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Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure-to-Rescue)

CBE ID
4125
Endorsement Status
E&M Committee Rationale/Justification

Perform additional reliability testing for endorsement review.

1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2028
1.6 Measure Description

Percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first “operating room” procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication. 

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.9 Care Setting
1.10 Measure Rationale

N/A as this is not a paired measure. 

Website URL not available; Final measure specifications for implementation will be made publicly available on CMS’ appropriate quality website, once finalized through the CBE endorsement and CMS rulemaking processes. 

1.20 Types of Data Sources
1.25 Data Source Details

Medicare inpatient claims data, including Medicare Inpatient Encounter (shadow billing) data for Medicare Advantage enrollees, in combination with validated death data from the Medicare Beneficiary Summary File or equivalent resources. CMS receives death information from a number of sources. The main sources CMS uses to develop its death information are Medicare claims data from the Medicare Common Working File (CWF), online date of death edits submitted by family members, and benefit information used to administer the Medicare program collected from the Railroad Retirement Board (RRB) and the Social Security Administration (SSA). Overall, over 99.9% of death days have been validated. As for other CMS 30-day mortality measures, the "Valid Date of Death Switch" is used to confirm that the exact day of death has been validated.