PQI Diabetes Composite and Future Direction of Prevention Quality Indicator Work AHRQ Quality Indicators program Organisation for Economic Co-operation and Development Paris, France May 22, 2015
Conceptual Framework for PQI COMMUNITY COMMUNITY Need for care Other care Prevention of Observation units disease Outpatient Long-term care for procedures chronic disease ED care Early intervention Hospital at home exacerbation Access to insurance/affordable convenient care Community/ environmental factors Health behaviors Social factors Hospital Admission (observations) Follow-up care/support Follow up care Care coordination Access to home health Community support
Background Current PQI structure Overall composite all PQI Acute (i.e., short-term avoidability) Dehydration, pneumonia, urinary tract infection, [short-term complications and uncontrolled diabetes?] Chronic (i.e., mixed short-term and long-term avoidability) COPD, asthma, hypertension, heart failure, [long-term complications of diabetes?], angina* International interest in diabetes-specific composite to focus on access to high quality ambulatory care for diabetes * Scheduled for retirement in V6.0, late 2015
Diabetes PQI Acute (reversible) complications Short term complications (PQI 01) most Type I, 82% DKA Uncontrolled diabetes (PQI 14) most Type II Acute-on-chronic Lower extremity amputation in diabetics (PQI 16) Long term complications (PQI 03) *PQI 16 may overlap with other indicators, especially PQI 03, as most amputations are attributed to diabetes with peripheral circulatory disorders, ICD-9-CM 250.7x
Example Constructs for Population Health Measures Construct: Underlying, unmeasurable, concept of interest Access to care (e.g., early intervention) Quality of care (e.g., chronic disease management) Health behaviors (e.g., self-care) Health of the community (e.g., environment and social context)
What is access to quality care? Access to care includes: Affordability Availability Adequacy/Quality of Community Based Care Timeliness Accessibility Knowledge/Understanding Quality of care includes: Care for established diabetes, blood sugar control Early detection/prevention of diabetes Care for acute events that may result from long-term complications (e.g., gastroparesis) Facilitating self-care
Complication Group Complications Not Elsewhere Classified (250.8x) Neurologic Complications (250.6x) Circulatory Complications (250.7x) Renal Complications (250.4x) Long-term Complications (PQI 03) What are these admissions? % of Top 3 secondary diagnoses admits % within group 51.4% 13.0% Osteomyelitis NOS ankle 8.1% Cellulitis of foot 5.0% Acute osteomyelitis, ankle/foot Top 3 principal procedures % within group 39.6% No procedures 14.6% Amputation of toe 4.9% Excisional debridement 3.6% Hemodialysis 27.0% 12.5% Gastroparesis 48.8% No procedures 6.3% Hemodialysis 5.8% EGD with closed biopsy 4.6% Excisional debridement 13.6% 19.9% Gangrene 12.3% Atherosclerosis with gangrene 6.2% 29% Hypertensive CKD, Unspec, Stage V ESRD 3.8% Hyposmolality and/or hyponatremia 3.3% End Stage Renal Disease 17.0% Amputation of toe 13.2% Other amputation below knee 11.8% Angioplasty of other noncoronary vessel(s) 31.1% No procedures 31.1% No procedures 19.6% Other kidney transplantation 13.1% Hemodialysis 6.4% Arteriovenostomy for renal dialysis Source: HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. (AHRQ QI Software Version 5.0)
Diabetes PQI Figure 1. Nationwide Rates per 100,000, 2008-2012, Diabetes PQI, Population Denominator 120.00 100.00 80.00 60.00 40.00 Short-term (PQI 01) Long-term (PQI 03) Uncontrolled (PQI 14) LE Amputation (PQI 16) 20.00 0.00 2008 2009 2010 2011 2012 Source: HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2008-2012. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. (AHRQ QI Software Version 5.0)
Correlations between PQIs Correlation of County-Level Diabetes PQI Population Denominator Rates Per 100,000, 2012, weighted and unweighted Indicator Short-term PQI 01 Long-term PQI 03 Uncontrolled PQI 14 Amputation PQI 16 Short-term PQI 01 0.6510 0.5516 0.4574 0.3346 0.5767 0.3461 Long-term PQI 03 Uncontrolled PQI 14 Amputation PQI 16 0.6510 0.5516 0.4574 0.3346 0.5767 0.3461 0.6857 0.6483 0.4170 0.5374 0.6857 0.4245 0.4170 1 0.2118 0.6483.04245 0.5374 0.2118 1 Source: HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. (AHRQ QI Software Version 5.0)
Denominator Choice Population Based Denominator Diabetes Prevalence Based Denominator All individuals 18 years and older, US Census Includes concepts of total population health, prevention of diabetes Consider expansion to include diabetics with related conditions (e.g., coronary artery disease) that have a less directly causal relationship with diabetes CDC estimates of diabetes prevalence in adults Based on self-report from Behavior Risk Factor Surveillance survey (random digit-dial telephone survey) Requires empiric Bayes GIS estimation for small counties Focuses indicator on established diabetics Removes some variation due to disease prevalence
Diabetes (adjusting for prevalence) Nationwide Rates per 100,000, 2008-2012, Diabetes PQI, Diabetes Denominator 2000.00 1800.00 1600.00 1400.00 1200.00 1000.00 800.00 600.00 Short-term (PQI 01) Long-term (PQI 03) Uncontrolled (PQI 14) LE Amputation (PQI 16) 400.00 200.00 0.00 2008 2009 2010 2011 2012 Source: HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2008-2012. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. (AHRQ QI Software Version 5.0)
Correlations between PQIs Correlation of County-Level Diabetes PQI Diabetes Denominator Rates Per 100,000, 2012, weighted and unweighted Indicator Short-term PQI 01 Short-term PQI 01 1 Long-term PQI 03 Uncontrolled PQI 14 Amputation PQI 16 Long-term PQI 03 Uncontrolled PQI 14 0.5475 0.4909 0.3268 0.2598 0.5475 0.6484 0.4909 1 0.3633 0.3268 0.6484 0.2598 0.3633 1 0.4858 0.6005 0.2807 0.4599 Amputation PQI 16 0.4858 0.2807 0.6005 0.4599 0.3448 0.1524 0.3448 0.1524 1 Source: HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. (AHRQ QI Software Version 5.0)
Summary Diabetes composite captures all hospitalizations for diabetes, based on principal diagnosis that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. When assigning codes for diabetes and its associated conditions, the code(s) from category 250 must be sequenced before the codes for the associated conditions. Adjusting for diabetes prevalence may better isolate component due to access and quality of health care Retains intercorrelations among components; in other words, these correlations are not driven by prevalence Removes part of the socioeconomic effect
Questions and discussion Web site: http://qualityindicators.ahrq.gov/ AHRQ QI documentation & software are available E-mail: support@qualityindicators.ahrq.gov PQI module team: Jonathan Shaw, MD MS; Sheryl Davies MBA; Kathryn McDonald MM (Stanford) Patrick S. Romano, MD MPH (contractor, Analytic Enhancement team, Stanford-UC Davis-Truven-Yale), psromano@ucdavis.edu Carol Stocks Carol.Stocks@ahrq.hhs.gov Mamatha Pancholi Mamatha.Pancholi@ahrq.hhs.gov 14