Empirical validity testing at the accountable entity-level (e.g., criterion validity, construct validity, known groups analysis)

This measure was developed to improve the quality of care delivered to patients undergoing urology procedures in an ambulatory surgical center (ASC). The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a urology surgery at an ASC among Medicare fee-for-service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. 

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.

Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data measures facility-level risk-standardized rate of readmission (RSRR) within 30 days of discharge from an inpatient admission, among Medicare Fee-For-Service (FFS) and Medicare Advantage (MA) patients aged 65 years and older. 

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. 

Percentage of home health episodes of care during which the patient improved in ability to ambulate. This is a rate/proportion measure targeted at older adults with multiple chronic conditions during home health quality of care episodes. 

Percentage of home health episodes of care during which the patient got better at bathing self. This is a rate/proportion measure targeted at elderly individuals with multiple chronic conditions during home health quality of care episodes. 

Percentage of home health episodes of care during which the patient got better at getting in and out of bed. This is a rate/proportion measure targeted at elderly individuals with multiple chronic conditions during home health quality of care episodes. 

Percentage of home health episodes of care during which the patient improved in ability to take their medicines correctly, by mouth. This is a rate/proportion measure targeted at elderly individuals with multiple chronic conditions during home health quality of care episodes. 

This measure estimates a hospital-level risk standardized mortality rate (RSMR) in adult patients without cardiogenic shock or cardiac arrest undergoing PCI. The outcome is defined as in-hospital mortality following a PCI procedure performed during the episode of care. Mortality is defined as death for any cause during the episode of care.