# Presentation: 547868

## AHRQ Quality Indicators NQF Update 

- Marybeth Farquhar, PhD, MSN, RN
- QI Users Meeting
- AHRQ 2nd Annual Conference
- Rockville, MD
- September 10, 2008

## QIs Submitted to NQF

- Submitted September 2006
- Select Individual QIs (34)
- Composite Measures (4)
- Reporting Template/Framework (2)
- Additional QIs submitted
- Perinatal Project (3)
- Perioperative Project (3)

## NQF TAPS

- Anesthesia & Surgery (16 measures)
- Patient Safety (14 measures)
- Pediatric (4 measures)
- Composite Measures (4 measures)
- Public Reporting & Implementation

**Notes:**
Surgery & Anesthesia advanced 11 of the 16 measures;
Patient Safety advanced 13 of the 14 measures;
Pediatric advanced 3 of the 4 measures;
Composite SC is finalizing a framework for both ambulatory and hospital composites, which should be out shortly.  Then they will evaluate the composites based on the developed framework.  
The PR TAP is finalizing their guidance document which should be out for public comment shortly.
The total number of measures recommended for advancement to CSAC (Consensus Standards Approval Committee) was 26 QIs.

## CSAC Determination

- Deliberated on April 24
- Vote
-  Advance 25 AHRQ QIs
- Defer 1 AHRQ QI (Stroke Project)
- NQF BOD
- Appeals process
- Project Completion: December 2008

## NQF Endorsed QIs

- Diabetes Project
- PQI #1 - Diabetes Short-term Complication Admission Rate and PQI #14 - Uncontrolled Diabetes Admission Rate.
- PQI #3 - Diabetes Long-term Complication Admission Rate.
- PQI #16 - Rate of Lower-extremity Amputation among Patients with Diabetes.
- Hospital Additional  Priorities 2005-06, Pneumonia Mortality Supplement
- IQI #20 – Inpatient Pneumonia Mortality

## NQF Endorsed QIs

- Ambulatory Care Project: Phase 3
- All PQIs & PQI Composite
- Standards of Hospital Care: Additional Priorities 2007
- Adults
- Death in low mortality DRGs (PSI 2)
- Death among surgical patients with treatable serious complications (PSI 4)
- Foreign body left in during procedure (PSI 5)
- Iatrogenic pneumothorax (PSI 6)
- Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 14)

## NQF Endorsed QIs

- Standards of Hospital Care: Additional Priorities 2007
- Accidental puncture and laceration (PSI 15)
- Transfusion reaction (PSI 16)
- Pediatrics
- Accidental Puncture or laceration (PDI 1)
- Decubitus Ulcer (PDI 2)
- Foreign Body left during procedure (PDI 3)
- Iatrogenic Pneumothorax in Non-neonates (PDI 5)
- Pediatric Heart Surgery Mortality (PDI 6)
- Pediatric Heart Surgery Volume (PDI 7)
- Postoperative Wound Dehiscence (PDI 11)
- Transfusion Reaction (PDI 13)

## NQF Endorsed QIs

- Standards of Hospital Care: Additional Priorities 2007
- Mortality Rates (Adults)
- Congestive heart failure (IQI 16)
- Stroke (IQI 17)
- Hip Fracture (IQI 19)
- Esophageal resection (IQI 18)
- Pancreatic resection (IQI 9)
- Abdominal aortic aneurysm repair (IQI 11)

## NQF Endorsed QIs

- Standards of Hospital Care: Additional Priorities 2007
- Volume of Procedures (Adults)
- Esophageal resection (IQI 1)
- Pancreatic resection (IQI 2)
- Abdominal aortic aneurysm repair (IQI 4)
- Hospital Level Procedure Utilization Rates
- Incidental appendectomy in the elderly (IQI 24)
- Bi-lateral cardiac catheterization (IQI 25)

## NQF Endorsed QIs

- Perinatal Care Project
- Nosocomial Blood Stream Infections in Neonates (NQI 3)
- Birth Trauma: Injury to Neonates (PSI 17)
- Hospital Perioperative Care
- Postoperative DVT or PE (PSI 12)

## CMS’ Reporting Hospital Quality Data for Annual Payment Update Program

- New Measures for FY 2010 Update
- SCIP Cardiovascular 2
- Heart Failure Readmission (30 day)
- PSI 4 (formerly FTR)
- Patient Safety Indicators
- Iatrogenic pneumothorax, adult
- Postoperative wound dehiscence
- Accidental puncture or laceration
- In patient Quality Indicators
- AAA Mortality Rate
- Hip fracture mortality rate

**Notes:**
PSI 4: Death among surgical patients with treatable serious complications

SCIP Cardiovascular 2, surgery patients on a beta blocker prior to arrival who received a beta blocker during the peri-operative period.

## CMS’ Reporting Hospital Quality Data for Annual Payment Update Program

- New Measures for FY 2010 Update
- Mortality for selected medical conditions
- Mortality for selected surgical procedures
- Complication/patient safety for selected indicators
- Cardiac Surgery Measure:  Participation in a systematic database for cardiac surgery

## NQF Guidelines for Consumer-Focused Public Reporting (August 2008)
7 Guidelines
Evaluated AHRQ Model Reports
Health Topic Template
Composite Template

- 7 Guidelines
- Evaluated AHRQ Model Reports
- Health Topic Template
- Composite Template

**QI Reporting Template**

**Notes:**
Based on extensive research (literature reviews, interviews w/ experts, two focus groups of medical officers and/or quality managers, four focus groups with the public who had recently experienced a hospital admission; and two rounds of cognitive interviews (19 interviews) to test draft versions of report template.
Form of dissemination:  Assumes website dissemination of hospital quality data but can be adapted to a printed report.
Indicators included: Includes all of the current IQIs and PSIs.  Four of the indicators are included but not labeled as “quality indicators”, and include four utilization rates for Caesarean sections and VBACs due to the controversy over the evidence and clarity about what is the “right” utilization rate for these procedures and directionality of the indicator.  Is more or less better?
Framing materials: A few easy to read materials that introduce key concepts such as elements of health care quality, how to use the report, what are the quality indicators, etc.
Organized by topic: Organized into nine topic areas.  The template permits users to select areas of interest to them as well as the indicators that they want to look at.  They can look at only one topic at a time, but are able to choose as many hospitals to include in the report as they would like.
Comparison chart across indicators: Users can select certain indicators of interest for inclusion of the comparison chart.  This chart is based on extensively tested in recent lab studies conducted as part of the CHAPS project.  Their research demonstrated that this kind of presentation of comparative data is far superior to other approaches—specifically people are much more likely to be able to identify high and low performances accurately and much more likely to use the information in making a decision.
Individual indicator graphs: The comparison chart is constructed so that once a selection is made, it takes the user to a horizontal bar graph which shows the absolute scores for each of the hospital's selected on a given indicator.  Special features include—the hospitals are ordered by performance, graphs covering volume and mortality for the same procedure are paired; the bar graph was designed to maximize comprehension of the bar showing the state or other average; graphs are structured to ensure that the numbers were always at least a whole integer
Technical details & resources:  This provides links to existing pages of the AHRQ QI website and has been included because testing indicates that even if people do not look at this kind of material, they want to know that it is there because it indicates that the sponsor is willing to be “transparent” about their methods.

## Composite Measures

- Inpatient Quality Indicators
- Mortality for Selected Procedures
- Mortality for Selected Conditions
- Patient Safety Indicators
- Overall Safety
- Pediatric Quality Indicators
- Overall Safety
- Prevention Quality Indicators
- Overall Preventable Admissions

**Notes:**
Many QI users expressed interest in the development of composite measures.  The goal of the effort was to develop a composite measure that might be used to monitor performance over time or across areas and populations using a methodology that could be applied at the national, regional, state or provider/area level.

## Acknowledgements

- 	As with any large, complex endeavor, the AHRQ Quality Indicators are supported by a team of researchers, clinicians, and others that work to constantly refine and improve the measures. There are a number of individuals that work on the QIs and contribute to their development and testing that should be acknowledged here, however, I would like to specifically acknowledge Jeffrey Geppert, J.D., of Battelle Memorial Institute; Patrick Romano, M.D., M.P.H., of the University of California; Sheryl M. Davies, M.A., and Kathryn M. McDonald, M.M., of Stanford University for their diligence and continued support of the program. I would also like to thank my colleagues at AHRQ for their suggestions and words of encouragement, but in particular, Mamatha Pancholi, the QI Project Officer, for her support and phenomenal focus over the past two years. I am honored and privileged to be part of an incredible team.