Statistical risk model

This is a patient-reported outcome performance measure (PRO-PM) consisting of an item response theory-based patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older with low back impairments. The change in FS is assessed using the Low Back FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older with neck impairments. The change in FS is assessed using the Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient, individual clinician, and clinic levels to assess quality.

A self-report outcome measure of change in functional status for patients 14 years+ with shoulder impairments. The change in functional status assess using FOTO’s (shoulder) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.

GAPPS is a measure of the number of preventable adverse events per 1,000 patient-days among pediatric inpatients. It is designed to compare rates across institutions and over time. The GAPPS measure utilizes the GAPPS trigger tool to identify adverse events.

HCAHPS (NQF #0166) is a 29-item survey instrument that produces 10 publicly reported measures:

6 multi-item measures (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, discharge information and care transition); and

4 single-item measures (cleanliness of the hospital environment, quietness of the hospital environment, overall rating of the hospital, and recommendation of hospital).

In-hospital deaths per 1,000 hospital discharges with heart failure as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

Adjusted percentage of adult hemodialysis patient-months using an autogenous arteriovenous fistula (AVF) as the sole means of vascular access.

The measure estimates a hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) for patients age 65 and older discharged from the hospital with a principal diagnosis of acute myocardial infarction (AMI). Readmission is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Readmissions are classified as planned and unplanned by applying the planned readmission algorithm.

This measure estimates hospital risk-standardized 30-day unplanned readmission rates following hospital stays with one or more qualifying vascular procedure in patients who are 65 years of age or older and either admitted to the hospital (inpatients) for their vascular procedure(s) or receive their procedure(s) at a hospital but are not admitted as an inpatient (outpatients). Both scenarios are hereafter referred to as "hospital stays."

The measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal diagnosis of AMI. Mortality is defined as death for any cause within 30 days after the date of admission for the index admission. CMS annually reports the measure for patients who are 65 years or older and are either Medicare fee-for-service (FFS) beneficiaries and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.