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## Complete Summary

#### TITLE

Postoperative hemorrhage and hematoma: rate per 1,000 eligible
admissions.

#### SOURCE(S)

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

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

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

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the number of patients with postoperative
hemorrhage or hematoma requiring a procedure per 1,000 eligible
admissions.

#### RATIONALE

This indicator is intended to flag cases of hemorrhage or hematoma
following a surgical procedure. It is based on an indicator developed as
part of the Complications Screening Program. This indicator limits
hemorrhage and hematoma codes to secondary procedure and diagnosis codes
in order to isolate those hemorrhages that can truly be linked to a
surgical procedure. High quality surgical technique and proper
prophylaxis in high risk patients may reduce the risk of this
complication.

#### PRIMARY CLINICAL COMPONENT

Post-operative hemorrhage; post-operative hematoma

#### DENOMINATOR DESCRIPTION

All elective\* surgical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs) and an International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an
operating room procedure

\*Elective - Admission type \# is recorded as elective (SID ATYPE = 3).

Exclude cases:

-   with ICD-9-CM codes for postoperative hemorrhage or postoperative
    hematoma in the principal diagnosis field

-   where the only operating room procedure is postoperative control of
    hemorrhage or drainage of hematoma

-   where a procedure for postoperative control of hemorrhage or
    drainage of hematoma occurs before the first operating room
    procedure. *Note: If day of procedure is not available in the input
    data file, the rate may be slightly lower than if the information
    was available*.

-   obstetrical patients in Major Diagnosis Category (MDC) 14
    (pregnancy, childbirth and puerperium)

-   neonates with birth weight less than 500 grams

**Note**: Refer to the original measure documentation for specific DRG
and ICD-9-CM codes.

#### NUMERATOR DESCRIPTION

Discharges among cases meeting the inclusion and exclusion rules for the
denominator with the following:

-   International Classification of Diseases, Ninth Revision, Clinical
    Modification (ICD-9-CM) code for postoperative hemorrhage
    [or]{.underline} postoperative hematoma in any secondary diagnosis
    field

> AND

-   ICD-9-CM code for postoperative control of hemorrhage
    [or]{.underline} for drainage of hematoma in any procedure code
    field

**Note**: Refer to the original measure documentation for specific
ICD-9-CM codes.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

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

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

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
Quality of care research

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Age less than 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Stratified rates will be available for patients with any diagnosis code
indicating for specified coagulopathies (Congenital clotting factor
deficiencies, Von Willebrand\'s disease, primary, secondary and
unspecified thrombocytopenia, intrinsic circulating anticoagulants,
defibrination syndrome and acquired coagulation factor deficiency) or
any procedure code for Extracorporeal Membrane Oxygenation (ECMO).

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

The incidence of post-operative hemorrhage or hematoma, using the
original Agency for Healthcare Research and Quality (AHRQ) Patient
Safety Indicators (PSI) definition was investigated in pediatric
populations (e.g., 1.02 per 1,000 discharges at 0 to 17 years, 1.50 at
18 to 44 years, 1.99 at 45 to 64 years, and 2.54 at 65 or more years).
Other groups have analyzed rates of this indicator using the publicly
available indicator definition applied to a pediatric population; this
definition differs slightly from the definition proposed for this
measure. Miller and Zahn analyzed Healthcare Cost and Utilization
Project (HCUP) data from 2000 and found 13 pediatric patients (0 to 18
years of age) per 10,000 discharges with the complication of
postoperative hemorrhage or hematoma. Additionally, they found that this
complication resulted in an increased mean length of stay (by 7.9 days)
and \$75,932 in increased charges in affected patients, with 3.5 times
higher odds of in-hospital mortality (after adjusting for age, gender,
expected payer, up to 30 comorbidities, and multiple hospital
characteristics, including ownership, teaching status, nursing
expertise, urban location, bed size, pediatric volume, coding intensity,
intensive care unit (ICU) bed percentage, and surgical discharge
percentage). Sedman et al. analyzed National Association of Children\'s
Hospitals and Related Institutions (NACHRI) data from 1992-2002 and
found observed rates varying from 2.6 per 1,000 patients in 2001 to 2.7
per 1,000 patients in 2002 (with no consistent trend over time).

#### EVIDENCE FOR INCIDENCE/PREVALENCE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Post-operative hemorrhage or hematoma is an issue of significant concern
in the pediatric population. For example, one of the most common
surgical procedures performed in this patient group is tonsillectomy
(with or without adenoidectomy) and peri-operative or post-operative
bleeding is one of the most concerning complications.

#### EVIDENCE FOR ASSOCIATION WITH VULNERABLE POPULATIONS

Derkay CS. A cost-effective approach for preoperative hemostatic
assessment in children undergoing adenotonsillectomy. Arch Otolaryngol
Head Neck Surg2000 May;126(5):688.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10807347)

Hartnick CJ, Ruben RJ. Preoperative coagulation studies prior to
tonsillectomy. Arch Otolaryngol Head Neck Surg2000 May;126(5):684-6.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10807345)

#### BURDEN OF ILLNESS

See the \"Incidence/Prevalence\" and \"Association with Vulnerable
Populations\" fields.

#### UTILIZATION

See the \"Incidence/Prevalence\" field.

#### COSTS

See the \"Incidence/Prevalence\" field.

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All elective surgical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs) and an International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an
operating room procedure (see the \"Denominator Inclusions/Exclusions\"
field)

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All elective\* surgical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs) and an International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an
operating room procedure

\*Elective - Admission type \# is recorded as elective (SID ATYPE = 3).

**Exclusions**\
Exclude cases:

-   with ICD-9-CM codes for postoperative hemorrhage or postoperative
    hematoma in the principal diagnosis field

-   where the only operating room procedure is postoperative control of
    hemorrhage or drainage of hematoma

-   where a procedure for postoperative control of hemorrhage or
    drainage of hematoma occurs before the first operating room
    procedure. *Note: If day of procedure is not available in the input
    data file, the rate may be slightly lower than if the information
    was available*.

-   obstetrical patients in Major Diagnosis Category (MDC) 14
    (pregnancy, childbirth and puerperium)

-   neonates with birth weight less than 500 grams

**Note**: Refer to the original measure documentation for specific DRG
and ICD-9-CM codes.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

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

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Institutionalization\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Discharges among cases meeting the inclusion and exclusion rules for the
denominator with the following:

-   International Classification of Diseases, Ninth Revision, Clinical
    Modification (ICD-9-CM) code for postoperative hemorrhage
    [or]{.underline} postoperative hematoma in any secondary diagnosis
    field

> AND

-   ICD-9-CM code for postoperative control of hemorrhage
    [or]{.underline} for drainage of hematoma in any procedure code
    field

**Note**: Refer to the original measure documentation for specific
ICD-9-CM codes.

**Exclusions**\
Unspecified

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

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

#### NUMERATOR TIME WINDOW

Institutionalization

#### DATA SOURCE

Administrative data

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

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

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Risk adjustment of the data is recommended using, at minimum,
birthweight, age in days, age and AHRQ Clinical Classification
Software\*.

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

[Specifically, for this measure]{.underline}:

Stratified rates will be available for patients with any diagnosis code
indicating for specified coagulopathies (Congenital clotting factor
deficiencies, Von Willebrand\'s disease, primary, secondary and
unspecified thrombocytopenia, intrinsic circulating anticoagulants,
defibrination syndrome and acquired coagulation factor deficiency) or
any procedure code for Extracorporeal Membrane Oxygenation (ECMO).

\***Note**: Information on the Clinical Classification Software (CCS)
for ICD-9-CM is available at
<http://hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp>.

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

The development of the Agency for Healthcare Research and Quality (AHRQ)
Pediatric Quality Indicators utilizes a four pronged approach:
identification of candidate indicators, literature review, empirical
analyses, and panel review. Candidate indicators were identified through
both published literature and a brief survey of national organizations.
Literature review provided descriptions and evaluations of some
candidate indicators and the underlying relationship to quality of care.
Empirical analyses were conducted to explore alternative definitions; to
assess nationwide rates and hospital variation; and to develop
appropriate methods to account for variation in risk. Clinical panel
review helped to refine indicator definitions and risk groupings, and to
establish face validity in light of the limited evidence from the
literature for most pediatric indicators. Information from these sources
was used to specify indicator definitions and make recommendations to
AHRQ regarding the best indicators for inclusion in the pediatric
indicator set.

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

Empirical analyses were conducted to provide the clinical panels and
peer review participants with additional information about the
indicators. These analyses were also used by the development team to
test the alternative specifications and the relative contribution of
indicator components in the numerator and denominator. These analyses
were not intended to inform issues of precision, bias and construct
validity, which will be addressed separately. The data source used in
the empirical analyses was the 2003 Kids\' Inpatient Sample (KID).

Refer to the original measure documentation for additional details.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA appropriateness
method user\'s manual. Santa Monica (CA): RAND; 2001. 109 p.

Green L, Lewis F. Measurement and evaluation in health education and
health promotion. Mountain View (CA): Mayfield Publishing Company; 1998.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Identifying Information

#### ORIGINAL TITLE

Postoperative hemorrhage and hematoma (PDI 8).

#### 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) Pediatric Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=8832)

#### DEVELOPER

Agency for Healthcare Research and Quality

#### ADAPTATION

This measure was adapted from the AHRQ Patient Safety Quality
Indicators.

#### PARENT MEASURE

Postoperative Hemorrhage or Hematoma (PSI 9) (Agency for Healthcare
Research and Quality \[AHRQ\])

#### RELEASE DATE

2006 Feb

#### REVISION DATE

2008 Feb

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

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

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

#### MEASURE AVAILABILITY

The individual measure, \"Postoperative Hemorrhage and Hematoma (PDI
8),\" is published in \"Measures of Pediatric Health Care Quality Based
on Hospital Administrative Data: The Pediatric Quality Indicators\" and
\"AHRQ Quality Indicators. Pediatric Quality Indicators: Technical
Specifications \[version 3.2\].\" These documents are available in
Portable Document Format (PDF) from the [Pediatric Quality Indicators
Download](http://www.qualityindicators.ahrq.gov/pdi_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. Pediatric quality indicators: software
    documentation \[version 3.2\] - SAS. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2008 Mar 10. 40 p. This
    document is available in Portable Document Format (PDF) from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_sas_documentation_v32.pdf).

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

-   Pediatric quality indicators (PedQI): covariates \[version 3.1\].
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2007 Mar 12. 52 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_v31.pdf).

-   Pediatric quality indicators (PedQI): covariates (with POA)
    \[version 3.1\]. Rockville (MD): Agency for Healthcare Research and
    Quality (AHRQ); 2007 Mar 12. 52 p. This document is available in PDF
    from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_poa_age_v31.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 Institute on December 28, 2007.
The information was verified by the measure developer on March 31, 2008.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008