Methodology

Table of Contents

Hospitals and Ambulatory Surgery Centers

Hospitals
Methodology for Adjusting Length of Stay (ALOS)

The data is risk adjusted using 3M All Patient Refined Diagnosis Related Groups (APR DRGs) and severity of illness levels in order to allow for meaningful comparisons. The primary reason for risk adjustment is to remove the long-standing and valid criticism that evaluative comparisons of two or more disparate groups based on observed reported data is often not an effective methodology due to differences in case-mix between the groups under study. This criticism in simpler terms is the "our patients are sicker than their patients" response.

In order to understand how data is adjusted for severity and case mix, three concepts must be introduced; observed value, expected value, and risk adjusted.

Observed Value

This is the reported value. For example, the observed average length of stay for a hospital is calculated by taking the total inpatient days for all patients and dividing this total by the total number of cases. The values used for days and cases are taken from information reported by the hospital to the Agency for Health Care Administration (AHCA).

Expected Value

Expected values are risk adjusted using 3M's APR DRGs and severity of illness as the methodology for risk adjustment.

Note: Expected value calculations for adults are APR DRG and age group specific for each product line age group and are based on one year of data. Expected value calculations for pediatrics are APR DRG and age group specific for each product line age group and are based on three years of data.

Before proceeding to an example of an expected value calculation, we need to first describe the APR DRG patient classification and severity assignment process. APR DRGs are a patient classification system with a primary objective of grouping types of patients treated by the resources they consume. 3M's APR DRGs assign a base APR DRG and a severity of illness to each case. Severity of illness is the extent of physiologic decompensation or organ system loss of function and is comprised of 4 levels:

  • 1 – Minor
  • 2 – Moderate
  • 3 – Major
  • 4 – Extreme

Assignment of severity of illness subclasses is based upon a number of factors, including the underlying base APR DRG assignment (determined by principal diagnosis, procedures, age, sex and discharge status), secondary diagnoses, and interactions amongst diagnoses.

The advantage of APR DRGs is that they acknowledge differences in severity of illness among patients within a single APR DRG, as fits with our real world understanding. For example, some pneumonia patients are much sicker than others, even though they may all be classified under the same DRG.

So how does this website use APR DRGs in calculating expected values? Each inpatient case is assigned an expected value which is the average value for that case's designated APR DRG and severity of illness level across the State of Florida. For example, a case is designated as a Simple Pneumonia (APR DRG 139) with a severity of illness level 2. The state average length of stay for all Simple Pneumonia (APR DRG 139) with severity of illness level 2 is 5.5 days. The expected value for this specific case's length of stay would then be 5.5 days.

Calculations:

Hospital's Observed ALOS:

Total hosp. days for the selected condition / total hosp. cases for the selected condition

Hospital's Expected ALOS:

Average of the expected hosp. length of stay for all cases for the selected condition at the hospital

Risk Adjusted Value

The risk-adjusted average length of stay is the best estimate, based on the statistical model, of what the provider's length of stay would have been if the provider had a mix of patients identical to the statewide mix. The risk adjusted value is the observed length of stay divided by the expected length of stay and multiplied by the state of Florida's average length of the stay for a medical condition/procedure.

Hospital's Risk adjusted ALOS:

Observed ALOS for the selected condition / Expected ALOS for the selected condition * State ALOS for the selected condition = Risk Adjusted ALOS
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Methodology for Potentially Preventable Readmissions (PPRs) and APR DRGs:

Statistical Methods

Introduction

The 3M™ APR™ DRG version 35 classification system categorizes patients based on their severity of illness and risk of mortality.

Potentially Preventable Readmission (PPRs) identify return hospitalizations that may have resulted from the process of care and treatment (readmission for a surgical wound infection) or lack of post admission follow-up (prescription not filled) rather than unrelated events that occur post admission (broken leg due to trauma).

In computing a hospital PPR rate, the numerator is defined as the number of initial admissions with one or more qualifying clinically related readmissions within a given time period.  The denominator of a readmission rate is identified as the number of initial admissions at risk for a potentially preventable readmission, excluding deaths and admission meeting the criteria for one or more global exclusions occurring in the index hospitalization, for the related population for the same time period.

Readmission rate:

The number of initial qualifying admissions with one or more PPRs

divided by

The number of admissions at risk for a PPR

Rates of PPR occurrence are calculated for each APR DRG category by severity of illness level. A PPR rate for each APR DRG by severity level was developed for the age 18 and over age group based on a 15-day readmission window for readmissions across hospitals. These rates are typically referred to as norms because they reflect the experience of groups of hospitals.

Using APR DRG categories to control differences in the clinical characteristics between their patients or those of the norm, individual hospitals can compare their PPR rates to those of the normative data. These comparisons will enable them to determine if and how their performance differs from comparable hospitals. A provider’s experiences and those of normative populations are likely to be different. This can represent a true difference or can be caused by normal variation. Statistical techniques can be used to determine which of the observed differences in outcomes are most likely to be true differences and which are probably the result of natural variation.

Observed Value

The observed readmission rates are calculated for each condition or procedure by dividing the number of initial discharges with one or more Potentially Preventable Readmissions, PPRs, by the total number of initial discharges. The AHCA normative database (State of Florida values) are calculated for each APR DRG and severity of illness subclass the same. The PPR observed value is calculated as follows:

Let:
N = observed rate
P = Number of initial discharges with one or more PPRs
D = Number of initial discharges at risk for a PPR
i = condition or procedure or an APR DRG category and a single severity of illness level

Ni=Pi/di

This number is displayed as PPRs per initial discharge to facilitate the calculations in the expected value computation example below.

Expected Values

The expected value of PPRs is the number of readmission chains (initial discharge with a PPR) a hospital, given its mix of patients as defined by APR DRG category and severity of illness level, would have experienced had its rate of PPRs been identical to that experienced by a reference or normative set of hospitals.

The technique by which the expected value or expected number of PPRs is calculated is called indirect standardization. For illustrative purposes, assume that every initial discharge can meet the criteria for having a PPR, a condition called being “at risk” for a PPR. All initial discharges will either have no PPRs or will have a chain of one and possibly more PPRs.

Once a set of PPR normative rates has been calculated by APR DRG by SOI, it can be applied at the APR DRG and SOI level to individual hospitals to compute the expected PPR rate for the hospital.  Then the PPR expected rate is adjusted for age over 85 and the presence of a major mental health problem as a comorbid condition. These adjustments were computed from the AHCA normative database for each of the three age groups.

Example Age and Mental Health PPR Rate Adjustment Factors

Condition Age < 85 Age >= 85
Major Mental Health 1.6394 1.5058
All Other 0.9435 1.1157

Consider the following example for computing a hospital’s expected PPR rate.  For each APR DRG by severity subclass, a normative PPR rate has been computed from the normative database.  Hospital AAA has 11 initial discharges in the database.  One of these initial discharges was globally excluded from the PPR computations because the patient left against medical advice.  Of the remaining 10 initial discharges, one of these initial discharges had a potentially preventable readmission within the defined readmission window.  The other nine initial discharges either did not have a subsequent admission within the defined readmission window or there was a subsequent readmission within the defined readmission window, however, the readmission was not identified as potentially preventable and therefore clinically excluded from being considered a PPR.  

Example Normative PPR Rates

APR DRG Severity Level Normative PPR Rate
1 1 5.2
1 2 6.4
1 3 6.9
1 4 7.3
2 1 7.2
2 2 8.9
2 3 9.1
2 4 9.9

Example Hospital Patient Discharge Readmission Data

Provider APR DRG - Severity Level Age Major Mental Health Condition Initial Discharge At Risk for PPR Initial Discharge With a PPR Normative PPR Rate MH & Age Adjusted Normative PPR Rate
AAA 1 – 4 87 Y Y Y 7.3 10.99
AAA 1 – 3 89 N Y N 6.9 7.70
AAA 2 – 4 70 Y Y N 9.9 16.23
AAA 1 – 2 45 Y N N ------ ------
AAA 1 – 1 35 N Y N 5.2 4.91
AAA 2 – 1 46 N Y N 7.2 6.80
AAA 2 – 2 88 Y Y N 8.9 13.40
AAA 2 – 3 23 Y Y N 9.1 14.92
AAA 1 – 3 85 N Y N 6.9 7.70
AAA 2 – 4 65 Y Y N 9.9 16.23
AAA 2 – 3 55 Y Y N 9.1 14.92

The provider's actual PPR rate is the number of initial discharges with one or more PPRs within the readmission window divided by the number of initial discharges at risk for a PPR (not globally excluded).  Provider AAA PPR rate equals 1 divided by 10 = 10%.  The expected PPR rate based on the initial discharges at risk for a PPR is the sum of the associated APR DRG by SOI normative PPR rate times the mental health and age adjustment factor divided by the number of initial discharges at risk for a PPR.

Example Hospital PPR Rate

Provider Number of Initial Discharge With a PPR Number of Initial Discharge At Risk for PPR Actual PPR Rate Expected PPR Rate
AAA 1 10 10.0% 11.4%


Risk Adjusted Value

It is not meaningful to compare expected values across hospitals. Thus, if one hospital has a higher expected value than another hospital, no conclusion can be made regarding the relative performance of the two hospitals. In order to directly compare the performance of two hospitals a risk adjusted value can be computed.  In other words, the expected value is relative to the hospital’s actual value while the risk adjusted value is relative to actual value in the reference database. Thus the risk adjusted value can be compared across hospitals.  The risk adjusted value is computed as follows:

                                        Hospital Actual PPR Rate
Risk Adjusted PPR Rate = -----------------------------------------  X Reference Actual PPR Rate
                                        Hospital Expected PPR Rate

The reference actual PPR rate is the overall PPR rate for the hospitals being compared.  If analysis is performed for a subset of cases, say cardiac surgical APR DRGs, then the overall PPR rate for all cardiac surgical APR DRGs would be the reference actual PPR rate from which a hospitals actual to expected PPR rate for cardiac surgical APR DRGs would be adjusted.

Statistical significance

The statistical techniques calculate the probability that an observed difference in performance between the provider and the norm is due to natural variation. A difference in performance between provider and norm is considered “significant” if the probability that a difference is due to natural variation is small. A difference is considered significant at the 0.05 level if the probability that the observed difference is due to natural variation is five percent or less (i.e., less than one chance in twenty).

Three interrelated factors determine whether a difference in performance is significant: the number of observations, the magnitude of the observed difference in performance, and the variability in performance of the hospital and of the norm. A small number of patients, a small observed difference in performance, or high variability within either the provider or the norm (i.e., high standard deviation) increase the probability that the observed difference is due to chance and does not represent a true difference. Conversely, a large number of patients, a large observed difference between provider and norm, or low variability within both hospital and norm make it more likely that the difference was not due to chance and does represent a true difference.

Further, an observed difference of the same magnitude may be significant in one comparison and not in another. The conclusion that a difference is significant indicates that the hospital and the norm have had true difference in performance.

There are several possible reasons why a difference may not be significant. There may be no true difference, and thus, no significant difference in performance is found. Alternatively, there may be too few observations or too much variability, or both, so that even a true difference cannot be detected. Thus, a difference which is not significant does not necessarily mean that there is no true difference in performance. It may simply mean that there were too few patients or too much variability to conclude that the observed difference was not due to chance.

The comparison of a provider’s performance to a norm requires the use of several distinct statistical methods. Outcome variables such as PPR rates are binary variables that indicate the occurrence or non-occurrence of an event such as a readmission following an initial discharge. Comparisons can be performed for data from a single APR DRG category and subclass, or they can be performed for data pooled across multiple APR DRG categories and subclasses.

Test of Significance

For binary data such as readmission, a test of significance of the difference between the actual and expected values can be performed by comparing readmission rates separately within each APR DRG category and subclass and then pooled across APR DRG categories and subclasses. The calculation of statistical significance for PPRs uses the Cochran-Mantel-Haenszel test (CMH) to calculate statistical significance for PPRs across APR DRG categories and severity of illness levels.

To test for statistical significance, it is assumed that the APR DRG category and severity of illness level for each initial discharge is known, as well as whether or not a PPR occurred within the window following the initial discharge. The tests of significance are to be calculated with only initial discharges at risk for PPRs.  In computing the test of significance, the normative statistic should take into account the adjustment for age over 85 and the presence of a major mental health problem as a comorbid condition based on hospital’s cases.

To calculate a CMH statistic, start with the 2 * 2 matrix used for the Chi Square test. The CMH statistic uses the data from one corner of the matrix and the marginals. It does not matter which corner; all will produce the same results. To simplify matters, we will use the upper left hand corner.

Calculate the expected value and variance of each cell.

Let:
j = APR DRG category and severity of illness level
E = Expected number of initial discharges with PPRs
C = Number of initial discharges with PPRs for a hospital
D = Number of initial discharges at risk for PPR for a hospital
F = Number of initial discharges with PPRs in norm
G = Number of initial discharges at risk for PPR in norm
A(m,a) = Adjustment factor for mental health status m and age category a
N(m,a) = Number of patients with mental health status m and age category a in hospital
J = Average adjustment factor for mental health status m and age category a in hospital

                        J = ∑ (N(m,a)A(m,a))/ ∑ N(m,a)
                             m,a                                   m,a

The expected value is calculated as follows:

E(Gj)=((Cj+(Fj*Jj))*(dj)\(dj+Gj)

The variance is calculated as follows:

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After, the expected value and variance are calculated, calculate the CMH statistic as follows:

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As the CMH statistic has a chi square distribution with 1 degree of freedom the following significance levels can be used:

Significance Level Х2
.1 2.7055
.05 3.8415
.01 6.6349

For the purposes of reporting statistical significance a significance level of .05, Х2 => 3.8415, was used. In addition, statistical significance will not be calculated if the overall number of initial discharges at risk for PPRs is less than forty or if the number of observed or expected initial discharges with PPRs is less than five for a provider.
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Hospital Inpatient Medical Conditions and Procedures - Adults

Bones and Joints

Back Problems

Back Problems – APR DRG 347

Disc Surgery

Disc Surgery – APR DRG 310

Femur Fracture Surgical Repair

Femur Fracture Surgical Repair – APR DRG 308

Fracture of Pelvis or Dislocation of Hip

Fracture of Pelvis or Dislocation of Hip – APR DRG 341

Hip Replacement (total and partial)

Hip Replacement - APR DRG 301

Knee Replacement (total and partial)

Knee Replacement – APR DRG 302

Leg Amputation

Leg Amputation – APR DRG 305

Shoulder, Upperarm and Forearm Procedures

Shoulder, Upperarm and Forearm Procedures – APR DRG 315

Spinal Fusion

Spinal Fusion – APR DRGs 303, 304 and 321

Tibia/Fibula Fracture Repair

Tibia/Fibula Fracture Repair – APR DRG 313
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Craniotomy (brain surgery)

Craniotomy (brain surgery) – APR DRGs 020 and 021

Stroke

Stroke – APR DRGs 044 and 045

Transient Cerebral Ischemia

Transient Cerebral Ischemia – APR DRG 047
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Cancer

Acute Leukemia

Acute Leukemia – APR DRG 690

Bone Marrow Transplant

Bone Marrow Transplant – APR DRGs 007 and 008 

Brain Cancer

Brain Cancer – APR DRG 41

Chemotherapy

Chemotherapy – APR DRGs 696 

Digestive System Cancer

Digestive System Cancer – APR DRG 240

Female Reproductive Cancer

Female Reproductive Cancer – APR DRG 530

Kidney / Ureter Removal

Kidney / Ureter Removal – APR DRG 442 

Leukemia / Lymphoma, Non - Surgical

Leukemia / Lymphoma, Non - Surgical – APR DRGs 691 and 694

Leukemia / Lymphoma, Surgical

Leukemia / Lymphoma, Surgical – APR DRGs 680 and 681 

Liver/Pancreatic Cancer

Liver Cancer – APR DRG 281 

Lung Cancer

Lung Cancer – APR DRG 136

Mastectomy

Mastectomy – APR DRG 362
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Diabetes/Endocrinology/Metabolism

Diabetes

Diabetes – APR DRG 420
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General Medical Information

Acute Pancreatitis

Acute Pancreatitis – APR DRG 282

Cellulitis

Cellulitis – APR DRG 383

Convulsions (Seizures)

Convulsions (Seizures) – APR DRG 53

Diverticulosis / Diverticulitis

Diverticulosis / Diverticulitis – APR DRG 244

Gastrointestinal Hemorrhage

Gastrointestinal Hemorrhage – APR DRGs 241, 242 and 253

Hypovolemia (Low Blood Volume)

Hypovolemia (Low Blood Volume) – APR DRG 422 

Inflammatory Bowel Disease

Inflammatory Bowel Disease – APR DRG 245

Kidney Injury or Disease

Kidney Injury or Disease – APR DRGs 469 and 470

Migraine and Other Headaches

Migraine and Other Headaches – APR DRG 054

Non-Bacterial Gastroenteritis, Nausea and Vomiting

Non-Bacterial Gastroenteritis, Nausea and Vomiting – APR DRG 249 

Septicemia (blood poisoning)

Septicemia (blood poisoning) – APR DRG 720 and 724

Sickle Cell Disease

Sickle Cell Disease – APR DRG 662 

Syncope (fainting)

Syncope (fainting) – APR DRG 204

Urinary Stones

Urinary Stones – APR DRG 465

Urinary Tract Infection

Urinary Tract Infection – APR DRG 463
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Heart and Circulatory System

Angina Pectoris and Coronary Atherosclerosis

Angina Pectoris and Coronary Atherosclerosis – APR DRG 198

Angioplasty

Angioplasty – APR DRGs 174 and 175 

Cardiac Catheterization

Cardiac Catheterization – APR DRGs 191 and 192

Cardiac Defibrillator and Heart Assist Anomaly

Cardiac Defibrillator and Heart Assist Anomaly – APR DRG 161

Cardiac Pacemaker Implant

Cardiac Pacemaker Implant – APR DRG 171 

Cardiac Valve Procedures without Cardiac Catheterization

Cardiac Valve Procedures without Cardiac Catheterization – APR DRG 163

Chest Pain

Chest Pain – APR DRG 203 

Coronary Bypass Surgery

Coronary Bypass Surgery – APR DRGs 165 and 166 

Heart Attack

Heart Attack – APR DRG 190 

Heart Failure

Heart Failure – APR DRG 194 

High Blood Pressure

High Blood Pressure – APR DRG 199

Irregular Heartbeat

Irregular Heartbeat – APR DRG 201

Other Cardiothoracic and Thoracic Vascular Procedures

Other Cardiothoracic and Thoracic Vascular Procedures – APR DRG 167

Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease (PVD) – APR DRG 197 

Pulmonary Edema and Respiratory Failure

Pulmonary Edema and Respiratory Failure – APR DRG 133
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Lungs

Asthma

Asthma – APR DRG 141

Chronic Obstructive Pulmonary Disease, COPD (pulmonary disease)

COPD (pulmonary disease) – APR DRG 140

Lung and Chest Procedures

Lung and Chest Procedures – APR DRGs 120 and 121

Pneumonia

Pneumonia – APR DRG 139

Pneumonitis, Aspiration

Pneumonitis, Aspiration – APR DRG 137
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Surgery

Appendectomy

Appendectomy – APR DRGs 233 and 234

Arteriovenostomy (renal dialysis)

Arteriovenostomy (renal dialysis) – APR DRG 444 

Gall Bladder Removal

Gall Bladder Removal – APR DRG 263

Heart and/or Lung Transplant

Heart and/or Lung Transplant – APR DRG 002 

Hernia Repair

Hernia Repair, Other – APR DRG 227

Inguinal, Femoral and Umbilical Hernia Procedures

Inguinal, Femoral and Umbilical Hernia Procedures – APR DRG 228

Kidney/Pancreas Transplant

Kidney/Pancreas Transplant – APR DRGs 006 and 440

Liver Transplant

Liver Transplant – APR DRG 001

Major Small and Large Bowel Procedures

Major Small and Large Bowel Procedures – APR DRGs 230 and 231

Major Stomach, Esophageal and Duodenal Procedures

Major Stomach, Esophageal and Duodenal Procedures – APR DRG 220

Minor Small and Large Bowel Procedures

Minor Small and Large Bowel Procedures – APR DRG 223

Obesity Procedures

Obesity Procedures – APR DRG 403

Peritoneal Adhesiolysis

Peritoneal Adhesiolysis - APR DRG 224

Radical Prostatectomy

Radical Prostatectomy – APR DRG 480

Thyroid, Parathyroid and Thyroglossal Procedures

Thyroid, Parathyroid and Thyroglossal Procedures – APR DRG 404

Transurethral Prostatectomy

Transurethral Prostatectomy – APR DRG 482

Urethral and Transurethral Procedures

Urethral and Transurethral Procedures – APR DRG 446
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Women's Health/Deliveries

Cesarean Section Delivery

Cesarean Section Delivery – APR DRG 540 - The data for cesarean deliveries include all ages.

Hysterectomies and Other Uterine and Adnexa Procedures

Hysterectomies and Other Uterine and Adnexa Procedures – APR DRGs 511, 512, 513 and 519

Vaginal Delivery

Vaginal Delivery – APR DRG 560 - The data for vaginal deliveries include all ages.
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Hospital Inpatient Medical Conditions and Procedures - Deliveries and Newborns

Baby with Complications

Baby with Complications – APR DRGs 583, 588, 589, 591, 593, 602, 603, 607, 608, 609, 611, 612, 613, 614, 621, 622, 623, 625, 626, 630, 631, 633, 634, 636, 639, 640 (APR DRG 640 is limited to Severity Levels 2, 3 and 4)

Normal Baby

Normal Baby – APR DRG 640 (limited to Severity Level 1)

Hospital Inpatient Medical Conditions and Procedures - Pediatrics

Appendectomy – Ages 1-17 years

Appendectomy – APR DRGs 233 and 234 (limited to Severity Level 1, minor) – Ages 1-17 years

Asthma – Ages 2-17 years

Asthma – AHRQ V2019 definition for Pediatric Quality Indicator 14 used to define this service line is at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_14_Asthma_Admission_Rate.pdf

Brain Surgery – Ages 0-17 years

Brain Surgery – APR DRGs 020, 021, and 022 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).

Bronchiolitis and RSV Pneumonia – Ages 0-4 years

Bronchiolitis and RSV Pneumonia – APR DRG 138 – Ages 0-4 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).

Cancer Care – Ages 0-17 years

Cancer Care – APR DRG 680, 681, 690, 691, 692, 694, and 041 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).

Cellulitis – Ages 0-17 years

Cellulitis – APR DRG 383 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).

Convulsions (Seizures) – Ages 0-4 years and 5-17 years

Convulsions (Seizures) – APR DRG 53 – Ages 0-4 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old) and ages 5-17.

Diabetes – Ages 6-17 years

Diabetes – AHRQ V2019 definition for Pediatric Quality Indicator 15 used to define this service line is at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_15_Diabetes_Short-term_Complications_Admission_Rate.pdf

Fever and Infectious Illness – Ages 0-17 years

Fever and Infectious Illness – APR DRGs 722, 723, and 113 – Ages 0-17 (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).

Gastroenteritis – Ages 3 months – 4 years and 5-17 years

AHRQ V2019 definition for Pediatric Quality Indicator 16 used to define this service line is at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_16_Gastroenteritis_Admission_Rate.pdf

Pneumonia, Other – Ages 2-17 years

Pneumonia, Other – APR DRG 139- Ages 2-17 years. Please refer to the link below for the exclusion rules for this service line: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_14_Asthma_Admission_Rate.pdf

Sickle Cell Disease – Ages 1-17 years

Sickle Cell Disease – APR DRG 662 – Ages 1-17.

Spinal Fusion – Ages 5-17 years

Spinal Fusion – APR DRGs 303, 304, and 321 – Ages 5-17 years.

Urinary Tract Infections – Ages 3 months to 17 years

Urinary Tract Infections – AHRQ V2019 definition for Pediatric Quality Indicator 18 used to define this service line is at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_18_Urinary_Tract_Infection_Admission_Rate.pdf

Viral Meningitis – Ages 0-17 years

Viral Meningitis – APR DRG 51 – Ages 0-17 years (excluding birth hospitalizations and newborn transfers less than or equal to 28 days old).
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Ambulatory (Outpatient) Surgery Centers

Enhanced Ambulatory Patient Groups (EAPGs)

EAPGs simplify ambulatory visits for analysis and reporting. This is achieved by identifying key diagnoses and procedures, both diagnostic and therapeutic, performed during an ambulatory visit. Once identified, these diagnoses and procedures are used to classify outpatient visits into categories, called EAPGs, that are both clinically and financial meaningful.

An overview of the 3M EAPG methodology is located at this link: https://apps.3mhis.com/docs/Groupers/Enhanced_Ambulatory_Patient_Grouping_EAPGS/methodology_overview/grp403_eapg_meth_overview.pdf

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Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Adults

Bones and Joints

Arthroscopy, Level I – EAPG 37

Arthroscopy, Level II – EAPG 38

Bunion Procedures – EAPG 45

Open or Percutaneous Treatment of Fractures – EAPG 43

Digestive System

Colonoscopy, Therapeutic – EAPG 137

Endoscopy of the Lower Airway – EAPG 64

Endoscopy of the Upper Airway, Level I – EAPG 62

Endoscopy of the Upper Airway, Level II – EAPG 63

Hernia Repair, Level I – EAPG 139

Hernia Repair, Level II – EAPG 140

Lower Gastrointestinal Endoscopy, Diagnostic – EAPG 136

Upper Gastrointestinal (GI) Endoscopy or Intubation, Diagnostic – EAPG 134

Upper Gastrointestinal (GI) Endoscopy or Intubation, Therapeutic – EAPG 135

Eyes

Cataract Procedures – EAPG 233

Laser Eye Procedures – EAPG 232

General Surgery

Facial and Ear, Nose and Throat Procedures, Level I – EAPG 252

Facial and Ear, Nose and Throat Procedures, Level II – EAPG 253

Facial and Ear, Nose and Throat Procedures, Level III – EAPG 254

Facial and Ear, Nose and Throat Procedures, Level IV – EAPG 255

Tonsil and Adenoid Procedures – EAPG 256

Heart and Circulatory System

Cardiac Catheterization, Diagnostic – EAPG 84

Pacemaker Insertion and Replacement – EAPG 86

Kidneys and Urologic System

Bladder and Kidney Procedures, Level I – EAPG 163

Bladder and Kidney Procedures, Level II – EAPG 164

Bladder and Kidney Procedures, Level III – EAPG 165

Extracorporeal Shock Wave Lithotripsy – EAPG 160

Skin

Excision and Biopsy of Skin and Soft Tissue, Level I – EAPG 9

Excision and Biopsy of Skin and Soft Tissue, Level II – EAPG 10

Excision and Biopsy of Skin and Soft Tissue, Level III – EAPG 11

Skin Debridement and Destruction, Level I – EAPG 6

Skin Debridement and Destruction, Level II – EAPG 7

Skin Debridement and Destruction, Level III – EAPG 8

Women’s Health

Breast Procedure, Level I – EAPG 20

Breast Procedure, Level II – EAPG 21

Breast Procedure, Level III – EAPG 22

Hysteroscopy – EAPG 200
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Ambulatory (Outpatient) Surgery Centers Procedures/Surgeries -- Pediatrics

Bones and Joints

Arthroscopy, Level I – EAPG 37

Arthroscopy, Level II – EAPG 38

Open or Percutaneous Treatment of Fractures – EAPG 43

Digestive System

Endoscopy of the Lower Airway – EAPG 64

Endoscopy of the Upper Airway, Level I – EAPG 62

Endoscopy of the Upper Airway, Level II – EAPG 63

Hernia Repair, Level I – EAPG 139

Hernia Repair, Level II – EAPG 140

Lower Gastrointestinal (GI) Endoscopy, Diagnostic – EAPG 136

Upper Gastrointestinal (GI) Endoscopy or Intubation, Diagnostic – EAPG 134

Upper Gastrointestinal (GI) Endoscopy or Intubation, Therapeutic – EAPG 135

Eyes

Strabismus (Repair of Cross-Eyed) and Muscle Eye Procedures – EAPG 239

General Surgery

Circumcision – EAPG 181

Facial and Ear, Nose and Throat Procedures, Level I – EAPG 252

Facial and Ear, Nose and Throat Procedures, Level II – EAPG 253

Facial and Ear, Nose and Throat Procedures, Level III – EAPG 254

Facial and Ear, Nose and Throat Procedures, Level IV – EAPG 255

Tonsil and Adenoid Procedures – EAPG 256
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Pediatric Quality Indicators – Complication and Mortality

The Agency for Healthcare Research and Quality (AHRQ) software (Version 2019) was used in calculating the Pediatric Quality Indicators (PDIs). This includes a 95% confidence interval for all statistical significance determinations. If a hospital had fewer than 30 cases, the results were redacted.

Confidence Intervals are used to identify which hospitals had significantly more or fewer complications than expected given the risk factors of their patients.  The confidence interval identifies the range in which the risk-adjusted rate may fall.  Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide risk adjusted complication rate.  Hospitals with significantly lower rates than expected given the severity of illness of their patients before surgery have the entire confidence interval range entirely below the statewide risk adjusted complication rate.  The more cases a provider performs, the narrower their confidence interval will be.  This is because as a provider performs more cases, the likelihood of chance variation in the risk adjusted complication rate decreases.  This methodology incorporates the Present on Admission (POA) indicator, when appropriate.

For more information, visit the Agency for Healthcare Research and Quality website (V2019 archives):
https://www.qualityindicators.ahrq.gov/Archive/

Accidental Puncture or Laceration - PDI 1

Accidental punctures or lacerations (secondary diagnosis) during procedure per 1,000 discharges for patients ages 17 years and younger. Includes metrics for discharges grouped by risk category. Excludes obstetric discharges, spinal surgery discharges, discharges with accidental puncture or laceration as a principal diagnosis, discharges with accidental puncture or laceration as a secondary diagnosis that is present on admission, normal newborns, and neonates with birth weight less than 500 grams. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V2019/TechSpecs/PDI_01_Accidental_Puncture_or_Laceration_Rate.pdf

Inpatient Mortality Indicators

The Agency for Healthcare Research and Quality (AHRQ) software (Version 2019) was used in calculating the Inpatient Mortality Indicators (IQIs). This includes a 95% confidence interval for all statistical significance determinations. If a hospital had fewer than 30 cases, the results were redacted.

Confidence Intervals are used to identify which hospitals had significantly more or fewer deaths than expected given the risk factors of their patients. The confidence interval identifies the range in which the risk-adjusted mortality rate may fall. Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide risk adjusted mortality rate. Hospitals with significantly lower rates than expected given the severity of illness of their patients before surgery have the entire confidence interval range entirely below the statewide risk adjusted mortality rate. The more cases a provider performs, the narrower their confidence interval will be. This is because as a provider performs more cases, the likelihood of chance variation in the risk adjusted mortality rate decreases.

For more information, visit the Agency for Healthcare Research and Quality website (Version 2019 archive):  https://www.qualityindicators.ahrq.gov/Archive/.
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Mortality Inpatient Procedures

Abdominal Aortic Aneurysm Repair (AAA) Mortality - IQI 11

In-hospital deaths per 1,000 discharges with abdominal aortic aneurysm (AAA) repair, ages 18 years and older. Includes metrics for discharges grouped based on AAA rupture status and repair type. Excludes obstetric discharges and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_11_Abdominal_Aortic_Aneurysm_(AAA)_Repair_Mortality_Rate.pdf

Carotid Endarterectomy Mortality (Surgical Removal of the Lining of the Carotid Artery) – IQI 31

In-hospital deaths per 1,000 discharges with a procedure for carotid endarterectomy (CEA), for patients 18 years of age and older. Excludes obstetric discharges and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_31_Carotid_Endarterectomy_Mortality_Rate.pdf

Coronary Artery Bypass Graft (CABG) Mortality - IQI 12

In-hospital deaths per 1,000 discharges with coronary artery bypass graft (CABG), ages 40 years and older. Excludes obstetric discharges and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_12_Coronary_Artery_Bypass_Graft_(CABG)_Mortality_Rate.pdf

Esophageal Resection Mortality (Surgical Removal of the Throat) - IQI 8

In-hospital deaths per 1,000 discharges with a procedure for esophageal resection or total gastrectomy and a diagnosis of esophageal cancer; or with a procedure for esophageal resection and a diagnosis of gastrointestinal cancer, ages 18 years and older. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_08_Esophageal_Resection_Mortality_Rate.pdf

Pancreatic Resection Mortality (Surgical Removal of the Pancreas) - IQI 9

In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics to stratify discharges grouped by presence or absence of a diagnosis of pancreatic cancer. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_09_Pancreatic_Resection_Mortality_Rate.pdf

PTCA Mortality – IQI 30

In-hospital deaths per 1,000 discharges with a procedure for percutaneous coronary intervention (PCI), for patients 40 years of age and older. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_30_Percutaneous_Coronary_Intervention_(PCI)_Mortality_Rate.pdf

Mortality Inpatient Conditions

Acute Myocardial Infarction (Heart Attack) - IQI 15

In-hospital deaths per 1,000 hospital discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes cases in hospice care at admission, obstetric discharges, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_15_Acute_Myocardial_Infarction_Mortality_Rate.pdf

Acute Myocardial Infarction (Heart Attack), Without Transfer Cases - IQI 32

In-hospital deaths per 1,000 hospital discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges, transfers to another hospital, cases in hospice care at admission, and transfers in from another acute care hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_32_Acute_Myocardial_Infarction_(AMI)_Mortality_Rate_Without_Transfer_Cases.pdf

Acute Stroke Mortality - IQI 17

In-hospital deaths per 1,000 hospital discharges with acute stroke as a principal diagnosis for patients ages 18 years and older. Includes metrics for discharges grouped by type of stroke. Excludes obstetric discharges, cases in hospice care at admission, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_17_Acute_Stroke_Mortality_Rate.pdf

Heart Failure (CHF) Mortality - IQI 16

In-hospital deaths per 1,000 hospital discharges with heart failure as a principal diagnosis for patients ages 18 years and older. Excludes cases in hospice care at admission, obstetric discharges, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_16_Heart_Failure_Mortality_Rate.pdf

Gastrointestinal (GI) Hemorrhage Mortality - IQI 18

In-hospital deaths per 1,000 discharges with a principal diagnosis of gastrointestinal hemorrhage; or a secondary diagnosis of esophageal varices with bleeding along with a qualifying associated principal diagnosis, for patients age 18 years and older. Excludes obstetric discharges, cases in hospice care at admission, discharges with a procedure for liver transplant, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_18_Gastrointestinal_Hemorrhage_Mortality_Rate.pdf

Hip Fracture Mortality - IQI 19

In-hospital deaths per 1,000 hospital discharges with hip fracture as a principal diagnosis for patients ages 65 years and older. Excludes periprosthetic fracture discharges, obstetric discharges, cases in hospice care at admission, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_19_Hip_Fracture_Mortality_Rate.pdf

Pneumonia Mortality - IQI 20

In-hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges, cases in hospice care at admission, and transfers to another hospital. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2019/TechSpecs/IQI_20_Pneumonia_Mortality_Rate.pdf

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Patient Safety Indicators

The Agency for Healthcare Research and Quality (AHRQ) software (Version 2019) was used in calculating the Patient Safety Indicators (PSIs). This includes a 95% confidence interval for all statistical significance determinations. If a hospital had fewer than 30 cases, the results were redacted.

Confidence Intervals are used to identify which hospitals had significantly more or fewer complications than expected given the risk factors of their patients.  The confidence interval identifies the range in which the risk-adjusted rate may fall.  Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide risk adjusted complication rate.  Hospitals with significantly lower rates than expected given the severity of illness of their patients before surgery have the entire confidence interval range entirely below the statewide risk adjusted complication rate.  The more cases a provider performs, the narrower their confidence interval will be.  This is because as a provider performs more cases, the likelihood of chance variation in the risk adjusted complication rate decreases.  This methodology incorporates the Present on Admission (POA) indicator, when appropriate.

For more information, visit the Agency for Healthcare Research and Quality website (Version 2019 archive):  https://www.qualityindicators.ahrq.gov/Archive/

Iatrogenic Pneumothorax - PSI 6

Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2019/TechSpecs/PSI_06_Iatrogenic_Pneumothorax_Rate.pdf

In Hospital Fall with Hip Fracture - PSI 8

In hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older. Excludes discharges with principal diagnosis of a condition with high susceptibility to falls (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), diagnoses associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy), a principal diagnosis of hip fracture, a secondary diagnosis of hip fracture present on admission, and obstetric cases. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2019/TechSpecs/PSI_08_In_Hospital_Fall_with_Hip_Fracture_Rate.pdf

Postoperative Pulmonary Embolism or Deep Vein Thrombosis - PSI 12

Perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes discharges with a principal diagnosis of pulmonary embolism or proximal deep vein thrombosis; with a secondary diagnosis of pulmonary embolism or proximal deep vein thrombosis present on admission; in which interruption of the vena cava or a pulmonary arterial thrombectomy occurs before or on the same day as the first operating room procedure; with extracorporeal membrane oxygenation; with acute brain or spinal injury present on admission; and obstetric cases. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2019/TechSpecs/PSI_12_Perioperative_Pulmonary_Embolism_or_Deep_Vein_Thrombosis_Rate.pdf

Pressure Ulcer - PSI 3

Stage III or IV pressure ulcers or unstageable (secondary diagnosis) per 1,000 discharges among surgical or medical patients ages 18 years and older. Excludes stays less than 3 days; cases with a principal stage III or IV (or unstageable) pressure ulcer diagnosis; cases with a secondary diagnosis of stage III or IV pressure ulcer (or unstageable) that is present on admission; obstetric cases; severe burns; exfoliative skin disorders. Additional details are provided at this link: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2019/TechSpecs/PSI_03_Pressure_Ulcer_Rate.pdf

Physician Volume

The inpatient physician volume data includes discharges with ICD-10-CM codes in the principal procedure field for those ages 18 and older for Total Hip Replacement and Total Knee Replacement. Physicians who performed less than 10 procedures statewide were suppressed from the data and will not be shown on the website. Due to the implementation of the ICD-10-CM codes, the following physician volume measures were not updated but will be included on the website in the near future: Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary Artery Bypass Graft (CABG) and Spinal Fusion.

IMPORTANT: This methodology varies from the Compare Hospitals facility level information thus the totals are not comparable.