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Refinement of the HCUP Quality Indicators

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Table 2S. Area Indicator List

Area Level Indicator Name	Type of Indicator	Indicator Description	Empirical Rating^a	Risk Adjustment Recommended	Literature Review Findings^b	Better Quality May Be Associated with:
CABG rate (#13)^d	Utilization	Number of CABGs per 100,000 population	19	Age and sex	X Proxy X Unclear construct validity X Unclear benchmark	Lower rates^c
Hysterectomy rate (#14)	Utilization	Number of hysterectomies per 100,000 population	22	Age and additional factors such as parity	X Proxy ? Confounding bias X Unclear construct validity X Unclear benchmark	Lower rates^c
Laminectomy rate (#15)	Utilization	Number of laminectomies per 100,000 population	20	Age and sex	X Proxy X Unclear construct validity X Unclear benchmark	Lower rates^c
PTCA rate (#16)^d	Utilization	Number of PTCAs per 100,000 population	19	Age and sex	X Proxy ? Selection bias X Unclear construct validity X Unclear benchmark	Lower rates^c
Dehydration admission rate (#17)^d	ACSC	Number of admissions for dehydration per 100,000 population	14	Age and sex	? Proxy ? Unclear construct validity ? Easily manipulated X Unclear benchmark	Lower rates^c
Bacterial pneumonia admission rate (#18)^d	ACSC	Number of admissions for bacterial pneumonia per 100,000 population	17	Age and sex	? Proxy ? Unclear construct validity ? Easily manipulated X Unclear benchmark	Lower rates^c
Urinary infection admission rate (#19)^d	ACSC	Number of admissions for urinary infection per 100,000 population	11	Age and sex	? Proxy ? Unclear construct validity ? Easily manipulated X Unclear benchmark	Lower rates^c
Perforated appendix admission rate (#20)	ACSC	Number of admissions for perforated as a share of all admissions for appendicitis within an area	17 Smoothing recommended	Age and sex	? Proxy	Lower rates
Angina admission rate (#21)^d	ACSC	Number of admissions for angina per 100,000 population	19	Age and sex	? Proxy ? Unclear construct validity ? Easily manipulated X Unclear benchmark	Lower rates^c
Adult asthma admission rate (#22)	ACSC	Number of admissions for asthma in adults per 100,000 population	16	Age and sex	? Proxy ? Easily manipulated X Unclear benchmark	Lower rates^c
COPD admission rate (#23)	ACSC	Number of admissions for COPD per 100,000 population	17	Age and sex. Potential supplement includes patient characteristics, such as smoking.	? Proxy ? Confounding bias ? Easily manipulated X Unclear benchmark	Lower rates^c
CHF admission rate (#24)	ACSC	Number of admissions for CHF per 100,000 population	14	Age and sex	? Proxy ? Easily manipulated X Unclear benchmark	Lower rates^c
Diabetes short term complication admission rate (#25)	ACSC	Number of admissions for diabetes short term complications per 100,000 population	14	Age and sex. Potential supplement includes population diabetes incidence rates.	? Proxy ? Confounding bias	Lower rates
Uncontrolled diabetes admission rate (#26)^d	ACSC	Number of admissions for uncontrolled diabetes per 100,000 population	14	Age and sex. Potential supplement includes population diabetes incidence rates.	? Proxy ? Confounding bias ? Easily manipulated	Lower rates
Diabetes long term complication admission rate (#27)	ACSC	Number of admissions for diabetes long term diabetes per 100,000 population	11	Age and sex. Potential supplement includes population diabetes incidence rates.	? Proxy ? Confounding bias ? Easily manipulated X Unclear benchmark	Lower rates
Hypertension admission rate (#28)	ACSC	Number of admissions for hypertension per 100,000 population	14	Age and sex	? Proxy ? Easily manipulated X Unclear benchmark	Lower rates^c
Lower extremity amputation in diabetics rate (#29)^d	ACSC	Number of admissions for lower extremity amputation in diabetics per 100,000 population	10 Smoothing recommended	Age and sex. Potential supplement includes population diabetes incidence rates.	? Proxy ? Unclear construct validity	Lower rates
Low birth weight rate (#30)^d	ACSC	Number low birth weight births as a share of all births in an area	11 out of 16^e Smoothing recommended	None available in HCUP. Potential supplement include clinical, link to mother's record, or link to birth record.	? Proxy ? Confounding bias X Unclear construct validity	Lower rates
Pediatric asthma admission rate (#31)	ACSC	Number of admissions for pediatric asthma per 100,000 population	18	Age and sex	? Proxy ? Easily manipulated X Unclear benchmark	Lower rates^c
Pediatric gastroenteritis admission rate (#32)^d	ACSC	Number of admissions for pediatric gastroenteritis per 100,000 population	17	Age and sex	? Proxy ? Unclear construct validity ? Easily manipulated X Unclear benchmark	Lower rates^c

^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. CABG and PTCA area utilization are not recommended as stand alone indicators. They are designed only for use with the corresponding volume and/or mortality measures. Seven ACSC measures (low birth weight, angina, urinary tract infection, bacterial pneumonia, lower extremity amputation, pediatric gastroenteritis, and dehydration) do not have studies confirming their construct validity as individual indicators of access to health care services. For this reason, it is recommended that they be used in conjunction with other ACSC indicators. Uncontrolled diabetes is designed to be combined with diabetes short term complications.
^e. Adequate risk adjustment for low birth weight was not available, and thus, bias was not tested.

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