The measure estimates a hospital-level risk-standardized complication rate (RSCR) associated with elective primary THA and TKA in Medicare Fee-For-Service beneficiaries who are age 65 and older. The outcome (complication) is defined as any one of the specified complications occurring from the date of index admission to 90 days post date of the index admission (the admission included in the measure cohort).
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
The outcome for this measure is any complication occurring during the index admission (not coded present on arrival) to 90 days post-date of the index admission. Complications are counted in the measure only if they occur during the index hospital admission or during a readmission. The complication outcome is a dichotomous (yes/no) outcome. If a patient experiences one or more of these complications in the applicable time period, the complication outcome for that patient is counted in the measure as a “yes”.
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1.15 Denominator
The target population for the publicly reported measure includes admissions for Medicare FFS beneficiaries who are at least 65 years of age undergoing elective primary THA and/or TKA procedures.
Additional details are provided in S.7 Denominator Details.
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Exclusions
This measure excludes index admissions for patients:
1. Without at least 90 days post-discharge enrollment in FFS Medicare;
2. Who were discharged against medical advice (AMA); or,
3. Who had more than two THA/TKA procedure codes during the index hospitalization.
After applying these exclusion criteria, we randomly select one index admission for patients with multiple index admissions in a calendar year. We therefore exclude the other eligible index admissions in that year.
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Most Recent Endorsement ActivityEndorsed Surgery Fall Cycle 2020Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
N/A
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Risk Adjustment
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6.1.2 Current or Planned Use(s)6.1.3 Current Use(s)
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