Hospital: Inpatient

The Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia who receive an excess antibiotic duration. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level for both quality improvement and pay-for-performance.

The Excess Days in Acute Care (EDAC) after Hospitalization for Acute Myocardial Infarction (AMI) (hereafter “AMI EDAC") measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for AMI. This measure is intended to improve the quality of care transitions provided to discharged patients hospitalized for AMI by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

This measure estimates a hospital-level risk-standardized readmission rate (RSRR) following PCI for Medicare Fee-for-Service (FFS) patients who are 65 years of age or older. The outcome is defined as unplanned readmission for any cause within 30 days following hospital stays. The measure includes both patients who are admitted to the hospital (inpatients) for their PCI and patients who undergo PCI without being admitted (outpatient or observation stay). A specified set of planned readmissions do not count as readmissions.

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.

This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older.

This electronic clinical quality measure (eCQM) assesses the proportion of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF).

This measure provides hospital specific risk-standardized rates of procedural complications following the implantation of an Implantable Cardioverter-Defibrillator (ICD) in patients at least 65 years of age. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) Electrophysiology Device Implant Registry (EPDI - formerly the ICD Registry) for risk adjustment linked with administrative claims data using indirect patient identifiers to identify procedural complications.

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.

The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), and assesses each group’s readmission rate.