Introduction
Measuring quality in facilities serving hospitalized patients is a complicated process requiring software access and accurately documented patient data. The Agency of Healthcare Research and Quality (AHRQ) offered a set of quality measures for inpatient hospitals to facilitate comparisons between diverse facilities. This essay explores three quality measures from the set (IQI 17, IQI 24, and IQI 19) with reference to inpatient non-pediatric hospitals.
Quality Measure 1: IQI 17 – Acute Stroke Mortality Rate
Definition of the Measure
IQI 17, acute stroke mortality rate, is the seventeenth measure in the list of inpatient quality indicators formulated by the AHRQ. As per the technical specifications document by the AHRQ, IQI 17 is defined as the rate of hospitalized patients’ deaths per one thousand discharges in which acute stroke is documented as the key diagnosis (Garmon & Kmitch, 2018; Zapatero-Gaviria et al., 2017). The AHRQ has specific indicators for pediatric populations, whereas IQI 17 only refers to patients at the age of majority and older. As a provider-level quality indicator, IQI 17 includes metrics to differentiate between the types of stroke (Zapatero-Gaviria et al., 2017). However, obstetric postpartum discharges and patient transfer cases are excluded from the relevant data.
Numerical Description, Risk Adjustment, and Data Collection for the Measure
The IQI 17 measurement is constructed by dividing the number of relevant deaths by the number of total discharges with the acute stroke diagnosis and multiplying the resulting rate by one thousand. The numerator is the number of lethal outcomes among cases that meet all inclusion/exclusion criteria and fall under the predetermined range of diagnostic codes, whereas the denominator presents the number of total discharges of adult patients with one out of fifteen diagnostic stroke codes (Zapatero-Gaviria et al., 2017). Risk adjustment is achieved by means of the stratification process in which the overall measure is further broken down into three subcategories with varying mortality risks: stroke-induced intracerebral hemorrhage (four different ICD codes), bleeding in the subarachnoid space (one ICD code), and brain ischemia (nine ICD codes) (Zapatero-Gaviria et al., 2017). Also, this indicator has a list of risk adjustment coefficients for six parameters, including age and all patient refined diagnosis-related groups (APR-DRG). Regarding data collection, no specific processes aside from using the facility’s internal discharge and death statistics are required to complete the necessary calculations.
External Comparison
The effective collection of data on stroke mortality among inpatients allows for inter-hospital comparisons for improvement opportunity identification. In its brochure on IQI indicators, the AHRQ lists the production of comparative public reports among the potential applications of the IQI quality assessment system (Zapatero-Gaviria et al., 2017). External comparisons of similar inpatient hospitals are conducted by means of open hospital ranking systems, for instance, the U.S. News and World Report Hospital Ranking, based on percentile ranking techniques (Lichtman et al., 2019). Therefore, hospital-reported mortality rates are used in intra-industry comparative reports.
Goal Setting and the Measure’s Importance to Inpatient Hospitals
The measure is critically important for inpatient facilities’ reputation, and the best risk reduction strategies for stroke survivors should inform goal setting. An aggressive and ambitious inpatient facility may set the goal of decreasing its acute stroke mortality rates by emphasizing blood pressure control techniques and related staff education, combating understaffing and drug administration delays, and other outcome improvement strategies (Lichtman et al., 2019). However, setting mortality-related goals is not always possible since lethal outcomes can be linked to a variety of unpredictable factors that hospital staff cannot influence, including patients’ age, comorbid conditions, or lifestyle-related risks. Regarding importance, inpatient hospitals care for their professional reputation, and abnormally elevated post-stroke mortality rates could suggest a decrease in the observance of safety guidelines or a spike in medication administration and care mistakes.
Patient Safety and the Cost of Healthcare and Poor Quality
The selected measure has implications for safety and care costs at the national level. Changes in stroke mortality rates may represent a consequence of underreported patient safety incidents and medication errors in acute neurological and cardiac care, which could make the indicator a reflection of the hospital’s situation with safety. In terms of costs, poor care quality leading to increased mortality generates a variety of expenses, including patients’ lost earnings because of premature death, costs from fruitless medication use, and hospital inpatient care costs (Luengo-Fernandez et al., 2020). In reference to the overall healthcare costs, the event of a stroke patient’s death does not generate extra expenses in itself, but multiple lethal cases may lead to quality improvement initiatives and associated staff training, equipment purchasing, or similar costs.
Quality Measure 2: IQI 24 – Incidental Appendectomy in the Elderly Rate
Definition of the Measure
The second quality measure is coded as IQI 24 and aims to measure appendix removal cases in the elderly population. This rate-based provider-level indicator measures the rate of discharged patients with incidental appendix removal per one thousand discharges for elderly inpatients (≥65 years) that underwent pelvic/abdominal surgeries (Utter et al., 2018). When calculating this rate, providers should not include and consider the cases of appendectomy in colon removal, pelvic exenteration surgeries, appendiceal cancer, and obstetric patients (Utter et al., 2018). Therefore, the selected quality indicator is indicative of incidental appendectomy rates in a specific age cohort.
Numerical Description, Risk Adjustment, and Data Collection for the Measure
By analogy with the previous indicator, IQI 24 is constructed by calculating the frequency of cases meeting the definition above per every thousand completed discharges. In this case, the numerator is the number of incidental appendectomy procedures that meet all IQI 24 inclusion criteria (diagnosis type, patient age, etc.) and do not belong to exceptions (cases with missing information, diagnoses specified in the description, etc.) (Utter et al., 2018). There is a list of four ICD procedure codes (4382, 471, 4711, and 4719) that make the case eligible for inclusion. The denominator is the total number of discharges in the elderly (≥65 years) that have the predetermined ICD codes for pelvic/abdominal surgeries – the list of relevant codes includes a few hundred items and specifies the codes to be excluded (AHRQ, n.d.). Regarding the formula, the rate is calculated by dividing the numerator by the denominator and multiplying the result by 1000. The measure is not risk-adjusted and is not mentioned in the agency’s official risk adjustment guidelines. Data collection is performed by using hospital records with complete information on patients’ age, diagnoses, and dates of surgeries.
External Comparison
As for external comparison, current sources do not mention the uses of IQI 24 rates for hospital ranking purposes, which might be due to the procedure’s ambiguity in terms of health outcomes. While some studies suggest that incidental appendectomies contribute to post-surgery infection and mortality rates, other sources argue that appendectomies with excellent aseptic techniques do not influence these outcomes (Lee et al., 2019). However, using AHRQ QI software, hospitals can compare their performance to national or state-level benchmarks, but data availability and uniformity at the state level may vary based on setting types and the version of the software (AHRQ, n.d.). Based on the hospital’s actual IQI 24 rate and the selected benchmark, the program calculates the percent difference in rates given the availability of risk-adjusted rates.
Goal Setting and the Measure’s Importance to Inpatient Hospitals
IQI 24 enables hospitals to identify quality improvement priorities and set goals, including conducting appendectomies less frequently. Incidental operations involving the removal of the appendix are not necessarily safe in patients of advanced age, and the rate may need to be reduced if it is significantly higher than the national benchmark (Lee et al., 2019). The AHRQ (n.d.) offers resources that facilitate goal-setting; for instance, using the prioritization matrix, inpatient facilities can identify the degree to which their IQI 24 results and large-scale strategic goals are aligned and then set individualized rate reduction goals to excel in the market. As for the indicator’s importance, appendectomies in non-appendiceal surgeries in the elderly can increase mortality rates and operative time, so keeping track of this quality measure in inpatient facilities is important to understand and address safety risks (Lee et al., 2019). Therefore, IQI 24 assists in identifying problematic areas in geriatric surgery.
Patient Safety and the Cost of Healthcare and Poor Quality
Regarding patient safety, IQI 24 promotes the collection of data on healthy appendix removal cases. The effectiveness and necessity of such manipulations vary depending on the patient’s characteristics and medical history (Lee et al., 2019). Since appendectomies in high-risk populations, including older adults, can lead to contamination in certain instances, exercising control over the incidence of this procedure can reinforce patient safety measures by making sure that surgeons conduct it only when potential benefits are significant (Lee et al., 2019). On the one hand, appendectomies in non-appendiceal surgeries can somewhat affect healthcare costs by causing prolonged operative time (Lee et al., 2019). On the other hand, such procedures might prevent future cases of appendicitis requiring hospitalization and surgical treatment, which decreases costs (Lee et al., 2019). As for the cost of poor quality, improperly conducted appendectomies in the elderly can increase the risks of recurrent Clostridium difficile infections, myocardial disease, inflammatory processes, and inflammatory bowel diseases (Lee et al., 2019). Therefore, it might cause extra treatment and rehabilitation costs if performed poorly.
Quality Measure 3: IQI 19 – Hip Fracture Mortality Rate
Definition of the Measure
IQI 19 is among the measures focused on the elderly population. It can be defined as the number of in-hospital lethal outcomes in elderly patients (≥65 years) with hip fractures as the key diagnosis (AHRQ, n.d.). The cases to be excluded are obstetric patients, transfers between different hospitals, and patients with periprosthetic fractures (AHRQ, n.d.). As a rate-based indicator, IQI 19 measures the rate of lethal outcomes per one thousand elderly patients with hip fractures.
Numerical Description, Risk Adjustment, and Data Collection for the Measure
Similar to the two previous indicators, IQI 19 is calculated by dividing the numerator by the denominator and multiplying the fraction by 1000. The denominator is the total number of discharges with hip fractures as the principal diagnosis (one of the eighteen ICD codes) and the patient’s age equal to or exceeding 65 (AHRQ, n.d.). The denominator cannot include periprosthetic fracture cases, cases with missing discharge status, transfers to other hospitals, younger patients, and obstetric diagnoses (AHRQ, n.d.). The numerator reflects the number of deaths in cases that meet the abovementioned inclusion rules. Like the previous indicators, data collection involves using the facility’s inpatient administrative data and searching the relevant items by diagnostic codes. As for risk adjustment, it is achieved by using the risk adjustment coefficients provided by the AHRQ (n.d.) in its guideline documents. IQI 19 has coefficients for seven parameters, including patient sex, age, several APR-DRGs, certain major diagnostic categories, and transfers (AHRQ, n.d.). Risk adjustments enable more accurate comparisons and quality-related conclusions.
External Comparison
Using their actual IQI 19 outcomes, inpatient hospitals can compare their situation with an average result for other facilities of that type in the state, region, or the entire country. As of now, the IQI 19 rate for U.S. hospitals is about 20 (AHRQ, n.d.). Hospitals that score much higher on this quality indicator may need to conduct internal investigations and study the deceased patients’ cases more closely to determine the chances of survival and the quality of treatment. QI software by the AHRQ can automatically produce comparative statistics by calculating percentile ranking based on a specific facility’s IQI 19 rate.
Goal Setting and the Measure’s Importance to Inpatient Hospitals
With the help of AHRQ tools, hospitals can set hip fracture mortality reduction goals if IQI 19 has been defined as a critical quality improvement area. Specific mortality reduction plans, however, should be formulated with reference to particular contributors to lethal outcomes, be it insufficient staff training, poor compliance with pressure ulcer prevention guidelines, infectious disease, and other factors. Current studies associate hip fracture mortality with COVID-19 (Thakrar et al., 2020). As for the indicator’s importance, considering the elderly population’s health characteristics, IQI 19 basically shows how well the facility cares for frail patients with multiple comorbidities and can shed light on deficiencies in this regard (Thakrar et al., 2020). Thus, among other things, infection prevention measures may need to be taken to emphasize patient safety and excel in the market.
Patient Safety and the Cost of Healthcare and Poor Quality
IQI 19 is closely linked to issues surrounding patient safety and healthcare costs. The indicator emphasizes patient safety by shedding light on the potential care quality and safety assurance deficiencies, including ineffective pressure ulcer prevention measures or the inability to prevent infectious diseases in the ward (Thakrar et al., 2020). As for care costs, hip fracture cases act as a substantial economic burden to the national healthcare system, accounting for billions of dollars annually (Thakrar et al., 2020). The costs of poor quality are the most relevant when it comes to non-hospital facilities in which older adults may get hip fractures, such as nursing homes (Thakrar et al., 2020). With that in mind, aside from hospital factors, facilities in which hip fractures occur are part of the problem.
Conclusion
All three quality measures shed light on the currency of medical practices, compliance with care guidelines, and clinical decision-making quality in inpatient hospitals. The benefits of such measures are numerous, ranging from identifying areas that require quality improvement initiatives to supporting hospitals in striving for excellence, thus promoting competition and patient-orientedness. Aside from patient safety, quality measures facilitate the recognition of manageable issues causing extra costs.
References
Agency for Healthcare Research and Quality. (n.d.). Fact sheet on inpatient quality indicators.
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Lee, J. Y., Sul, Y. H., Ye, J. B., Go, S. J., Lee, J. S., Kim, H. R., Yoong, S. Y., & Kim, J. S. (2019). The benefits and risks of performing incidental appendectomy. Journal of Acute Care Surgery, 9(2), 35-38.
Lichtman, J. H., Leifheit, E. C., Wang, Y., & Goldstein, L. B. (2019). Hospital quality metrics: “America’s Best Hospitals” and outcomes after ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 28(2), 430-434.
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Thakrar, A., Chui, K., Kapoor, A., & Hambidge, J. (2020). Thirty-day mortality rate of patients with hip fractures during the COVID-19 pandemic: A single centre prospective study in the United Kingdom. Journal of Orthopaedic Trauma, 34(9), e325-e329.
Utter, G. H., Cox, G. L., Atolagbe, O. O., Owens, P. L., & Romano, P. S. (2018). Conversion of the Agency for Healthcare Research and Quality’s quality indicators from ICD-9-CM to ICD-10-CM/PCS: The process, results, and implications for users. Health Services Research, 53(5), 3704-3727.
Zapatero-Gaviria, A., Elola-Somoza, F. X., Casariego-Vales, E., Fernandez-Perez, C., Gomez-Huelgas, R., Bernal, J. L., & Barba-Martín, R. (2017). RECALMIN: The association between the management of Spanish National Health Service Internal Medical Units and health outcomes. International Journal for Quality in Health Care, 29(4), 507-511.