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

Measure Description: The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:
• Blood pressure less than 140/90 mmHg
• On a statin medication, unless allowed contraindications or exceptions are present
• Non-tobacco user
• On daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present

Exclusions

PSI 90 is a composite of ten adverse event indicators that summarizes hospitals’ performance on patient safety for the CMS Medicare fee-for-service population. The timeframe used in the CMS Hospital Acquired Conditions Reduction Program (HACRP) and CareCompare public reporting are set within the Inpatient Prospective Payment Systems (IPPS) Final Rule annually. Typically, the performance periods use multiple months of claims data.

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.

Percentage of pediatric (< 18 years old) peritoneal dialysis patient-months whose delivered peritoneal dialysis dose was a weekly Kt/Vurea >= 1.8 (dialytic + residual)

The chest imaging-confirmed measure of pneumonia diagnosis is a process measure of inpatient hospitalizations that identifies the proportion of adult patients hospitalized patients with a discharge diagnosis of pneumonia and who received systemic or oral antimicrobials at any time during admission who received chest imaging that supported the diagnosis of pneumonia, as recommended by clinical practice guidelines.  The measure applies to a target population of adult hospitalized patients.

This measure estimates a hospital-level risk standardized survival rate (RSSR) for adult patients aged 18 years and older who experience an in-hospital cardiac arrest.

Percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first “operating room” procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication. 

This is a measure of follow-up clinical visits for patients with chronic conditions who have experienced an acute exacerbation of one of six conditions (eight categories) of interest (coronary artery disease [CAD] {high or low acuity}, hypertension {high or medium acuity}, heart failure [HF], diabetes, asthma, and chronic obstructive pulmonary disease [COPD]) and are among adult Medicare Fee-for-Service (FFS) beneficiaries who are attributed to entities participating in the CMMI Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) model.