Highest Opportunity for Improvement

This measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option. This proposal is to focus on patients who have undergone any one of 7 common, important surgical procedures: total replacement of the knee or hip, lower back surgery for spinal stenosis of herniated disc, radical prostatectomy for prostate cancer, mastectomy for early stage breast cancer or percutaneous coronary intervention (PCI) for stable angina.

This measure assesses the proportion of infants with permanent hearing loss with an Individual Family Service Plan (IFSP) to receive intervention services under Part C of the Individuals with Disabilities Education Act (IDEA) that is signed by the time the infant is 6 months of age.

The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

Percentage of patients aged 18 years and older undergoing infrainguinal lower extremity bypass who are prescribed a statin medication at discharge. This measure is proposed for both hospitals and individual providers.

The STS Individual Surgeon Composite Measure for Adult Cardiac Surgery includes five major procedures (isolated CABG, isolated AVR, AVR+CABG, MVRR, MVRR+CABG) and comprises the following two domains:

Domain 1 – Risk-Adjusted Operative Mortality
Operative mortality is defined as death before hospital discharge or within 30 days of the operation.

Domain 2 – Risk-Adjusted Major Morbidity
Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation,
2. Deep sternal wound infection,

The STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score measures surgical performance for MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF). To assess overall quality, the STS MVRR +CABG Composite Score comprises two domains consisting of six measures:

Domain 1 – Absence of Operative Mortality

The STS Mitral Valve Repair/Replacement (MVRR) Composite Score measures surgical performance for isolated MVRR with or without concomitant tricuspid valve repair (TVr), surgical ablation for atrial fibrillation (AF), or repair of atrial septal defect (ASD). To assess overall quality, the STS MVRR Composite Score comprises two domains consisting of six measures:

Domain 1 – Absence of Operative Mortality

Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool