Outcome Indicators for the HCBS Population
Outcome Indicator Development
AHRQ developed the set of indicators used in this report through
an extensive process that included an environmental scan, expert input, and
validity and reliability testing. All but two of the indicators (Pressure Ulcer
and Injurious Falls) build on existing AHRQ Prevention Quality Indicators
(PQIs; go to http://www.qualityindicators.ahrq.gov/Modules/pqi_overview.aspx). The development process is described in detail elsewhere (Schultz, et
al., 2012). The final set of indicators represents potentially avoidable
inpatient admissions for 13 conditions, drawing on both the MAX and MedPAR data
to identify admissions.
The 13 outcome indicators judged to be of sufficient
validity and reliability for the HCBS population, based on testing to date,
- Short-Term Complications of Diabetes.
- Asthma or Chronic Obstructive Pulmonary Disease.
- Congestive Heart Failure.
- Composite: Potentially Preventable Infection:
- Bacterial Pneumonia.
- Urinary Tract Infection.
- Infection Due to Device or Implant.
- Composite: Ambulatory Care Sensitive Condition (ACSC): Chronic
- Composite: ACSC: Acute Conditions.
- Composite: ACSC: Overall.
- Pressure Ulcer.
- Injurious Falls.
For each measure, the numerator represents the number of potentially
avoidable inpatient hospital admissions and the denominator represents the
number of HCBS participants divided by 100,000. Thus, the indicator as a whole
reflects the rate of potentially avoidable inpatient admissions per 100,000
Because the HCBS population is dynamic, with individuals
changing eligibility, enrollment, and service use throughout the year, we
calculate the indicators for each quarter rather than for the entire year. In
quarters when an individual does not meet our HCBS population definition, that
individual is excluded from the denominator and any corresponding hospital
admissions are excluded from the numerator. The quarterly rates are then
annualized for presentation in this report. Excluding noneligible quarters
means that the total number of people in the HCBS population at any point in
2005 is greater than the total number of people included in the outcome
Details of each of the measure specifications, including
numerator exclusions, are available in Schultz, et al. (2012). We note that one
validated numerator exclusion, same-day admissions to a hospital for the same
individual, was finalized after the preparation of the tables for this report. Thus,
the admission rates in our report may be slightly larger than admission rates
reflected in the measures reports, but qualitative conclusions are not affected
by this minor difference.
All analyses that use the outcome indicators have several
additional exclusions from the denominator, over and above the exclusions used
in defining the HCBS population. We exclude individuals in a managed acute care
plan or a managed long-term care plan. Thus, we exclude the entire State of
Arizona, which has managed acute care for all Medicaid beneficiaries through an
1115 waiver. We also exclude individuals who exhibit institutional care use but
no HCBS use during a quarter as demonstrated by MAX claims; individuals under
age 18; and data from Wisconsin, Washington, and Maine due to missing data on
These indicators are intended for use by policymakers as
tools for monitoring the welfare of recipients and should be applicable across
diverse HCBS populations and across States. In their current state of
development, they are not appropriate for use in establishing accountability of
individual providers or State programs. The selected outcomes are clearly
affected by the availability and quality of primary, acute, and long-term care
and the underlying health and behaviors of the individuals, but none of the
measures used in this report are risk adjusted.
Outcome Indicator Rates
Overall outcome indicator rates in the HCBS population vary
considerably across measures, as shown in Table A. Short-Term
Complications of Diabetes and Injurious Falls exhibit the lowest rates, with
fewer than 300 potentially avoidable hospital admissions per 100,000 HCBS participants.
The ACSC Overall Composite exhibits the highest rate, at almost 18,000
admissions per 100,000 HCBS participants. Rates for most of the other
indicators fall between 2,000 and 8,000 admissions per 100,000 HCBS participants.
Table A also displays outcome indicator rates for the full
Medicaid population. Although the pattern from measure to measure is similar in
the two populations, the rates in the HCBS population are consistently and
dramatically higher than in the full Medicaid population, more than twice as
high for almost all measures. Thus, while the HCBS population constitutes just
4 percent of the overall Medicaid population, it is a particularly sick part of
the Medicaid population and one where efforts to reduce potentially avoidable
hospitalizations may be most needed.
In the sections that follow, we examine these outcome
indicator rates with respect to specific participant, policy, and area
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