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Refinement of the HCUP Quality Indicators

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Table 1S. Provider Indicator List

Provider Level Indicator Name	Type of Indicator	Indicator Description	Empirical Rating^a	Risk Adjustment Recommended	Caveats of Use From the Literature Review^b	Better Quality May Be Associated with:
AAA repair volume (#1)	Volume	Raw volume compared to annual thresholds (20, 32 procedures)	Not applicable	Not applicable	X Proxy ? Easily manipulated	Higher rates
Carotid endarterectomy volume (#2)	Volume	Raw volume compared to annual thresholds (50, 101 procedures)	Not applicable	Not applicable	X Proxy X Easily manipulated	Higher rates
CABG volume (#3)	Volume	Raw volume compared to annual thresholds (100, 200 procedures)	Not applicable	Not applicable	X Proxy ? Easily manipulated	Higher rates
Esophageal resection volume (#4)	Volume	Raw volume compared to annual thresholds (6, 7 procedures)	Not applicable	Not applicable	X Proxy ? Easily manipulated	Higher rates
Pancreatic resection volume (#5)	Volume	Raw volume compared to annual thresholds (10, 11 procedures)	Not applicable	Not applicable	X Proxy ? Easily manipulated	Higher rates
Pediatric heart surgery volume (#6)	Volume	Raw volume compared to annual thresholds (100 procedures)	Not applicable	Not applicable	X Proxy ? Easily manipulated	Higher rates
PTCA volume (#7)	Volume	Raw volume compared to annual thresholds (200, 400 procedures)	Not applicable	Not applicable	X Proxy ? Selection bias X Easily manipulated	Higher rates
Cesarean section rate (#8)	Utilization	Number of cesarean sections per 100 deliveries	17	Age adjustment, and potentially supplemental (clinical data, linked to infant record, or linked to birth record)	? Confound- ing bias ? Unclear construct validity ? Unclear benchmark	Lower rates^c
Incidental appendectomy among elderly rate (#9)	Utilization	Number of incidental appendectomies per 100 abdominal surgeries	13 Smoothing recommended	Age and sex	? Unclear construct validity ? Easily manipulated	Lower rates
Bi-lateral cardiac catheterization rate (#10)	Utilization	Number of bilateral caths per 100 cardiac caths	25	None required	? Selection bias ? Unclear construct validity	Lower rates
VBAC rate (#11)	Utilization	Number of vaginal births per 100 deliveries in women with previous cesarean section	19	Age adjustment, and potentially supplemental (clinical data, linked to infant record, or linked to birth record)	X Selection bias ? Confound- ing bias ? Unclear construct validity ? Unclear benchmark	Higher rates^c
Laparoscopic cholecystectomy (#12)	Utilization	Number of lap. cholecystectomies per 100 cholecystectomies	20	Age and sex adjustment, and potentially supplemental clinical.	X Selection bias X Confound- ing bias ? Unclear construct validity X Easily manipulated X Unclear benchmark	Higher rates^c
AMI mortality (#33)	In-hospital Mortality	Number of deaths per 100 discharges for AMI	5 Smoothing recommended	APR-DRG	X Information bias X Confound- ing bias	Lower rates
CHF mortality (#34)	In-hospital Mortality	Number of deaths per 100 discharges for CHF	6 Smoothing recommended	APR-DRG	X Selection bias X Information bias X Confound- ing bias	Lower rates
GI hemorrhage mortality (#35)	In-hospital Mortality	Number of deaths per 100 discharges for GI hemorrhage	5 Smoothing recommended	APR-DRG	X Confound- ing bias ? Unclear construct validity	Lower rates
Hip fracture mortality (#36)	In-hospital Mortality	Number of deaths per 100 discharges for hip fracture	10 Smoothing recommended	APR-DRG	? Information bias X Confound- ing bias ? Unclear construct validity	Lower rates
Pneumonia mortality (#37)	In-hospital Mortality	Number of deaths per 100 discharges for pneumonia	7 Smoothing recommended	APR-DRG	X Selection bias ? Information bias X Confound- ing bias	Lower rates
Stroke mortality (#38)	In-hospital Mortality	Number of deaths per 100 discharges for stroke	10 Smoothing recommended	APR-DRG	X Selection bias ? Information bias X Confound- ing bias	Lower rates
AAA repair mortality (#39)	Post- procedural Mortality	Number of deaths per 100 AAA repairs	8 Smoothing recommended	APR-DRG, though impact may be impaired by skewed distribution.	X Confound- ing bias ? Unclear construct validity	Lower rates
CABG mortality (#40)	Post- procedural Mortality	Number of deaths per 100 CABG procedures	5 Smoothing recommended	APR-DRG	? Selection bias X Confound- ing bias ? Unclear construct validity ? Easily manipulated	Lower rates
Craniotomy mortality (#41)	Post- procedural Mortality	Number of deaths per 100 craniotomies	6 Smoothing recommended	APR-DRG	X Confound- ing bias ? Unclear construct validity	Lower rates
Esophageal resection mortality (#42)	Post- procedural Mortality	Number of deaths per 100 esophageal resections for cancer	8 Smoothing recommended	APR-DRG, though impact may be impaired by skewed distribution.	? Confound- ing bias ? Unclear construct validity	Lower rates
Hip replacement mortality (#43)	Post- procedural Mortality	Number of deaths per 100 hip replacements	3 Smoothing recommended	APR-DRG	? Selection bias ? Confound- ing bias ? Unclear construct validity	Lower rates
Pancreatic resection mortality (#44)	Post- procedural Mortality	Number of deaths per 100 pancreatic resections for cancer	5 Smoothing recommended	APR-DRG, though impact may be impaired by skewed distribution.	? Confound- ing bias ? Unclear construct validity	Lower rates
Pediatric heart surgery mortality (#45)^d	Post- procedural Mortality	Number of deaths per 100 heart surgeries in patients under age 18 years	3 Smoothing recommended	APR-DRG	X Confound- ing bias ? Unclear construct validity Unclear benchmark	Lower rates

^a. Each indicator is rated from 0-26 on its empirical performance of precision and minimum bias with 0 indicating the lowest empirical rating (poor performance) and 26 indicating the highest performance.
^b. Each indicator was evaluated for seven caveats (proxy, selection bias, information bias, confounding bias, unclear construct validity, easily manipulated, unclear benchmark). A question mark preceding the caveat means that this is a theoretical or suggested concern. A checkmark means that this is a concern that has been demonstrated.
^c. For some indicators, very low or very high rates may indicate a potential quality problem. The direction listed is the direction for improvement given the current rates for these indicators.
^d. Pediatric heart surgery mortality is not recommended as a stand alone indicator, because of ample evidence for confounding bias in the absence of more sophisticated risk-adjustment. It is designed only for use with the corresponding volume measure, or with risk-adjustment methods such as those described in the detailed literature review.

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