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Hospital 90-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery

CBE ID
3494
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2025
1.3 Measure Description

This measure estimates a hospital-level, risk-standardized mortality rate (RSMR) for patients 65 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 90 days of the procedure date of an index CABG admission. The measure was developed using Medicare Fee-for-Service (FFS) patients 65 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the mortality outcome. This measure may be used in one or more to be defined 90-day payment models.

        • 1.5 Measure Type
          1.7 Electronic Clinical Quality Measure (eCQM)
          1.8 Level Of Analysis
          1.20 Testing Data Sources
        • 1.14 Numerator

          The outcome for this measure is 90-day all-cause mortality. Mortality is defined as death for any reason within 90 days of the procedure date from the index admission for patients 65 and older discharged from the hospital after undergoing isolated CABG surgery.

        • 1.15 Denominator

          This claims-based measure can be used in the patient cohort aged 65 years or older.
          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. CMS publicly reports this measure for those patients 65 years or older who are Medicare FFS beneficiaries admitted to non-federal hospitals.
          If a patient has more than one qualifying isolated CABG admission in the measure period, the first CABG admission is selected for inclusion in the measure and the subsequent CABG admission(s) are excluded from the cohort.

        • Exclusions

          The 90-day CABG surgery mortality measure excludes index admissions for patients:
          1) With inconsistent or unknown vital status or other unreliable data.
          2) Who leave the hospital against medical advice (AMA).
          3) With qualifying CABG procedures subsequent to another qualifying CABG procedure during the measurement period.

        • 1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Endorsed Surgery Spring Cycle 2019
          Initial Endorsement
          Last Updated
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Steward Organization Copyright

          N/A

              • Risk Adjustment
                Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off