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Complete Summary


TITLE

Gastrointestinal (GI) hemorrhage: mortality rate.

SOURCE(S)

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.


  • AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Feb 29. 37 p.

Measure Domain

PRIMARY MEASURE DOMAIN

SECONDARY MEASURE DOMAIN

Does not apply to this measure

Brief Abstract

DESCRIPTION

This measure is used to assess the number of deaths per 100 discharges with principal diagnosis code of gastrointestinal (GI) hemorrhage.

Limited evidence supports the construct validity of this indicator. Risk adjustment for clinical factors, or at a minimum 3M™ All-Patient Refined Diagnosis-Related Groups (APR-DRGs), is recommended because of the substantial confounding bias for this indicator.

RATIONALE

About 30% of personal health care expenditures in the United States go towards hospital care, and the rate of growth in spending for hospital services has only recently leveled out after several years of increases following a half a decade of declining growth. Simultaneously, concerns about the quality of health care services have reached a crescendo with the Institute of Medicine's series of reports describing the problem of medical errors and the need for a complete restructuring of the health care system to improve the quality of care. Policymakers, employers, and consumers have made the quality of care in U.S. hospitals a top priority and have voiced the need to assess, monitor, track, and improve the quality of inpatient care.

Gastrointestinal (GI) hemorrhage may lead to death when uncontrolled, and the ability to manage severely ill patients with comorbidities may influence the mortality rate. Better processes of care may reduce mortality for GI hemorrhage, which represents better quality.

Note:

The following caveats were identified from the literature review for the "Gastrointestinal Hemorrhage Mortality Rate" indicator:

  • Confounding biasb: Patient characteristics may substantially affect the performance of the indicator; risk adjustment is recommended.
  • Unclear constructa: There is uncertainty or poor correlation with widely accepted process measures.

Refer to the original measure documentation for further details.

a - The concern is theoretical or suggested, but no specific evidence was found in the literature.

b - Indicates that the concern has been demonstrated in the literature.

PRIMARY CLINICAL COMPONENT

Gastrointestinal (GI) hemorrhage; mortality

DENOMINATOR DESCRIPTION

All discharges, age 18 years and older, with principal diagnosis code for gastrointestinal (GI) hemorrhage

Exclude cases:

  • Missing discharge disposition
  • Transferring to another short-term hospital
  • Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and puerperium)
  • MDC 15 (newborns and other neonates)

Note: Refer to the Technical Specifications document for specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

NUMERATOR DESCRIPTION

Number of deaths among cases meeting the inclusion and exclusion rules for the denominator

Evidence Supporting the Measure

EVIDENCE SUPPORTING THE CRITERION OF QUALITY

  • 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

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

State of Use of the Measure

STATE OF USE

Current routine use

CURRENT USE

External oversight/State government program
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 greater than or equal to 18 years

TARGET POPULATION GENDER

Either male or female

STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

Characteristics of the Primary Clinical Component

INCIDENCE/PREVALENCE

Unspecified

ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

BURDEN OF ILLNESS

Rates of mortality in gastrointestinal (GI) hemorrhage vary from 0% to 29%, with most studies reporting rates of 3.5% to 11%.

EVIDENCE FOR BURDEN OF ILLNESS

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

UTILIZATION

Unspecified

COSTS

Unspecified

Institute of Medicine National Healthcare Quality Report Categories

IOM CARE NEED

Getting Better

IOM DOMAIN

Effectiveness

Data Collection for the Measure

CASE FINDING

Users of care only

DESCRIPTION OF CASE FINDING

Discharges, age 18 years and older, with gastrointestinal (GI) hemorrhage (see the "Denominator Inclusions/Exclusions" field)

DENOMINATOR SAMPLING FRAME

Patients associated with provider

DENOMINATOR INCLUSIONS/EXCLUSIONS

Inclusions
All discharges, age 18 years and older, with principal diagnosis code for gastrointestinal (GI) hemorrhage

Note: Refer to the Technical Specifications document for specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

Exclusions
Exclude cases:

  • Missing discharge disposition
  • Transferring to another short-term hospital
  • Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and puerperium)
  • MDC 15 (newborns and other neonates)

RELATIONSHIP OF DENOMINATOR TO NUMERATOR

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

DENOMINATOR (INDEX) EVENT

Clinical Condition
Institutionalization

DENOMINATOR TIME WINDOW

Time window is a single point in time

NUMERATOR INCLUSIONS/EXCLUSIONS

Inclusions
Number of deaths among cases meeting the inclusion and exclusion rules for the denominator

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

Clinical 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 subgroup (stratification on patient factors, geographic factors, etc.)
Case-mix adjustment
Risk adjustment method widely or commercially available

DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

STANDARD OF COMPARISON

External comparison at a point in time
External comparison of time trends
Internal time comparison

Evaluation of Measure Properties

EXTENT OF MEASURE TESTING

Each potential quality indicator was evaluated against the following six criteria, which were considered essential for determining the reliability and validity of a quality indicator: face validity, precision, minimum bias, construct validity, fosters real quality improvement, and application. The project team searched Medline for articles relating to each of these six areas of evaluation. Additionally, extensive empirical testing of all potential indicators was conducted using the 1995-97 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and Nationwide Inpatient Sample (NIS) to determine precision, bias, and construct validity. Table 2 in the original measure documentation summarizes the results of the literature review and empirical evaluations on the Inpatient Quality Indicators. Refer to the original measure documentation for details.

EVIDENCE FOR RELIABILITY/VALIDITY TESTING

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

Identifying Information

ORIGINAL TITLE

Gastrointestinal hemorrhage mortality rate (IQI 18).

MEASURE COLLECTION

MEASURE SET NAME

DEVELOPER

Agency for Healthcare Research and Quality

FUNDING SOURCE(S)

Agency for Healthcare Research and Quality (AHRQ)

COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators are in the public domain and the specifications come from multiple sources, including the published and unpublished literature, users, researchers, and other organizations. AHRQ as an agency is responsible for the content of the indicators.

FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

None

ADAPTATION

Measure was not adapted from another source.

RELEASE DATE

2002 Jun

REVISION DATE

2008 Feb

MEASURE STATUS

This is the current release of the measure.

This measure updates previous versions:

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals -- volume, mortality, and utilization [version 3.0]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Feb 20. 99 p.
  • AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 37 p.

SOURCE(S)

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.


  • AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Feb 29. 37 p.

MEASURE AVAILABILITY

COMPANION DOCUMENTS

The following are available:

NQMC STATUS

This NQMC summary was completed by ECRI on December 4, 2002. The information was verified by the Agency for Healthcare Research and Quality on December 26, 2002. This NQMC summary was updated by ECRI on April 7, 2004, August 19, 2004, and March 4, 2005. The information was verified by the measure developer on April 22, 2005. This NQMC summary was updated again by ECRI Institute on August 17, 2006, on May 29, 2007, and again on October 20, 2008.

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