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## Complete Summary

#### TITLE

Decubitus ulcer: rate per 1,000 discharges.

#### SOURCE(S)

AHRQ quality indicators. Guide to patient safety indicators \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ)AHRQ Pub; 2007 Mar 12. 76 p.(AHRQ Pub; no. 03-R203).

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the number of cases of decubitus ulcer
per 1,000 discharges with a length of stay greater than 4 days.

#### RATIONALE

Hospitals in the United States provide the setting for some of life\'s
most pivotal events - the birth of a child, major surgery, treatment for
otherwise fatal illnesses. These hospitals house the most sophisticated
medical technology in the world and provide state-of-the-art diagnostic
and therapeutic services. But access to these services comes with
certain costs. About 30% of personal health care expenditures in the
United States go towards hospital care, and the rate of growth in
spending for hospital services has only recently leveled out after
several years of increases following a half a decade of declining
growth. Simultaneously, concerns about the quality of health care
services have reached a crescendo with the Institute of Medicine\'s
series of reports describing the problem of medical errors and the need
for a complete restructuring of the health care system to improve the
quality of care. Policymakers, employers, and consumers have made the
quality of care in U.S. hospitals a top priority and have voiced the
need to assess, monitor, track, and improve the quality of inpatient
care.

Widespread consensus exists that health care organizations can reduce
patient injuries by improving the environment for safety from
implementing technical changes, such as electronic medical record
systems, to improving staff awareness of patient safety risks. Clinical
process interventions also have strong evidence for reducing the risk of
adverse events related to a patient\'s exposure to hospital care.
Patient Safety Indicators (PSIs), which are based on computerized
hospital discharge abstracts from the AHRQ\'s Healthcare Cost and
Utilization Project (HCUP), can be used to better prioritize and
evaluate local and national initiatives. Analyses of these and similar
inexpensive, readily available administrative data sets may provide a
screen for potential medical errors and a method for monitoring trends
over time.

The Decubitus Ulcer indicator\* is intended to flag cases of in-hospital
decubitus ulcers. Its definition is limited to decubitus ulcer as
secondary diagnosis to better screen out cases that may be present on
admission. In addition, this indicator excludes patients who have a
length of stay of 4 days or less, as it is unlikely that a decubitus
ulcer would develop within this period of time. Finally, this indicator
excludes patients who are particularly susceptible to decubitus ulcer,
namely patients with major skin disorders (Major Diagnostic Category 9
\[MDC 9\]) and paralysis.

\*The following concerns affect the validity of this indicator:

-   *Underreporting or screening*: Conditions included in this indicator
    may not be systematically reported (leading to an artificially low
    rate) or may be routinely screened for (leading to a higher rate in
    facilities that screen).

-   *Heterogeneous severity*: This indicator includes codes that
    encompass several levels of severity of a condition that cannot be
    ascertained by the codes.

-   *Case mix bias*: This indicator was felt to be particularly subject
    to systematic bias, and Diagnosis-Related Group (DRG) and
    comorbidity risk adjustment may not adequately address the concern.

Refer to the original measure documentation for further information.

#### PRIMARY CLINICAL COMPONENT

Decubitus ulcer

#### DENOMINATOR DESCRIPTION

All medical and surgical discharges, 18 years and older, defined by
specific Diagnosis-Related Groups (DRGs)

Exclude cases:

-   with length of stay of less than 5 days

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code of decubitus ulcer in the
    principal diagnosis field or in a secondary diagnosis field if
    present on admission, if known

-   Major Diagnostic Category (MDC) 9 (Skin, Subcutaneous Tissue, and
    Breast)

-   MDC 14 (pregnancy, childbirth, and puerperium)

-   with any diagnosis of hemiplegia, paraplegia, or quadriplegia

-   with an ICD-9-CM diagnosis code of spina bifida or anoxic brain
    damage

-   with an ICD-9-CM procedure code for debridement or pedicle graft
    **before or on the same day** as the major operating room procedure
    (surgical cases only)

-   admitted from a long-term care facility

-   transferred from an acute care facility

**Note**: Refer to the Technical Specifications document cited in the
\"Companion Documents\" field for specific DRGs and ICD-9-CM codes.

#### NUMERATOR DESCRIPTION

Discharges with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code of decubitus ulcer in
any secondary diagnosis field among cases meeting the inclusion and
exclusion rules for the denominator

**Note**: Refer to the Technical Specifications document cited in the
\"Companion Documents\" field for specific ICD-9-CM codes.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

AHRQ quality indicators. Guide to patient safety indicators \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ)AHRQ Pub; 2007 Mar 12. 76 p.(AHRQ Pub; no. 03-R203).

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
National reporting\
Quality of care research

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Nurses

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

Age greater than or equal to 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Unspecified

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All medical and surgical discharges, 18 years and older, defined by
specific Diagnosis-Related Groups (DRGs) (see the \"Denominator
Inclusions/Exclusions\" field)

**Note**: Refer to the Technical Specifications document cited in the
\"Companion Documents\" field for specific DRGs.

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All medical and surgical discharges, 18 years and older, defined by
specific Diagnosis-Related Groups (DRGs)

Include only patients with a length of stay of 5 or more days.

**Exclusions**\
Exclude cases:

-   with length of stay of less than 5 days

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code of decubitus ulcer in the
    principal diagnosis field or in a secondary diagnosis field if
    present on admission, if known

-   Major Diagnostic Category (MDC) 9 (Skin, Subcutaneous Tissue, and
    Breast)

-   MDC 14 (pregnancy, childbirth, and puerperium)

-   with any diagnosis of hemiplegia, paraplegia, or quadriplegia

-   with an ICD-9-CM diagnosis code of spina bifida or anoxic brain
    damage

-   with an ICD-9-CM procedure code for debridement or pedicle graft
    **before or on the same day** as the major operating room procedure
    (surgical cases only)

-   admitted from a long-term care facility

-   transferred from an acute care facility

**Note**: Refer to the Technical Specifications document cited in the
\"Companion Documents\" field for specific DRGs and ICD-9-CM codes.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Institutionalization\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Discharges with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code of decubitus ulcer in
any secondary diagnosis field among cases meeting the inclusion and
exclusion rules for the denominator

**Note**: Refer to the Technical Specifications document cited in the
\"Companion Documents\" field for specific ICD-9-CM codes.

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Institutionalization

#### DATA SOURCE

Administrative data

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Analysis by high-risk subgroup (stratification on vulnerable
populations)\
Analysis by subgroup (stratification on patient factors, geographic
factors, etc.)\
Risk adjustment method widely or commercially available

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Risk adjustment of the data is recommended using age, sex, modified
Diagnosis-Related Group (DRG), and comorbidity categories.

Application of multivariate signal extraction (MSX) to smooth risk
adjusted rates is also recommended.

#### STANDARD OF COMPARISON

External comparison at a point in time\
External comparison of time trends\
Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

The Patient Safety Indicators (PSIs) were evaluated by the project team
using empirical analyses to explore the frequency and variation of the
indicators, the potential bias, based on limited risk adjustment, and
the relationship between indicators. The data sources used in the
empirical analyses were the 1997 Florida State Inpatient Database (SID)
for initial testing and development and the 1997 Healthcare Cost and
Utilization Project (HCUP) State Inpatient Database for 19 States for
the final empirical analyses.

All potential indicators were examined empirically by developing and
conducting statistical tests for precision, bias, and relatedness of
indicators. Three different estimates of hospital performance were
calculated for each indicator:

1.  The raw indicator rate was calculated using the number of adverse
    events in the numerator divided by the number of discharges in the
    population at risk by hospital.

2.  The raw indicator was adjusted to account for differences among
    hospitals in age, gender, modified Diagnosis-Related Group (DRG),
    and comorbidities.

3.  Multivariate signal extraction methods were applied to adjust for
    reliability by estimating the amount of \"noise\" (i.e., variation
    due to random error) relative to the amount of \"signal\" (i.e.,
    systematic variation in hospital performance or reliability) for
    each indicator.

The project team constructed a set of statistical tests to examine the
precision, bias, and relatedness of indicators for all accepted
Provider-level Indicators, and precision and bias for all accepted
Area-level Indicators. It should be noted that rates based on fewer than
30 cases in the numerator or the denominator are not reported.

The project team conducted a structured review of each indicator to
evaluate the face validity (from a clinical perspective) of the
indicators. The methodology for the structured review was adapted from
the RAND/UCLA Appropriateness Method and consisted of an initial
independent assessment of each indicator by clinician panelists using an
initial questionnaire, a conference call among all panelists, followed
by a final independent assessment by clinician panelists using the same
questionnaire. The review sought to establish *consensual validity*,
which \"extends face validity from one expert to a panel of experts who
examine and rate the appropriateness of each item\...\" The panel
process served to refine definitions of some indicators, add new
measures, and dismiss indicators with major concerns from further
consideration.

Refer to the original measure documentation for additional details.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

AHRQ quality indicators. Guide to patient safety indicators \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ)AHRQ Pub; 2007 Mar 12. 76 p.(AHRQ Pub; no. 03-R203).

### Identifying Information

#### ORIGINAL TITLE

Decubitus ulcer (PSI 3).

#### MEASURE COLLECTION

[Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=341)

#### MEASURE SET NAME

[Agency for Healthcare Research and Quality (AHRQ) Patient Safety
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=4063)

#### DEVELOPER

Agency for Healthcare Research and Quality

#### INCLUDED IN

National Healthcare Disparities Report (NHDR)\
National Healthcare Quality Report (NHQR)

#### ADAPTATION

This indicator was originally proposed by Iezzoni and colleagues (1994)
as part of Complications Screening Program (CSP) (CSP 6, \"cellulitis or
decubitus ulcer\"). Needleman and Buerhaus (2001) identified decubitus
ulcer as an \"outcome potentially sensitive to nursing.\" The American
Nurses Association (1999), its State associations, and the California
Nursing Outcomes Coalition have identified the total prevalence of
inpatients with Stage I, II, III, or IV pressure ulcers as a
\"nursing-sensitive quality indicator for acute care settings.\"

#### RELEASE DATE

2003 Mar

#### REVISION DATE

2007 Mar

#### MEASURE STATUS

This is the current release of the measure.

This measure updates a previous version: AHRQ quality indicators. Guide
to patient safety indicators \[version 3.0a\]. Rockville (MD): Agency
for Healthcare Research and Quality (AHRQ); 2006 May 1. 78 p. (AHRQ Pub;
no. 03-R203).

#### SOURCE(S)

AHRQ quality indicators. Guide to patient safety indicators \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ)AHRQ Pub; 2007 Mar 12. 76 p.(AHRQ Pub; no. 03-R203).

#### MEASURE AVAILABILITY

The individual measure, \"Decubitus Ulcer (PSI 3),\" is published in
\"AHRQ Quality Indicators. Guide to Patient Safety Indicators.\" This
document is available in [Portable Document Format
(PDF)](http://www.qualityindicators.ahrq.gov/downloads/psi/psi_guide_v31.pdf)
from the [Patient Safety Indicators
Download](http://www.qualityindicators.ahrq.gov/psi_download.htm) page
at the Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators Web site.

For more information, please contact the QI Support Team at
<support@qualityindicators.ahrq.gov>.

#### COMPANION DOCUMENTS

The following are available:

-   AHRQ quality indicators. Patient safety indicators: technical
    specifications \[version 3.1\]. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2007 Mar 12. 107 p.

-   AHRQ quality indicators. Patient safety indicators: software
    documentation \[version 3.1\] - SAS. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2007 Mar 12. 42 p. This
    document is available in PDF from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/psi/psi_sas_documentation_v31.pdf).

-   AHRQ quality indicators. Software documentation: Windows \[version
    3.1a\]. Rockville (MD): Agency for Healthcare Research and Quality
    (AHRQ); 2007 Apr 6. 99 p. This document is available in PDF from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/winqi/AHRQ_QI_Windows_Software_Documentation_V31a.pdf).

-   Patient safety indicators: covariates \[version 3.1\]. Rockville
    (MD): Agency for Healthcare Research and Quality (AHRQ); 2007
    Mar 12. 27 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/psi/psi_covariates_v31.pdf).

-   Patient safety indicators: covariates (with POA) \[version 3.1\].
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2007 Mar 12. 27 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/psi/psi_covariates_poa_v31.pdf).

-   Remus D, Fraser I. Guidance for using the AHRQ quality indicators
    for hospital-level public reporting or payment. Rockville (MD):
    Agency for Healthcare Research and Quality; 2004 Aug. 24 p. This
    document is available in PDF from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/archives/documents/qi_guidance.pdf).

-   AHRQ summary statement on comparative hospital public reporting.
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2005 Dec. 1 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/news/AHRQSummaryStatement.pdf).

-   Guidance for using the AHRQ quality indicators for public reporting
    or payment - appendix A: current uses of AHRQ quality indicators and
    considerations for hospital-level reporting. Rockville (MD): Agency
    for Healthcare Research and Quality (AHRQ); 2005 Dec. A1-13 p. This
    document is available in PDF from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/technical/qi_guidance_appendix_A.pdf).

-   Guidance for using the AHRQ quality indicators for public reporting
    or payment - appendix B: public reporting evaluation
    framework\--comparison of recommended evaluation criteria in five
    existing national frameworks. Rockville (MD): Agency for Healthcare
    Research and Quality (AHRQ); 2005 Dec. B1-4 p. This document is
    available in PDF from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/technical/qi_guidance_appendix_B.pdf).

-   UCSF-Stanford Evidence-based Practice Center. Davies GM, Geppert J,
    McClellan M, et al. Refinement of the HCUP quality indicators.
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2001 May. (Technical review; no. 4). This document is available in
    PDF from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/technical/qi_technical_summary.pdf).

-   HCUPnet. \[internet\]. Rockville (MD): Agency for Healthcare
    Research and Quality (AHRQ); 2004 \[accessed 2007 May 21\].
    \[Various pagings\]. HCUPnet is available from the [AHRQ Web
    site](http://hcup.ahrq.gov/HCUPnet.asp). See the related
    [QualityTools](http://www.innovations.ahrq.gov/content.aspx?id=543)
    summary.

#### NQMC STATUS

This NQMC summary was completed by ECRI on October 1, 2003. The
information was verified by the measure developer on October 29, 2003.
This NQMC summary was updated by ECRI on February 7, 2005 and on April
11, 2006. The information was verified by the measure developer on July
31, 2006. This NQMC summary was updated again by ECRI on June 12, 2007.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008