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

Patient Safety: Surgical Care

 

Measures

Hospitalized adult surgical patients who experience postoperative pneumonia or a thromboembolic venous event(s)
Hospitalized adult major surgical patients who develop postoperative pneumonia
A composite measure of hospitalized adult surgical patients who experience postoperative pneumonia or a venous thromboembolic event(s)
Postoperative hemorrhage or hematoma with surgical drainage or evacuation
Adult surgery patients who received ten recommended care practices
Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision
Adult surgery patients who had prophylactic antibiotics discontinued within 24 hours after surgery end time
Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) per 1,000 surgical hospital discharges
Postoperative respiratory failure per 1,000 adult elective surgical hospital discharges
Postoperative physiologic/metabolic derangements per 1,000 elective surgical hospital discharges
Postoperative hip fractures per 1,000 surgical hospital discharges
Reclosure of postoperative abdominal wound separation per 1,000 abdominopelvic-surgery hospital discharges
Hospitalized adult patients who develop postoperative adverse events associated with hip joint replacement due to degenerative conditions
Hospitalized adult surgical patients who develop postoperative adverse events associated with hip joint replacement due to fracture
Hospitalized adult surgical patients who develop postoperative adverse events associated with hip joint replacement due to fracture or degenerative conditions
Hospitalized adult surgical patients who develop postoperative adverse events associated with knee joint replacement
 


 

Measure Title

Hospitalized adult surgical patients who experience postoperative pneumonia or a thromboembolic venous event(s)

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 who had at least one of the selected major surgical procedures identified as part of the SCIP and did not have pneumonia or venous thromboembolic event(s) prior to the procedure

Numerator

A subset of the denominator who developed postoperative pneumonia or venous thromboembolic event(s)

Comments

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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 major surgical patients who develop postoperative pneumonia

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 who had at least one of the selected major surgical procedures identified as part of the SCIP and did not have pneumonia prior to the procedure

Numerator

A subset of the denominator with a diagnosis of and treatment for postoperative pneumonia

Comments

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data, Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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

A composite measure of hospitalized adult surgical patients who experience postoperative pneumonia or a venous thromboembolic event(s)

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 who had one or more of certain major surgical procedures identified as part of the SCIP during the index hospital stay

Numerator

A subset of the denominator with a diagnosed pulmonary embolism (PE) or deep vein thrombosis (DVT) during the index hospital stay

Comments

MPSMS data were abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data, Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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

Postoperative hemorrhage or hematoma with surgical drainage or evacuation

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

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

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

Denominator

Measure is estimated at the discharge level and the population level:

  • Discharge measure: Inpatient hospital surgical discharges age 18 and over, excluding obstetric.
  • Population measure: U.S. population age 18 and over.

Numerator

Measure is estimated at the discharge level and the population level:

  • Discharge measure: Subset of the denominator with a secondary diagnosis indicating postoperative hemorrhage or postoperative hematoma.
  • Population measure: Subset of the denominator with any principal or secondary diagnosis of hemorrhage or postoperative hematoma.

Comments

The AHRQ PSI software requires that the hemorrhage or hematoma complicating procedure 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 control of the hemorrhage or hematoma is not verifiable as following surgery. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric conditions and admissions in which the control of the hemorrhage or hematoma is the only operating room procedure.

Rates are adjusted by gender, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers to the hospital. When reporting is by gender, 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

Adult surgery patients who received ten recommended care practices

Measure Source

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Hospital Inpatient Quality Reporting (HIQR) Program

Table Description

Geographic Representation

National, State

Years Available

National: 2009-2011

State: 2009-2011

Population Subgroups

Age, race/ethnicity, sex

Data Sources

National and State

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Clinical Data Warehouse (CDW) for Hospital Inpatient Quality Reporting (HIQR) Program

Denominator

Discharged adult hospital patients who had undergone select surgeries without evidence of prior infection

Numerator

Subset of the denominator who received all 10 recommended care practices included in the composite:

  • Prophylactic antibiotic received within one hour prior to surgical incision (SCIP-Inf-1).
  • Appropriate prophylactic antibiotic selection to prevent infection (SCIP-Inf-2).
  • Prophylactic antibiotics discontinued within 24 hours (48 hours for cardiac surgery) after surgery end time (SCIP-Inf-3).
  • Controlled postoperative blood glucose for cardiac surgery patients (SCIP-Inf-4).
  • Appropriate surgical site hair removal (SCIP-Inf-6).
  • Urinary catheter removed on postoperative day one or day two.
  • Perioperative temperature management.
  • Recommended venous thromboembolism prophylaxis ordered based on surgery type (SCIP-VTE-1).
  • Appropriate venous thromboembolism prophylaxis received within 24 hours prior to and after surgery (SCIP-VTE-2).
  • Beta blocker therapy during the perioperative period for patients on it prior to arrival (SCIP-Card-2).

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Measure Title

Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision

Measure Source

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Hospital Inpatient Quality Reporting (HIQR) Program

Table Description

Geographic Representation

National, State

Years Available

National: 2005-2011

State: 2005-2011

Population Subgroups

Age, race/ethnicity, sex

Data Sources

National and State

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Clinical Data Warehouse (CDW) for Hospital Inpatient Quality Reporting (HIQR) Program

Denominator

Discharged adult hospital patients undergoing select surgeries without evidence of prior infection

Numerator

Subset of the denominator who had prophylactic antibiotics within 1 hour prior to surgery

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Measure Title

Adult surgery patients who had prophylactic antibiotics discontinued within 24 hours after surgery end time

Measure Source

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Hospital Inpatient Quality Reporting (HIQR) Program

Table Description

Geographic Representation

National, State

Years Available

National: 2005-2011

State: 2005-2011

Population Subgroups

Age, race/ethnicity, sex

Data Sources

National and State

Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Clinical Data Warehouse (CDW) for Hospital Inpatient Quality Reporting (HIQR) Program

Denominator

Discharged adult hospital patients undergoing select surgeries without evidence or prior infection

Numerator

Subset of the denominator who had prophylactic antibiotics discontinued within 24 hours after surgery end time

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Measure Title

Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) per 1,000 surgical hospital discharges

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

2001-2010

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

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

Denominator

Hospital surgical patients, age 18 and over, excluding patients admitted for deep vein thrombosis or pulmonary embolism, obstetric admissions, and patients with secondary procedures for interruption of vena cava before or after surgery or as the only procedure

Numerator

Subset of the denominator with any secondary diagnosis of PE or DVT

Comments

The AHRQ PSI software requires that the PE or DVT 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 interruption of vena cava is not verifiable as following surgery. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric conditions and admissions in which the interruption of vena cava is the only operating room procedure.

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

Postoperative respiratory failure per 1,000 elective surgical hospital discharges

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) and Pediatric Quality Indicators (PDIs)

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

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

Denominator

All elective hospital surgical discharges (age 18 and over and less than 18), excluding patients with respiratory disease, circulatory disease, neuromuscular disorders, obstetric conditions, and secondary procedure of tracheostomy before or after surgery or as the only procedure

Numerator

Subset of the denominator with any secondary diagnosis of acute respiratory failure or reintubation procedure at specific postoperative intervals

Comments

The AHRQ PSI software requires that the respiratory failure 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 tracheostomy is not verifiable as following surgery. Consistent with the AHRQ PSI software, the following cases are excluded: admissions with respiratory disease, circulatory disease, craniofacial anomalies, or neuromuscular disorders; obstetric admissions; and admissions in which the tracheostomy is the only operating room procedure.

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

Postoperative physiologic/metabolic derangements per 1,000 elective surgical hospital discharges

Measure Source

Agency for Healthcare Research and Quality (AHRQ), Center for Organization, Delivery, 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

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

Denominator

All elective hospital surgical discharges for people age 18 and over, excluding those with selected serious diseases (see Comments) and obstetric admissions

Numerator

Subset of the denominator with any secondary diagnosis indicating physiologic and metabolic derangements; discharges with acute renal failure must be accompanied by a procedure code for dialysis.

Comments

The AHRQ PSI software requires that the physiologic and metabolic derangements 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 derangement is not verifiable as following surgery. Consistent with the AHRQ PSI software, the following cases are excluded: cases with a preexisting condition of physiologic and metabolic derangements or chronic renal failure; cases with acute renal failure where a procedure for dialysis occurs before or on the same day as the first operating room procedure; cases with both a diagnosis code of ketoacidosis, hyperosmolarity, or other coma and a principal diagnosis of diabetes; cases with both a secondary diagnosis code for acute renal failure and a principal diagnosis of acute myocardial infarction, cardiac arrhythmia, cardiac arrest, shock, hemorrhage, or gastrointestinal hemorrhage; and obstetric admissions.

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

Postoperative hip fractures per 1,000 surgical discharges

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

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

Denominator

Inpatient hospital surgical discharges, age 18 and over, who were not susceptible to falling

Numerator

Subset of the denominator with any secondary diagnosis indicating hip fracture

Comments

The AHRQ PSI software requires that the hip fracture 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 hip fracture repair is not verifiable as following surgery. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric cases; admissions for seizure, syncope, stroke, coma, cardiac arrest, poisoning, trauma, delirium and other psychoses, anoxic brain injury, metastatic cancer, lymphoid/bone malignancy, or self-inflicted injury; admissions for diseases and disorders of the musculoskeletal system and connective tissue; and admissions in which hip fracture repair is the only operating room procedure.

Rates are adjusted by major diagnostic category (MDC). 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

Reclosure of postoperative abdominal wound separation per 1,000 abdominopelvic surgery hospital discharges

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, States

Years Available

State: 2000-2010

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

State

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

National

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

Denominator

Discharge measure: Inpatient hospital surgical (abdominopelvic surgery with a length of stay of 2 or more days) discharges age 18 and over, excluding obstetric admissions.

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

Numerator

Discharge measure: Subset of the denominator with a secondary procedure indicating reclosure of postoperative disruption of abdominal wall.

Population measure: Subset of the denominator with a secondary procedure indicating reclosure of postoperative disruption of abdominal wall.

Comments

Reclosure of abdominal wound dehiscence is not verifiable as following surgery and may have occurred on or before the abdominopelvic procedure. Consistent with the AHRQ PSI software, the following cases are excluded: obstetric admissions and admissions in an immunocompromised state.

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

Hospitalized adult patients who develop postoperative adverse events associated with hip joint replacement due to degenerative conditions

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 in the MPSMS sample who had a surgical procedure performed (defined by procedure code 81.51) to replace a hip joint due to degenerative conditions

Numerator

A subset of the denominator who experienced at least one of the following:

  • Postoperative infection (acute or early deep), dehiscence, necrosis, hematoma, nerve injury, major bleeding, dislocation, cardiovascular complications, catheter-associated urinary tract infection or pneumonia.
  • Return to operating room after procedure (excludes same side revision).
  • Revision during the index hospital stay (same side as index procedure).
  • Periprosthetic fracture.
  • Postoperative venous thromboembolic event during hospital stay.

Comments

Postoperative infections are determined by documentation of early prosthetic joint or wound infection or acute and early deep hip infection, excluding superficial infection. Wound complications other than infection include dehiscence, hematoma, and necrosis. Cardiovascular complications include myocardial infarction, congestive heart failure, and arrhythmia requiring treatment.

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data, Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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 surgical patients who develop postoperative adverse events associated with hip joint replacement due to fracture

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

Patients in the MPSMS sample who had a surgical procedure performed (defined by procedure code 8152) to replace a fractured hip joint

Numerator

Subset of the denominator who experienced at least one of the following:

  • Postoperative infections (acute or early deep), dehiscence, necrosis, hematoma, nerve injury, major bleeding, dislocation, cardiovascular complications, catheter-associated urinary tract infection or pneumonia.
  • Return to operating room after procedure (excludes same side revision).
  • Revision during the index hospital stay (same side as index procedure).
  • Periprosthetic fracture.
  • Postoperative venous thromboembolic event during hospital stay.

Comments

Postoperative infections are determined by documentation of early prosthetic joint or wound infection or acute and early deep hip infection, excluding superficial infection. Wound complications other than infection include dehiscence, hematoma, and necrosis.

Cardiovascular complications include myocardial infarction, congestive heart failure, and arrhythmia requiring treatment.

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data, Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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 surgical patients who develop postoperative adverse events associated with hip joint replacement due to fracture or degenerative conditions

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 in the MPSMS sample who had a surgical procedure performed to replace a hip joint due to degenerative conditions (defined by procedure code 81.51) or a fractured hip (defined by procedure code 81.52)

Numerator

A subset of the denominator who experienced at least one of the following:

  • Postoperative infections (acute or early deep), dehiscence, necrosis, hematoma, nerve injury, major bleeding, dislocation, cardiovascular complications, catheter-associated urinary tract infection or pneumonia.
  • Return to operating room after procedure (excludes same side revision).
  • Revision during the index hospital stay (same side as index procedure).
  • Periprosthetic fracture.
  • Postoperative venous thromboembolic event during hospital stay.

Comments

Postoperative infections are determined by documentation of early prosthetic joint or wound infection or acute and early deep hip infection, excluding superficial infection. Wound complications other than infection include dehiscence, hematoma, and necrosis. Cardiovascular complications include myocardial infarction, congestive heart failure, and arrhythmia requiring treatment.

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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 surgical patients who develop postoperative adverse events associated with knee joint replacement

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 in the MPSMS sample who undergo a knee joint replacement

Numerator

A subset of the denominator who experienced at least one of the following:

  • Postoperative infections (acute or early deep), dehiscence, necrosis, hematoma, nerve injury, major bleeding, dislocation, cardiovascular complications, catheter-associated urinary tract infection or pneumonia.
  • Periprosthetic fracture.
  • Return to operating room after procedure (excludes same side revision).
  • Revision during the index hospital stay (same side as index procedure).
  • Postoperative venous thromboembolic event during hospital stay.

Comments

Postoperative infections are determined by documentation of early prosthetic joint or wound infection or acute and early deep knee infection, excluding superficial infection. Wound complications other than infection include dehiscence, hematoma, and necrosis. Cardiovascular complications include myocardial infarction, congestive heart failure, and arrhythmia requiring treatment.

Differences in the knee joint replacement measure specifications between 2002 discharges and 2003-2007, 2009-2011 discharges:

MPSMS data are abstracted from the medical record for the index hospital stay. Beginning with the 2009 MPSMS data, Medicare Eligibility and National Claims History databases were no longer applicable or available for the MPSMS sample.

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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Page last reviewed July 2014
Page originally created July 2014
Internet Citation: National Healthcare Quality & National Healthcare Disparities Reports: Measure Specification Appendix, 2013. Content last reviewed July 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/findings/nhqrdr/nhqrdr13/measurespec/patient_safety_surgical.html

 

The information on this page is archived and provided for reference purposes only.

 

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