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2009 National Healthcare Quality & Disparities Reports

Data Sources—Agency for Healthcare Research and Quality (AHRQ)

Healthcare Cost and Utilization Project (HCUP)

Sponsor

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ).

Description

HCUP databases bring together the data collection efforts of State government data organizations, hospital associations, private data organizations, and the Federal Government to create a national information resource of discharge-level health care data.

HCUP includes a collection of longitudinal hospital care data, with all-payer, discharge-level information beginning in 1988. Four HCUP discharge datasets were used in this report:

The HCUP Statewide Inpatient Databases (SID) include all hospitals with all of their discharges from participating States. In aggregate, the 2006 SID represents almost 90% of all U.S. hospital discharges, about 32 million inpatient discharge abstracts from 38 States.

The SID contains a core set of clinical and nonclinical information on all patients, regardless of payer. In addition to the core set of uniform data elements common to all of the SID, some include other elements, such as the patient's race.
The Nationwide Inpatient Sample (NIS) is a stratified sample of hospitals drawn from the subset of hospitals in participating States that can be matched to the American Hospital Association (AHA) survey data. Hospitals are stratified by region, location/teaching status (within region), bed size category (within region and location/teaching status), and ownership (within region, location/teaching, and bed size categories). Weights are used to develop national estimates. The 2006 NIS contains about 8 million discharges from 1,045 hospitals located in 38 States, approximating a 20% stratified sample of U.S. community hospitals.
The Nationwide Emergency Department Sample (NEDS) was constructed using the HCUP State Emergency Department Databases (SEDD) and the SID. The SEDD captures discharge information on ED visits that do not result in an admission (i.e., treat-and-release visits and transfers to another hospital). The SID contains information on patients initially seen in the ED and then admitted to the same hospital.

The NEDS is a stratified sample of 20% of U.S. hospital-based ED events drawn from the States providing ED data to HCUP. Twenty-four HCUP Partner States participated in the 2006 NEDS: AZ, CA, CT, FL, GA, HI, IA, IN, KS, MA, MD, ME, MN, MO, NE, NH, NJ, OH, SC, SD, TN, UT, VT, and WI.
The SID disparities analysis file is a special analysis file created from SID data to provide national estimates for the National Healthcare Disparities Report. It consists of weighted records from a sample of hospitals from 25 States participating in HCUP that have high-quality race/ethnicity data: AR, AZ, CA, CO, CT, FL, GA, HI, KS, MA, MD, MI, MO, NH, NJ, NY, OK, RI, SC, TN, TX, UT, VA, VT, and WI in 2006. The 25 States accounted for 60% of U.S. hospital discharges (based on the AHA annual survey), about 60% of White and African Americans in the Nation, and more than 80% of Asians and Pacific Islanders and Hispanics.

The HCUP databases maintain the combined categorization of race/ethnicity categories, resulting in the categories of Hispanic of all races, and non-Hispanic African Americans, Asians and Pacific Islanders, and Whites. Not all States collect race and ethnicity data uniformly; when a State and its hospitals collect Hispanic ethnicity separately from race, HCUP uses Hispanic ethnicity to override any other race category.

Community hospitals from the 25 States were sampled to approximate a 40% stratified sample of U.S. community hospitals, with stratification based on 5 hospital characteristics: geographic region, hospital ownership, urbanized location, teaching status, and bed size. Hospitals were excluded from the sampling frame if the coding of patient race was suspect. Once the 40% sample was drawn, discharge-level weights were developed to produce national-level estimates when applied to the SID disparities analysis file.

The final SID disparities analysis file included about 15 million hospital discharges from almost 1,900 hospitals. The SID disparities analysis file used the same sampling and weighing strategy used for the NIS, except for the differences described here. The SID disparities analysis file used the same imputation procedures as described for the NIS for race/ethnicity data as well as for missing age, gender, ZIP code, and payer data. For information on imputation procedures, go to: Coffey R, Barrett M, Houchens R, et al. Methods applying AHRQ quality indicators to Healthcare Cost and Utilization Project (HCUP) data for the seventh (2009) National Healthcare Quality Report. HCUP Methods Series Report #2009-01. Rockville, MD: Agency for Healthcare Research and Quality; 2009. Online August 17, 2009. Available at: http://www.hcup-us.ahrq.gov/reports/methods.jsp.

Primary Content

The HCUP NIS and SID contain more than 100 clinical and nonclinical data variables, including age, gender, race, ethnicity, length of stay, discharge status, source of payment, total charges, hospital size, ownership, region, teaching status, diagnoses, and procedures.

The NHQR and NHDR measures that use HCUP data are based on AHRQ Quality Indicators (QIs), a set of algorithms that may be applied to hospital administrative data to quantify quality issues among inpatient populations. The QIs fall into four categories:

Inpatient Quality Indicators (IQIs) reflect quality of care in hospitals and currently include 15 mortality indicators for conditions or procedures for which mortality can vary from hospital to hospital; 11 utilization indicators for procedures for which utilization varies across hospitals or geographic areas; and 6 volume indicators for procedures for which outcomes may be related to the volume of procedures performed.
Prevention Quality Indicators (PQIs) identify hospital admissions for 14 ambulatory care-sensitive conditions, which evidence suggests could have been avoided, in part, through high-quality outpatient care.
Patient Safety Indicators (PSIs) reflect potential inpatient complications and other patient safety concerns following surgeries, other procedures, and childbirth. The most recent version of the PSI software has 27 measures.
Pediatric Quality Indicators (PDIs) examine 18 conditions that pediatric patients experience within the health care system that may be preventable by changes at the system or provider level. In earlier versions of the QI software, some PDI measures were part of the IQI, PSI, and PQI modules.

Population Targeted

Any person, U.S. citizen or foreign, using non-Federal, nonrehabilitation, community hospitals in the United States as defined by AHA.

AHA defines community hospitals as "all non-Federal, short-term, general, and other specialty hospitals, excluding hospital units of institutions." Included among community hospitals are specialty hospitals, such as obstetrics-gynecology, ear-nose-throat, short-term rehabilitation, orthopedic, and pediatric institutions. Also included are public hospitals and academic medical centers. The NIS and analyses of the SID for this report excluded short-term rehabilitation hospitals (beginning with 1998 data), long-term hospitals, psychiatric hospitals, and alcoholism/chemical dependency treatment facilities.

Although not all States participate in the HCUP database, the NIS, the NEDS, and the SID disparities analysis files are weighted to give national estimates using weights based on all U.S. community, nonrehabilitation hospitals in the AHA Annual Survey Database (Health Forum, LLC, 2007).

Demographic Data

Age, gender, race, insurance coverage, median household income of the patient's ZIP Code, urbanized location, and region of the United States.

Years Collected

Since 1988.

Schedule

Annual.

Geographic Estimates

National, four U.S. Census Bureau regions, States (for States participating in SID that agree to the release).

Contact Information

Agency home page: http://www.ahrq.gov.

Data system home page: http://www.ahrq.gov/data/hcup/.

AHRQ Quality Indicators: http://www.qualityindicators.ahrq.gov.

References

Use of AHRQ Quality Indicator Software in Generating NHQR Tables

The following AHRQ QI software versions were used for generating the HCUP tables in this report: IQI Version 3.1, PQI Version 3.1, PSI Version 3.1, and PDI Version 3.1. For more information, go to the methods section for each quality report, available at http://www.qualityindicators.ahrq.gov.

For detailed information about each measure, refer to the individual guides to the quality indicators listed below, available from the archives at http://www.qualityindicators.ahrq.gov.

Inpatient Quality Indicators (IQI)

AHRQ Quality Indicators—Guide to Inpatient Quality Indicators: quality of care in hospitals—volume, mortality, and utilization. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

Prevention Quality Indicators (PQI)

AHRQ Quality Indicators—Guide to Prevention Quality Indicators: hospital admission for ambulatory care sensitive conditions. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

Patient Safety Indicators (PSI)

AHRQ Quality Indicators—Guide to Patient Safety Indicators. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

Pediatric Quality Indicators (PDI)

Measures of pediatric health care quality based on hospital administrative data: the Pediatric Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; 2006.

Sources of HCUP Data

Arizona Department of Health Services
Arkansas Department of Health
California Office of Statewide Health Planning and Development
Colorado Hospital Association
Connecticut Chime, Inc.
Florida Agency for Health Care Administration
Georgia Hospital Association
Hawaii Health Information Corporation
Illinois Department of Public Health
Indiana Hospital Association
Iowa Hospital Association
Kansas Hospital Association
Kentucky Cabinet for Health and Family Services
Maine Health Data Organization
Maryland Health Services Cost Review Commission
Massachusetts Division of Health Care Finance and Policy
Michigan Health and Hospital Association
Minnesota Hospital Association
Missouri Hospital Industry Data Institute
Nebraska Hospital Association
Nevada Department of Health and Human Services
New Hampshire Department of Health and Human Services
New Jersey Department of Health and Senior Services
New York State Department of Health
North Carolina Department of Health and Human Services
Ohio Hospital Association
Oklahoma State Department of Health
Oregon Association of Hospitals and Health Systems
Rhode Island Department of Health
South Carolina State Budget and Control Board
South Dakota Association of Healthcare Organizations
Tennessee Hospital Association
Texas Department of State Health Services
Utah Department of Health
Vermont Association of Hospitals and Health Systems
Virginia Health Information
Washington State Department of Health
West Virginia Health Care Authority
Wisconsin Department of Health and Family Services

State sources listed above may not participate in all years or in all HCUP databases.

Hospital Survey on Patient Safety Culture (HSPSC)

Sponsor

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ).

Mode of Administration

AHRQ has established the HSPSC Comparative Database. The database contains voluntarily submitted data from U.S. hospitals that administered the survey.

Hospitals administered paper surveys, Web, or mixed-mode surveys. For the 2009 HSPSC, 74% of hospitals administered the survey to all staff or a sample of all staff from all hospital departments.

Survey Sample Design

All types of hospitals are eligible, from acute care to rehabilitation and psychiatric hospitals, but the hospital must be located in the United Statesor in a U.S. territory.

Hospitals are not a statistically selected sample of all U.S. hospitals. However, the characteristics of the database hospitals are fairly consistent with the distribution of U.S. hospitals registered with the American Hospital Association (AHA).

Primary Survey Content

The survey measures staff perceptions of patient safety in their work area/unit, as well as perceptions about patient safety in the hospital as a whole. The following 12 areas of patient safety are included, with each area measured by 3 or 4 survey questions:

Unit-Level Safety Areas Covered:

Overall perceptions of safety.
Frequency of events reported.
Supervisor/manager expectations and actions promoting patient safety.
Organizational learning-continuous improvement.
Teamwork within units.
Communication openness.
Feedback and communication about error.
Nonpunitive response to error.
Staffing.

Hospitalwide Safety Areas Covered:

Hospital management support for patient safety.
Teamwork across hospital units.
Handoffs and transitions.

The survey also includes two questions that ask respondents to provide an overall grade on patient safety for their work area/unit and to indicate the number of events they have reported over the past 12 months.

Population Targeted

Hospitals located in the United States or in a U.S. territory.

Demographic Data

Hospital location, teaching status, bed size, ownership and control, and geographic region; staff work area/unit, position, and interaction with patients.

Years Collected

2007 and 2008.

Schedule

Selected years.

Geographic Estimates

National and regions.

Contact Information

Agency home page: http://www.ahrq.gov.

Data system home page: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.

References

Sorra J, Famolaro T, Dyer N, et al. Hospital Survey on Patient Safety Culture 2009 comparative database report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290200710024C). Rockville, MD: Agency for Healthcare Research and Quality; March 2009. AHRQ Publication No. 09-0030.

Medical Expenditure Panel Survey (MEPS)

Sponsor

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ); and Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).

Mode of Administration

The MEPS Household Component (HC) is an interviewer-administered CAPI (computer-assisted personal interview) household survey. The Self-Administered Questionnaire and Diabetes Care Survey are self-administered paper questionnaires.

Survey Sample Design

The MEPS HC is a random subsample of households participating in the previous year's National Health Interview Survey (NHIS). The NHIS is a multistage area probability design that permits the representative sampling of households and oversampling of Blacks and Hispanics. The MEPS HC oversamples households with Asian and low-income persons. Each year, MEPS collects data on more than 30,000 people. The overall response rate for the 2006 MEPS is about 58%.

The MEPS HC is a panel survey. In this design, 2 calendar years of information are collected from each household in a series of five rounds of data collection over a 2½-year period. These data are then linked with additional information collected from the respondents' medical providers, employers, and insurance providers. This series of data collection activities is repeated each year on a new sample of households, resulting in overlapping panels of survey data.

Primary Survey Content

MEPS comprises three component surveys: the Household Component (HC), the Medical Provider Component, and the Insurance Component. The MEPS HC collects detailed data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The data for this report are primarily from the following sections of the 2002-2006 MEPS HC:

Self-Administered Questionnaire (SAQ): This self-administered paper questionnaire collects a variety of health and health care quality measures of adults.
Diabetes Care Survey: This self-administered paper questionnaire, given to persons identified as ever having had diabetes, asks about their diabetes care.
Child Health and Preventive Care (CHPR) section: Starting in 2001, the CHPR section was added to the MEPS HC interviews during the second half of the year. It included health care quality measures taken from the health plan version of CAHPS® (Consumer Assessment of Healthcare Providers and Systems); the Children With Special Health Care Needs screener questions; children's general health status as measured by several questions from the General Health Subscale of the Child Health Questionnaire; Columbia Impairment Scale questions about possible child behavioral problems; and child preventive care questions. Before 2001, the CAHPS questions and the Children With Special Health Care Needs screener questions had been in the Parent-Administered Questionnaire (PAQ). Therefore, estimates from 2001 may not be comparable with estimates for 2000 or earlier years.
Access to Care: The Access to Care section of the MEPS HC gathers information on five main topic areas: family members' origins and preferred languages; family members' usual source of health care; characteristics of usual source of health care providers; satisfaction with and access to the usual source of health care provider; and access to medical treatment, dental treatment, and prescription medicines.
Preventive Care: For each person, a series of questions was asked primarily about the receipt of preventive care or screening examinations.

Population Targeted

The MEPS HC is a nationally representative survey of the U.S. civilian noninstitutionalized population.

Demographic Data

The MEPS-HC collects data on demographic characteristics including age, gender, race, ethnicity, education, industry and occupation, employment status, household composition, and family income. Race and ethnicity variables and categories changed in 2002 to be compliant with Office of Management and Budget (OMB) standards that required changes by 2003.

Years Collected

1996 to present.

Schedule

Annual.

Geographic Estimates

National. The HC data also can be shown for the four U.S. Census Bureau regions (Northeast, Midwest, South, and West), as well as residence location status.

Notes

Estimates in the NHQR and NHDR Data Tables appendix based on MEPS data are weighted to reflect the experiences of the U.S. civilian noninstitutionalized population. Standard errors of the estimates were derived using SUDAAN statistical software, which factors in the complex survey design of MEPS. Estimates were suppressed if sample size was under 100 or if relative standard error was greater than 30%.

The residence location categories were merged from the 2006 NCHS Urban-Rural Classification Scheme for Counties data. The data have a six-level urban-rural classification scheme for U.S. counties and county equivalents:

Large central metropolitan.
Large fringe metropolitan.
Medium metropolitan.
Small metropolitan (nonmetro).
Noncore (nonmetro).

The county classifications are based on OMB definitions of metropolitan and nonmetropolitan counties (2003 version with revisions through 2005), the U.S. Department of Agriculture Economic Research Service's Rural-Urban Continuum Code and Urban Influence Code classifications, and certain U.S. Census 2000 and 2004 postcensal population county-level estimates.

For more information on the NCHS Urban-Rural Classification Scheme for Counties, go to http://www.cdc.gov/nchs/data_access/urban_rural.htm.

Activity limitations are defined as physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and/or engaging in work or social activities.

Limitations in basic activities represent problems with mobility and other basic functioning at the person level. Basic activities include problems with: mobility; self-care (activities of daily living, or ADLs); domestic life (instrumental ADLs); and activities dependent on sensory functioning (limited to persons who are blind or deaf).

Limitations in complex activities represent limitations encountered when the person, in interaction with his or her environment, attempts to participate in community life. Complex activities include limitations experienced in work and in community, social, and civic life. These two categories are not mutually exclusive since persons may have limitations both in basic activities and in complex activities.

Neither basic nor complex activities includes adults with neither basic nor complex activity limitations.

Contact Information

Agency home page: http://www.ahrq.gov.

Data system home page: http://meps.ahrq.gov.

References

Ezzati-Rice TM, Rohde F, Greenblatt J. Sample design of the Medical Expenditure Panel Survey Household Component, 1998-2007. Methodology Report No. 22. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. Available at: http://meps.ahrq.gov/mepsweb/data_files/publications/mr22/mr22.pdf. [Plugin Software Help]

Cohen J. Design and methods of the Medical Expenditure Panel Survey Household Component. MEPS Methodology Report No. 1. Rockville, MD: Agency for Health Care Policy and Research; 1997. AHCPR Publication No. 97-0026.

Cohen S. Sample design of the 1996 Medical Expenditure Panel Survey Household Component. MEPS Methodology Report No. 2. Rockville, MD: Agency for Health Care Policy and Research; 1997. AHCPR Publication No. 97-0027.

Cohen JW, Monheit AC, Beauregard KM, et al. The Medical Expenditure Panel Survey: A national health information resource. Inquiry 1996/1997;33:373-89. Rockville, MD: Agency for Health Care Policy and Research; 1997. Also available as AHCPR Publication No. 97-R043.

National CAHPS® Benchmarking Database (NCBD)—Health Plan Survey Database

Sponsor

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ) in association with a consortium of public and private organizations.

Mode of Administration

By responding to a standardized set of questions administered through a mail or telephone questionnaire, health plan members report on their experiences and rate their health plans and providers in several areas. Participation in the CAHPS® database is voluntary.

Medicare Managed Care data were obtained from the Centers for Medicare & Medicaid Services (CMS) for survey participants. The 4.0 and 3.0 Medicaid data were obtained from data submitted directly to the CAHPS® database by State Medicaid agencies and individual health plans. The 4.0 and 3.0 commercial sector data were obtained from the National Committee for Quality Assurance (NCQA), under an agreement between the CAHPS® database and NCQA.

Survey Sample Design

CAHPS® surveys are administered to a random sample of health plan members by independent survey vendors, following standardized procedures. Since 1998, health plans, purchaser groups, State organizations, and others have participated in this component.

The CAHPS® sampling recommendation is to achieve a minimum of 300 completed responses per plan, with a 50% response rate. The plan samples are not adjusted for unequal probabilities of selection, based on the principle that the precision of the estimates depends primarily on the sample size and not on the size of the population from which it is drawn. Therefore, the given sample size will give the same precision for means or rates regardless of the overall size of the population.

Primary Survey Content

The 4.0 version of the CAHPS® Adult and Child Health Plan Surveys reporting questions fall into four major "composites" that summarize consumer experiences in the following areas: access to needed care, rapid access to care, doctor-patient communication, and health plan information and customer service.

Population Targeted

CAHPS® has specific populations for specific surveys and databases, such as adults, children, children with chronic conditions, and commercial insurance, Medicaid, and Medicare clients. Refer to specific tables and measure specifications for more details.

Estimates for tables based on CAHPS® data were calculated using plan-level weights; i.e., all respondents in a plan received the same weight. Further, all plans within a State were weighted to contribute equally to the State-level statistic.

Demographic Data

Age, gender, education, race, ethnicity, region, insurance coverage, and health status.

Years Collected

Since 1998. The database currently contains CAHPS® Health Plan Survey data from 1998 to present.

Schedule

Annual.

Geographic Estimates

State; four U.S. Census Bureau regions.

Contact Information

Agency home page: http://www.ahrq.gov/.

Data system home page: https://www.cahps.ahrq.gov/default.asp.

References

What consumers say about their experiences with their health plans and medical care. The National CAHPS® Benchmarking Database. CAHPS® Health Plan Survey chartbook. Rockville, MD: Agency for Healthcare Research and Quality; October 2008. AHRQ Publication No. 08-CAHPS001-EF. Available at: https://www.cahps.ahrq.gov/content/NCBD/Chartbook/HEALTHPLAN08/index.html.

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