Diabetes mellitus: lower-extremity amputation rate.

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Diabetes mellitus: lower-extremity amputation rate.
National Quality Measures Clearinghouse

SOURCE(S)

* 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 (AHRQ); 2007 Mar 12. 59 p. (AHRQ Pub; no. 02-R0203).

Measure Domain
PRIMARY MEASURE DOMAIN

Population Health

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SECONDARY MEASURE DOMAIN

Access
Brief Abstract
DESCRIPTION

This measure is used to assess the number of admissions for lower-extremity amputation among patients with diabetes per 100,000 population.

As a Prevention Quality Indicator (PQI), lower-extremity amputations among patients with diabetes is not a measure of hospital quality, but rather one measure of outpatient and other health care. PQIs are correlated with each other and may be used in conjunction as an overall examination of outpatient care.
RATIONALE

Prevention is an important role for all health care providers. Providers can help individuals stay healthy by preventing disease, and they can prevent complications of existing disease by helping patients live with their illnesses. To fulfill this role, however, providers need data on the impact of their services and the opportunity to compare these data over time or across communities. Local, State, and Federal policymakers also need these tools and data to identify potential access or quality-of-care problems related to prevention, to plan specific interventions, and to evaluate how well these interventions meet the goals of preventing illness and disability.

While these indicators use hospital inpatient data, their focus is an outpatient health care. Except in the case of patients who are readmitted soon after discharge from a hospital, the quality of inpatient care is unlikely to be a significant determinant of admission rates for ambulatory care sensitive conditions. Rather, the Prevention Quality Indicators (PQIs) assess the quality of the health care system as a whole, and especially the quality of ambulatory care, in preventing medical complications. As a result, these measures are likely to be of the greatest value when calculated at the population level and when used by public health groups, State data organizations, and other organizations concerned with the health of populations.

These indicators* serve as a screening tool rather than as definitive measures of quality problems. They can provide initial information about potential problems in the community that may require further, more in-depth analysis.

Diabetes is a major risk factor for lower-extremity amputation, which can be caused by infection, neuropathy, and microvascular disease.

Proper and continued treatment and glucose control may reduce the incidence of lower-extremity amputation.

*The following caveats were identified from the literature review for the "Rate of Lower-extremity Amputation Among Patients with Diabetes" indicator:

* Proxya: Indicator does not directly measure patient outcomes but an aspect of care that is associated with the outcome; thus, it is best used with other indicators that measure similar aspects of care.
* Unclear constructa: There is uncertainty or poor correlation with widely accepted process measures.

Refer to the original measure documentation for further details.

Note:

a - The concern is theoretical or suggested, but no specific evidence was found in the literature.
PRIMARY CLINICAL COMPONENT

Diabetes mellitus; lower-extremity amputation; hospital admission rates
DENOMINATOR DESCRIPTION

Population in Metro Area or county, age 18 years and older
NUMERATOR DESCRIPTION

All non-maternal discharges, age 18 years and older, with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes* for lower-extremity amputation in any field and diagnosis code* for diabetes in any field

Exclude cases:

* transferring from another institution
* Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and puerperium)
* MDC 15 (newborn and other neonates)
* with trauma diagnosis code* in any field

*Refer to Technical Specifications document cited in the "Companion Documents" field for ICD-9-CM codes.
Evidence Supporting the Measure
EVIDENCE SUPPORTING THE VALUE OF MONITORING THE ASPECT OF POPULATION HEALTH

* One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Evidence Supporting Need for the Measure
NEED FOR THE MEASURE

Monitoring health state(s)
Variation in health state(s)
EVIDENCE SUPPORTING NEED FOR THE MEASURE

* 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 (AHRQ); 2007 Mar 12. 59 p. (AHRQ Pub; no. 02-R0203).

State of Use of the Measure
STATE OF USE

Current routine use
CURRENT USE

Monitoring health state(s)
Application of Measure in its Current Use
CARE SETTING

Ambulatory Care
Community Health Care
PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses
Physician Assistants
Physicians
Public Health Professionals
LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Counties or Cities
TARGET POPULATION AGE

Age greater than or equal to 18 years
TARGET POPULATION GENDER

Either male or female
STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified
Characteristics of the Primary Clinical Component
INCIDENCE/PREVALENCE

* Lower-extremity amputation (LEA) affects up to 15% of all patients with diabetes in their lifetimes.
* In the United States, diabetes is the leading cause of nontraumatic amputations (approximately 57,000 per year).

EVIDENCE FOR INCIDENCE/PREVALENCE

* Centers for Disease Control and Prevention (CDC). National diabetes fact sheet: national estimates and general information on diabetes in the United States. Atlanta (GA): U.S. Department of Health and Human Services; 1999.


* Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes (technical review). Diabetes Care 1998 Dec;21(12):2161-77. PubMed

ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified
BURDEN OF ILLNESS

Unspecified
UTILIZATION

Unspecified
COSTS

Unspecified
Institute of Medicine National Healthcare Quality Report Categories
IOM CARE NEED

Living with Illness
IOM DOMAIN

Effectiveness
Timeliness
Data Collection for the Measure
CASE FINDING

Both users and nonusers of care
DESCRIPTION OF CASE FINDING

Population in Metro Area or county, age 18 years and older
DENOMINATOR SAMPLING FRAME

Geographically defined
DENOMINATOR INCLUSIONS/EXCLUSIONS

Inclusions
Population in Metro Area or county, age 18 years and older

Exclusions
Unspecified
RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are not equally eligible to appear in the numerator
DENOMINATOR (INDEX) EVENT

Patient Characteristic
DENOMINATOR TIME WINDOW

Time window is a single point in time
NUMERATOR INCLUSIONS/EXCLUSIONS

Inclusions
All non-maternal discharges, age 18 years and older, with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes* for lower-extremity amputation in any field and diagnosis code* for diabetes in any field

Exclusions
Exclude cases:

* transferring from another institution
* Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and puerperium)
* MDC 15 (newborn and other neonates)
* with trauma diagnosis code* in any field

*Refer to Technical Specifications document cited in the "Companion Documents" field for ICD-9-CM codes.
MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.
NUMERATOR TIME WINDOW

Institutionalization
DATA SOURCE

Administrative data
LEVEL OF DETERMINATION OF QUALITY

Does not apply to this measure
TYPE OF HEALTH STATE

Adverse Health State
PRE-EXISTING INSTRUMENT USED

Unspecified
Computation of the Measure
SCORING

Rate
INTERPRETATION OF SCORE

A lower score is desirable
ALLOWANCE FOR PATIENT FACTORS

Analysis by subgroup (stratification on patient factors, geographic factors, etc.)
Risk adjustment method widely or commercially available
DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Observed (raw) rates may be stratified by areas (Metro Areas or counties), age groups, race/ethnicity categories, and sex.

Risk adjustment of the data is recommended using age and sex.

Application of multivariate signal extraction (MSX) to smooth risk adjusted rates is also recommended.
STANDARD OF COMPARISON

External comparison at a point in time
External comparison of time trends
Internal time comparison
Prescriptive standard
PRESCRIPTIVE STANDARD

Healthy People 2010 has set a goal of reducing the number of lower-extremity amputations to 1.8 per 1,000 persons with diabetes.
EVIDENCE FOR PRESCRIPTIVE STANDARD

* U.S. Department of Health and Human Services. Healthy people 2010: understanding and improving health. Conference ed. Washington (DC): Government Printing Office; 2000.

Evaluation of Measure Properties
EXTENT OF MEASURE TESTING

Each potential quality indicator was evaluated against the following six criteria, which were considered essential for determining the reliability and validity of a quality indicator: face validity, precision, minimum bias, construct validity, fosters real quality improvement, and application. The project team searched Medline for articles relating to each of these six areas of evaluation. Additionally, extensive empirical testing of all potential indicators was conducted using the 1995-97 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and Nationwide Inpatient Sample (NIS) to determine precision, bias, and construct validity. Table 1 in the original measure documentation summarizes the results of the literature review and empirical evaluations on the Prevention Quality Indicators (PQI). Refer to the original measure documentation for details.
EVIDENCE FOR RELIABILITY/VALIDITY TESTING

* 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 (AHRQ); 2007 Mar 12. 59 p. (AHRQ Pub; no. 02-R0203).

Identifying Information
ORIGINAL TITLE

Rate of lower-extremity amputation among patients with diabetes (PQI 16).
MEASURE COLLECTION

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators
MEASURE SET NAME

Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators
DEVELOPER

Agency for Healthcare Research and Quality
FUNDING SOURCE(S)

Agency for Healthcare Research and Quality (AHRQ)
COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

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

None
ENDORSER

National Quality Forum
ADAPTATION

This measure was not adapted from another source.
RELEASE DATE

2001 Oct
REVISION DATE

2007 Mar
MEASURE STATUS

This is the current release of the measure.

This measure updates a previous version: AHRQ quality indicators. Guide to prevention quality indicators: hospital admission for ambulatory care sensitive conditions [version 3.0a]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Feb 20. 58 p. (AHRQ Pub; no. 02-R0203).
SOURCE(S)

* 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 (AHRQ); 2007 Mar 12. 59 p. (AHRQ Pub; no. 02-R0203).

MEASURE AVAILABILITY

The individual measure, "Rate of Lower-Extremity Amputation among Patients with Diabetes (PQI 16)," is published in "AHRQ Quality Indicators. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Sensitive Conditions." This document is available in Portable Document Format (PDF) from the Prevention Quality Indicators Download page at the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Web site.

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

The following are available:

* AHRQ quality indicators. Prevention quality indicators: technical specifications [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 22 p. This document is available in Portable Document Format (PDF) from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Web site.
* AHRQ quality indicators. Prevention quality indicators: software documentation [version 3.1] - SAS. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 38 p. This document is available in PDF from the AHRQ Quality Indicators Web site.
* AHRQ quality indicators. Software documentation: Windows [version 3.1a]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Apr 6. 99 p. This document is available in PDF from the AHRQ Quality Indicators Web site.
* Prevention quality indicators (PQI): covariates [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 17 p. This document is available in PDF from the AHRQ Quality Indicators Web site.
* Prevention quality indicators (PQI): covariates (age only) [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 17 p. This document is available in PDF from the AHRQ Quality Indicators Web site.
* Remus D, Fraser I. Guidance for using the AHRQ quality indicators for hospital-level public reporting or payment. Rockville (MD): Agency for Healthcare Research and Quality; 2004 Aug. 24 p. This document is available in PDF from the AHRQ Quality Indicators Web site.
* UCSF-Stanford Evidence-based Practice Center. Davies GM, Geppert J, McClellan M, et al. Refinement of the HCUP quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2001 May. (Technical review; no. 4). This document is available in PDF from the AHRQ Quality Indicators Web site.
* HCUPnet. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 [accessed 2007 May 21]. [Various pagings]. HCUPnet is available from the AHRQ Web site. See the related QualityTools summary.

NQMC STATUS

This NQMC summary was completed by ECRI on December 19, 2002. The information was verified by the Agency for Healthcare Research and Quality on January 9, 2003. This NQMC summary was updated by ECRI on April 6, 2004, February 18, 2005, February 27, 2006, and again on June 15, 2007.
COPYRIGHT STATEMENT

No copyright restrictions apply.
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