AHRQ QIs and Risk Adjustment

Does the software account for patients assigned hospice or Do Not Resuscitate (DNR) status?

The exclusion of patients in hospice units or with documented DNR status is often desired for mortality indicators. However, since the indicators were based on a common denominator dataset, HCUP, which did not include data elements for DNR status or hospice designation, these variables could not be utilized. Hospice and DNR patients are not differentiated from other patients in the AHRQ QI software. If the input data available to the software user contains variables designating patient DNR status or hospitalization in a hospice unit, the user may choose to exclude these patients from the input data set. This should be done with caution recognizing that the calculated rates will likely differ from any comparison or reference rates produced from data that did not differentiate these patients.

Do the QI software modules provide an option to use the new Metropolitan Statistical Area definitions that were released by the Office of Management and Budget in June 2003? Do the QI software modules provide an option to use the newly defined Micropolitan Statistical Area definitions?

No, the current versions of the QI software modules do not permit the use of the new Metropolitan Statistical Area definitions or the newly defined Micropolitan Statistical Area definitions. The population data files used in the current versions of the software are based on publicly available Census data that were released on April 17, 2003 prior to the June 6, 2003 release of the new definitions of Metropolitan Statistical Areas and Micropolitan Statistical Areas (see OMB Bulletin 03-04). Users can report data using the new area definitions by aggregating the software’s county level output by summing the observed (or implied risk-adjusted) numerator and denominator for each component county.

Can the area measures be calculated using the patient’s county or zip code?

Yes, the software will stratify by the value in the FIPS State and County data element.  If this represents the patient's FIPS Code (State and County) the output will be calculated by patients county of residence; if this represents the hospital's FIPS Code the output will be calculated by hospitals county (hospital locale).

Can I use the AHRQ QIs software if Hospital Federal Information Processing Standard (FIPS) State and County codes are not available?

The Prevention Quality Indicators (PQIs) and the area Inpatient Quality Indicators (IQIs) cannot be calculated when FIPS codes are missing and the software will return missing values for all of the indicators in the PQIs and the area IQIs. The FIPS State and County codes are needed to identify the relevant reference populations that are used for the appropriate denominators in the definitions of these indicators. The hospital level IQIs and the Patient Safety Indicators (PSIs) can be calculated when the hospital FIPS codes are missing because these indicators do not depend upon area population values. In cases where you do not have FIPS State and County codes for the hospitals you are including in your analysis for the hospital level IQIs or the PSIs, a missing value should be entered for this variable in all patient records.

How does the software deal with invalid International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes?

The software assumes that all input variables contain only valid/non-missing values. Running the software on data that contains missing or invalid data (e.g., ICD-9-CM diagnosis codes, patient disposition codes) may produce questionable and invalid results. All input variables should be validated prior to running the software.

How does one assign Diagnosis-Related Groups (DRGs)?

Diagnosis-Related Groups (DRGs) are a patient classification system based on a patient’s International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes, among other variables. DRGs are designated by the Centers for Medicare and Medicaid Services (CMS). Software groupers are available from various vendors to assign DRGs.

Are the All-Patient Refined Diagnosis-Related Groups (APR-DRGs) necessary for risk adjustment in the Inpatient Quality Indicators (IQIs)?

The APR-DRGs are used to risk-adjust the IQIs for patient clinical condition and severity of illness or risk of mortality. If the patient APR-DRG is not available, the software will risk-adjust using information on age and gender only, which is less desirable than using the APR-DRGs. Although the AHRQ QIs program modules are free, the APR-DRGs is a commercially licensed software package that may be obtained from the 3M Corporation. The 3M Corporation did not have any affiliation with development of the AHRQ QIs. Future versions of the AHRQ QIs software may incorporate alternative clinical classification systems.

Are All-Patient Refined Diagnosis-Related Groups (APR-DRGs) the same as Diagnosis-Related Groups (DRGs)?

Although both APR-DRGs and DRGs are based on a patient’s International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes, they are different patient classification schemes. The 3M Corporation developed and sells a widely used software product to define risk adjustment categories called APR-DRGs, which has the advantage of subclass groupings for Severity of Illness and Risk of Mortality. DRGs are designated by the Centers for Medicare and Medicaid Services (CMS) and software groupers are available from various vendors to assign DRGs.