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Background: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery., Methods: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020., Results: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain., Conclusion: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered., Study Design: Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015., Results: Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure., Conclusion: The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis., Methods: We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes., Results: Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings., Conclusions: Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Aim: To determine whether research funded by the Patient-centered Outcomes Research Institute (PCORI) is consistent with the original aims of Congress and unique among other major USA funders. Methods: We compared a sample of funded projects from PCORI, NIH (Phase IV) and agency for healthcare research and quality (AHRQ; American Recovery and Reinvestment Act [ARRA]-based comparative effectiveness research funding) from 2014 to 2018 on number of outcomes/study, patient-centeredness of outcomes (those related to survival, function, symptoms and health-related quality of life) and other features that may characterize patient-centered research (e.g., whether conducted in a real-world setting) using PCORI portfolio data and ClinicalTrials.gov. Results: The mean number of outcomes in PCORI studies (≥9) appeared higher than NIH (≥3)/AHRQ (5.5); a higher percentage of outcomes/study were patient-centered: >85% PCORI versus 50% AHRQ and ≤30% NIH. The majority of PCORI studies (≥74%) were conducted in a real-world setting; this characteristic could not be identified for NIH/AHRQ studies. Conclusion: PCORI-funded studies appear to have unique aspects relative to NIH and AHRQ that are consistent with PCORI's aims of patient-centeredness.

Objective: To compare the Agency for Healthcare Research and Quality's Quality and Safety Review System (QSRS) and the proposed triadic structure for the 11th version of the International Classification of Disease (ICD-11) in their ability to capture adverse events in U.S. hospitals., Data Sources/study Setting: One thousand patient admissions between 2014 and 2016 from three general, acute care hospitals located in Maryland and Washington D.C., Study Design: The admissions chosen for the study were a random sample from all three hospitals., Data Collection/extraction Methods: All 1000 admissions were abstracted through QSRS by one set of Certified Coding Specialists and a different set of coders assigned the draft ICD-11 codes. Previously assigned ICD-10-CM codes for 230 of the admissions were also used., Principal Findings: We found less than 20 percent agreement between QSRS and ICD-11 in identifying the same adverse event. The likelihood of a mismatch between QSRS and ICD-11 was almost twice that of a match. The findings were similar to the agreement found between QSRS and ICD-10-CM in identifying the same adverse event. When coders were provided with a list of potential adverse events, the sensitivity and negative predictive value of ICD-11 improved., Conclusions: While ICD-11 may offer an efficient way of identifying adverse events, our analysis found that in its draft form, it has a limited ability to capture the same types of events as QSRS. Coders may require additional training on identifying adverse events in the chart if ICD-11 is going to prove its maximum benefit., (© Health Research and Educational Trust.)

Background: Adverse safety events (ASE) during hospitalization may contribute to renal decline or poor outcomes. Understanding factors contributing to ASE in chronic kidney disease (CKD) is limited. The objective is to compare differences and determine predictors of renal pertinent ASE in discharges for CKD., Method: A cross-sectional analysis of the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality 2012 data. The study included adults age ≥18 years with discharge diagnosis for CKD stages 1-4, excluding cancer of the kidney and renal pelvis, renal transplant, end-stage renal disease. Predictors included study sample characteristics, including patient demographics, comorbidity, and hospitalization-related variables. Outcomes assessed included distribution of ASE (angioedema, confusion, muscle weakness or cramps, lower extremity edema (LEE), falls, hypoglycemia, nausea-vomiting-diarrhea (NVD), and skin rash), mean total charge per hospital event, and length-of-stay. The analytical approach used descriptive statistics (means and proportions) and bivariate analysis to compare differences (ASE versus none). Predictors of ASE were explored using multivariate logistic regression., Results: 10.3% of inpatient discharges for CKD showed an ASE. Mean charges (USD 48,072 vs. 46,996), days length-of-stay (6.8 vs. 5.7), number of diagnosis on record (6.8 vs. 5.7), geographical region (Midwest, and West), and type of hospital (rural) were significantly associated with ASE. Most common ASEs were confusion (18%), LEE (21.3%), and NVD (50.7%). Odds of ASE increased for age, female gender, rural hospitals, geographical region, and diagnosis for anemia, coagulopathies, depression, fluid and electrolyte disorders, neurological disorders, psychoses, and weight loss., Conclusions: We identified key factors that increase the risk of ASE in patients with CKD. Opportunities exist to reduce ASE in CKD., (© 2019 S. Karger AG, Basel.)

Research Objective: This study examines small area variations in readmission rates to assess whether higher readmission rate in an area is associated with higher clusters of patients with multiple chronic conditions., Study Design: The study uses hospital discharge data of adult (18+) patients in 6 U.S. states for 2009 from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, linked to contextual and provider data from Health Resources and Services Administration. A multivariate cross sectional design at primary care service area (PCSA) level is used., Principal Findings: Adjusting for area characteristics, the readmission rates were significantly higher in PCSAs having higher proportions of patients with 2-3 chronic conditions and those with 4+ chronic conditions, compared with areas with a higher concentration of patients with 0-1 chronic conditions., Conclusions: Using small area analysis, the study shows that areas with higher concentration of patients with increased comorbid conditions are more likely to have higher readmission rates., (© Health Research and Educational Trust.)

This study's purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers' collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers., (© The Author(s) 2014.)

Background: No studies have assessed the incidence of craniocervical arterial dissections (CCADs) and its association to mortality in hospitalized patients with a primary diagnosis of atraumatic subarachnoid hemorrhage (SAH) requiring aneurysmal repair. We hypothesize that the incidence of CCADs in these patients has increased over time as well as its association to mortality., Methods: We conducted a 9 year retrospective assessment of the incidence of CCADs in patients hospitalized with a primary diagnosis of an SAH requiring repair and the effect of CCAD on mortality. Using the Nationwide Inpatient Sample (NIS), we queried records from 2003 to 2011 for an ICD-9 (International Classification of Diseases-9) code corresponding to admissions for atraumatic SAH. Demographical data, incidence of CCADs, type of aneurysmal repair, length of hospital stay, and hospital mortality were recorded. Multivariate logistical regression models were fitted to assess for the impact of CCAD on inhospital mortality and morbidity., Results: During the period 2003-2011, of the NIS reported 18,260 patients who required aneurysmal SAH repair, 9737 (53.32%) underwent endovascular coiling and 8523 (46.48%) had surgical clipping. There were 131 patients in the cohort with reported CCADs: 94 (71.75%) of these patients had received endovascular coiling repair and 37 (28.25%) had undergone surgical clipping repair. Patients who underwent endovascular coiling had a higher rate of CCADs in this cohort (OR 2.94; 95% CI 2.00 to 4.31, p<0.0001). The incidence of CCADs in this population increased by an average rate of 9.4% per year (OR 1.14; 95% CI 1.06 to 1.23, p<0.0006), from 0.49% in 2003 to 1.10% in 2011. The diagnosis of CCAD added 3 and 6 more days to median length of hospitalization stay for surgical clipping and endovascular coiling, respectively. The unadjusted rate of mortality was 8.4% in the CCADs subgroup, and the presence of CCAD was not a predictor of mortality in our multivariate regression model (OR 0.68; 95% CI 0.36 to 1.27, p=0.2244)., Conclusions: Our study indicates an annual increase in the incidence of CCADs in patients admitted with SAH who require aneurysmal repair. More than two-thirds of these patients that developed CCADs had undergone endovascular coiling repair. A diagnosis of CCAD increased the length of hospital stay but had no statistically significant association with mortality in this patient population., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations., Patients and Methods: The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011., Results: From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion)., Conclusion: These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Object: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are publicly reported metrics used to gauge the quality of health care provided by health care institutions. To better understand the prevalence of these events in hospitalized patients treated for ruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of subarachnoid hemorrhage and procedure codes for either coiling or clipping in the Nationwide Inpatient Sample database., Methods: The authors queried the Nationwide Inpatient Sample database, part of the AHRQ's Healthcare Cost and Utilization Project, for all hospitalizations between 2002 and 2010 involving coiling or clipping of ruptured cerebral aneurysms. The incidence rate of each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The authors used the SAS statistical software package to calculate incidence rates and perform multivariate analyses to determine the effects of patient variables on the probability of developing each indicator., Results: There were 62,972 patient admissions with a diagnosis code of subarachnoid hemorrhage between the years 2002 and 2010; 10,274 (16.3%) underwent clipping and 8248 (13.1%) underwent endovascular coiling. A total of 6547 PSI and HAC events occurred within the 10,274 patients treated with clipping; at least 1 PSI or HAC occurred in 47.9% of these patients. There were 5623 total PSI and HAC events among the 8248 patients treated with coils; at least 1 PSI or HAC occurred in 51.0% of coil-treated patients. Age, sex, comorbidities, hospital size, and hospital type had statistically significant associations with indicator occurrence. Compared with patients without events, those treated by either clipping or coiling and had at least 1 PSI during their hospitalization had significantly longer lengths of stay (p < 0.001), higher hospital costs (p < 0.001), and higher in-hospital mortality rates (p < 0.001)., Conclusions: These results estimate baseline national rates of PSIs and HACs in patients treated for ruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

Objective: The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 10, "Postoperative Physiologic and Metabolic Derangement" (PPMD), uses administrative data to detect postoperative acute kidney injury (AKI) requiring dialysis and diabetes-related complications. We sought to evaluate the indicator's criterion validity., Research Design: We conducted a retrospective cross-sectional study of hospitalization records flagged positive and negative by PSI 10 from a diverse set of 35 hospitals between February 1, 2006 and June 30, 2009. Trained nurse abstractors reviewed medical records. We determined the indicator's sensitivity, specificity, and positive and negative predictive values., Results: Of 94 records flagged by PSI 10 (87 for AKI, 7 for diabetic complications, 1 for both), 69 (73%) involved an accurately coded event; 60 (64%; 95% CI, 46%-79%) represented true PPMD from a clinical perspective. Two of 8 records flagged for diabetic complications were true events. Nineteen false positives involved preoperative renal failure. Three of 230 records flagged negative (enriched with questionably negative records) represented true PPMD. The indicator's sensitivity was 66% (20%-94%), specificity 99.9% (99.5%-100%), and negative predictive value 99.9% (99.4%-100%). Considering dialysis access procedures tantamount to dialysis and excluding records with lower urinary tract obstruction might increase the sensitivity and positive predictive value to 98% (87%-100%) and 72% (50%-87%), respectively., Conclusions: PSI 10 mostly concerns AKI and currently has moderate criterion validity, which might improve with increased use of "present on admission" coding, abandonment of the diabetes criteria, and adjustments to the indicator specifications regarding dialysis access and urinary tract obstruction.

Background: By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care., Objective: Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission., Methods: We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003-2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting "Technical Care," "Continuity of Care," and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s)., Results: The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19-1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03-1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27-2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08-1.22) to 37% higher for the Continuity of Care composite (CI, 1.26-1.50)., Conclusions: Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.

Objective: Provide a comparison of health care expenditure estimates for 2007 from the Medical Expenditure Panel Survey (MEPS) and the National Health Expenditure Accounts (NHEA). Reconciling these estimates serves two important purposes. First, it is an important quality assurance exercise for improving and ensuring the integrity of each source's estimates. Second, the reconciliation provides a consistent baseline of health expenditure data for policy simulations. Our results assist researchers to adjust MEPS to be consistent with the NHEA so that the projected costs as well as budgetary and tax implications of any policy change are consistent with national health spending estimates., Data Sources: The Medical Expenditure Panel Survey produced by the Agency for Healthcare Research and Quality, and the National Health Center for Health Statistics and the National Health Expenditures produced by the Centers for Medicare & Medicaid Service's Office of the Actuary., Results: In this study, we focus on the personal health care (PHC) sector, which includes the goods and services rendered to treat or prevent a specific disease or condition in an individual. The official 2007 NHEA estimate for PHC spending is $1,915 billion and the MEPS estimate is $1,126 billion. Adjusting the NHEA estimates for differences in underlying populations, covered services, and other measurement concepts reduces the NHEA estimate for 2007 to $1,366 billion. As a result, MEPS is $240 billion, or 17.6 percent, less than the adjusted NHEA total.

Background: Length of stay is an important indicator of quality of care in Emergency Departments (ED). This study explores the duration of patients' visits to the ED for which they are treated and released (T&R)., Methods: Retrospective data analysis and multivariate regression analysis were conducted to investigate the duration of T&R ED visits. Duration for each visit was computed by taking the difference between admission and discharge times. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for 2008 were used in the analysis., Results: The mean duration of T&R ED visit was 195.7 minutes. The average duration of ED visits increased from 8 a.m. until noon, then decreased until midnight at which we observed an approximately 70-minute spike in average duration. We found a substantial difference in mean duration of ED visits (over 90 minutes) between Mondays and other weekdays during the transition time from the evening of the day before to the early morning hours. Black / African American patients had a 21.4-minute longer mean duration of visits compared to white patients. The mean duration of visits at teaching hospitals was substantially longer than at non-teaching hospitals (243.8 versus 175.6 minutes). Hospitals with large bed size were associated with longer duration of visits (222.2 minutes) when compared to hospitals with small bed size (172.4 minutes) or those with medium bed size (166.5 minutes). The risk-adjusted results show that mean duration of visits on Mondays are longer by about 4 and 9 percents when compared to mean duration of visits on non-Monday workdays and weekends, respectively., Conclusions: The duration of T&R ED visits varied significantly by admission hour, day of the week, patient volume, patient characteristics, hospital characteristics and area characteristics.

Background: In recent years, the U.S. government has designated funding of several large-scale initiatives for comparative effectiveness research (CER) in health care. The American Recovery and Reinvestment Act (ARRA) of 2009 apportioned more than $1 billion to support CER programs administered by the Department of Health and Human Services (DHHS), the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality (AHRQ). CER is generally defined as the undertaking of original research or systematic reviews of published literature in order to compare the benefits and risks of different approaches to preventing, diagnosing, or treating diseases. These approaches may include diagnostic tests, medications, medical devices, and surgeries. The overall goals of CER are to support informed health care decisions by patients, clinicians, payers, and policy makers and to apply its evidence to ultimately improve the quality, effectiveness, and efficiency of health care., Objectives: To (a) provide managed care professionals with general definitions of CER, specifically as it is administered by AHRQ; (b) discuss the importance of CER to clinical and managed care pharmacists; and (c) summarize key methods and findings from AHRQ's 2007 comparative effectiveness review on therapies for rheumatoid arthritis (RA)., Summary: As supported by AHRQ, CER is conducted in order to synthesize comprehensive evidence on the comparative benefits and harms of treatment interventions. The findings from comparative effectiveness reviews can thus contribute to informing therapeutic strategies and treatment decisions. In 2007, a multitude of RA treatment options and studies motivated AHRQ to commission a systematic comparative effectiveness review. Conducted by investigators at the RTI-University of North Carolina Evidence-Based Practice Center, the review included comparisons of synthetic disease-modifying antirheumatic drugs (DMARDs), biologic agents, synthetic DMARDs versus biologic agents, and various combination therapies. Head-to-head comparisons of synthetic DMARDs generally revealed no significant differences in long-term clinical and radiographic outcomes, or in functional capacity or health-related quality of life. Two nonrandomized prospective cohort studies and 1 open-label effectiveness trial reported no differences in ACR20 and ACR50 response rates in patients treated with the tissue necrosis factor (TNF)-alpha inhibitors etanercept and infliximab. Comparisons of TNF-alpha inhibitors generally indicated no significant differences in rates of adverse events, including serious infections, and no increases in rates over time. In comparisons of a biologic agent combined with methotrexate versus a biologic agent alone, combination therapies were generally associated with better clinical response rates and better outcomes of functional capacity and quality of life. The most common adverse events observed in studies on biologic agents were diarrhea, headache, nausea, rhinitis, injection site reactions, and upper respiratory tract infections.

This study uses longitudinal data of inpatient treatment from the Agency for Healthcare Research and Quality's (AHRQ's) Healthcare Cost and Utilization Project (HCUP) to examine the differences in historical trends and build future projections of charges, costs, and lengths of stay (LOS) for inpatient treatment of four of the most prevalent cancer types: breast, colon, lung, and prostate. We stratify our data by hospital ownership type and for the aforementioned four major cancer types. We use the Kruskal Wallis (nonparametric ANOVA) Test and time series models to analyze variance and build projections, respectively, for mean charges per discharge, mean costs per discharge, mean LOS per discharge, mean charges per day, and mean costs per day. We find that significant differences exist in both the mean charges per discharge and mean charges per day for breast, colon, lung, and prostate cancers and in the mean LOS per discharge for breast cancer. Additionally, we find that both mean charges and mean costs are forecast to continue increasing while mean LOS are forecast to continue decreasing over the forecast period 2008 to 2012. The methodologies we employ may be used by individual hospital systems, and by health care policy-makers, for various financial planning purposes. Future studies could examine additional financial and nonfinancial variables for these and other cancer types, test for geographic disparities, or focus on procedural-level hospital measures.

Background: Hospital administrative data are being used to identify patients with postoperative venous thromboembolism (VTE), either pulmonary embolism (PE) or deep-vein thrombosis (DVT). However, few studies have evaluated the accuracy of these ICD-9-CM codes across multiple hospitals., Methods and Materials: The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI)-12 was used to identify cases with postoperative VTE in 80 hospitals that volunteered for either an AHRQ or University HealthSystem Consortium (UHC) validation project. Trained abstractors using a standardized tool and guidelines retrospectively verified all coded VTE events., Results: In the combined samples, the positive predictive value of the set of prespecified VTE codes for any acute VTE at any time during the hospitalization was 451 of 573 = 79% (95% CI: 75%-82%). However, the positive predictive value for acute lower extremity DVT or PE diagnosed after an operation was 209 of 452 = 44% (95% CI: 37%-51%) in the UHC sample and 58 of 121 = 48% (95% CI: 42-67%) in the AHRQ sample. Fourteen percent of all cases had an acute upper extremity DVT, 6% had superficial vein thrombosis and 21% had no acute VTE, however, 61% of the latter had a documented prior/chronic VTE. In the UHC cohort, the sensitivity for any acute VTE was 95.5% (95% CI: 86.4%-100%); the specificity was 99.5% (95% CI: 99.4%-99.7%)., Conclusion: Current PSI 12 criteria do not accurately identify patients with acute postoperative lower extremity DVT or PE. Modification of the ICD-9-CM codes and implementation of "present on admission" flags should improve the predictive value for clinically important VTE events.

Purpose: We investigated the relationship between blindness and vision impairment and access to medical care., Methods: Pooled data from the Medical Expenditure Panel Survey (MEPS) years 2002-2004 were used to identify non-institutionalized individuals over the age of 40 with either self-reported blindness, vision impairment, or no vision impairment (n = 40,643). Differences in access to care measures by vision status were assessed, after adjusting for the complex sampling design of the MEPS, using either two-sided z-tests or two-sided t-tests., Results: Individuals with blindness and vision impairment report having more access problems related to cost of care, availability of insurance coverage, transportation issues, and refusal of services by providers, although they do not report lower rates of having a usual source of care compared to those without vision impairment., Conclusions: The results suggest that access to care for individuals with blindness and vision impairment is problematic, for reasons that are amenable to policy interventions.

Objective: Determine the degree of congruence between several measures of adverse events., Design: Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods., Setting: Mayo Clinic Rochester hospitals., Participants: All inpatients discharged in 2005 (n = 60 599)., Interventions: Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission., Main Outcome Measure: Agreement of identification between methods., Results: About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI., Conclusions: Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Background: Patient safety is recognised worldwide as a major healthcare issue. The US Agency for Healthcare Research and Quality developed a series of evidence-based Patient Safety Indicators for use with hospital administrative data, but to date these have not been translated for use in the UK. They measure harm due to treatment and include infections, obstetric tears and foreign bodies left in the patient following surgery. We aimed to apply 10 of the AHRQ indicators for use in English routine hospital admissions data as the first step in validation, and describe their rates in relation to established measures of negative outcome such as mortality., Methods: Translation of US coding systems into England systems using look-up files and clinical coding advice. Descriptive analysis of rates, length of stay, mortality and emergency readmission. Qualitative feedback from hospitals on their rates and level of interest in the indicators., Results: The translation presented a number of challenges, particularly regarding the lack of direct correspondence between the two procedure coding systems. There were a total of 35,918 potential adverse events among the nine successfully translated indicators in England in the financial year 2005/6, with wide variation between hospital trusts. Potential adverse events were usually associated with higher mortality and unplanned readmission rates and longer length of stay. Postoperative sepsis, for example, had a rate of 4.2 per 1000 admissions and was associated with a median length of stay of 19 days compared with 6 days for admissions for operations without sepsis recorded, and was associated with a mortality of 14.7% compared with 0.5%., Conclusions: These indicators have potential for use in tracking progress in harm-reducing programmes, but prospective evaluation of data quality and coding practices is required to fully assess their utility.

Background: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) screen for potentially preventable complications in hospitalized patients using hospital administrative data. The PSI for postoperative venous thromboembolism (VTE) relies on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in secondary diagnoses fields. In a clinical validation study of the PSI for postoperative VTE, natural language processing (NLP), supplemented by pharmacy and billing data, was used to identify VTE events missed by medical records coders., Methods: In a retrospective review of postsurgical discharges, charts were processed using the AHRQ PSI software. Cases were identified as possible false negatives by flagging charts for possible VTEs using pharmacy and billing data to identify all patients who were therapeutically anticoagulated or had placement of an inferior vena caval filter. All charts were reviewed by a physician blinded to screening results. Physician interpretation was considered the gold standard for VTE classification., Results: The AHRQ PSI had a positive predictive value (PPV) of .545 (95% confidence interval [CI], .453-.634) and a negative predictive value (NPV) of .997 (95% CI, .995-.999). Sensitivity was .87 and specificity was .98. Secondary coding review suggested that all 9 false-negative results were miscoded; if they had been properly coded, the sensitivity would increase to 1.00. Most false-positive cases resulted from superficial venous clots identified by the PSI due to coding ambiguity., Discussion: The VTE PSI performed well as a screening tool but generated a significant number of false-positive cases, a problem that could be substantially reduced with improved coding methods.

Objectives: With >6 million hospital stays, costing almost $50 billion annually, hospitalized children represent an important population for which most inpatient quality indicators are not applicable. Our aim was to develop indicators using inpatient administrative data to assess aspects of the quality of inpatient pediatric care and access to quality outpatient care., Methods: We adapted the Agency for Healthcare Research and Quality quality indicators, a publicly available set of measurement tools refined previously by our team, for a pediatric population. We systematically reviewed the literature for evidence regarding coding and construct validity specific to children. We then convened 4 expert panels to review and discuss the evidence and asked them to rate each indicator through a 2-stage modified Delphi process. From the 2000 and 2003 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database, we generated national estimates for provider level indicators and for area level indicators., Results: Panelists recommended 18 indicators for inclusion in the pediatric quality indicator set based on overall usefulness for quality improvement efforts. The indicators included 13 hospital-level indicators, including 11 based on complications, 1 based on mortality, and 1 based on volume, as well as 5 area-level potentially preventable hospitalization indicators. National rates for all 18 of the indicators varied minimally between years. Rates in high-risk strata are notably higher than in the overall groups: in 2003 the decubitus ulcer pediatric quality indicator rate was 3.12 per 1000, whereas patients with limited mobility experienced a rate of 22.83. Trends in rates by age varied across pediatric quality indicators: short-term complications of diabetes increased with age, whereas admissions for gastroenteritis decreased with age., Conclusions: Tracking potentially preventable complications and hospitalizations has the potential to help prioritize quality improvement efforts at both local and national levels, although additional validation research is needed to confirm the accuracy of coding.

Purpose: Little is known about the distribution of eye and vision conditions among children and about possible disparities in the distribution of these conditions. The purpose of this report is to describe the prevalence of diagnosed eye and vision conditions among children younger than 18 years in the United States., Design: Repeated population-based cross-sectional study., Participants: Forty-eight thousand three hundred four members of randomly selected households in the U.S. who were younger than 18 years in the years 1996 through 2001 were analyzed., Methods: The prevalence of children with diagnosed eye and vision conditions was estimated using self-reported information from the nationally representative Medical Expenditure Panel Surveys (MEPS) for 1996 through 2001. Descriptive statistics are presented, and the associations between the likelihood of diagnosed eye and vision conditions and child and family characteristics were assessed using logistic regression analyses adjusted for the complex survey design of MEPS., Main Outcome Measures: Prevalence of diagnosed eye and vision conditions and measures of the association between diagnosed eye and vision conditions and child and family characteristics., Results: On average, approximately 6.8% (95% confidence interval [CI], 6.4%-7.2%) of children < 18 years in the U.S. have a diagnosed eye and vision condition, ranging from 8.6% (95% CI, 7.8%-9.5%) in 1996 to 5.8% (95% CI, 5.2%-6.4%) in 2001. Excluding conjunctivitis, the 4 most common conditions were refractive disorders, potentially blinding disorders, trauma or injury, and other disorders not elsewhere classified. White children, children with more educated mothers, and children living in higher income families were more likely to have a diagnosed eye and vision condition. Hispanic children, children in very good or excellent health, and uninsured children were less likely to have any self-reported diagnosed eye and vision condition., Conclusions: This article presents a method for using MEPS to identify children younger than 18 years with eye and vision conditions. Although this method does not identify all children with eye and vision conditions, it does identify children with diagnosed eye and vision conditions. Results provide some evidence that underprivileged children may be underdiagnosed, undertreated, or both, placing them at risk for future problems.

Objective: Our objective with this study was to assess the extent to which patients who are seen by practitioners in Pediatric Research in Office Settings, a national primary care practice-based research network, are representative of those who are seen in ambulatory office-based pediatric primary care in the United States., Methods: Pediatric Research in Office Settings patient data were collected from the offices of 57 randomly selected network practitioners as part of an Agency for Healthcare Research and Quality-funded effort to describe primary care visits and replicate the National Ambulatory Medical Care Survey in primary care practice-based research networks. These data were from 1706 randomly selected pediatric patient visits that occurred between March and June 2002. National comparison data were 948 randomly selected pediatric patient visits that occurred between March and June 2000 in the offices of the 33 primary care pediatric practitioners who had participated in the National Ambulatory Medical Care Survey. The groups were compared on patient demographics (age, gender, race, ethnicity, and socioeconomic status, as represented by Medicaid status), visit characteristics (percentages of patients referred, practitioner designation of visit as acute versus nonacute, and continuity of care), the top patient/parent-articulated reasons for visit, and the top practitioner diagnoses., Results: Comparisons revealed substantial similarities between Pediatric Research in Office Settings and national data, including gender, ethnicity, socioeconomic status, and visit characteristics. Differences were noted for age and race, with Pediatric Research in Office Settings children approximately 1 year older and comprising a significantly lower proportion of black patients than their National Ambulatory Medical Care Survey counterparts. Although the top 6 reasons that were articulated by parents for outpatient visits in the 2 groups were remarkably similar in rank order and proportions, there were overall differences, mostly attributable to a larger number of the "other" category in the Pediatric Research in Office Settings cases. There were no significant differences among the top 5 practitioner visit diagnoses between the Pediatric Research in Office Settings and National Ambulatory Medical Care Survey data., Conclusions: The Pediatric Research in Office Settings patient population is reasonably representative of patients who are seen in US ambulatory office-based pediatric primary care practices; therefore, the Pediatric Research in Office Settings is an appropriate laboratory for studies of care in such settings.