Agency for Healthcare Research and Quality

**Patient Safety Indicators (PSIs)**

**Log of Revisions to PSI Documentation and Software**

Updated March 16, 2007

The following table summarizes all of the revisions made to the PSI
documentation and software since the original release of the version 2.1
software and documents in March 2003. The table lists the revision
number, the date the revision was made, the component affected by the
change and a short summary of the changes that were made. For
convenience and ease of use, the changes are listed in reverse
chronological order with the most recent changes appearing first in the
table. This log of revisions is current as of the date noted above.

+----------+---------+------------+-----------------------------------+
| ***      | ***     | ***Co      | ***Changes***                     |
| Version/ | Date*** | mponent*** |                                   |
| Revision |         |            |                                   |
| n        |         |            |                                   |
| umber*** |         |            |                                   |
+==========+=========+============+===================================+
| V 3.1a   | March   | SAS        | Added program to calculate the    |
|          | 16,     | Software   | PSI composite measure. The new    |
|          | 2007    | and        | files are PSI_COMPOSITE.SAS and   |
|          |         | Doc        | MSXPSC31.TXT.                     |
|          |         | umentation |                                   |
+----------+---------+------------+-----------------------------------+
| V 3.1a   | March   | SAS        | 1.  Amended the aggregation       |
|          | 16,     | Software   |     algorithm to correctly sum    |
|          | 2007    |            |     the numerator and denominator |
|          |         |            |     counts across stratifiers.    |
|          |         |            |     (PSSASA2).                    |
|          |         |            |                                   |
|          |         |            | 2.  Amended the expected rate     |
|          |         |            |     calculation to correctly      |
|          |         |            |     assign the modified DRG to    |
|          |         |            |     the intercept term. (PSFMTS,  |
|          |         |            |     PSSASP3)                      |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | Software,  | 1.  Implemented changes           |
|          | 12,     | Software   |     associated with ICD-9-CM      |
|          | 2007    | Docu       |     coding updates for Fiscal     |
|          |         | mentation, |     Year (FY) 2007 (effective     |
|          |         | Guide, and |     10-1-2006). See separate      |
|          |         | Technical  |     documentation on ICD-9 coding |
|          |         | Spec       |     updates for specific          |
|          |         | ifications |     details.[^1]                  |
|          |         |            |                                   |
|          |         |            | 2.  The years for which the       |
|          |         |            |     ICD-9-CM and DRG codes        |
|          |         |            |     defining PSIs are valid was   |
|          |         |            |     amended to be through FY 2007 |
|          |         |            |     instead of FY 2006, that is,  |
|          |         |            |     the codes in the software are |
|          |         |            |     effective through September   |
|          |         |            |     30, 2007.                     |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | Software   | 1.  The FY2007 release of the PSI |
|          | 12,     | (SAS and   |     includes an option to         |
|          | 2007    | Windows)   |     incorporate the Present on    |
|          |         | and        |     Admission indicator into the  |
|          |         | Doc        |     specifications.               |
|          |         | umentation |                                   |
|          |         |            | 2.  Added Data Elements           |
|          |         |            |     DXATADMIT1 - DXATADMIT30 to   |
|          |         |            |     indicate whether the          |
|          |         |            |     corresponding diagnosis       |
|          |         |            |     (i.e., DX1 - DX30) was        |
|          |         |            |     Present on Admission.         |
|          |         |            |                                   |
|          |         |            | 3.  Added an option for using     |
|          |         |            |     weighted data (i.e.,          |
|          |         |            |     discharge weights like those  |
|          |         |            |     used in the National          |
|          |         |            |     Inpatient Sample).            |
|          |         |            |                                   |
|          |         |            | 4.  Added data element DISCWT to  |
|          |         |            |     hold weight to assign to      |
|          |         |            |     discharge.                    |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | Software   | 1.  Updated the coefficients used |
|          | 12,     | (SAS and   |     in the calculation of         |
|          | 2007    | Windows),  |     expected and risk-adjusted    |
|          |         | Software   |     rates to the 2002-2004        |
|          |         | Doc        |     reference population.         |
|          |         | umentation |                                   |
|          |         | and        | 2.  Based on recommendations of   |
|          |         | Covariates |     the Risk Adjustment and       |
|          |         | document   |     Hierarchical Modeling (RAHM)  |
|          |         |            |     Workgroup, computed           |
|          |         |            |     covariates using logistic     |
|          |         |            |     regression model with a       |
|          |         |            |     hospital random-effect        |
|          |         |            |     instead of the existing       |
|          |         |            |     simple logistic model.        |
|          |         |            |     Because the AHRQ QI use a     |
|          |         |            |     large sample, the impact on   |
|          |         |            |     the covariates of using the   |
|          |         |            |     hierarchical model (and hence |
|          |         |            |     the impact on the             |
|          |         |            |     risk-adjusted rates) is       |
|          |         |            |     minor.                        |
|          |         |            |                                   |
|          |         |            | 3.  Updated Covariates document   |
|          |         |            |     to include the POA            |
|          |         |            |     coefficients.                 |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | Software   | 1.  Age-, race-, gender- and      |
|          | 12,     | (SAS and   |     county-specific population    |
|          | 2007    | Windows)   |     estimates used for AHRQ QI    |
|          |         |            |     area rates were updated to    |
|          |         |            |     use revised post-censal       |
|          |         |            |     estimates for years 2001      |
|          |         |            |     through 2005 and projections  |
|          |         |            |     for the years 2006 and 2007.  |
|          |         |            |                                   |
|          |         |            | 2.  The AHRQ co-morbidity         |
|          |         |            |     software was incorporated     |
|          |         |            |     unchanged, except for minor   |
|          |         |            |     syntax changes to conform to  |
|          |         |            |     our variable names. Also, one |
|          |         |            |     obsolete ICD-9-CM code, "347  |
|          |         |            |     ", was added to insure        |
|          |         |            |     backwards compatibility to    |
|          |         |            |     2002 for the NEURO            |
|          |         |            |     co-morbidity.                 |
|          |         |            |                                   |
|          |         |            | 3.  The syntax will compute       |
|          |         |            |     risk-adjusted rates and       |
|          |         |            |     observed-to-expected ratios   |
|          |         |            |     for the pre-defined set of    |
|          |         |            |     stratification variables      |
|          |         |            |     (e.g., age, gender, payer,    |
|          |         |            |     race). When stratifications   |
|          |         |            |     other than hospital or area   |
|          |         |            |     are selected, the RPPSxx      |
|          |         |            |     variables and their           |
|          |         |            |     confidence intervals are      |
|          |         |            |     observed/expected ratios to   |
|          |         |            |     avoid confounding with risk   |
|          |         |            |     adjustment variables          |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | Software   | 1.  Revised inclusion criteria    |
|          | 12,     | (SAS and   |     for Death in Low Mortality    |
|          | 2007    | Windows)   |     DRGs (PSI #2) based on        |
|          |         | and        |     analysis of 2002-2004 data.   |
|          |         | Technical  |     Deleted DRG 061 and added     |
|          |         | Spec       |     codes 353, 375, 425, 497,     |
|          |         | ifications |     498, and 518.                 |
|          |         |            |                                   |
|          |         |            | 2.  Revised numerator inclusion   |
|          |         |            |     criteria for Postoperative    |
|          |         |            |     Hemorrhage and Hematoma (PSI  |
|          |         |            |     #9) to require a diagnosis of |
|          |         |            |     hemorrhage or hematoma and a  |
|          |         |            |     procedure for control of      |
|          |         |            |     hemorrhage or drainage of     |
|          |         |            |     hematoma.\                    |
|          |         |            |     \                             |
|          |         |            |     Impact: The rate increases by |
|          |         |            |     about 25%.                    |
+----------+---------+------------+-----------------------------------+
| V 3.1    | March   | SAS        | 1.  Added flag &POAFG to          |
|          | 12,     | Software   |     CONTROL_PSI.SAS to indicate   |
|          | 2007    | and        |     whether Present on Admission  |
|          |         | Doc        |     data is available.            |
|          |         | umentation |                                   |
|          |         |            | 2.  Added alternative POA         |
|          |         |            |     parameter files of            |
|          |         |            |     risk-adjustment covariates    |
|          |         |            |     and population rates using    |
|          |         |            |     2002-2004 SID data from       |
|          |         |            |     California and New York.      |
|          |         |            |                                   |
|          |         |            | 3.  Co-morbidity software that    |
|          |         |            |     was developed and is          |
|          |         |            |     maintained by AHRQ has been   |
|          |         |            |     integrated into PSI syntax,   |
|          |         |            |     relieving users of the need   |
|          |         |            |     to run this software prior to |
|          |         |            |     PSSAS1.SAS and then to match  |
|          |         |            |     the results to their input    |
|          |         |            |     discharge data.               |
+----------+---------+------------+-----------------------------------+
| V 3.0a   | May 1,  | Technical  | 1.  Edited denominator            |
|          | 2006    | Spec       |     specification of PSI #2 to    |
|          |         | ifications |     reflect SAS software (Windows |
|          |         |            |     and SPSS updated).            |
|          |         |            |                                   |
|          |         |            | 2.  Corrected denominator         |
|          |         |            |     specification of PSI #4       |
|          |         |            |     (Sepsis).                     |
|          |         |            |                                   |
|          |         |            | 3.  Edited denominator            |
|          |         |            |     specification of PSI #6, PSI  |
|          |         |            |     #15, and PSI #17 for clarity. |
|          |         |            |                                   |
|          |         |            | 4.  Edited exclusion              |
|          |         |            |     specification of PSI #10 to   |
|          |         |            |     reflect SAS software (Windows |
|          |         |            |     and SPSS updated).            |
|          |         |            |                                   |
|          |         |            | 5.  Edited immunocompromised      |
|          |         |            |     state specification (multiple |
|          |         |            |     indicators) to reflect SAS    |
|          |         |            |     software (Windows and SPSS    |
|          |         |            |     updated).                     |
+----------+---------+------------+-----------------------------------+
| V 3.0a   | May 1,  | SAS        | 1.  CONTROL_PSI.SAS -- Renamed    |
|          | 2006    | Software   |     %COMOB to %COMOBFG.           |
|          |         | and        |                                   |
|          |         | Doc        | 2.  PSSAS1.SAS - SAS -- Renamed   |
|          |         | umentation |     %COMOB to %COMOBFG.           |
|          |         |            |                                   |
|          |         |            | 3.  PSASA2.SAS -- Fixed CSV       |
|          |         |            |     column header for OAPS27.     |
|          |         |            |                                   |
|          |         |            | 4.  PSSASP3.SAS -- Changed age    |
|          |         |            |     parameter for PSI #17 from 2  |
|          |         |            |     to 7 to prevent run error     |
|          |         |            |     when age is invalid (note:    |
|          |         |            |     users should verify cases in  |
|          |         |            |     denominator have age = 0).    |
|          |         |            |                                   |
|          |         |            | 5.  Added SAS syntax file to      |
|          |         |            |     merge user data file with     |
|          |         |            |     file created using updated    |
|          |         |            |     AHRQ comorbidities software.  |
+----------+---------+------------+-----------------------------------+
| V 3.0a   | May 1,  | Guide      | Edited denominator specification  |
|          | 2006    |            | of PSIs #6, 13-15, and 17 for     |
|          |         |            | clarity.                          |
+----------+---------+------------+-----------------------------------+
| V 3.0a   | May 1,  | All        | Edited PDF files to make URLs in  |
|          | 2006    | documents  | header or footer clickable links. |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software,  | 1.  Implemented changes           |
|          | ebruary | Software   |     associated with ICD-9-CM      |
|          | 20,     | Docu       |     coding updates for Fiscal     |
|          | 2006    | mentation, |     Year (FY) 2006 (effective     |
|          |         | Guide, and |     10-1-2005). See separate      |
|          |         | Technical  |     documentation on ICD-9 coding |
|          |         | Spec       |     updates for specific details. |
|          |         | ifications |                                   |
|          |         |            | 2.  The years for which the       |
|          |         |            |     ICD-9-CM and DRG codes        |
|          |         |            |     defining PSIs are valid was   |
|          |         |            |     amended to be through FY 2006 |
|          |         |            |     instead of FY 2005, that is,  |
|          |         |            |     the codes in the software are |
|          |         |            |     effective through September   |
|          |         |            |     30, 2006.                     |
|          |         |            |                                   |
|          |         |            | 3.  Dropped PSIs #27-29 and       |
|          |         |            |     revised PSIs #18-20 to limit  |
|          |         |            |     OB Trauma numerator           |
|          |         |            |     definitions to 3^rd^ and      |
|          |         |            |     4^th^ degree lacerations.     |
|          |         |            |                                   |
|          |         |            | 4.  Added area-level version of   |
|          |         |            |     Postoperative Hemorrhage or   |
|          |         |            |     Hematoma as PSI #27.          |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software,  | 1.  Revised multiple indicators   |
|          | ebruary | Guide, and |     to exclude pediatric          |
|          | 20,     | Technical  |     populations (age less than    |
|          | 2006    | Spec       |     18). Specifically, PSIs #3-4, |
|          |         | ifications |     6, 8-15, 22, 25, and 27.      |
|          |         |            |                                   |
|          |         |            | 2.  Revised multiple indicators   |
|          |         |            |     to exclude pediatric          |
|          |         |            |     populations (age less         |
|          |         |            |     than 18) unless MDC 14.       |
|          |         |            |     Specifically, PSIs #1-2, 5,   |
|          |         |            |     7, 16, 21, and 23-24.         |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software,  | 3.  Modified denominator for PSI  |
|          | ebruary | Guide, and |     #3 (decubitus ulcer) to       |
|          | 20,     | Technical  |     exclude transfers from acute  |
|          | 2006    | Spec       |     care facility, spina bifida   |
|          |         | ifications |     or anoxic brain damage        |
|          |         |            |     diagnosis, and debridement or |
|          |         |            |     pedicle graft procedures.     |
|          |         |            |                                   |
|          |         |            | 4.  Modified criteria for PSI #6  |
|          |         |            |     and PSI #22 (iatrogenic       |
|          |         |            |     pneumothorax) to drop         |
|          |         |            |     exclusion for trauma and add  |
|          |         |            |     exclusions for chest trauma,  |
|          |         |            |     diaphragmatic surgery repair, |
|          |         |            |     and pleural effusion.         |
|          |         |            |                                   |
|          |         |            | 5.  Modified criteria for PSI #7  |
|          |         |            |     (selected infections due to   |
|          |         |            |     medical care) and PSI #14     |
|          |         |            |     (postop wound dehiscence) to  |
|          |         |            |     exclude length of stay less   |
|          |         |            |     than 2 days.                  |
|          |         |            |                                   |
|          |         |            | 6.  Modified criteria for PSI #8  |
|          |         |            |     (postop hip fracture) to      |
|          |         |            |     exclude hip fracture repair   |
|          |         |            |     that occurs before or on the  |
|          |         |            |     same day as the major         |
|          |         |            |     operating room procedure      |
|          |         |            |     code.                         |
|          |         |            |                                   |
|          |         |            | 7.  Modified criteria for PSI #10 |
|          |         |            |     (postop physiological and     |
|          |         |            |     metabolic derangement) to     |
|          |         |            |     exclude principal diagnosis   |
|          |         |            |     of chronic renal failure in   |
|          |         |            |     cases of acute renal failure. |
|          |         |            |                                   |
|          |         |            | 8.  Modified specification for    |
|          |         |            |     PSI #11 (postop respiratory   |
|          |         |            |     failure) to add procedure     |
|          |         |            |     codes for postoperative       |
|          |         |            |     reintubation procedures based |
|          |         |            |     on number of days after major |
|          |         |            |     operating room procedure to   |
|          |         |            |     numerator and exclude         |
|          |         |            |     neuromuscular disorder        |
|          |         |            |     diagnosis from denominator.   |
|          |         |            |                                   |
|          |         |            | 9.  Modified denominator of PSI   |
|          |         |            |     #14 and PSI #24 (postop wound |
|          |         |            |     dehiscence) to exclude        |
|          |         |            |     immunocompromised state.      |
|          |         |            |                                   |
|          |         |            | 10. Modified denominator of PSI   |
|          |         |            |     #17 (birth trauma) to limit   |
|          |         |            |     to in-hospital live births    |
|          |         |            |     admitted between 0 and 28     |
|          |         |            |     days of age.                  |
|          |         |            |                                   |
|          |         |            | 11. Modified criteria for PSI     |
|          |         |            |     #18 - PSI #20 (birth trauma)  |
|          |         |            |     to limit numerator to 3^rd^   |
|          |         |            |     and 4^th^ degree lacerations. |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software,  | 1.  Added diagnosis codes 785.52  |
|          | ebruary | and        |     (Septic shock), 785.59 (Other |
|          | 20,     | Technical  |     shock without mention of      |
|          | 2006    | Spec       |     trauma), and 998.0            |
|          |         | ifications |     (Postoperative shock) to list |
|          |         |            |     of diagnosis codes for Sepsis |
|          |         |            |     (PSI #4 and PSI #13.)         |
|          |         |            |                                   |
|          |         |            | 2.  Added code 586 (Renal         |
|          |         |            |     failure, unspecified) and     |
|          |         |            |     997.5 (Urinary complications) |
|          |         |            |     to numerator specification    |
|          |         |            |     for acute renal failure in    |
|          |         |            |     PSI #10 (postop physiological |
|          |         |            |     and metabolic derangement.)   |
|          |         |            |                                   |
|          |         |            | 3.  Revised list of diagnosis     |
|          |         |            |     codes included in diagnosis   |
|          |         |            |     of immunocompromised states   |
|          |         |            |     (PSI #2, 4, 7, 13-14, 23-24). |
|          |         |            |                                   |
|          |         |            | 4.  Added diagnosis codes to      |
|          |         |            |     definition of infection used  |
|          |         |            |     as denominator exclusion for  |
|          |         |            |     PSI #4 (FTR) and PSI #13      |
|          |         |            |     (postop sepsis).              |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Guide      | 1.  Moved Appendix A into new     |
|          | ebruary |            |     document *Patient Safety      |
|          | 20,     |            |     Indicators Technical          |
|          | 2006    |            |     Specifications*.              |
|          |         |            |                                   |
|          |         |            | 2.  Removed Appendix B.           |
|          |         |            |                                   |
|          |         |            | 3.  Added new section \"Using     |
|          |         |            |     Different Types of QI         |
|          |         |            |     Rates.\"                      |
|          |         |            |                                   |
|          |         |            | 4.  Added explanation of changes  |
|          |         |            |     to area definitions and new   |
|          |         |            |     stratification options.       |
|          |         |            |                                   |
|          |         |            | 5.  Changed \"MSA\" to \"Metro    |
|          |         |            |     Area\" throughout the         |
|          |         |            |     document.                     |
+----------+---------+------------+-----------------------------------+
| V3.0     | F       | Guide,     | 1.  Removed Appendices that were  |
|          | ebruary | Software   |     copies of Change Log and      |
|          | 20,     | Docu       |     Indicator Changes documents.  |
|          | 2006    | mentation, |                                   |
|          |         | Guide, and | 2.  Added Appendix of Links to    |
|          |         | Technical  |     all IQI documents and         |
|          |         | Spec       |     additional resources.         |
|          |         | ifications |                                   |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software   | 1.  Amended Table 2 to add        |
|          | ebruary | Doc        |     variables for expected, lower |
|          | 20,     | umentation |     and upper CI levels, and      |
|          | 2006    | (SAS and   |     standard error of smoothed    |
|          |         | SPSS)      |     rate.                         |
|          |         |            |                                   |
|          |         |            | 2.  Amended Table 3 to include    |
|          |         |            |     the new 1995-2006 census data |
|          |         |            |     (POP95TO06.TXT).              |
|          |         |            |                                   |
|          |         |            | 3.  Removed section               |
|          |         |            |     \"Interpreting the Results\". |
|          |         |            |                                   |
|          |         |            | 4.  Replaced example printouts    |
|          |         |            |     with tables explaining        |
|          |         |            |     contents of columns in        |
|          |         |            |     printouts.                    |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software   | 1.  Removed outdated HCUP         |
|          | ebruary | and        |     comorbidity program.          |
|          | 20,     | Software   |                                   |
|          | 2006    | Doc        | 2.  Advised users to run HCUP     |
|          |         | umentation |     Comorbidity Software, Version |
|          |         |            |     3.0 as a separate program     |
|          |         | (SAS only) |     before running PSIs if        |
|          |         |            |     risk-adjusted rates are       |
|          |         |            |     desired.                      |
|          |         |            |                                   |
|          |         |            | 3.  Amended Table 4 to specify    |
|          |         |            |     that AHRQ Comorbidity         |
|          |         |            |     Variables are required to     |
|          |         |            |     generate risk-adjusted rates. |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software   | 1.  Added the 1995-2006 Census    |
|          | ebruary |            |     data (e.g., POP95TO06.TXT).   |
|          | 20,     |            |                                   |
|          | 2006    |            | 2.  Updated the covariates to 3M  |
|          |         |            |     APR-DRG Version 20.0 (i.e.,   |
|          |         |            |     COVIQP30.TXT)                 |
|          |         |            |                                   |
|          |         |            | 3.  Changed the computation of    |
|          |         |            |     the risk-adjusted rate to use |
|          |         |            |     a proportional formula for    |
|          |         |            |     indirect standardization.     |
|          |         |            |                                   |
|          |         |            | 4.  Added a computation of        |
|          |         |            |     confidence limits.            |
|          |         |            |                                   |
|          |         |            | 5.  Changed name of data element  |
|          |         |            |     HOSPSTCO to PSTCO.            |
|          |         |            |                                   |
|          |         |            | 6.  Added parameter POPYEAR to    |
|          |         |            |     specify year for Census data. |
+----------+---------+------------+-----------------------------------+
| V 3.0    | F       | Software   | Updated the coefficients used in  |
|          | ebruary | (SAS and   | the calculation of expected and   |
|          | 20,     | SPSS),     | risk-adjusted rates to the 2003   |
|          | 2006    | Software   | reference population.             |
|          |         | Doc        |                                   |
|          |         | umentation |                                   |
|          |         | and        |                                   |
|          |         | Covariates |                                   |
|          |         | document   |                                   |
+----------+---------+------------+-----------------------------------+
| V 2.1    | F       | Software   | Updated the coefficients used in  |
| R3a      | ebruary | (SAS and   | the calculation of expected and   |
|          | 15,     | SPSS),     | risk-adjusted rates to the 2002   |
|          | 2005    | Software   | reference population.             |
|          |         | Doc        |                                   |
|          |         | umentation | NOTE: The Guide to Patient Safety |
|          |         | and        | Indicators, Operating Room        |
|          |         | Covariates | Procedure Codes, and Fiscal Year  |
|          |         | document   | 2005 Coding Changes documents     |
|          |         |            | were not updated and Revision 3   |
|          |         |            | remains the current version.      |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | January | Software   | Modified documentation to reflect |
| 3        | 17,     | (SAS and   | changes in indicators associated  |
|          | 2005    | SPSS) and  | with ICD-9-CM coding updates for  |
|          |         | Guide      | FY 2005 (effective 10-1-2004).    |
|          |         |            | See separate documentation on     |
|          |         |            | ICD-9 coding updates for specific |
|          |         |            | details.                          |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | January | Guide      | 1.  Updated the provider, area    |
| 3        | 17,     |            |     and population rates in Table |
|          | 2005    |            |     1 and Table 2 and the         |
|          |         |            |     detailed evidence section     |
|          |         |            |     using data from the 2002 HCUP |
|          |         |            |     SID files.                    |
|          |         |            |                                   |
|          |         |            | 2.  In the detailed evidence      |
|          |         |            |     section, added a cross        |
|          |         |            |     reference from each indicator |
|          |         |            |     description to the            |
|          |         |            |     indicator\'s detailed         |
|          |         |            |     definition in Appendix A.     |
|          |         |            |                                   |
|          |         |            | 3.  Included Appendix A titles of |
|          |         |            |     detailed definitions in the   |
|          |         |            |     Table of Contents.            |
|          |         |            |                                   |
|          |         |            | 4.  Removed the Operating Room    |
|          |         |            |     Procedure Codes from Appendix |
|          |         |            |     C and reorganized the         |
|          |         |            |     Appendices. The Operating     |
|          |         |            |     Room Procedure Codes are now  |
|          |         |            |     provided as a separate        |
|          |         |            |     downloadable document.        |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | January | Software   | 1.  Added the 2003 census data    |
| 3        | 17,     | (SAS and   |     (i.e., QICTY03.TXT)           |
|          | 2005    | SPSS)      |                                   |
|          |         |            | 2.  Added optional data elements  |
|          |         |            |     YEAR (year of patient         |
|          |         |            |     discharge) and DQTR (calendar |
|          |         |            |     quarter of patient discharge) |
|          |         |            |     to the specifications of the  |
|          |         |            |     input file.                   |
|          |         |            |                                   |
|          |         |            | 3.  Added new user control        |
|          |         |            |     parameter YEARQTR to          |
|          |         |            |     CONTROL_PSI.SAS and           |
|          |         |            |     PSSPS1.SPS. The default       |
|          |         |            |     setting for this parameter in |
|          |         |            |     the syntax is 0. If the data  |
|          |         |            |     elements YEAR and DQTR are    |
|          |         |            |     available in the input data   |
|          |         |            |     file the parameter would be   |
|          |         |            |     set to 1.                     |
|          |         |            |                                   |
|          |         |            | Note: If available, these data    |
|          |         |            | elements are used to implement a  |
|          |         |            | coding change to Postoperative    |
|          |         |            | Wound Dehiscence (PSI #14) that   |
|          |         |            | adds ICD-9-CM code 44.99 to the   |
|          |         |            | denominator for discharges        |
|          |         |            | occurring on or after 10/1/2004.  |
|          |         |            | However, ICD-9 code 44.99 will    |
|          |         |            | not be retained in the            |
|          |         |            | denominator if the data elements  |
|          |         |            | year and quarter of discharge are |
|          |         |            | not available or if the user      |
|          |         |            | selects the option not to retain  |
|          |         |            | code 44.99 for purposes of        |
|          |         |            | trending over time.               |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | January | Software   | 1.  Table 3 was amended to        |
| 3        | 17,     | Doc        |     include the 2003 census data  |
|          | 2005    | umentation |     (i.e., QICTY03.TXT).          |
|          |         | (SAS and   |                                   |
|          |         | SPSS)      | 2.  Added instructions for        |
|          |         |            |     setting new user control      |
|          |         |            |     parameter YEARQTR to          |
|          |         |            |     CONTROL_PSI.SAS and           |
|          |         |            |     PSSPS1.SPS.                   |
|          |         |            |                                   |
|          |         |            | 3.  Added descriptions of         |
|          |         |            |     optional data elements YEAR   |
|          |         |            |     (year of patient discharge)   |
|          |         |            |     and DQTR (calendar quarter of |
|          |         |            |     patient discharge) to Table   |
|          |         |            |     4.                            |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | N       | Software   | Corrected syntax for the option   |
| 2a       | ovember | (SAS)      | to export program output of       |
|          | 19,     |            | PSSASP2.SAS and PSSASP3.SAS to    |
|          | 2004    |            | comma-delimited files that can    |
|          |         |            | then be read by Excel. NOTE: The  |
|          |         |            | changes do not affect the SPSS    |
|          |         |            | syntax.                           |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | N       | Software   | Updated zip files to exclude the  |
| 2a       | ovember | (SAS and   | QICTYAxx.TXT census files, which  |
|          | 19,     | SPSS)      | are not required for risk         |
|          | 2004    |            | adjustment for the PSI module.    |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | N       | Covariates | Revised to include additional     |
| 2a       | ovember |            | columns (i.e. the number of       |
|          | 19,     |            | covariates and the odds ratio)    |
|          | 2004    |            | and to correct the covariate      |
|          |         |            | labels. NOTE: The changes do not  |
|          |         |            | affect the covariate values or    |
|          |         |            | the calculation of risk-adjusted  |
|          |         |            | rates.                            |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | October | Guide      | 1.  Modified documentation to     |
| 2        | 22,     |            |     reflect changes in indicators |
|          | 2004    |            |     associated with ICD-9-CM      |
|          |         |            |     coding updates for FY 2004    |
|          |         |            |     (effective 10-1-2003). See    |
|          |         |            |     separate documentation for    |
|          |         |            |     specific details.             |
|          |         |            |                                   |
|          |         |            | 2.  Changed syntax of             |
|          |         |            |     \"hospital-level\" to         |
|          |         |            |     \"provider-level\" throughout |
|          |         |            |     the documentation.            |
|          |         |            |                                   |
|          |         |            | 3.  Added PSI number to each      |
|          |         |            |     Indicator name.               |
|          |         |            |                                   |
|          |         |            | 4.  Updated empirical results for |
|          |         |            |     Table 1, and limited contents |
|          |         |            |     to Provider-level PSIs.       |
|          |         |            |                                   |
|          |         |            | 5.  Added Table 2, listing        |
|          |         |            |     Area-level PSIs.              |
|          |         |            |                                   |
|          |         |            | 6.  Added caption for Table 3,    |
|          |         |            |     Indicators and Use of         |
|          |         |            |     External Cause-of-Injury      |
|          |         |            |     Codes.                        |
|          |         |            |                                   |
|          |         |            | 7.  Modified PSI #2 (death in low |
|          |         |            |     mortality DRGs). The          |
|          |         |            |     indicator is reported as a    |
|          |         |            |     single measure, but also      |
|          |         |            |     stratified by type of DRG:    |
|          |         |            |     adult medical, pediatric      |
|          |         |            |     medical, adult surgical (with |
|          |         |            |     OR procedure), adult surgical |
|          |         |            |     (without OR procedure),       |
|          |         |            |     pediatric surgical (with OR   |
|          |         |            |     procedure), pediatric         |
|          |         |            |     surgical (without OR          |
|          |         |            |     procedure), obstetric and     |
|          |         |            |     psychiatric. A list of low    |
|          |         |            |     mortality DRGs by type is     |
|          |         |            |     included PSI Guide.           |
|          |         |            |                                   |
|          |         |            | > Impact: Among the low mortality |
|          |         |            | > DRGs, about 25% of the          |
|          |         |            | > discharges and 60% of the       |
|          |         |            | > deaths are "adult medical"      |
|          |         |            | > DRGs. Psychiatric DRGs also     |
|          |         |            | > have a higher share of deaths   |
|          |         |            | > (10%) than discharges (6%).     |
|          |         |            | > Death among the other DRG types |
|          |         |            | > is very rare (0.1% or less).    |
|          |         |            | > Few low mortality surgical DRGs |
|          |         |            | > do not have an operating room   |
|          |         |            | > procedure, so the adult or      |
|          |         |            | > pediatric surgical DRG (without |
|          |         |            | > OR procedure) will generally be |
|          |         |            | > missing or zero for most        |
|          |         |            | > hospitals.                      |
|          |         |            |                                   |
|          |         |            | 8.  Modified PSI #14,             |
|          |         |            |     Postoperative Wound           |
|          |         |            |     Dehiscence, to include only   |
|          |         |            |     OR procedures in the          |
|          |         |            |     definition of abdominopelvic  |
|          |         |            |     surgery.                      |
|          |         |            |                                   |
|          |         |            | Impact: Small (less than 1%)      |
|          |         |            | decrease in the denominator and   |
|          |         |            | resulting small increase in the   |
|          |         |            | rate due to exclusion of a        |
|          |         |            | low-risk procedure.               |
|          |         |            |                                   |
|          |         |            | 9.  Modified PSI #17, Birth       |
|          |         |            |     Trauma, to exclude preterm    |
|          |         |            |     infants with subdural or      |
|          |         |            |     cerebral hemorrhage or        |
|          |         |            |     osteogenesis imperfecta       |
|          |         |            |     infants with injury to        |
|          |         |            |     skeleton from the numerator   |
|          |         |            |     only. NOTE: The infants       |
|          |         |            |     remain in the population at   |
|          |         |            |     risk for other types of birth |
|          |         |            |     trauma.                       |
|          |         |            |                                   |
|          |         |            | > Impact: Small (less than 1%)    |
|          |         |            | > increase in the denominator and |
|          |         |            | > resulting small decrease or no  |
|          |         |            | > impact in the rate (i.e. the    |
|          |         |            | > risk of other types of birth    |
|          |         |            | > trauma for these two            |
|          |         |            | > populations is less than or no  |
|          |         |            | > different than for other        |
|          |         |            | > births).                        |
|          |         |            |                                   |
|          |         |            | 10. Added three new Indicators    |
|          |         |            |     #27-29, to include            |
|          |         |            |     third-degree lacerations for  |
|          |         |            |     each of three types of        |
|          |         |            |     delivery: Vaginal with and    |
|          |         |            |     without instruments, and      |
|          |         |            |     Cesarean.                     |
|          |         |            |                                   |
|          |         |            | > Impact: The rate for OB Trauma  |
|          |         |            | > is generally 5-10% higher when  |
|          |         |            | > including 3^rd^ degree          |
|          |         |            | > lacerations                     |
|          |         |            |                                   |
|          |         |            | 11. Limited the surgical DRG      |
|          |         |            |     inclusion criteria to major   |
|          |         |            |     OR procedures for PSI #1,     |
|          |         |            |     8-13, all of which deal with  |
|          |         |            |     postoperative illness or      |
|          |         |            |     injury.                       |
|          |         |            |                                   |
|          |         |            | > Impact: Medium (1-4%) decrease  |
|          |         |            | > in the denominator. The impact  |
|          |         |            | > on the rate varies by           |
|          |         |            | > indicator. PSIs 1, 8 and 9 have |
|          |         |            | > a medium (1-3%) increase in the |
|          |         |            | > rate. PSIs 10 and 12 have a     |
|          |         |            | > small (less than 1%) decrease   |
|          |         |            | > in the rate. PSIs 11 and 13     |
|          |         |            | > have a medium (3-4%) decrease   |
|          |         |            | > in the rate.                    |
|          |         |            |                                   |
|          |         |            | 12. Modified PSIs #1, 3, 5, 6, 7, |
|          |         |            |     8, 9, 10, 11, 12, 13, 15. 16  |
|          |         |            |     to exclude discharges with a  |
|          |         |            |     PSI-defining secondary        |
|          |         |            |     diagnosis and a different     |
|          |         |            |     PSI-defining principal        |
|          |         |            |     diagnosis (but within the     |
|          |         |            |     same PSI definition).         |
|          |         |            |                                   |
|          |         |            | > Impact: Small (less than 1%)    |
|          |         |            | > decrease in the denominator.    |
|          |         |            | > The impact on the rate varies   |
|          |         |            | > by indicator. PSIs 1, 3, 6, 7,  |
|          |         |            | > 8, 10, 11, 13 and 16 have a     |
|          |         |            | > small (less than 1%) increase   |
|          |         |            | > in the rate. PSI 9 has a small  |
|          |         |            | > (less than 1%) decrease in the  |
|          |         |            | > rate. PSI 15 has a medium       |
|          |         |            | > (2-3%) decrease in the rate.    |
|          |         |            | > PSIs 5 and 12 have a large      |
|          |         |            | > (5-9%) decrease in the rate.    |
|          |         |            |                                   |
|          |         |            | 13. Modified PSIs #8, 9, 11, 12   |
|          |         |            |     to exclude discharges where   |
|          |         |            |     the only OR procedure is a    |
|          |         |            |     PSI-related procedure.        |
|          |         |            |                                   |
|          |         |            | > Impact: Small (less than 1%)    |
|          |         |            | > decrease in the denominator.    |
|          |         |            | > The impact on the rate varies   |
|          |         |            | > by indicator. PSI 11 has a      |
|          |         |            | > small (less than 1%) decrease   |
|          |         |            | > in the rate. PSI 9 has a medium |
|          |         |            | > (1-2%) decrease in the rate.    |
|          |         |            | > PSIs 8 and 12 have a large      |
|          |         |            | > (15-65%) decrease in the rate.  |
|          |         |            |                                   |
|          |         |            | 14. Modified PSIs #8, 9, 11, 12,  |
|          |         |            |     14 to exclude discharges      |
|          |         |            |     where a PSI-related procedure |
|          |         |            |     precedes the                  |
|          |         |            |     denominator-defining OR       |
|          |         |            |     procedure.                    |
|          |         |            |                                   |
|          |         |            | > Impact: Small (less than 1%)    |
|          |         |            | > decrease in the denominator.    |
|          |         |            | > The impact on the rate varies   |
|          |         |            | > by indicator. PSI 9 has a large |
|          |         |            | > (65-70%) increase in the rate.  |
|          |         |            | > PSIs 11 and 12 have a small     |
|          |         |            | > (less than 1%) decrease in the  |
|          |         |            | > rate. PSI 8 has a medium (3-4%) |
|          |         |            | > decrease in the rate. PSI 14    |
|          |         |            | > has a large (8-9%) decrease in  |
|          |         |            | > the rate.                       |
|          |         |            |                                   |
|          |         |            | 15. Modified Area level PSI #24,  |
|          |         |            |     Postoperative Wound           |
|          |         |            |     Dehiscence, to drop the       |
|          |         |            |     requirement that the wound    |
|          |         |            |     reclosure occurs in a         |
|          |         |            |     discharge with a procedure    |
|          |         |            |     code of abdominopelvic        |
|          |         |            |     surgery.                      |
|          |         |            |                                   |
|          |         |            | > Impact: Numerator increases by  |
|          |         |            | > about 40%.                      |
|          |         |            |                                   |
|          |         |            | 16. Added code 72.79 to the       |
|          |         |            |     definition of                 |
|          |         |            |     instrument-assisted delivery  |
|          |         |            |     in PSI #18, 19.               |
|          |         |            |                                   |
|          |         |            | > Impact: Transfers about 33% of  |
|          |         |            | > the denominator from PSI 19 to  |
|          |         |            | > PSI 18. Because the OB Trauma   |
|          |         |            | > rate for these cases is higher  |
|          |         |            | > than average for PSI 19 and     |
|          |         |            | > lower than average for PSI 18,  |
|          |         |            | > and because the OB Trauma rate  |
|          |         |            | > for PSI 19 is lower than PSI    |
|          |         |            | > 18, the rate for both           |
|          |         |            | > indicators decreases by 3-10%.  |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | October | Software   | 1.  Implemented syntax changes    |
| 2        | 22,     | (SAS and   |     associated with ICD-9-CM      |
|          | 2004    | SPSS)      |     coding updates from FY 2004   |
|          |         |            |     (effective 10-1-2003). See    |
|          |         |            |     separate documentation on     |
|          |         |            |     ICD-9 coding updates for      |
|          |         |            |     specific details.             |
|          |         |            |                                   |
|          |         |            | 2.  Implemented all syntax        |
|          |         |            |     changes required to implement |
|          |         |            |     the indicator modifications   |
|          |         |            |     (noted above under Guide) and |
|          |         |            |     incorporated the related      |
|          |         |            |     documentation in the Software |
|          |         |            |     manuals.                      |
|          |         |            |                                   |
|          |         |            | 3.  Modified the age, DRG and co  |
|          |         |            |     morbidity aggregations used   |
|          |         |            |     in the risk-adjustment to     |
|          |         |            |     reflect the new rates and to  |
|          |         |            |     group the DRGs by MDC         |
|          |         |            |     (including an MDC-specific    |
|          |         |            |     other category)               |
|          |         |            |                                   |
|          |         |            | 4.  Added the calculation and     |
|          |         |            |     reporting of the expected     |
|          |         |            |     rate at the stratification    |
|          |         |            |     level selected by the user.   |
|          |         |            |     The SAS (PSSASP3.SAS) and     |
|          |         |            |     SPSS (PSSPSP3.SPS) software   |
|          |         |            |     now calculates the            |
|          |         |            |     risk-adjusted rate, the       |
|          |         |            |     expected rate and the         |
|          |         |            |     smoothed rate. The rates are  |
|          |         |            |     saved in the output file. The |
|          |         |            |     user also has the option to   |
|          |         |            |     print the rates or save the   |
|          |         |            |     rates in a comma-delimited    |
|          |         |            |     ASCII file.                   |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | October | Software   | Inserted "PS" in format names for |
| 2        | 22,     | (SAS)      | age, sex, DRG and co morbidity    |
|          | 2004    |            | aggregations in SAS programs to   |
|          |         |            | distinguish these formats from    |
|          |         |            | similarly named formats used by   |
|          |         |            | other indicator software.         |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | May 28, | Guide      | 1.  Updated empirical results for |
| 1        | 2003    |            |     Table 1.                      |
|          |         |            |                                   |
|          |         |            | 2.  Corrected error in Failure to |
|          |         |            |     Rescue Sepsis (denominator,   |
|          |         |            |     exclusion criteria).          |
|          |         |            |     Corrected syntax excludes     |
|          |         |            |     patients with a length of     |
|          |         |            |     stay less than 4 days.        |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | May 28, | Software   | 1.  Corrected error in Failure to |
| 1        | 2003    | (SAS)      |     Rescue Sepsis (denominator,   |
|          |         |            |     exclusion criteria).          |
|          |         |            |     Corrected syntax excludes     |
|          |         |            |     patients with a length of     |
|          |         |            |     stay less than 4 days.        |
|          |         |            |                                   |
|          |         |            | 2.  Made minor syntax change to   |
|          |         |            |     pathname syntax to ease use.  |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | May 28, | Software   | Added instructions for obtaining  |
| 1        | 2003    | Doc        | confidence interval module.       |
|          |         | umentation |                                   |
|          |         | (SAS)      |                                   |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | May     | Software   | Parameter files: Updated the      |
| 1        | 28,2003 | reference  | parameter reference files.        |
|          |         | files      |                                   |
|          |         | (SAS)      |                                   |
+----------+---------+------------+-----------------------------------+
| V 2.1 R  | May     | Software   | Released SPSS software which      |
| 1        | 28,2003 | and        | incorporates all changes noted    |
|          |         | Doc        | for SAS.                          |
|          |         | umentation |                                   |
|          |         | (SPSS)     |                                   |
+----------+---------+------------+-----------------------------------+

[^1]: *Fiscal year 2007 coding changes, February 2007*, available at
    <http://www.qualityindicators.ahrq.gov/psi_download.htm>