Maintenance

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 either a principal discharge diagnosis of pneumonia (including aspiration pneumonia) or a principal discharge diagnosis of sepsis (not severe sepsis) with a secondary diagnosis of pneumonia (including aspiration pneumonia) coded as present on admission (POA). Readmission is defined as an unplanned readmission for any cause within 30 days of the discharge date for the index admission.

The measure estimates a hospital-level risk-standardized readmission rate (RSRR), defined as unplanned readmission for any cause within 30-days from the date of discharge for a qualifying index CABG procedure, in patients 65 years and older.

An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

This measure estimates a hospital-level, risk-standardized mortality rate (RSMR) for patients 65 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 90 days of the procedure date of an index CABG admission. The measure was developed using Medicare Fee-for-Service (FFS) patients 65 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the mortality outcome. This measure may be used in one or more to be defined 90-day payment models.

This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication, subsequently suffer the harm of an opioid-related adverse event, and are administered an opioid antagonist (naloxone) within 12 hours. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting.

This ratio electronic clinical quality measure (eCQM) assesses the number of hospital days with a severe hyperglycemic event (a blood glucose result >300 mg/dL, or a day in which a blood glucose value was not documented and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL) per the total qualifying hospital days among inpatient encounters for patients 18 years and older who have either:

1. A diagnosis of diabetes mellitus,

This electronic clinical quality measure (eCQM) assesses the proportion of inpatient admissions for patients aged 18 years and older who received at least one antihyperglycemic medication during their hospitalization, and who suffered a severe hypoglycemic event (blood glucose less than 40 mg/dL) within 24 hours of the administration of an antihyperglycemic agent.

This measure provides hospital specific risk-standardized rates of procedural complications following the implantation of an Implantable Cardioverter-Defibrillator (ICD) in patients at least 65 years of age. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) Electrophysiology Device Implant Registry (EPDI - formerly the ICD Registry) for risk adjustment linked with administrative claims data using indirect patient identifiers to identify procedural complications.

Hospital specific risk-adjusted measure of mortality or one or more of the following major complications (cardiac arrest, myocardial infarction, CVA/stroke, on ventilator >48 hours, acute renal failure (requiring dialysis), bleeding/transfusions, graft/prosthesis/flap failure, septic shock, sepsis, and organ space surgical site infection), within 30 days of a lower extremity bypass (LEB) in patients age 16 and older.

Hospital Visits after Hospital Outpatient Surgery measures facility-level risk-standardized rate of acute, unplanned hospital visits within 7 days of a procedure performed at a hospital outpatient department (HOPD) 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. 

This measure was developed to improve the quality of care delivered to patients undergoing orthopedic procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of acute, unplanned hospital visits within seven days of qualified orthopedic surgeries or procedures performed 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.