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Recently hospitalized residents with pressure ulcers (risk adjusted)

CBE ID
0187
Project
Endorsed
New or Maintenance
Endorsement and Maintenance (E&M) Cycle
Is Under Review
No
Measure Description

Recently hospitalized residents with pressure ulcers

  • Measure Type
    Electronic Clinical Quality Measure (eCQM)
    Level Of Analysis
    Numerator

    SNF PPS Patients who satisfy either of the following conditions:
    1. On the SNF PPS 5-day assessment, the patient had no pressure ulcers (M2a[t-1]=0) AND, on the SNF PPS 14-day assessment, the patient has at least a stage 1 pressure ulcer (M2a[t]=1,2,3, or 4).
    2. On the SNF PPS 5-day assessment, the patient had a pressure ulcer (M2a[t-1] = 1,2,3, or 4) AND on the SNF PPS 14-day assessment, pressure ulcers worsened or failed to improve (M2a[t]>=M2a[t-1]).

    Denominator

    All patients with a valid SNF PPS 14-day assessment (AA8b=7) AND a valid preceding SNF PPS 5-day assessment (AA8b=1).

    Exclusions

    Exclusions: Patients satisfying the following condition:
    1.M2a is missing on the 14-day assessment [t
    2. M2a is missing on the 5-day assessment [t-1] and M2a shows presence of pressure ulcers on the 14-day assessment (M2a=1,2,3, or 4.
    3. The Patient is in a facility with a Post Acute Care Admission Sample size of 0 (i.e., there are no SNF PPS 5-day assessments with AA8b =1 in the facility over the previous 12 months)

    Covariates:
    1. Indicator of history of unresolved pressure ulcer on the SNF PPS 5-day assessment. Covariate =1 if M3 =1.
    Covariate =0 if M3 =0.
    2. Indicator of requiring limited or more assistance in bed mobility on the SNF PPS 5-day assessment:
    Covariate = 1 if G1a(A) = 2,3,4, or8.
    Covariate = 0 if G1a(A) =0 or 1.
    3. Indicator of bowel incontinence at least one/week on the SNF PPS 5-day assessment:
    Covariate =1 if H1a 2,3, or 4.
    Covariate =0 if H1a = 0 or 1.
    4. Indicator of diabetes or peripheral vascular disease on the SNF PPS 5-day assessment:
    Covariate =1 if I1a checked (value 1) or I1j checked (value 1).
    Covariate =0 if I1a not checked (value 0) and I1j not checked (value 0).
    5. Indicator of Low Body Mass Index (BMI) on the SNF PPS 5-day assessment:
    Covariate = 1 if BMI >=12 and =19.
    Covariate = 0 if BMI > 19 and = 40.
    Where: BMI = weight(kg)/height2 (m2) = ((K2b*0.45)/(((K2a)*.0254)^2))

    (Note: An implausible BMI value 12 or >40 will be treated as a missing value on this covariate.

    Testing Data Sources
  • Most Recent Endorsement Activity
    Measure Retired and Endorsement Removed Nursing Homes- 2004
    Initial Endorsement
    Endorsement Status
    Last Updated
    Removal Date