This measure estimates hospital risk-standardized 30-day unplanned readmission rates following hospital stays with one or more qualifying vascular procedure in patients who are 65 years of age or older and either admitted to the hospital (inpatients) for their vascular procedure(s) or receive their procedure(s) at a hospital but are not admitted as an inpatient (outpatients). Both scenarios are hereafter referred to as "hospital stays."
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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 30-day all-cause unplanned readmission following a qualifying index hospital stay (see S.7-S.11 for more details). We define a readmission as a subsequent hospital inpatient admission within 30 days of either the discharge date (for inpatients) or claim end date (for outpatients – hereafter referred to as "discharge date") following a qualifying hospital stay. We do not count as readmissions any subsequent outpatient procedures or any subsequent admissions which are identified as "staged" or planned. If a patient has more than one unplanned readmission within 30 days of discharge from the index hospital stay, only the first one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each index hospital stay has an unplanned readmission within 30 days. (See S.6, Numerator Details, for more information.)
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1.15 Denominator
The target population for this measure includes inpatient and outpatient hospital stays for patients at least 65 years of age who receive one or more qualifying vascular procedure.
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Exclusions
Hospital stays are excluded from the cohort if they met any of the following criteria:
1) Lack of follow-up in Medicare FFS for at least 30 days post-discharge. Hospital stays for patients without at least 30 days of enrollment in Medicare FFS after discharge from the index stay are excluded.
Rationale: We exclude these hospital stays because the 30-day readmission outcome cannot be assessed in this group.
2) Hospital stays for patients who leave hospital against medical advice (AMA). Hospital stays for patients who are discharged AMA are excluded.
Rationale: We exclude hospital stays for patients who are discharged AMA because providers in these circumstances do not have the opportunity to deliver full care and prepare the patient for discharge.
3) Hospital stays with a qualifying vascular procedure that occur within 30 days of a previous hospital stay with a qualifying vascular procedure. Subsequent hospital stays with a qualifying vascular procedure within 30 days of discharge from an index hospital stay will not be counted as another index hospital stay.
Rationale: Qualifying vascular procedures occurring within 30 days of discharge from an index hospital stay fall within the 30-day readmission assessment period during which no new hospital stay can be counted as an index hospital stay. They are considered readmissions. Any vascular hospital stay is either an index stay or a potential readmission, but not both.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed All-Cause Admissions and Readmissions Spring Cycle 2020Initial EndorsementLast UpdatedRemoval Date
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Steward Organization Email
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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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Planned Use
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