Medicare Quality Monitoring System (MQMS) Report: Patient...

Contract No.: GS-10F-0050L Task Order No.: CMS-02-01175 MPR Reference No.: 8908-005

Medicare Quality Monitoring System (MQMS) Report: Patient Safety, 2000 and 2001 Final Report November 7, 2003

Submitted to:

Centers for Medicare and Medicaid Services Center for Beneficiary Choices/ Quality Measurement and Health Assessment Group South Bldg., S3-24-05 7500 Security Blvd. Mail Stop S3-02-01 Baltimore, MD 21244-1850

Project Officer: Lein Han

Submitted by:

Mathematica Policy Research, Inc. 600 Maryland Ave., SW, Suite 550 Washington, DC 20024-2512 Telephone: (202) 484-9220 Facsimile: (202) 863-1763

Project Director: Myles Maxfield

C O N T E N T S

Chapter Page

EXECUTIVE SUMMARY................................................................................... xv

I. INTRODUCTION.................................................................................................. 1 The MQMS Patient Safety Measures ..........................................................1

II. RATES OF PATIENT SAFETY MEASURES AT THE OVERALL

NATIONAL LEVEL AND FOR SELECTED BENFICIARY SUBGROUPS ........................................................................................................... 3

III. ADDITIONAL ANALYSES OF SELECTED PERI- AND

POSTOPERATIVE MEASURES ......................................................................13 Anesthesia Complications and Reactions ..................................................13 Postoperative Hemorrhage or Hematoma..................................................16 Postoperative Physiologic or Metabolic Derangement..............................19 Postoperative Respiratory Failure..............................................................23 Postoperative Septicemia ...........................................................................25 Postoperative Wound Dehiscence..............................................................29

REFERENCES.......................................................................................................31

L I S T O F F I G U R E S

Figure Page

II.1. Rates of MQMS Patient Safety Measures for 2000 and 2001 combined, Overall U.S................................................................................................................. 4

II.2a. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Age Groups .......................................................................................................... 5

II.2b. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Age Groups .......................................................................................................... 6

II.3. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Gender .................................................................................................................. 7

II.4. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Race ....................................................................................................................... 8

II.5. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Dual Eligibility ..................................................................................................... 9

II.6. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Reason for Medicare Entitlement ...................................................................10

II.7. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Rural or Urban Residency ................................................................................11

II.8. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Region of the U.S. .............................................................................................12

III.1. Frequency of Specific Complications Among Discharges with an Anesthetic Complication or Reaction (N=1,516) ..............................................13

III.2. Ten Most Frequent DRGs Among Discharges with Anesthesia Complications and Reactions (N=1,512) ............................................................14

III.3. DRGs with the Ten Highest Rates of Anesthetic Complications and Reactions, Among all Discharges Eligible for That Outcome.........................15

III.4. Frequency of Principal Procedures Among Discharges with a Postoperative Hemorrhage or Hematoma (N=14,891)....................................16

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List of Figures

III.5. Frequency of DRGs Among Discharges with a Postoperative Hemorrhage or Hematoma (N=14,891) .............................................................17

III.6. Ten DRGs with the Highest Rates of Postoperative Hemorrhage or Hematoma, Among all Discharges Eligible for That Outcome ......................18

III.7. Frequency of Specific Complications Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,272) .................19

III.8. Frequency of Principal Procedures Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,199) .................20

III.9. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,199) .....21

III.10. DRGs with the Ten Highest Rates of Postoperative Physiologic or Metabolic Derangement, Among all Discharges Eligible for That Outcome ..................................................................................................................22

III.11. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with Postoperative Respiratory Failure (N=18,087)..........................................23

III.12. DRGs with the Ten Highest Rates of Postoperative Respiratory Failure, Among all Discharges Eligible for That Outcome..............................24

III.13. Frequency of Specific Septicemia Diagnoses Among Discharges with Postoperative Septicemia (N=14,393) .................................................................25

III.14. Frequency of Principal Procedures Among Discharges with Postoperative Septicemia (N=14,069) .................................................................26

III.15. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with Postoperative Septicemia (N=14,069) ........................................................27

III.16. DRGs with the Ten Highest Rates of Postoperative Septicemia, Among all Discharges Eligible for That Outcome ............................................28

III.17. Frequency of Principal Procedures Among Discharges with Postoperative Wound Dehiscence (N=4,201) ...................................................29

A C K N O W L E D G E M E N T S A N D D I S C L A I M E R

Mathematica Policy Research, Inc. (MPR) prepared this report under contract GS-10F-0050L, task order CMS-02-01175, with the Centers for Medicare & Medicaid Services. MPR would like to acknowledge the contribution of RTI International, which created some of the intermediate data files that served as input for this report. We would also like to acknowledge the direction and comments of Lein Han, Neil Gittings, and Aaron Goldfarb of CMS. The report was prepared by Arnold Chen, Nazmul Khan, Randall Brown, Myles Maxfield, Daryl Hall, Alfreda Holmes, Cindy McClure, Jennifer Chiaramonti, Bryan Gustus, and Jill Miller of MPR.

Opinions and interpretations expressed herein are not necessarily the position of CMS or any other federal agency.

A B O U T M Q M S

BACKGROUND The Medicare Quality Monitoring System (MQMS) is a system that monitors the quality

of care delivered to Medicare fee-for-service beneficiaries. The MQMS is developed in the context of growing public concerns over quality of care, patient safety, and hospital performance. It is directed by the Centers for Medicare & Medicaid Services (CMS) with assistance from its contractors. MQMS development and production involves a diverse group of CMS staff, including clinical area team leaders (clinicians), epidemiologists, statisticians, and data analysts in the central and regional offices. CMS also consulted with leading experts in other federal agencies—such as the Agency for Health Care Research and Quality, the Centers for Disease Control—and in quality improvement organizations and academia.

PURPOSE MQMS uses Medicare administrative and survey data to track trends, patterns, and

variations in health, disease-specific, and procedure-specific outcomes at the national and state level that are related to CMS’ quality improvement program and initiatives. It provides input for broad and high-level policy making and program planning within CMS.

• Specifically, the MQMS data are to be used for:

- Identifying potential quality problems

- Targeting interventions

- Prioritizing activities & allocation of resources

- Focusing on a particular problem

- Raising research questions/hypotheses for further investigation

• The MQMS data should not be interpreted as:

- Research that links cause and effect

- Evaluation of the performance of individual Quality Improvement Organizations (QIOs) or states.

- Evaluation of the effectiveness of the QIO program or other CMS quality improvement policies and initiatives

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About MQMS

POPULATION AND HEALTH ISSUES EXAMINED The MQMS population consists of Medicare fee-for-service (FFS) beneficiaries.

MQMS is limited to FFS beneficiaries because of the current lack of encounter data from Medicare managed care plans. The analysis is limited to the national and/or state level, showing trends over time for various demographic and geographic subgroups. The trends and patterns are adjusted for variations in the age and sex composition of the population. MQMS monitors the following types of quality measures:

• Mortality, survival rates, readmission rates, length of stay, and cost of hospitalizations for five conditions common in the Medicare population—acute myocardial infarction (AMI), heart failure, pneumonia, stroke, and diabetes

• Mortality and readmission rates following cancer-related and cardiac-related high-risk surgical procedures

• Patient safety

• Preventable hospitalization

METHODS MQMS products, listed below, are designed as national- and state-level monitoring

tools, and not as provider-level monitoring tools. Since the figures are presented at the national, regional, and state levels, they are adjusted to a standard distribution of age and sex. The age-sex adjustment eliminates population differences in age and sex distributions between states, between years, or between subgroups as a cause of the MQMS findings.1

MQMS results are not risk adjusted beyond the age-sex adjustment. This approach assumes that the distribution of health risks is similar from one state population to another state population, or between subgroups being compared, and that the distribution of health risks in the national population is similar from one year to another. CMS continues to assess the validity of this assumption.

MQMS results are based on data from all fee-for-service beneficiaries and claims, rather than a sample of such beneficiaries and claims. This means that the rates presented in MQMS reports do not contain sampling error. MQMS rates are not presented with confidence intervals or significance testing, since these intervals and tests are based on properties of sampling error. This approach implies that the FFS population is not interpreted as a sample drawn from a super-population, such as all Medicare beneficiaries or FFS beneficiaries from another time period.

1 For reasons of policy relevance, and because of numerous changes in the ICD-9 codes used to define the patient safety measures, this report focuses on a cross-sectional analysis of 2000 and 2001, the years for which the most recent data are available.

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About MQMS

MQMS results are subject to measurement error in the Denominator File and MedPAR database, as well as to modeling error resulting from the age-sex adjustment. CMS continues to investigate the magnitude of these errors.

PRODUCTS The MQMS products are a series of reports on quality measures, a set of tables on

CMS’ web site, plus the data files at the person and aggregate level used to generate the reports and documentation of the methodology. The reports are available on the CMS website; the data files are located on the CMS mainframe. To facilitate the use of the data and replication of the analysis, CMS makes available SAS programs and data processing documentation. Access to the data can be granted to CMS analysts on request. Other federal agencies and CMS contractors may obtain the data through a formal data request process.

MQMS reports include:

• MQMS Report: Beneficiary Characteristics and Utilization, 1992-2001

• MQMS Report: Acute Myocardial Infarction (AMI), 1992-2001

• MQMS Report: Patient Safety, 2000 and 2001

• MQMS Report: Heart Failure, 1992-2001

• MQMS Report: Pneumonia, 1992-2001

• MQMS Report: Preventable Hospitalizations, 1992-2001

• MQMS Report: Stroke, 1992-2001

• MQMS Report: Cancer-Related High-risk Surgeries, 1992-2001

• MQMS Report: Cardiac-Related High-risk Surgeries, 1992-2001

• MQMS Report: Diabetes, 1992-2001

E X E C U T I V E S U M M A R Y

This report presents rates of 12 potentially preventable adverse events occurring during hospital care (the MQMS Patient Safety Measures) among discharges of Medicare beneficiaries in the fee-for-service program in the years 2000 and 2001. The MQMS Patient Safety Measures have been selected and adapted from the Patient Safety Indicators developed by Stanford University and the Agency for Healthcare Research and Quality (McDonald et al. 2002). The source of data for this report is Medicare claims and enrollment data. This report and several companion reports together constitute a large scale surveillance effort. The current report addresses three specific questions:

• What are overall rates of the 12 Patient Safety Measures?

• How do these rates differ among the following seven demographic and geographic subgroups: (1) age, (2) gender, (3) race, (4) dual eligibility, (5) reason for Medicare entitlement, (6) rural or urban residence, and (7) region of the U.S.?

• What specific complications, procedures, and Diagnosis Related Groups (DRGs) make up or have the highest rates of selected Patient Safety Measures related to perioperative care?

Rates of MQMS Patient Safety Measures for the Overall Nation

• Rates of Patient Safety Measures have a wide range, with the most common one, Decubitus Ulcers, occurring relatively frequently (27 events per 1,000 discharges), and the most uncommon one, Foreign Body Left in During Procedure, occurring only rarely (0.08 events per 1,000 discharges). Quality improvement efforts focused on the more common events may have a higher yield than efforts focused on the rare ones.

• Although other studies have used very different data sources, patient populations, and measurement methods, rates of MQMS Patient Safety Measures are roughly comparable to previously reported results.

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Executive Summary

Rates of MQMS Patient Safety Measures for Beneficiary Subgroups

• By Age Groups

- Rates of Decubitus Ulcer increase sharply with increasing age, with a fourfold increase between the oldest and youngest age groups.

- Rates of Postoperative Septicemia have a “U” shaped distribution, with the highest rates in the oldest and youngest age groups, and intermediate rates in the other age groups.

- Rates of inpatient hip fractures increase with older age. - Rates of Selected Infections due to Medical Care (primarily catheter

related infections) vary inversely with age.

• By Gender

- Males have consistently worse rates in Postoperative Septicemia, Postoperative Respiratory Failure, and Postoperative Abdominopelvic Wound Dehsicence. The septicemia finding is consistent with other recent research.

- Women have a higher rate for Postoperative Hip Fractures, but equal rates for all Inpatient Hip Fractures.

• By Race

- African-Americans have the highest rates and Whites the lowest for Decubitus Ulcers, Postoperative Septicemia, Selected Infections due to Medical Care, and Postoperative Respiratory Failure. The septicemia finding has also been recently reported by other researchers.

• By Dual Eligibility

- Dually eligible beneficiaries have roughly twice the rates of Decubitus Ulcers, Postoperative Septicemia, and Postoperative Respiratory Failure as non-dually eligible ones.

- Dually eligible beneficiaries also have worse rates for Postoperative Abdominopelvic Wound Dehiscence, Selected Infections Due to Medical Care, and Postoperative Hip Fracture, although the differences are smaller.

• By Reason for Medicare Entitlement

- Beneficiaries with ESRD have much worse rates (compared to Aged and Disabled beneficiaries) for all but three Patient Safety Measures (Postoperative Abdominopelvic Wound Dehiscence, Inpatient Hip Fracture, and Postoperative Hip Fracture). Disabled beneficiaries tend to

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Executive Summary

have the lowest rates, and aged beneficiaries tend to have intermediate rates.

• By Rural or Urban Residence

- Urban beneficiaries have rates of Decubitus Ulcer that are 40 percent higher than rural beneficiaries.

- Urban beneficiaries have slightly higher rates of Postoperative Septicemia and Postoperative Respiratory Failure than rural beneficiaries.

• By Region of the U.S.

- There is no consistent pattern of differences across regions. Rates of Decubitus Ulcers are higher in the South and Northeast than in the West and the Midwest. Rates of Postoperative Septicemia and Postoperative Respiratory Failure are somewhat higher in the South than in the other regions.

Specific Complications, Procedures, and Diagnosis Related Groups Related to Six Selected Peri- and Postoperative Patient Safety Measures

• Anesthesia Complications and Reactions

- The most common complications were adverse effects from unspecified general anesthetics, unspecified spinal anesthetics, and intravenous anesthetics.

- Major Joint and Limb Reattachment Procedures of the Lower Extremity is the most common single DRG, but most discharges belong to a mixed group of discharges with many DRGs.

- The DRGs with the ten highest rates of anesthetic complications include orthopedic surgeries (back and neck, major joint and limb, and hip and femur procedures), gastrointestinal surgeries (major small and large bowel procedures, laparoscopic cholecystectomy), thoracic surgeries (major chest procedurers), and vascular surgeries (extracranial vascular, and other vascular procedures). Rates of anesthetic complications across DRGs vary widely, from 0.14 per 1,000 to 1.18 per 1,000 discharges.

• Postoperative Hemorrhage or Hematoma

- No one procedure or group of procedures predominates. The single most common procedure (carotid endarterectomy) makes up only 10 percent of all discharges with this complication.

- No one DRG predominates, either. The single most common DRG (Other Vascular Procedures with Complications or Comorbidities) represents about 14 percent of all discharges.

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Executive Summary

- The Liver Transplant DRG has a rate of this complication (35.6 events per 1,000 discharges) more than twice as high as the DRG with the next highest rate (Kidney Transplant, at 14.9 per events per 1,000 discharges).

- Other DRGs, representing a variety of urological, gastrointestinal, and general surgical admissions, have rates ranging from 9 to 13 events per 1,000 discharges.

• Postoperative Physiologic or Metabolic Derangement

- Ninety percent of the complications in this measure are due to acute renal failure, with the remainder due to diabetes.

- The single most common procedure is kidney transplant.

- Other procedures include resection of abdominal aortic aneurysm, creation of arteriovenous fistula for hemodialysis, angioplasty or atherectomy of non-coronary vessel, other peripheral vascular shunt or bypass, aortocoronary bypass-3 vessels, nephroureterectomy, and total knee replacement.

- Some procedures may be markers for underlying severity of illness—temporary tracheostomy and excisional wound debridement.

- No single DRG or group of DRGs predominates.

- Kidney transplant is the DRG with the highest rate by far (about 80 events per 1,000 discharges), about 4 times higher than the next highest rate (19 events per 1,000 discharges, for temporary tracheostomy), and 10 to 20 times higher than the other rates (4 to 7 events per 1,000 discharges)

• Postoperative Respiratory Failure

- The most common DRG is tracheostomy for respiratory failure, about a third of the total. These procedures might be in response to (and not necessarily a cause of) prolonged respiratory failure and ventilator dependence.

- Tracheostomy for respiratory failure is also the DRG with a much higher rate of this complication than other DRGs.

• Postoperative Septicemia

- Nearly half of discharges with postoperative septicemia were coded as nonspecific septicemia.

- Thirty-five percent of discharges were due to gram positive organisms, or about three-quarters of cases with a specified bacterial organism. Twelve percent of discharges were due to gram negative organisms, about one quarter of cases with a specified bacterial organism. These results are similar to other recent results.

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Executive Summary

- The most common procedure was temporary tracheostomy.

- DRGs for major vascular and abdominal surgeries were the most common.

- The DRG Tracheostomy Except for Face, Neck, and Mouth Diagnoses had the highest rate. This DRG may be a marker for severity of illness.

• Postoperative Wound Dehiscence

- The most common procedures include several major gastrointestinal and abdominal surgeries, consistent with another recent study.

M E D I C A R E Q U A L I T Y M O N I T O R I N G S Y S T E M

( M Q M S ) R E P O R T :

P A T I E N T S A F E T Y , 2 0 0 0 A N D 2 0 0 1

I. INTRODUCTION

The safety of American health care is an important public health and policy issue. In its report To Err Is Human, the Institute of Medicine estimated that 44,000 to 98,000 people die each year from medical errors occuring in hospitals (Kohn et al., 2000). That report, along with widely reported news stories of medical mistakes, opened the eyes of the public, policymakers, and health care providers to the frequency and seriousness of patient safety problems.

This report uses data from the Medicare Quality Monitoring System (MQMS) to study rates of serious, potentially preventable adverse events occurring during hospital care that are measurable with hospital administrative discharge data. Although adverse events will occur even with the safest of care, and may not occur despite highly unsafe care, potentially preventable adverse events should in general occur less frequently with high-quality, error-free care, and more frequently with lower quality, error-prone care. The adverse events reported here are a subset of the of the Patient Safety Indicators (PSIs) researched and developed by Stanford University for the Agency for Healthcare Quality and Research (AHRQ).

The MQMS Patient Safety Measures

The MQMS Patient Safety Measures include a subset of 11 of the original 20 PSIs developed by Stanford University and AHRQ (McDonald et al. 2002), and an alternative definition of one of the 11, for a total of 12 measures. The alternatively defined measure is a variation of the AHRQ postoperative hip fracture indicator. The AHRQ indicator (which we call the “AHRQ Postoperative Hip Fracture” measure) includes only surgical discharges.

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Patient Safety, 1995-2001

The CMS MQMS Patient Safety Measure Workgroup (see Appendix A) felt that patients with medical discharges should be included as well. The AHRQ postoperative hip fracture indicator also excludes patients with the following diagnoses: musculoskeletal and connective tissue diseases, seizure disorder, syncope, stroke, coma, cardiac arrest, poisoning, trauma, delirium and other psychoses, anoxic brain injury, metastatic cancer, lymphoid malignancy, bone malignancy, or self-inflicted injury, whereas the CMS MQMS Patient Safety Measure Workgroup felt that patients with these diagnoses were especially vulnerable to injury and ought to be included. Thus, MQMS includes an inpatient hip fracture measure (called “MQMS Inpatient Hip Fracture”) that is derived from the original AHRQ indicator but that has much broader inclusion criteria.

The nine PSIs not included in MQMS are—Death in Low Mortality DRGs, Failure to Rescue, Postoperative Thromboembolism, Accidental Puncture and Laceration, Transfusion Reaction, and the four PSIs for obstetrical care. The obstetrical PSIs were not included because most female Medicare beneficiaries are beyond the age of childbearing. Reasons for not including the remaining five PSIs in MQMS are detailed in Appendix A. The 12 MQMS Patient Safety Measures are thus as follows:

1. Anesthesia Reactions and Complications

2. Decubitus Ulcer

3. Foreign Body Left in During Procedure

4. Iatrogenic Pneumothorax

5. Postoperative Hemorrhage or Hematoma

6. AHRQ Postoperative Hip Fracture

7. MQMS Inpatient Hip Fracture

8. Postoperative Physiologic or Metabolic Derangement

9. Postoperative Respiratory Failure

10. Postoperative Septicemia

11. Postoperative Abdominopelvic Wound Dehiscence

12. Selected Infections Due to Medical Care

Section II of the report presents results for the Patient Safety Measures at the national level, and results within the following beneficiary subgroups:

1. Age

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2. Gender

3. Race

4. Dual Eligibility (for both Medicare and Medicaid)

5. Reason for Medicare Entitlement

6. Rural or Urban Residence

7. Region of the U.S.

Because of the low rates of several of the outcomes, data are presented for the years 2000 and 2001 combined. The two most infrequent outcomes (Anesthetic Complications and Reactions and Foreign Body Left in During Procedure) are shown only in the overall U.S. chart and the tabular results in Appendix B because of the difficulty of displaying them in the same charts as the other outcomes.

To remove the contributions of age and sex differences to any observed differences between subgroups, the subgroup results have been age, sex, or age and sex adjusted to the July 1999 Medicare fee-for-service population. Thus, in the gender comparisons, the male and female subgroups have been adjusted to the age distribution of the July 1999 reference population, in the age group comparisons, the age subgroups have been adjusted to the sex distribution of the reference population, and in the remaining subgroup comparisons, results have been adjusted to both the age and sex distributions of the reference population.

Section III of the report examines six selected peri- and postoperative Patient Safety Measures in greater detail. Frequencies of the adverse events, procedures, and diagnoses that make up Anesthesia Reactions and Complications, Postoperative Hemorrhage or Hematoma, Postoperative Metabolic or Physiologic Derangements, Postoperative Sepsis, and Postoperative Wound Dehiscence, are examined.

Appendix A describes in detail the methods behind the MQMS Patient Safety Measures: their rationale, the data sources, the samples and populations, and their specification and calculation. Appendix B contains full results in tabular form. Finally, for comparison purposes, Appendix C displays results from the Stanford/AHRQ researchers’ analysis of the Nationwide Inpatient Sample.

II. RATES OF PATIENT SAFETY MEASURES AT THE OVERALL NATIONAL LEVEL AND FOR SELECTED BENFICIARY SUBGROUPS

Figure II.1 shows rates of the Patient Safety Measures at an overall national level. There is a wide range of frequencies of the measures.

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Figure II.1. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, Overall U.S.

• Rates of the indicators range over several orders of magnitude. The three measures

with the highest rates were Decubitus Ulcers, Postoperative Septicemia, and Postoperative Respiratory Failure, occurring at rates of roughly 27, 13, and 8 events per 1,000 discharges.

• The three measures with the lowest rates, Iatrogenic Pneumothorax, Anesthetic Complications and Reactions, and Foreign Body Left in During Procedure, are many orders of magnitude less common, occurring once only every 1,000, 5,000, and 13,000, discharges, respectively.

• Efforts to track and investigate the more commonly adverse events may have a higher yield than efforts to track the rare events. As discussed in the Introduction, subsequent charts omit Anesthesia Complications and Reactions, and Foreign Body Left in During Procedure because of the difficulty of displaying them on the same scale as the other indicators (tabular results for these two measures are in Appendix B).

• The rate for the MQMS Inpatient Hip Fracture measure is higher than that for the AHRQ Postoperative Hip Fracture measure. This is not surprising, as the MQMS measure includes many discharges at high risk for inpatient hip fracture that were excluded from the AHRQ measure.

• It is difficult to find data on adverse events from hospital care that are comparable to the MQMS results. Most other studies have used different data sources, such as direct clinician observation or medical charts; have included the general hospital population and not just Medicare beneficiaries; have reported rates of all complications and not of individual complications; or have used different denominators to calculate rates, such as events per hospital bed, events per day of catheter insertion, or events per area population.

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- Previous estimates of the incidence of decubitus ulcers in general hospital populations have ranged from 27 to 295 per 1,000 (Gerson 1975; Clare and Kadhom 1988).

- A recent study reported incidences of retained instruments and sponges following major surgery of 0.05 to 0.1 per 1,000 inpatient operations (Gawande et al. 2003). Because they used malpractice claims data, the authors noted their results were likely underestimates.

- Morgan et al. (1985) found a rate of 19 falls per 1,000 hospitalized elderly patients. They included all falls, however, and not only those resulting in serious injury. In a study that included all inpatients, and not only Medicare beneficiaries, Bates et al. reported a rate of falls with serious injury of 0.4 per 1,000 discharges.

Figure II.2 shows the strong dependence of several of the rates of patient safety measures on age.

Figure II.2a. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Age Groups

NOTE: Results adjusted to the sex distribution of the July 1999 Medicare fee-for-service population.

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Figure II.2b. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Age Groups

NOTE: Results adjusted to the sex distribution of the July 1999 Medicare fee-for-service population.

• Rates of Decubitus Ulcer increase sharply with increasing age. The rate in the oldest age group is between and three and four times that in the youngest age group.

• Postoperative Septicemia shows a “U” shaped distribution, with the highest rates in the oldest and youngest age groups, and intermediate rates in the other age groups.

• Both hip fracture indicators show increasing rates with older age.

• Selected Infections due to Medical Care shows an inverse relation with age, with rates decreasing as age increases.

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Figure II.3 shows that rates for a number of the patient safety measures also vary substantially between males and females.

Figure II.3. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Gender

NOTE: Results adjusted to the age distribution of the July 1999 Medicare fee-for-service population.

• Males have consistently worse rates in Postoperative Septicemia, Postoperative Respiratory Failure, and Postoperative Abdominopelvic Wound Dehiscence.

• Martin et al. (2003) studied all hospital septicemia, not just postoperative septicemia, but also found septicemia to be more common among men than women.

• Women have a higher rate for the AHRQ Postoperative Hip Fracture indicator but rates are equal for the MQMS Inpatient Hip Fracture indicator, possibly due to higher risk among the male discharges excluded from the AHRQ measure, but included in the MQMS measure.

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Figure II.4 shows that there are also some striking differences in rates of events by race.

Figure II.4. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Race

NOTE: Results adjusted to the age and sex distribution of the July 1999 Medicare fee-for-service population.

• For Decubitus Ulcers, Postoperative Septicemia, Selected Infections due to Medical Care, and Postoperative Respiratory Failure, African-Americans tend to have the highest rates and Whites the lowest.

Dual eligibility is another source of variation for many of the Patient Safety Measures.

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3.7

2.8

7.5

11.8

23.6

0.8

1.5

2.9

2.4

2.5

4.1

9.2

17.8

31.0

1.6

1.6

3.2

1.2

2.5

4.4

12.2

33.8

1.0

1.3

2.3

2.5

2.8

5.2

12.1

26.3

54.6

2.9

24.2

2.94.1

0 10 20 30 40 50










Decubitus Ulcers


White Other Unknown African American

9


Figure II.5. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Dual Eligibility


• Decubitus Ulcers, Postoperative Septicemia, and Postoperative Respiratory Failure show striking differences by dual eligibility status, with dually eligible beneficiaries having roughly twice the rates of these outcomes as non-dually eligible ones.

• Dually eligible beneficiaries also have worse rates for Postoperative Abdominopelvic Wound Dehiscence, Selected Infections Due to Medical Care, and Postoperative Hip Fracture, although the differences are smaller.

1.4

2.3

1.7

3.4

2.9

3.4

7.2

11.8

22.5

2.0

2.4

2.4

4.6

3.8

5.7

12.7

44.0

1.1

22.0

1.0

0 5 10 15 20 25 30 35 40 45










Decubitus Ulcers


Not Dually Eligible Dually Eligible

10


Figure II.6. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Reason for Medicare Entitlement

NOTE: Results adjusted to the age and sex distribution of the reference population of the July 1999 Medicare fee-for-service population. For the two subgroups in which not all age groups are represented—Aged Only, which has no cases less than age 65, and Disabled Only, which has no cases over age 65—the rates have been further adjusted by dividing by the proportion in the reference population of those over and under age 65, respectively (see Appendix A).

• Beneficiaries with ESRD have much worse rates in all but Postoperative

Abdominopelvic Wound Dehiscence and the two hip fracture measures.

• Beneficiaries entitled to Medicare only by disablement tend to have the lowest rates, and aged beneficiaries tend to have intermediate rates.

1.2

2.2

4.0

4.2

2.3

13.4

2.9

2.2

29.1

16.5

0.8

0.5

1.6

4.4

2.2

8.0

3.7

1.1

20.9

14.8

1.5

1.7

2.4

2.5

4.1

17.5

19.4

19.6

45.6

50.7

0 10 20 30 40 50









Decubitus Ulcers


Events per 1,000 DischargesAged only Disabled only ESRD

11


Figure II.7. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Rural or Urban Residency


• Relative to rural beneficiaries, rates of Decubitus Ulcers are about 40 percent higher among urban beneficiaries.

• Rates of Postoperative Septicemia and Postoperative Respiratory Failure are slightly higher among urban beneficiaries.

0.9

1.2

1.7

3.6

2.4

2.4

3.8

7.3

12.2

21.4

1.1

1.5

1.9

3.5

2.3

3.6

3.6

8.1

14.0

29.5

0 5 10 15 20 25 30










Decubitus Ulcers


Rural Urban

12


Figure II.8. Rates of MQMS Patient Safety Measures for 2000 and 2001 Combined, by Region of the U.S.


0.1

0.2

1.1

1.3

2.0

3.3

2.2

3.6

3.8

6.9

11.4

30.7

0.1

0.2

1.0

1.3

1.7

3.5

2.4

3.0

4.0

7.5

12.0

23.7

0.1

0.3

1.0

1.5

1.9

3.6

2.4

3.2

3.7

9.4

16.2

28.8

0.1

0.3

1.1

1.4

1.7

3.8

2.5

3.4

3.3

6.0

11.0

25.3

0 5 10 15 20 25 30

Foreign Body Left in DuringProcedure

Anesthesia Reactions andComplications


Postoperative Physiologic orMetabolic Derangement

AHRQ Postoperative HipFracture



Selected Infections Due toMedical Care

Postoperative AbdominopelvicWound Dehiscence

Postoperative RespiratoryFailure


Decubitus Ulcers


Northeast Midwest South West

13


• There are regional differences for some of the measures, but there is no consistent pattern across the indicators. Compared to the West and the Midwest, rates of Decubitus Ulcers are higher in the South and Northeast. The South has somewhat higher rates of Postoperative Septicemia and Postoperative Respiratory Failure.

III. ADDITIONAL ANALYSES OF SELECTED PERI- AND POSTOPERATIVE MEASURES

The CMS MQMS Patient Safety Measure Workgroup also recommended simple additional analyses of selected peri- and postoperative measures in order to better understand these measures, and to provide additional support for their face validity. This section shows the frequencies of the constituent complications that make up two of the indicators—Anesthesia Complications and Reactions, and Postoperative Metabolic or Physiologic Derangements—that are constructed by combining several ICD-9-CM codes for specific complications.

In addition, this section also displays the frequencies of the principal procedures and DRGs associated with these two indicators, as well as the indicators Postoperative Hemorrhage or Hematoma, Postoperative Respiratory Failure, Postoperative Septicemia, and Postoperative Abdominal-pelvic Wound Dehiscence. Finally, the section displays the DRGs with the highest rates of the above indicators.

Anesthesia Complications and Reactions

Figure III.1. Frequency of Specific Complications Among Discharges with an Anesthetic Complication or Reaction (N=1,516)a

aThe number of anesthesia complications (1,516) is slightly larger than the number of discharges with anesthesia complications (1,512) because a few cases had more than one anesthesia complication.

48.9%

19.1%

9.4%

8.2%

5.4%

3.7%2.8%2.5%

Unspecified general anesthesics

Unspecified spinal anesthetics

Intravenous anesthetics

Peripheral nerve and plexus blocking agents

Non-halothane inhaled anestheticsc

Surface and infiltration anesthetics

Other and unspecified local anesthetics

Miscellaneous diagnoses

Adverse Effects of:

14


Figure III.2. Ten Most Frequent DRGs Among Discharges with Anesthesia Complications and Reactions (N=1,512)

• Among discharges with an Anesthetic Complication or Reaction, the most common complications were adverse effects from unspecified general anesthetics, unspecified spinal anesthetics, and intravenous anesthetics. Discharges with these three complications made up roughly 77 percent of all discharges with an anesthetic complication.

• Major Joint and Limb Reattachment Procedures of the Lower Extremity is the most common single DRG, representing 21 percent of the discharges with an anesthetic complication. The largest category (48 percent) is a mixed group of discharges that includes 721 discharges in 137 separate DRGs.

21.2%

6.0%

5.3%

3.9%

3.4%

3.0%2.7%

47.7%

1.9%2.4%

2.5%

Major joint and limb reattachment procedures oflower extremity

Hip and femur procedures except major joint, age>17, with complications or comorbidities

Major small and large bowel procedures withcomplications or comorbidities

Non-extensive operating room procedure unrelatedto the principal diagnosis

Extensive operating room procedure unrelated tothe principal diagnosis

Major chest procedures

Back and neck procedures except spinal fusion,with complications or comorbidities

Laparoscopic cholecystectomy without commonduct exploration. with complications orcomorbiditiesExtracranial vascular procedures

Other vascular procedures with complications orcomorbidities

Remaining DRGs

15


Figure III.3. DRGs with the Ten Highest Rates of Anesthetic Complications and Reactions, Among all Discharges Eligible for That Outcome

• There is a wide range in rates of anesthetic complications, with the highest rate (1.18

per 1,000 discharges) about nine times that of the lowest rate (0.13 per 1,000).

• A wide variety of DRGs are represented among those with the ten highest rates of anesthetic complications, including orthopedic surgeries (back and neck, major joint and limb, and hip and femur procedures), gastrointestinal surgeries (major small and large bowel procedures, laparoscopic cholecystectomy), thoracic surgeries (major chest procedures), and vascular surgeries (extracranial vascular, and other vascular procedures).

• DRGs 468 and 477 (extensive and non-extensive operative procedures unrelated to the principal diagnosis) both identify cases in which patients have undergone operating-room procedures unrelated to the principal diagnosis. Examples of DRG 468 include a patient admitted for pneumonia who suffers a fall and hip fracture, and undergoes hip repair, and a patient admitted for pancreatitis who develops a pulmonary embolus and undergoes interruption of the inferior vena cava.2 DRGs 468 and 477 thus include cases for which unplanned surgery may have been

2 CMS moved interruption of the vena cava out of DRG 468 in August 2002 (Federal

Register 2002), but the clinical scenario presented here would have been correctly coded as DRG 468 during 2000 and 2001, the period of the data used in this report.

0.14

0.17

0.20

0.31

0.34

0.38

0.44

0.45

0.56

0.65

1.18

0.00 0.20 0.40 0.60 0.80 1.00 1.20

Other vascular procedures with complicationsor comorbidities (478)

All other discharges/DRGs

Extracranial vascular procedures (005)

Major small and large bowel procedures withcomplications or comorbidities (148)

Laparoscopic cholecystectomy without commonduct exploration with complications or comorbidities (493)

Hip and femur procedures except major joint, age >17 with complications or comorbidities (210)

Extensive operating room procedure unrelated tothe principal diagnosis (468)

Major joint and limb reattachment procedures of the lower extremity (209)

Major chest procedures (075)

Back and neck procedures except spinalfusion with complications or comorbidities (499)

Non-extensive operating roomprocedure unrelated to the principal diagnosis (477)

Events per 1,000 Discharges in the DRG

16


required on short notice to treat an acute problem, and for which the risk of an anesthetic reaction or complication may be higher.3


Figure III.4. Frequency of Principal Procedures Among Discharges with a Postoperative Hemorrhage or Hematoma (N=14,891)

• Among discharges with a postoperative hemorrhage or hematoma, no one

procedure or group of procedures predominates. The single most common procedure (carotid endarterectomy) makes up only 10 percent of all discharges with this complication. The 64 percent labeled as “remaining dicharges/all other procedures” represents a large number of procedures, each representing less than 2 percent of the total.

3 There is some evidence from the joint QIO/CMS Payment Error Prevention Program

(PEPP), however, that the accuracy of hospital coding for DRGs 468 and 477 may be lower than for other DRGs (OMPRO 2003a; OMPRO 2003b; Healthcare Management Advisors 2003), mainly because of incorrect coding of the principal diagnosis. Thus, some of the operating room procedures under DRGs 468 and 477 may actually have been related to the true principal diagnoses.

10.0%

5.2%

5.0%

4.3%

2.8%

1.9%

1.8%1.8%

1.8%1.7%

63.8%

Carotid endarterectomy

Transurethral resection of prostate (TURP)

Vascular shunt and bypass

Excisional wound debridement

Revision of vascular procedure

Suture of artery

Laparoscopic cholecystectomy

Aortocoronary bypass-two coronary arteries

Aortocoronary bypass-three coronary arteries

Unilateral simple mastectomy with excision of regionalnodesRemaining discharges/all other procedures

17


Figure III.5. Frequency of DRGs Among Discharges with a Postoperative Hemorrhage or Hematoma (N=14,891)

• As with Figure III.3, there are no dominant DRGs, with the single most common

DRG (Other Vascular Procedures with Complications or Comorbidities) representing about 14 percent of all discharges with a postoperative hemorrhage or hematoma. A mixed group of DRGs, each representing 2 percent or less of the total, make up 48 percent of the total.

• Some of the procedures and types of admission in Figures III.4 and III.5 were also ones that Gawande et al. (1999), using 1992 data from two states, reported as having high rates of preventable postoperative bleeding—vascular surgery, TURP, coronary artery bypass grafting, colectomy, and cholecystectomy.

13.9%

10.0%

5.2%

4.6%

3.8%

3.2%

3.0%3.0%

2.9%2.4%

48.0%

Other vascular procedures with complications orcomorbiditiesExtracranial vascular procedures

Major cardiovascular procedures with complications orcomorbiditiesTURP with complications or comorbidities

OR procedure for infectious and parasitic disease

Major small and large bowel procedure with complicationsor comorbiditiesPermanent cardiac pacemaker without AMI, HF, or shock

CABG without PTCA or cardiac catheterization

CABG without cardiac catheterization

Cardiac valve procedures without cardiac catheterization

Remaining discharges

18


Figure III.6. Ten DRGs with the Highest Rates of Postoperative Hemorrhage or Hematoma, Among all Discharges Eligible for That Outcome

• The rate of postoperative hemorrhage or hematoma among discharges in the Liver

Transplant DRG (35.6 per 1,000 discharges) stands out. It is more than twice the next highest rate 14.9 per 1,000, for Kidney Transplant.

• The remaining nine DRGs, representing a variety of urological, gastrointestinal, and general surgical admissions, have rates of postoperative hemorrhage or hematoma that are roughly similar, ranging from 9 to 13 per 1,000 discharges.

1.9

8.7

9.6

9.7

9.7

9.8

10.5

11.2

13.3

14.9

35.6

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

All other eligible discharges/DRGs

Wound debridements for injuries (440)

Transurethral prostatectomy with complications or comorbidities (336)

Total mastectomy for malignancy with complications, comorbidities (257)

Other vascular procedures with complications or comorbidities (478)

Minor bladder procedures with complications or comorbidities (308)

Other hepatobiliary or pancreas operating room procedures (201)

Sialoadenectomy (50)

Skin graft and/or debridement except for skin ulcer or cellulitis with complications orcomorbidities (265)

Kidney transplant (302)

Liver transplant (480)

Rate of events, per 1,000 discharges with the DRG

19


Postoperative Physiologic or Metabolic Derangement

Figure III.7. Frequency of Specific Complications Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,272)a

aThe number of postoperative metabolic and physiologic complications (4,272) is somewhat larger than the number of discharges with a postoperative metabolic and physiologic derangements (4,199) because some cases had more than one postoperative metabolic or physiologic derangement.

• Ninety percent of the complications in this measure, which includes both acute

renal failure and acute crises from uncontrolled diabetes, are, in fact, due to acute renal failure (58 percent from nonspecific acute renal failure and 32 percent from acute tubular necrosis). Nearly all of the remaining ten percent of the cases are postoperative metabolic derangements from diabetes.

57.5%

31.5%

4.9%

3.9%1.3%

Unspecified/classified acute renal failure

Acute tubular necrosis

Type I diabetes with ketoacidosis

Type II diabetes with ketoacidosis

Type II diabetes with hyperosmolar nonketotic state

Type I diabetes with other coma (diabetic ketoacidotic,hypoglycemic)Type II DM with other coma (diabetic ketoacidotic,hypoglycemic)Type I diabetes with hyperosmolar state

Acute papillary necrosis

20


Figure III.8. Frequency of Principal Procedures Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,199)

• The single most common procedure is kidney transplant, representing 14 percent of

discharges with a postoperative physiologic or metabolic derangement. All other procedures each represent about 6 percent or less of the total, with 58 percent of the total made up of procedures that represent 2 percent each.

• Some of the procedures could possibly be therapeutic in response to renal failure or damage, such as kidney transplant, creation of arteriovenous fistula for hemodialysis, and nephroureterectomy, rather than procedures that preceded and caused the complication. However, some of the same procedures could also be causative (such as renal dysfunction following transplantion of a kidney, or operative complications following nephroureterectomy).

• Other procedures seem more likely to be causative, such as those associated with hemodynamic instability, blood loss, or radiographic contrast administration (resection of abdominal aortic aneurysm, angioplasty or atherectomy of non-coronary vessel, other peripheral vascular shunt or bypass, aortocoronary bypass-3 vessels, and total knee replacement)

• Finally, some procedures may be markers for underlying severity of illness-- temporary tracheostomy for prolonged ventilatory dependence and ICU stay, and excisional wound debridement for severe trauma, burns, or soft tissue infection.

4.7%

2.5%

2.2%

2.1%2.0%

2.0%1.9%

5.3%

5.6%

14.2%

57.6%

Kidney transplantResection of abdominal aortic aneurysmCreation of arterio-venous fistula for dialysisTemporary tracheostomyAngioplasty or atherectomy of non-coronary vesselOther peripheral vascular shunt or bypassAortocoronary bypass-3 vesselsExcisional wound debridementNephroureterectomyTotal knee replacementRemaining discharges/all other procedures

21


Figure III.9. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with a Postoperative Physiologic or Metabolic Derangement (N=4,199)

• No single DRG or small group of DRGs predominates. The DRGs may represent

a mixture of discharges for therapy for renal failure, discharges for procedures with a high risk of renal failure, and discharges that are markers for underlying conditions that have a high risk of renal failure.

14.0%

9.2%

6.7%

5.2%

4.8%

4.0%4.0%3.9%3.2%

3.2%

41.8%

Kidney transplant

Major cardiovascular procedures with complications orcomorbiditiesTracheostomy except for face, mouth, and neck diagnoses

Other vascular procedures with complications orcomorbiditiesOther kidney and urinary tract operating room procedures

Cardiac valve and other major cardiothoracic procedureswithout cardiac catheterizationCoronary bypass without PTCA or cardiac catheterization

Extensive operating room procedure unrelated to principaldiagnosisMajor small and large bowel procedures with complicationsor comorbiditiesOther circulatory system operating room procedures

Remaining discharges/all other DRGs

22


Figure III.10. DRGs with the Ten Highest Rates of Postoperative Physiologic or Metabolic Derangement, Among all Discharges Eligible for That Outcome

• Kidney transplant is the DRG with the highest rate by far of postoperative physiologic or metabolic derangement, with a rate (about 80 per 1,000 discharges) that is about 4 times higher than the next highest rate (19 per 1,000 for tracheostomy, and 10 to 20 times higher than the other rates.

• Tracheostomy, Except for Face, Mouth and Neck Diagnoses, the DRG with the next highest rate, again is likely a marker for underlying prolonged ventilatory dependence and critical illness. This DRG is often used for patients requiring prolonged mechanical ventilation and a protracted ICU stay. These critically ill patients are often susceptible to renal and metabolic problems.

• The remaining DRGs have rates in the 4 to 7 per 1,000 range and appear to represent discharges for conditions with a high risk of acute renal failure.

0.7

4.3

5.9

6.9

6.9

7.0

7.1

7.3

7.4

19.4

80.2

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

All other

Pancreas, liver & shunt procedures w cc

Other circulatory system O.R.procedures

Other kidney & urinary tract O.R.procedures

Kidney,ureter & major bladder proc fornon-neopl w cc

Extensive O.R. procedure unrelated toprincipal diagnosis

O.R. procedure for infectious & parasiticdisease

Other cardiothoracic procedures

Major cardiovascular procedures w cc

Tracheostomy except for face, mouth &neck diagnoses

Kidney transplant


23



Figure III.11. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with Postoperative Respiratory Failure (N=18,087)

• The most common DRG among discharges with postoperative respiratory failure is

Tracheostomy, Except for Face, Mouth, and Neck Diagnoses (DRG 483) representing about a third of the total. These procedures might be in response to (and not necessarily a cause of) prolonged respiratory failure and ventilator dependence. As mentioned before, the DRG may be susceptible to hospital coding error.

• The remaining DRGs are major procedures for which postoperative respiratory failure could be a possible complication.

32.1%

10.7%

5.6%4.5%

4.1%2.8%

2.6%

2.3%

2.2%

2.0%

31.0%

Tracheostomy, except for face, mouth, and neck diagnoses

Major small and large bowel procedures with complicationsor comorbiditiesMajor joint and limb reattachment procedures

Stomach, esophageal, & duodenal procedures age >17with complications or comorbiditiesExtensive operating room procedure unrelated to principaldiagnosisExtracranial vascular procedures

Operating room procedure for infectious and parasiticdiseasesKidney, ureter and major bladder procedures for neoplasm

Craniotomy age >17, except for trauma

Spinal fusion except cervical, with complications orcomorbiditiesRemaining discharges/all other DRGs

24


Figure III.12. DRGs with the Ten Highest Rates of Postoperative Respiratory Failure, Among all Discharges Eligible for That Outcome

• Once again, tracheostomy except for face, mouth, and neck diagnoses

(tracheostomy for respiratory failure) is the DRG with a much higher rate than the others (10 to 20 times higher than the other DRGs).

• Most of the other DRGs are conditions for which postoperative respiratory failure seems to be a clinically plausible complication of care.

4.3

21.1

22.3

23.8

31.3

31.7

34.5

36.4

38.2

42.3

396.8

0 50 100 150 200 250 300 350 400


Craniotomy for trauma age >17 (002)

Tracheostomy with face, mouth, and neck diagnoses (482)

Myeloproliferative disorder or poorly differentiatedneoplasm with major operating room procedure with

complications or comorbidities (406)

Other digestive system operating room procedure with complications orcomorbidities (170)

Pancreas, liver and shunt procedure with complications or comorbidities(191)

Operating room procedure for infectious andparasitic disease (415)

Extensive operating room procedure unrelated to principal diagnosis(468)

Stomach, esophageal and duodenal procedure age >17 withcomplications or comorbidities (154)

Bone Marrow Transplant (481)

Tracheostomy except for face, mouth, and neck diagnoses (483)


25



Figure III.13. Frequency of Specific Septicemia Diagnoses Among Discharges with Postoperative Septicemia (N=14,393)

aThe number of postoperative septicemia complications (14,393) is somewhat larger than the number of discharges with postoperative septicemia (14,069) because some cases had more than one postoperative septicemia complication. • Nearly half of discharges with postoperative septicemia were coded as nonspecific

septicemia.

• Thirty-five percent of all discharges with postoperative septicemia, or about three-quarters of cases with a specified bacterial organism, are coded as due to gram positive organisms (staphylococci, streptococci, or pneumococci).

• About 12 percent of all discharges with postoperative septicemia, or about one quarter of cases with a specified bacterial organism, are coded as due to gram negative organisms (gram-negative, E.Coli, Pseudomonas, and Serratia species).

• Using hospital discharge abstract data from 2000 to study all cases of hospital sepsis (not just postoperative cases) Martin et al. (2003) found gram-positive bacteria to be the predominant organisms, representing slightly over half of cases with an identified pathogen. Gram-negative bacteria accounted for 38 percent of cases with an identified pathogen.

• Martin et al. (2003) validated a small sample of cases with a diagnosis of sepsis in hospital discharge abstract data against medical record data. They found the discharge diagnosis to be a reasonably accurate way of identifying cases with chart confirmed sepsis. Martin et al.’s results on the accuracy of a discharge diagnosis of sepsis are also similar to earlier studies.

47.6%

17.0%

11.3%

6.1%

5.6%

5.0%

2.7%2.5%

Unspecified septicemiaS. aureus septicemiaUnclassified or unspecified staphylococcal septicemiaStreptococcal septicemiaUnclassified or unspecified gram-negative septicemiaUnclassified septicemiaE coli septicemiaPseudomonas septicemiaSerratia septicemiaAnaerobic septicemiaPneumococcal septicemiaH. influenzae septicemia

26


Figure III.14. Frequency of Principal Procedures Among Discharges with Postoperative Septicemia (N=14,069)

• The most common procedure among patients discharged with postoperative

septicemia was a temporary tracheostomy. Again, these procedures most likely were for management of prolonged ventilator dependence, and not necessarily a causative factor in the development of the septicemia.

11.0%

5.6%

3.8%

3.4%

2.7%

2.2%

2.1%

1.9%

1.8%1.7%

63.8%

Temporary tracheostomy

Excisional wound debridement

Above knee amputation

Below knee amputatation

Resection of abdominal aortic aneursym with graft

Revision of previous vascular anastomosis of blood vesselvascular procedure or declotting of graftOther permament tracheostomy

Creation of peripheral arteriovenous fistula for dialysis

Peripheral vascular shunt or bypass

Partial small bowel resection

Remaining discharges/all other procedures

x

27


Figure III.15. Frequency of Diagnosis Related Groups (DRGs) Among Discharges with Postoperative Septicemia (N=14,069)

• Major vascular and abdominal surgeries are heavily represented among these DRGs, and it seems clinically plausible that postoperative septicemia could complicate these procedures.

• DRG 468 (extensive operating procedure unrelated to principal diagnosis) and DRG 483 (tracheostomy except for face, mouth, and neck diagnoses) appear again (see Figures III.2 and III.3, III.9 and III.10, and III.11 and III.12). They may represent cases requiring unexpected surgeries for severe, acute problems, or with prolonged respiratory failure and ICU stays, both of which increase the risk for septicemia.

15.9%

7.0%

6.9%

6.3%

5.4%

4.6%4.4%3.1%

2.6%2.6%

41.1%

Tracheostomy except for face, mouth, and neck diagnoses

Amputation for circulatory system disorders except underupper limb and toeMajor small and large bowel procedures with complicationsor comorbiditiesOther vascular procedures with complications orcomorbiditiesMajor cardiovascular procedures with complications orcomorbiditiesOther circulatory system operating room procedures

Extensive operating room procedure unrelated to principaldiagnosisMajor joint and limb reattachment procedures

Cardiac valve procedures without cardiac catheterization

Skin graft and/or debridement for skin ulcer or cellulitis withcomplications or comorbiditiesRemaining cases/all other DRGs

28


Figure III.16. DRGs with the Ten Highest Rates of Postoperative Septicemia, Among all Discharges Eligible for That Outcome

• DRG 483 (Tracheostomy Except for Face, Mouth, or Neck Diagnoses--see Figure III.10) has the highest rate of postoperative septicemia by far. As discussed earlier, these likely represent persons with prolonged ventilatory failure and ICU stays, who are prone to septicemia.

Rate of events, per 1,000

9.0

40.5

41.8

42.0

44.0

44.2

49.2

54.9

69.1

78.4

209.8

0.0 50.0 100.0 150.0 200.0 250.0


Biliary tract procedure except only cholecystectomy with or without common ductexploration with complications or comorbidities (193)

Other digestive system operating room procedures with complications or comorbidities(170)

Amputation for circulatory system disorders except upper limb and toe (113)

Transurethral procedures with complications or comorbidities (310)

Cardiac pacemaker revision except device replacement (117)

Pancreas, liver, and shunt procedures with complications or comorbidities (191)

Extensive operating room procedure unrelated to principal diagnosis (468)

Other circulatory system operating room procedures (120)

Knee procedures with principal diagnosis of infection with complications or comorbidities(501)

Tracheostomy except for face, mouth and neck diagnoses (483)

Events per 1,000 Discharges in the DRG

29


Postoperative Wound Dehiscence

Figure III.17. Frequency of Principal Procedures Among Discharges with Postoperative Wound Dehiscence (N=4,201)

• The most common procedures include several major gastrointestinal and abdominal surgeries. Gawande et al. (1999), using data from 1992 from two states, also found high rates of preventable technical wound complications among discharges for abdominal aortic aneurysm repair, colon resection, cholecystectomy, and hysterectomy.

9.8%

9.6%

6.0%

5.0%

4.6%

4.2%

3.6%

3.1%3.0%2.5%

48.5%

SigmoidectomyRight hemicolectomyPartial small bowel resectionResection of abdominal aortic aneurysmOther peritoneal adhesiolysisLeft hemicolectomyTemporary tracheostomyRadical cystectomyTotal abdominal hysterectomyCholecystectomyRemaining discharges/all other procedures

R E F E R E N C E S

Agency for Health Care Research and Quality. “Changes to Indicator Definitions Before Software Release.” March 13, 2003”, [http://www.qualityindicators.ahrq.gov/downloads/pub/psi/psi_indicator_changes_March2003.pdf], accessibility verified July 8, 2003.

Agency for Health Care Research and Quality. “Log of Changes to the Guide and Software.” May 28, 2003. [http://www.qualityindicators.ahrq.gov/downloads/pub/psi/psi_log_May2003.pdf], accessibility verified July 8, 2003.

Agency for Healthcare Research and Quality. "Quality Indicator Publications and References." [http://www.qualityindicators.ahrq.gov/data/hcup/qireferences.htm], accessed April 21, 2003.

Agency for Healthcare Research and Quality. “Measures of Patient Safety Based on Hospital Administrative Data: The Patient Safety Indicators.” [http://www.ahrq.gov/clinic/psindinv.htm] Accessed January 13, 2003.

Agency for Healthcare Research and Quality. “State Inpatient Databases (SID): Powerful Databases for Analyzing Hospital Care.” [http://www.ahrq.gov/data/hcup/hcupsid.htm], accessed December 9, 2002.

Bates DW, K Pruess, P Souney, R Platt. “Serious Falls in Hospitalized Patients: Correlates and Resource Utilization.” American Journal of Medicine, 1995; vol. 99: pp 137-143.

Clarke M. and H.M. Kadhom. “The Nursing Prevention of Pressure Sores in Hospital and Community Patients.” Journal of Advanced Nursing, vol. 13, no. 3, May 1988, pp. 365-373.

Cummings, Steven R. and L. Joseph Melton III. "Epidemiology and Outcomes of Osteoporotic Fractures." Lancet, vol. 359, May 18, 2002, pp. 1761-1767.

Federal Register, “Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2003 Rates; Final Rule.” vol. 67, no. 148, August 1, 2002, pp. 49999-50001.

32

Gawande, Atul A., David M. Studderts, E. John Orav, Troyen A. Brennan, and Michael J. Zinner. “Risk Factors for Retained Instruments and Sponges after Surgery.” The New England Journal of Medicine, vol. 348; no. 3, January 16, 2003, pp. 229-35.

Gawande, Atul A., Eric J. Thomas, Michael J. Zinner, and Troyen A. Brennan. “The Incidence and Nature of Surgical Adverse Events in Colorado and Utah.” Surgery, vol. 126, no. 1, July 1999, pp. 66-75.

Gerson L.W. “The Incidence of Pressure Sores in Active Treatment Hospitals.” International Journal of Nursing Studies, vol. 12, no. 4, 1975, pp. 201-204.

Healthcare Management Advisors. “HMA’s PEPP Resource Center.” [http://www.hma.com/Articles/peppmain.htm], accessibility verified July 8, 2003.

Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson, Editors. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, Washington, D.C., 2000.

Martin, Greg S., David M. Mannino, Stephanie Eaton, and Marc Moss. "The Epidemiology of Sepsis in the United States from 1979 Through 2000." The New England Journal of Medicine. vol. 348, no. 16, April 17, 2003, pp. 1546-1554.

McDonald Kathryn M., Patrick S. Romano, Jeffrey Geppert, Sheryl M. Davies, Bradford W. Duncan, Kaveh G. Shojania, and Angela Hansen. “Measures of Patient Safety Based on Hospital Administrative Data: The Patient Safety Indicators.” Technical Review 5, AHRQ Publication No. 02-0038 . Rockville, MD: Agency for Healthcare Research and Quality, August 2002.

Morgan VT, Mathison JH, Rice JC, Clemmer DI. “Hospital Falls: A Persistent Problem.” American Journal of Public Health, vol. 75, 1985, pp. 775-777.

OMPRO. “DRG Validation Project, Year Two (2001) Coding Accuracy.” [http://www.ompro.org/downloads/PEPP_downloads/DRG02report.pdf], accessibility verified July 8, 2003.

OMPRO. “DRG Validation Project. Coding Tips: DRGs 468/477.” [http://www.ompro.org/downloads/PEPP_downloads/DRG468.doc], accessibility verified July 8, 2003.

Romano, Patrick S., Jeffrey J. Geppert, Sheryl Davies, Marlene R. Miller, Anne Elilxhauser, and Kathryn M. McDonald. "A National Profile of Patient Safety in U.S. Hospitals." Health Affairs, vol. 22, no. 2, March/April 2003, pp 154-166.

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A P P E N D I X A

M Q M S P A T I E N T S A F E T Y M E A S U R E S

S P E C I F I C A T I O N S A N D M E T H O D S

A-3

Appendix A: MQMS Patient Safety Measure Specifications and Methods

The MQMS Patient Safety Measures are a subset of the Patient Safety Indicators (PSIs) developed by Stanford University and AHRQ (McDonald et al. 2002). A CMS MQMS Patient Safety Measure workgroup (including several clinicians) reviewed the 20 PSIs and selected 12 on the basis of face validity and relevance to Medicare beneficiaries. The panel’s reasons for not selecting the other eight PSIs are listed in Table A.1 The panel felt, however, that some of the PSI measures not included this year might be appropriate for future MQMS Patient Safety reports after additional analysis.

A ninth PSI, Transfusion Reaction, was ultimately also not included in the MQMS Patient Safety Report because the number of events was too small. There were only 115 discharges with this indicator among 22,100,608 discharges in 2000 and 2001, for a rate of 0.005 events per 1,000 discharges.

CMS panelists also recommended a number of additional analyses. One of the these was the creation of a modified version of the AHRQ postoperative hip fracture indicator that would eliminate most of the exclusions of the original AHRQ indicator. The CMS panelists’ discussed many of the same issues as had the Stanford/AHRQ panelists (AHRQ 2002)—whether medical discharges should be included, whether some in-hospital falls and hip fractures are truly non-preventable, and whether patients at higher risk for hip fracture should be excluded.

The consensus of the CMS panelists was that patients with higher risks for hip fracture should prompt increased vigilance by hospital staff and should therefore not be excluded. They also felt the cost of including “false-positive” cases by not excluding medical discharges and cases that may have had a fracture on admission was worth the gain of identifying additional cases of in-hospital fracture. A new MQMS Inpatient Hip Fracture measure was therefore constructed, in which the following discharges excluded by the original AHRQ indicator were now included—[medical discharges], discharges in the major diagnostic category of musculoskeletal and connective tissue disease (MDC 8), and discharges with principal diagnoses codes for [seizure], [syncope], [coma], [cardiac arrest], [poisoning], [trauma], [delirium and other psychoses], [anoxic brain injury], [metastatic cancer], [lymphoid malignancy], [bone malignancy], and [self-inflicted injury].4

The CMS panelists also wished to see the component diagnoses, procedures, and types of admissions that made up several of the postoperative indicators. The recommended pie charts and frequency counts are presented in Section III of the body of the report and in Tables B.9 through B.25 in Appendix B.

The MQMS Patient Safety Measures calculated in this report are based on the "hospital-level" PSIs developed by the Stanford/AHRQ researchers (as opposed to the six “area-level” PSIs that they also developed).5 Hospital-level PSIs use only complications listed in the secondary diagnosis

4 Items in bold and brackets are specified in the ICD-9-CM and DRG listings in the back of this Appendix.

5 The six Stanford/AHRQ area-level PSIs are: (1) Foreign Body Left in During Procedure, (2) Iatrogenic Pneumothorax, (3) Infection due to Medical Care, (4) Accidental Puncture or Laceration (one of the Stanford/AHRQ PSIs not included among the MQMS Patient Safety Measures--see below), (5) Transfusion Reaction, and (6) Postoperative Wound Dehiscence.

A-4 _______________________________________________________________________


codes, and are thus meant to capture adverse events that occur during the same hospital stay. Area-level PSIs use exactly the same ICD-9-CM codes as the hospital-level PSIs, but include complications listed in any coding position (including the principal diagnosis code). They are thus meant to also capture hospitalizations for complications resulting either from care received during a previous hospital stay but not detected until after discharge, or to care received in the outpatient setting. Future MQMS Patient Safety reports may include area-level measures.

A-5


Table A.1. Stanford/AHRQ PSIs Not Included in the Current MQMS Patient Safety Report Name of Stanford AHRQ/PSI Consensus of CMS MQMS Patient Safety

Measure Workgroup Death in Low Mortality Diagnosis Related Groups (DRGs)

The low mortality DRGs were identified through AHRQ's HCUP data, which include many non-Medicare patients. Work group members recommended redefining the low mortality DRGs based on Medicare data, after which this measure might be appropriate to include in future MQMS Patient Safety reports.

Failure to Rescue The workgroup members were uncertain about the face validity of this measure, and noted that the AHRQ panelists had similar concerns. Like the AHRQ panelists, the CMS workgroup members also worried that temporal and regional practice variations in the use of DNR orders might bias results. Furthermore, AHRQ recently recommended excluding patients over age 75 from this measure (AHRQ 2003).

Accidental Puncture or Laceration The workgroup members were concerned about the face validity and specificity (false-positive rate) of this measure. They felt that coding for this complication varies widely between surgeons, and that many identified cases would probably have no problem with patient safety.

Postoperative Pulmonary Embolism or Deep Venous Thrombosis

The workgroup members were concerned about the sensitivity (false negative rate) of this outcome, as well as bias from temporal and regional variations in hospital length of stay. The workgroup suggested exploring a 30-day version or area-level version of this measure, for possible inclusion in future versions of the MQMS Patient Safety report.

Birth Trauma—Injury to Neonate Obstetric and neonatal care are not relevant to the vast majority of Medicare beneficiaries.

Obstetric Trauma—Cesarean Delivery Same as above

Obstetric Trauma—Vaginal Delivery With Instrument

Same as above

Obstetric Trauma—Vaginal Delivery With out Instrument

Same as above

A-6 _______________________________________________________________________


NOTE: The Stanford/AHRQ PSI Transfusion Reactions was also not included in the MQMS Patient Safety Report because there were too few events. There were 115 cases among 22,100,608 discharges in 2000 and 2001, for a rate of 0.005 events per 1,000 discharges.

A-7


The following tables describe the specifications of the 12 Patient Safety Measures included in this report. Bold terms in square brackets (for example, [surgical] discharges) refer to specified sets of ICD-9-CM or DRG codes in the large list of codes in the back of this appendix.

Table A.2 Specifications for MQMS Patient Safety Measures (from McDonald et al. 2002)

Patient Safety Measure 1. Anesthesia Reactions and Complications.

Rationale This measure includes adverse reactions to anesthetic drugs and misplacement of breathing tubes (endotracheal tubes) for general anesthesia. High rates of such events may indicate problems with unsafe care.

Population Beneficiaries eligible for Medicare in January of calendar years 2000 and 2001, enrolled in Part A for the full year, and not enrolled in Medicare managed care at any point in the year. Beneficiaries who died during either calendar year but who would have otherwise qualified are included.

Computation Numerator: Discharges with ICD-9-CM diagnosis codes for [anesthesia complications] in any secondary diagnosis field.

Denominator: All [surgical] discharges. Rates are expressed in events per 1,000 discharges.

Data Sources MedPAR File Denominator File CMS Cross-Reference File

Exclusions Missing or invalid values for state, sex, race, Medicare Status

Discharges from all hospitals other than short-stay hospitals

Duplicate records

Discharges from stand-alone emergency rooms

Discharges with invalid procedure codes

Discharges for Medicare beneficiaries whose Health Insurance Claim Number (HICNO) does not have a match in CMS’s Cross-Reference File

Overlapping beneficiary acute-care, short-stay hospital claims

Discharges with codes for poisoning due to anesthetics [E855.1, 968.1-4, 968.7] AND any diagnosis code for [active drug dependence], [active nondependent abuse of drugs], or [self- inflicted injury]

Adjustment For subgroup comparisons, rates are age/sex adjusted using 18 age/sex groups and the Medicare Part A FFS population as of July 1, 1999 as the standard population. There are two subgroups that are missing some of the age groups-Aged Only, which has no cases less than age 65, and Disabled Only, which has no cases over age 65. Applying weights from the standard population to these subgroups would result in misleadingly low rates, since the weights to not add up to one because of the missing age cells. The rates of these two subgroups have been “reinflated” by dividing by the proportions in the standard population of the corresponding age groups. Thus, age-sex adjusted rates for the Aged Only subgroup have been divided by the proportion of those over age 65 in the standard population (0.8453), and age-sex adjusted rates for the Disabled Only subgroup have been divided by the proportion of those under age 65 (0.1547).

Period 2000-2001

Stratifiers Age (0-54, 55-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94,95+) on July 1 of the reference year.

Race (white, black, other)

A-8 _______________________________________________________________________


Sex

Reason for Medicare eligibility (aged, disabled, and ESRD. The categories aged with ESRD, disabled with ESRD, and ESRD only are grouped together as “ESRD”)

Dual enrollment defined as enrolled in Medicare Part A and with Medicaid buy-in at least one month during the calendar year.*

Urban/rural based on the metropolitan statistical area (MSA) and Bureau of Economic Analysis (BEA) State and County Crosswalk File developed for the CMS’ Prospective Payment System. All counties in an MSA are designated as urban; all other counties are considered rural.

Census region of the beneficiary’s residence on March 31 of the year following the reference year

Census division of the beneficiary’s residence on March 31 of the year following the reference year

State of the beneficiary’s residence on March 31of the year following the reference year

* The Medicare data do not record true dual enrollment status but only whether a state Medicaid program pays the beneficiary’s Medicare premiums, co-pays, and deductibles. The payment of these Medicare expenses by Medicaid does not always translate into full Medicaid coverage. Nevertheless, the buy-in indicator in the Medicare data is a reasonably accurate indicator of beneficiary poverty.

A-9


Patient Safety Measure 2. Decubitus Ulcers

Rationale Decubitus ulcers, also known as pressure ulcers or “bedsores” can be prevented through good nursing and medical care.


Computation Numerator: Discharges with ICD-9-CM code of 707.0 in any secondary diagnosis field. Denominator: All [medical] and [surgical] discharges with a length of stay of more than 4 days. Rates are expressed in events per 1,000 discharges.




Duplicate records





Discharges in MDC 9 or with any diagnosis of [hemiplegia, paraplegia, or quadriplegia].

Patients admitted from a [long term care facility].


Period 2000-2001

Stratifiers Age (0-54, 55-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94, 95+) on July 1 of the reference year.


Sex


A-10 ______________________________________________________________________








A-11


Patient Safety Measure 3. Foreign Body Left In During Procedure

Rationale The accidental leaving behind of medical equipment or objects following a procedure should virtually never occur.


Computation Numerator: Discharges with ICD-9-CM codes for [foreign body left in during procedure] in any secondary diagnosis field.

Denominator: All [medical] and [surgical] discharges. Rates are expressed in events per 1,000 discharges.




Duplicate records






Period 2000-2001



Sex



Urban/rural based on the metropolitan statistical area (MSA) and Bureau of

A-12 ______________________________________________________________________


Economic Analysis (BEA) State and County Crosswalk File developed for the CMS’ Prospective Payment System. All counties in an MSA are designated as urban; all other counties are considered rural.





A-13


Patient Safety Measure 4. Iatrogenic Pneumothorax

Rationale Iatrogenic Pneumothorax means accidental lung puncture (pneumothorax) from medical care (iatrogenic). Most cases of iatrogenic pneumothorax occur during the insertion of intravenous catheters into the great veins of the heart through the neck area. High rates may indicate problems with care.


Computation Numerator: Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field.



Exclusions Discharges with any diagnosis of [trauma]

Discharges with any code indicating [thoracic surgery] or [lung or pleural biopsy] or [cardiac surgery].

Missing or invalid values for state, sex, race, Medicare Status


Duplicate records






Period 2000-2001



Sex

Reason for Medicare eligibility (aged, disabled, and ESRD. The categories aged with ESRD, disabled with ESRD, and ESRD only are grouped together as

A-14 ______________________________________________________________________


“ESRD”)







A-15


Patient Safety Measure 5. Selected Infections Due to Medical Care

Rationale This measure includes infections due to indwelling medical devices such as catheters. Such infections can be prevented with good medical care and surveillance.


Computation Numerator: Discharges with ICD-9-CM code of 999.3 or 996.62 in any secondary diagnosis field.



Exclusions Discharges with any diagnosis code for [immunocompromised] state or [cancer].



Duplicate records






Period 2000-2001



Sex

Reason for Medicare eligibility (aged, disabled, ESRD, aged with ESRD, disabled with ESRD).


A-16 ______________________________________________________________________







A-17


Patient Safety Measure 6. Postoperative Hemorrhage or Hematoma

Rationale High rates of severe bleeding (hemorrhage) or large collections of blood in the body (hematoma) following surgery may indicate problems with care.


Computation Numerator: Discharges with ICD-9-CM codes for [postoperative hemorrhage] or [postoperative hematoma] in any secondary diagnosis field AND code for postoperative [control of hemorrhage] or [drainage of hematoma] in any secondary procedure code field, among surgical discharges. Procedure code for postoperative control of hemorrhage or hematoma must occur on the same day or after the principal procedure.



Exclusions All obstetric admissions (MDC 14 and 15)



Duplicate records






Period 2000-2001



Sex

Reason for Medicare eligibility (aged, disabled, ESRD, aged with ESRD, disabled

A-18 ______________________________________________________________________


with ESRD).







A-19


Patient Safety Measure 7. Postoperative Hip Fracture

Rationale Elderly patients are prone to confusion and agitation following anesthesia and surgery. Good nursing and medical care can prevent injuries from such problems. A high rate of accidental falls with severe injury (hip fracture) after surgery may indicate problems with care.


Computation Numerator: Discharges with ICD-9-CM code for [hip fracture] in any secondary diagnosis among surgical discharges.



Exclusions Patients who have musculoskeletal and connective tissue diseases (MDC 8).

Patients with principal diagnosis codes for [seizure], [syncope], [stroke], [coma], [cardiac arrest], [poisoning], [trauma], [delirium and other psychoses], or [anoxic brain injury].

Patients with any diagnosis of [metastatic cancer], [lymphoid malignancy] or [bone malignancy], [self-inflicted injury].

Patients 17 years of age and younger.



Duplicate records






Period 2000-2001

Stratifiers Age (0-54, 55-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94, 95+) on July 1 of the

A-20 ______________________________________________________________________


reference year.


Sex








A-21


Patient Safety Measure 8. MQMS Inpatient Hip Fracture

Rationale Elderly patients are prone to confusion and agitation during hospitalization. Good nursing and medical care can prevent injuries from such problems. A high rate of accidental falls with severe injury (hip fracture) may indicate problems with care.


Computation Numerator: Discharges with ICD-9-CM code for [hip fracture] in any secondary diagnosis.

Denominator: All [medical] and [surgical] discharges. Rates are expressed in events per 1,000 discharges


Exclusions Patients 17 years of age and younger.



Duplicate records






Period 2000-2001

A-22 ______________________________________________________________________




Sex








A-23


Patient Safety Measure 9. Postoperative Metabolic or Physiologic Derangement

Rationale The measure includes the development of uncontrolled diabetes or acute kidney failure following elective surgeries. High rates of such events may indicate problems with care.


Computation Numerator: Discharges with ICD-9-CM codes for [physiologic and metabolic derangements] in any secondary diagnosis field among surgical discharges. Discharges with acute renal failure (subgroup of [physiologic and metabolic derangements]) must be accompanied by a procedure code for dialysis (39.95, 54.98).

Denominator: All [elective] [surgical] discharges. Rates are expressed in events per 1,000 discharges.


Exclusions Patients with both a diagnosis code of ketoacidosis, hyperosmolarity or other coma (subgroups of physiologic and metabolic derangements coding) AND a principal diagnosis of [diabetes].

Patients with both a secondary diagnosis code for acute renal failure (subgroup of [physiologic and metabolic derangements] coding) AND a principal diagnosis of [acute myocardial infarction], [cardiac arrhythmia], [cardiac arrest], [shock], [hemorrhage] or [gastrointestinal hemorrhage].

All obstetric admissions (MDC 14 and 15).



Duplicate records






A-24 ______________________________________________________________________


Period 2000-2001



Sex








A-25


Patient Safety Measure 10. Postoperative Respiratory Failure

Rationale This measure includes the acute development of the inability to breathe or the failure of lung function (such as requiring a mechanical ventilator) following elective surgeries. High rates of such events may indicate problems of care.


Computation Numerator: Discharges with ICD-9-CM codes for acute respiratory failure (518.81 or 518.84) in any secondary diagnosis field among surgical discharges..



Exclusions Patients with respiratory or circulatory diseases (MDC 4 and MDC 5).

All obstetric admissions (MDC 14 and 15)



Duplicate records






Period 2000-2001

Stratifiers Age (0-54, 55-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94,95+) on July 1 of the reference year.


Sex


Dual enrollment defined as enrolled in Medicare Part A and with Medicaid buy-in

A-26 ______________________________________________________________________


at least one month during the calendar year.*






A-27


Patient Safety Measure 11. Postoperative Septicemia

Rationale High rates of severe or overwhelming infection (septicemia) following elective surgeries may indicate problems of care.


Computation Numerator: Discharges with ICD-9-CM code for [sepsis] in any secondary diagnosis field among population at risk.



Exclusions Patients with a principal diagnosis of [infection], or any code for [immunocompromised] state, or [cancer].

Patients with a length of stay of three days or less.

All obstetric admissions (MDC 14 and 15).



Duplicate records






Period 2000-2001



Sex

Reason for Medicare eligibility (aged, disabled, ESRD, aged with ESRD, disabled

A-28 ______________________________________________________________________


with ESRD).







A-29


Patient Safety Measure 12. Postoperative Wound Dehiscence

Rationale This measure include the reopening or splitting apart of surgical wounds following surgery on the abdomen or pelvis. A high rate of such events may indicate a problem with care.


Computation Numerator: Discharges with ICD-9-CM codes for reclosure of postoperative disruption of abdominal wall (54.61) in any secondary procedure field.

Denominator: All [abdominopelvic] surgical discharges. Rates are expressed in events per 1,000 discharges.



All obstetric admissions (MDC14 and 15).


Duplicate records






Period 2000-2001



Sex



A-30 ______________________________________________________________________







A

ppendix A: Patient M

easure Safety Specifications and Methods

Lists of ICD-9-CM and DRG Codes Used to Define the Following Terms in Specifications for Patient Safety Measures (from McDonald et al. 2002) Abdominopelvic Active drug dependence Active nondependent abuse of drugs Acute myocardial infarction Anesthesia complications Anoxic brain injury Birth trauma Bone malignancy Cancer Cardiac arrest Cardiac arrhythmia Cardiac surgery Cesarean delivery Coma Control of postoperative hemorrhage Deep vein thrombosis Delirium and other psychoses241 Diabetes Drainage of hematoma Elective Foreign body left in during procedure Gastrointestinal (GI) hemorrhage Hemiplegia, paraplegia, or quadriplegia Hemorrhage Hip fracture Immunocompromised Indications of current drug abuse Infection Instrument assisted delivery

Liveborn Long term care facility Low mortality Lung or pleural biopsy Lymphoid malignancy Medical Metastatic cancer Obstetric trauma Physiologic and metabolic derangements Poisoning Postoperative hematoma Postoperative hemorrhage or hematoma Preterm infant Pulmonary embolism Seizure Self inflicted injury Sepsis Shock Stroke Surgica Syncope Technical difficulty Thoracic surgery Transferred to acute care facility Transferred from acute care facility Transfusion reaction Trauma Vaginal delivery FTR-FAILURE TO RESCUE

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PHA

GO

ENTE

RO

STO

MY

42

.65

AN

TEST

ERN

AL

ESO

PHA

GEA

L A

NA

STO

MO

SIS

WIT

H IN

TER

POSI

TIO

N O

F C

OLO

N

42.6

6 O

THER

AN

TEST

ERN

AL

ESO

PHA

GO

CO

LOST

OM

Y

42.9

1 LI

GA

TIO

N O

F ES

OPH

AG

EAL

VA

RIC

ES

43.0

G

AST

RO

STO

MY

43

.19

OTH

ER G

AST

RO

STO

MY

43

.3

PYLO

RO

MY

OTO

MY

43

.42

LOC

AL

EXC

ISIO

N O

F O

THER

LES

ION

OR

TI

SSU

E O

F ST

OM

AC

H

43.4

9 O

THER

DES

TRU

CTI

ON

OF

LESI

ON

OR

TI

SSU

E O

F ST

OM

AC

H

43.5

PA

RTI

AL

GA

STR

ECTO

MY

WIT

H

AN

AST

OM

OSI

S TO

ESO

PHA

GU

S 43

.6

PAR

TIA

L G

AST

REC

TOM

Y W

ITH

A

NA

STO

MO

SIS

TO D

UO

DEN

UM

43

.7

PAR

TIA

L G

AST

REC

TOM

Y W

ITH

A

NA

STO

MO

SIS

TO JE

JUN

UM

43

.81

PAR

TIA

L G

AST

REC

TOM

Y W

ITH

JEJU

NA

TR

AN

SPO

SITI

ON

43

.89

OTH

ER P

AR

TIA

L G

AST

REC

TOM

Y

43.9

1 TO

TAL

GA

STR

ECTO

MY

WIT

H

INTE

STIN

AL

INTE

RPO

SITI

ON

43

.99

OTH

ER T

OTA

L G

AST

REC

TOM

Y

44.0

0 V

AG

OTO

MY

, NO

S

44.0

1 TR

UN

CA

L V

AG

OTO

MY

44

.02

HIG

HLY

SEL

ECTI

VE

VA

GO

TOM

Y

44.0

3 O

THER

SEL

ECTI

VE

VA

GO

TOM

Y

44.1

1 TR

AN

SAB

DO

MIN

AL

GA

STR

OSC

OPY

44

.15

OPE

N B

IOPS

Y O

F ST

OM

AC

H

44.2

1 D

ILA

TIO

N O

F PY

LOR

US

BY

INC

ISIO

N

44.2

9 O

THER

PY

LOR

OPL

AST

Y

44.3

1 H

IGH

GA

STR

IC B

YPA

SS

44.3

9 O

THER

GA

STR

OEN

TER

OST

OM

Y

44.4

0 SU

TUR

E O

F PE

PTIC

ULC

ER, N

OS

44.4

1 SU

TUR

E O

F G

AST

RIC

ULC

ER S

ITE

44.4

2 SU

TUR

E O

F D

UO

DEN

AL

ULC

ER S

ITE

44.5

R

EVIS

ION

OF

GA

STR

IC A

NA

STO

MO

SIS

44.6

1 SU

TUR

E O

F LA

CER

ATI

ON

OF

STO

MA

CH

44

.63

CLO

SUR

E O

F O

THER

GA

STR

IC F

ISTU

LA

44.6

4 G

AST

RO

PEX

Y

44.6

5 ES

OPH

AG

OG

AST

RO

PLA

STY

44

.66

OTH

ER P

RO

CED

UR

ES F

OR

CR

EATI

ON

OF

ESO

PHA

GO

GA

STR

IC S

PHIN

CTE

RIC

C

OM

PETE

NC

E 44

.69

OTH

ER R

EPA

IR O

F ST

OM

AC

H

44.9

1 LI

GA

TIO

N O

F G

AST

RIC

VA

RIC

ES

44.9

2 IN

TRA

OPE

RA

TIV

E M

AN

IPU

LATI

ON

OF

STO

MA

CH

45

.00

INC

ISIO

N O

F IN

TEST

INE,

NO

S 45

.01

INC

ISIO

N O

F D

UO

DEN

UM

45

.02

OTH

ER IN

CIS

ION

OF

SMA

LL IN

TEST

INE

45.0

3 IN

CIS

ION

OF

LAR

GE

INTE

STIN

E 45

.31

OTH

ER L

OC

AL

EXC

ISIO

N O

F LE

SIO

N O

F D

UO

DEN

UM

45

.32

OTH

ER D

ESTR

UC

TIO

N O

F LE

SIO

N O

F D

UO

DEN

UM

45

.33

LOC

AL

EXC

ISIO

N O

F LE

SIO

N O

R T

ISSU

E O

F SM

ALL

INTE

STIN

E, E

XC

EPT

DU

OD

ENU

M

45.3

4 O

THER

DES

TRU

CTI

ON

OF

LESI

ON

OF

SMA

LL IN

TEST

INE,

EX

CEP

T D

UO

DEN

UM

45

.41

EXC

ISIO

N O

F LE

SIO

N O

R T

ISSU

E O

F LA

RG

E IN

TEST

INE

45.4

9 O

THER

DES

TRU

CTI

ON

OF

LESI

ON

OF

LAR

GE

INTE

STIN

E 45

.50

ISO

LATI

ON

OF

INTE

STIN

AL

SEG

MEN

T,

NO

S 45

.51

ISO

LATI

ON

OF

SEG

MEN

T O

F SM

ALL

IN

TEST

INE

45.5

2 IS

OLA

TIO

N O

F SE

GM

ENT

OF

LAR

GE

INTE

STIN

E 45

.61

MU

LTIP

LE S

EGM

ENTA

L R

ESEC

TIO

N O

F SM

ALL

INTE

STIN

E

A-33

Appendix A: Patient Measure Safety Specifications and Methods

45.6

2 O

THER

PA

RTI

AL

RES

ECTI

ON

OF

SMA

LL

INTE

STIN

E 45

.63

TOTA

L R

EMO

VA

L O

F SM

ALL

INTE

STIN

E 45

.71

MU

LTIP

LE S

EGM

ENTA

L R

ESEC

TIO

N O

F LA

RG

E IN

TEST

INE

45.7

2 C

ESEC

TOM

Y

45.7

3 R

IGH

T H

EMIC

OLE

CTO

MY

45

.74

RES

ECTI

ON

OF

TRA

NSV

ERSE

CO

LON

45

.75

LEFT

HEM

ICO

LEC

TOM

Y

45.7

6 SI

GM

OID

ECTO

MY

45

.79

OTH

ER P

AR

TIA

L EX

CIS

ION

OF

LAR

GE

INTE

STIN

E 45

.8

TOTA

L IN

TRA

-AB

DO

MIN

AL

CO

LEC

TOM

Y

45.9

0 IN

TEST

INA

L A

NA

STO

MO

SIS,

NO

S 45

.91

SMA

LL-T

O-S

MA

LL IN

TEST

INA

L A

NA

STO

MO

SIS

45.9

2 A

NA

STO

MO

SIS

OF

SMA

LL IN

TEST

INE

TO

REC

TAL

STU

MP

45.9

3 O

THER

SM

ALL

-TO

-LA

RG

E IN

TEST

INA

L A

NA

STO

MO

SIS

45.9

4 LA

RG

E-TO

-LA

RG

E IN

TEST

INA

L A

NA

STO

MO

SIS

45.9

5 A

NA

STO

MO

SIS

TO A

NU

S 46

.01

EXTE

RIO

RIZ

ATI

ON

OF

SMA

LL

INTE

STIN

E 46

.03

EXTE

RIO

RIZ

ATI

ON

OF

LAR

GE

INTE

STIN

E 46

.10

CO

LOST

OM

Y, N

OS

46.1

1 TE

MPO

RA

RY

CO

LOST

OM

Y

46.1

3 PE

RM

AN

ENT

CO

LOST

OM

Y

46.2

0 IL

EOST

OM

Y, N

OS

46.2

1 TE

MPO

RA

RY

ILES

OST

OM

Y

46.2

2 C

ON

TIN

ENT

ILEO

STO

MY

46

.23

OTH

ER P

ERM

AN

ENT

ILEO

STO

MY

46

.40

REV

ISIO

N O

F IN

TEST

INA

STO

MA

, NO

S 46

.41

REV

ISIO

N O

F ST

OM

A O

F SM

ALL

IN

TEST

INE

46.4

2 R

EPA

IR O

F PE

RIC

OLO

STO

MY

HER

NIA

46

.43

OTH

ER R

EVIS

ION

OF

STO

MA

OF

LAR

GE

INTE

STIN

E 46

.50

CLO

SUR

E O

F IN

TEST

INA

L ST

OM

A, N

OS

46.5

1 C

LOSU

RE

OF

STO

MA

OF

SMA

LL

INTE

STIN

E 46

.52

CLO

SUR

E O

F ST

OM

A O

F LA

RG

E IN

TEST

INE

46.6

0 FI

XA

TIO

N O

F IN

TEST

INE,

NO

S 46

.61

FIX

ATI

ON

OF

SMA

LL IN

TEST

INE

TO

AB

DO

MIN

AL

WA

LL

46.6

2 O

THER

FIX

ATI

ON

OF

SMA

LL IN

TEST

INE

46

.63

FIX

ATI

ON

OF

LAR

GE

INTE

STIN

E TO

A

BD

OM

INA

L W

ALL

46.6

4 O

THER

FIX

ATI

ON

OF

LAR

GE

INTE

STIN

E 46

.72

CLO

SUR

E O

F FI

STU

LA O

F D

UO

DEN

UM

46

.74

CLO

SUR

E O

F FI

STU

LA O

F SM

ALL

IN

TEST

INE,

EX

CEP

T D

UO

DEN

UM

46

.76

CLO

SUR

E O

F FI

STU

LA O

F LA

RG

E IN

TEST

INE

46.8

0 IN

TRA

-AB

DO

MIN

AL

MA

NIP

ULA

TIO

N O

F IN

TEST

INE,

NO

S 46

.81

INTR

A-A

BD

OM

INA

L M

AN

IPU

LATI

ON

OF

SMA

LL IN

TEST

INE

46.8

2 IN

TRA

-AB

DO

MIN

AL

MA

NIP

ULA

TIO

N O

F LA

RG

E IN

TEST

INE

46.9

1 M

YO

TOM

Y O

F SI

GM

OID

CO

LON

46

.92

MY

OTO

MY

OF

OTH

ER P

AR

TS O

F C

OLO

N

46.9

3 R

EVIS

ION

OF

AN

AST

OM

OSI

S O

F SM

ALL

IN

TEST

INE

46.9

4 R

EVIS

ION

OF

AN

AST

OM

OSI

S O

F LA

RG

E IN

TEST

INE

46.9

9 O

THER

OPE

RA

TIO

NS

ON

INTE

STIN

ES

47.0

9 O

THER

APP

END

ECTO

MY

47

.19

OTH

ER IN

CID

ENTA

L A

PPEN

DEC

TOM

Y

47.2

D

RA

INA

GE

OF

APP

END

ICEA

L A

BSC

ESS

47.9

1 A

PPEN

DEC

TOM

Y

47.9

2 C

LOSU

RE

OF

APP

END

ICEA

L FI

STU

LA

47.9

9 O

THER

OPE

RA

TIO

N A

PPEN

DIX

48

.41

SUB

MU

CO

SAL

RES

ECTI

ON

OF

REC

TUM

48

.49

OTH

ER P

ULL

-TH

RO

UG

H R

ESEC

TIO

N O

F R

ECTU

M

48.5

A

BD

OM

INO

PER

INEA

L R

ESEC

TIO

N O

F R

ECTU

M

48.7

5 A

BD

OM

INA

L PR

OC

TOPE

XY

50

.0

HEP

ATO

TOM

Y

50.1

2 O

PEN

BIO

PSY

OF

LIV

ER

50.2

1 M

AR

SUPI

ALI

ZATI

ON

OF

LESI

ON

OF

LIV

ER

50.2

2 PA

RTI

AL

HEP

ATE

CTO

MY

50

.29

OTH

ER D

ESTR

UC

TIO

N O

F LE

SIO

N O

F LI

VER

50

.3

LOB

ECTO

MY

OF

LIV

ER

50.4

TO

TAL

HEP

ATE

CTO

MY

50

.51

AU

XIL

IAR

Y L

IVER

TR

AN

SPLA

NT

50.5

9 O

THER

TR

AN

SPLA

NT

OF

LIV

ER

50.6

9 O

THER

REP

AIR

OF

LIV

ER

51.0

3 O

THER

CH

OLE

CY

STO

STO

MY

51

.04

OTH

ER C

HO

LEC

YST

OTO

MY

51

.13

OPE

N B

IOPS

Y O

F G

ALL

BLA

DD

ER O

R

BIL

E D

UC

TS

51.2

1 O

THER

PA

RTI

AL

CH

OLE

CY

STEC

TOM

Y

51.2

2 C

HO

LEC

YST

ECTO

MY

51.3

1 A

NA

STO

MO

SIS

OF

GA

LLB

LAD

DER

TO

H

EPA

TIC

DU

CTS

51

.32

AN

AST

OM

OSI

S O

F G

ALL

BLA

DD

ER T

O

INTE

STIN

E 51

.33

AN

AST

OM

OSI

S O

F G

ALL

BLA

DD

ER T

O

PAN

CR

EAS

51

.34

AN

AST

OM

OSI

S O

F G

ALL

BLA

DD

ER T

O

STO

MA

CH

51

.35

OTH

ER G

ALL

BLA

DD

ER A

NA

STO

MO

SIS

51.3

6 C

HO

LED

OC

HO

ENTE

RO

STO

MY

51

.37

AN

AST

OM

OSI

S O

F H

EPA

TIC

DU

CT

TO

GA

STR

OIN

TEST

INA

L TR

AC

T 51

.39

OTH

ER B

ILE

DU

CT

AN

AST

OM

OSI

S 51

.41

CO

MM

ON

DU

CT

EXPL

OR

ATI

ON

FO

R

REM

OV

AL

OF

CA

LCU

LUS

51.4

2 C

OM

MO

N D

UC

T EX

PLO

RA

TIO

N F

OR

R

ELIE

F O

F O

THER

OB

STR

UC

TIO

N

51.4

3 IN

SER

TIO

N O

F C

HO

LED

OC

HO

HEP

ATI

C

TUB

E FO

R D

ECO

MPR

ESSI

ON

51

.49

INC

ISIO

N O

F O

THER

BIL

E D

UC

TS F

OR

R

ELIE

F O

F O

BST

RU

CTI

ON

51

.51

EXPL

OR

ATI

ON

OF

CO

MM

ON

DU

CT

51.5

9 IN

CIS

ION

OF

OTH

ER B

ILE

DU

CT

51.6

1 EX

CIS

ION

OF

CY

STIC

DU

CT

REM

NA

NT

51.6

2 EX

CIS

ION

OF

AM

PULL

A O

F V

ATE

R W

ITH

R

EIM

PLA

NTA

TIO

N O

F C

OM

MO

N D

UC

T 51

.63

OTH

ER E

XC

ISIO

N O

F C

OM

MO

N D

UC

T

51.6

9 EX

CIS

ION

OF

OTH

ER B

ILE

DU

CT

51.7

1 SI

MPL

E SU

TUR

E O

F C

OM

MO

N B

ILE

DU

CT

51.7

2 C

HO

LED

OC

HO

PLA

STY

51

.79

REP

AIR

OF

OTH

ER B

ILE

DU

CTS

51

.81

DIL

ATI

ON

OF

SPH

INC

TER

OF

OD

DI

51.8

2 PA

NC

REA

TIC

SPH

INC

TER

OTO

MY

51

.83

PAN

CR

EATI

C S

PHIN

CTE

RO

PLA

STY

51

.89

OTH

ER O

PER

ATI

ON

S O

N S

PHIN

CTE

R O

F O

DD

I 51

.92

CLO

SUR

E O

F C

HO

LEC

YST

OST

OM

Y

51.9

3 C

LOSU

RE

OF

OTH

ER B

ILIA

RY

FIS

TULA

51

.94

REV

ISIO

N O

F A

NA

STO

MO

SIS

OF

BIL

IAR

Y

TRA

CT

51.9

5 R

EMO

VA

L O

F PR

OST

HET

IC D

EVIC

E FR

OM

BIL

E D

UC

T 51

.99

OTH

ER O

PER

ATI

ON

S O

N B

ILIA

RY

TR

AC

T 52

.01

DR

AIN

AG

E O

F PA

NC

REA

TIC

CY

ST B

Y

CA

THET

ER

52.0

9 O

THER

PA

NC

REA

TOTO

MY

52

.12

OPE

N B

IOPS

Y O

F PA

NC

REA

S

App

endix

A:

MQ

MS

Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

ethod

s

A-34

52.2

2 O

THER

EX

CIS

ION

OR

DES

TRU

CTI

ON

OF

LESI

ON

OR

TIS

SUE

OF

PAN

CR

EAS

OR

PA

NC

REA

TIC

DU

CT

52.3

M

AR

SUPI

ALI

ZATI

ON

OF

PAN

CR

EATI

C

CY

ST

52.4

IN

TER

NA

L D

RA

INA

GE

OF

PAN

CR

EATI

C

CY

ST

52.5

1 PR

OX

IMA

L PA

NC

REA

TEC

TOM

Y

52.5

2 D

ISTA

L PA

NC

REA

TEC

TOM

Y

52.5

3 R

AD

IAL

SUB

TOTA

L PA

NC

REA

TEC

TOM

Y

52.5

9 O

THER

PA

RTI

AL

PAN

CR

EATE

CTO

MY

52

.6

TOTA

L PA

NC

REA

TEC

TOM

Y

52.7

R

AD

ICA

L PA

NC

REA

TIC

OD

UO

DEN

ECTO

MY

52

.80

PAN

CR

EATI

C T

RA

NSP

LAN

T, N

OS

52.8

1 R

EIM

PLA

NTA

TIO

N

52.8

2 H

OM

OTR

AN

SPLA

NT

OF

PAN

CR

EAS

52.8

3 H

ETER

OTR

AN

SPLA

NT

OF

PAN

CR

EAS

52.9

2 C

AN

NU

LATI

ON

OF

PAN

CR

EATI

C D

UC

T 52

.95

OTH

ER R

EPA

IR O

F PA

NC

REA

S 52

.96

AN

AST

OM

OSI

S O

F PA

NC

REA

S 52

.99

OTH

ER O

PER

ATI

ON

S O

N P

AN

CR

EAS

53.0

0 U

NIL

ATE

RA

L R

EPA

IR O

F IN

GU

INA

L H

ERN

IA, N

OS

53.0

1 R

EPA

IR O

F D

IREC

T IN

GU

INA

L H

ERN

IA

53.0

2 R

EPA

IR O

F IN

DIR

ECT

ING

UIN

AL

HER

NIA

53

.03

AIR

OF

DIR

ECT

ING

UIN

AL

HER

NIA

53

.04

REP

AIR

OF

IND

IREC

T IN

GU

INA

L H

ERN

IA

WIT

H G

RA

FT O

R P

RO

STH

ESIS

53

.05

REP

AIR

OF

ING

UIN

AL

HER

NIA

WIT

H

GR

AFT

OR

PR

OST

HES

IS, N

OS

53.1

0 B

ILA

TER

AL

REP

AIR

OF

ING

UIN

AL

HER

NIA

, NO

S 53

.11

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ATE

RA

L R

EPA

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T IN

GU

INA

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IA

53.1

2 B

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TER

AL

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OF

IND

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T IN

GU

INA

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IA

53.1

3 B

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TER

AL

REP

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OF

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UIN

AL

HER

NIA

, ON

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ND

ON

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53.1

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AL

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OF

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53

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53

.16

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INA

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ITH

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GR

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53.2

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53

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53

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54

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54

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UN

SPEC

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D

304.

91

UN

SPEC

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RU

G D

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ON

TIN

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US

App

endix

A:

MQ

MS

Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

ethod

s

A-36

304.

92

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SPEC

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A

ctiv

e no

ndep

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nt a

buse

of d

rugs

IC

D-9

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dia

gnos

is c

odes

: 30

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A

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30

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02

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IC

305.

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D

305.

11

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305.

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IC

305.

20

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IS A

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30

5.21

C

AN

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OU

S 30

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AN

NA

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USE

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305.

30

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30

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30

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305.

90

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, OR

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305.

91

OTH

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5.92

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THER

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UG

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A

cute

myo

card

ial i

nfar

ctio

n IC

D-9

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dia

gnos

is c

odes

: 41

0.00

A

MI O

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RA

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–

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41

0.01

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41

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–

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AR

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41

0.21

A

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41

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AM

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41

0.71

A

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END

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ITE

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41

0.91

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SIT

E - I

NIT

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F C

AR

E A

nest

hesi

a co

mpl

icat

ions

IC

D-9

-CM

dia

gnos

is c

odes

: E8

76.3

O

THER

AN

D U

NSP

ECIF

IED

M

ISA

DV

ENTU

RES

DU

RIN

G M

EDIC

AL

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EN

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NG

LY

PLA

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IC

PRO

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55.1

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THER

NER

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US

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RES

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TS

OTH

ER C

ENTR

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NER

VO

US

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DEP

RES

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TS A

ND

AN

ESTH

ETIC

S:

E938

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HA

LOTH

AN

E E9

38.2

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THER

GA

SEO

US

AN

ESTH

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S E9

38.3

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E938

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LEX

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ESTH

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INA

L A

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E938

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OTH

ER A

ND

UN

SPEC

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OC

AL

AN

ESTH

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STEM

DEP

RES

SAN

TS A

ND

AN

ESTH

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S:

968.

1 H

ALO

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968.

2 O

THER

GA

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S 96

8.3

INTR

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S 96

8.4

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8.7

SPIN

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S A

noxi

c br

ain

inju

ry

ICD

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M d

iagn

osis

cod

es:

348.

1 A

NO

XIC

BR

AIN

DA

MA

GE

A-37


Bir

th tr

aum

a

ICD

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M d

iagn

osis

cod

es:

767.

0

SUB

DU

RA

L A

ND

CER

EBR

AL

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OR

RH

AG

E (D

UE

TO T

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UM

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INTR

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M A

NO

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767.

3 IN

JUR

IES

TO S

KEL

ETO

N (E

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LUD

ES

CLA

VIC

LE)

767.

4

INJU

RY

TO

SPI

NE

AN

D S

PIN

AL

CO

RD

76

7.7

O

THER

CR

AN

IAL

AN

D P

ERIP

HER

AL

NER

VE

INJU

RIE

S 76

7.8

O

THER

SPE

CIF

IED

BIR

TH T

RA

UM

A

767.

9

BIR

TH T

RA

UM

A, U

NSP

ECIF

IED

B

one

mal

igna

ncy

ICD

-9-C

M d

iagn

osis

cod

es (a

ll 4th

and

5th d

igits

) :

170

MA

LIG

NA

NT

NEO

PLA

SM O

F B

ON

E A

ND

A

RTI

CU

LAR

CA

RTI

LAG

E C

ance

r IC

D-9

-CM

dia

gnos

is c

odes

( all

4th a

nd 5

th d

igits

) :

140

MA

LIG

NA

NT

NEO

PLA

SM O

F LI

P 14

1

MA

LIG

NA

NT

NEO

PLA

SM O

F TO

NG

UE

142

MA

LIG

NA

NT

NEO

PLA

SM O

F M

AJO

RIT

Y

SALI

VA

RY

GLA

ND

S 14

3 M

ALI

GN

AN

T N

EOPL

ASM

OF

GU

M

144

MA

LIG

NA

NT

NEO

PLA

SM O

F FL

OO

R O

F M

OU

TH

145

MA

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NA

NT

NEO

PLA

SM O

F O

THER

AN

D

UN

SPEC

IFIE

D P

AR

TS O

F M

OU

TH

146

MA

LIG

NA

NT

NEO

PLA

SM O

F O

RO

PHA

RY

NX

14

7 M

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GN

AN

T N

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ASM

OF

NA

SOPH

AR

YN

X

148

MA

LIG

NA

NT

NEO

PLA

SM O

F H

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PHA

RY

NX

14

9 M

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AN

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ASM

OF

OTH

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ND

IL

L-D

EFIN

ED S

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WIT

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150

MA

LIG

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PLA

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AG

US

151

MA

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H

152

MA

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ALL

IN

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INC

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DU

OD

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M

153

MA

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NT

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PLA

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F C

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N

154

MA

LIG

NA

NT

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PLA

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JUN

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NU

S

155

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D

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156

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ALL

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157

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S 15

8 M

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PER

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M

159

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NT

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PLA

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THER

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SIT

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NS

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16

0 M

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OF

NA

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CA

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IES,

MID

DLE

EA

R, A

ND

A

CC

ESSO

RY

SIN

USE

S 16

1 M

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OF

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X

162

MA

LIG

NA

NT

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PLA

SM O

F TR

AC

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, B

RO

NC

HU

S, A

ND

LU

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16

3 M

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AN

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OF

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16

4 M

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GN

AN

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ASM

OF

THY

MU

S,

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RT,

AN

D M

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16

5 M

ALI

GN

AN

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ASM

OF

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L-D

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ED S

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ND

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RA

CIC

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GA

NS

170

MA

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NA

NT

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PLA

SM O

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A

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CU

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1 M

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AN

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ASM

OF

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VE

AN

D O

THER

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FT T

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E 17

2 M

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GN

AN

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ELA

NO

MA

OF

SKIN

17

4 M

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GN

AN

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ASM

OF

FEM

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B

REA

ST

175

MA

LIG

NA

NT

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PLA

SM O

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ALE

B

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ST

176

KA

RPO

SI’S

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RC

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A

179

MA

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TER

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PA

RT

UN

SPEC

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D

180

MA

LIG

NA

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F C

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IX

UTE

RI

181

MA

LIG

NA

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PLA

SM O

F EY

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2 M

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S 18

3 M

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EXA

184

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185

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186

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18

7 M

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188

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9 M

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190

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19

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OF

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OF

NER

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US

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193

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G

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D

194

MA

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195

MA

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196

SEC

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M

ALI

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19

7 SE

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198

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NA

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OF

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19

9 M

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ON

OF

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20

0 LY

MPH

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RC

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A A

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20

1 H

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OF

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HIS

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CY

TIC

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SUES

20

3 M

ULT

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251.

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RIE

S 38

.87

OTH

ER S

UR

GIC

AL

OC

CLU

SIO

N O

F V

ESSE

LS A

BD

OM

INA

L V

EIN

S 38

.88

OTH

ER S

UR

GIC

AL

OC

CLU

SIO

N O

F LO

WER

LIM

B A

RTE

RIE

S 38

.89

OTH

ER S

UR

GIC

AL

OC

CLU

SIO

N O

F LO

WER

LIM

B V

EIN

S

App

endix

A:

MQ

MS

Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

ethod

s

A-40

39.4

1 C

ON

TRO

L O

F H

EMO

RR

HA

GE

AFT

ER

TON

SILL

ECTO

MY

AN

D

AD

ENO

IDEC

TOM

Y

39.9

8 C

ON

TRO

L O

F H

EMO

RR

HA

GE

NO

S 49

.95

CO

NTR

OL

OF

(PO

STO

PER

ATI

VE)

H

EMO

RR

HA

GE

OF

AN

US

57.9

3 C

ON

TRO

L O

F (P

OST

OPE

RA

TIV

E)

HEM

OR

RH

AG

E O

F B

LAD

DER

60

.94

CO

NTR

OL

OF

(PO

STO

PER

ATI

VE)

H

EMO

RR

HA

GE

OF

PRO

STA

TE

Dee

p ve

in th

rom

bosi

s IC

D-9

-CM

dia

gnos

is c

odes

: 45

1.11

PH

LEB

ITIS

AN

D T

HR

OM

BO

SIS

OF

FEM

OR

AL

VEI

N (D

EEP)

(SU

PER

FIC

IAL)

45

1.19

PH

LEB

ITIS

AN

D T

HR

OM

BO

PHLE

BIT

IS -

O

F D

EEP

VES

SEL

OF

LOW

ER

EXTR

EMIT

IES

- OTH

ER

451.

2 PH

LEB

ITIS

AN

D T

HR

OM

BO

PHLE

BIT

IS O

F LO

WER

EX

TREM

ITIE

S U

NSP

ECIF

IED

45

1.81

PH

LEB

ITIS

AN

D T

HR

OM

BO

PHLE

BIT

IS O

F IL

IAC

VEI

N

451.

9 PH

LEB

ITIS

AN

D T

HR

OM

BO

PHLE

BIT

IS O

F O

THER

SIT

ES -

OF

UN

SPEC

IFIE

D S

ITE

453.

8 O

THER

VEN

OU

S EM

BO

LISM

AN

D

THR

OM

BO

SIS

OF

OTH

ER S

PEC

IFIE

D

VEI

NS

453.

9 O

THER

VEN

OU

S EM

BO

LISM

AN

D

THR

OM

BO

SIS

OF

UN

SPEC

IFIE

D S

ITE

Del

iriu

m a

nd o

ther

psy

chos

es

ICD

-9-C

M d

iagn

osis

cod

es (i

nclu

des a

ll 4th

and

5th d

igits

) 29

0 SE

NIL

E A

ND

PR

ESEN

ILE

OR

GA

NIC

PS

YC

HO

TIC

CO

ND

ITIO

NS

291

ALC

OH

OLI

C P

SYC

HO

SES

292

DR

UG

PSY

CH

OSE

S 29

3 TR

AN

SIEN

T O

RG

AN

IC P

SYC

HO

TIC

C

ON

DIT

ION

S 29

4 O

THER

OR

GA

NIC

PSY

CH

OTI

C

CO

ND

ITIO

NS

295

SCH

IZO

PHR

ENIC

DIS

OR

DER

S 29

6 A

FFEC

TIV

E PS

YC

HO

SES

297

PAR

AN

OID

STA

TES

298

OTH

ER N

ON

OR

GA

NIC

PSY

CH

OSE

S

299

PSY

CH

OSE

S W

ITH

OR

IGIN

SPE

CIF

IC T

O

CH

ILD

HO

OD

D

iabe

tes

ICD

-9-C

M d

iagn

osis

cod

es:

250.

0 D

IAB

ETES

MEL

LITU

S W

ITH

OU

T M

ENTI

ON

OF

CO

MPL

ICA

TIO

N

250.

1 D

IAB

ETES

WIT

H K

ETO

AC

IDO

SIS

250.

2 D

IAB

ETES

WIT

H H

YPE

RO

SMO

LAR

ITY

25

0.3

DIA

BET

ES W

ITH

OTH

ER C

OM

A

250.

4 D

IAB

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WIT

H R

ENA

L M

AN

IFES

TATI

ON

S 25

0.5

DIA

BET

ES W

ITH

OPH

THA

LMIC

M

AN

IFES

TATI

ON

S 25

0.6

DIA

BET

ES W

ITH

NEU

RO

LOG

ICA

L M

AN

IFES

TATI

ON

S 25

0.7

DIA

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ES W

ITH

PER

IPH

ERA

L C

IRC

ULA

TOR

Y D

ISO

RD

ERS

250.

8 D

IAB

ETES

WIT

H O

THER

SPE

CIF

IED

M

AN

IFES

TATI

ON

S 25

0.9

DIA

BET

ES W

ITH

OTH

ER U

NSP

ECIF

IED

C

OM

PLIC

ATI

ON

S D

rain

age

of h

emat

oma

ICD

-9-C

M p

roce

dure

cod

es:

18.0

9 O

THER

INC

ISIO

N O

F EX

TER

NA

L EA

R

54.0

IN

CIS

ION

OF

AB

DO

MIN

AL

WA

LL

54.1

2 R

EOPE

NIN

G O

F R

ECEN

T LA

PAR

OTO

MY

SI

TE

59.1

9 O

THER

INC

ISIO

N O

F PE

RIV

ESIC

LE

TISS

UE

61.0

IN

CIS

ION

AN

D D

RA

INA

GE

OF

SCR

OTU

M

AN

D T

UN

ICA

VA

GIN

ALI

S 69

.98

OTH

ER O

PER

ATI

ON

S O

N S

UPP

OR

TIN

G

STR

UC

TUR

ES O

F U

TER

US

70.1

4 O

THER

VA

GIN

OTO

MY

71

.09

OTH

ER IN

CIS

ION

OF

VU

LVA

AN

D

PER

INEU

M

75.9

1 EV

AC

UA

TIO

N O

F O

BST

ETR

ICA

L IN

CIS

ION

AL

HEM

ATO

MA

OF

PER

INEU

M

75.9

2 EV

AC

UA

TIO

N O

F O

THER

HEM

ATO

MA

OF

VU

LVA

OR

VA

GIN

A

86.0

4 O

THER

INC

ISIO

N W

ITH

DR

AIN

AG

E O

F SK

IN A

ND

SU

BC

UTA

NEO

US

TISS

UE

Ele

ctiv

e

AD

MIS

SIO

N T

YPE

IS

REC

OR

DED

AS

ELEC

TIV

E (A

TYPE

= 3

)

Fore

ign

body

left

in d

urin

g pr

oced

ure

ICD

-9-C

M d

iagn

osis

cod

es:

998.

4

FOR

EIG

N B

OD

Y A

CC

IDEN

TALL

Y L

EFT

DU

RIN

G A

PR

OC

EDU

RE

998.

7 A

CU

TE R

EAC

TIO

N T

O F

OR

EIG

N

SUB

STA

NC

E A

CC

IDEN

TALL

Y L

EFT

DU

RIN

G A

PR

OC

EDU

RE

FOR

EIG

N B

OD

Y L

EFT

IN D

UR

ING

: E8

71.0

SU

RG

ICA

L O

PER

ATI

ON

E8

71.1

IN

FUSI

ON

OR

TR

AN

SFU

SIO

N

E871

.2

KID

NEY

DIA

LYSI

S O

R O

THER

PE

RFU

SIO

N

E871

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INJE

CTI

ON

OR

VA

CC

INA

TIO

N

E871

.4

END

OSC

OPI

C E

XA

MIN

ATI

ON

E8

71.5

A

SPIR

ATI

ON

OF

FLU

ID O

R T

ISSU

E,

PUN

CTU

RE,

AN

D C

ATH

ETER

IZA

TIO

N

E871

.6

HEA

RT

CA

THET

ERIZ

ATI

ON

E8

71.7

R

EMO

VA

L O

F C

ATH

ETER

OR

PA

CK

ING

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71.8

O

THER

SPE

CIF

IED

PR

OC

EDU

RES

E8

71.9

U

NSP

ECIF

IED

PR

OC

EDU

RE

Gas

troi

ntes

tinal

(GI)

hem

orrh

age

ICD

-9-C

M d

iagn

osis

cod

es:

456.

0 ES

OPH

AG

EAL

VA

RIC

ES W

ITH

BLE

EDIN

G

456.

20

ESO

PHA

GEA

L V

AR

ICES

IN D

ISEA

SES

CLA

SSIF

IED

ELS

EWH

ERE

WIT

H

BLE

EDIN

G

530.

7 G

AST

RO

ESO

PHA

GEA

L LA

CER

ATI

ON

- H

EMO

RR

HA

GE

SYN

DR

OM

E 53

0.82

ES

OPH

AG

EAL

HEM

OR

RH

AG

E 53

1.00

G

AST

RIC

ULC

ER A

CU

TE W

ITH

H

EMO

RR

HA

GE

- WIT

HO

UT

MEN

TIO

N O

F O

BST

RU

CTI

ON

53

1.01

G

AST

RIC

ULC

ER A

CU

TE W

ITH

H

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RR

HA

GE

- WIT

H O

BST

RU

CTI

ON

A-41


531.

20

GA

STR

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UTE

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ND

PER

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OF

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STR

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TIO

N

531.

21

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STR

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N

531.

40

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OF

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531.

41

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N

531.

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531.

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61

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533.

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PEPT

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AG

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OF

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PEPT

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20

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61

PEPT

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4.41

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4.61

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537.

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-W

ITH

HEM

OR

RH

AG

E 56

2.12

D

IVER

TIC

ULO

SIS

OF

CO

LON

- W

ITH

H

EMO

RR

HA

GE

562.

13

DIV

ERTI

CU

LITI

S O

F C

OLO

N -

WIT

H

HEM

OR

RH

AG

E 56

9.3

HEM

OR

RH

AG

E O

F R

ECTU

M A

ND

AN

US

569.

85

AN

GIO

DY

SPLA

SIA

OF

INTE

STIN

E -

WIT

H

HEM

OR

RH

AG

E 57

8.0

GA

STR

OIN

TEST

INA

L H

EMO

RR

HA

GE,

H

EMA

TEM

ESIS

57

8.1

GA

STR

OIN

TEST

INA

L H

EMO

RR

HA

GE,

B

LOO

D IN

STO

OL

578.

9 G

AST

RO

INTE

STIN

AL

HEM

OR

RH

AG

E,

HEM

OR

RH

AG

E O

F G

AST

RO

INTE

STIN

AL

TRA

CT,

UN

SPEC

IFIE

D

Hem

iple

gia,

par

aple

gia,

or

quad

ripl

egia

ICD

-9-C

M d

iagn

osis

cod

es (i

nclu

des a

ll 4th

and

5th d

igits

):

342.

0 FL

AC

CID

HEM

IPLE

GIA

34

2.1

SPA

STIC

HEM

IPLE

GIA

34

2.8

OTH

ER S

PEC

IFIE

D H

EMIP

LEG

IA

342.

9 H

EMIP

LEG

IA, U

NSP

ECIF

IED

34

3.0

INFA

NTI

LE C

EREB

RA

L PA

LSY

, DIP

LEG

IC

App

endix

A:

MQ

MS

Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

ethod

s

A-42

343.

1 IN

FAN

TILE

CER

EBR

AL

PALS

Y,

HEM

IPLE

GIC

34

3.2

INFA

NTI

LE C

EREB

RA

L PA

LSY

, Q

UA

DR

IPLE

GIC

34

3.3

INFA

NTI

LE C

EREB

RA

L PA

LSY

, M

ON

OPL

EGIC

34

3.4

INFA

NTI

LE C

EREB

RA

L PA

LSY

IN

FAN

TILE

HEM

IPLE

GIA

34

3.8

INFA

NTI

LE C

EREB

RA

L PA

LSY

OTH

ER

SPEC

IFIE

D IN

FAN

TILE

CER

EBR

AL

PALS

Y

343.

9 IN

FAN

TILE

CER

EBR

AL

PALS

Y,

INFA

NTI

LE C

EREB

RA

L PA

LSY

, U

NSP

ECIF

IED

34

4.0

QU

AD

RIP

LEG

IA A

ND

QU

AD

RIP

AR

ESIS

34

4.1

PAR

APL

EGIA

34

4.2

DIP

LEG

IA O

F U

PPER

LIM

BS

344.

3 M

ON

OPL

EGIA

OF

LOW

ER L

IMB

34

4.4

MO

NO

PLEG

IA O

F U

PPER

LIM

B

344.

5 U

NSP

ECIF

IED

MO

NO

PLEG

IA

344.

6 C

AU

DA

EQ

UIN

A S

YN

DR

OM

E 34

4.8

OTH

ER S

PEC

IFIE

D P

AR

ALY

TIC

SY

ND

RO

MES

34

4.9

PAR

ALY

SIS,

UN

SPEC

IFIE

D

438.

2 H

EMIP

LEG

IA/H

EMIP

AR

ESIS

43

8.3

MO

NO

PLEG

IA O

F U

PPER

LIM

B

438.

4 M

ON

OPL

EGIA

OF

LOW

ER L

IMB

43

8.5

OTH

ER P

AR

ALY

TIC

SY

ND

RO

ME

Hem

orrh

age

ICD

-9-C

M d

iagn

osis

cod

es:

285.

1 A

CU

TE P

OST

HEM

OR

RH

AG

IC A

NEM

IA

459.

0 O

THER

DIS

OR

DER

S O

F C

IRC

ULA

TOR

Y

SYST

EM, H

EMO

RR

HA

GE,

UN

SPEC

IFIE

D

958.

2 C

ERTA

IN E

AR

LY C

OM

PLIC

ATI

ON

S O

F TR

AU

MA

, SEC

ON

DA

RY

AN

D

REC

UR

REN

T H

EMO

RR

HA

GE

998.

11

HEM

OR

RH

AG

E C

OM

PLIC

ATI

NG

A

PRO

CED

UR

E H

ip fr

actu

re

ICD

-9-C

M d

iagn

osis

cod

es: (

incl

udes

all

5th d

igits

)

820.

0

FRA

CTU

RE

OF

NEC

K O

F FE

MU

R-

TRA

NSC

ERV

ICA

L FR

AC

TUR

E, C

LOSE

D

820.

1

FRA

CTU

RE

OF

NEC

K O

F FE

MU

R-

TRA

NSC

ERV

ICA

L FR

AC

TUR

E, O

PEN

82

0.2

FR

AC

TUR

E O

F N

ECK

OF

FEM

UR

- PE

RTR

OC

HA

NTE

RIC

FR

AC

TUR

E, C

LOSE

D

820.

3

FRA

CTU

RE

OF

NEC

K O

F FE

MU

R-

PER

TRO

CH

AN

TER

IC F

RA

CTU

RE,

OPE

N

820.

8 U

NSP

ECIF

IED

PA

RT

OF

NEC

K O

F FE

MU

R,

CLO

SED

82

0.9

UN

SPEC

IFIE

D P

AR

T O

F N

ECK

OF

FEM

UR

, O

PEN

Im

mun

ocom

prom

ised

ICD

-9-C

M d

iagn

osis

cod

es (i

nclu

des a

ll 4

th a

nd 5

th

digi

ts)

042

HU

MA

N IM

MU

NO

DEF

ICIE

NC

Y V

IRU

S D

ISEA

SE

136.

3 PN

EUM

OC

YST

OSI

S 27

9.0

DEF

FIC

IEN

CY

OF

HU

MO

RA

L IM

MU

NIT

Y

279.

1 D

EFFI

CIE

NC

Y O

F C

ELL-

MED

IATE

D

IMM

UN

ITY

27

9.2

CO

MB

INED

IMM

UN

ITY

DEF

FIC

IEN

CY

27

9.3

UN

SPEC

IFIE

D IM

MU

NIT

Y D

EFFI

CIE

NC

Y

279.

4 A

UTO

IMM

UN

E D

ISEA

SE, N

OT

ELSE

WH

ERE

CLA

SSIF

IED

27

9.8

OTH

ER S

PEC

IFIE

D D

ISO

RD

ERS

INV

OLV

ING

TH

E IM

MU

NE

MEC

HA

NIS

M

279.

9 U

NSP

ECIF

IED

DIS

OR

DER

OF

IMM

UN

E M

ECH

AN

ISM

99

6.8

CO

MPL

ICA

TIO

NS

OF

TRA

NSP

LAN

TED

O

RG

AN

V

42.0

K

IDN

EY R

EPLA

CED

BY

TR

AN

SPLA

NT

V42

.1

HEA

RT

REP

LAC

ED B

Y T

RA

NSP

LAN

T V

42.6

LU

NG

REP

LAC

ED B

Y T

RA

NSP

LAN

T V

42.7

LI

VER

REP

LAC

ED B

Y T

RA

NSP

LAN

T V

42.8

1 B

ON

E M

AR

RO

W S

PEC

IFIE

D B

Y

TRA

NSP

LAN

T V

42.8

2 PE

RIP

HER

AL

STEM

CEL

LS R

EPLA

CED

BY

TR

AN

SPLA

NT

V42

.83

PAN

CR

EAS

REP

LAC

ED B

Y T

RA

NSP

LAN

T V

42.8

4 IN

TEST

INES

REP

LAC

ED B

Y T

RA

NSP

LAN

T V

42.8

9 O

THER

REP

LAC

ED B

Y T

RA

NSP

LAN

T IC

D-9

-CM

pro

cedu

re c

odes

(inc

lude

s 4th

and

5th

dig

its:)

33.5

LU

NG

TR

AN

SPLA

NT

33.6

C

OM

BIN

ED H

EAR

T-LU

NG

TR

AN

SPLA

NTA

TIO

N

37.5

H

EAR

T TR

AN

SPLA

NTA

TIO

N

41.0

O

PER

ATI

ON

S O

N B

ON

E M

AR

OW

AN

D

SPLE

EN

50.5

LI

VER

TR

AN

SPLA

NT

55.6

9 O

THER

KID

NEY

TR

AN

SPLA

NTA

TIO

N

52.8

0 PA

NC

REA

TIC

TR

AN

SPLA

NT,

NO

S 52

.81

REI

MPL

AN

TATI

ON

OF

PAN

CR

EATI

C

TISS

UE

52.8

3 H

ETER

OTR

AN

SPLA

NT

OF

PAN

CR

EAS

52.8

5 A

LLO

TRA

NSP

LAN

TATI

ON

OF

CEL

LS O

F IS

LETS

OF

LAN

GER

HA

NS

52.8

6 TR

AN

SPLA

NTA

TIO

N O

F C

ELLS

OF

ISLE

TS O

F LA

NG

ERH

AN

S, N

OS

Dia

gnos

tic R

elat

ed G

roup

s (D

RGs)

: 48

8 H

IV W

ITH

EX

TEN

SIV

E O

R P

RO

CED

UR

E 48

9 H

IV W

ITH

MA

JOR

REL

ATE

D C

ON

DIT

ION

49

0 H

IV W

ITH

OR

WIT

HO

UT

OTH

ER

REL

ATE

D C

ON

DIT

ION

In

dica

tions

of c

urre

nt d

rug

abus

e IC

D-9

-CM

dia

gnos

is c

odes

TO

XIC

EFF

ECT

OF

ALC

OH

OL:

98

0.0

ETH

YL

ALC

OH

OL

980.

1 M

ETH

YL

ALC

OH

OL

980.

2 IS

OPR

OPY

L A

LCO

HO

L 98

0.3

FUSE

L O

IL

981

TOX

IC E

FFEC

T O

F PE

TRO

LEU

M

PRO

DU

CTS

SO

LVEN

TS O

THER

TH

AN

PET

RO

LEU

M-B

ASE

D:

982.

0 B

ENZE

NE

AN

D H

OM

OLO

GU

ES

982.

1 C

AR

BO

N T

ETR

AC

HLO

RID

E 98

2.2

CA

RB

ON

DIS

ULF

IDE

982.

3 O

THER

CH

LOR

INA

TED

HY

DR

OC

AR

BO

N

SOLV

ENTS

98

2.4

NIT

RO

GLY

CO

L 98

2.8

OTH

ER N

ON

PETR

OLE

UM

-BA

SED

SO

LVEN

TS

983.

0 TO

XIC

EFF

ECT

OF

CO

RR

OSI

VE

AR

OM

ATI

CS

A-43


983.

1 TO

XIC

EFF

ECT

OF

AC

IDS

983.

2 TO

XIC

EFF

ECT

OF

CA

UST

IC A

LKA

LID

ES

983.

9 TO

XIC

EFF

ECT

OF

CA

UST

IC,

UN

SPEC

IFIE

D

TOX

IC E

FFEC

T O

F LE

AD

AN

D IT

S C

OM

POU

ND

S (I

NC

LUD

ING

FU

MES

): 98

4.0

INO

RG

AN

IC L

EAD

CO

MPO

UN

DS

984.

1 O

RG

AN

IC L

EAD

CO

MPO

UN

DS

984.

8 O

THER

LEA

D C

OM

POU

ND

S 98

4.9

UN

SPEC

IFIE

D L

EAD

CO

MPO

UN

D

TOX

IC E

FFEC

T O

F O

THER

MET

ALS

: 98

5.0

MER

CU

RY

AN

D IT

S C

OM

POU

ND

S 98

5.1

AR

SEN

IC A

ND

ITS

CO

MPO

UN

DS

985.

2 M

AN

GA

NES

E A

ND

ITS

CO

MPO

UN

DS

985.

3 B

ERY

LLIU

M A

ND

ITS

CO

MPO

UN

DS

985.

4 A

NTI

MO

NY

AN

D IT

S C

OM

POU

ND

S 98

5.5

CA

DM

IUM

AN

D IT

S C

OM

POU

ND

S 98

5.6

CH

RO

MIU

M

985.

8 O

THER

SPE

CIF

IED

MET

ALS

98

5.9

UN

SPEC

IFIE

D M

ETA

L 98

6 TO

XIC

EFF

ECT

OF

CA

RB

ON

MO

NO

XID

E TO

XIC

EFF

ECT

OF

OTH

ER G

ASE

S, F

UM

ES, O

R

VA

POR

S:

987.

0 LI

QU

EFIE

D P

ETR

OLE

UM

GA

SES

987.

1 O

THER

HY

DR

OC

AR

BO

N G

AS

987.

2 N

ITR

OG

EN O

XID

ES

987.

3 SU

LFU

R D

IOX

IDE

987.

4 FR

EON

98

7.5

LAC

RIM

OG

ENIC

GA

S 98

7.6

CH

LOR

INE

GA

S 98

7.7

HY

DR

OC

YA

NIC

AC

ID G

AS

987.

8 O

THER

SPE

CIF

IED

GA

SES,

FU

MES

, OR

V

APO

RS

987.

9 U

NSP

ECIF

IED

GA

S, F

UM

E, O

R V

APO

R

NO

XIO

US

SUB

STA

NC

ES E

ATE

N A

S FO

OD

: 98

8.0

FISH

AN

D S

HEL

LFIS

H

988.

1 M

USH

RO

OM

S 98

8.2

BER

RIE

S A

ND

OTH

ER P

LAN

TS

988.

8 O

THER

SPE

CIF

IED

NO

XIO

US

SUB

STA

NC

ES E

ATE

N A

S FO

OD

TO

XIC

EFF

ECT

OF

OTH

ER S

UB

STA

NC

ES, C

HIE

FLY

N

ON

MED

ICIN

AL

AS

TO S

OU

RC

E:

989.

0 H

YD

RO

CY

AN

IC A

CID

AN

D C

YA

NID

ES

989.

1 ST

RY

CH

NIN

E A

ND

SA

LTS

989.

2 C

HLO

RIN

ATE

D H

YD

RO

CA

RB

ON

S 98

9.3

OR

GA

NO

PHO

SPH

ATE

AN

D C

AR

BA

MA

TE

989.

4 O

THER

PES

TIC

IDES

, NEC

98

9.5

VEN

OM

98

9.6

SOA

PS A

ND

DET

ERG

ENTS

98

9.7

AFL

ATO

XIN

AN

D O

THER

MY

CO

TOX

IN

[FO

OD

CO

NTA

MIN

AN

TS]

989.

8 O

THER

SU

BST

AN

CES

, CH

IEFL

Y

NO

NM

EDIC

IAN

AS

TO S

OU

RC

E 98

9.9

UN

SPEC

IFIE

D S

UB

STA

NC

E, C

HIE

FLY

N

ON

MED

ICIN

AL

AS

TO S

OU

RC

E 29

1.0

ALC

OH

OL

WIT

HD

RA

WA

L D

ELIR

IUM

29

1.1

ALC

OH

OL

AM

NES

TIC

SY

ND

RO

ME

291.

2 O

THER

ALC

OH

OLI

C D

EMEN

TIA

29

1.3

ALC

OH

OL

WIT

HD

RA

WL

HA

LLU

CIN

OSI

S 29

1.4

IDIO

SYN

CR

ATI

C A

LCO

HO

L IN

TOX

ICA

TIO

N

291.

5 A

LCO

HO

L JE

ALO

USY

29

1.8

OTH

ER S

PEC

IFIE

D A

LCO

HO

LIC

PS

YC

HO

SIS

291.

81

ALC

OH

OL

WIT

HD

RA

WA

L 29

1.9

ALC

OH

OLI

C P

SYC

HO

SES

DR

UG

PSY

CH

OSE

S:

292.

0 D

RU

G W

ITH

DR

AW

L SY

ND

RO

ME

292.

11

DR

UG

-IN

DU

CED

OR

GA

NIC

DEL

USI

ON

AL

SYN

DR

OM

E 29

2.12

D

RU

G- I

ND

UC

ED H

ALL

UC

INO

SIS

292.

2 PA

THO

LOG

ICA

L D

RU

G IN

TOX

ICA

TIO

N

292.

81

DR

UG

-IN

DU

CED

DEL

IRIU

M

292.

82

DR

UG

-IN

DU

CED

DEM

ENTI

A

292.

83

DR

UG

-IN

DU

CED

AM

NES

TIC

SY

ND

RO

ME

292.

84

DR

UG

-IN

DU

CED

OR

GA

NIC

AFF

ECTI

VE

SYN

DR

OM

E 29

2.89

O

THER

SPE

CIF

IED

DR

UG

-IN

DU

CED

M

ENTA

L D

ISO

RD

ERS

292.

9 U

NSP

ECIF

IED

DR

UG

-IN

DU

CED

MEN

TAL

DIS

OR

DER

(in

clud

es a

ll 4th

and

5th d

igits

) 30

3.0

AC

UTE

ALC

OH

OLI

C IN

TOX

ICA

TIO

N

303.

9 O

THER

AN

D U

NSP

ECIF

IED

ALC

OH

OL

.\DEP

END

ENC

E 30

4.0

OPI

OID

TY

PE D

EPEN

DEN

CE

304.

1 B

AR

BIT

UR

ATE

AN

D S

IMIL

AR

LY A

CTI

NG

SE

DA

TIV

E O

R H

YPN

OTI

C D

EPEN

DEN

CE

304.

2 C

OC

AIN

E D

EPEN

DEN

CE

30

4.3

CA

NN

AB

IS D

EPEN

DEN

CE

304.

4 A

MPH

ETA

MIN

E A

ND

OTH

ER

PSY

CH

OST

IMU

LAN

T D

EPEN

DEN

CE

304.

5 H

ALL

UC

INO

GEN

DEP

END

ENC

E 30

4.6

OTH

ER S

PEC

IFIE

D D

RU

G D

EPEN

DEN

CE

304.

7 C

OM

BIN

ATI

ON

S O

F O

PIO

ID T

YPE

DR

UG

W

ITH

AN

Y O

THER

30

4.8

CO

MB

INA

TIO

NS

OF

DR

UG

DEP

END

ENC

E EX

CLU

DIN

G O

PIO

ID T

YPE

DR

UG

30

4.9

UN

SPEC

IFIE

D D

RU

G D

EPEN

DEN

CE

305.

0 A

LCO

HO

L A

BU

SE

305.

2 C

AN

NA

BIS

AB

USE

30

5.3

HA

LLU

CIN

OG

EN A

BU

SE

305.

4 B

AR

BIT

UR

ATE

AN

D S

IMIL

AR

LY A

CTI

NG

SE

DA

TIV

E O

R H

YPN

OTI

C A

BU

SE

305.

5 O

PIO

ID A

BU

SE

305.

6 C

OC

AIN

E A

BU

SE

305.

7 A

MPH

ETA

MIN

E O

R R

ELA

TED

AC

TIN

G

SYM

PATH

OM

IMET

IC A

BU

SE

305.

8 A

NTI

DEP

RES

SAN

T TY

PE A

BU

SE

305.

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App

endix

A:

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Patie

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Mea

sure

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nd M

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App

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Mea

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App

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Patie

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Mea

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Met

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r IC

D-9

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dia

gnos

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odes

(inc

lude

s all

4th a

nd 5

th d

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):

196

SEC

ON

DA

RY

AN

D U

NSP

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M

ALI

GN

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OF

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Y M

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GN

AN

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ND

DIG

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VE

SYST

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198

SEC

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MA

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NA

NT

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PLA

SM

OF

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ITES

19

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D

Obs

tetr

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a IC

D-9

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dia

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odes

: 66

4.30

,1,4

TR

AU

MA

TO

PER

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M A

ND

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LVA

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UR

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Y, F

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PE

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OTH

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AU

MA

, LA

CER

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OF

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66

5.40

, 1, 4

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IGH

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OTH

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AU

MA

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RY

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PEL

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GA

NS

ICD

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roce

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cod

es:

75.5

0 R

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UR

REN

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IC

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NS

UTE

RU

S 75

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OF

CU

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OB

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75.5

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Phys

iolo

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and

met

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gem

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IC

D-9

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dia

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: D

IAB

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WIT

H K

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SIS:

25

0.10

TY

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, OR

UN

SPEC

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D T

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ON

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ON

TRO

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TY

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LLED

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TY

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CO

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DIA

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ITH

HY

PER

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250.

20

TYPE

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TY

PE, N

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: 25

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TY

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UN

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TY

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TY

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A-51


AC

UTE

REN

AL

FAIL

UR

E:

584.

5 W

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LES

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OF

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THER

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58

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Po

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ICD

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M d

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cod

es (i

nclu

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th a

nd 5

th d

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):

960

POIS

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CS

961

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962

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963

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TS

964

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ENTS

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BLO

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ITU

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96

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Y A

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NTI

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AN

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MA

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TS A

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A

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RU

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967

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DEP

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PSY

CH

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970

POIS

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971

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972

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976

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TS, P

AIN

TS, A

ND

V

AR

NIS

HES

E8

62

AC

CID

ENTA

L PO

ISO

NIN

G B

Y

PETR

OLE

UM

PR

OD

UC

TS, O

THER

SO

LVEN

TS A

ND

TH

EIR

VA

POR

S, N

EC

E863

A

CC

IDEN

TAL

POIS

ON

ON

ING

BY

A

GR

ICU

LTU

RA

L A

ND

HO

RTI

CU

LTU

RA

L C

HEM

ICA

L A

ND

PH

AR

MA

CEU

TIC

AL

PREP

AR

ATI

ON

S O

THER

TH

AN

PLA

NT

FOO

DS

AN

D F

ERTI

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RS

E864

A

CC

IDEN

TAL

POIS

ON

ING

BY

C

OR

RO

SIV

ES A

ND

CA

UST

ICS,

NEC

E8

65

AC

CID

ENTA

L PO

ISO

NIN

G F

RO

M

POIS

ON

OU

S FO

OD

STU

FFS

AN

D

POIS

ON

OU

S PL

AN

TS

E866

A

CC

IDEN

TAL

POIS

ON

G B

Y O

THER

AN

D

UN

SPEC

IFIE

D S

OLI

D A

ND

LIQ

UID

SU

BST

AN

CES

E8

67

AC

CID

ENTA

L PO

ISO

NO

ING

BY

GA

S D

ISTR

IBU

TED

BY

PIP

ELIN

E E8

68

AC

CID

ENTA

L PO

ISO

NIN

G B

Y O

THER

U

TILI

TY G

AS

AN

D O

THER

CA

RB

ON

M

ON

OX

IDE

E869

A

CC

IDEN

TAL

POIS

ON

ING

BY

OTH

ER

GA

SES

AN

D V

APO

RS

E951

SU

ICID

E A

ND

SEL

F-IN

FLIC

TED

PO

ISO

NIN

G B

Y G

ASE

S IN

DO

MES

TIC

USE

E9

52

SUIC

IDE

AN

D S

ELF-

INFL

ICTE

D

POIS

ON

ING

BY

OTH

ER G

ASE

S A

ND

V

APO

RS

E962

A

SSA

ULT

BY

PO

ISO

NIN

G

E980

PO

ISO

NIN

G B

Y S

OLI

D O

R L

IQU

ID

SUB

STA

NC

ES, U

ND

ETER

MIN

ED

WH

ETH

ER A

CC

IDEN

TALL

Y O

R

PUR

POSE

LY IN

FLIC

TED

E9

81

POIS

ON

ING

BY

GA

SES

IN D

OM

ESTI

C

USE

, UN

DET

ERM

INED

WH

ETH

ER

AC

CID

ENTA

LLY

OR

PU

RPO

SELY

IN

FLIC

TED

E9

82

POIS

ON

ING

BY

OTH

ER G

ASE

S,

UN

DET

ERM

INED

WH

ETH

ER

AC

CID

ENTA

LLY

OR

PU

RPO

SELY

IN

FLIC

TED

Po

stop

erat

ive

hem

atom

a IC

D-9

-CM

dia

gnos

is c

odes

: 99

8.12

H

EMA

TOM

A C

OM

PLIC

ATI

NG

A

PRO

CED

UR

E Po

stop

erat

ive

hem

orrh

age

or h

emat

oma

ICD

-9-C

M d

iagn

osis

cod

es:

998.

11

HEM

OR

RH

AG

E C

OM

PLIC

ATI

NG

A

PRO

CED

UR

E Pr

eter

m in

fant

IC

D-9

-CM

dia

gnos

is c

odes

: 76

5.01

-765

.08

EXTR

EME

IMM

ATU

RIT

Y

765.

11-7

65.1

8 O

THER

PR

ETER

M IN

FAN

TS

App

endix

A:

MQ

MS

Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

ethod

s

A-52

Pulm

onar

y em

bolis

m

ICD

-9-C

M d

iagn

osis

cod

es:

415.

11

IAG

TRO

GEN

IC P

ULM

ON

AR

Y E

MB

OLI

SM

AN

D IN

FAR

CTI

ON

41

5.19

O

THER

PU

LMO

NA

RY

EM

BO

LISM

Se

izur

e IC

D-9

-CM

dia

gnos

is c

odes

: 34

5.00

G

ENER

ALI

ZED

NO

NC

ON

VU

LSIV

E EP

ILEP

SY -

WIT

HO

UT

MEN

TIO

N O

F IN

TRA

CTA

BLE

EPI

LEPS

Y

345.

01

GEN

ERA

LIZE

D N

ON

CO

NV

ULS

IVE

EPIL

EPSY

- W

ITH

INTR

AC

TAB

LE

EPIL

EPSY

34

5.10

G

ENER

ALI

ZED

CO

NV

ULS

IVE

EPIL

EPSY

- W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE

EPIL

EPSY

34

5.11

G

ENER

ALI

ZED

CO

NV

ULS

IVE

EPIL

EPSY

- W

ITH

INTR

AC

TAB

LE E

PILE

PSY

34

5.2

EPIL

EPSY

-PET

IT M

AL

STA

TUS

345.

3 EP

ILEP

SY-G

RA

ND

MA

L ST

ATU

S 34

5.40

PA

RTI

AL

EPIL

EPSY

, WIT

H IM

PAIR

MEN

T O

F C

ON

SCIO

USN

ESS

- WIT

H

INTR

AC

TAB

LE E

PILE

PSY

34

5.41

PA

RTI

AL

EPIL

EPSY

, WIT

H IM

PAIR

MEN

T O

F C

ON

SCIO

USN

ESS

- WIT

HO

UT

MEN

TIO

N O

F IN

TRA

CTA

BLE

EPI

LEPS

Y

345.

50

PAR

TIA

L EP

ILEP

SY, W

ITH

OU

T M

ENTI

ON

O

F IM

PAIR

MEN

T O

F C

ON

SCIO

USN

ESS,

- W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE

EPIL

EPSY

34

5.51

PA

RTI

AL

EPIL

EPSY

, WIT

HO

UT

MEN

TIO

N

OF

IMPA

IRM

ENT

OF

CO

NSC

IOU

SNES

S -

WIT

H IN

TRA

CTA

BLE

EPI

LEPS

Y

345.

60

INFA

NTI

LE S

PASM

S - W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE E

PILE

PSY

34

5.61

IN

FAN

TILE

SPA

SMS

- WIT

H

INTR

AC

TAB

LE E

PILE

PSY

34

5.70

EP

ILEP

SIA

PA

RTI

ALI

S C

ON

TIN

UA

- W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE

EPIL

EPSY

34

5.71

EP

ILEP

SIA

PA

RTI

ALI

S C

ON

TIN

UA

- W

ITH

IN

TRA

CTA

BLE

EPI

LEPS

Y

345.

80

OTH

ER F

OR

MS

OF

EPIL

EPSY

- W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE E

PILE

PSY

34

5.81

O

THER

FO

RM

S O

F EP

ILEP

SY -

WIT

H

INTR

AC

TAB

LE E

PILE

PSY

34

5.90

EP

ILEP

SY, U

NSP

ECIF

IED

- W

ITH

OU

T M

ENTI

ON

OF

INTR

AC

TAB

LE E

PILE

PSY

34

5.91

EP

ILEP

SY, U

NSP

ECIF

IED

- W

ITH

IN

TRA

CTA

BLE

EPI

LEPS

Y

780.

31

FEB

RIL

E C

ON

VU

LSIO

NS

780.

39

OTH

ER C

ON

VU

LSIO

NS

780.

3 C

ON

VU

LSIO

NS

(OLD

CO

DE

NO

LO

NG

ER

VA

LID

) Se

lf in

flict

ed in

jury

IC

D-9

-CM

dia

gnos

is c

odes

: SU

ICID

E A

ND

SEL

F-IN

FLIC

TED

PO

ISO

NIN

G B

Y

SOLI

D O

R L

IQU

ID S

UB

STA

NC

E:

E950

.0

AN

ALG

ESIC

S, A

NTI

PYR

ETIC

S, A

ND

A

NTI

RH

EUM

ATI

CS

E950

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BA

RB

ITU

RA

TES

E950

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OTH

ER S

EDA

TIV

E A

ND

HY

PNO

TIC

S E9

50.3

TR

AN

QU

ILIZ

IER

S A

ND

OTH

ER

PSY

CH

OTR

OPI

C A

GEN

TS

E950

.4

OTH

ER S

PEC

IFIE

D D

RU

GS

AN

D

MED

ICIN

AL

SUB

STA

NC

ES

E950

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UN

SPEC

IFIE

D D

RU

G O

R M

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INA

L SU

BST

AN

CE

E950

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AG

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ULT

UR

AL

AN

D H

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ULT

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AL

CH

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AL

AN

D P

HA

RM

AC

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CA

L PR

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NS

OTH

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HA

N P

LAN

T FO

OD

S A

ND

FER

TILI

ZER

S E9

50.7

C

OR

RO

SIV

E A

ND

CA

UST

IC S

UB

STA

NC

ES

E950

.8

AR

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IC A

ND

ITS

CO

MPO

UN

DS

E950

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OTH

ER A

ND

UN

SPEC

IFIE

D S

OLI

D A

ND

LI

QU

ID S

UB

STA

NC

ES

SUIC

IDE

AN

D S

ELF-

INFL

ICED

PO

ISO

NIN

G B

Y

GA

SES

IN D

OM

ESTI

C U

SE:

E951

.0

GA

S D

ISTR

IBU

TED

BY

PIP

ELIN

E E9

51.1

LI

QU

EFIE

D P

ETR

OLE

UM

GA

S D

ISTR

IBU

TED

IN M

OB

ILE

CO

NTA

INER

S E9

51.8

O

THER

S U

TILI

TY G

ASE

S E9

52.0

M

OTO

R V

EHIC

LE E

XH

AU

ST G

AS

E952

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OTH

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AR

BO

N M

ON

OX

IDE

E952

.8

OTH

ER S

PEC

IFIE

D G

ASE

S A

ND

VA

POR

S E9

52.9

U

NSP

ECIF

IED

GA

SES

AN

D V

APO

RS

SUIC

IDE

AN

D S

ELF-

INFL

ICTE

D IN

JUR

Y B

Y

HA

NG

ING

, STR

AN

GU

LATI

ON

, AN

D S

UFF

OC

ATI

ON

: E9

53.0

H

AN

GIN

G

E953

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SUFF

OC

ATI

ON

BY

PLA

STIC

BA

G

E953

.8

OTH

ER S

PEC

IFIE

D M

EAN

S E9

54

SUIC

IDE

AN

D S

ELF-

INFL

ICTE

D IN

JUR

Y

BY

SU

BM

ERSI

ON

[DR

OW

NIN

G]

SUIC

IDE

AN

D S

ELF-

INFL

ICTE

D IN

JUR

Y B

Y

FIR

EAR

MS

AN

D E

XPL

OSI

VES

: E9

55.0

H

AN

DG

UN

E9

55.1

SH

OTG

UN

E9

55.2

H

UN

TIN

G R

IFLE

E9

55.3

M

ILIT

AR

Y F

IREA

RM

S E9

55.4

O

THER

AN

D U

NSP

ECIF

IED

FIR

EAR

MS

E955

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EXPL

OSI

VES

E9

55.9

U

NSP

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IED

E9

56

SUIC

IDE

AN

D S

ELF

INFL

ICTE

D IN

JUR

Y

BY

CU

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G A

ND

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RC

ING

IN

STR

UM

ENT

SUIC

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AN

D S

ELF-

INFL

ICTE

D IN

JUR

Y B

Y

JUM

PIN

G F

RO

M A

HIG

H P

LAC

E:

E957

.0

RES

IDEN

TIA

L PR

EMIS

ES

E957

.1

OTH

ER M

AN

-MA

DE

STR

UC

TUR

ES

E957

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NA

TUR

AL

SITE

S E9

57.3

U

NSP

ECIF

IED

SU

ICID

E A

ND

SEL

F-IN

FLIC

TED

INJU

RY

BY

OTH

ER

AN

D U

NSP

ECIF

IED

MEA

NS:

E9

58.0

JU

MPI

NG

OR

LY

ING

BEF

OR

E M

OV

ING

O

BJE

CT

E958

.1

BU

RN

S, F

IRE

E958

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SCA

LD

E958

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EXTR

EMES

OF

CO

LD

E958

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ELEC

TRO

CU

TIO

N

E958

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CR

ASH

ING

OF

MO

TOR

VEH

ICLE

E9

58.6

C

RA

SHIN

G O

F A

IRC

RA

FT

E958

.7

CA

UST

IC S

UB

STA

NC

ES E

XC

EPT

POIS

ON

ING

E9

58.8

O

THER

SPE

CIF

IED

MEA

NS

E958

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UN

SPEC

IFIE

D M

EAN

S Se

psis

IC

D-9

-CM

dia

gnos

is c

odes

: 03

8.0

STR

EPTO

CO

CC

AL

SEPT

ICEM

IA

A-53


038.

10

STA

PHY

LOC

OC

CA

L SE

PTIC

EMIA

, U

NSP

ECIF

IED

03

8.11

ST

APH

YLO

CO

CC

US

AU

REU

S SE

PTIC

EMIA

03

8.19

O

THER

STA

PHY

LOC

OC

CA

L SE

PTIC

EMIA

03

8.2

PNEU

MO

CO

CC

AL

SEPT

ICEM

IA

(STR

EPTO

CO

CC

US

PNEU

MO

NIA

E SE

PTIC

EMIA

) 03

8.3

SEPT

ICEM

IA D

UE

TO A

NA

ERO

BES

SE

PTIC

EMIA

DU

E TO

03

8.40

G

RA

M-N

EGA

TIV

E O

RG

AN

ISM

, U

NSP

ECIF

IED

03

8.41

H

EMO

PHIL

US

INFL

UEN

ZAE

038.

42

ESC

HER

ICH

IA C

OLI

03

8.43

PS

EUD

OM

ON

AS

038.

44

SER

RA

TIA

03

8.49

SE

PTIC

EMIA

DU

E TO

OTH

ER G

RA

M-

NEG

ATI

VE

OR

GA

NIS

MS

038.

8 O

THER

SPE

CIF

IED

SEP

TIC

EMIA

S 03

8.9

UN

SPEC

IFIE

D S

EPTI

CEM

IA

Shoc

k IC

D-9

-CM

dia

gnos

is c

odes

: SH

OC

K W

ITH

OU

T M

ENTI

ON

OF

TRA

UM

A:

785.

50

SHO

CK

, UN

SPEC

IFIE

D

785.

51

CA

RD

IOG

ENIC

SH

OC

K

785.

59

OTH

ER

Stro

ke

ICD

-9-C

M d

iagn

osis

cod

es:

430

SUB

AR

AC

HN

OID

HEM

OR

RH

AG

E 43

1 IN

TRA

CER

EBR

AL

HEM

OR

RH

AG

E 43

2.0

NO

NTR

AU

MA

TIC

EX

TRA

DU

RA

L H

EMO

RR

HA

GE

432.

1 SU

BD

UR

AL

HEM

OR

RH

AG

E 43

2.9

UN

SPEC

IFIE

D IN

TRA

CR

AN

IAL

HEM

OR

RH

AG

E 43

6 A

CU

TE, B

UT

ILL-

DEF

INED

C

EREB

RO

VA

SCU

LAR

DIS

EASE

O

CC

LUSI

ON

AN

D S

TEN

OSI

S O

F PR

ECER

EBR

AL

AR

TER

IES:

433.

01

BA

SILA

R A

RTE

RY

, WIT

H C

EREB

RA

L IN

FAR

CTI

ON

43

3.11

C

AR

OTI

D A

RTE

RY

, WIT

H C

EREB

RA

L IN

FAR

CTI

ON

43

3.21

V

ERTE

BR

AL

AR

TER

Y, W

ITH

CER

EBR

AL

INFA

RC

TIO

N

433.

31

MU

LTIP

LE A

ND

BIL

ATE

RA

L W

ITH

C

EREB

RA

L IN

FAR

CTI

ON

43

3.81

O

THER

SPE

CIF

IED

PR

ECER

EBR

AL

AR

TER

Y W

ITH

CER

EBR

AL

INFA

RC

TIO

N

433.

91

OC

CLU

SIO

N A

ND

STE

NO

SIS

OF

PREC

EREB

RA

L A

RTE

RIE

S, U

NSP

ECIF

IED

PR

ECER

EBR

AL

AR

TER

Y W

ITH

C

EREB

RA

L IN

FAR

CTI

ON

O

CC

LUSI

ON

OF

CER

EBR

AL

AR

TER

IES:

43

4.01

C

EREB

RA

L TH

RO

MB

OSI

S - W

ITH

C

EREB

RA

L IN

FAR

CTI

ON

43

4.11

C

EREB

RA

L EM

BO

LISM

- W

ITH

C

EREB

RA

L IN

FAR

CTI

ON

43

4.91

C

EREB

RA

L A

RTE

RY

OC

CLU

SIO

N,

UN

SPEC

IFIE

D -

WIT

H C

EREB

RA

L IN

FAR

CTI

ON

Su

rgic

al

Dia

gnos

tic R

elat

ed G

roup

s (D

RGs)

: 00

1 C

RA

NIO

TOM

Y, A

GE

GR

EATE

R T

HA

N 1

7 EX

CEP

T FO

R T

RA

UM

A

00

2 C

RA

NIO

TOM

Y F

OR

TR

AU

MA

, AG

E G

REA

TER

TH

AN

17

003

CR

AN

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MY

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17

004

SPIN

AL

PRO

CED

UR

ES

005

EXTR

AC

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NIA

L V

ASC

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R

PRO

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UR

ES

006

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NN

EL R

ELEA

SE

007

PER

IPH

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L A

ND

CR

AN

IAL

NER

VE

AN

D

OTH

ER N

ERV

OU

S SY

STEM

PR

OC

EDU

RES

W

ITH

CC

00

8 PE

RIP

HER

AL

AN

D C

RA

NIA

L N

ERV

E A

ND

O

THER

NER

VO

US

SYST

EM P

RO

CED

UR

ES

WIT

HO

UT

CC

03

6 R

ETIN

AL

PRO

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UR

ES

037

OR

BIT

AL

PRO

CED

UR

ES

038

PRIM

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IS P

RO

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UR

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039

LEN

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RES

WIT

H O

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ITH

OU

T V

ITR

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040

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AO

CU

LAR

PR

OC

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RES

EX

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RB

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GE

GR

EATE

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7 04

1 EX

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App

endix

A:

MQ

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Patie

nt S

afety

Mea

sure

Speci

ficat

ions a

nd M

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s

A-58

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42

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Ex

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[I

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DIA

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RR

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A-63


SHO

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9.10

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OR

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669.

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ELIV

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CO

MPL

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TIO

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669.

13

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PAR

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OR

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MPL

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TIO

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669.

14

SHO

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AN

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ELIV

ERY

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7.5

CA

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53

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App

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A P P E N D I X B D E T A I L E D T A B L E S

B-3 Table Page

B.1 MQMS Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges Overall U.S. and by Gender, 2000 and 2001...............................................................................................................5

B.2 MQMS Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S.

and by Age Groups up to Age 74, 2000 and 2001..................................................................................6 B.3 MQMS Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S.

and by Age Groups Age 75 through 95+, 2000 and 2001.......................................................................7 B.4 Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S. and

by Racial Groups, 2000 and 2001...........................................................................................................8 B.5 Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S. and by

Reason for Medicare Entitlement, 2000 and 2001..................................................................................9 B.6 Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S. and by

Dual Eligible Status, 2000 and 2001 .....................................................................................................10 B.7 Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S. and by

Beneficiary Residence in Urban or Rural Location, 2000 and 2001 .....................................................11 B.8 Patient Safety Measure Rates per 1,000 Eligible Hospital Discharges, Overall U.S. and by

Region of the U.S. 2000 and 2001 ........................................................................................................12 B.9 Frequency of Specific Complications Among Discharges with Anesthesia Complications and

Reactions (N=1,516) .............................................................................................................................13 B.10 Ten Most Frequent DRGs Among Discharges with Anesthesia Complications and Reactions

(N=1,512) ............................................................................................................................................14 B.11 DRGs with the Ten Highest Rates of Anesthetic Complications and Reactions, Among

all Discharges Eligible for That Outcome ..............................................................................................15 B.12 Ten Most Frequent Procedures Among Discharges with Postoperative Hemorrhage or Hematoma

(N = 14,891)...........................................................................................................................................16 B.13 Ten Most Frequent DRGs Among Discharges with Postoperative Hemorrhage or Hematoma

(N = 14,891)...........................................................................................................................................17 B.14 Ten DRGs with the Highest Rates of Postoperative Hemorrhage or Hematoma, Among

all Discharges Eligible for That Outcome ..............................................................................................18 B.15 Frequency of Specific Complications Among Discharges with Postoperative Metabolic

and Physiologic Derangements (N=4,272)............................................................................................19 B.16 Ten Most Frequent Procedures Among Discharges with Postoperative Metabolic or Physiologic

Derangements (N = 4,199)....................................................................................................................20 B.17 Ten Most Frequent DRGs Among Discharges with Postoperative Metabolic or Physiologic

Derangement (N = 4,199)......................................................................................................................21 B.18 DRGs with the Ten Highest Rates of Postoperative Physiologic or Metabolic Derangement,

Among all Discharges Eligible for That Outcome..................................................................................22 B.19 Ten Most Frequent DRGs Among Discharges with Postoperative Respiratory Failure

(N = 18,087)...........................................................................................................................................23

B-4

Table Page

B.20 DRGs with the Ten Highest Rates of Postoperative Respiratory Failure, Among all Discharges Eligible for That Outcome......................................................................................................................24

B.21 Frequency of Specific Complications Among Discharges with Postoperative Septicemia

(N = 14,393)...........................................................................................................................................25 B.22 Ten Most Frequent Procedures Among Discharges with Postoperative Septicemia (N = 14,069)......26 B.23 Ten Most Frequent DRGs Among Discharges with Postoperative Septicemia (N = 14,069) ..............27 B.24 DRGs with the Ten Highest Rates of Postoperative Septicemia, Among all Discharges Eligible for

That Outcome........................................................................................................................................28 B.25 Ten Most Frequent Procedures Among Discharges with Postoperative Wound Dehiscence

(N = 4,201) ............................................................................................................................................29 C.1 Comparison of Stanford/AHRQ Results Using HCUP Nationwide Inpatient Sample Data and MQMS

Results: Overall US and by White or African-American (Events per 1,000 Discharges) ........................3

B-

5

Tabl

e B

.1 M

QM

S Pa

tient

Saf

ety

Mea

sure

Rat

es p

er 1

,000

Elig

ible

Hos

pita

l Dis

char

ges

Ove

rall

U.S

. and

by

Gen

der,

2000

and

200

1

Ove

rall

US

M

ale

Fem

ale

(N

umer

ator

/Den

omin

ator

) (N

umer

ator

/Den

omin

ator

) (N

umer

ator

/Den

omin

ator

) A

nest

hetic

com

plic

atio

ns a

nd

reac

tions

0.

24

0.21

0.

26

(1

,512

/6,3

34,9

55)

(614

/2,9

41,3

76)

(898

/3,3

93,5

79)

Dec

ubitu

s ul

cer

27.3

7 27

.41

27.2

4

(270

,515

/8,8

27,8

16)

(109

,733

/3,7

47,5

02)

(160

,782

/5,0

80,3

14)

Fore

ign

body

left

in d

urin

g pr

oced

ure

0.07

9 0.

082

0.07

6

(1,6

25/2

2,10

0,60

8)

(761

/9,5

42,0

03)

(864

/12,

558,

605)

Ia

troge

nic

pneu

mot

hora

x 1.

04

0.94

1.

11

(2

1,22

9/19

,988

,288

) (8

,281

/8,6

45,4

46)

(12,

948/

11,3

42,8

42)

Sel

ecte

d in

fect

ions

due

to m

edic

al

care

3.

22

3.21

3.

26

(5

3,09

9/18

,203

,102

) (2

4,08

9/7,

607,

494)

(2

9,01

0/10

,595

,608

) M

QM

S in

patie

nt h

ip fr

actu

re

3.54

2.

53

4.07

(23,

035/

6,33

3,98

5)

(6,9

16/2

,940

,822

) (1

6,11

9/3,

393,

163)

A

HR

Q P

osto

pera

tive

hip

fract

ure

1.82

1.

34

2.09

(7,4

17/4

,217

,677

) (2

,621

/2,1

53,2

35)

(4,7

96/2

,064

,442

) P

osto

pera

tive

hem

orrh

age

or

hem

atom

a 2.

34

2.66

2.

12

(1

4,89

1/6,

329,

226)

(7

,852

/2,9

41,3

76)

(7,0

39/3

,387

,850

) P

osto

pera

tive

phys

iolo

gic

or

met

abol

ic p

robl

em

1.43

1.

79

1.10

(4,1

99/3

,128

,714

) (2

,467

/1,4

69,9

18)

(1,7

32/1

,658

,796

) P

osto

pera

tive

resp

irato

ry fa

ilure

7.

85

9.18

6.

83

(1

8,08

7/2,

314,

370)

(9

,068

/988

,972

) (9

,019

/1,3

25,3

98)

Pos

tope

rativ

e se

ptic

emia

13

.44

15.9

5 11

.57

(1

4,06

9/1,

081,

253)

(7

,478

/485

,293

) (6

,591

/595

,960

) P

osto

pera

tive

wou

nd d

ehis

cenc

e 3.

70

5.65

2.

26

(4

,201

/1,1

06,7

14)

(2,8

08/4

95,5

85)

(1,3

93/6

11,1

29)

SOU

RCE

: Co

mbi

ned

2000

and

200

1 M

QM

S da

ta ff

rom

Med

icare

clai

ms a

nd e

nrol

lmen

t dat

a.

NO

TE:

Bot

h m

ale

and

fem

ale

subg

roup

s ad

just

ed to

the

age

dist

ribut

ion

of th

e Ju

ly 1

999

Med

icar

e P

art A

FFS

pop

ulat

ion

usin

g ni

ne a

ge g

roup

s. R

esul

ts o

btai

ned

usin

g A

HR

Q

softw

are

dow

nloa

ded

May

31,

200

3 (A

HR

Q 2

003)

.

B-6

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.2

MQ

MS

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y A

ge G

roup

s up

to A

ge 7

4, 2

000

and

2001

O

vera

ll U

S

50-5

4 55

-64

65-6

9 70

-74

(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)A

nest

hetic

com

plic

atio

ns a

nd

reac

tions

0.

24

0.16

0.

22

0.25

0.

25

(1

,512

/6,3

34,9

55)

(63/

415,

258)

(8

3/39

3,14

5)

(276

/1,1

11,9

08)

(327

/1,3

20,7

40)

Dec

ubitu

s ul

cer

27.3

7 19

.54

26.0

8 23

.00

21.9

6

(270

,515

/8,8

27,8

16)

(11,

892/

600,

846)

(1

4,11

1/53

7,71

2)

(25,

577/

1,11

6,94

1)

(31,

317/

1,42

7,19

4)

Fore

ign

body

left

in d

urin

g pr

oced

ure

0.07

9 0.

083

0.09

3 0.

091

0.09

2

(1,6

25/2

2,10

0,60

8)

(142

/1,7

24,8

54)

(133

/1,4

09,5

83)

(275

/3,0

36,0

73)

(348

/3,7

63,4

57)

Iatro

geni

c pn

eum

otho

rax

1.04

0.

76

0.87

1.

00

1.04

(21,

229/

19,9

88,2

88)

(1,1

98/1

,608

,816

) (1

,122

/1,3

13,2

25)

(2,7

25/2

,764

,442

) (3

,511

/3,4

05,1

28)

Sel

ecte

d in

fect

ions

due

to

med

ical

car

e 3.

22

7.00

5.

38

4.16

2.

44

(5

3,09

9/18

,203

,102

) (1

0,19

1/1,

473,

614)

(6

,449

/1,2

06,9

95)

(10,

198/

2,45

9,99

1)

(7,3

64/3

,014

,125

) M

QM

S in

patie

nt h

ip fr

actu

re

3.54

1.

22

1.57

1.

35

1.95

(23,

035/

6,33

3,98

5)

(552

/429

,564

) (6

34/4

08,3

53)

(1,5

11/1

,149

,552

) (2

,569

/1,3

54,4

62)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

0.41

0.

80

0.67

0.

91

(7

,417

/4,2

17,6

77)

(127

/294

,463

) (2

17/2

84,4

01)

(492

/779

,721

) (7

72/8

98,1

56)

Pos

tope

rativ

e he

mor

rhag

e or

he

mat

oma

2.34

3.

15

2.47

2.

21

2.17

(14,

891/

6,32

9,22

6)

(1,3

08/4

09,5

31)

(972

/393

,143

) (2

,484

/1,1

11,9

08)

(2,9

19/1

,320

,740

) P

osto

pera

tive

phys

iolo

gic

or

met

abol

ic p

robl

em

1.43

3.

62

2.18

1.

15

1.00

(4,1

99/3

,128

,714

) (7

23/1

96,4

16)

(426

/189

,225

) (7

27/6

22,7

71)

(766

/744

,044

) P

osto

pera

tive

resp

irato

ry

failu

re

7.85

7.

47

9.72

6.

37

6.86

(18,

087/

2,31

4,37

0)

(1,2

07/1

61,7

11)

(1,3

08/1

33,9

37)

(2,9

16/4

56,2

59)

(3,7

70/5

48,1

89)

Pos

tope

rativ

e se

ptic

emia

13

.44

22.5

5 20

.04

12.1

3 10

.12

(1

4,06

9/1,

081,

253)

(1

,557

/68,

262)

(1

,435

/70,

594)

(2

,465

/200

,586

) (2

,540

/247

,896

) P

osto

pera

tive

wou

nd

dehi

scen

ce

3.70

3.

08

4.46

3.

24

3.91

(4,2

01/1

,106

,714

) (2

99/9

8,76

0)

(305

/65,

198)

(7

02/2

05,2

45)

(961

/234

,149

)

SO

UR

CE:

C

ombi

ned

2000

and

200

1 M

QM

S d

ata

from

Med

icar

e cl

aim

s an

d en

rollm

ent d

ata.

N

OTE

: A

ge s

ubgr

oups

adj

uste

d to

the

sex

dist

ribut

ion

of th

e Ju

ly 1

999

Med

icar

e P

art A

FFS

pop

ulat

ion.

R

esul

ts o

btai

ned

usin

g A

HR

Q s

oftw

are

dow

nloa

ded

May

31,

200

3 (A

HR

Q 2

003)

.

B-7

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.3

MQ

MS

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y A

ge G

roup

s A

ge 7

5 th

roug

h 95

+, 2

000

and

2001

Ove

rall

US

75

-79

80-8

4 85

-89

90-9

4 95

+

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

Ane

sthe

tic c

ompl

icat

ions

and

re

actio

ns

0.24

0.

25

0.23

0.

26

0.26

0.

32

(1

,512

/6,3

34,9

55)

(327

/1,3

22,6

28)

(220

/964

,472

) (1

44/5

42,3

39)

(55/

207,

366)

(1

7/57

,099

) D

ecub

itus

ulce

r 27

.37

27.0

9 33

.87

41.4

3 52

.15

66.0

0

(270

,515

/8,8

27,8

16)

(45,

722/

1,68

7,67

3)

(52,

617/

1,55

6,20

3)

(47,

553/

1,15

1,58

5)

(29,

319/

563,

479)

(1

2,40

7/18

6,18

3)

Fore

ign

body

left

in d

urin

g pr

oced

ure

0.07

9 0.

078

0.05

9 0.

054

0.02

7 0.

020

(1

,625

/22,

100,

608)

(3

28/4

,199

,325

) (2

16/3

,690

,434

) (1

40/2

,608

,928

) (3

5/1,

256,

879)

(8

/411

,075

) Ia

troge

nic

pneu

mot

hora

x 1.

04

1.14

1.

16

1.23

1.

14

1.07

(21,

229/

19,9

88,2

88)

(4,3

12/3

,789

,475

) (3

,879

/3,3

18,8

00)

(2,8

69/2

,325

,793

) (1

,256

/1,1

05,2

37)

(357

/357

,372

) S

elec

ted

infe

ctio

ns d

ue to

m

edic

al c

are

3.22

2.

31

2.02

1.

57

1.23

0.

90

(5

3,09

9/18

,203

,102

) (7

,836

/3,3

90,9

62)

(6,0

61/3

,027

,088

) (3

,378

/2,1

87,0

24)

(1,3

08/1

,080

,236

) (3

14/3

63,0

67)

MQ

MS

inpa

tient

hip

frac

ture

3.

54

3.21

5.

50

9.31

13

.82

16.5

0

(23,

035/

6,33

3,98

5)

(4,1

69/1

,322

,066

) (5

,130

/928

,923

) (4

,904

/507

,360

) (2

,732

/185

,864

) (8

34/4

7,84

1)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

1.51

2.

81

5.03

8.

23

11.4

6

(7,4

17/4

,217

,677

) (1

,281

/883

,741

) (1

,699

/620

,871

) (1

,621

/322

,714

) (9

10/1

07,7

76)

(298

/25,

834)

P

osto

pera

tive

hem

orrh

age

or

hem

atom

a 2.

34

2.49

2.

29

2.37

1.

81

1.09

(14,

891/

6,32

9,22

6)

(3,3

32/1

,322

,628

) (2

,204

/964

,472

) (1

,264

/542

,339

) (3

54/2

07,3

66)

(54/

57,0

99)

Pos

tope

rativ

e ph

ysio

logi

c or

m

etab

olic

pro

blem

1.

43

1.07

1.

22

1.13

0.

92

0.92

(4,1

99/3

,128

,714

) (7

58/6

92,4

71)

(534

/434

,084

) (2

13/1

89,1

84)

(43/

50,3

64)

(9/1

0,15

5)

Pos

tope

rativ

e re

spira

tory

fa

ilure

7.

85

7.93

9.

35

10.1

4 11

.03

9.43

(18,

087/

2,31

4,37

0)

(4,0

09/5

07,1

75)

(2,9

65/3

19,5

75)

(1,4

22/1

41,6

98)

(416

/38,

134)

(7

4/7,

692)

P

osto

pera

tive

sept

icem

ia

13.4

4 10

.91

12.5

5 15

.33

16.5

3 22

.20

(1

4,06

9/1,

081,

253)

(2

,656

/242

,188

) (1

,950

/156

,849

) (1

,053

/70,

338)

(3

14/1

9,88

7)

(99/

4,65

3)

Pos

tope

rativ

e w

ound

de

hisc

ence

3.

70

4.07

3.

69

3.76

4.

40

4.43

(4,2

01/1

,106

,714

) (9

08/2

20,3

91)

(573

/157

,508

) (3

09/8

7,46

3)

(119

/31,

031)

(2

5/6,

969)

S

OU

RC

E:

Com

bine

d 20

00 a

nd 2

001

MQ

MS

dat

a fro

m M

edic

are

clai

ms

and

enro

llmen

t dat

a.

NO

TE:

Age

sub

grou

ps a

djus

ted

to th

e se

x di

strib

utio

n of

the

July

199

9 M

edic

are

Par

t A F

FS p

opul

atio

n. R

esul

ts o

btai

ned

usin

g A

HR

Q s

oftw

are

dow

nloa

ded

May

31,

20

03 (A

HR

Q 2

003)

.

B-8

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.4

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y R

acia

l Gro

ups,

200

0 an

d 20

01

O

vera

ll U

S

Whi

te

Afri

can-

Am

eric

an

Oth

er

Unk

now

n

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

Ane

sthe

tic c

ompl

icat

ions

an

d re

actio

ns

0.24

0.

24

0.21

0.

21

0.10

(1,5

12/6

,334

,955

) (1

,357

/5,5

30,8

27)

(109

/569

,404

) (4

4/22

2,57

9)

(2/1

2,14

5)

Dec

ubitu

s ul

cer

27.3

7 23

.64

54.5

5 30

.99

33.8

1

(270

,515

/8,8

27,8

16)

(196

,144

/7,3

22,8

52)

(61,

473/

1,11

3,17

0)

(11,

815/

367,

433)

(1

,083

/24,

361)

Fo

reig

n bo

dy le

ft in

dur

ing

proc

edur

e 0.

079

0.08

4 0.

058

0.05

5 0.

049

(1

,625

/22,

100,

608)

(1

,426

/18,

633,

443)

(1

46/2

,540

,492

) (5

1/87

0,50

2)

(2/5

6,17

1)

Iatro

geni

c pn

eum

otho

rax

1.04

1.

06

0.98

0.

76

1.59

(21,

229/

19,9

88,2

88)

(18,

273/

16,7

23,6

29)

(2,2

80/2

,407

,447

) (6

12/8

06,7

33)

(64/

50,4

79)

Sel

ecte

d in

fect

ions

due

to

med

ical

car

e 3.

22

2.78

5.

16

4.08

4.

45

(5

3,09

9/18

,203

,102

) (3

7,62

1/15

,278

,316

) (1

2,33

7/2,

134,

455)

(3

,008

/743

,392

) (1

33/4

6,93

9)

MQ

MS

inpa

tient

hip

frac

ture

3.

54

3.68

2.

31

2.87

3.

19

(2

3,03

5/6,

333,

985)

(2

1,23

8/5,

530,

462)

(1

,171

/569

,167

) (5

49/2

22,2

11)

(77/

12,1

45)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

1.90

1.

31

1.54

1.

58

(7

,417

/4,2

17,6

77)

(6,7

14/3

,625

,351

) (4

79/4

21,7

00)

(198

/163

,103

) (2

6/7,

523)

P

osto

pera

tive

hem

orrh

age

or h

emat

oma

2.34

2.

25

2.77

2.

47

2.54

(14,

891/

6,32

9,22

6)

(12,

593/

5,52

7,32

4)

(1,6

84/5

67,6

58)

(577

/222

,106

) (3

7/12

,138

) P

osto

pera

tive

phys

iolo

gic

or

met

abol

ic p

robl

em

1.43

1.

24

2.53

2.

38

1.23

(4,1

99/3

,128

,714

) (3

,289

/2,8

00,0

87)

(642

/227

,114

) (2

59/9

6,99

1)

(9/4

,522

) P

osto

pera

tive

resp

irato

ry

failu

re

7.85

7.

51

12.0

9 9.

18

12.2

1

(18,

087/

2,31

4,37

0)

(15,

608/

2,08

0,59

8)

(1,8

12/1

60,6

75)

(627

/69,

636)

(4

0/3,

461)

P

osto

pera

tive

sept

icem

ia

13.4

4 11

.81

26.3

3 17

.85

24.1

9

(14,

069/

1,08

1,25

3)

(10,

951/

953,

954)

(2

,438

/90,

477)

(6

38/3

5,14

8)

(42/

1,67

4)

Pos

tope

rativ

e w

ound

de

hisc

ence

3.

70

3.73

4.

09

2.87

2.

93

(4

,201

/1,1

06,7

14)

(3,6

62/9

56,2

18)

(408

/105

,804

) (1

25/4

2,46

4)

(6/2

,228

) S

OU

RC

E:

Com

bine

d 20

00 a

nd 2

001

MQ

MS

dat

a fro

m M

edic

are

clai

ms

and

enro

llmen

t dat

a.

NO

TE:

Rac

ial s

ubgr

oups

adj

uste

d to

the

age

and

sex

dis

tribu

tion

of t

he J

uly

1999

Med

icar

e P

art

A F

FS p

opul

atio

n us

ing

18 a

ge a

nd s

ex c

ells

. R

esul

ts

obta

ined

usi

ng A

HR

Q s

oftw

are

dow

nloa

ded

May

31,

200

3 (A

HR

Q 2

003)

.

B-9

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.5

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y R

easo

n fo

r Med

icar

e En

title

men

t, 20

00 a

nd 2

001

Ove

rall

US

A

ged

Dis

able

d E

SR

D

(N

umer

ator

/Den

omin

ator

) (N

umer

ator

/Den

omin

ator

) (N

umer

ator

/Den

omin

ator

) (N

umer

ator

/Den

omin

ator

) A

nest

hetic

com

plic

atio

ns a

nd re

actio

ns

0.24

0.

37

0.17

0.

21

(1

,512

/6,3

34,9

55)

(1,3

34/5

,367

,769

) (1

19/6

52,0

22)

(59/

315,

164)

D

ecub

itus

ulce

r 27

.37

29.1

0 20

.87

45.5

8

(270

,515

/8,8

27,8

16)

(231

,874

/7,4

40,1

38)

(19,

940/

940,

633)

(1

8,70

1/44

7,04

5)

Fore

ign

body

left

in d

urin

g pr

oced

ure

0.07

9 0.

0784

0.

0820

0.

0827

(1,6

25/2

2,10

0,60

8)

(1,3

15/1

8,45

7,75

4)

(223

/2,6

72,5

48)

(87/

970,

306)

Ia

troge

nic

pneu

mot

hora

x 1.

04

1.17

0.

77

1.45

(21,

229/

19,9

88,2

88)

(18,

203/

16,5

86,2

25)

(1,9

52/2

,482

,027

) (1

,074

/920

,036

) S

elec

ted

infe

ctio

ns d

ue to

med

ical

car

e 3.

22

2.91

3.

65

19.4

1

(53,

099/

18,2

03,1

02)

(27,

858/

15,0

75,6

41)

(8,3

73/2

,326

,143

) (1

6,86

8/80

1,31

8)

MQ

MS

inpa

tient

hip

frac

ture

3.

54

4.05

1.

55

2.38

(23,

035/

6,33

3,98

5)

(21,

510/

5,36

7,76

9)

(983

/651

,957

) (5

42/3

14,2

59)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

2.16

0.

55

1.72

(7,4

17/4

,217

,677

) (6

,836

/3,5

00,1

65)

(253

/441

,748

) (3

28/2

75,7

64)

Pos

tope

rativ

e he

mor

rhag

e or

hem

atom

a 2.

34

2.29

2.

20

4.10

(14,

891/

6,32

9,22

6)

(12,

017/

5,36

7,76

9)

(1,4

04/6

46,4

08)

(1,4

70/3

15,0

49)

Pos

tope

rativ

e ph

ysio

logi

c or

met

abol

ic p

robl

em

1.43

2.

21

1.09

19

.56

(4

,199

/3,1

28,7

14)

(2,2

20/2

,689

,160

) (3

33/3

26,8

71)

(1,6

46/1

12,6

83)

Pos

tope

rativ

e re

spira

tory

failu

re

7.85

13

.45

7.98

17

.48

(1

8,08

7/2,

314,

370)

(1

5,09

1/1,

994,

881)

(2

,045

/262

,847

) (9

51/5

6,64

2)

Pos

tope

rativ

e se

ptic

emia

13

.44

16.5

2 14

.84

50.7

4

(14,

069/

1,08

1,25

3)

(9,8

23/9

18,8

30)

(1,7

08/1

18,5

75)

(2,5

38/4

3,84

8)

Pos

tope

rativ

e w

ound

deh

isce

nce

3.70

4.

22

4.37

2.

45

(4

,201

/1,1

06,7

14)

(3,5

41/9

24,2

59)

(501

/128

,635

) (1

59/5

3,82

0)

SO

UR

CE:

C

ombi

ned

2000

and

200

1 M

QM

S d

ata

from

Med

icar

e cl

aim

s an

d en

rollm

ent d

ata.

N

OTE

: Th

e E

SR

D s

ubgr

oup

com

pris

es th

e D

isab

led

with

ES

RD

, ES

RD

onl

y, a

nd A

ged

with

ES

RD

ent

itlem

ent c

ateg

orie

s, th

e D

isab

led

subg

roup

cor

resp

onds

to

the

Dis

able

d w

ithou

t E

SR

D e

ntitl

emen

t ca

tego

ry,

and

the

Age

d su

bgro

up c

orre

spon

ds t

o th

e A

ged

with

out

ES

RD

ent

itlem

ent

cate

gory

. T

he

subg

roup

s ha

ve b

een

adju

sted

to th

e ag

e an

d se

x di

strib

utio

n of

the

July

199

9 M

edic

are

Par

t A F

FS p

opul

atio

n us

ing

18 a

ge a

nd s

ex c

ells

. To

mak

e up

for t

he a

bsen

ce o

f cas

es le

ss th

an a

ge 6

5, th

e ag

e-se

x ad

just

ed ra

tes

for t

he A

ged

subg

roup

hav

e be

en “r

einf

late

d” b

y di

vidi

ng b

y th

e pr

opor

tion

of

bene

ficia

ries

over

age

65

in th

e re

fere

nce

popu

latio

n (0

.845

3).

The

age-

sex

adju

sted

rat

es fo

r th

e D

isab

led

subg

roup

hav

e lik

ewis

e be

en d

ivid

ed b

y 0.

1547

(see

App

endi

x A

for f

urth

er d

etai

ls).

Res

ults

obt

aine

d us

ing

AH

RQ

sof

twar

e do

wnl

oade

d M

ay 3

1, 2

003

(AH

RQ

200

3).

B-10

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.6 P

atie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y D

ual E

ligib

le S

tatu

s, 2

000

and

2001

Ove

rall

US

D

ual E

ligib

le

Non

-dua

l Elig

ible

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

Ane

sthe

tic c

ompl

icat

ions

and

reac

tions

0.

24

0.17

0.

25

(1

,512

/6,3

34,9

55)

(203

/1,1

56,6

77)

(1,3

09/5

,178

,278

) D

ecub

itus

ulce

r 27

.37

44.0

2 22

.54

(2

70,5

15/8

,827

,816

) (1

01,9

32/2

,275

,886

) (1

68,5

83/6

,551

,930

) Fo

reig

n bo

dy le

ft in

dur

ing

proc

edur

e 0.

079

0.06

2 0.

083

(1

,625

/22,

100,

608)

(3

42/5

,524

,296

) (1

,283

/16,

576,

312)

Ia

troge

nic

pneu

mot

hora

x 1.

04

0.96

1.

06

(2

1,22

9/19

,988

,288

) (4

,790

/5,1

13,2

51)

(1,2

83/1

6,57

6,31

2)

Sel

ecte

d in

fect

ions

due

to m

edic

al c

are

3.22

3.

85

2.95

(53,

099/

18,2

03,1

02)

(19,

634/

4,80

9,11

7)

(33,

465/

13,3

93,9

85)

MQ

MS

inpa

tient

hip

frac

ture

3.

54

4.64

3.

36

(2

3,03

5/6,

333,

985)

(1

7,90

2/5,

178,

041)

(5

,133

/1,1

55,9

44)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

2.43

1.

72

(7

,417

/4,2

17,6

77)

(1,7

21/7

99,2

08)

(5,6

96/3

,418

,469

) P

osto

pera

tive

hem

orrh

age

or h

emat

oma

2.34

2.

43

2.31

(14,

891/

6,32

9,22

6)

(2,8

60/1

,152

,345

) (1

2,03

1/5,

176,

881)

P

osto

pera

tive

phys

iolo

gic

or m

etab

olic

pro

blem

1.

43

2.00

1.

36

(4

,199

/3,1

28,7

14)

(1,0

18/4

59,6

66)

(3,1

81/2

,669

,048

) P

osto

pera

tive

resp

irato

ry fa

ilure

7.

85

12.6

8 7.

23

(1

8,08

7/2,

314,

370)

(3

,783

/337

,534

) (1

4,30

4/1,

976,

836)

P

osto

pera

tive

sept

icem

ia

13.4

4 21

.96

11.7

8

(14,

069/

1,08

1,25

3)

(4,0

17/1

83,7

92)

(10,

052/

897,

461)

P

osto

pera

tive

wou

nd d

ehis

cenc

e 3.

70

5.66

3.

41

(4

,201

/1,1

06,7

14)

(959

/206

,960

) (3

,242

/899

,754

) S

OU

RC

E:

Com

bine

d 20

00 a

nd 2

001

MQ

MS

dat

a fro

m M

edic

are

clai

ms

and

enro

llmen

t dat

a.

NO

TE:

The

dual

elig

ibili

ty s

ubgr

oups

hav

e be

en a

djus

ted

to th

e ag

e an

d se

x di

strib

utio

n of

the

July

199

9 M

edic

are

Par

t A F

FS p

opul

atio

n us

ing

18 a

ge a

nd s

ex

cells

. R

esul

ts o

btai

ned

usin

g A

HR

Q s

oftw

are

dow

nloa

ded

May

31,

200

3 (A

HR

Q 2

003)

.

B-11

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.7

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y B

enef

icia

ry R

esid

ence

in U

rban

or R

ural

Lo

catio

n, 2

000

and

2001

Ove

rall

US

U

rban

R

ural

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

(Num

erat

or/D

enom

inat

or)

Ane

sthe

tic c

ompl

icat

ions

and

reac

tions

0.

24

0.24

0.

24

(1

,512

/6,3

34,9

55)

(1,0

89/4

,550

,990

) (4

23/1

,783

,965

) D

ecub

itus

ulce

r 27

.37

29.5

3 21

.35

(2

70,5

15/8

,827

,816

) (2

14,5

59/6

,480

,246

) (5

5,95

6/2,

347,

570)

Fo

reig

n bo

dy le

ft in

dur

ing

proc

edur

e 0.

079

0.07

8 0.

081

(1

,625

/22,

100,

608)

(1

,137

/15,

761,

553)

(4

88/6

,339

,055

) Ia

troge

nic

pneu

mot

hora

x 1.

04

1.08

0.

95

(2

1,22

9/19

,988

,288

) (1

5,71

7/14

,243

,239

) (5

,512

/5,7

45,0

49)

Sel

ecte

d in

fect

ions

due

to m

edic

al c

are

3.22

3.

57

2.37

(53,

099/

18,2

03,1

02)

(41,

700/

12,8

91,0

49)

(11,

399/

5,31

2,05

3)

MQ

MS

inpa

tient

hip

frac

ture

3.

54

3.51

3.

64

(2

3,03

5/6,

333,

985)

(6

,408

/1,7

83,7

67)

(16,

627/

4,55

0,21

8)

AH

RQ

Pos

tope

rativ

e hi

p fra

ctur

e 1.

82

1.85

1.

73

(7

,417

/4,2

17,6

77)

(5,5

12/3

,035

,681

) (1

,905

/1,1

81,9

96)

Pos

tope

rativ

e he

mor

rhag

e or

hem

atom

a 2.

34

2.33

2.

39

(1

4,89

1/6,

329,

226)

(1

0,56

0/4,

546,

711)

(4

,331

/1,7

82,5

15)

Pos

tope

rativ

e ph

ysio

logi

c or

met

abol

ic p

robl

em

1.43

1.

51

1.23

(4,1

99/3

,128

,714

) (3

,112

/2,2

18,7

02)

(1,0

87/9

10,0

12)

Pos

tope

rativ

e re

spira

tory

failu

re

7.85

8.

06

7.34

(18,

087/

2,31

4,37

0)

(13,

174/

1,64

4,71

5)

(4,9

13/6

69,6

55)

Pos

tope

rativ

e se

ptic

emia

13

.44

14.0

4 12

.16

(1

4,06

9/1,

081,

253)

(1

0,13

9/75

0,27

3)

(3,9

30/3

30,9

80)

Pos

tope

rativ

e w

ound

deh

isce

nce

3.70

3.

65

3.85

(4,2

01/1

,106

,714

) (2

,952

/793

,388

) (1

,249

/313

,326

) S

OU

RC

E:

Com

bine

d 20

00 a

nd 2

001

MQ

MS

dat

a fro

m M

edic

are

clai

ms

and

enro

llmen

t dat

a.

NO

TE:

The

urba

n an

d ru

ral s

ubgr

oups

hav

e be

en a

djus

ted

to th

e ag

e an

d se

x di

strib

utio

n of

the

July

199

9 M

edic

are

Par

t A F

FS p

opul

atio

n us

ing

18 a

ge a

nd

sex

cells

. R

esul

ts o

btai

ned

usin

g A

HR

Q s

oftw

are

dow

nloa

ded

May

31,

200

3 (A

HR

Q 2

003)

.

B-12

App

endix

B:

Deta

iled

Table

s

Tabl

e B

.8

Patie

nt S

afet

y M

easu

re R

ates

per

1,0

00 E

ligib

le H

ospi

tal D

isch

arge

s, O

vera

ll U

.S. a

nd b

y R

egio

n of

the

U.S

. 200

0 an

d 20

01

O

vera

ll U

S

Nor

thea

st

Mid

wes

t W

est

Sou

th

(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)(N

umer

ator

/Den

omin

ator

)A

nest

hetic

com

plic

atio

ns

and

reac

tions

0.

24

0.21

0.

22

0.28

0.

26

(1

,512

/6,3

34,9

55)

(252

/1,1

76,8

09)

(355

/1,6

76,1

31)

(249

/882

,360

) (6

48/2

,533

,202

) D

ecub

itus

ulce

r 27

.37

30.7

0 23

.75

25.2

8 28

.85

(2

70,5

15/8

,827

,816

) (6

6,93

7/1,

913,

259)

(5

5,53

9/2,

144,

793)

(2

7,69

0/99

6,11

8)

(117

,512

/3,6

30,6

79)

Fore

ign

body

left

in d

urin

g pr

oced

ure

0.07

9 0.

080

0.07

5 0.

108

0.07

4

(1,6

25/2

2,10

0,60

8)

(318

/4,3

16,5

52)

(390

/5,6

89,3

31)

(289

/2,8

06,9

05)

(620

/9,0

07,2

76)

Iatro

geni

c pn

eum

otho

rax

1.04

1.

10

0.99

1.

13

1.04

(21,

229/

19,9

88,2

88)

(4,4

41/3

,910

,511

) (5

,228

/5,1

23,6

55)

(2,8

86/2

,515

,265

) (8

,630

/8,1

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B-13

Appendix B: Detailed Tables

Table B.9 Frequency of Specific Complications Among Discharges with Anesthesia Complications and Reactions (N=1,516)a

Description of Specific Complication (ICD-9-CM code)

Number of this

complication

Percent of All Anesthetic

Complications Adverse effects of unspecified general anesthetics (E9384)b 742 48.9 Adverse effects of unspecified spinal anesthetics (E9387) 289 19.1 Adverse effects of intravenous anesthetics (E9383)c 142 9.4 Adverse effects of peripheral nerve and plexus blocking agents (E9386) 125 8.2 Adverse effects of non-halothane inhaled anesthetics (E9382)d 82 5.4 Adverse effects of surface and infiltration anesthetics (E9385) 56 3.7 Adverse effects of other and unspecified local anesthetics (E9389)e 42 2.8 Poisoning by unspecified general anesthetics (9684)f 12 0.8 Poisoning by intravenous anesthetics (9683)c 7 0.5 Poisoning by spinal anesthetics (9687) 5 0.3 Accidental poisoning by other central nervous system depressants (E8551)g

5 0.3

Poisoning by non-halothane inhaled anesthetics (9682)d 3 0.2 Adverse effects of halothane (E9381) 2 0.1 Misplaced endotracheal tube (E8763) 2 0.1 Poisoning by halothane (9681) 2 0.1 aThe number of anesthesia complications (1,516) is slightly larger than the number of discharges with anesthesia complications (1,512) because a few cases had more than one anesthesia complication.

bThe “E93xx” codes are from the series of codes called “Drugs, medicinal, and biological substances causing adverse effects in therapeutic use.” These include correct drugs properly administered in therapeutic dosage, causing any adverse effect including allergic or hypersensitivity reactions.

cKetamine, methohexital, and thiobarbiturates, such as thiopental sodium

dHalogenated hydrocarbon derivatives besides halothane, ether, and nitrous oxide

eLidocaine, cocaine, procaine, and tetracaine

fThe 96xx codes are from the series of codes called “Poisoning by drugs, medicinal, and biological substances.” These include overdose of the substances, or inadvertent administration of the wrong substance.

gThis E85xx code is from the series of codes called “Accidental poisoning by drugs, medicinal, and biological substances.” These include accidental overdose of a drug, administration of the wrong drug, and drug accidents in the use of the drugs in medical and surgical procedures.

B-14


Table B.10 Ten Most Frequent DRGs Among Discharges with Anesthesia Complications and Reactions (N=1,512)

Description of DRG (DRG code) Number of discharges

Percent of All Discharges with an

Anesthetic Complication Major joint and limb reattachment procedures of lower extremity (209) 320 21.3 Hip and femur procedures except major joint, age >17, with complications or comorbidities (210) 90 5.9 Major small and large bowel procedures with complications or comorbidities (148) 80 5.3 Non-extensive operating room procedure unrelated to the principal diagnosis (477) 59 3.9 Extensive operating room procedure unrelated to the principal diagnosis (468) 52 3.4 Major chest procedures (075) 45 3.0 Back and neck procedures except spinal fusion, with complications or comorbidities (499) 41 2.7 Laparoscopic cholecystectomy without common duct exploration with complications or comorbidities (493) 38 2.5 Extracranial vascular procedure (005) 37 2.4 Other vascular procedures with complications or comorbidities (478) 29 1.9 Remaining discharges/all other DRGs 721 47.7 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data.

B-15


Table B.11 DRGs with the Ten Highest Rates of Anesthetic Complications and Reactions, Among all Discharges Eligible for That Outcome

Description of DRG (DRG code)

Number of discharges with

the DRG

Number of discharges with the DRG, and

with the outcome


discharges with the DRG

Non-extensive operating room procedure unrelated to the principal diagnosis (477) 49,802 59 1.18 Back and neck procedures except spinal fusion with complications or comorbidities (499) 62,649 41 0.65 Major chest procedures (075) 79,780 45 0.56 Major joint and limb reattachment procedures of the lower extremity (209) 710,686 320 0.45 Extensive operating room procedure unrelated to the principal diagnosis (468) 118,970

52 0.44

Hip and femur procedures except major joint, age >17 with complications or comorbidities (210) 237,452 90 0.38 Laparoscopic cholecystectomy without common duct exploration with complications or comorbidities (493) 111,730 38 0.34 Major small and large bowel procedures with complications or comorbidities (148) 255,003 80 0.31 Extracranial vascular procedures (005) 182,065 37 0.20 All other discharges/DRGs 4,313,889 721 0.17 Other vascular procedures with complications or comorbidities (478) 212,929 29 0.14 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. NOTE: Only rates with greater than 25 discharges in the numerator and the denominator are reported.

B-16


Table B.12 Ten Most Frequent Procedures Among Discharges with Postoperative Hemorrhage or Hematoma (N = 14,891)

Description of Procedure (ICD-9-CM Procedure Code) Number of discharges

Percent of Discharges with Postoperative Hemorrhage or

Hematoma Carotid endarterectomy (38.12) 1,482 10.0 Transurethral prostatectomy (60.29) 772 5.2 Vascular shunt and bypass (39.29) 750 5.0 Excisional wound debridement (86.22) 641 4.3 Vascular procedure revision (39.49) 415 2.8 Suture of artery (39.31) 276 1.9 Laparoscopic cholecystectomy (51.23) 269 1.8 Aortocoronary bypass-2 coronary arteries (36.12) 267 1.8 Aortocoronary bypass-3 coronary arteries (36.13) 261 1.8 Unilateral simple mastectomy with excision of regional lymph nodes (85.43)

252

1.7

Remaining discharges/all other procedures 9,506 63.8 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data.

B-17


Table B.13 Ten Most Frequent DRGs Among Discharges with Postoperative Hemorrhage or Hematoma (N = 14,891)

Description of DRG (DRG Code) Number of discharges

Percent of Discharges with Postoperative Hemorrhage

or Hematoma Other vascular procedures with complications or comorbidities (478)

2,067

13.9

Extracranial vascular procedures (005) 1,483 10.0 Major cardiovascular procedures with complications or comorbidities (110)

767

5.2


692

4.6

Operating room procedure for infectious & parasitic diseases (415)

567

3.8

Major small & large bowel procedures with complications or comorbidities (148)

477

3.2

Permanent cardiac pacemaker implant without acute myocardial infarction, heart failure, or shock (116)

445

3.0

Coronary bypass without PTCA or cardiac catheterization (109)

442

3.0

Coronary bypass without cardiac catheterization (107) 432 2.9 Cardiac valve procedures without cardiac catheterization (105) 364 2.4 Remaining discharges/all other DRGs 7,155 48.0

SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data.

B-18


Table B.14 Ten DRGs with the Highest Rates of Postoperative Hemorrhage or Hematoma, Among all Discharges Eligible for That Outcome


Number of discharges with

the DRG

Number of discharges with the DRG, and with the

outcome



Liver transplant (480) 1,405 50 35.6 Kidney transplant (302) 16,272 242 14.9 Skin graft and/or debridement except for skin ulcer or cellulitis with complications or comorbidities (265)

7,886 105 13.3

Sialoadenectomy (50) 4,985 56 11.2 Other hepatobiliary or pancreas operating room procedures (201)

2,769 29 10.5

Minor bladder procedures with complications or comorbidities (308)

14,494 142 9.8

Other vascular procedures with complications or comorbidities (478)

212,929 2,067 9.7

Total mastectomy for malignancy with complications, comorbidities (257)

32,425 315 9.7


72,149 692 9.6

Wound debridements for injuries (440) 10,493 91 8.7 All other eligible discharges/DRGs 5,953,419 11,102 1.9 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. NOTE: Only rates with greater than 25 discharges in the numerator and the denominator are reported

B-19


Table B.15 Frequency of Specific Complications Among Discharges with Postoperative Metabolic and Physiologic Derangements (N=4,272)a

Frequency of Specific Complications (ICD-9-CM diagnosis code)

Number of this Complication

Percent of All Postoperative Metabolic or Physiologic

Complications Unspecified or unclassified acute renal failure (584.8, 584.9) 2,458 57.5 Acute tubular necrosis (584.5) 1,346 31.5 Type I diabetes with ketoacidosis (250.11, 250.13) 210 4.9 Type II diabetes with ketoacidosis (250.10, 250.12) 168 3.9 Type II diabetes with hyperosmolar nonketotic coma (250.20, 250.22)

57

1.3 Type I diabetes with other coma (DKA with coma, hypoglycemia) (250.31, 250.33)

13

0.3

Type II diabetes with other coma (DKA with coma, hypoglycemia) (250.30, 250.32)

10

0.2

Type I diabetes with hyperosmolar state (250.21, 250.23) 8 0.19 Acute papillary necrosis (584.7) 2 0.05

SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. aThe number of postoperative metabolic and physiologic complications (4,272) is somewhat larger than the number of discharges with a postoperative metabolic and physiologic derangements (4,199) because some cases had more than one postoperative metabolic or physiologic derangement.

B-20


Table B.16 Ten Most Frequent Procedures Among Discharges with Postoperative Metabolic or Physiologic Derangements (N = 4,199)

Description of Procedure (ICD-9-CM procedure code) Number of discharges

Percent of Discharges

with Postoperative Metabolic or Physiologic

Derangements Kidney transplant (55.69) 597 14.2 Resection of abdominal aortic aneurysm (38.44) 236 5.6 Creation of arteriovenous fistula for dialysis (39.27) 223 5.3 Temporary tracheostomy (31.1) 196 4.7 Angioplasty or atherectomy of non-coronary vessel (39.50) 103 2.5 Other peripheral vascular shunt or bypass (39.29) 93 2.2 Aortocoronary bypass-3 coronary arteries (36.13) 87 2.1 Excisional wound debridement (86.22) 86 2.1 Nephroureterectomy (55.51) 82 2.0 Total knee replacement (81.54) 78 1.9 Remaining discharges/all other procedures 2,418 57.6 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data.

B-21


Table B.17 Ten Most Frequent DRGs Among Discharges with Postoperative Metabolic or Physiologic Derangement (N = 4,199)


Percent of Discharges with Postoperative Metabolic or Physiologic Derangement

Kidney transplant (302) 589 14.0 Major cardiovascular procedures with complications or comorbidities (110) 388 9.2 Tracheostomy except for face, mouth, and neck diagnoses (483) 280 6.7 Other vascular procedures with complications or comorbidities (478) 217 5.2 Other kidney and urinary tract operating room procedures (315) 201 4.8 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization (105) 170 4.0 Coronary bypass without PTCA or cardiac catheterization (109) 166 4.0 Extensive operating room procedure unrelated to principal diagnosis (468) 162 3.9 Major small and large bowel procedures with complications or comorbidities (148) 136 3.2 Other circulatory system operating room procedures (120) 134 3.2 Remaining discharges/all other DRGs 1,756 41.8


B-22


Table B.18 DRGs with the Ten Highest Rates of Postoperative Physiologic or Metabolic Derangement, Among all Discharges Eligible for That Outcome


Number of discharges

with the DRG


with the DRG, and with the

outcome



Kidney transplant (302) 7,347 589 80.2 Tracheostomy except for face, mouth, and neck diagnoses (483) 14,415 280 19.4 Major cardiovascular procedures with complications or comorbidities (110) 52,444 388 7.4 Other cardiothoracic procedures (108) 6,293 46 7.3 Operating room procedure for infectious and parasitic disease (415) 14,970 107 7.1 Extensive operating room procedure unrelated to principal diagnosis (468) 23,284 162 7.0 Kidney, ureter, and major bladder procedure for non-neoplastic disease with complications or comorbidities (304) 11,404 79 6.9 Other kidney and urinary tract operating room procedures (315) 29,041 201 6.9 Other circulatory system operating room procedures (120) 22,653 134 5.9 Pancreas, liver, and shunt procedures with complications or comorbidities (191) 9,853 42 4.3 All other eligible discharges/DRGs 2,937,000 2,171 0.7 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. NOTE: Only rates with greater than 25 discharges in the numerator and the denominator are reported.

B-23


Table B.19 Ten Most Frequent DRGs Among Discharges with Postoperative Respiratory Failure (N = 18,087)


Percent of Discharges

with Postoperative Respiratory

Failure Tracheostomy except for face, mouth, and neck diagnoses (483) 5,808 32.1 Major small and large bowel procedures with complications, comorbidities (148) 1,935 10.7 Major joint and limb reattachment procedures (209) 1,018 5.6 Stomach, esophageal, and duodenal procedures age >17 with complications or comorbidities (154) 814 4.5 Extensive operating room procedure unrelated to principal diagnosis (468) 744 4.1 Extracranial vascular procedures (005) 513 2.8 Operating room procedure for infectious and parasitic diseases (415) 465 2.6 Kidney, ureter and major bladder procedures for neoplasm (303) 425 2.3 Craniotomy age >17, except for trauma (001) 404 2.2 Spinal fusion except cervical with complications or comorbidities (497) 355 2.0 Remaining discharges/all other DRGs 5,606 31.0


B-24


Table B.20 DRGs with the Ten Highest Rates of Postoperative Respiratory Failure, Among All Discharges Eligible for That Outcome



with the DRG

Number of discharges in the DRG

with the outcome

Rate of events,

per 1,000 discharges

with the DRG

Tracheostomy except for face, mouth, and neck diagnoses (483) 14,606 5,808 397.6 Bone Marrow Transplant (481) 1,008 42 41.7 Tracheostomy with face, mouth, and neck diagnoses (482) 7,183 278 38.7 Craniotomy for trauma age >17 (002) 1,421 53 37.3 Stomach, esophageal and duodenal procedure age >17 with complications or comorbidities (154) 23,745 814 34.3 Extensive operating room procedure unrelated to principal diagnosis (468) 23,365 744 31.8 Operating room procedure for infectious and parasitic disease (415) 14,972 465 31.1 Percutaneous cardiovascular procedure with acute myocardial infarction (516) 2,386 65 27.2 Pancreas, liver and shunt procedure with complications or comorbidities (191) 9,863 232 23.5 Other digestive system operating room procedure with complications or comorbidities (170) 5,556 123 22.1 All other discharges/DRGs 2,210,265 9,463 4.3 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. NOTE: Only rates with greater than 25 discharges in the numerator and the denominator are reported.

B-25


Table B.21 Frequency of Specific Complications Among Discharges with Postoperative Septicemia (N = 14,393)a

Description of Specific Complications (ICD-9-CM code) Number of discharges

Percent of All Discharges

with Postoperative

Septicemia Unspecified septicemia (389) 6,853 47.6 S. aureus septicemia (381.1) 2,445 17.0 Unclassified or unspecified staphylococcal septicemia (381.0, 381.9) 1,625 11.3 Streptococcal septicemia (380) 875 6.1 Unclassified or unspecified gram-negative septicemia (384.0, 384.9) 801 5.6 Unclassified septicemia (388) 714 5.0 E. coli septicemia (384.2) 393 2.7 Pseudomonas septicemia (384.3) 365 2.5 Serratia septicemia (384.4) 121 0.8 Anaerobic septicemia (383) 118 0.8 Pneumococcal septicemia (382) 76 0.5 H. influenzae septicemia (384.1) 7 0.05


aThe number of postoperative septicemia complications (14,393) is somewhat larger than the number of discharges with postoperative septicemia (14,069) because some cases had more than one postoperative septicemia complication.

B-26


Table B.22 Ten Most Frequent Procedures Among Discharges with Postoperative Septicemia (N = 14,069)



with Postoperative

Septicemia Temporary tracheostomy (31.1) 1,549 11 Excisional wound debridement (86.22) 785 5.6 Above knee amputation (84.17) 529 3.8 Below knee amputation (84.15) 479 3.4 Resection of abdominal aortic aneurysm with graft (38.44) 385 2.7 Revision of previous vascular anastomosis of blood vessel vascular procedure or declotting of graft (39.49) 310 2.2 Other permanent tracheostomy (31.29) 293 2.1 Creation of peripheral arteriovenous fistula for dialysis (39.27) 267 1.9 Peripheral vascular shunt or bypass (39.29) 256 1.8 Partial small bowel resection (45.62) 246 1.7 Remaining discharges/all other procedures 8,970 63.8


B-27


Table B.23 Ten Most Frequent DRGs Among Discharges with Postoperative Septicemia (N = 14,069)



with Postoperative

Septicemia Tracheostomy except for face, mouth, and neck diagnoses (483) 2,244 15.9 Amputation for circulatory system disorders except under upper limb and toe (113) 978 7.0 Major small and large bowel procedures with complications or comorbidities (148) 974 6.9 Other vascular procedures with complications or comorbidities (478) 891 6.3 Major cardiovascular procedures with complications or comorbidities (110) 766 5.4 Other circulatory system operating room procedures (120) 644 4.6 Extensive operating room procedure unrelated to principal diagnosis (468) 624 4.4 Major joint and limb reattachment procedures (209) 436 3.1 Cardiac valve procedures without cardiac catheterization (105) 362 2.6 Skin graft and/or debridement for skin ulcer or cellulitis with complications or comorbidities (263) 362 2.6 Remaining discharges/all other DRGs 5,788 41.1


B-28


Table B.24 DRGs with the Ten Highest Rates of Postoperative Septicemia, Among all Discharges Eligible for That Outcome



with this DRG


with the DRG, and with the outcome

Rate of events, per

1,000 Discharges

with the DRG

Tracheostomy except for face, mouth, and neck diagnoses (483) 10,697 2,244 209.8 Knee procedures with principal diagnosis of infection with complications or comorbidities (501) 1,122 88 78.4 Other circulatory system operating room procedures (120) 9,316 644 69.1 Extensive operating room procedure unrelated to principal diagnosis (468) 11,371 624 54.9 Pancreas, liver, and shunt procedures with complications or comorbidities (191) 2,154 106 49.2 Cardiac pacemaker revision except device replacement (117) 634 28 44.2 Transurethral procedures with complications or comorbidities (310) 1,204 53 44.0 Amputation for circulatory system disorders except upper limb and toe (113) 23,303 978 42.0 Other digestive system operating room procedures with complications or comorbidities (170) 1,388 58 41.8 Biliary tract procedure except only cholecystectomy with or without common duct exploration with complications or comorbidities (193) 1,061 43 40.5 All other discharges/DRGs 1,019,003 9,203 9.0 SOURCE: Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data. NOTE: Only rates with greater than 25 discharges in the numerator and the denominator are reported.

B-29


Table B.25 Ten Most Frequent Procedures Among Discharges with Postoperative Wound Dehiscence (N = 4,201)



with a Postoperative

Wound Dehiscence

Sigmoidectomy (45.76) 410 9.8 Right hemicolectomy (45.73) 404 9.6 Partial small bowel resection (45.62) 252 6.0 Resection of abdominal aortic aneurysm (38.44) 210 5.0 Other peritoneal adhesiolysis (54.59) 195 4.6 Left hemicolectomy (45.75) 176 4.2 Temporary tracheostomy (31.1) 152 3.6 Radical cystectomy (57.71) 132 3.1 Total abdominal hysterectomy (68.4) 126 3.0 Cholecystectomy (51.22) 106 2.5 Remaining discharges/all other procedures 2,038 48.6


A P P E N D I X C C O M P A R I S O N O F S T A N F O R D / A H R Q

R E S U L T S U S I N G H C U P N A T I O N W I D E I N P A T I E N T S A M P L E D A T A ,

A N D M Q M S R E S U L T S

C-3

Appendix C: Comparison of Stanford/AHRQ Results Using HCUP Nationwide Inpatient Sample Data, and MQMS Results

Table C.1 Comparison of Stanford/AHRQ Results Using HCUP Nationwide Inpatient Sample Data and MQMS Results: Overall US and by White or African-American (Events per 1,000 Discharges)

Overall US White African

American Anesthesia Reactions and Complications

AHRQ 0.6 0.6 0.5 MQMS c0.2 0.2 0.2

Foreign Body

AHRQ 0.08 0.09 0.07 MQMS 0.1 0.1 0.1

Selected infections due to Medical Care

AHRQ 1.9 1.8 2.8 MQMS 3.2 2.8 5.2

Postoperative Hip Fracture

AHRQ 0.8 0.9 0.5 MQMS 1.8 1.9 1.3


AHRQ 0.7 0.7 0.7 MQMS 1.0 1.1 1.0

Decubitus Ulcer

AHRQ 21.3 19.1 32.1 MQMS 27.3 23.6 54.6

Postoperative hemorrhage or hematoma

AHRQ 2.1 2.0 2.0 MQMS 2.3 2.3 2.8

Postoperative physiologic or metabolic derangement

AHRQ 0.9 0.8 1.1 MQMS 1.4 1.2 2.5

Postoperative respiratory failure

AHRQ 3.6 3.4 4.8 MQMS 7.9 7.5 12.1

Postoperative septicemia

AHRQ 10.9 9.6 15.0 MQMS 13.4 11.8 26.3

Postoperative wound dehiscence

AHRQ 1.9 1.9 2.2 MQMS 3.7 3.7 4.1

Source: Romano et al. 2003 and Combined 2000 and 2001 MQMS data from Medicare claims and enrollment data.

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