHRQ Quality Indicators are only for use with administrative data in acute care hospitals, and are not available for other types of settings (e.g., long-term care, outpatient, ambulatory, hospice, individual practice, emergency department, or diagnostic centers) or populations (e.g., mental health or substance abuse, emergency preparedness, patient falls, rehabilitation, readmission, surgery, heparin therapy, c. difficile, or nursing quality). Other agencies may have quality indicators for other settings, so you are encouraged to check the National Quality Measures Clearinghouse or National Quality Forum website. The Healthcare Cost and Utilization Project (HCUP) also produces tools helpful to crosswalks and software. However, AHRQ Quality Indicators for certain ambulatory care sensitive conditions indicators for adults (see PQI module) and children (see PDI module) are available.

Documentation (SAS^® or WinQI) is available regarding interpretation. AHRQ Quality Indicators user support does not provide support with interpretation of individual cases or advice on how to apply codes to a specific case.

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Is benchmark information available?

Date Published: February 28, 2011
Date Updated: June 1, 2012

Yes. There are three sources of benchmark information available. The first source is the Reference Population rate used in the calculation of the risk-adjusted rate using indirect standardization. There are two (equivalent) ways a hospital might use the Reference Population rate: compare the hospital's observed rate to the hospital's expected rate (the observed-to-expected ratio) or compare the hospital's risk-adjusted rate to the Reference Population Rate. The second source is the comparative data (available on the AHRQ Quality Indicators website) based on the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). A hospital may use the NIS to compare the hospital's risk-adjusted rate to the risk-adjusted rate from a nationally representative sample of hospitals. Additionally, QI summary statistics are available via HCUPnet at http://hcupnet.ahrq.gov/.

Each year we incorporate the new coding changes and other software updates into the AHRQ Quality Indicators software and release the most updated version, usually by the end of Spring. We informally compare rates for indicators from year to year and look for unexpected percentage changes, and update the indicators to conform to yearly changes in ICD-9-CM diagnosis codes and procedure codes, so a formal test using confidence intervals would be of limited use, given the time delay in having data with the current coding structure. Our indicators are reviewed carefully for validity and many have been endorsed by the National Quality Forum (NQF); they tend to be very complex and depend on detailed diagnosis and procedure coding. When new codes are added or revised, our priority is on specificity and sensitivity. Additionally, updates are typically made to the software to improve usability and enhance the functionality.

We provide extensive documentation on the specific Quality Indicators, the software, and the methodology for creating the Quality Indicators. Some commonly asked questions are:

• How do I learn about changes?
  • Consult the relevant Quality Indicators module page ( PQI, IQI, PSI, PDI)
    • From here you can see the Log of Coding Updates and Revisions, which documents all changes to the measures and software for that particular module.
  • Consult the Quality Indicators software page
    • Review the release notes for SAS and WinQI
    • Review the results of comparison testing
• Where can I see a listing of all the ICD-9 codes?
  • A list of ICD-9 codes can be found here: https://www.cms.gov/ICD9ProviderDiagnosticCodes/06_codes.asp
• How do I learn about prevalence, costs, length of stay, etc.?
  • HCUPNet is one resource to learn about various health statistics via http://hcupnet.ahrq.gov/

Our current documentation is available for download in PDF format for ease of compatibility. We do not provide the Word versions of the PDF documents.

The AHRQ Quality Indicators are focused on quality and are less focused on prevalence and incidences of all cases. For example, we are not interested in all strokes but only the most acute strokes where evidence suggests that some of the variability among hospitals might be reduced through improved processes of care.

These rates would likely be too narrow and based on too few cases to be of value. The indicators were developed and validated with clinical consultants, expert panels, and considerable research as to their validity, reliability, and usefulness in identifying classes of events that may be problems and that are actionable. Also, many are endorsed by the NQF.

There is a significant interest in additional stratifications of the data (e.g., hemorrhagic vs. ischemic stroke. Users of the Windows^® software (WINQI) may use the custom stratification feature of the provider level reports to review risk-adjusted rates by these types of clinical classifications. One concern is reliability as you drill down into more specific strata because of the low frequency of many of the indicators.

The AHRQ QI support line is available to answer your questions about the QI definitions and receive your feedback on those definitions; however, the QI support line does not provide consultation on appropriate use of the codes. If you have questions about individual cases or general coding guidelines please follow either of these approaches:

1. If you have questions or disagreements about coding of individual cases, a special quarterly publication called Coding Clinic for ICD-9-CM provides interpretation and coding guidance on the proper use of ICD-9-CM. This quarterly resource is published by the American Hospital Association. However, the four Cooperating Parties for ICD-9-CM [i.e., American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS)] have final approval of the content of this official publication. The Editorial Advisory Board for Coding Clinic for ICD-9-CM is a voluntary advisory board. Any interested stakeholder may submit a case for coding adjudication to the American Hospital Association's Central Office on ICD-9-CM, following the procedure described here: http://www.ahacentraloffice.com/ahacentraloffice/shtml/icd9cm.shtml.
2. If you have questions or disagreements about general coding guidelines, the CMS and the NCHS are the two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS). They are in charge of the ICD-9-CM Coordination and Maintenance Committee. They provide the official guidelines for coding and reporting using the International Classification of Diseases. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM (i.e., AHA, AHIMA, CMS and NCHS).
   
   The following representatives for coding issues or guidelines are:
   
   CMS
   Patricia E. Brooks, RHIA
   Co-Chairperson, ICD-9-CM Coordination and Maintenance
   Hospital and Ambulatory Policy Group
   Division of Acute Care C4-08-06
   7500 Security Boulevard,
   Baltimore, Maryland 21244-1850
   patricia.brooks@cms.hhs.gov
   
   NCHS
   Donna Pickett, RHIA
   Co-Chairperson, ICD-9-CM Coordination and Maintenance
   NCHS
   3311 Toledo Road
   Hyattsville, Maryland 20782
   d.pickett@cdc.gov
   
   
   AHA
   Nelly Leon-Chisen, RHIA
   Director, Central Office on ICD-9-CM
   AHA
   One North Franklin
   Chicago, Illinois 60606
   nleon@aha.org
   
   AHIMA
   Sue Bowman, MJ, RHIA, CCS
   Senior Director, Classification and Coding
   AHIMA
   233 N. Michigan Avenue
   21st Floor
   Chicago, Illinois 60601-5809
   sue.bowman@ahima.org
   
   For ICD-9-CM Coordination and Maintenance Committee Meetings
   https://www.cms.gov/Medicare/Coding/ICD10/ICD-9-CM-Coordination-and-Maintenance-Committee-Meetings.html
   
   For ICD-9-CM Guidelines (scroll to the bottom for the latest version)
   http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
   
   For ICD-10-CM Guidelines (2012) - - download "Official ICD-10-CM Guidelines"
   https://www.cms.gov/Medicare/Coding/ICD10/2012-ICD-10-CM-and-GEMs.html
   
   For ICD-10-PCS Guidelines (2013) - download "Official ICD-10-PCS Coding Guidelines"
   https://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html
   
   

The QI will be updated for ICD-10-CM/PCS on a timeline that is consistent with the Centers for Medicare and Medicaid Services (CMS) implementation. There is currently a report, entitled “ICD-9-CM to ICD-10-CM/PCS Conversion of AHRQ Quality Indicators” available on the QI website, which details some of the considerations that are part of the conversion.

To learn about quality measures other than the QI you can search the National Quality Measure Clearinghouse or National Quality Forum , where you will find measures from other topic areas that use a variety of data sources.