The measure estimates a hospital-level RSMR for patients 18 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 30 days of the procedure date of an index CABG admission. An index CABG admission is the hospitalization for a qualifying isolated CABG procedure considered for the mortality outcome. The measure was developed using Medicare Fee-for-Service (FFS) patients 65 years and older and was tested in all-payer patients 18 years and older.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.20 Testing Data Sources
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1.14 Numerator
The outcome for this measure is 30-day all-cause mortality. Mortality is defined as death for any reason within 30 days of the procedure date from the index admission for patients discharged from the hospital after undergoing isolated CABG surgery.
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1.15 Denominator
This claims-based measure can be used in either of two patient cohorts: (1) patients aged 65 years or older or (2) patients aged 18 years or older. We have tested the measure in both age groups.
The cohort includes admissions for patients who receive a qualifying isolated CABG procedure (see the attached Data Dictionary) and with a complete claims history for the 12 months prior to admission. The measure is publicly reported by CMS for those patients 65 years or older who are Medicare FFS beneficiaries admitted to non-federal hospitals.
For patients with more than one qualifying CABG surgery admission in the measurement period, the first CABG admission is selected for inclusion in the measure and the subsequent CABG admission(s) are excluded from the cohort.
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Exclusions
The CABG surgery mortality measure excludes index admissions for patients:
1. With inconsistent or unknown vital status or other unreliable demographics (age and gender) data; or,
2. Discharged against medical advice (AMA).
For patients with more than one qualifying CABG surgery admission in the measurement period, the first CABG admission is selected for inclusion in the measure and the subsequent CABG admission(s) are excluded from the cohort.
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OLD 1.12 MAT output not attachedAttached
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Most Recent Endorsement ActivityCardiovascular Fall 2022Initial EndorsementLast Updated
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Steward Organization EmailSteward Organization Copyright
N/A
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)
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Planned UseUse In Federal Program
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Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Fall 2022 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Fall 2022 “Intent to Submit.” Battelle took over the E&M work for the Fall 2022 cycle after developers and/or stewards submitted their full measure information to NQF, which for CBE #2558, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2024-02/2558.zip
Battelle took over the E&M work beginning with the public comment period to close the E&M committees for the post-comment meeting, convening the CSAC to render a final endorsement decision, and executing the appeals period.