Quantifying the episode-related costs of AHRQ's prevention quality indicators

Research Objective: The objective was to develop and test a method of quantifying episode-related costs for each of the fourteen Prevention Quality Indicator (PQI) events defined by the Agency for Healthcare Research and Quality (AHRQ). PQIs are a set of ambulatory care sensitive measures drawn from hospital discharge data that identify conditions for which good outpatient care can potentially prevent the need for hospitalization due to complications or disease progression. Study Design, Population, and Time Frame: The study was a cross-sectional analysis of medical and pharmacy claims data drawn from the commercial membership of a large health plan in the southeastern United States in 2009. All adult subscribers between ages 18-64 who had a hospital discharge in calendar year 2009 for one (or more) of the fourteen PQI-defined hospitalizations were included in the study population. Specifications provided by AHRQ were used to identify and operationalize each of the fourteen PQIs at the member-level from medical claims data for inpatient hospital discharges during the 2009 study period. Inpatient admission and discharge dates for each PQI-defined hospital stay were collected and used to create temporal PQI-defined episodes at the member level. All of an individual member's services and costs that were incurred during the same time period as the PQI-defined hospital stay were grouped together to create the PQI-defined episode. Total costs within each PQI-defined episode were allocated to one of six categories: inpatient, outpatient, practitioner, ancillary, pharmacy, and absenteeism. Total PQI costs were quantified as the sum of the episode-related costs for each of the fourteen PQIs. Principal Findings: Results demonstrated significant additional episode-related costs for each of the fourteen PQIs beyond the costs incurred solely due to inpatient hospital charges. In addition, there was substantial variation across the fourteen PQIs by total episode-related costs as well as variation by the six cost categories within each PQI-defined episode. Conclusions & Implications: Total costs for AHRQ-defined PQIs can be quantified by taking an episodal perspective. By not limiting the scope of analysis solely to the hospital claim on which the PQI event is recorded, such a perspective provides a more accurate picture of the total costs incurred due to these preventable hospitalizations. PQI hospitalizations are more costly to payers and employers than may originally have been thought. This finding creates an additional economic incentive to better manage the ambulatory care sensitive conditions upon which the fourteen AHRQ PQIs are based.