Composite Measure

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types:

This measure is an all-or-none composite of the number of patients following an ICD/CRT-D implant procedure who received prescriptions for all medications (Angiotensin-converting enzyme inhibitors (ACE-I)/ Angiotensin receptor blockers (ARB)/ Angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers) for which they are eligible at discharge and those patients with procedures that fulfill class I, IIa, or IIb guideline indications.

This outcome measure assesses individuals on the activities that are meaningful to them. The target population for this measure is adults with disabilities who receive HCBS or HCBS-like services. This is a self-contained measure that can be administered independently of other RTCOM measures. 

This outcome measure assesses an individual's level of social inclusion and to what degree they are connected to others in their community. The target population for this measure is adults with disabilities who receive HCBS or HCBS-like services. This is a self-contained measure that can be administered independently of other RTCOM measures. 

The measure is administered through an in-person or video-conferencing interview where an interviewer guides an individual through a series of questions (i.e., items) on the measure. There are 14 items on this measure:

This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.

The STS AVR+CABG Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1.

STS AVR Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1. reoperations for any cardiac reason, 2.

The STS CABG Composite Score comprises four domains consisting of 11 individually NQF-endorsed cardiac surgery measures:
Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure;

The STS Individual Surgeon Composite Measure for Adult Cardiac Surgery includes five major procedures (isolated CABG, isolated AVR, AVR+CABG, MVRR, MVRR+CABG) and comprises the following two domains:

Domain 1 – Risk-Adjusted Operative Mortality
Operative mortality is defined as death before hospital discharge or within 30 days of the operation.

Domain 2 – Risk-Adjusted Major Morbidity
Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation,
2. Deep sternal wound infection,

The STS Lobectomy Composite Score comprises two domains:

1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.