# Established Child Health Care Quality Measures

AHRQ Quality Indicators

[]{#contents .anchor}Contents

-   [Pediatric Quality Indicators](#pediatric-quality-indicators)

-   [[Child Measures Included]{.underline}](#child-measures-included)

-   [[Users]{.underline}](#hedisusers)

-   [[Comparisons and Trends]{.underline}](#hedistrends)

-   [[Service Delivery and Units of
    Analysis]{.underline}](#service-delivery-and-units-of-analysis)

-   [[Length-of-Enrollment Requirements]{.underline}](#hedisenrollment)

-   [[Data Sources]{.underline}](#hedisdata)

-   [[Development Process]{.underline}](#development-process)

-   [[Criteria Used]{.underline}](#criteria-used)

-   [[More Information and User
    Support]{.underline}](#more-information-and-user-support)

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators
(QIs) can provide information on the quality of hospital care and the
adequacy of outpatient and other health care services in an area. They
are produced using readily available hospital administrative data.
Although they are not definitive measures, AHRQ QIs are a screening tool
to help identify areas of clinical and community health care appropriate
for further, more in-depth analysis.

\[Note: AHRQ QIs were formerly called HCUP QIs. HCUP refers to the
Healthcare Cost and Utilization Project, a Federal-State-industry
partnership sponsored by AHRQ.\]

AHRQ QIs help identify:

-   Potentially preventable complications such as infections due to
    medical care.

-   Adverse outcomes such as in-hospital mortality.

-   Potentially problematic utilization rates for specific inpatient
    procedures thought to be over-, under-, or misused.

-   Potential problems with outpatient and other health care in an area,
    generally a metropolitan statistical area (MSA) or county, as
    reflected in rates of hospitalization for ambulatory-care-sensitive
    conditions.

AHRQ QIs are based on readily available hospital discharge
administrative data. Policymakers and other users can often get hospital
administrative data from their State government or from hospitals. AHRQ
QIs, which include 6 specific pediatric and neonatal indicators and 36
QIs that include the pediatric population, were refined through an AHRQ
contract with the University of California at San Francisco-Stanford
University Evidence-based Practice Center (UCSF-Stanford EPC).

AHRQ QIs fall into three modules called:

-   Prevention Quality Indicators (PQIs).

-   Inpatient Quality Indicators (IQIs).

-   Patient Safety Indicators (PSIs).

UCSF-Stanford EPC researchers were asked to assess the original QIs,
refine and enhance them, and develop additional QIs as appropriate. They
conducted a literature search, interviewed technical experts and QI
users, assessed alternative risk adjustment strategies, and evaluated
existing and potential QIs using a variety of statistical techniques.
Existing and potential QIs were evaluated for:

-   Face validity (making sense logically and clinically).

-   Precision.

-   Minimum bias.

-   Construct validity (correlation with other measures of the same
    aspects of care).

-   Potential to foster real quality improvement.

-   Actual application.

*Example*: Hospital discharge data for a given condition, e.g.,
pediatric asthma, can be analyzed to identify outlier rates
significantly above or below the average by:

-   Age group.

-   Discharge status (routine, to another institution, to home health
    care, etc.).

-   Race and ethnicity (if available in the data).

-   Geographic area (rural, urban).

If hospitals serving a particular program or population exhibit unusual
patterns, more focused analysis can follow.

**Online Resources:**

The complete report of the UCSF-Stanford EPC technical review,
*Refinement of the AHRQ Quality Indicators*, is available at:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm).

AHRQ QI software includes specifications that allow users to produce
comparative statistics and examine trends over time. Go to:
[[http://www.qualityindicators.ahrq.gov]{.underline}](http://www.qualityindicators.ahrq.gov/)

## Pediatric Quality Indicators

The Pediatric Quality Indicators (PDIs) are a set of measures that can
be used with hospital inpatient discharge data to provide a perspective
on the quality of pediatric healthcare. For more information on PDIs, go
to:
[[http://www.qualityindicators.ahrq.gov/pdi_overview.htm]{.underline}](http://www.qualityindicators.ahrq.gov/pdi_overview.htm)

To download PDI software, a users guide, and technical specifications,
go to:
[[http://www.qualityindicators.ahrq.gov/pdi_download.htm]{.underline}](http://www.qualityindicators.ahrq.gov/pdi_download.htm)

Child-Specific QIs

There are seven AHRQ QIs specific to children:

-   [[The Pediatric Asthma Admission Rate
    QI]{.underline}](#the-pediatric-asthma-admission-rate-qi)

-   [[The Pediatric Gastroenteritis Admission Rate
    QI]{.underline}](#the-pediatric-gastroenteritis-admission-rate-qi)

-   [[The Low Birth Weight QI]{.underline}](#the-low-birth-weight-qi)

-   [[The Pediatric Heart Surgery Volume
    QI]{.underline}](#the-pediatric-heart-surgery-volume-qi)

-   [[The Pediatric Heart Surgery Mortality
    QI]{.underline}](#the-pediatric-heart-surgery-mortality-qi)

-   [[The Birth Trauma PSI]{.underline}](#the-birth-trauma-psi)

# The Pediatric Asthma Admission Rate QI

The pediatric asthma admission rate PQI describes the admission rate for
pediatric asthma per 100,000 population of children under age 18,
excluding newborns and other neonates, within a geographic area such as
an MSA or county.

This is an ambulatory-care-sensitive indicator. It is not a measure of
hospital quality, but instead reflects the quality of outpatient and
other health care services in the area.

There is no clear benchmark describing a preferred or appropriate level
of pediatric asthma admissions. This QI can be used alone or in
conjunction with other ambulatory-care-sensitive indicators. When using
this QI, it is important to pay attention to high or low values that
might bias the rate.

**Online Resource:** Consult pages 313-17 in the UCSF-Stanford EPC
report for a more detailed analysis. To download the report, go to:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm)

# The Pediatric Gastroenteritis Admission Rate QI

The pediatric gastroenteritis admission rate PQI describes the admission
rate for dehydration per 100,000 population of children under age 18,
excluding newborns and other neonates, within a geographic area such as
an MSA or county.

This is an ambulatory-care-sensitive indicator. It is not a measure of
hospital quality, but instead reflects the quality of outpatient and
other health care services in the area.

There is no clear benchmark describing a preferred or appropriate level
of pediatric gastroenteritis admissions. This QI is best used in
conjunction with other ambulatory-care-sensitive indicators such as the
pediatric asthma admission rate QI or the low birth weight QI.

**Online Resource:** Consult pages 318-21 in the UCSF-Stanford EPC
report for a more detailed analysis. To download the report, go to:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm)

#### The Low Birth Weight QI

The low birth weight PQI describes the number of births below 2500 grams
per 100 births in a geographic area such as an MSA or county.

This is an ambulatory-care-sensitive indicator. It is not a measure of
hospital quality, but instead reflects the quality of outpatient and
other health care services in the area.

Lower rates of low-weight births are preferable to higher ones. It is
known that numerous factors outside of the health care system impact the
low birth weight rate, but appropriate risk-adjusting mechanisms are not
presently available. This QI should not be used alone, but can be used
in conjunction with other ambulatory-care-sensitive QIs such as the
pediatric asthma admission rate QI or the pediatric gastroenteritis
admission rate QI.

**Online Resource:** Consult pages 309-12 in the UCSF-Stanford EPC
report for a more detailed analysis. To download the report, go to:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm)

#### The Pediatric Heart Surgery Volume QI

The pediatric heart surgery volume IQI describes the rate of discharge
at a hospital for pediatric heart surgeries performed on children under
age 18, excluding newborns and other neonates.

This is a volume indicator. Current evidence shows that a higher volume
of such surgeries at a hospital may be associated with better outcomes.
Volume measures are not direct measures of quality, however, and the
relationship between volume and outcome may change as technology changes
or providers become more experienced. The pediatric heart surgery volume
QI should be used in conjunction with other measures, such as the
pediatric heart surgery mortality QI.

**Online Resource:** Consult pages 206-9 in the UCSF-Stanford EPC report
for a more detailed analysis. To download the report, go to:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm)

#### The Pediatric Heart Surgery Mortality QI

The pediatric heart surgery mortality IQI describes the number of deaths
at a hospital following pediatric heart surgery per 100 pediatric heart
surgeries performed on children under age 18, excluding newborns and
other neonates.

This is a mortality indicator. Risk adjustment beyond that possible on
the basis of administrative data is desirable. Lower rates are clearly
preferred. This QI is not recommended as a stand-alone indicator. Use of
this QI in conjunction with the pediatric heart surgery volume QI may
offer a more comprehensive perspective.

**Online Resource:** Consult pages 373-6 in the UCSF-Stanford EPC report
for a more detailed analysis. To download the report, go to:
[[http://www.ahrq.gov/clinic/tp/hcupqitp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/hcupqitp.htm)

#### The Birth Trauma PSI

The birth trauma PSI identifies cases of birth trauma per 1,000 liveborn
births in a hospital.

This is a patient safety indicator intended to flag preventable
complications of full-term deliveries. The measure excludes preterm
deliveries since birth trauma for these patients may be less preventable
than for full-term infants.

Risk adjustment beyond that possible using only administrative data is
desirable. While not a definitive measure of quality, this measure can
be used to identify potential opportunities for improvement.

**Online Resource:** Consult page 55 in the *Guide to Patient Safety
Indicators*. Go to:
[[http://www.qualityindicators.ahrq.gov/psi_download.htm]{.underline}](http://www.qualityindicators.ahrq.gov/psi_download.htm)

Other QIs That Can Be Used for Children

AHRQ QIs can be applied to a child population as well. These include:

-   Dehydration Admission Rate.

-   Bacterial Pneumonia Admission Rate.

-   Urinary Infection Admission Rate.

-   Perforated Appendix Admission Rate.

-   Diabetes Complications Admission Rate.

**Online Resource:** For a complete list of AHRQ QIs with relevance to
children, go to:
[[http://www.ahrq.gov/chtoolbx/QIstab.htm]{.underline}](http://www.ahrq.gov/chtoolbx/QIstab.htm)

[Return to Contents](#contents)
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## Child Measures Included

The QI software, currently in SAS and SPSS programming language, is in
the public domain and is available free of charge. Rates can be produced
for individual hospitals or geographic regions and compared with State
or other averages. Go to [Data Sources](#data-sources) for a discussion
of available data sources to assist in your analyses.

[[]{#hedisusers .anchor}Return to Contents](#contents)
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## Users

AHRQ QI users include:

-   State purchasers.

-   Academic researchers.

-   Peer review organizations.

-   State data organizations.

-   State hospital associations.

-   Health care providers.

-   Business coalitions.

[[]{#hedistrends .anchor}Return to Contents](#contents)
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## Comparisons and Trends

AHRQ QIs are designed to provide initial feedback about clinical areas
appropriate for further, more in-depth analysis. Many of the indicators
measure areas in which variables are at work and where patient risk
factors may play a large part. The measures should be viewed as screens
to identify potential problem areas for further examination.

AHRQ QIs can be used:

-   For quality improvement.

-   To compare and trend performance over time.

They are **not** designed to:

-   Assist in program management decisions.

-   Provide definitive quality assessments.

-   Make purchasing decisions.

-   Provide information for public reporting on individual hospitals.

[Return to Contents](#contents)
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## Service Delivery and Units of Analysis

Because AHRQ QIs use hospital discharge rates drawn from hospital
administrative data, they typically are not specific to any particular
service delivery system, such as managed care organizations,
primary-care case management programs, and fee-for-service delivery
programs. AHRQ QIs can be used for statewide, regional, or local
analysis if data from the relevant hospitals are available. More
detailed analyses may be possible using State Medicaid claims data.

[[]{#hedisenrollment .anchor}Return to Contents](#contents)
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## Length-of-Enrollment Requirements

Length-of-enrollment requirements do not apply to AHRQ QIs.

[[]{#hedisdata .anchor}Return to Contents](#contents)
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## Data Sources

HCUPnet includes the largest collection of longitudinal hospital care
data in the United States and can be used to calculate AHRQ QIs.

**Online Resource:** For more information on HCUPnet, go to:
[[http://hcup.ahrq.gov/HCUPnet.asp]{.underline}](http://hcup.ahrq.gov/HCUPnet.asp)

These databases enable research on a broad range of health policy
issues, including cost and quality of health services, medical practice
patterns, access to health care programs, and outcome of treatment at
the national, State, and local levels. Three databases have specific
relevance to children.

-   The HCUP Kids\' Inpatient Database (KID) is a unique longitudinal
    database of hospital inpatient pediatric discharges. Researchers and
    policymakers use the KID to analyze hospital utilization, charges,
    and outcomes for children across the United States. The KID\'s large
    sample size enables analyses of rare conditions, such as congenital
    anomalies, as well as uncommon treatments, such as organ
    transplantation.

> The KID is currently available for the years 1997 and 2000 and
> contains clinical and nonclinical information on all patients,
> regardless of payer, including persons covered by Medicare, Medicaid,
> private insurance, and the uninsured. Discharge weights are provided
> for calculating national estimates. Access to the KID is available
> through the HCUP Central Distributor and is open to users who sign a
> data use agreement. Uses are limited to research and aggregate
> statistical reporting.
>
> **Online Resource:** For more information on the HCUP Kids\' Inpatient
> Database, go to:
> [[http://www.hcup-us.ahrq.gov/kidoverview.jsp]{.underline}](http://www.hcup-us.ahrq.gov/kidoverview.jsp)

-   The HCUP State Inpatient Databases (SID) are a powerful set of
    longitudinal hospital inpatient databases. Researchers and
    policymakers use the SID to investigate questions unique to one
    State; to compare data from two or more States; to conduct market
    area variation analyses; and to identify State-specific trends in
    inpatient care utilization, access, charges, and outcomes.

> The SID are composed of annual State-specific files that share a
> common structure and common data elements, subjected to a common set
> of edits. The SID contain a core set of clinical and nonclinical
> information on all patients, regardless of payer, including persons
> covered by Medicare, Medicaid, private insurance, and the uninsured.
> The uniform format of the SID helps facilitate cross-State
> comparisons. Access to the SID from participating States is available
> through the HCUP Central Distributor. Uses are limited to research and
> aggregate statistical reporting.
>
> **Online Resource:** For more information on the HCUP State Inpatient
> Databases, go to:
> [[http://www.hcup-us.ahrq.gov/sidoverview.jsp]{.underline}](http://www.hcup-us.ahrq.gov/sidoverview.jsp)

-   The HCUP Nationwide Inpatient Sample (NIS) is a unique and powerful
    database of hospital inpatient stays. It is the largest all-payer
    inpatient care database in the United States, containing data from
    more than 7 million hospital stays and approximately 1,000
    hospitals. Researchers and policymakers use the NIS to identify,
    track, and analyze trends in health care utilization, access,
    charges, quality, and outcomes in the United States. It is ideal for
    developing national estimates and for research that requires a large
    sample size, such as rare conditions, uncommon treatments, and
    special patient populations.

> The NIS contains clinical and nonclinical information on all patients,
> regardless of payer, including persons covered by Medicare, Medicaid,
> private insurance, and the uninsured. Discharge weights are provided
> for calculating national estimates. Access to the NIS is available
> through the HCUP Central Distributor and is open to users who sign a
> data use agreement. Uses are limited to research and aggregate
> statistical reporting.
>
> **Online Resource:** For more information on the HCUP Nationwide
> Inpatient Sample, go to:
> [[http://www.hcup-us.ahrq.gov/nisoverview.jsp]{.underline}](http://www.hcup-us.ahrq.gov/nisoverview.jsp)

The KID, NIS, and SID databases can be used to explore age-specific
analyses. The KID is specific to children. All neonates and children are
also included in the SID and NIS.

AHRQ QIs can be calculated using HCUP or any similar hospital
administrative or claims data. The QI documentation provides details on
data format and other data requirements of the QI software.

**Online Resources:**

For more information on HCUP, go to:
[[http://www.ahrq.gov/data/hcup/]{.underline}](http://www.ahrq.gov/data/hcup/)

For more information on AHRQ QIs, go to:
[[http://www.qualityindicators.ahrq.gov]{.underline}](http://www.qualityindicators.ahrq.gov/)

[Return to Contents](#contents)
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## Development Process

HCUP is a Federal-State-industry health data partnership sponsored by
AHRQ. Researchers at AHRQ developed the original HCUP QIs using the HCUP
databases. The refined AHRQ QIs were developed through an AHRQ contract
with the University of California at San Francisco-Stanford University
Evidence-based Practice Center.

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## Criteria Used

Criteria used in developing the original HCUP QIs included:

-   Use of readily available, standardized, inexpensive data (hospital
    discharge data).

-   Development of a format allowing organizations to use their own data
    or other locally available data.

-   Preference for simple rather than more complex methodology wherever
    possible.

-   Building on measures already in use.

The refined AHRQ QIs were enhanced by:

-   Adding QIs, including additional pediatric QIs.

-   Providing population-based denominators when appropriate.

-   Addressing issues of risk adjustment.

-   Providing methods to help stabilize low-frequency indicators.

**Online Resources:**

For more information on the development and uses of the QIs, see:

Johantgen M, Elixhauser A, Ball J, et al. Quality indicators using
hospital discharge data: State and national applications. *Jt Comm J
Qual Improv* 1998 Feb;88-105.\
Abstract available on PubMed®:\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9547683&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9547683&dopt=Abstract)

For more information on the refined QIs, see:

Davies S, Geppert J, McClellan M, et al. *Refinement of the HCUP Quality
Indicators*. Technical Review 4. (Prepared by the UCSF-Stanford
Evidence-based Practice Center). AHRQ Publication No. 01-0035. Rockville
(MD): Agency for Healthcare Research and Quality. May 2001.\
Go to:
[[http://www.qualityindicators.ahrq.gov/downloads.htm]{.underline}](http://www.qualityindicators.ahrq.gov/downloads.htm)

For more information on the Patient Safety Indicators, see:

McDonald K, Romano P, Geppert J, et al. *Measures of Patient Safety
Based on Hospital Administrative Data---The Patient Safety Indicators*.
Technical Review 5 (Prepared by the University of California San
Francisco-Stanford Evidence-based Practice Center under Contract No.
290-97-0013). AHRQ Publication No. 02-0038. Rockville (MD): Agency for
Healthcare Research and Quality. August 2002.\
Go to:
[[http://www.qualityindicators.ahrq.gov/psi_download.htm]{.underline}](http://www.qualityindicators.ahrq.gov/psi_download.htm)

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## More Information and User Support

E-mail <support@qualityindicators.ahrq.gov> for more information about
AHRQ QIs and for user support.

**Online Resource:** QI information, including software in a
downloadable format, is available on the AHRQ QI Web site. Go to:
[http://www.qualityindicators.ahrq.gov](http://www.qualityindicators.ahrq.gov/)

[Return to Contents](#contents)
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