Management of Acute Events, Chronic Disease, Surgery, and Behavioral Health

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

This is a weighted composite measure comprised of six component measures: three all-cause risk standardized outcome measures on all-cause mortality, bleeding, acute kidney injury and three process measures focused on discharge on guideline directed medical therapy, referral to a cardiac rehabilitation program and PCI performed within ninety minutes of symptoms for patients with acute myocardial infarctions. The target population includes adults (age 18 and greater) undergoing percutaneous coronary interventions. The timeframe for reporting will be a rolling four quarters.  

Percentage of all patient months for adult patients (>= 18 years old) whose delivered peritoneal dialysis dose was a weekly Kt/V urea >= 1.7 (dialytic + residual). 

Percentage of adult dialysis patients with a 6-month rolling average phosphorus value greater than or equal to 6.5 mg/dL.  

The measure estimates the hospital-level, risk-standardized mortality rate (RSMR) for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage[MA]) discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure includes the National Institutes of Health (NIH) Stroke Scale as an assessment of stroke severity upon admission in the risk-adjustment model.