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Fall 2023

Valid for Measure Submission

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

CBE ID
4210

Pediatric All-Condition Readmission Measure

This measure calculates case-mix-adjusted readmission rates, defined as the percentage of admissions followed by 1 or more readmissions within 30 days, for patients less than 18 years old. The measure covers patients discharged from general acute care hospitals, including children’s hospitals.

CBE ID
2393

Pediatric Lower Respiratory Infection Readmission Measure

This measure calculates case-mix-adjusted readmission rates, defined as the percentage of admissions followed by 1 or more readmissions within 30 days, following hospitalization for lower respiratory infection (LRI) in patients less than 18 years old. The measure covers patients discharged from general acute care hospitals, including children’s hospitals.

CBE ID
2414

Risk-Adjusted Operative Mortality for Aortic Valve Replacement (AVR)

Percent of patients aged 18 years and older undergoing Aortic Valve Replacement (AVR) who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

CBE ID
0120

Risk-Adjusted Operative Mortality for Aortic Valve Replacement (AVR) + CABG Surgery

Percent of patients aged 18 years and older undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

CBE ID
0123

Risk-Adjusted Operative Mortality for CABG

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

CBE ID
0119

Risk-Adjusted Operative Mortality for Mitral Valve (MV) Replacement

Percent of patients aged 18 years and older undergoing MV Replacement who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

CBE ID
0121

Risk-Adjusted Operative Mortality for Mitral Valve (MV) Replacement + CABG Surgery

Percent of patients aged 18 years and older undergoing combined MV Replacement and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

CBE ID
0122