Last updated: May 17, 2016
|CMS Measure ID:||CMS172v5|
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
|Initial Patient Population:||
All hospital discharges for selective surgery with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission
The measure is divided into 8 populations by type of surgery. Each denominator provides criteria for the types of surgery
Denominator for population 1 - Coronary artery bypass graft (CABG) procedures
Denominator for population 2 - Other cardiac surgery excluding CABG
Denominator for population 3 - Hip arthroplasty
Denominator for population 4 - Knee arthroplasty
Denominator for population 5 - Colon surgery
Denominator for population 6 - Abdominal hysterectomy
Denominator for population 7 - Vaginal hysterectomy
Denominator for population 8 - Vascular surgery
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
|Measure Steward:||Centers for Medicare & Medicaid Services|
|Domain:||Efficiency and Cost Reduction Use of Healthcare Resources|
|Next Version:||Prophylactic Antibiotic Selection for Surgical Patients|
|Previous Version:||Prophylactic Antibiotic Selection for Surgical Patients|
Improvement noted as an increase in rate
The measurement period is one calendar year but the reporting period is 3 months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul - Sep, Q4 = Oct - Dec.
Numerator element guidance:
Vancomycin is acceptable for CABG, other cardiac procedures, hip arthroplasty, knee arthroplasty and vascular surgery if there is an increased MRSA rate facility-wide or operation-specific. For the purpose of using vancomycin for prophylaxis, it is expected that vancomycin is given ONLY if one of the allowable conditions is TRUE.
- Copyright updated.
- Disclaimer updated.
- eMeasure version number incremented.
- Updated Denominator Exclusions in the header to align with the measure logic.
- Updated Guidance in the header to align with the measure logic.
- Updated Initial Population header statement to align with the measure logic.
- eMeasure version number incremented from 5.0.000 to 5.1.000.
- A duplicative logic sequence checking to see if a patient had antibiotics within 24 hours before the surgery throughout the rest of the inpatient encounter was removed, leaving only one check for this Denominator exclusion. Phrases removed:AND: AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM';)' <= 1440 minute(s) starts before start of 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)' AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM';)' starts after start of ('Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)' during 'Occurrence A of Encounter, Performed: Encounter Inpatient';) .
- Changed timing relationship from 1 year to 365 days to increase specificity.
- Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
- Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
- Introduced the new timing operator overlaps to replace two lines of logic (AND/AND NOT) or to enforce when an event or set of events occur to meet the measure intent.
- Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity.
- Patient Characteristic Expired is fixed to SNOMED code 419099009 (Dead) and therefore cannot be further qualified with a value set.
- Removed the following logic from the Denominator Exclusions: OR: - AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: Substance or Medication Administration Route IV, oral or IM)' <= 1440 minute(s) starts before start of 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia' - AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: Substance or Medication Administration Route IV, oral or IM)' starts after start of ('Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia' during Occurrence A of $EncounterInpatient ) as it was duplicative of other logic present in the Denominator Exclusions.
- Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
- Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
- Replaced 'starts before or during' (SBOD) with 'starts before end of' (SBE).
- The attribute 'incision datetime' was removed from all instances of 'Procedure, Performed: General or Neuraxial Anesthesia'. This value set contains concepts related to anesthesia, not the surgery itself. As anesthesia does not have an incision date and time, but a start datetime and end datetime the incision datetime was removed.
- Removed logic for Clinical Trial Participant from the Denominator Exclusions.
- The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.
- Additional SNOMED codes which map to ICD9CM codes were added to this value set SCIP Major Surgical Procedure (OID 2.16.840.1.113883.3.666.5.1250).
- In the value sets for infection in the denominator exclusions, codes and concepts which represent a history of MRSA have been removed and codes and concepts which represent an active diagnosis of MRSA infection will remain. The new value set with codes and concepts representing a history of MRSA in the past will be used in numerator logic with a new datatype of 'Diagnosis, Resolved' as a reason to give Vancomycin. The OID for this value set is: 2.16.840.1.1137220.127.116.111.8.
- SNOMED codes in value sets used for the data category 'diagnosis' were reviewed and were removed unless the domain was disorder, finding, situation or event.
- The value set was removed from Patient Characteristic Expired: Expired as it is now fixed to a single SNOMED code: 419099009 (Dead) and cannot further be qualified with a value set.
- Value set Abdominal hysterectomy (OID 2.16.840.1.113883.3.666.5.710): Updated value set name from Hospital measures-Abdominal hysterectomy to Abdominal Hysterectomy and deleted 1 ICD10PCS (0UTC0ZZ), 1 ICD9CM (68.31) and 3 SNOMED codes (176795006, 387645003, 414575003).
- Value set Acute care hospital (OID 2.16.840.1.113883.3.666.5.684): Updated value set name form Hospital Measures-Acute care hospital to Acute care hospital and deleted 15 SNOMED codes and add 1 SNOMED code.
- Value set Acute care hospital encounter (OID 2.16.840.1.113883.3.666.5.2289): Updated the value set name from Hospital measures-Acute care hospital encounter to Acute care hospital Inpatient Encounter.
- Value set Antibiotics for Prophylaxis for Hysterectomy Surgeries (OID 2.16.840.1.113883.3.666.5.729): Deleted 1 RXNORM code (204931).
- Value set Any infection (OID 2.16.840.1.113883.3.666.5.696): Updated value set name from Hospital Measures - Any infection to Any infection, deleted 1 ICD9CM and 62 SNOMED codes and added 245 SNOMED codes.
- Value set Beta lactams for allergy determination (OID 2.16.840.1.113883.3.666.5.1058): Updated value set name from Hospital Measures-Beta lactams for allergy determination to Beta Lactams for Allergy Determination and added 1 RXNORM code (203117).
- Value set CABG Surgeries (OID 2.16.840.1.113883.3.666.5.694): Updated value set name from Hospital measures-CABG to CABG Surgeries, deleted 1 SNOMED code (440332008), and added 13 SNOMED codes (119564002, 17073005, 175021005, 175022003, 175024002, 175025001, 175026000, 175029007, 405598005, 405599002, 418551006, 61236006, 8876004).
- Value set Cardiac Surgery Other Than CABG (OID 2.16.840.1.113883.3.666.5.701): Updated value set name from Hospital measures-Other Cardiac Surgery to Cardiac Surgery Other Than CABG and deleted 5 SNOMED Codes (172921000, 232855005, 232856006, 442525005, 67460004) and 1 ICD9CM code (35.98).
- Value set Cardiac Valve Surgery (OID 2.16.840.1.113883.3.666.5.2275): Updated value set name from Hospital Measures-Cardiac Valve Surgery to Cardiac Valve Surgery and added 46 SNOMED codes.
- Value set Chronic Wound Care (OID 2.16.840.1.113883.3.666.5.719): Updated value set name from Hospital Measures-Chronic Wound Care to Chronic Wound Care.
- Value set Clinical Trial Participant (OID 2.16.840.1.113883.3.526.2.643): Removed value set from this measure.
- Value set Colon surgery (OID 2.16.840.1.113883.3.666.5.705): Updated value set name from Hospital measures- Colon surgery to Colon Surgery, deleted 2 ICD9CM and 18 SNOMED codes, and added 1 ICD9CM and 14 SNOMED codes.
- Value set Hemodialysis or peritoneal dialysis (OID 2.16.840.1.113883.3.666.5.2282): Updated the value set name from Hospital measures-Hemodialysis or peritoneal dialysis to Hemodialysis or Peritoneal Dialysis and added 2 SNOMED codes (302497006, 71192002).
- Value set Hip arthroplasty (OID 2.16.840.1.113883.3.666.5.703): Updated value set name from Hospital measures-Hip arthroplasty to Hip arthroplasty, deleted 14 ICD10PCS and 5 SNOMED codes, and added 15 SNOMED codes.
- Value set IM or PO Antimicrobial medications (OID 2.16.840.1.113718.104.22.1685.5): Deleted 4 RXNORM codes (197456, 476193, 476299, 854812).
- Value set IM or PO Antimicrobial Medications (OID 2.16.840.1.113722.214.171.1245.5): Deleted 5 RXNORM codes (204931, 240639, 476193, 476299, 197456).
- Value set Intramuscular Or PO Route (OID 2.16.840.1.1137126.96.36.1995.6): Updated value set name from IM or PO route to Intramuscular or PO route.
- Value set IV Aminoglycosides (OID 2.16.840.1.113883.3.666.5.727): Updated value set name from Hospital Measures-IV Aminoglycosides to IV Aminoglycosides.
- Value set IV Antibiotics Used For Prophylaxis For Colon Surgery (OID 2.16.840.1.113883.3.666.5.724): Updated value set name from Hospital Measures-IV Colon-Antibiotics to IV Antibiotics Used For Prophylaxis for Colon Surgery and deleted 1 RXNORM code (204931).
- Value set IV Antimicrobial medication (OID 2.16.840.1.113883.3.666.5.765): Deleted 2 RXNORM codes (204931, 240639) and added 1 RXNORM code (1483787).
- Value set IV Aztreonam (OID 2.16.840.1.113883.3.666.5.728): Updated value set name from Hospital Measures-IV Aztreonam to IV Aztreonam.
- Value set IV Cefazolin (OID 2.16.840.1.1137188.8.131.525.7): Added 1 RXNORM code (1483787).
- Value set IV Clindamycin (OID 2.16.840.1.113883.3.666.5.893): Updated value set names from Hospital Measures-IV Clindamycin to IV Clindamycin.
- Value set IV Ertapenem (OID 2.16.840.1.113883.3.666.5.725): Updated value set name from Hospital Measures-IV Ertapenem to IV Ertapenem.
- Value set IV Metronidazole (OID 2.16.840.1.113883.3.666.5.708): Updated value set name from Hospital Measures-IV Metronidazole to IV Metronidazole.
- Value set IV Quinolones Used For Prophylaxis For Hysterectomy And Colon Surgery (OID 2.16.840.1.113883.3.666.5.767): Updated value set name from Hospital Measures-IV Hysterectomy and Colon Quinolones to IV Quinolones Used For Prophylaxis for Hysterectomy and Colon Surgery.
- Value set IV Vancomycin (OID 2.16.840.1.113883.3.666.5.766): Updated value set name from Hospital measures-IV Vancomycin to IV Vancomycin and added 1 RXNORM code (1421612).
- Value set Knee arthroplasty (OID 2.16.840.1.113883.3.666.5.1816): Updated value set name from Hospital measures-Knee arthroplasty to Knee Arthroplasty Surgery. Deleted 3 SNOMED codes (179406003, 179411001, 179416006) and Added 11 SNOMED codes (179351002, 265170009, 442102003, 442655008, 443543000, 443658004, 443681002, 443682009, 444463001, 450818008, 609588000).
- Value set MRSA Colonization or Infection (OID 2.16.840.1.113883.3.666.5.2278): Removed value set from this measure.
- Value set Pocketed Device Implantation Procedures (OID 2.16.840.1.113883.3.666.5.1741): Updated value set name from Hospital measures-Pacemaker or implantable defibrillator insertion procedure to Pocketed Device Implantation Procedures. Deleted 6 ICD10PCS (0JPT0PZ, 0JPT3PZ, 0KXF0ZZ, 0KXG0ZZ, 0PT10ZZ, 0PT20ZZ), 1 SNOMED (384684002), and 2 ICD9CM codes (39.86, 39.88).
- Value set Request of physician (OID 2.16.840.1.113883.3.666.5.2254): Updated value set name from Hospital measures - Request of physician to Request of physician.
- Value set SCIP Major Surgical Procedure (OID: 2.16.840.1.1138184.108.40.206.7.1.2): Deleted 2 ICD9CM and 451 SNOMED codes and added 1 ICD10PCS and 98 SNOMED codes.
- Value set Substance Or Medication Administration Route IV (OID 2.16.840.1.113883.3.666.5.1108): Updated value set name from Hospital measures-Route IV to Substance or Medication Administration Route IV.
- Value set Substance Or Medication Administration Route IV Oral Or IM (OID 2.16.840.1.113883.3.666.5.1111): Updated the value set name from Hospital measures-Route IV, oral or IM to Substance or Medication Administration Route IV, oral or IM and deleted 1 SNOMED code (272394005).
- Value set Vaginal hysterectomy (OID 2.16.840.1.113883.3.666.5.712): Updated value set name from Hospital measures-Vaginal hysterectomy to Vaginal Hysterectomy. Deleted 1 ICD10PCS code (0UT9FZZ) and 1 ICD9CM code (68.71), and added 9 SNOMED codes (112918004, 27185000, 30160001, 413145007, 43791001, 54490004, 63516002, 699789005, 77902002).
- Value set Vascular surgery (OID 2.16.840.1.113883.3.666.5.713): Updated value set name from Hospital measures-Vascular surgery to Vascular Surgery and added 7 SNOMED codes (14259004, 19606007, 35653006, 405397001, 71198003, 77163008, 77773000).
- Value sets were reviewed for category or header codes and these were removed if found in the value sets.
- This measure contains multiple Population Criteria sections. The earlier version of this measure contained mismatches between the applicable Population Criteria human readable narrative sections and their associated computer-readable sections in the XML file. This issue has been corrected.