General Questions About the AHRQ QIs

What are the AHRQ QIs?

The AHRQ QIs are a set of quality indicators organized into three "modules," each of which measures quality associated with processes of care that occurred in an outpatient or an inpatient setting. All three modules rely solely on hospital inpatient administrative data:

1. Prevention Quality Indictors (PQIs)--or ambulatory care sensitive conditions--identify hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
2. Inpatient Quality Indicators (IQIs) reflect quality of care inside hospitals and include:
   • Inpatient mortality for medical conditions.
   • Inpatient mortality for surgical procedures.
   • Utilization of procedures for which there are questions of overuse, underuse, or misuse.
   • Volume of procedures for which there is evidence that a higher volume of procedures maybe associated with lower mortality.
3. Patient Safety Indicators (PSIs) also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.

The detailed technical reports on the PQIs/IQIs and PSIs are available for download. These reports are results of projects conducted for AHRQ by the University of California at San Francisco (UCSF)-Stanford Evidence-based Practice Center (EPC).

Why were the AHRQ QIs developed?

Health care decision makers need user-friendly data and tools that will help them:

• Assess the effects of health care program and policy choices.
• Guide future health care policy making.
• Accurately measure outcomes, community access to care, utilization, and costs.

The Agency for Healthcare Research and Quality (AHRQ) has developed an array of health care decision making and research tools that can be used by program managers, researchers, and others at the Federal, State and local levels.

One of these tools is the AHRQ Quality Indicators (QIs), which use hospital administrative data to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time. They represent a refinement of the Quality Indicators developed in the early 1990s as part of the Healthcare Cost and Utilization Project (HCUP). The original HCUP quality indicators were expanded to form the AHRQ QIs by:

1. Identifying quality indicators reported in the literature and in use by health care organizations.
2. Evaluating both the HCUP QIs and other indicators using literature review and empirical methods.
3. Incorporating risk adjustment.

What questions can the AHRQ QIs help users answer?

Hospitals and hospital systems can use AHRQ QIs to help answer the following types of questions:

• How does our hospital's cesarean section rate compare to the State or the Nation?
• Do other hospitals have similar mortality rates following hip replacement?
• How does the volume of coronary artery bypass graft procedures in my hospital compare with other hospitals?

State data organizations and community health partnerships can use AHRQ QIs to ask questions that provide initial feedback about clinical areas appropriate for further, more in-depth analysis, such as:

• What can the pediatric AHRQ Prevention QIs tell me about the adequacy of pediatric primary care in my community?
• How does the hysterectomy rate in our area compare with the State and national average?
• State hospital associations can use the AHRQ QIs to do quick screens of hospital quality and primary care access.

Other potential users include managed care organizations, business-health coalitions, State data organizations, and others poised to begin assessments using hospital discharge data to answer questions such as:

• Can we design community interventions to reduce hospital admission rates in areas with high rates of diabetes complications?
• Which AHRQ QIs can be incorporated into performance management initiatives for our member hospitals?

Federal and State policymakers can use the AHRQ QIs to track health care quality in the United States over time and to assess whether health care quality is improving, for example:

• How does the rate of coronary artery bypass graft procedures vary over time and across regions of the United States?
• What is the national average for bilateral cardiac catheterization (a procedure that is not generally recommended) and how has this changed over time?

How can the AHRQ QIs be used in quality assessment?

Hospitals and other organizations may use the AHRQ QIs without collecting new data by following these steps:

1. Identify the performance measure(s) of particular interest from the list of QIs. For example, a group interested in studying children's health might select the pediatric care indicators.
2. Determine what hospital(s) will be included in the assessment. For example, a local organization examining access to primary care in the community might include data from all local-area hospitals.
3. Acquire the relevant hospital discharge data from individual hospitals, State association or data organization, or State agency that makes discharge data available. As of June 2004, 36 States are part of the Healthcare Cost and Utilization Project (HCUP), an ongoing Federal-State-private sector collaboration to build uniform databases from administrative hospital-based data. The National Association of Health Data Organizations (http://www.nahdo.org) provides information on how to access State datasets.
4. Calculate the QI rates, using the AHRQ QI software, hospital discharge data of interest, and the SAS® or SPSS® statistical software.
5. Use the calculated rates as a first step in tracking hospital outcomes and primary care access. A hospital might compare rates with existing benchmarks, e.g., State or national averages, hospital peer groups, or the experience of a particular hospital or group of hospitals tracked over time. The rates might be stratified by payer category, patient race or ethnicity, etc.
6. For those QI rates that suggest potential for improvement, develop a plan to study the clinical outcomes and associated processes in more depth.

The AHRQ QIs were designed with the goal of creating tools for quality tracking and improvement and have been extensively used for these purposes. While the focus of the initial QI development work was not on hospital-level comparative reporting or other uses of the measures for purchasing and payment, the increased demand for standardized hospital-level comparative data in a time of growing quality concerns has led to their adoption for these purposes. As a result of the quality measurement evolution and the changing reporting landscape, potential users of the QIs and other indicators based on administrative data have been asking for some guidance on how to evaluate these measures for use in hospital reporting and payment. Users are encouraged to clearly define their needs for quality measurement and evaluate any measure, AHRQ QI or other, for their specific purpose. Users should consider limitations associated with the use of administrative data, risk adjustment capabilities, the potential impact of variations in coding practices (such as the reporting of E-codes), and potential impact of practice patterns (such as the tendency to perform a procedure in an outpatient setting). In addition, users may wish to carefully consider the presentation of results to avoid potential confusion and over-interpretation of indicator results.

Are there examples of how the AHRQ QIs have been used?

In 2003, the Agency for Healthcare Research and Quality published the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) which provide a comprehensive picture of the level and variation of quality within four components of health care quality— effectiveness, safety, timeliness, and patient centeredness. These reports incorporated many Prevention Quality Indicators and Patient Safety Indicators (selected IQIs are under evaluation for inclusion in the next reports).  These reports are available at the AHRQ Quality Tools Web site at http://www.qualitytools.ahrq.gov.

The AHRQ Quality Indicators are now being used for applications beyond quality improvement. Some organizations have used the AHRQ Quality Indicators to produce web based, comparative reports on hospital quality, such as the Texas Heath Care Information Council and the Niagara Coalition. Other organizations have incorporated selected AHRQ QIs into pay for performance demonstration projects or similar programs, such as the Centers for Medicare and Medicaid Services (CMS) and Anthem Blue Cross Blue Shield of Virginia where hospitals would be financially rewarded for performance.

AHRQ will be releasing a document to assist users who are considering use of the AHRQ QIs for purposes other than quality improvement.  The release of the AHRQ publication "Guidance for Using the AHRQ Quality Indicators for Hospital-Level Public Reporting or Payment" will be announced on the QI LISTSERV®.

What are the differences between the HCUP QIs and the AHRQ QIs?

The AHRQ Quality Indicators (QIs) are a refinement of the Healthcare Cost and Utilization Project (HCUP) Quality Indicators previously developed by AHRQ. Although the HCUP QIs were used as a starting point for developing the AHRQ QIs, many changes to the indicator set were made. The changes fall into several categories, listed and described below.

1. HCUP QIs Removed Due to Poor Current Evidence for Use

   Some HCUP indicators are not included in the newer AHRQ QIs set because a review of the evidence revealed low likelihood of an indicator being a useful screen for real quality problems. The evidence was derived from studies reported in the literature, empirical tests of precision, and clinician evaluations of possible problems with measuring the indicator using routinely collected administrative data. Thus, the following indicators were removed due to potential poor performance:

   1. Inhospital Mortality Following Common Elective Procedures
      • Inhospital mortality following hysterectomy
      • Inhospital mortality following laminectomy/spinal fusion
      • Inhospital mortality following cholecystectomy
      • Inhospital mortality following transurethral resection of prostate
      • Inhospital mortality following knee replacement
   2. Coded Complications
      • Wound infection
   3. Complications among Surgical Patients
      • Acute myocardial infarction after major surgery
      • Gastrointestinal hemorrhage or ulceration after major surgery
      • Mechanical complications due to device implant, or grant (excluding organ transplant)
      • Urinary tract infection after major surgery
      • Pneumonia after major surgery/invasive vascular procedure
   4. Utilization of Surgical Procedures
      • Transurethral resection of the prostate
   5. Access to Primary Care
      • Very low birth weight
      • Cerebrovascular disease among nonelderly adults
        
        
2. HCUP QIs Changed to Area-level AHRQ QIs

   Several indicators were considered less valid at the hospital level than at the area level. For these indicators a more appropriate denominator is considered to be the area population.

   HCUP QI	Corresponding AHRQ QIs
   Hysterectomy (Utilization of Surgical Procedures)	Hysterectomy (IQI 28, Area-level Utilization Rates)
   Laminectomy and/or spinal fusion (Utilization of Surgical Procedures)	Laminectomy or spinal fusion (IQI 29, Area-level Utilization Rates)
   Coronary artery bypass graft (CABG) (Utilization of Surgical Procedures)	Coronary artery bypass graft (IQI 26, Area-level Utilization Rates)
   Low birth weight (Access to Primary Care)	Low birth weight (PQI 9)
   Pediatric asthma discharges (Access to Primary Care)	Pediatric asthma (PQI 4)
   Diabetes short-term complications (Access to Primary Care)	Diabetes short-term complication (PQI 1)
   Diabetes long-term complications (Access to Primary Care)	Diabetes long-term complication (PQI 3)
   Perforated appendix (Access to Primary Care)	Perforated appendix (PQI 2)

   
   
   
3. HCUP QIs Changed to Hospital-level AHRQ QIs

   A few indicators were retained as hospital level indicators, but required refinement to the population at risk, often restricting the population at risk to an elective surgical population. These restrictions were based on empirical analyses, review of past literature, or clinician evaluations.

   HCUP QI	Corresponding AHRQ QIs
   Venous thrombosis or pulmonary embolism after major surgery/invasive vascular procedure (Complications among Surgical Patients)	Postoperative pulmonary embolism or deep vein thrombosis (PSI 12)

   
   
   
4. HCUP QI Components Used for New Indicator

   Only parts of some indicators were retained in the AHRQ QIs set, with some HCUP QIs being split into several more specific indicators.

   HCUP QI	Corresponding AHRQ QIs
   Obstetrical complications (Coded Complications)	Birth trauma – injury to neonate (PSI 17) Obstetric trauma – vaginal delivery with instrument (PSI 18) Obstetric trauma – vaginal delivery without instrument (PSI 19) Obstetric trauma – cesarean section delivery (PSI 20)
   Adverse effects and iatrogenic complications (Coded Complications)	Various PSIs
   Pulmonary compromise after major surgery (Complications among Surgical Patients)	Postoperative respiratory failure (PSI 11)
   Immunization-preventable pneumonia and influenza among the elderly (Access to Primary Care)	Bacterial pneumonia (PQI 11)

   
   
   
5. HCUP QI Retained As Is or With Minor Revisions
   
   

   HCUP QI	Corresponding AHRQ QIs
   Inhospital mortality following hip replacement	Hip replacement (IQI 14, Mortality Rates for Procedures)
   Cesarean section delivery (Utilization, Obstetric)	Cesarean section delivery (IQI 21, Hospital-level Procedure Utilization Rates)
   Successful vaginal birth after cesarean section (VBAC) (Utilization, Obstetric)	Vaginal birth after Cesarean section (IQI 22, Hospital-level Procedure Utilization Rates)
   Incidental appendectomy (Utilization, Surgical)	Incidental appendectomy in the elderly (IQI 24, Hospital-level Procedure Utilization Rates)
   Laparoscopic cholecystectomy (Utilization, Surgical)	Laparoscopic cholecystectomy (IQI 23, Hospital-level Procedure Utilization Rates)

   
   
   
6. New Indicators Added

   A number of indicators were added to the AHRQ QIs set in order to broaden the coverage of possible quality concerns. These additional indicators were based on recent work reported in peer review literature or conducted by the Stanford-UCSF Evidence-based Practice Center.

   Inpatient Quality Indicators (IQIs)

   1. Mortality Rates for Medical Conditions
      • Acute myocardial infarction (IQI 15)
      • Congestive heart failure (IQI 16)
      • Stroke (IQI 17)
      • Gastrointestinal hemorrhage (IQI 18)
      • Hip fracture (IQI 19)
      • Pneumonia (IQI 20)
   2. Mortality Rates for Surgical Procedures
      • Esophageal resection (IQI 8)
      • Pancreatic resection (IQI 9)
      • Pediatric heart surgery (IQI 10)
      • Abdominal aortic aneurysm repair (IQI 11)
      • Coronary artery bypass graft (IQI 12)
   3. Hospital-level Procedure Utilization Rates
      • Bi-lateral cardiac catheterization (IQI 25)
   4. Area-level Utilization Rates
      • Percutaneous transluminal coronary angioplasty (IQI 27)
   5. Volume of Procedures
      • Esophageal resection (IQI 1)
      • Pancreatic resection (IQI 2)
      • Pediatric heart surgery (IQI 3)
      • Abdominal aortic aneurysm repair (IQI 4)
      • Coronary artery bypass graft (IQI 5)
      • Percutaneous transluminal coronary angioplasty (IQI 6)
      • Carotid endarterectomy (IQI 7)

   Prevention Quality Indicators

   1. Ambulatory Care Sensitive Conditions
      • Chronic obstructive pulmonary disease (PQI 5)
      • Pediatric gastroenteritis (PQI 6)
      • Hypertension (PQI 7)
      • Congestive heart failure (PQI 8)
      • Dehydration (PQI 10)
      • Urinary infections (PQI 12)
      • Angina without procedure (PQI 13)
      • Uncontrolled diabetes (PQI 14)
      • Adult asthma (PQI 15)
      • Lower extremity amputations among patients with diabetes  (PQI 16)

   Patient Safety Indicators (PSIs)

   1. Hospital/Provider Rates
      • Complications of anesthesia (PSI 1)
      • Death in low mortality DRGs (PSI 2)
      • Decubitus ulcer (PSI 3)
      • Failure to rescue (PSI 4)
      • Foreign body left in during procedure (PSI 5)
      • Iatrogenic pneumothorax (PSI 6)
      • Selected infections due to medical care (PSI 7)
      • Postoperative hip fracture (PSI 8)
      • Postoperative hemorrhage or hematoma (PSI 9)
      • Postoperative sepsis (PSI 13)
      • Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 14)
      • Accidental puncture and laceration (PSI 15) Transfusion reaction (PSI 16)
   2. Area-level Patient Safety Indicators
      • Foreign body left in during procedure (PSI 21)
      • Iatrogenic pneumothorax (PSI 22)
      • Selected infections due to medical care (PSI 23)
      • Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 24)
      • Accidental puncture and laceration (PSI 25)
      • Transfusion reaction (PSI 26)

Who developed the AHRQ QIs?

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) were developed by an EPC team between 1998 and 2002 under an AHRQ contract.  Additional information on the project background, project development team, and project support team is available at the Project Background page on this web site.