Outcome

The Standardized Ratio of Emergency Department Encounters Occurring Within 30 Days of Hospital Discharge for Dialysis Facilities (ED30) is defined to be the ratio of observed over expected events. The numerator is the observed number of index discharges from acute care hospitals that are followed by an outpatient emergency department encounter within 4-30 days after discharge for eligible adult Medicare dialysis patients treated at a particular dialysis facility.

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.

Percentage of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure.

A reliability adjusted measure of AAA repair performance that optimally combines two important domains: AAA hospital volume and AAA operative mortality, to provide predictions on hospital AAA survival rates in patients age 18 and over.

A reliability adjusted measure of Esophagectomy surgical performance that optimally combines two important domains: Esophagectomy hospital volume and Esophagectomy operative mortality, to provide predictions on hospital Esophagectomy survival rates in patients age 18 and over.

A reliability adjusted measure of pancreatic resection surgical performance that optimally combines two important domains: Pancreatic resection hospital volume and pancreatic operative mortality, to provide predictions on hospital pancreatic survival rates in patients age 18 and.

This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.

This facility-level measure estimates an all-cause, unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease.

The performance period for the measure is 24 months.

Percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first “operating room” procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication.