Facility

Goal:

The CTM-3 is a hospital level measure of performance that reports the average patient reported quality of preparation for self-care response among adult patients discharged from general acute care hospitals within the past 30 days.

This measure estimates hospital risk standardized odds ratio for death from all causes within 30 days following transcatheter aortic valve replacement. The measure uses clinical data available in the STS/ACC TVT Registry for risk adjustment. For the purpose of development and testing, the measure used site-reported 30-day follow-up data contained in the STS/ACC TVT Registry.

This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention (PCI) among patients who are 18 years of age or older with STEMI or cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) CathPCI Registry for risk adjustment. For the purpose of development and testing, the measure cohort was derived in a Medicare fee-for-service (FFS) population of patients 65 years of age or older with a PCI.

This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention (PCI) among patients who are 18 years of age or older without STEMI and without cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) CathPCI Registry for risk adjustment. For the purpose of development and testing, the measure used a Medicare fee-for-service (FFS) population of patients 65 years of age or older with a PCI.

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

The 30-Day Risk Standardized All-Cause Emergency Department Visit Following an Inpatient Psychiatric Facility (IPF) Discharge (IPF ED Visit) measure assesses the proportion of patients ages 18 and older with an emergency department (ED) visit, including observation stays, for any cause, within 30 days of discharge from an IPF, without subsequent admission. The IPF ED Visit measure is an outcome-based measure. 

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 all adult cancer patients covered as Fee-for-Service Medicare beneficiaries 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.]