National Healthcare Quality & National Healthcare Disparities Reports: Measure Specification Appendix, 2013

Measures

Rate of either central line-associated bloodstream infections (CLABSIs) or mechanical adverse events per 1,000 patients who had a central line placed during the index hospital stay
Hospitalized adult patients with central line-associated bloodstream infections (CLABSIs)
Mechanical adverse events in adult patients receiving central venous catheter placement
Accidental puncture or laceration during procedure
Hospital admissions with iatrogenic pneumothorax per 1,000 medical and surgical admissions, adults
Deaths per 1,000 elective-surgery admissions having developed specified complications of care during hospitalization, ages 18-89 or obstetric admissions
Deaths per 1,000 discharges in low-mortality diagnosis-related groups (DRGs) 
Adult patients with one or more hospital-acquired pressure ulcers
 

Measure Title

Composite measure:Rate of either central line-associated bloodstream infections (CLABSIs) or mechanical adverse events per 1,000 patients who had a central line placed during the index hospital stay

Measure Source

The Medicare Patient Safety Monitoring System (MPSMS)

Table Description

Geographic Representation

National

Years Available

2009-2011

Population Subgroups

Age, CHF/pulmonary edema, COPD, cerebrovascular disease, coronary artery disease, corticosteroids, diabetes, gender, obesity, race/ethnicity, renal disease, smoking

Data Sources

CMS Inpatient Quality Reporting (IQR) Program, formerly referred to as the CMS Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU), MPSMS

Denominator

All patients from the MPSMS sample with documentation of placement of at least one vascular access device terminating at, or close to, the heart in one of the central vessels, who do not have an infection on admission. The following are considered central veins for this measure: antecubital, femoral, basilic, cephalic, internal and external jugular, and subclavian veins. Pulmonary artery catheters (Swan-Ganz catheters) are included in this measure.

Numerator

Subset of the denominator who develop a central line-associated bloodstream infection, or experience a central line-associated mechanical adverse event

Comments

CLABSI is determined by documentation of at least one blood culture, drawn at least 2 days after placement of a central line, and positive for at least one of the following pathogens:

• Acinetobacter.
• Beta-hemolytic streptococci.
• Candida.
• Candida glabrata.
• Enterobacter spp.
• Enterococcus spp.
• Escherichia coli.
• Klebsiella spp.
• Methicillin-resistant Staphylococcus aureus.
• Proteus mirabilis.
• Pseudomonas aeruginosa.
• Pseudomonas other.
• Serratia marcescens.
• Staphylococcus aureus.
• Viridans streptococci.
• Others as determined by review of clinical expert.

At least two positive cultures are required for Coagulase-negative staphylococci, Staphylococcus epidermis, Staphylococcus not otherwise specified, Staphylococcus other.

Patient has no other source of documented infection.

Central line-associated mechanical adverse event is determined by documentation of:

• An allergic reaction (only when CPR is administered within 15 minutes of catheter insertion).
• Arrhythmia.
• Perforation.
• Pneumothorax.
• Hematoma/bleeding.
• Shearing off of catheter.
• Air embolism.
• Misplaced catheter.
• Thrombosis/embolism.
• Knotting of pulmonary artery catheter.
• Catheter occlusion.
• Leaking.
• Others as determined by review of clinical expert.

MPSMS data are abstracted from the medical record for the index hospital stay.

In 2009, the lead agency for MPSMS transitioned from the Centers for Medicare & Medicaid Services (CMS) to the Agency for Healthcare Research and Quality (AHRQ).

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Measure Title

Hospitalized adult patients with central line-associated bloodstream infections (CLABSIs)

Measure Source

The Medicare Patient Safety Monitoring System (MPSMS)

Table Description

Geographic Representation

National

Years Available

2009-2011

Population Subgroups

Age, CHF/pulmonary edema, COPD, cerebrovascular disease, coronary artery disease, corticosteroids, diabetes, gender, obesity, race/ethnicity, renal disease, smoking

Data Source

CMS Inpatient Quality Reporting (IQR) Program, formerly referred to as the CMS Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU), MPSMS

Denominator

All patients from the MPSMS sample with documentation of placement of at least one vascular access device terminating at, or close to, the heart in one of the central vessels, who do not have an infection on admission The following are considered central veins for this measure: antecubital, femoral, basilic, cephalic, internal and external jugular, and subclavian veins. Pulmonary artery catheters (Swan-Ganz catheters) are included in this measure.

Numerator:

A subset of the denominator with a CLABSI

Comments

CLABSI is determined by documentation of at least one blood culture, drawn at least 2 days after placement of a central line, and positive for at least one of the following pathogens:

• Acinetobacter.
• Beta-hemolytic streptococci.
• Candida.
• Candida glabrata.
• Enterobacter spp.
• Enterococcus spp.
• Escherichia coli.
• Klebsiella spp.
• Methicillin-resistant Staphylococcus aureus.
• Proteus mirabilis.
• Pseudomonas aeruginosa.
• Pseudomonas other.
• Serratia marcescens.
• Staphylococcus aureus.
• Viridans streptococci.
• Others as determined by review of clinical expert.

At least two positive cultures are required for Coagulase-negative staphylococci, Staphylococcus epidermis, Staphylococcus not otherwise specified, Staphylococcus other.

Patient has no other source of documented infection.

MPSMS data are abstracted from the medical record for the index hospital stay. In 2009, the lead agency for MPSMS transitioned from the Centers for Medicare & Medicaid Services (CMS) to the Agency for Healthcare Research and Quality (AHRQ).

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Measure Title

Mechanical adverse events in adult patients receiving central venous catheter placement

Measure Source

The Medicare Patient Safety Monitoring System (MPSMS)

Table Description

Geographic Representation

National

Years Available

2009-2011

Population Subgroups

Age, CHF/pulmonary edema, COPD, cerebrovascular disease, coronary artery disease, corticosteroids, diabetes, gender, obesity, race/ethnicity, renal disease, smoking

Data Source

CMS Inpatient Quality Reporting (IQR) Program, formerly referred to as the CMS Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU), MPSMS

Denominator

All Medicare fee-for-service (FFS) discharges from the MPSMS sample with placement of at least one vascular access device terminating at, or close to, the heart or in one of the great vessels The following are considered great vessels for this measure: aorta, vena cava, brachiocephalic veins, iliac vein, internal jugular veins, and subclavian veins.

Numerator

Subset of the denominator with CVC-associated mechanical adverse events. A CVC-associated mechanical adverse event is defined as the presence in the medical record of at least one of the following:

• Allergic reaction (only when CPR is performed within 15 minutes).
• Perforation.
• Pneumothorax.
• Hematoma.
• Shearing off of the catheter.
• Air embolism.
• Misplaced catheter.
• Thrombosis/embolism.
• Knotting of the pulmonary artery catheter.
• Bleeding.
• Catheter occlusion.
• Leaking.
• Other.

Comments

Data were not collected in 2008. The 2002-2007 data include Medicare beneficiaries discharged from January to December and the 2009 data include Medicare beneficiaries discharged from January to September.

MPSMS is a nationwide surveillance system designed to identify rates of specific adverse events within the hospitalized Medicare FFS population. An adverse event is defined as an unintended patient harm, injury, or loss more likely associated with the patient’s interaction with the health care delivery system than from diseases the patient may have.

In 2009, the lead agency for MPSMS transitioned from the Centers for Medicare & Medicaid Services (CMS) to the Agency for Healthcare Research and Quality (AHRQ).

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Measure Title

Accidental puncture or laceration during procedure

Measure Source

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets (CDOM), Healthcare Cost and Utilization Project (HCUP), Patient Safety Indicators (PSIs)

Table Description

Geographic Representation

National

Years Available

2000-2010

Population Subgroups

Age, bed size (hospital), gender, health insurance, geographic location (hospital and residence), income, ownership of hospital, region, teaching status of hospital

Data Source

National AHRQ, CDOM, HCUP, Nationwide Inpatient Sample (NIS), State Inpatient Databases (SID) disparities analysis file, and AHRQ Quality Indicators, modified version 4.1

Denominator

Hospital medical and surgical discharges among people age 18 and under or age 18 and over, as appropriate, excluding obstetric admissions

Numerator

Numerator differs for measures at the discharge level and the population level:

• Discharge measures: Subset of the denominator with secondary diagnosis denoting accidental cut, puncture, perforation, or laceration during a procedure.
• Population measures: Subset of the denominator with any principal or secondary diagnosis denoting accidental cut, puncture, perforation, or laceration during a procedure, such as cases from earlier admissions or from other hospitals.

Comments

The AHRQ PSI software requires that the accidental puncture or laceration be reported as a secondary diagnosis (rather than the principal diagnosis), but unlike the AHRQ PSI software, the secondary diagnosis could be present on admission. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric admissions and admissions involving spinal surgery.

Rates are adjusted by age, gender, age-gender interactions, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers to the hospital. When reporting is by age, the adjustment is by gender, comorbidities, MDC, DRG, and transfers to the hospital; when reporting is by gender, the adjustment is by age, comorbidities, MDC, DRG, and transfers to the hospital. The AHRQ PSI software was modified to not use the present on admission (POA) indicators (or estimates of the likelihood of POA for secondary diagnosis).

Although not all States participate in the HCUP database, NIS is weighted to give national estimates using weights based on all U.S. community, nonrehabilitation hospitals in the American Hospital Association Annual Survey Database.

SID includes a powerful set of hospital databases from data organizations in participating States. SID contains the universe of the inpatient discharge abstracts in participating States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, SID encompasses about 90% of all U.S. community hospital discharges. SID contains a core set of clinical and nonclinical information on all patients, regardless of payer, including people covered by Medicare, Medicaid, and private insurance, as well as uninsured people. In addition to the core set of uniform data elements common to all SID, some databases within SID include other elements, such as the patient’s race.

The SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from the following 37 States: AK, AR, AZ, CA, CO, CT, FL, GA, HI, IA, IL, IN, KS, KY, MA, MD, MI, MO, MS, NC, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, and WY.

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Measure Title

Hospital admissions with iatrogenic pneumothorax per 1,000 medical and surgical admissions, adults

Measure Source

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets (CDOM), Healthcare Cost and Utilization Project (HCUP), Patient Safety Indicators (PSIs)

Table Description

Geographic Representation

National, State

Years Available

State: 2000, 2004, 2007, 2008, 2009, 2010

National: 2000-2010

Population Subgroups

Age, bed size (hospital), gender, health insurance, geographic location (hospital and residence), income, ownership of hospital, region, teaching status of hospital

Data Sources

National

AHRQ, CDOM, HCUP, Nationwide Inpatient Sample (NIS) and AHRQ Quality Indicators, modified version 4.1

State

National AHRQ, CDOM, HCUP, State Inpatient Databases (SID) and AHRQ Quality Indicators, modified version 4.1

Denominator

Discharge measure: All medical and surgical hospital discharges, age 18 and over, excluding patients with chest trauma or pleural effusion, thoracic surgery, lung or pleural biopsy, cardiac surgery, diaphragmatic surgery, or obstetric admissions.

Population measures: U.S. population age 18 and over

Numerator

Discharge measure: Subset of the denominator with any secondary diagnosis of iatrogenic pneumothorax.

Population measure: Subset of the denominator with any principal or secondary diagnosis of iatrogenic pneumothorax.

Comments

The AHRQ PSI software requires that the iatrogenic pneumothorax be reported as a secondary diagnosis (rather than the principal diagnosis), but unlike the AHRQ PSI software, the secondary diagnosis could be present on admission. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric admissions and admissions with chest trauma, pleural effusion, thoracic surgery, lung/pleural biopsy, diaphragmatic surgery repair, or cardiac surgery.

Rates are adjusted by age, gender, age-gender interactions, comorbidities, major diagnostic category (MDC), and diagnosis-related group (DRG). When reporting is by age, the adjustment is by gender, comorbidities, MDC, and DRG; when reporting is by gender, the adjustment is by age, comorbidities, MDC, and DRG. The AHRQ PSI software was modified to not use the present on admission (POA) indicators (or estimates of the likelihood of POA for secondary diagnosis).

Although not all States participate in the HCUP database, NIS is weighted to give national estimates using weights based on all U.S. community, nonrehabilitation hospitals in the American Hospital Association Annual Survey Database.

SID includes a powerful set of hospital databases from data organizations in participating States. SID contains the universe of the inpatient discharge abstracts in participating States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, SID encompasses about 90% of all U.S. community hospital discharges. SID contains a core set of clinical and nonclinical information on all patients, regardless of payer, including people covered by Medicare, Medicaid, and private insurance, as well as uninsured people. In addition to the core set of uniform data elements common to all SID, some databases within SID include other elements, such as the patient’s race.

The SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from the following 37 States: AK, AR, AZ, CA, CO, CT, FL, GA, HI, IA, IL, IN, KS, KY, MA, MD, MI, MO, MS, NC, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, and WY.

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Measure Title

Deaths per 1,000 elective-surgery admissions having developed specified complications of care during hospitalization, ages 18-89 or obstetric admissions

Measure Source

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets (CDOM), Healthcare Cost and Utilization Project (HCUP), Patient Safety Indicators (PSIs)

Table Description

Geographic Representation

National, State

Years Available

State: 2000, 2004, 2007, 2008, 2009, 2010

National: 2000-2010

Population Subgroups

Age, bed size (hospital), gender, health insurance, geographic location (hospital and residence), income, ownership of hospital, region, teaching status of hospital

Data Sources

National and State

AHRQ, CDOM, HCUP, Nationwide Inpatient Sample (NIS) and AHRQ Quality Indicators, modified version 4.1

State

National AHRQ, CDOM, HCUP, State Inpatient Databases (SID) and AHRQ Quality Indicators, modified version 4.1

Denominator

Hospital inpatient discharges, ages 18-89 years, with potential complications of care, excluding patients transferred in or out or patients admitted from long-term-care facilities

Numerator

Subset of the denominator with discharge disposition indicating death

Comments

Potential complications of care include pneumonia, deep vein thrombosis/pulmonary embolism, sepsis, acute renal failure, shock/cardiac arrest, and gastrointestinal hemorrhage/acute ulcer.

Consistent with the AHRQ PSI software, complications of care include acute renal failure, pneumonia, pulmonary embolism, deep vein thrombosis, sepsis, shock, cardiac arrest, gastrointestinal hemorrhage, and acute ulcer with transfers to another hospital excluded. The AHRQ PSI software requires that the complication be reported as a secondary diagnosis (rather than the principal diagnosis), but unlike the AHRQ PSI software, the secondary diagnosis could be present on admission. In addition, the surgery is not verifiable as occurring in the first 2 days of the inpatient stay.

Rates are adjusted by age, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers to the hospital. When reporting is by age, the adjustment is by comorbidities, MDC, DRG, and transfers to the hospital. The AHRQ PSI software was modified to not use the present on admission (POA) indicators (or estimates of the likelihood of POA for secondary diagnosis).

Although not all States participate in the HCUP database, NIS is weighted to give national estimates using weights based on all U.S. community, nonrehabilitation hospitals in the American Hospital Association Annual Survey Database.

SID includes a powerful set of hospital databases from data organizations in participating States. SID contains the universe of the inpatient discharge abstracts in participating States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, SID encompasses about 90% of all U.S. community hospital discharges. SID contains a core set of clinical and nonclinical information on all patients, regardless of payer, including people covered by Medicare, Medicaid, and private insurance, as well as uninsured people. In addition to the core set of uniform data elements common to all SID, some databases within SID include other elements, such as the patient’s race.

The SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from the following 37 States: AK, AR, AZ, CA, CO, CT, FL, GA, HI, IA, IL, IN, KS, KY, MA, MD, MI, MO, MS, NC, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, and WY.

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Measure Title

Deaths per 1,000 discharges in low-mortality diagnosis-related groups (DRGs)

Measure Source

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets (CDOM), Healthcare Cost and Utilization Project (HCUP), Patient Safety Indicators (PSIs)

Table Description

Geographic Representation

National, State

Years Available

State: 2000, 2004, 2007, 2008, 2009, 2010

National: 2000-2010

Population Subgroups

Age, bed size (hospital), gender, health insurance, geographic location (hospital and residence), income, ownership of hospital, region, teaching status of hospital

Data Source

National and State

AHRQ, CDOM, HCUP, Nationwide Inpatient Sample (NIS) and AHRQ Quality Indicators, modified version 4.1

State

National AHRQ, CDOM, HCUP, State Inpatient Databases (SID) and AHRQ Quality Indicators, modified version 4.1

Denominator

Hospital admissions among people age 18 and over or obstetric conditions, in low-mortality DRGs (defined as DRGs with less than a 05% mortality rate), excluding patients with trauma, immunocompromised state, or cancer

Numerator

Subset of the denominator with discharge disposition indicating death

Comments

Consistent with the AHRQ PSI software, admissions with expected low mortality are identified by Medicare Severity DRG or DRG, depending on the date of discharge. Exclusions include admissions with cancer, admissions in an immunocompromised state, and admissions involving a traumatic injury. Low-mortality DRGs are defined as DRGs with less than a 0.5% mortality rate, such as cesarean section without complications, major male pelvic procedures, and syncope and collapse.

Rates are adjusted by age, gender, age-gender interactions, comorbidities, DRG, and transfers to the hospital. When reporting is by age, the adjustment is by gender, comorbidities, DRG, and transfers to the hospital; when reporting is by gender, the adjustment is by age, comorbidities, DRG, and transfers to the hospital. The AHRQ PSI software was modified to not use the present on admission (POA) indicators (or estimates of the likelihood of POA for secondary diagnosis).

Although not all States participate in the HCUP database, NIS is weighted to give national estimates using weights based on all U.S. community, nonrehabilitation hospitals in the American Hospital Association Annual Survey Database.

SID includes a powerful set of hospital databases from data organizations in participating States. SID contains the universe of the inpatient discharge abstracts in participating States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, SID encompasses about 90% of all U.S. community hospital discharges. SID contains a core set of clinical and nonclinical information on all patients, regardless of payer, including people covered by Medicare, Medicaid, and private insurance, as well as uninsured people. In addition to the core set of uniform data elements common to all SID, some databases within SID include other elements, such as the patient’s race.

The SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from the following 37 States: AK, AR, AZ, CA, CO, CT, FL, GA, HI, IA, IL, IN, KS, KY, MA, MD, MI, MO, MS, NC, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, and WY.

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Measure Title

Adult patients with one or more hospital-acquired pressure ulcers

Measure Source

The Medicare Patient Safety Monitoring System (MPSMS):

Table Description

Geographic Representation

National

Years Available

2004, 2005, 2006, 2007, 2009

Population Subgroups

Age, CHF/pulmonary edema, COPD, cerebrovascular disease, coronary artery disease, corticosteroids, diabetes, gender, obesity, race/ethnicity, renal disease, smoking

Data Source

CMS Inpatient Quality Reporting (IQR) Program, formerly referred to as the CMS Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU), MPSMS

Denominator

All patients in the MPSMS sample

Numerator

A subset of the denominator who develop at least one pressure ulcer during the index hospital stay in a location (anatomical region) other than in a location where a pressure ulcer was found on arrival

Comments

Anatomical regions include: coccyx/sacrum, hips and buttocks, heels, ankles, and elbows.

MPSMS data are abstracted from the medical record for the index hospital stays. In 2009, the lead agency for MPSMS transitioned from the Centers for Medicare & Medicaid Services (CMS) to the Agency for Healthcare Research and Quality (AHRQ).

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