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Centers for Medicare & Medicaid Services

ESRD Dialysis Patient Life Goals Survey (PaLS)

  • The PaLS is used to generate a patient-level t-score that reflects patient-reported satisfaction with how well his/her/their facility is doing in discussing life goals with the patient as part of the treatment planning process.

    CBE ID
    3742

ESRD- HD Adequacy CPM III: Minimum Delivered Hemodialysis Dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 90 days or greater.

  • Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2 during the reporting period.

    CBE ID
    0250

Evaluation of Left ventricular systolic function (LVS)

  • Percentage of heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.

    CBE ID
    0135

Excess days in acute care (EDAC) after hospitalization for acute myocardial infarction (AMI)

  • This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for acute myocardial infarction (AMI) to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients hospitalized with AMI by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

    CBE ID
    2881

Excess days in acute care (EDAC) after hospitalization for heart failure (HF)

  • The measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for HF to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients who had a HF hospitalization by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

    CBE ID
    2880

Excess days in acute care (EDAC) after hospitalization for pneumonia

  • This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for pneumonia, including aspiration pneumonia or for sepsis (not severe sepsis) with a secondary discharge diagnosis of pneumonia coded in the claim as present on admission (POA) and no secondary diagnosis of severe sepsis coded as POA.

    CBE ID
    2882

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

  • This measure was developed to improve the quality of care delivered to patients undergoing outpatient colonoscopy procedures. The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure, estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a colonoscopy procedure performed at a hospital outpatient department (HOPD) or ambulatory surgical center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and older.

    CBE ID
    2539

Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers

  • This measure was developed to improve the quality of care delivered to patients undergoing general surgery procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of return to a hospital for an acute, unplanned hospital visit within seven days of qualified general surgery procedures performed at an ambulatory surgical center (ASC) among Medicare Fee-For-Service (FFS) patients aged 65 years and older.

    CBE ID
    3357

Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

  • This measure calculates the percentage of Emergency Department (ED) acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. The measure is calculated using chart-abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

    CBE ID
    0288

Fibrinolytic Therapy received within 30 minutes of hospital arrival

  • Percentage of acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.

    CBE ID
    0164