Methodology
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Hospital/Ambulatory Surgery Center Update Timeline Methodology for Adjusting Charges and Length of Stay Methodology for Readmission Rate Hospital Inpatient Medical Conditions and Procedures - Adults Diabetes/Endocrinology/Metabolism Hospital Inpatient Medical Conditions and Procedures - Deliveries and Newborns Hospital Inpatient Medical Conditions and Procedures - Pediatrics Ambulatory (Outpatient) Surgery Centers Methodology for Adjusting Charges Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Adults Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Pediatrics Inpatient Mortality Indicators Mortality Inpatient Procedures Mortality Inpatient Conditions Patient Safety Indicators - Complication and Infection HospitalsMethodology for Adjusting Charges and Length of StayThe data is risk adjusted for patient severity in order to allow for meaningful comparisons. The primary reason for risk adjustment is to remove the long-standing and valid criticism that evaluative comparisons of two or more disparate groups based on observed reported data is often not an effective methodology due to differences in case-mix between the groups under study. This criticism in simpler terms is the "our patients are sicker than their patients" response. In order to understand how data is adjusted for severity and case mix, three concepts must be introduced; observed value, expected value, and risk adjusted. Important - The time period for adults represents July 2006 – June 2007 data and pediatrics uses 3 years of data July 2004 – June 2007. Observed Value This is the reported value. For example, the observed average length of stay for a hospital is calculated by taking the total inpatient days for all patients and dividing this total by the total number of cases. The values used for days and cases are taken from information reported by the hospital to the Agency for Health Care Administration (AHCA). Expected Value Expected values are severity adjusted according to case mix, using 3M's All Patient Refined Diagnosis Related Groups (APR-DRGs) as the methodology for severity adjustment. Note: Expected value calculations for adults are APRDRG and age group specific for each product line age group. Expected value calculations for pediatrics are APRDRG and age group specific for each product line age group. Also, the values for pediatrics are based on three years of data, July 2004 – June 2007. Before proceeding to an example of an expected value calculation, we need to first describe the APR-DRG patient classification and severity assignment process. Medicare DRGs and AP-DRGs are patient classification systems with a primary objective of grouping types of patients treated by the resources they consume. 3M's APR-DRGs build upon these systems by going beyond the simple assignment of a base DRG by also assigning to each case a severity of illness, defined as: Severity of illness: the extent of physiologic decompensation or organ system loss of function Severity of illness subclasses are numbered as either 1 (minor), 2 (moderate), 3 (major), or 4 (extreme). Assignment of severity of illness subclasses is based upon a number of factors, including the underlying base APR-DRG assignment (determined by principal diagnosis, procedures, age, sex and discharge status), secondary diagnoses, and interactions amongst diagnoses. The advantage of APR-DRGs is that they acknowledge differences in severity of illness among patients within a single APR-DRG, as fits with our real world understanding. For example, some pneumonia patients are much sicker than others, even though they may all be classified under the same DRG. So how does this website use APR-DRGs in calculating expected values? Each inpatient case is assigned an expected value which is the average value for that case's designated APR-DRG and severity of illness level across the State of Florida. For example, a case is designated as a Simple Pneumonia (APR-DRG 139) with a severity of illness level 2. The state average length of stay for all Simple Pneumonia (APR-DRG 139) with severity of illness level 2 is 5.5 days. The expected value for this specific case's length of stay would then be 5.5 days. Calculations: Hospital's Observed ALOS: Total hosp. days for the selected condition / total hosp. cases for the selected condition Hospital's Expected ALOS: Average of the expected hosp. length of stay for all cases for the selected condition at the hospital Risk Adjusted Value The risk-adjusted average length of stay is the best estimate, based on the statistical model, of what the provider's length of stay would have been if the provider had a mix of patients identical to the statewide mix. The risk adjusted value is the observed length of stay divided by the expected length of stay and multiplied by the state of Florida's average length of the stay for a medical condition/procedure. Hospital's Risk adjusted ALOS: Observed ALOS for the selected condition / Expected ALOS for the selected condition * State ALOS for the selected condition = Risk Adjusted ALOS Potentially Preventable Readmissions and APR DRGs:Statistical Methods Introduction The 3M™ APR™ DRG classification system categorizes patients based on their severity of illness and risk of mortality. In version 25.0 of the APR DRG classification system, there are 314 APR DRG categories, each of which is subdivided into four subclasses for a total of 1,356 unique patient categories. Potentially Preventable Readmission (PPRs) identify return hospitalizations that may have resulted from the process of care and treatment (readmission for a surgical wound infection) or lack of post admission follow-up (prescription not filled) rather than unrelated events that occur post admission (broken leg due to trauma). In computing a hospital PPR rate, the numerator is defined as the number of initial admissions with one or more qualifying clinically related readmissions within a given time period. The denominator of a readmission rate is identified as the number of initial admissions at risk for a potentially preventable readmission, excluding deaths and admission meeting the criteria for one or more global exclusions occurring in the index hospitalization, for the related population for the same time period. the number of initial qualifying admissions with one or more PPRs divided by the number of admissions at risk for a PPR Rates of PPR occurrence can be calculated for each APR DRG category by severity of illness level. The rates used for the ACHA public reporting are based on data from The Florida Center for Health Information and Policy Analysis Hospital Inpatient Database, April 2006 – March 2007. These statewide rates were calculated using the full dataset for the following three age groups: 18 and over, 18 – 64, and 65 and over. A PPR rate for each APR-DRG by severity level was developed for each of these three age groups based on a 15 day readmission window for readmissions across hospitals. These rates are typically referred to as norms because they reflect the experience of groups of hospitals. Using APR DRG categories to control differences in the clinical characteristics between their patients or those of the norm, individual hospitals can compare their PPR rates to those of the normative data. These comparisons will enable them to determine if and how their performance differs from comparable hospitals. A provider’s experiences and those of normative populations are likely to be different. This can represent a true difference or can be caused by normal variation. Statistical techniques can be used to determine which of the observed differences in outcomes are most likely to be true differences and which are probably the result of natural variation. Observed Value The observed readmission rates are calculated for each condition or procedure by dividing the number of initial discharges with one or more Potentially Preventable Readmissions, PPRs, by the total number of initial discharges. The AHCA normative database (state values) are calculated for each APR DRG and severity of illness subclass the same. The PPR is calculated as follows: Let:
This number is displayed as PPRs per initial discharge to facilitate the calculations in the expected value computation example below. Data from April 2006 – March 2007 was used to compute PPR observed rates. Expected Values The expected value of PPRs is the number of readmission chains (initial discharge with a PPR) a hospital, given its mix of patients as defined by APR DRG category and severity of illness level, would have experienced had its rate of PPRs been identical to that experienced by a reference or normative set of hospitals. The technique by which the expected value or expected number of PPRs is calculated is called indirect standardization. For illustrative purposes, assume that every initial discharge can meet the criteria for having a PPR, a condition called being “at risk” for a PPR. All initial discharges will either have no PPRs or will have a chain of one and possibly more PPRs. Once a set of PPR normative rates has been calculated by APR-DRG by SOI, it can be applied at the APR-DRG and SOI level to individual hospitals to compute the expected PPR rate for the hospital. Then the PPR expected rate is adjusted for age over 85 and the presence of a major mental health problem as a comorbid condition. These adjustments were computed from the AHCA normative database for each of the three age groups. Example Age and Mental Health PPR Rate Adjustment Factors
Consider the following example for computing a hospital’s expected PPR rate. For each APR-DRG by severity subclass, a normative PPR rate has been computed from the normative database. Hospital AAA has 11 initial discharges in the database. One of these initial discharges was globally excluded from the PPR computations because the patient left against medical advice. Of the remaining 10 initial discharges, one of these initial discharges had a potentially preventable readmission within the defined readmission window. The other nine initial discharges either did not have a subsequent admission within the defined readmission window or there was a subsequent readmission within the defined readmission window, however, the readmission was not identified as potentially preventable and therefore clinically excluded from being considered a PPR. Example Normative PPR Rates
Example Hospital Patient Discharge Readmission Data
The providers actual PPR rate is the number of initial discharges with one or more PPRs within the readmission window divided by the number of initial discharges at risk for a PPR (not globally excluded). Provider AAA PPR rate equals 1 divided by 10 = 10%. The expected PPR rate based on the initial discharges at risk for a PPR is the sum of the associated APR-DRG by SOI normative PPR rate times the mental health and age adjustment factor divided by the number of initial discharges at risk for a PPR. Example Hospital PPR Rate
Risk Adjusted Value It is not meaningful to compare expected values across hospitals. Thus, if one hospital has a higher expected value than another hospital, no conclusion can be made regarding the relative performance of the two hospitals. In order to directly compare the performance of two hospitals a risk adjusted value can be computed. In other words, the expected value is relative to the hospital’s actual value while the risk adjusted value is relative to actual value in the reference database. Thus the risk adjusted value can be compared across hospitals. The risk adjusted value is computed as follows:
Hospital Actual PPR Rate The reference actual PPR rate is the overall PPR rate for the hospitals being compared. If analysis is performed for a subset of cases, say cardiac surgical APR DRGs, then the overall PPR rate for all cardiac surgical APR DRGs would be the reference actual PPR rate from which a hospitals actual to expected PPR rate for cardiac surgical APR DRGs would be adjusted. Statistical significance The statistical techniques calculate the probability that an observed difference in performance between the provider and the norm is due to natural variation. A difference in performance between provider and norm is considered “significant” if the probability that a difference is due to natural variation is small. A difference is considered significant at the 0.05 level if the probability that the observed difference is due to natural variation is five percent or less (i.e., less than one chance in twenty). Three interrelated factors determine whether a difference in performance is significant: the number of observations, the magnitude of the observed difference in performance, and the variability in performance of the hospital and of the norm. A small number of patients, a small observed difference in performance, or high variability within either the provider or the norm (i.e., high standard deviation) increase the probability that the observed difference is due to chance and does not represent a true difference. Conversely, a large number of patients, a large observed difference between provider and norm, or low variability within both hospital and norm make it more likely that the difference was not due to chance and does represent a true difference. Further, an observed difference of the same magnitude may be significant in one comparison and not in another. The conclusion that a difference is significant indicates that the hospital and the norm have had true difference in performance. There are several possible reasons why a difference may not be significant. There may be no true difference, and thus, no significant difference in performance is found. Alternatively, there may be too few observations or too much variability, or both, so that even a true difference cannot be detected. Thus, a difference which is not significant does not necessarily mean that there is no true difference in performance. It may simply mean that there were too few patients or too much variability to conclude that the observed difference was not due to chance. The comparison of a provider’s performance to a norm requires the use of several distinct statistical methods. Outcome variables such as PPR rates are binary variables that indicate the occurrence or non-occurrence of an event such as a readmission following an initial discharge. Comparisons can be performed for data from a single APR DRG category and subclass, or they can be performed for data pooled across multiple APR DRG categories and subclasses. Test of Significance For binary data such as readmission, a test of significance of the difference between the actual and expected values can be performed by comparing readmission rates separately within each APR DRG category and subclass and then pooled across APR DRG categories and subclasses. The calculation of statistical significance for PPRs uses the Cochran-Mantel-Haenszel test (CMH) to calculate statistical significance for PPRs across APR DRG categories and severity of illness levels. To test for statistical significance, it is assumed that the APR DRG category and severity of illness level for each initial discharge is known, as well as whether or not a PPR occurred within the window following the initial discharge. The tests of significance are to be calculated with only initial discharges at risk for PPRs. In computing the test of significance, the normative statistic should take into account the adjustment for age over 85 and the presence of a major mental health problem as a comorbid condition based on hospital’s cases. To calculate a CMH statistic, start with the 2 * 2 matrix used for the Chi Square test. The CMH statistic uses the data from one corner of the matrix and the marginals. It does not matter which corner; all will produce the same results. To simplify matters, we will use the upper left hand corner. Calculate the expected value and variance of each cell. Let:
J = ∑ (N(m,a)A(m,a))/ ∑ N(m,a) The expected value is calculated as follows:
The variance is calculated as follows:
After, the expected value and variance are calculated, calculate the CMH statistic as follows:
As the CMH statistic has a chi square distribution with 1 degree of freedom the following significance levels can be used:
For the purposes of reporting statistical significance a significance level of .05, Х2 => 3.8415, was used. In addition, statistical significance will not be calculated if the overall number of initial discharges at risk for PPRs is less than forty or if the number of observed or expected initial discharges with PPRs is less than five for a provider. Hospital Inpatient Medical Conditions and Procedures - AdultsBones and JointsBack Problems – APR-DRG code 347 Disc Surgery – APR-DRG code 310 Femur Fracture Surgical Repair Femur Fracture Surgical Repair – APR-DRG code 308 Hip Replacement - Primary APR- DRG code 301 Knee Replacement – APR-DRG code 302 Leg Amputation – APR- DRG code 305 Spinal Fusion – APR-DRG codes 303, 304 and 321 Tibia/Fibula Fracture Repair – APR- DRG code 313 Brain and Nervous SystemCraniotomy (brain surgery) – APR-DRG codes 20 and 21 Stroke – APR-DRG codes 44 and 45 Transient Cerebral Ischemia – APR-DRG code 47 CancerAcute Leukemia – APR-DRG code 690 Bone Marrow Transplant – APR-DRG code 3 Brain Cancer – APR-DRG code 41 Chemotherapy – APR-DRG code 693 Digestive System Cancer – APR-DRG code 240 Female Reproductive Cancer – APR-DRG code 530 Kidney / Ureter Removal – APR-DRG code 442 Leukemia / Lymphoma, Non - Surgical Leukemia / Lymphoma, Non - Surgical – APR-DRG code 691 and 694 Leukemia / Lymphoma, Surgical – APR-DRG code 681 Liver Cancer – APR-DRG code 281 Lung Cancer – APR-DRG code 136 Mastectomy – APR-DRG code 362
Diabetes/Endocrinology/MetabolismDiabetes – APR-DRG code 420 General Medical InformationAcute Pancreatitis – APR-DRG code 282 Cellulitis – APR-DRG code 383 Convulsions (Seizures) – APR-DRG code 53 Diverticulosis / Diverticulitis Diverticulosis / Diverticulitis – APR-DRG code 244 Gastrointestinal Hemorrhage – APR-DRG codes 241, 242 and 253 Hypovolemia (Low Blood Volume) Hypovolemia (Low Blood Volume) – APR-DRG code 422 Renal Failure – APR-DRG code 460 Septicemia (blood poisoning) – APR-DRG codes 720 and 724 Sickle Cell Disease – APR-DRG code 662 Syncope (fainting) – APR-DRG code 204 Urinary Stones – APR-DRG code 465 Urinary Tract Infection – APR-DRG code 463 Heart and Circulatory SystemAngioplasty – APR-DRG codes 174 and 175 Cardiac Catheterization – APR-DRG codes 191 and 192 Cardiac Pacemaker Implant – APR-DRG code 171 Chest Pain – APR-DRG code 203 Coronary Bypass Surgery – APR-DRG codes 165 and 166 Heart Attack – APR-DRG code 190 Heart Failure – APR-DRG code 194 High Blood Pressure – APR-DRG code 199 Irregular Heartbeat – APR-DRG code 201 Peripheral Vascular Disease (PVD) Peripheral Vascular Disease (PVD) – APR-DRG code 197 LungsChronic Obstructive Pulmonary Disease, COPD (pulmonary disease) COPD (pulmonary disease) – APR-DRG code 140 Lung and Chest Procedures – APR-DRG codes 120 and 121 Pneumonia – APR-DRG code 139 Pneumonitis, Aspiration – APR-DRG codes 137 SurgeryAppendectomy – APR-DRG code 225 Arteriovenostomy (renal dialysis) Arteriovenostomy (renal dialysis) – APR-DRG code 444 Gall Bladder Removal – APR-DRG 262 Heart and/or Lung Transplant – APR-DRG code 2 Hernia Repair, Other – APR-DRG code 227 Kidney/Pancreas Transplant – APR-DRG codes 6 and 440 Laparoscopic Gall Bladder Removal Laparoscopic Gall Bladder Removal – APR-DRG code 263 Liver Transplant – APR-DRG code 1 Major Small and Large Bowel Procedures Major Small and Large Bowel Procedures – APR-DRG code 221 Obesity Procedures – APR-DRG code 403 Peritoneal Adhesiolysis - APR-DRG code 224 Radical Prostatectomy – APR-DRG code 480 Transurethral Prostatectomy – APR-DRG code 482 Women's HealthHysterectomies and Other Uterine and Adnexa Procedures Hysterectomies and Other Uterine and Adnexa Procedures – APR-DRG codes 511, 512, 513 and 519 Hospital Inpatient Medical Conditions and Procedures - Deliveries and NewbornsBaby with Complications – APR-DRG codes 583, 588, 589, 591, 593, 602, 603, 607, 608, 609, 611, 612, 613, 614, 621, 622, 623, 625, 626, 630, 631, 633, 634, 636, 639, 640 (APR-DRG 640 is limited to Severity Levels 2, 3 and 4) Cesarean Section Delivery – APR-DRG code 540 - The data for cesarean deliveries include all ages. Normal Baby – APR-DRG code 640 (limited to Severity Level 1) Vaginal Delivery – APR-DRG code 560 - The data for vaginal deliveries include all ages. Hospital Inpatient Medical Conditions and Procedures - PediatricsAppendectomy – APR-DRG code 225 (limited to Severity Level 1, minor) – Ages 1-17. Asthma –Inclusions: ICD-9-CM principal diagnosis codes of asthma, 49300, 49301, 49302, 49310, 49311, 49312, 49320, 49321, 49322, 49381, 49382, 49390, 49391, and 49392. Exclusions: Excludes those patients with a diagnosis code for cystic fibrosis and anomalies of the respiratory system. Excludes transfers from other institutions. Excludes cases ages 0-1. Excludes cases in MDC 14 (obstetrics). Please refer to PDI 14 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for further information regarding methodology. Brain Surgery – APR-DRG codes 20, 21, and 22 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old). Bronchiolitis and RSV Pneumonia – APR-DRG code 138 – Ages 0-4 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old). Cancer Care – APR-DRG codes 680, 681, 690, 691, 692, 693, 694, and 41 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old). Convulsions (Seizures) – APR-DRG code 53 – Ages 0-4 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old) and ages 5-17. Diabetes – Inclusions: All non-maternal discharges ages 6 to 17 years with ICD-9-CM principal diagnosis codes for short-term complications (ketoacidosis, hyperosmolarity, coma) including 25010, 25011, 25012, 25013, 25020, 25021, 25022, 25023, 25030, 25031, 25032, and 25033. Exclusions: Excludes transfers from other institutions. Excludes cases in MDC 14 (obstetrics). Please refer to PDI 15 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for further information regarding methodology. Fever and Infectious Illness – APR-DRG codes 722, 723, and 113 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old). Gastroenteritis – Ages 3 months-4 years and 5-17 years. Gastroenteritis – Inclusions: All non-maternal discharges ages 3 months-4 years and 5-17 years with ICD-9-CM principal diagnosis code for gastroenteritis or with a secondary diagnosis code of gastroenteritis and a principal diagnosis code of dehydration. ICD-9-CM gastroenteritis diagnosis codes 00861, 00862, 00863, 00864, 00865, 00866, 00867, 00869, 0088, 0090, 0091, 0092, 0093, and 5589. ICD-9-CM dehydration diagnosis codes 27650, 27651, 27652, and 2765. Exclusions: Excludes transfers from other institutions. Excludes ages less than or equal to 90 days (or neonates if age in days is missing). Exclude those with a diagnosis code of gastrointestinal abnormalities or bacterial gastroenteritis. Excludes cases in MDC 14 (obstetrics). Please refer to PDI 16 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for further information regarding methodology. Pneumonia, Other – APR 139. Inclusions: Includes ages 2-17. Exclusions: Excludes transfers from other institutions. Exclude cases in MDC 14 (obstetrics). Excludes those patients with a diagnosis code for cystic fibrosis and anomalies of the respiratory system. Please refer to PDI 14 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for further information regarding methodology. Sickle Cell Disease – Ages 1-17. Sickle Cell Disease – APR-DRG code 662 – Ages 1-17. Spinal Fusion – Ages 5-17 years. Spinal Fusion – APR-DRG codes 303, 304, and 321 – Ages 5-17 years. Urinary Tract Infections – Ages 3 months to 17 years. Urinary Tract Infections – Inclusions: All non-maternal discharges ages 3 months to 17 years with ICD-9-CM urinary tract principal diagnosis codes 59010, 59011, 5902, 5903, 59080, 59081, 5909, 5950, 5959, 5990. Exclusions: : Excludes transfers from other institutions. Exclude those patients with a diagnosis code of kidney/urinary tract disorder and with a diagnosis code of high or intermediate-risk immunocompromised state. Excludes ages less than or equal to 90 days (or neonates if age in days is missing). Excludes cases in MDC 14 (obstetrics). Please refer to PDI 18 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for a list of the kidney/urinary disorder diagnosis codes and refer to Appendixes C and D for ICD-9-CM Codes for Immunocompromised States and ICD-9-CM Codes for Intermediate-risk Immunocompromised States and more detailed information regarding methodology. Viral Meningitis – APR-DRG code 51 – Ages 0-17 years (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old). Ambulatory (Outpatient) Surgery
Centers
|
|
CPT-4 Code APG 025 |
Total Facility Cases |
Total Facility Charge |
Facility Average Charge |
State of Florida (Normative) Average Charge |
Facility Cases * State of Florida (Normative) Average Charge |
|
29881 |
75 |
$20,000 |
$267 |
$340 |
$25,500 |
|
29826 |
200 |
$110,000 |
$550 |
$540 |
$108,000 |
|
29877 |
175 |
$150,000 |
$857 |
$750 |
$131,250 |
|
29880 |
50 |
$60,000 |
$1,200 |
$1,000 |
$50,000 |
|
Total |
500 |
$340,000 |
$680 |
|
$314,750 |
For calculating charges, the CPT-4 code is used.
Calculations:
Facility's Observed Charges:
Total facility charges / total facility cases = $340,000/500 = $680
Facility's Expected Charges:
Total charges using State of Florida charges / total facility cases = $314,750/500 = $630
This example demonstrates the power of using APGs to calculate expected values. While the observed charge for Arthroscopy patients was $680, we see that the expected value, given the distribution of cases within Arthroscopy by CPT-4, was actually $50 less than observed, or $630.
To summarize, expected charges for an APG is impacted directly by two key factors:
1. State of Florida average charges at each individual CPT-4 within the APG
2. The distribution of facility cases within the APG across the CPT-4s
Risk Adjusted Value
The risk-adjusted average charge is the best estimate, based on the statistical model, of what the provider's charge would have been if the provider had a mix of patients identical to the statewide mix. The risk adjusted value is the observed charge divided by the expected charge and multiplied by the State of Florida's average charge for a procedure.
Facility's Risk Adjusted Charges:
Observed charges / Expected charges * State charges = Risk Adjusted charges
$680 / $630 * $570 = $615
Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Adults
Arthroscopy, APG 025
Breast Reconstruction and Mastectomy, APG 012
Cataract Procedures, APG 214
Complex Cystourethroscopy and Litholapaxy, APG 134
Complex Excision, Biopsy and Debridement, APG 007
Complex Facial and Ears, Nose, and Throat (ENT) Procedures, APG 234
Complex Laparoscopic Procedures, APG 123
Complex Skin Repairs Including Integument Grafts, Transfer & Rearrange, APG 009
Diagnostic Cardiac Catheterization, APG 076
Diagnostic Upper Gastrointestinal (GI) Endoscopy or Intubation, APG 115
Hernia and Hydrocele Procedures, APG 119
Hysteroscopy, APG 179
Laser Eye Procedures, APG 213
Lower Gastrointestinal (GI) Endoscopy, APG 117
Nerve Repair and Destruction, APG 198
Nervous System Injections, Stimulations or Cranial Tap, APG 195
Simple Cystourethroscopy, APG 136
Simple Debridement and Destruction, APG 006
Simple Excision and Biopsy, APG 008
Simple Facial and Ears, Nose, and Throat (ENT) Procedures, APG 235
Simple Hand and Foot Musculoskeletal Procedures, APG 024
Simple Incision and Excision of Breast, APG 011
Superficial Needle Biopsy and Aspiration, APG 002
Therapeutic Upper Gastrointestinal (GI) Endoscopy or Intubation, APG 116
Tonsil and Adenoid Procedures, APG 236
Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Pediatrics
Arthroscopy, APG 025
Bronchoscopy, APG 053 and 055
Circumcision, APG 154
Cleft Palate Repair, APG 239
Diagnostic Cardiac Catheterization, APG 076
Diagnostic Upper Gastrointestinal Endoscopy, APG 115
Ear Tube Placement, APG 235
Hernia and Hydrocele Procedures, APG 119
Lower Gastrointestinal Endoscopy, APG 117
Strabismus (Repair of Crossed Eyes), APG 220
Tonsil and Adenoid Removal, APG 236
Treatment of Fractures, APGs 028, 029 and 030
Inpatient Mortality Indicators
The Agency for Healthcare Research and Quality (AHRQ) software (Version 3.2) was used in calculating the Inpatient Mortality Indicators and Patient Safety Indicators. This includes a 95% confidence interval for all statistical significance determinations. If a hospital had fewer than 30 cases, the results were redacted.
Confidence Intervals are used to identify which hospitals had significantly more or fewer deaths than expected given the risk factors of their patients. The confidence interval identifies the range in which the risk-adjusted mortality rate may fall. Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide risk adjusted mortality rate. Hospitals with significantly lower rates than expected given the severity of illness of their patients before surgery have the entire confidence interval range entirely below the statewide risk adjusted mortality rate. The more cases a provider performs, the narrower their confidence interval will be. This is because as a provider performs more cases, the likelihood of chance variation in the risk adjusted mortality rate decreases.
For more information, visit the Agency for Healthcare Research and Quality website at: www.qualityindicators.ahrq.gov.
Mortality Inpatient Procedures
Abdominal Aortic Aneurysm Repair (AAA) Mortality - IQI 11
Inclusions: Number of deaths with a code of AAA repair in any procedure field and a diagnosis of AAA in any field divided by discharges, age 18 years or older, with ICD-9 codes of 3834, 3844, 3864 or 3971 in any procedure field and an AAA diagnosis code of 4413 and 4414 in any field. Exclusions: Excludes cases with missing discharge disposition. Exclude cases transferring to another short-term hospital. Excludes cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates).
Coronary Artery Bypass Graft (CABG) Mortality - IQI 12
Inclusions: Number of deaths with a code of CABG in any procedure field divided by discharges, age 40 years and older, with ICD-9 codes of 3610 through 3619 in any procedure field. Exclusions: Excludes cases with missing disposition. Excludes cases transferring to another short-term hospital. Excludes cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates).
Craniotomy Mortality (Surgical opening of the skull) - IQI 13
Inclusions: Number of deaths with DRG code for craniotomy (DRG 001, 002, 528, 529, 530, and 543) divided by all discharges, age 18 years and older with DRG code for craniotomy (DRG 001, 002, 528, 529, 530, and 543). Exclusions: Excludes cases with a principal diagnosis of head trauma. Excludes cases missing discharge disposition. Excludes cases transferring to another short-term hospital. Please refer to IQI 13 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the detailed list of the head trauma diagnosis codes and more detailed information regarding methodology.
Esophageal Resection Mortality (Surgical Removal of the Throat) - IQI 8
Inclusions: Number of deaths with a code of esophageal resection in any procedure field and a diagnosis code of esophageal cancer in any field divided by discharges, age 18 years and older, with ICD-9 procedure codes of 424 -4269 in any field and a ICD-9 diagnosis code of 1500, 1501, 1502, 1503, 1504, 1505, 1508 or 1509 for esophageal cancer in any field. Exclusions: Excludes cases with missing discharge disposition. Excludes cases transferring to another short-term hospital. Excludes cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates).
Hip Replacement Mortality - IQI 14
Inclusions: Number of deaths with a procedure code of partial or full hip replacement in any field divided by all discharges, age 18 years and older, with a procedure code of partial or full hip replacement in any field. Include only discharges with uncomplicated cases: diagnosis codes for osteoarthrosis of hip in any field. Exclusions: Excludes cases with missing discharge disposition. Excludes cases transferring to another short-term hospital. Exclude cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates). Please refer to IQI 14 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9 hip replacement procedure and osteoarthrosis diagnosis codes and more detailed information regarding methodology.
Pancreatic Resection Mortality (Surgical Removal of the Pancreas) - IQI 9
Inclusions: Number of deaths with a code of pancreatic resection in any procedure field and a diagnosis code of pancreatic cancer in any field divided by discharges, age 18 and older, with ICD-9 codes of 526 or 527 in any procedure field and a diagnosis code of 1520, 1561, 1562, 1570, 1571, 1572, 1573, 1574, 1578 and 1579 for pancreatic cancer in any field. Exclusions: Excludes cases with missing discharge disposition. Excludes cases transferring to another short-term hospital. Excludes cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates).
Mortality Inpatient Conditions
Acute Myocardial Infarction (Heart Attack) - IQI 15
Inclusions: Number of deaths with a principal diagnosis code of AMI ICD-9 codes 41001, 41011, 41021, 41031, 41041, 41051, 41061, 41071, 41081, or 41091 divided by all discharges, age 18 years and older, with a principal diagnosis code of AMI ICD-9 codes 41001, 41011, 41021, 41031, 41041, 41051, 41061, 41071, 41081, or 41091. Exclusions: Excludes cases where transferred to another short-term hospital. Excludes cases with missing discharge disposition.
Acute Myocardial Infarction (Heart Attack), Without Transfer Cases - IQI 32
Inclusions: Number of deaths with a principal diagnosis code of AMI ICD-9 codes 41001, 41011, 41021, 41031, 41041, 41051, 41061, 41071, 41081, or 41091.divided by all discharges, age 18 and older, with a principal diagnosis code of AMI. Exclusions: Excludes cases where transferred to or from another short-term hospital. Excludes missing admission source and missing discharge disposition.
Acute Stroke Mortality - IQI 17
Inclusions: Number of deaths with a principal diagnosis code for stroke 430, 431, 4320, 4321, 4329, 43301, 43311, 43321, 43331, 43381, 43391, 43401, 43411, or 43491 divided by all discharges, age 18 and older, with a principal diagnosis code of CHF 430, 431, 4320, 4321, 4329, 43301, 43311, 43321, 43331, 43381, 43391, 43401, 43411, 43491 or 436. Exclusions: Excludes cases transferring to another short-term hospital. Exclude cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates). Excludes cases with missing discharge disposition.
Congestive Heart Failure (CHF) Mortality - IQI 16
Inclusions: Number of deaths with a principal diagnosis code of CHF divided by all discharges, ages 18 years and older, with principal diagnosis of CHF. Exclusions: Excludes cases with missing discharge disposition. Exclude cases transferring to another short-term hospital. Excludes cases in MDC 14 (obstetrics) and MDC 15 (newborns and other neonates). Please refer to IQI 16 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9 CHF diagnosis codes and more detailed information regarding methodology.
Gastrointestinal (GI) Hemorrhage Mortality - IQI 18
Inclusions: Number of deaths with a principal diagnosis code of gastrointestinal hemorrhage divided by all discharges with principal diagnosis code for gastrointestinal hemorrhage. Include ages 18 years and older. Exclusions: Excludes cases transferring to another short-term hospital. Excludes cases in MDC 14 and MDC 15. Excludes cases with missing discharge disposition. Please refer to IQI 18 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9 gastrointestinal hemorrhage diagnosis codes and more detailed information regarding methodology.
Hip Fracture Mortality - IQI 19
Inclusions: Number of deaths with a principal diagnosis code of hip fracture divided by all discharges, age 18 and older, with a principal diagnosis code for hip fracture. Exclusions: Excludes cases transferring to another short-term hospital. Excludes cases in MDC 14 and MDC 15. Excludes cases with missing discharge disposition. Please refer to IQI 19 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9 hip fracture diagnosis codes and more detailed information regarding methodology.
Inclusions: Number of deaths with a principal diagnosis code of pneumonia divided by all discharges, age 18 years and older, with principal diagnosis code of pneumonia. Exclusions: Excludes cases transferring to another short-term hospital. Exclude cases in MDC 14 and MDC 15. Excludes cases with missing discharge disposition. Please refer to IQI 20 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9 pneumonia diagnosis codes and more detailed information regarding methodology.
Patient Safety Indicators - Complication and Infection Including Complication Index
The Agency for Healthcare Research and Quality (AHRQ) software (Version 3.2) was used in calculating the Inpatient Mortality Indicators and Patient Safety Indicators. This includes a 95% confidence interval for all statistical significance determinations. If a hospital had fewer than 30 cases, the results were redacted.
Confidence Intervals are used to identify which hospitals had significantly more or fewer complications than expected given the risk factors of their patients. The confidence interval identifies the range in which the risk-adjusted rate may fall. Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide risk adjusted complication rate. Hospitals with significantly lower rates than expected given the severity of illness of their patients before surgery have the entire confidence interval range entirely below the statewide risk adjusted complication rate. The more cases a provider performs, the narrower their confidence interval will be. This is because as a provider performs more cases, the likelihood of chance variation in the risk adjusted complication rate decreases.
For more information, visit the Agency for Healthcare Research and Quality website at: www.qualityindicators.ahrq.gov
Iatrogenic Pneumothorax - PSI 6
Inclusions: Cases of iatrogenic pneumothorax per 1,000 discharges. Include discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field. Includes all medical and surgical discharges, ages 18 years and older defined by specific DRGs.
Exclusions: Cases with ICD-9-CM code of 512.1 in the principal diagnosis field or secondary diagnosis present on admission, if known. Exclude cases in MDC 14 (obstetrics). Excludes patients with diagnosis code of chest trauma or pleural effusion. Excludes patients with any procedure code of diaphragmatic surgery repair, thoracic surgery, lung or pleural biopsy, or patients assigned to cardiac surgery DRGs.
Reference: For more detailed information regarding methodology please refer to PSI 6 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of ICD-9-CM chest trauma and pleural effusion diagnosis codes, thoracic surgery, local excision or destruction of lesion or tissue lung, repair and plastic operation on lung and bronchus, lung transplant, diagnostic procedures on chest wall, pleura, mediastinum, and diaphragm, repair of chest wall, operations on diaphragm, operations on thoracic duct, esophagotomy, excision of esophagus, intrathoracic anastomosis of exophagus, antesternal anastomosis, other repair of esophagus, lung or pleural biopsy procedure codes and cardiac surgery DRGs.
Infections Due to Medical Care - PSI 7
Inclusions: Cases selected infections due to medical care, secondary diagnosis per 1,000 discharges. Includes discharges with ICD-9-CM codes 999.3 or 996.62 in any secondary diagnosis field. Includes discharges for all medical and surgical discharges, ages 18 years and older or MDC 14 (obstetrics), defined by specific DRGs.
Exclusions: Excludes cases with ICD-9-CM code of 999.3 or 996.62 in the principal or secondary diagnosis field present on admission, if known. Excludes cases with length of stay between 0-1 days. Excludes cases with any code of immunocompromised state or cancer or with cancer DRG.
Reference: For more detailed information regarding methodology please refer to PSI 7 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the list of applicable codes and/ or DRGs refer to Appendixes B, F, D, E and Q for applicable surgical discharge DRGs, medical discharge DRGs, ICD-9-CM codes for immunocompromised states, cancer codes and cancer DRGs, respectively.
Inclusions: Cases of secondary sepsis diagnosis per 1,000. Include elective surgery discharges with ICD-9-CM code for sepsis in any secondary diagnosis field. Include all elective surgical discharges age 18 and older defined by specific DRGs and an ICD-9-CM code for an operating room procedure.
Exclusions: Excludes cases with preexisting (principal or secondary diagnosis present on admission, if known) sepsis or infection. Excludes cases with any code for immunocompromised state of cancer. Excludes cases in MDC 14 (obstetrics). Excludes cases with length of stay 0-3 days.
Reference: For more detailed information regarding methodology please refer to PSI 13 (AHRQ Version 3.2) at www.qualityindicators.ahrq.gov for the detailed list diagnosis codes and DRGs refer to Appendixes O,P, D, E, and Q for applicable sepsis diagnosis codes, infection diagnosis codes and DRGS, ICD-9-CM codes for immunocompromised states, cancer codes and cancer DRGs, respectively.
