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Davies SM, Geppert J, McClellan M, et al. Refinement of the HCUP Quality Indicators. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 May. (Technical Reviews, No. 4.)
This appendix includes a compilation of the indicators that we located during the Phase 1 literature review (Identifying indicators), and through interviews.
The indicators are organized by measure type (structural indicators; process indicators - utilization, length of stay; outcome indicators - ACSC/avoidable hospitalizations, complications, mortality) and by clinical domain (medical, surgical, chronic, obstetric, neonatal, pediatric, psychiatric). In some cases multiple definitions appear in the literature. Alternate definitions are noted.
The current users or developers include all the groups/individuals that we identified during our Phase 1 literature review and through phone interviews.
The literature and empirical columns refer to whether or not a detailed literature or empirical review was completed for the indicator. These reviews appear in the main text.
The reason for selection or exclusion refers to our selection process for determining which indicators to review extensively with the structured evaluation framework. The criteria and process are described in the methods section.
The indicator number is the number that has been assigned to each indicator as a unique identifier used throughout the report.
| Measure Type and Clinical Domain | Indicator Name | Current Users or Developers | Evidence Review* | Reason for selection or exclusion | Indicator # in text body | |
|---|---|---|---|---|---|---|
| Empirical | Literature | |||||
| Structure measures: Volume Outcome measures: Examples: | ||||||
| Acute myocardial infarction (AMI) | Suggested uses in literature (Halm, Dudley) | Providers have limited control over frequency of AMI admissions, controversy over actual volume-outcome relationship | - | |||
| Amputation of lower limb | No recent studies | - | ||||
| Abdominal Aortic Aneurysm (AAA) repair | x | x | Relatively frequent procedure, with strong established volume-outcome relationship | 1 | ||
| Carotid endarectomy | x | x | Frequent, high complication, mortality rates | 2 | ||
| Cerebral aneurysm repair | Small number of recent studies. | - | ||||
| Cholecystectomy | No recent studies. Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Coronary Artery Bypass Graft (CABG) surgery | x | x | Frequent, PTCA alternative, documented relationship, current HCUP QI utilization | 3 | ||
| Esophageal resection | x | x | Though infrequent, the volume outcome relationship is particularly strong. | 4 | ||
| Gastric surgery | No recent studies. Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Heart transplantation | Small number of recent studies. | - | ||||
| Hepatic resection | Infrequent procedure, low provider variation | - | ||||
| Hernia repair | Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Hip fracture | Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Human Immunodeficiency Virus (HIV) | Literature showing relationship is based on data over a decade old. Recent advances and changes in treatment call into question the validity of those results in the year 2000. | - | ||||
| Lower extremity arterial bypass surgery | Small number of recent studies, 2 out of 3 showed no volume effect. | - | ||||
| Pancreatic resection | x | x | Though infrequent, volume relationship to outcome is very strong. | 5 | ||
| Pediatric heart surgery | x | x | Pediatrics is a focus area for new HCUP indicators, strong volume-outcome relationship | 6 | ||
| Prostatectomy | Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Percutaneous Transluminal Coronary Angioplasty (PTCA) | x | x | Frequent, CABG alternative, documented relationship with volume | 7 | ||
| Total knee replacement | Few recent studies. | - | ||||
| Total hip replacement | Conflicting evidence as to the volume-outcome relationship. | - | ||||
| Process Measures, provider level: Potentially overused: Cesarean sections: | ||||||
| Primary cesarean section |
| Combined in all cesarean section | ||||
| Repeat cesarean section |
| |||||
| All cesarean section |
| x | x | Current HCUP indicator | 8 | |
| Surgical: | ||||||
| Incidental appendectomy |
| x | x | Current HCUP | 9 | |
| Bilateral cardiac catheterization |
| x | x | Common procedures with clear indications and overuse documentation. | 10 | |
| Radical mastectomy |
| p | Many mastectomy or lumpectomy procedures are performed on an outpatient basis. | - | ||
| Potentially underused: Vaginal delivery after cesarean section (VBAC): | ||||||
| Vaginal Birth After C-section (VBAC) |
| x | x | VBAC is a current HCUP measure | 11 | |
| Laparoscopic cholecystectomy |
| x | x | Current HCUP with extensive literature | 12 | |
| Process Measures, area level: Potentially overused: Surgical: | ||||||
| Carotid endarterectomy |
| p | Common procedure, with evidence of potential overuse. Low precision using HCUP NIS data. | - | ||
| Cataract surgery |
| Potentially outpatient procedure | - | |||
| Cholecystectomy |
| Potentially outpatient procedure | - | |||
| Colonoscopy |
| Outpatient procedure | - | |||
| Coronary angiography (includes diagnostic testing for coronary artery disease) |
| Outpatient procedure | - | |||
| Coronary artery bypass graft (CABG) |
| x | x | Current HCUP | 13 | |
| Hysterectomy |
| x | x | Current HCUP | 14 | |
| Joint replacement (hip and knee) |
| Though high variability of procedure makes indicator potentially precise, inappropriateness rates not studied extensively due to inherent subjectivity of indication for procedure. | - | |||
| Laminectomy and/or spinal fusion |
| x | x | Current HCUP | 15 | |
| Transurethral resection of the prostate (TURP) |
| p | Current HCUP, low precision | - | ||
| Radical prostatectomy (all and over 75 years) |
| p | Current HCUP, low precision | - | ||
| PTCA |
| x | x | Common procedure, high area variation, and evidence of misuse. | 16 | |
| Sinus surgery |
| Potentially outpatient procedure | - | |||
| Upper GI tract endoscopy |
| Outpatient procedure | - | |||
| Length of stay (LOS): | Since LOS is usually used as a resource measure and not typically as a quality indicator, we did not include any of the LOS indicators in our recommendations. | |||||
| Medical Examples: | ||||||
| Chemotherapy |
| Not typically a quality indicator | - | |||
| GI Hemorrhage |
| Not typically a quality indicator | - | |||
| Heart failure and shock |
| Not typically a quality indicator | - | |||
| HIV related admissions |
| Not typically a quality indicator | - | |||
| Pneumonia |
| Not typically a quality indicator | - | |||
| Rehabilitation |
| Not typically a quality indicator | - | |||
| Stroke |
| Not typically a quality indicator | - | |||
| Surgery Examples: | ||||||
| Bone and joint procedures |
| Not typically a quality indicator | - | |||
| Coronary procedures | Not typically a quality indicator | - | ||||
| Circulation disorders with catheterization | Not typically a quality indicator | - | ||||
| Craniotomy | Not typically a quality indicator | - | ||||
| Hip replacement surgery | Not typically a quality indicator | - | ||||
| Percutaneous transluminal coronary angioplasty (PTCA) | Not typically a quality indicator | - | ||||
| Obstetric: | ||||||
| Cesarean section with complications |
| Not typically a quality indicator | - | |||
| Cesarean section without complications |
| Not typically a quality indicator | - | |||
| Vaginal delivery with complications |
| Not typically a quality indicator | - | |||
| Vaginal delivery without complications |
| Not typically a quality indicator | - | |||
| Neonatal: | ||||||
| Normal neonatal |
| Not typically a quality indicator | - | |||
| Neonatal with complication |
| Not typically a quality indicator | - | |||
| Pediatric: | ||||||
| Pediatric asthma/bronchitis |
| Not typically a quality indicator | - | |||
| Psychiatric: | ||||||
| Psychoses |
| Not typically a quality indicator | - | |||
| Proxy-Outcome measures: Conditional length of stay: | ||||||
| All discharges, length of stay |
| A new indicator in development, will be considered in complications module. | - | |||
| Outcomes measures: Ambulatory care sensitive conditions/Avoidable hospitalizations: Medical: | ||||||
| AMI |
| Not included in most commonly used ACSC indicator sets. | - | |||
| Cellulitis (or abscess, or other soft tissue infection, or lymphadenitis) |
| p | Low precision using HCUP NIS data set | - | ||
| Congenital syphilis |
| Infrequent | - | |||
| Dehydration/volume depletion |
| x | x | Measured with adequate precision. | 17 | |
| Delivery, high risk/complicated |
| Possibly need detailed clinical data. | - | |||
| Dental conditions |
| Infrequent | - | |||
| Gangrene |
| Infrequent | - | |||
| Gastroenteritis |
| p | Low precision for adults. Evaluated as a pediatric measure. | - | ||
| Hypoglycemia |
| p | Low precision. | |||
| Hypokalemia |
| Infrequent, outside of eating disorder treatment centers | - | |||
| Immunization preventable diseases (includes pneumonia and influenza in elderly) |
| p | Current HCUP Indicator. Low precision, combined with Pneumonia avoidable hospitalization indicator | - | ||
| Malnutrition |
| Infrequent, outside of eating disorder treatment centers | - | |||
| Pelvic inflammatory disease |
| Infrequent | - | |||
| Pneumonia (defs may include bacterial pneumonia, pleurisy, bronchitis, bronchiolotis, pharyngitis, and sinsusitis) |
| x | x | Common admission, measured with adequate precision. | 18 | |
| Pyelonephritis/Urinary Tract Infection |
| x | x | Measured with adequate precision | 19 | |
| Ruptured/perforated appendix |
| x | x | Current HCUP QI, measured with adequate precision. | 20 | |
| Severe ear, nose and throat infections |
| p | Low precision using HCUP NIS data set | - | ||
| Skin graft with cellulitis |
| p | Low precision using HCUP NIS data set | |||
| Stroke (def may specify with hypertension) |
| Not included in most commonly used ACSC indicator sets. | - | |||
| Tuberculosis (may include other respiratory infections) |
| Infrequent | - | |||
| Chronic: | ||||||
| Angina |
| x | x | Common admission, measured with adequate precision. | 21 | |
| Anemia (includes iron deficiency anemia) |
| |||||
| Asthma |
| x | x | A current HCUP QI as a pediatric measure. | 22 | |
| Asthma and bronchitis |
| Evaluated asthma without bronchitis. | - | |||
| Cancer, breast (female) |
| Not included in most sets of ACSC indicators. | - | |||
| Cancer, cervical (invasive) |
| Not included in most sets of ACSC indicators. | - | |||
| Cerebrovascular disease among non-elderly adults |
| p | Current HCUP QI, low precision using HCUP NIS data set. | - | ||
| Chronic obstructive pulmonary disease (COPD) |
| x | x | Frequent cause of admission, guidelines for ambulatory management, differences in practice patterns. | 23 | |
| Congestive heart failure (CHF; may include CHF and pulmonary edema or shock) |
| x | x | Common chronic condition with relatively frequent hospitalizations | 24 | |
| Diabetes, all |
| |||||
| Diabetes (short-term complications or A,B,C) |
| x | x | Current HCUP QI with complications | 25 | |
| Diabetes, uncontrolled |
| x | x | Addendum indicator for use with diabetes short-term complications to make definition consistent with HP2010. | 26 | |
| Diabetes (long-term complications) |
| x | x | Current HCUP QI with complications | 27 | |
| Diabetic ketoacidosis (DKA) |
| A current HCUP QI as a diabetes complication measure | - | |||
| Hypertension (includes malignant) |
| x | x | Measured with adequate precision. | 28 | |
| Lower extremity amputation |
| x | x | Healthy People 2000 goal, low precision using HCUP NIS data set. | 29 | |
| Perforated/bleeding ulcer |
| Infrequent | - | |||
| Rheumatic fever |
| |||||
| Seizures and convulsions (may include convulsions 'A' & 'B'; epilepsy or grand mal status) |
| p | Low precision | - | ||
| Pediatrics: | ||||||
| Failure to thrive |
| Infrequent | - | |||
| Immunization preventable diseases (measles, mumps, and/or polio) |
| Infrequent | - | |||
| Iron deficiency anemia |
| Infrequent | - | |||
| Low birthweight |
| x | x | Current HCUP QI | 30 | |
| Pediatric acute otitis media |
| Infrequent (as a primary diagnosis excluding surgery patients) | - | |||
| Pediatric Asthma (may include bronchitis & asthma) |
| x | x | Frequent cause of admission, guidelines for ambulatory management, differences in practice patterns | 31 | |
| Pediatric burns |
| A good potential injury indicator, which was not our primary focus. | - | |||
| Pediatric diabetes |
| p | Frequent cause of admission, very low precision | - | ||
| Pediatric gastroenteritis |
| x | x | Frequent cause of admission, guidelines for ambulatory management, differences in practice patterns | 32 | |
| Pediatric mastoiditis |
| Infrequent | - | |||
| Pediatric nausea and vomiting |
| Infrequent | - | |||
| Pediatric urinary tract infection |
| Infrequent | - | |||
| Pediatric viral meningitis |
| Infrequent | ||||
| Pediatric viral syndrome |
| Frequent cause of admission | - | |||
| Very low birthweight |
| p | Current HCUP, low precision using HCUP NIS data set. | - | ||
| Complications: | REVIEW OF COMPLICATIONS IN SEPARATE REPORT | |||||
| In-hospital Mortality: | ||||||
| Overall mortality |
| Potentially very biased due to heterogeneous patient population; difficult to determine an appropriate intervention | - | |||
| Medical: | ||||||
| Acute myocardial infarction (AMI) |
| x | x | Already a substantial amount of information on hospital performance with AMI, including the Medicare Cooperative Cardiovascular project; other HCUP QI focus on procedures for the treatment of MI (PTCA, CABG). | 33 | |
| Angina |
| Have indicator for AMI mortality, one of the other conditions covered by the MHA aggregate measure | - | |||
| Bone marrow transplant (BMT) |
| Limited number of providers, infrequent | - | |||
| Chronic obstructive pulmonary disease |
| A progressive chronic disease ; more difficult to evaluate without longitudinal data | - | |||
| Congestive heart failure (CHF) |
| x | x | Substantial literature, some use as quality indicator. Related to other indicators as overall cardiovascular care. | 34 | |
| Adult diabetes |
| Very rare cause of death ; other indicators (cardiovascular, infections) capture deaths in this population. | - | |||
| GI hemorrhage |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume). | 35 | |
| Heart failure and shock |
| p | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume), measured with low precision. | - | ||
| Hip fracture |
| x | x | Common admission in the elderly with relatively high mortality rates. Substantial literature regarding hip fracture mortality. | 36 | |
| HIV |
| Data unavailable. Confounds due to HAART, home IV antibiotics, etc. | - | |||
| Lung cancer |
| A progressive disease requiring clinical risk adjustment (PHC4 uses clinical risk adjustment) | ||||
| Pneumonia |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume). | 37 | |
| Pneumonia/hemo thorax mortality |
| Limited use | - | |||
| Renal failure |
| Disease is rarely fatal by itself, associated with other serious complications or comorbidities. | - | |||
| Respiratory failure |
| Often coded based on physiological state, rather than as a treatable condition. | - | |||
| Septicemia |
| Limited evidence located. | - | |||
| Stroke |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume). | 38 | |
| Trauma |
| Potential need for emergency room data and/or clinical data on injury severity. | - | |||
| Surgical: | ||||||
| Abdominal aortic aneurysm repair |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume). | 39 | |
| Carotid endarterectomy |
| p | Preliminary exploration of indicator to focus on related aspects of particular condition (i.e., mortality, utilization, volume). Excluded due to low precision. | - | ||
| Circulation disorder with catheterization |
| In general, avoid non-complication related procedure based mortality measures due to problems of patient selection | - | |||
| Cholecystectomy |
| p | Current HCUP QI, low precision. | - | ||
| Coronary artery bypass graft (CABG) |
| x | x | Already widely reported in multiple states. | 40 | |
| Coronary Procedures |
| In general, avoid non-complication related procedure based mortality measures due to problems of patient selection | - | |||
| Craniotomy |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume) | 41 | |
| Esophageal resection |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume) | 42 | |
| Knee replacement |
| p | Current HCUP QI. Low precision. | - | ||
| Hip replacement |
| x | x | Current HCUP QI | 43 | |
| Hysterectomy |
| p | Current HCUP QI. Low precision. | - | ||
| Laminectomy/spinal fusion |
| p | Current HCUP QI. Low precision. | - | ||
| Orthopedic surgery |
| In general, avoid non-complication related procedure based mortality measures due to problems of patient selection | - | |||
| Pancreatic resection |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume) | 44 | |
| Perioperative mortality |
| Potentially very biased due to heterogeneous patient population; difficult to determine an appropriate intervention | - | |||
| Percutaneous transluminal coronary angioplasty (PTCA) |
| p | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume) Low precision. | - | ||
| Prostatectomy |
| In general, avoid non-complication related procedure based mortality measures due to problems of patient selection | - | |||
| Transurethral resection of prostate (TURP) |
| p | x | Current HCUP QI. Low precision. | - | |
| Pediatric: | ||||||
| Overall pediatric mortality |
| Potentially very biased due to heterogeneous patient population; difficult to determine an appropriate intervention | - | |||
| Neonatal mortality |
| Potentially very biased due to heterogeneous patient population; difficult to determine an appropriate intervention | - | |||
| Pediatric heart surgery |
| x | x | Indicator selected to focus on related aspects of particular condition (i.e., mortality, utilization, volume) | 45 | |
| Psychiatric: | ||||||
| Depression |
| Infrequent in acute care setting | - | |||
| Other measures: | ||||||
| Newborn Outcomes |
| Difficult to implement without longitudinal data | - | |||
| Public Health Measures: | ||||||
| Admission for AMI |
| Included in previously considered indicators | - | |||
| Adolescent mothers |
| These indicators generally are underreported, and have less connection with the health care system | - | |||
| Child abuse |
| These indicators generally are underreported, and have less connection with the health care system | - | |||
| External injury (firearms) |
| These indicators generally are underreported, and have less connection with the health care system | - | |||
| Motor vehicle accident (MVA) |
| These indicators generally are underreported, and have less connection with the health care system | - | |||
| Substance abuse |
| Difficult to determine from discharge data true cases, infrequent in acute care setting | - | |||
| Stroke/TIA |
| Included in previously considered indicators | - | |||
| Suicide attempt |
| Concern about reporting bias. | - | |||
*An "x" placed in the empirical or literature evidence review column denotes that the review was conducted; a "p" denotes that preliminary analyses were conducted, but that the indicators' performance was poor on statistical tests of precision.
- Inventory of Indicators - Refinement of the HCUP Quality IndicatorsInventory of Indicators - Refinement of the HCUP Quality Indicators
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