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Measure Summary
This measure is endorsed by the National Quality Forum
Title
Pediatric heart surgery: volume.
Source(s)
AHRQ QI. Pediatric quality indicators #7: technical specifications. Pediatric heart surgery volume [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 3 p.

AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 4.4]. Appendices. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 61 p.

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Structure
Secondary Measure Domain
Clinical Quality Measure: Outcome

Brief Abstract

Description

Please note: This measure summary will be fully specified once the updated AHRQ User Guide is released in early 2013.

Rationale

Volume is not a direct measure of the quality or outcomes of care. Although higher volumes have been repeatedly associated with better outcomes after pediatric cardiac surgery, these findings may be limited by inadequate risk adjustment.

Only one study used prospectively collected clinical data to estimate the association between hospital volume and mortality following pediatric cardiac surgery. Hannan et al. ordered all cardiac surgical procedures by their actual mortality rates in the 1992 to 1995 Cardiac Surgery Reporting System database. Expert clinicians then grouped the procedures into four clinically sensible subgroups, designed to achieve maximal separation of crude mortality rates (from 1.4% for Category I to 20.1% for Category IV). A multivariate model that included age, complexity category, and four comorbidities (preoperative cyanosis or hypoxia, barotraumas, pulmonary hypertension, major extracardiac anomalies) achieved excellent calibration and discrimination (c=0.818). Using this model to estimate risk-adjusted mortality, Hannan et al. found a statistically significant hospital effect (8.26% risk-adjusted mortality at hospitals with fewer than 100 cases per year, versus 5.95% at higher volume hospitals), which was limited to surgeons who performed at least 75 cases per year. Lower volume surgeons experienced relatively high mortality, regardless of total hospital volume. Risk-adjusted mortality differed between low and high-volume hospitals for all 4 complexity categories, although the smallest difference occurred for the highest risk procedures.

Two other studies using hospital discharge data found similar effects of hospital volume. Using aggregated data from California (1988) and Massachusetts (1989), Jenkins et al. estimated risk-adjusted mortality rates of 8.35% and 5.95% at low-volume (100 or fewer cases) and high-volume (more than 100 cases), respectively. However, they also demonstrated especially high risk-adjusted mortality (18.5%) at very low-volume hospitals with fewer than 10 annual cases, and especially low mortality (3.0%) at very high-volume hospitals with more than 300 annual cases. Jenkins et al. could not evaluate the impact of surgeon volume, but they did report stronger volume effects for higher-risk procedures (e.g., odds ratio [OR]=12.1 and 3.2 for Category III to IV procedures at hospitals with less than 10 and 10-100 annual cases, versus OR=2.4 for Category I to II procedures at hospitals with 10-100 annual cases). Finally, Sollano et al. applied the same 4-category risk adjustment procedure developed by Jenkins to hospital discharge data from New York State in 1990 to 1995. They reported a modest but statistically significant effect (OR=0.944 for each additional 100 annual cases), which was limited to neonates (OR=0.636) and post-neonatal infants (OR=0.720) in stratified analyses.

Primary Health Components

Unspecified

Denominator Description

This measure applies to providers of pediatric heart surgery (one provider at a time).

Numerator Description

Discharges under age 18 with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for either congenital heart disease or non-specific heart surgery with ICD-9-CM diagnosis of congenital heart disease in any field (see the related "Numerator Inclusions/Exclusions" field)

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use of the Measure

State of Use
Current routine use
Current Use
Unspecified

Application of the Measure in its Current Use

Measurement Setting
Unspecified
Professionals Involved in Delivery of Health Services
Unspecified
Least Aggregated Level of Services Delivery Addressed
Unspecified
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Age

Unspecified

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care

Data Collection for the Measure

Case Finding Period

Unspecified

Denominator Sampling Frame
Unspecified
Denominator Time Window
Unspecified
Denominator Inclusions/Exclusions

Inclusions
This measure applies to providers of pediatric heart surgery (one provider at a time).

Exclusions
Unspecified

Exclusions/Exceptions
Unspecified
Numerator Inclusions/Exclusions

Inclusions
Discharges under age 18 with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for either congenital heart disease (1 P) or non-specific heart surgery (2P) with ICD-9-CM diagnosis of congenital heart disease (2D) in any field

Exclusions
Exclude cases:

  • Major Diagnostic Category (MDC) 14 (pregnancy, childbirth and puerperium)
  • With transcatheter interventions (either 3AP, 3BP, 3CP, 3DP, 3EP with any diagnosis code of 3D, or 3FP) as single cardiac procedures, performed without bypass (5P) but with catheterization (6P)
  • With septal defects (4P) as single cardiac procedures without bypass (5P)
  • With missing discharge gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes. See also the Pediatric Quality Indicators Appendices.

Numerator Search Strategy
Unspecified
Data Source
Administrative clinical data
Instruments Used and/or Associated with the Measure

Unspecified

Computation of the Measure

Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Unspecified

Identifying Information

Original Title

PDI #7 pediatric heart surgery volume.

Measure Set Name
Submitter
Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]
Developer
Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]
Funding Source(s)

Agency for Healthcare Research and Quality (AHRQ)

Composition of the Group that Developed the Measure

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

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser
National Quality Forum
NQF Number
0340
Date of Endorsement

2013 Apr 3

Adaptation

Unspecified

Date of Most Current Version in NQMC
2012 Mar
Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 4.2]. PDI #7 pediatric heart surgery volume. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 4 p.

Please note: This measure summary will be fully specified once the updated AHRQ User Guide is released in early 2013.

Source(s)
AHRQ QI. Pediatric quality indicators #7: technical specifications. Pediatric heart surgery volume [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 3 p.

AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 4.4]. Appendices. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 61 p.
Measure Availability

The individual measure, "PDI #7 Pediatric Heart Surgery Volume," is published in "AHRQ Quality Indicators. Pediatric Quality Indicators: Technical Specifications." This document is available in Portable Document Format (PDF) from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Web site External Web Site Policy.

For more information, please contact the QI Support Team at support@qualityindicators.ahrq.gov.

Companion Documents

The following are available:

  • AHRQ quality indicators. Pediatric quality indicator comparative data: based on the 2009 Nationwide Inpatient Sample (NIS) [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Aug. 19 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicators. Pediatric quality indicators (PDI) risk adjustment coefficients for the PDI [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 73 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicators. Pediatric quality indicators composite measure workgroup. Final report. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar. various p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • HCUPnet: a tool for identifying, tracking, and analyzing national hospital statistics. [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [accessed 2010 Jan 4]. HCUPnet is available from the AHRQ Web site External Web Site Policy. See the related QualityTools External Web Site Policy summary.
NQMC Status

This NQMC summary was completed by ECRI Institute on December 28, 2007. The information was verified by the measure developer on March 31, 2008. This NQMC summary was updated by ECRI Institute on June 25, 2010. This NQMC summary was reviewed and edited by ECRI Institute on July 15, 2011. This NQMC summary was retrofitted into the new template on July 19, 2011. This NQMC summary was updated again by ECRI Institute on February 28, 2013.

Copyright Statement

No copyright restrictions apply.

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