Systematic assessment of face validity of the measure’s performance score as an indicator of quality or resource use

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.

The Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Participants measure is a risk-adjusted, state-level measure that assesses rates of hospital admissions for ambulatory care sensitive conditions per 1,000 Medicaid HCBS participants aged 18 years and older. This measure has three rates reported for potentially avoidable inpatient hospital admissions:

1. Chronic Conditions
2. Acute Conditions
3. Chronic and Acute Conditions Composite

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. 

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.

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.

This electronic Clinical Quality Measure (eCQM) reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening (BI-RADS 0) or screening-to-diagnostic (BI-RADS 4, 5) mammogram during the measurement period (i.e., calendar year) who received timely diagnostic resolution defined as either follow-up imaging with negative/benign/probably benign results or a breast biopsy within 60 days after their index (i.e., first) abnormal screening mammogram.

This electronic Clinical Quality Measure (eCQM) reports the percentage of patients aged 45 to 75 years with at least one positive stool-based colorectal cancer screening test (i.e., high-sensitivity guaiac fecal occult blood test, fecal immunochemical test, or Cologuard) during the measurement period (i.e., calendar year) who completed a colonoscopy within 180 days after their index (i.e., first) positive stool-based test result date.

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. 

The Use of Pharmacotherapy for Opioid Use Disorder measure evaluates the percentage of Medicaid or Medicare-Medicaid participants, aged 18 years and older, who have been diagnosed with an opioid use disorder (OUD) who filled a prescription for, were administered, or dispensed, a Food and Drug Administration (FDA)-approved medication to treat or manage OUD during the measurement year.