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## Complete Summary

#### TITLE

Adult asthma: hospital admission rate.

#### SOURCE(S)

AHRQ quality indicators. Guide to prevention quality indicators:
hospital admission for ambulatory care sensitive conditions \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ); 2007 Mar 12. 59 p.(AHRQ Pub; no. 02-R0203).

AHRQ quality indicators. Prevention quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. 22 p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Population Health

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

Access

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the number of admissions for asthma in
adults per 100,000 population.

As a Prevention Quality Indicator (PQI), adult asthma is not a measure
of hospital quality, but rather one measure of outpatient and other
health care. Providers may reduce admission rates without actually
improving quality by shifting care to an outpatient setting.

Admission rates that are drastically below or above the average or
recommended rates should be further examined.

#### RATIONALE

Prevention is an important role for all health care providers. Providers
can help individuals stay healthy by preventing disease, and they can
prevent complications of existing disease by helping patients live with
their illnesses. To fulfill this role, however, providers need data on
the impact of their services and the opportunity to compare these data
over time or across communities. Local, State, and Federal policymakers
also need these tools and data to identify potential access or
quality-of-care problems related to prevention, to plan specific
interventions, and to evaluate how well these interventions meet the
goals of preventing illness and disability.

While these indicators use hospital inpatient data, their focus is an
outpatient health care. Except in the case of patients who are
readmitted soon after discharge from a hospital, the quality of
inpatient care is unlikely to be a significant determinant of admission
rates for ambulatory care sensitive conditions. Rather, the Prevention
Quality Indicators (PQIs) assess the quality of the health care system
as a whole, and especially the quality of ambulatory care, in preventing
medical complications. As a result, these measures are likely to be of
the greatest value when calculated at the population level and when used
by public health groups, State data organizations, and other
organizations concerned with the health of populations.

These indicators\* serve as a screening tool rather than as definitive
measures of quality problems. They can provide initial information about
potential problems in the community that may require further, more
in-depth analysis.

Asthma is one of the most common reasons for hospital admission and
emergency room care. Most cases of asthma can be managed with proper
ongoing therapy on an outpatient basis. Most published studies combine
admission rates for children and adults; therefore, areas may wish to
examine this indicator together with pediatric asthma (see the related
National Quality Measures Clearinghouse \[NQMC\] summary of the Agency
for Healthcare Research and Quality \[AHRQ\] indicator [Asthma Admission
Rate (Area Level): Rate per 100,000
Population](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=8855&string=)).

Proper outpatient treatment may reduce the incidence or exacerbation of
asthma requiring hospitalization.

\*The following caveats were identified from the literature review for
the \"Adult Asthma Admission Rate\" indicator:

-   *Proxy***^a^**: Indicator does not directly measure patient outcomes
    but an aspect of care that is associated with the outcome; thus, it
    is best used with other indicators that measure similar aspects of
    care.

-   *Easily manipulated***^a^**: Use of the indicator may create
    perverse incentives to improve performance on the indicator without
    truly improving quality of care.

-   *Unclear benchmark***^b^**: The \"correct rate\" has not been
    established for the indicator; national, regional, or peer group
    averages may be the best benchmark available.

Refer to the original measure documentation for further details.

**Note**:

**a** - The concern is theoretical or suggested, but no specific
evidence was found in the literature.

**b** - Indicates that the concern has been demonstrated in the
literature.

#### PRIMARY CLINICAL COMPONENT

Adult asthma; hospital admission rates

#### DENOMINATOR DESCRIPTION

Population in Metro Area or county, age 18 years and older

#### NUMERATOR DESCRIPTION

All non-maternal discharges, age 18 years and older, with International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) principal diagnosis code\* for asthma

Exclude cases:

-   Transferring from another institution

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and
    puerperium)

-   MDC 15 (newborn and other neonates)

-   With any diagnosis code\* of cystic fibrosis and anomalies of the
    respiratory system

\*Refer to the Technical Specifications document for specific ICD-9-CM
codes.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE VALUE OF MONITORING THE ASPECT OF POPULATION HEALTH

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   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

Monitoring health state(s)\
Variation in health state(s)

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

AHRQ quality indicators. Guide to prevention quality indicators:
hospital admission for ambulatory care sensitive conditions \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ); 2007 Mar 12. 59 p.(AHRQ Pub; no. 02-R0203).

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Monitoring health state(s)\
National reporting

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Community Health Care

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Physician Assistants\
Physicians\
Public Health Professionals

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Counties or Cities

#### 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

-   Black patients have consistently been shown to have higher asthma
    admission rates, even when stratifying for income and age.

-   Billings et al. found that low-income zip codes in New York City had
    6.4 times more asthma hospitalizations than high-income zip codes.
    Household income explained 70% of this variation.

-   Millman et al. reported that low-income zip codes had 5.8 times more
    asthma hospitalizations per capita than high-income zip codes.

#### EVIDENCE FOR ASSOCIATION WITH VULNERABLE POPULATIONS

Billings J, Zeital L, Lukomnik J, Carey T, Blank A, Newman L. Analysis
of variation in hospital admission rates associated with area income in
New York City \[unpublished\].

Millman M, editor(s). Access to health care in America. Committee on
Monitoring Access to Personal Health Care Services. Washington (DC):
National Academy Press; 1993. 240 p.

Ray NF, Thamer M, Fadillioglu B, Gergen PJ. Race, income, urbanicity,
and asthma hospitalization in California: a small area analysis.
Chest1998 May;113(5):1277-84.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9596306)

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Timeliness

### Data Collection for the Measure

#### CASE FINDING

Both users and nonusers of care

#### DESCRIPTION OF CASE FINDING

Population in Metro Area or county, age 18 years and older

#### DENOMINATOR SAMPLING FRAME

Geographically defined

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Population in Metro Area or county, age 18 years and older

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are not equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Patient Characteristic

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All non-maternal discharges, age 18 years and older, with International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) principal diagnosis code\* for asthma

**Exclusions**\
Exclude cases:

-   Transferring from another institution

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and
    puerperium)

-   MDC 15 (newborn and other neonates)

-   With any diagnosis code\* of cystic fibrosis and anomalies of the
    respiratory system

\*Refer to the Technical Specifications document for specific ICD-9-CM
codes.

#### 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

Does not apply to this measure

#### TYPE OF HEALTH STATE

Adverse Health State

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

A lower score is desirable

#### ALLOWANCE FOR PATIENT FACTORS

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

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Observed (raw) rates may be stratified by areas (Metro Areas or
counties), age groups, race/ethnicity categories, and sex.

Risk adjustment of the data is recommended using age and sex.

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

Each potential quality indicator was evaluated against the following six
criteria, which were considered essential for determining the
reliability and validity of a quality indicator: face validity,
precision, minimum bias, construct validity, fosters real quality
improvement, and application. The project team searched Medline for
articles relating to each of these six areas of evaluation.
Additionally, extensive empirical testing of all potential indicators
was conducted using the 1995-97 Healthcare Cost and Utilization Project
(HCUP) State Inpatient Databases (SID) and Nationwide Inpatient Sample
(NIS) to determine precision, bias, and construct validity. Table 1 in
the original measure documentation summarizes the results of the
literature review and empirical evaluations on the Prevention Quality
Indicators (PQI). Refer to the original measure documentation for
details.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

AHRQ quality indicators. Guide to prevention quality indicators:
hospital admission for ambulatory care sensitive conditions \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ); 2007 Mar 12. 59 p.(AHRQ Pub; no. 02-R0203).

### Identifying Information

#### ORIGINAL TITLE

Adult asthma admission rate (PQI 15).

#### 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) Prevention Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=343)

#### DEVELOPER

Agency for Healthcare Research and Quality

#### FUNDING SOURCE(S)

Agency for Healthcare Research and Quality (AHRQ)

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators
are in the public domain and the specifications come from multiple
sources, including the published and unpublished literature, users,
researchers, and other organizations. AHRQ as an agency is responsible
for the content of the indicators.

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

None

#### ENDORSER

National Quality Forum

#### INCLUDED IN

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

#### ADAPTATION

This indicator was originally developed by Billings and colleagues in
conjunction with the United Hospital Fund of New York.

#### PARENT MEASURE

Unspecified

#### RELEASE DATE

2001 Oct

#### REVISION DATE

2008 Feb

#### MEASURE STATUS

This is the current release of the measure.

This measure updates previous versions:

-   AHRQ quality indicators. Guide to prevention quality indicators:
    hospital admission for ambulatory care sensitive conditions
    \[version 3.0a\]. Rockville (MD): Agency for Healthcare Research and
    Quality (AHRQ); 2006 Feb 20. 58 p. (AHRQ Pub; no. 02-R0203).

-   AHRQ quality indicators. Prevention quality indicators: technical
    specifications \[version 3.1\]. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2007 Mar 12. 22 p.

#### SOURCE(S)

AHRQ quality indicators. Guide to prevention quality indicators:
hospital admission for ambulatory care sensitive conditions \[version
3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
(AHRQ); 2007 Mar 12. 59 p.(AHRQ Pub; no. 02-R0203).

AHRQ quality indicators. Prevention quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. 22 p.

#### MEASURE AVAILABILITY

The individual measure, \"Adult Asthma Admission Rate (PQI 15),\" is
published in \"AHRQ Quality Indicators. Guide to Prevention Quality
Indicators\" and \"AHRQ Quality Indicators. Prevention Quality
Indicators: Technical Specifications.\" These documents are available in
Portable Document Format (PDF) from the [Prevention Quality Indicators
Download](http://www.qualityindicators.ahrq.gov/pqi_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. Prevention quality indicators: software
    documentation \[version 3.2\] - SAS. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2008 Mar 10. 32 p. This
    document is available in Portable Document Format (PDF) from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_sas_documentation_v32.pdf).

-   AHRQ quality indicators. Software documentation: Windows \[version
    3.2\]. Rockville (MD): Agency for Healthcare Research and Quality
    (AHRQ); 2008 Mar 10. 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_V32.pdf).

-   Prevention quality indicators (PQI): covariates \[version 3.1\].
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2007 Mar 12. 17 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_covariates_v31.pdf).

-   Prevention quality indicators (PQI): covariates (age only) \[version
    3.1\]. Rockville (MD): Agency for Healthcare Research and Quality
    (AHRQ); 2007 Mar 12. 17 p. This document is available in PDF from
    the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_covariates_age_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).

-   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 December 19, 2002. The
information was verified by the Agency for Healthcare Research and
Quality on January 9, 2003. This NQMC summary was updated by ECRI
Institute on April 6, 2004, February 18, 2005, February 27, 2006, June
15, 2007 and again on November 26, 2008.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### Disclaimer

#### NQMC DISCLAIMER

The National Quality Measures Clearinghouse™ (NQMC) does not develop,
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All measures summarized by NQMC and hosted on our site are produced
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Measures represented on the NQMC Web site are submitted by measure
developers, and are screened solely to determine that they meet the NQMC
Inclusion Criteria which may be found at
<http://www.qualitymeasures.ahrq.gov/about/inclusion.aspx>.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or its reliability and/or validity of the quality
measures and related materials represented on this site. The inclusion
or hosting of measures in NQMC may not be used for advertising or
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Readers with questions regarding measure content are directed to contact
the measure developer.

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© 2009 National Quality Measures Clearinghouse

Date Modified: 1/19/2009