Maintenance

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

Number of rehospitalizations occurring within 30 days of discharge from an acute care hospital (prospective payment system (PPS) or critical access hospital (CAH)) per 1000 FFS Medicare beneficiaries at the state and community level by quarter and year.

The TAVR 30-day morbidity/mortality composite is a hierarchical, multiple outcome risk model that estimates risk standardized results (reported as a “site difference”) for the purpose of benchmarking site performance. This measure estimates hospital risk standardized site difference for 5 endpoints (death from all causes, stroke, major or life-threatening bleeding, acute kidney injury, moderate or severe paravalvular aortic regurgitation) within 30 days following transcatheter aortic valve replacement.

30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which adult cancer patients have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.”

In-hospital deaths per 1,000 discharges with abdominal aortic aneurysm (AAA) repair, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. 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.]

The number of hospital discharges with a procedure for abdominal aortic aneurysm (AAA) repair for patients 18 years and older or obstetric patients. Includes optional metrics for the number of discharges grouped by rupture status and procedure type.

Accidental punctures or lacerations (secondary diagnosis) during procedure per 1,000 discharges for patients ages 17 years and younger. Includes metrics for discharges grouped by risk category. Excludes obstetric discharges, spinal surgery discharges, discharges with accidental puncture or laceration as a principal diagnosis, discharges with accidental puncture or laceration as a secondary diagnosis that is present on admission, normal newborns, and neonates with birth weight less than 500 grams.

To assess the use of and persistence to ACE inhibitors or Angiotensin receptor blockers (ARB) among members with CAD or other atherosclerotic vascular disease (i.e., peripheral arterial disease, atherosclerotic aortic disease and carotid artery disease) who are at high risk for coronary events during a one year period. High-risk comorbidities are defined as heart failure, hypertension, diabetes, or chronic kidney disease (excluding stage V and patients on dialysis).

Proportion of ICD implant patients with a diagnosis of LVSD who are prescribed ACE-I or ARB therapy at discharge.

Percentage of heart failure (HF) patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.