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Fall 2024

Valid for Measure Submission

Hospice Visits in the Last Days of Life

The proportion of hospice patients who received hospice visits from a Registered Nurse or Medical Social Worker (non-telephonically) associated with the measured hospice entity during at least two of the final three days of life.

CBE ID
3645

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Ischemic Stroke Hospitalization with Claims-Based Risk Adjustment for Stroke Severity

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.

CBE ID
4595

Hospital-Level, Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

The measure estimates a hospital-level risk-standardized complication rate (RSCR) associated with elective primary THA and/or TKA procedures for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage [MA]) aged 65 and older. The outcome (complication) is defined as any one of the specified complications occurring from the date of index admission to up to 90 days after the index admission. Complications are counted in the measure only if they occur during the index hospital admission or during a readmission.

CBE ID
1550

Hybrid Hospital‐Wide (All‐Condition, All‐Procedure) Risk‐Standardized Mortality Measure with Claims and Electronic Health Record Data

Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Claims and Electronic Health Record Data measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date for Medicare fee-for-service and Medicare Advantage patients who are between the ages of 65 and 94. 

CBE ID
3502e

Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

The Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia. Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms.

CBE ID
4545e

Minimum spKt/V for Pediatric Hemodialysis Patients

Percentage of patient months for all pediatric (<18 years old) in-center hemodialysis patients in which the delivered dose of hemodialysis (calculated from the last measurement of the month using the UKM or Daugirdas II formula) was spKt/V >= 1.2.

CBE ID
1423

Patient Safety Indicator (PSI) 90: Patient Safety and Adverse Events Composite

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.

CBE ID
0531