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Endorsed

Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following coronary artery bypass graft (CABG) surgery

The measure estimates a hospital-level risk-standardized readmission rate (RSRR), defined as unplanned readmission for any cause within 30-days from the date of discharge for a qualifying index CABG procedure, in patients 65 years and older.

An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

CBE ID
2515

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

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.

CBE ID
3494

Hospital Harm Pressure Injury

This electronic clinical quality measure (eCQM) assesses the proportion of inpatient hospitalizations for patients ages 18 years and older at the start of the encounter who suffer the harm of developing a new stage 2, stage 3, stage 4, deep tissue, or unstageable pressure injury.
CBE ID
3498e

Hospital Harm – Falls with Injury

This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older.

CBE ID
4120e

Hospital Harm – Opioid-Related Adverse Events

This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication, subsequently suffer the harm of an opioid-related adverse event, and are administered an opioid antagonist (naloxone) within 12 hours. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting.

CBE ID
3501e

Hospital Harm – Postoperative Respiratory Failure

This electronic clinical quality measure (eCQM) assesses the proportion of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF).

CBE ID
4130e

Hospital Harm – Severe Hyperglycemia

This ratio electronic clinical quality measure (eCQM) assesses the number of hospital days with a severe hyperglycemic event (a blood glucose result >300 mg/dL, or a day in which a blood glucose value was not documented and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL) per the total qualifying hospital days among inpatient encounters for patients 18 years and older who have either:

1. A diagnosis of diabetes mellitus,

CBE ID
3533e

Hospital Harm-Acute Kidney Injury

This electronic clinical quality measure (eCQM) assesses the proportion of inpatient hospitalizations for patients 18 years of age or older who have an acute kidney injury (stage 2 or greater) that occurred during the encounter. Acute kidney injury (AKI) stage 2 or greater is defined as a substantial increase in serum creatinine value, or by the initiation of kidney dialysis (continuous renal replacement therapy (CRRT), hemodialysis or peritoneal dialysis).
CBE ID
3713e

Hospital Visits after Hospital Outpatient Surgery

Hospital Visits after Hospital Outpatient Surgery measures facility-level risk-standardized rate of acute, unplanned hospital visits within 7 days of a procedure performed at a hospital outpatient department (HOPD) among Medicare Fee-For-Service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. 

CBE ID
2687

Hospital-level 30-day risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA in Medicare Fee-For-Service (FFS) beneficiaries who are 65 years and older. The outcome (readmission) is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission (the admission included in the measure cohort). A specified set of planned readmissions do not count in the readmission outcome.

CBE ID
1551