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Pancreatic Resection Mortality Rate (IQI 9)

CBE ID
0365
1.4 Project
Surgery
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Fall 2017
Is Under Review
No
1.3 Measure Description

In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

    • 1.14 Numerator

      Overall:
      Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator.

      Stratum A:
      Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator.

      Stratum B:
      Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator.

    • 1.15 Denominator

      Overall:
      Discharges, for patients ages 18 years and older, with any-listed ICD-9-CM procedure codes for partial pancreatic resection or any-listed ICD-9-CM procedure codes for total pancreatic resection.

      Stratum A:
      Discharges, for patients ages 18 years and older, with either:
      • any-listed ICD-9-CM procedure codes for partial pancreatic resection (see above) and any-listed ICD-9-CM diagnosis codes for pancreatic cancer; or
      • any-listed ICD-9-CM procedure codes for total pancreatic resection (see above) and any- listed ICD-9-CM diagnosis codes for pancreatic cancer

      Stratum B:
      Discharges, for patients ages 18 years and older, with either:
      • any-listed ICD-9-CM procedure codes for partial pancreatic resection (see above) without any-listed ICD-9-CM diagnosis codes for pancreatic cancer (see above); or
      • any-listed ICD-9-CM procedure codes for total pancreatic resection (see above) without any-listed ICD-9-CM diagnosis codes for pancreatic cancer (see above)

    • Exclusions

      Overall:
      Exclude cases:
      • with any-listed ICD-9-CM diagnosis code for acute pancreatitis
      • transferring to another short-term hospital (DISP=2)
      • MDC 14 (pregnancy, childbirth, and puerperium)
      • with missing discharge disposition (DISP=missing), gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

      Stratum A:
      Exclude cases:
      • with any-listed ICD-9-CM diagnosis code for acute pancreatitis (see above)
      • transferring to another short-term hospital (DISP=2)
      • MDC 14 (pregnancy, childbirth, and puerperium)
      • with missing discharge disposition (DISP=missing), gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

      Stratum B:
      Exclude cases:
      • with any-listed ICD-9-CM diagnosis code for acute pancreatitis (see above)
      • transferring to another short-term hospital (DISP=2)
      • MDC 14 (pregnancy, childbirth, and puerperium)
      • with missing discharge disposition (DISP=missing), gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Surgery Fall Cycle 2017
      Initial Endorsement
      Last Updated
      Removal Date