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  • Measure Summary
  • NQMC:010390
  • Mar 2015
  • NQF-Endorsed Measure

Gastroenteritis admission: percentage of admissions for a principal diagnosis of gastroenteritis, or for a principal diagnosis of dehydration with a secondary diagnosis of gastroenteritis, per 100,000 population, ages 3 months through 17 years.

AHRQ QI research version 5.0. Pediatric quality indicator 16 technical specifications: gastroenteritis admission rate. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Mar. 3 p.
National Quality Forum measure information: gastroenteritis admission rate (PDI 16). Washington (DC): National Quality Forum (NQF); 2014 Sep 18. 15 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates previous versions:

  • AHRQ QI. Pediatric quality indicators #16: technical specifications. Gastroenteritis admission rate [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 2 p.
  • AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 4.4]. Appendices. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 61 p.

Primary Measure Domain

Related Population Health Measures: Population Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of admissions for a principal diagnosis of gastroenteritis, or for a principal diagnosis of dehydration with a secondary diagnosis of gastroenteritis, per 100,000 population, ages 3 months through 17 years.

Rationale

Gastroenteritis is a leading infectious disease of childhood acute infections and leading cause of hospitalization. Many cases of gastroenteritis can be prevented by vaccination with the rotavirus vaccine and through hygienic practices. Most cases of mild to moderate gastroenteritis can be treated in the outpatient arena. Early treatment focuses on oral rehydration.

Access to outpatient care may prevent illness through improved education about prevention, improved vaccination rates, and early access to treatment and/or treatment advice. Clinical practice guidelines suggest that prevention of gastroenteritis is preventable; and hence, hospitalizations for gastroenteritis are preventable.

This measure is an avoidable hospitalization/ambulatory care sensitive condition (ACSC) type indicator. ACSC type indicators are not measures of hospital quality, but rather measures of potentially avoidable hospitalization if appropriate outpatient care, other healthcare services or community services were accessed and obtained (i.e., measures of the health care system broadly defined). These measures are designed to assess population access to timely, high quality outpatient and public health services in a particular geographic area, for the purpose of managing chronic disease or diagnosing acute illnesses before progressing to inpatient treatment. These measures are of most interest to comprehensive health care delivery systems, such as some health maintenance organizations (HMOs), accountable care organizations (ACOs) or public health agencies. ACSC indicators correlate with each other and they may be used in conjunction as an overall examination of outpatient care and access to care at a national, regional or county level.

The improvement in the measure equates to less hospitalizations for acute gastroenteritis. This essentially means the population is experiencing better management of acute gastroenteritis given the reduction in the complications related to gastroenteritis.

Evidence for Rationale

National Quality Forum measure information: gastroenteritis admission rate (PDI 16). Washington (DC): National Quality Forum (NQF); 2014 Sep 18. 15 p.

Primary Health Components

Pediatrics; gastroenteritis; dehydration; ambulatory care sensitive condition (ACSC)

Denominator Description

Population ages 2 through 17 years in metropolitan area or county (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Discharges, for patients ages 3 months through 17 years, with either:

  • A principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for gastroenteritis; or
  • Any secondary ICD-9-CM diagnosis codes for gastroenteritis and a principal ICD-CM diagnosis code for dehydration

See the related "Numerator Inclusions/Exclusions" field.

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Approximately 1 in every 50 children born each year (less than 18 years of age) in a developed nation, such as the United States (U.S.), is hospitalized for acute gastroenteritis sometime during childhood. Viral gastroenteritis accounts for approximately 3% to 5% of all hospital days and 7% to 10% percent of hospitalizations each year for children younger than 18 years (Glass et al., 2001; Velázquez et al., 1996). More than 95% of viral gastroenteritis hospitalizations occur in children younger than 5 years with the highest rate of illness occurring in children between 3 and 24 months of age (Newburg et al., 1998; Velázquez et al., 1996). Among children younger than 5 years, the average rate of illness ranges from one to five episodes per child-year, resulting in a total of 15 to 25 million episodes of acute gastroenteritis per year in the U.S. (Matson & Estes, 1990; Tucker et al., 1998; Ho et al., 1998). Approximately 3 to 5 million of these episodes result in clinician visits, and 200,000 in hospitalization. Following the reintroduction of rotavirus immunization in 2006, norovirus (a calicivirus) has become the leading cause of gastroenteritis among young children in the U.S. Before rotavirus immunization, approximately one-half of hospitalizations for acute, nonbacterial gastroenteritis in children in the U.S. were caused by rotavirus, and 5% to 15% each by caliciviruses, astroviruses, and enteric adenoviruses. The remaining one-fourth to one-third of cases cannot be linked to any of these pathogens, but probably represent under diagnosis of the common pathogens (Staat et al., 2002; Oh, Gaedicke, & Schrieier, 2003). Many hospitalizations can be prevented by use of oral rehydration therapy in the community. Oral rehydration solution is regard as many as one of the most important medical advances of the 20th century (Chow, Leung, & Hon, 2010). However, despite overwhelming evidence to support the usage of oral rehydration therapy, it is under used (Chow, Leung, & Hon, 2010). Data from Europe, Australia and Canada show that 80% to 94% of hospitalized children do not have any signs of dehydration and yet they still received intravenous therapy.

An original study from New York on gastroenteritis reported a 1.87-fold variation in gastroenteritis hospitalization rates for ages 0 to 64, with a coefficient of variation of 0.438 and 22% of variance explained by household income (Billings et al., n.d.). Another study reported that low-income zip codes had 1.9 times more pediatric gastroenteritis hospitalizations per capita than high-income zip codes in the same 11 states in 1988 (Millman, 1993). Similarly, a retrospective analysis of the 1995 to 1996 cohort of infants born in Western Australia showed that aboriginal infants were hospitalized for gastroenteritis 8 times more frequently, and readmitted 2.7 times more frequently than their non-Aboriginal peers (Gracey, Lee, & Yau, 2004). These findings suggest that this indicator may be marker for poor access to outpatient care.

Evidence for Additional Information Supporting Need for the Measure

Billings J, Zeital L, Lukomnik J, Carey T, Blank A, Newman L. Analysis of variation in hospital admission rates associated with area income in New York City [unpublished].

Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112. PubMed External Web Site Policy

Glass RI, Bresee J, Jiang B, Gentsch J, Ando T, Fankhauser R, Noel J, Parashar U, Rosen B, Monroe SS. Gastroenteritis viruses: an overview. Novartis Found Symp. 2001;238:5-19; discussion 19-25. PubMed External Web Site Policy

Gracey M, Lee AH, Yau KK. Hospitalisation for gastroenteritis in Western Australia. Arch Dis Child. 2004 Aug;89(8):768-72. PubMed External Web Site Policy

Ho MS, Glass RI, Pinsky PF, Young-Okoh NC, Sappenfield WM, Buehler JW, Gunter N, Anderson LJ. Diarrheal deaths in American children. Are they preventable?. JAMA. 1988 Dec 9;260(22):3281-5. PubMed External Web Site Policy

Matson DO, Estes MK. Impact of rotavirus infection at a large pediatric hospital. J Infect Dis. 1990 Sep;162(3):598-604. PubMed External Web Site Policy

Millman ML, editor(s). Access to health care in America. Washington (DC): National Academy Press; 1993.

National Quality Forum measure information: gastroenteritis admission rate (PDI 16). Washington (DC): National Quality Forum (NQF); 2014 Sep 18. 15 p.

Newburg DS, Peterson JA, Ruiz-Palacios GM, Matson DO, Morrow AL, Shults J, Guerrero ML, Chaturvedi P, Newburg SO, Scallan CD, Taylor MR, Ceriani RL, Pickering LK. Role of human-milk lactadherin in protection against symptomatic rotavirus infection. Lancet. 1998 Apr 18;351(9110):1160-4. PubMed External Web Site Policy

Oh DY, Gaedicke G, Schreier E. Viral agents of acute gastroenteritis in German children: prevalence and molecular diversity. J Med Virol. 2003 Sep;71(1):82-93. PubMed External Web Site Policy

Staat MA, Azimi PH, Berke T, Roberts N, Bernstein DI, Ward RL, Pickering LK, Matson DO. Clinical presentations of rotavirus infection among hospitalized children. Pediatr Infect Dis J. 2002 Mar;21(3):221-7. PubMed External Web Site Policy

Tucker AW, Haddix AC, Bresee JS, Holman RC, Parashar UD, Glass RI. Cost-effectiveness analysis of a rotavirus immunization program for the United States. JAMA. 1998 May 6;279(17):1371-6. PubMed External Web Site Policy

Velázquez FR, Matson DO, Calva JJ, Guerrero L, Morrow AL, Carter-Campbell S, Glass RI, Estes MK, Pickering LK, Ruiz-Palacios GM. Rotavirus infections in infants as protection against subsequent infections. N Engl J Med. 1996 Oct 3;335(14):1022-8. PubMed External Web Site Policy

Extent of Measure Testing

Reliability Testing

The developer's metric of reliability is the signal to noise ratio, which is the ratio of the between area variance (signal) to the within area variance (noise). The formula is signal / (signal + noise). There is an area-specific signal to noise ratio, which is used as an empirical Bayes univariate shrinkage estimator. The overall signal to noise ratio is a weighted average of the area-specific signal-to-noise ratio, where the weight is [1 / (signal + noise)^2]. The signal is calculated using an iterative method. The analysis reports the reliability of the risk-adjusted rate (before applying the empirical Bayes univirate shrinkage estimator).

Overall the risk-adjusted rate is strongly reliable. Based on a norm of a signal-to-noise ratio of 0.80, 80% of areas exceed the norm. Reliability is less than the norm in areas with population less than approximately 1,600 persons, meaning that the performance score is reliability adjusted closer to the shrinkage target in those areas.

Validity Testing

The developer conducted construct validity testing to examine the association between the risk-adjusted rate and area structural characteristics potentially associated with quality of care, including prior performance, using regression analysis.

Given the stated rationale, the expectation for the regression analysis given the expected relationship between the "Less Access to High Quality Outpatient Care" construct validity measure (F1) and the area risk-adjusted rate is a positive, statistically significant coefficient. The expectation for the regression analysis given the expected relationship between the "More Market Competition" construct validity measure (F2) and the area risk-adjusted rate is a positive, statistically significant coefficient. The results are consistent with expectations. Also, past performance is a strong predictor of current performance with a coefficient of 0.91.

Refer to the original measure documentation for additional measure testing information.

Evidence for Extent of Measure Testing

National Quality Forum measure information: gastroenteritis admission rate (PDI 16). Washington (DC): National Quality Forum (NQF); 2014 Sep 18. 15 p.

State of Use

Current routine use

Current Use

Monitoring and planning

Monitoring health state(s)

Pay-for-performance

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Regional, County or City

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age 3 months to 17 years

Target Population Gender

Either male or female

Public Health Aims for Quality

Population-centered

Risk Reducing

Vigilant

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Time window can be determined by user, but is generally a calendar year.

Denominator Sampling Frame

Geographically defined

Denominator (Index) Event or Characteristic

Geographic Location

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Population ages 3 months through 17 years in the metropolitan area (MA) or county. Discharges in the numerator are assigned to the denominator based on the MA or county of the patient residence, not the MA or county of the hospital where the discharge occurred.

Note: The term "MA" was adopted by the United States (U.S.) Census in 1990 and referred collectively to metropolitan statistical areas (MSAs), consolidated metropolitan statistical areas (CMSAs), and primary metropolitan statistical areas (PMSAs). In addition, "area" could refer to either 1) Federal Information Processing Standard (FIPS) county, 2) modified FIPS county, 3) 1999 Office of Management and Budget (OMB) Metropolitan Statistical Area, or 4) 2003 OMB Metropolitan Statistical Area. Micropolitan Statistical Areas are not used in the Quality Indicator (QI) software.

Exclusions
Unspecified

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
Discharges, for patients ages 3 months through 17 years, with either:

  • A principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for gastroenteritis; or
  • Any secondary ICD-9-CM diagnosis codes for gastroenteritis and a principal ICD-CM diagnosis code for dehydration

Note: Refer to the original measure documentation for ICD-9-CM codes. See also the Pediatric Quality Indicators Appendices.

Exclusions
Exclude cases:

  • With any-listed ICD-9-CM diagnosis codes for gastrointestinal abnormalities
  • With any-listed ICD-9-CM diagnosis codes for bacterial gastroenteritis
  • Transfer from a hospital (different facility)
  • Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
  • Transfer from another health care facility
  • Neonates if age in days is missing
  • Major Diagnostic Categories (MDC) 14 (pregnancy, childbirth, and puerperium)
  • With missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing)

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Type of Health State

Proxy for Health State

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

Allowance for Patient or Population Factors

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

The predicted value for each case is computed using a hierarchical model (logistic regression with area random effect) and covariates for gender and age (in age groups). The reference population used in the regression is the universe of discharges for states that participate in the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data (SID) for the year 2010 (combined), a database consisting of 44 states and approximately 5 million pediatric discharges, and the United States (U.S.) Census data by county. The expected rate is computed as the sum of the predicted value for each case divided by the number of cases for the unit of analysis of interest (i.e., area). The risk adjusted rate is computed using indirect standardization as the observed rate divided by the expected rate, multiplied by the reference population.

Additional information on methodology can be found in the Empirical Methods document on the Agency for Healthcare Research and Quality (AHRQ) Quality Indicator Web site External Web Site Policy and in the supplemental information.

Refer to the original measure documentation for the specific covariates for this measure.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

PDI 16: gastroenteritis admission rate.

Measure Collection Name

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators

Measure Set Name

Pediatric Quality Indicators

Submitter

Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]

Developer

Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]

Funding Source(s)

Agency for Healthcare Research and Quality (AHRQ)

Composition of the Group that Developed the Measure

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicator (QI) measures are developed by a team of clinical and measurement experts in collaboration with AHRQ. The AHRQ QIs are continually updated as a result of new research evidence and validation efforts, user feedback, guidance from the National Quality Forum (NQF), and general advances in the science of quality measurement.

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

0727

Date of Endorsement

2014 Sep 18

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Mar

Measure Maintenance

Measure is reviewed and updated on a yearly basis

Date of Next Anticipated Revision

Spring 2016 (version 6.0, including International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] and International Classification of Diseases, Tenth Revision, Procedure Coding System [ICD-10-PCS] compatible software)

Measure Status

This is the current release of the measure.

This measure updates previous versions:

  • AHRQ QI. Pediatric quality indicators #16: technical specifications. Gastroenteritis admission rate [version 4.4]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 2 p.
  • AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 4.4]. Appendices. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Mar. 61 p.

Source(s)

AHRQ QI research version 5.0. Pediatric quality indicator 16 technical specifications: gastroenteritis admission rate. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Mar. 3 p.

National Quality Forum measure information: gastroenteritis admission rate (PDI 16). Washington (DC): National Quality Forum (NQF); 2014 Sep 18. 15 p.

Measure Availability

Source available from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Web site External Web Site Policy.

For more information, contact the AHRQ QI Support Team at E-mail: QIsupport@ahrq.hhs.gov; Phone: 301-427-1949.

Companion Documents

The following are available:

  • AHRQ quality indicators. Pediatric quality indicators (PDI) parameter estimates [version 5.0]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Mar. 98 p. This document is available from the AHRQ Quality Indicators Web site External Web Site Policy.
  • ARHQ quality indicators. Pediatric quality indicators benchmark data tables [version 5.0]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Mar. 13 p. This document is available from the AHRQ Quality Indicators Web site External Web Site Policy
  • AHRQ quality indicators. Pediatric quality indicators composite measure workgroup. Final report. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar. various p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.  
  • HCUPnet: a tool for identifying, tracking, and analyzing national hospital statistics. [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [accessed 2015 Sep 10]. HCUPnet is available from the AHRQ Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on December 28, 2007. The information was verified by the measure developer on March 31, 2008.

This NQMC summary was updated by ECRI Institute on June 25, 2010.

This NQMC summary was reviewed and edited by ECRI Institute on July 15, 2011.

This NQMC summary was retrofitted into the new template on July 19, 2011.

This NQMC summary was updated by ECRI Institute on February 28, 2013 and again on December 1, 2015. The information was verified by the measure developer on January 19, 2016.

Copyright Statement

No copyright restrictions apply.

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