Definitions

    Abdominal Aortic Anuerysm (AAA) Repair Mortality Rate Abdominal aortic aneurysm repair is a relatively rare procedure performed after the abdominal portion of the aorta has ruptured due to aneurysm. This surgical procedure requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as arrhythmias, acute myocardial infarction, colonic ischemia, and death.

    Abdominal Aortic Aneurysm (AAA) Repair Volume Abdominal Aortic Aneurysm repair is a relatively rare procedure performed after the abdominal portion of the aorta has ruptured due to aneurysm. This surgical procedure requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as arrhythmias, acute myocardial infarction, colonic ischemia, and death.

    Accidental Puncture or Laceration Rate is defined as cases of technical difficulty (e.g., accidental cut or laceration during procedure) per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    Acute conditions are severe and sudden in onset. Symptoms appear, change, or worsen rapidly, as in a heart attack or broken bone.

    Acute Myocardial Infarction (AMI) Mortality Rate also known as a heart attack. This occurs when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. When the heart muscle can't get the oxygen and nutrients it needs the part of the heart tissue that is affected may die. Timely and effective treatments for AMI, which are essential for patient survival, include appropriate use of thrombolytic therapy and revascularization.

    Acute Stroke Mortality Rate Quality treatment for acute stroke must be timely and efficient to prevent potentially fatal brain tissue death and patients may not present until after the fragile window of time has passed.

    Admission from another hospital indicates the patient was admitted to the hospital from another short term, acute-care hospital. This usually signifies that the patient required the transfer in order to obtain more specialized services that the originating hospital could not provide.

    Admission from long term care facility indicates the patient was admitted from a long term facility, such as a nursing home.

    Admission Rate Number of admissions per 100,000 individuals in the population.

    Adult Asthma Admission Rate defined as admissions for adult asthma per 100,000 population. Asthma is one of the most common reasons for hospital admission and emergency room care. Proper outpatient treatment may reduce the incidence or exacerbation of asthma requiring hospitalization, and lower rates represent better quality care. Most published studies combine admission rates for children and adults; therefore, areas may wish to examine this indicator together with pediatric asthma.

    Age group indicates the age of the patient at the time of admission or encounter, in groups of years. Information is listed as provided in the medical record.

    Agency for Healthcare Research and Quality (AHRQ) AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Additional information about AHRQ can be found at www.ahrq.gov.

    AHRQ Quality Indicators - Go to the website for AHRQ Quality Indicators at www.qualityindicators.ahrq.gov.

    All-listed diagnoses include the principal diagnosis plus additional conditions that coexist at the time of admission or that develop during the stay, and which have an effect on the treatment or length of stay in the hospital.

    All-listed procedures include all procedures performed during the hospital stay.

    Angina without Procedure Admission Rate is defined as admissions for angina (without procedures) per 100,000 population. Both stable and unstable angina are symptoms of potential coronary artery disease. Effective management of coronary disease reduces the occurrence of major cardiac events such as heart attacks, and may also reduce admission rates for angina. Proper outpatient treatment may reduce admissions for angina (without procedures), and lower rates represent better quality care.

    Bacterial Pneumonia Admission Rate is defined as admissions for bacterial pneumonia per 100,000 population. Bacterial pneumonia is a relatively common acute condition, treatable for the most part with antibiotics. If left untreated in susceptible individuals, such as the elderly, pneumonia can lead to death. Proper outpatient treatment may reduce admissions for bacterial pneumonia in non-susceptible individuals, and lower rates represent better quality care.

    Bilateral Cardiac Catheterization Rate Right-side coronary catheterization incidental to left-side catheterization has little additional benefit for patients without clinical indications for right-side catheterization. This is a diagnostic test that can show if blood vessels to the heart are narrowed or blocked. Most people only need it done on the left side of their heart. This quality indicator reports the proportion of patients who received heart catheterization on both sides of the heart.

    Carotid Endarterectomy (CEA) Volume Carotid endarterectomy is a fairly common surgical procedure designed to clean out a blocked carotid artery in order to restore normal blood flow to the brain. This procedure requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as abrupt carotid occlusion with or without stroke, myocardial infarction, and death. MONAHRQ calculates mortality for CEA, so that the volumes for this procedure can be examined in conjunction with mortality. However, the mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.

    Cesarean Delivery Rate Cesarean delivery is the most common operative procedure performed in the United States and is associated with higher costs than vaginal delivery. Despite a recent decrease in the rate of Cesarean deliveries, many organizations have aimed to monitor and reduce the rate.

    Charge is the amount the hospital charged for the entire hospital stay. It does not include professional (MD) fees. If you asked for information about procedures, charges will reflect the total hospital charge, not the charge for that procedure. Charges are not necessarily how much was reimbursed.

    Chronic condition is defined as a condition that lasts 12 months or longer and meets one or both of the following tests: (a) it places limitations on self-care, independent living, and social interactions; and (b) it results in the need for ongoing intervention with medical products, services, and special equipment.

    Chronic Obstructive Pulmonary Disease (COPD) Admission Rate is defined as admissions for chronic obstructive pulmonary disease per 100,000 population. COPD comprises three primary diseases that cause respiratory dysfunction, asthma, emphysema, and chronic bronchitis, each with distinct etiologies, treatments, and outcomes. This indicator examines emphysema and bronchitis; asthma is discussed separately for children and adults. Proper outpatient treatment may reduce admissions for COPD, and lower rates represent better quality care.

    Clinical Classifications Software (CCS) categorizes patient diagnoses and procedures into a manageable number of clinically meaningful categories. Instead of wading through the 12,000 diagnosis codes and 3,500 procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification (IDC-9-CM), the CCS groups them into about 260 diagnosis categories and 230 procedure categories. This "clinical grouper" makes it easier to quickly understand patterns of diagnoses and procedures. Each hospital stay can have multiple diagnoses and multiple procedures. CCS was developed at the Agency for Healthcare Research and Quality (AHRQ). Additional information can be found at www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.

    Congestive Heart Failure (CHF) Mortality Rate Congestive heart failure is a condition in which the heart can't pump enough blood to the body's other organs and is a progressive, chronic disease. CHF has substantial short-term mortality which can vary from provider to provider.

    Coronary Artery Bypass Graft (CABG) Area Rate Coronary artery bypass graft is a relatively common procedure that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart and is performed on patients with coronary artery disease. No ideal rate for CABG has been established.

    Coronary Artery Bypass Graft (CABG) Mortality Rate Coronary artery bypass graft is a relatively common procedure that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart. This procedure requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications such as myocardial infarction, stroke, and death.

    Coronary Artery Bypass Graft (CABG) Volume Coronary artery bypass graft is a relatively common procedure that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart. This procedure requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as myocardial infarction, stroke, and death.

    Craniotomy Mortality Rate Craniotomy for the treatment of subarachnoid hemorrhage or cerebral aneurysm entails substantially high post-operative mortality rates. Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space.

    Congestive Heart Failure (CHF) Admission Rate is defined as admissions for congestive heart failure per 100,000 population. CHF can be controlled in an outpatient setting for the most part; however, the disease is a chronic progressive disorder for which some hospitalizations are appropriate. Proper outpatient treatment may reduce admissions for CHF, and lower rates represent better quality care.

    Costs tend to reflect the actual costs of production (while charges represent what the hospital billed for the case). Total charges were converted to costs using cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS). In general, costs are less than charges.

    Death Rate Death rate is how often patients who were treated for a particular illness or who had a particular procedure died before leaving the hospital. Usually the death rate is displayed as the number of deaths out of 100 or 1,000 patients. This information is noted at the bottom of each chart.

    Dehydration Admission Rate is defined as admissions for dehydration per 100,000 population. Dehydration is a serious acute condition that occurs in frail patients and patients with other underlying illnesses following insufficient attention and support for fluid intake. Dehydration can for the most part be treated in an outpatient setting, but it is potentially fatal for elderly, very young children, frail patients, or patients with serious comorbid conditions. Proper outpatient treatment may reduce admissions for dehydration, and lower rates represent better quality care.

    Denominator the number of people (population) who are potentially capable of experiencing the event or outcome of interest. The denominator, along with the numerator, is used to calculate rates. The denominator is the bottom half of a fraction.

    Diabetes Long-Term Complication Admission Rate is defined as admissions for diabetic long-term complications per 100,000 population. Long-term complications of diabetes mellitus include renal, eye, neurological, and circulatory disorders. Long-term complications occur at some time in the majority of patients with diabetes to some degree. Proper outpatient treatment and adherence to care may reduce the incidence of diabetic long-term complications, and lower rates represent better quality care.

    Diabetes Short-Term Complication Admission Rate is defined as admissions for diabetic short-term complications per 100,000 population. Short-term complications of diabetes mellitus include diabetic ketoacidosis, hyperosmolarity, and coma. These life-threatening emergencies arise when a patient experiences an excess of glucose (hyperglycemia) or insulin (hypoglycemia). Proper outpatient treatment and adherence to care may reduce the incidence of diabetic short-term complications, and lower rates represent better quality care.

    Diagnosis Related Groups (DRGs) are the diagnosis codes doctors and hospitals put on patient's medical bills that Medicare uses to decide how much to pay the hospital.

    Discharge The hospital discharge (i.e., the hospital stay) is the unit of analysis, not a person or patient. Thus, a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.

    Discharge Rate The expected rate is the rate the provider would have if it performed the same as the reference population given the provider's actual case-mix (e.g., age, gender, DRG, and comorbidity categories).

    Discharge Status indicates the disposition of the patient at discharge from the hospital, e.g., routine (home); to another short term hospital; to a nursing home; to home health care; or against medical advice (AMA).

    Do hospitals that treat sicker patients have worse death rates? Hospitals that treat sicker patients do not necessarily have worse death rates. The hospital-specific 30-day death (mortality) rates used in this report have been adjusted to account for differences in patients' health before their hospital admission. Sicker patients or patients with more health-related risks may be more likely to die than healthier patients. Moreover, patients who are sicker may be more likely to be treated at particular hospitals while patients who are healthier may be more likely to be treated at other hospitals. To compare hospitals fairly (and to avoid penalizing those that treat sicker patients) it is therefore important to consider differences in patients' health before they were admitted to the hospital. The statistical process of accounting for differences in patients' sickness before they were admitted to the hospital is called risk-adjustment. This statistical process aims to 'level the playing field' by accounting for health risks that patients have before they enter the hospital.

    Esophageal Resection Mortality Rate Esophageal cancer is a malignant tumor of the esophagus. In order to remove the tumor a rare surgical procedure is performed which requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, pneumonia, anastomotic breakdown, and death.

    Esophageal Resection Volume Esophageal surgery, a rare procedure that involves the removal of a mass in the esophagus, requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, pneumonia, anastomotic breakdown, and death.

    If the observed rate is higher than the expected rate (i.e., the ratio of observed/expected is greater than 1.0, or observed minus expected is positive), then the implication is that the provider performed worse than the reference population for that particular indicator. Users may want to focus on these indicators for quality improvement.

    If the observed rate is lower than the expected rate (i.e., the ratio of observed/expected is less than 1.0, or observed minus expected is negative), then the implication is that the provider performed better than the reference population. Users may want to focus on these indicators for identifying best practices.

    Foreign Body Left in During Procedure Rate is defined as discharges with foreign body accidentally left in during procedure per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    Gastrointestinal (GI) Hemorrhage Mortality Rate GI hemorrhage may lead to death when uncontrolled and the ability to manage severely ill patients with comorbidities may influence the mortality rate.

    Gender is coded as male or female, and appears as provided in the medical record.

    Hip Fracture Mortality Rate Hip fractures, which are a common cause of morbidity and functional decline among elderly persons, are associated with a significant increase in the subsequent risk of mortality.

    Hip Replacement Mortality Rate Total hip arthroplasty (joint surgery) is an elective procedure performed to improve function and relieve pain among patients with chronic osteoarthritis, rheumatoid arthritis, or other degenerative processes involving the hip joint.

    Hospital charge is the amount the hospital charged for the entire hospital stay. It does not include professional (MD) fees. If you asked for information about procedures, charges will reflect the total hospital charge, not the charge for that procedure. Charges are not necessarily how much was reimbursed.

    Hospital costs tend to reflect the actual costs of production (while charges represent what the hospital billed for the case). Total charges were converted to costs using cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS). In general, costs are less than charges.

    Hospital Referral Regions (HRRs) are based on the Dartmouth Atlas Hospital Referral regions, which are defined as regional markets for tertiary medical care. HRR is defined by zip codes. For more information, please visit www.dartmouthatlas.org.

    Hospital Service Areas (HSAs) are based on the Dartmouth Atlas Hospital Service Areas, which are defined as local healthcare markets for hospital care. HSAs are based on the collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area. HSAs were defined by assigning ZIP codes to the hospital area where the greatest proportion of their Medicare residents were hospitalized. MONAHRQ applies these areas to all payers. For more information, please visit http://www.dartmouthatlas.org.

    How should the risk-adjusted death (mortality) rates and interval estimates be used? Risk-adjusted death (mortality) rates are estimated for individual hospitals based on information taken from a particular time period. If a slightly different time period had been chosen, chances are that each hospital's results would have been somewhat different.

    Researchers almost always report a range ("confidence interval" or in this case an "interval estimate") around their estimates, to show how much variation might be due to this kind of chance. A confidence interval or interval estimate tells us we can be reasonably "confident" (in this case, 95% confident) that a hospital's death (mortality) rate fell somewhere within this specified range. The smaller the range, the more precise the estimate.

    When hospitals treat a very large number of patients, chance differences will not have much effect on the overall rates. The range will be small, and the estimated death (mortality) rates will be more precise. In hospitals that treat smaller numbers of patients, however, even small chance differences could have a big impact on death (mortality) rates. The 95% confidence interval, or range, will be large, and the estimated death (mortality) rates will be much less precise. Because the number of patients treated at U.S. hospitals varies widely, the precision of hospitals' estimated death (mortality) rates also varies.

    Hypertension Admission Rate is defined as admissions for hypertension per 100,000 population. Hypertension is a chronic condition that is often controllable in an outpatient setting with appropriate use of drug therapy. Proper outpatient treatment may reduce admissions for hypertension, and lower rates represent better quality care.

    Hysterectomy Area Rate Hysterectomy is performed on patients with a number of indications, such as recurrent uterine bleeding, chronic pelvic pain, or menopause, usually in some combination. No ideal rate for hysterectomy has been established.

    Iatrogenic Pneumothorax Rate is defined as cases of iatrogenic pneumothorax caused by medical care per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    ICD-9-CM stands for the "International Classification of Diseases - 9th revision - Clinical Modification." All diagnoses (or conditions) and all procedures that patients receive in the hospital are assigned an ICD-9-CM code. Codes for diagnoses can be up to 5 digits long and codes for procedures can be up to 4 digits long. There are about 12,000 diagnosis codes and about 3,500 procedure codes. Each hospital stay can have multiple diagnoses and multiple procedures.

    Incidental Appendectomy in the Elderly Rate Removal of the appendix incidental to other abdominal surgery-such as urological, gynecological, or gastrointestinal surgeries-is intended to eliminate the risk of future appendicitis and to simplify any future differential diagnoses of abdominal pain.

    Inpatient Quality Indicators (IQIs) The IQIs are a set of measures that can be used with hospital inpatient discharge data to provide a perspective on quality. The IQIs include a variety of indicators, which are measured at the provider, hospital, or area level. Additional information can be found at www.qualityindicators.ahrq.gov.

    • Volume indicators are proxy, or indirect, measures of quality. They are based on evidence suggesting that hospitals performing more of certain intensive, high-technology, or highly complex procedures may have better outcomes for those procedures. Volume indicators simply represent counts of admissions in which these procedures were performed. The following are volume indicators:
      1. Esophageal resection volume
      2. Pancreatic resection volume
      3. Abdominal aortic aneurysm (AAA) repair volume
      4. Coronary artery bypass graft (CABG) volume
      5. Percutaneous transluminal coronary angioplasty (PTCA) volume
      6. Carotid endarterectomy (CEA) volume
    • Mortality indicators for inpatient procedures include procedures for which mortality has been shown to vary across institutions and for which there is evidence that high mortality may be associated with poorer quality of care. The following are mortality indicators for inpatient procedures:
      1. Esophageal resection mortality rate
      2. Pancreatic resection mortality rate
      3. Abdominal aortic aneurysm (AAA) repair mortality rate
      4. Coronary artery bypass graft (CABG) mortality rate
      5. Percutaneous transluminal coronary angioplasty (PTCA) mortality rate
      6. Carotid endarterectomy (CEA) mortality rate
      7. Craniotomy mortality rate
      8. Hip replacement mortality rate
    • Mortality indicators for inpatient conditions include conditions for which mortality has been shown to vary substantially across institutions and for which evidence suggests that high mortality may be associated with deficiencies in the quality of care. The following are mortality indicators for inpatient conditions:
      1. Acute myocardial infarction (AMI) mortality rate
      2. Congestive heart failure (CHF) mortality rate
      3. Acute stroke mortality rate
      4. Gastrointestinal hemorrhage mortality rate
      5. Hip fracture mortality rate
      6. Pneumonia mortality rate
    • Utilization indicators examine procedures whose use varies significantly across hospitals or areas, and for which questions have been raised about overuse, underuse, or misuse. High or low rates for these indicators are likely to represent inappropriate or inefficient delivery of care.
      • Hospital-level utilization indicators:
        1. Cesarean delivery rate
        2. Primary Cesarean delivery rate
        3. Vaginal birth after Cesarean (VBAC) rate
        4. Laparoscopic cholecystectomy rate
        5. Incidental appendectomy in the elderly rate
      • Area-level utilization indicators:
        1. Coronary artery bypass graft (CABG) area rate
        2. Percutaneous transluminal coronary angioplasty (PTCA) area rate
        3. Hysterectomy area rate
        4. Laminectomy or spinal fusion area rate

    Laminectomy or Spinal Fusion Area Rate Laminectomy, a removal of a portion of the vertebra (in the back), is performed on patients with a herniated disc or spinal stenosis (narrowing of the spaces in the spine). No ideal rate for laminectomy has been established.

    Laparoscopic Cholecystectomy Rate Surgical removal of the gall bladder (cholecystectomy) performed with a laparoscope (a surgical instrument used to make small incisions) has been identified as an underused procedure. Laparoscopic cholecystectomy is associated with less morbidity in less severe cases.

    Length of stay (LOS) is the number of nights the patient remained in the hospital for this stay. A patient admitted and discharged on the same day has a length of stay = 0.

    Low Birth Weight Rate is defined as the number of low birth weight infants per 100 births. Infants may be low birth weight because of inadequate interuterine growth or premature birth. Risk factors include sociodemographic and behavioral characteristics, such as low income and tobacco use during pregnancy. Proper preventive care may reduce incidence of low birth weight, and lower rates represent better quality care.

    Lower-Extremity Amputation Rate among Patients with Diabetes is defined as admissions for lower-extremity amputation in patients with diabetes per 100,000 population. Diabetes is a major risk factor for lower-extremity amputation, which can be caused by infection, neuropathy, and microvascular disease. Proper and continued treatment and glucose control may reduce the incidence of lower-extremity amputation, and lower rates represent better quality care.

    Major Diagnostic Categories (MDCs) are broad groups of Diagnosis Related Groups (DRGs) that relate to an organ or a system (such as the digestive system) and not to an etiology. Examples include MDC 01 - Diseases and Disorders of the Nervous System, MDC 02 - Diseases and Disorders of the Eye, MDC 03 - Diseases and Disorders of the Ear, Nose, Mouth and Throat. Each hospital stay has one DRG and one MDC assigned to it.

    Measures of quality Go to Inpatient Quality Indicators (IQIs)

    Medicaid Go to Payer.

    Medicare Go to Payer.

    Midwest U.S. Go to Region.

    Mortality Rate Number of deaths per 100,000 individuals in the population.

    Northeast U.S. Go to Region.

    Observed Rate is the raw rate generated by MONAHRQ from the data the user provided. If the observed rate is higher than the expected rate (i.e., the ratio of observed/expected is greater than 1.0, or observed minus expected is positive), then the implication is that the provider performed worse than the reference population for that particular indicator. Users may want to focus on these indicators for quality improvement.

    If the observed rate is lower than the expected rate (i.e., the ratio of observed/expected is less than 1.0, or observed minus expected is negative), then the implication is that the provider performed better than the reference population. Users may want to focus on these indicators for identifying best practices.

    Region refers to one of the four regions defined by the Bureau of the Census: Midwest, Northeast, South, and West.

    Numerator is the number of individuals who actually experience the event or outcome of interest. The numerator, along with the denominator, is used to calculate rates. The numerator is the top half of a fraction.

    Pancreatic Resection Mortality Rate Pancreatic removal is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, anastomotic breakdown, and death. The mortality rate show how often patients died from this procedure.

    Pancreatic Resection Volume Pancreatic removal is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, anastomotic breakdown, and death. The volume measure shows how often this procedure is performed.

    Patient age in years is calculated on the basis of the admission date to the hospital and date of birth. Information is listed as provided in the medical record.

    Patient Safety Indicators (PSIs) The PSIs are a set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are likely amenable to prevention by changes at the system or provider level. Additional information can be found at www.qualityindicators.ahrq.gov.

    PSIs are defined on two levels: the provide level and the area level.

    • Provider-level indicators provide a measure of the potentially preventable complication for patients who received their initial care and the complication of care within the same hospitalization. Provider-level indicators include only those cases where a secondary diagnosis code flags a potentially preventable complication.

      1. Accidental Puncture or Laceration
      2. Birth Trauma - Injury to Neonate
      3. Complications of Anesthesia
      4. Death in Low-Mortality DRGs
      5. Decubitus Ulcer
      6. Failure to Rescue
      7. Foreign Body Left During Procedure
      8. Iatrogenic Pneumothorax
      9. Obstetric Trauma - Vaginal with Instrument
      10. Obstetric Trauma - Vaginal without Instrument
      11. Obstetric Trauma - Cesarean Delivery
      12. Postoperative Hip Fracture
      13. Postoperative Hemorrhage or Hematoma
      14. Postoperative Physiologic and Metabolic Derangements
      15. Postoperative Respiratory Failure
      16. Postoperative Pulmonary Embolism or Deep Vein Thrombosis
      17. Postoperative Sepsis
      18. Postoperative Wound Dehiscence
      19. Selected Infections Due to Medical Care
      20. Transfusion Reaction

    • Area-level indicators capture all cases of the potentially preventable complication that occur in a given area (e.g., metropolitan area or county) either during hospitalization or resulting in subsequent hospitalization. Area-level indicators are specified to include principal diagnosis, as well as secondary diagnoses, for the complications of care. This specification adds cases where a patient's risk of the complication occurred in a separate hospitalization.

      1. Accidental Puncture or Laceration
      2. Foreign Body Left During Procedure
      3. Iatrogenic Pneumothorax
      4. Postoperative Hemorrhage or Hematoma
      5. Postoperative Wound Dehiscence
      6. Selected Infections Due to Medical Care
      7. Transfusion Reaction

    Payer is the expected payer for the hospital stay. To make coding uniform across all HCUP data sources, Payer combines detailed categories into more general groups:

    • Medicaid is a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
    • Medicare includes fee-for-service and managed care Medicare patients.
    • Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.
    • Uninsured includes an insurance status of "self-pay" and "no charge".
    • Other includes Worker's Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.
    • Missing designates that no payer information was provided in the medical record.

    When more than one payer is listed for a hospital discharge the first-listed payer is used.

    Percutaneous Transluminal Coronary Angioplasty (PTCA) Area Rate Percutaneous transluminal coronary angioplasty is one of several procedures used to open a blocked blood vessel and is performed on patients with coronary artery disease. No ideal rate for PTCA has been established.

    Percutaneous Transluminal Coronary Angioplasty (PTCA) Volume Percutaneous transluminal coronary angioplasty is one of several procedures used to open a blocked blood vessel and is performed on patients with coronary artery disease. It is a relatively common procedure that requires proficiency with the use of complex equipment, and technical errors may lead to clinically significant complications. MONAHRQ calculates mortality for PTCA, so that the volumes for this procedure can be examined in conjunction with mortality. However, the mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.

    Perforated Appendix Admission Rate is defined as admissions for perforated appendix per 100 admissions for appendicitis within Metro Area or county. Perforated appendix may occur when appropriate treatment for acute appendicitis is delayed for a number of reasons, including problems with access to care, failure by the patient to interpret symptoms as important, and misdiagnosis and other delays in obtaining surgery. Timely diagnosis and treatment may reduce the incidence of perforated appendix, and lower rates represent better quality care.

    Pneumonia Mortality Rate Pneumonia is an inflammation of the lungs caused by a viral or bacterial infection. This fills your lungs with mucus and lowers the oxygen level in your blood. Symptoms can include fever, fatigue, difficulty breathing, chills, a "wet" cough, and chest pain. Treatment with appropriate antibiotics may reduce mortality from pneumonia, which is a leading cause of death in the United States.

    Post-Operative Hemorrhage or Hematoma Rate is intended to capture cases of hemorrhage or hematoma following a surgical procedure. The rate is cases of hematoma or hemorrhage requiring a procedure per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    Post-Operative Wound Dehiscence Rate is intended to capture cases of wound dehiscence in patients who have undergone abdominal and pelvic surgery. The rate is defined as cases of reclosure of postoperative disruption of abdominal wall per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    Potentially avoidable stays The percentage of hospital admissions that could have been eliminated if the patient had received appropriate care earlier.

    Prevention Quality Indicators (PQIs) The PQIs are a set of measures that can be used with hospital inpatient discharge data to identify "ambulatory care sensitive conditions" (ACSCs) in adult populations. ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. Additional information can be found at www.qualityindicators.ahrq.gov.

    Even though IQIs are based on hospital inpatient data, they provide insight into the quality of the health care system outside the hospital setting. Patients with diabetes may be hospitalized for diabetic complications if their conditions are not adequately monitored or if they do not receive the patient education needed for appropriate self-management. Patients may be hospitalized for asthma if primary care providers fail to adhere to practice guidelines or to prescribe appropriate treatments. Patients with appendicitis who do not have ready access to surgical evaluation may experience delays in receiving needed care, which can result in a life-threatening condition-perforated appendix. Rates of low birth weight can be reduced by providing mothers with adequate prenatal care.

    The PQIs consist of the following 14 ACSCs, which are measured as rates of admission to the hospital:

      1. Adult Asthma Admission Rate
      2. Angina without Procedure Admission Rate
      3. Bacterial Pneumonia Admission Rate
      4. Chronic Obstructive Pulmonary Disease Admission Rate df
      5. Congestive Heart Failure Admission Rate
      6. Dehydration Admission Rate
      7. Diabetes Short-term Complications Admission Rate
      8. Diabetes Long-term Complications Admission Rate df
      9. Hypertension Admission Rate
      10. Low Birth Weight Rate
      11. Rate of Lower-extremity Amputation among Patient with Diabetes
      12. Perforated Appendix Admission Rate
      13. Urinary Tract Infection Admission Rate
      14. Uncontrolled Diabetes Admission Rates

    Prevention Quality Indicators (PQI) Composite - Acute Conditions The acute care PQI composite is based on rates of admission for dehydration, bacterial pneumonia, and urinary tract infections.

    Prevention Quality Indicators (PQI) Composite - Chronic Conditions The chronic care PQI composite is based on rates of admission for diabetes short-term complications, diabetes long-term complication, chronic obstructive pulmonary disease, hypertension, congestive heart failure, angina without procedure, uncontrolled diabetes, adult asthma, and lower-extremity amputation among patients with diabetes.

    Prevention Quality Indicators (PQI) Composite - Overall The overall PQI composite is based on rates of admission for diabetes short-term complications, diabetes long-term complication, chronic obstructive pulmonary disease, hypertension, congestive heart failure, angina without procedure, uncontrolled diabetes, adult asthma, lower-extremity amputation among patients with diabetes, dehydration, bacterial pneumonia, and urinary tract infections.

    Principal diagnosis The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The principal diagnosis is always the reason for admission.

    Principal procedure The procedure that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or the procedure that was necessary to take care of a complication. If two procedures appear to meet this definition, then the one most related to the principal diagnosis should be selected as the principal procedure.

    Private insurance Go to Payer.

    Procedure Rate Number of procedures per 100,000 individuals in the population.

    Quality Indicators Measures of health care quality that make use of readily available hospital inpatient administrative data. There are four types of quality indicators - Prevention (PQI), Inpatient (IQI), Patient Safety (PSI), and Pediatric (PDI).

    Race/ethnicity of the patient as listed in the medical record. Not every State provides this information, thus race/ethnicity is not available for every State or for the national estimates.

    Rate A rate is how often a particular event occurs in a population. For example, how often a procedure was done in a population, or how many cases of a particular condition occur in a population. Sometimes the rate is displayed as the number of procedures out of 100, 1,000, 10,000 or 100,000. This information is noted at the bottom of each chart.

    Risk-adjustment Go to Do hospitals that treat sicker patients have worse death rates?

    Selected Infections Due to Medical Care Rate is intended to flag cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters. The rate is defined as cases of ICD-9-CM codes 9993 or 99662 per 1,000 discharges. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    South U.S. Go to Region.

    Total U.S. Go to Region.

    Transfusion Reaction Rate is defined as cases of major reactions due to transfusions (ABO and Rh) per 100,000 population. The denominator is the population of county or Metro Area associated with FIPS code of patient's residence or hospital location.

    Uncontrolled Diabetes Admission Rate is defined as admissions for uncontrolled diabetes per 100,000 population. Uncontrolled diabetes should be used in conjunction with short-term complications of diabetes, which include diabetic ketoacidosis, hyperosmolarity, and coma. Proper outpatient treatment and adherence to care may reduce the incidence of uncontrolled diabetes, and lower rates represent better quality care.

    Uninsured Go to Payer.

    Urinary Tract Infection (UTI) Admission Rate is defined as admissions for urinary tract infection per 100,000 population. UTI is a common acute condition that can, for the most part, be treated with antibiotics in an outpatient setting. However, this condition can progress to more clinically significant infections, such as pyelonephritis, in vulnerable individuals with inadequate treatment. Proper outpatient treatment may reduce admissions for urinary infection, and lower rates represent better quality care.

    Utilization Statistics These statistics show how often a group of people use health care services in a defined area.

    Vaginal Birth after Cesarean (VBAC) Rate The policy of recommending vaginal birth after Cesarean delivery represents to some degree a matter of opinion on the relative risks and benefits of a trial of labor in patients with previous Cesarean delivery.

    West U.S. Go to Region.

    What Do Mortality Categories Show? These categories show how hospitals' 30-Day Death (mortality) rates compare to to a benchmark. The default benchmark in this website is the average for the input dataset (the overall average for the data being displayed in the website). This comparison is made after adjustmenting for how sick patients were before they were admitted to the hospital and taking into account differences in death rates that might be due to chance:

    • Better Than Average - Hospitals in the Better Than Average Rate category have 30-day death (mortality) rates that are lower than the benchmark rate and we can be 95% certain that this difference is not due to chance.
    • No Different than Average - Many hospitals in the No Different Than Average category have 30-day death (mortality) rates that are about the same as the benchmark rate. Other hospitals in this category have rates that are higher or lower, but we cannot be 95% certain that these differences are not due to chance. One cannot be certain about differences when a hospital has very few relevant patients.
    • Worse Than Average - Hospitals in the Worse Than Average category have 30-day death (mortality) rates that are higher than the benchmark rate and we can be 95% certain that this difference is not due to chance.

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