Back to top
Top
U.S. flag

An official website of the United States government

Dot gov

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Https

Secure .gov websites use HTTPS
A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

Hospital Harm - Opioid-Related Adverse Events

Compare Versions of: "Hospital Harm - Opioid-Related Adverse Events"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare version to

Measure Information 2024 Reporting Period
Title Hospital Harm - Opioid-Related Adverse Events
CMS eCQM ID CMS819v2
Short Name

HH-ORAE

NQF Number 3501e
Description

This measure assesses the number of inpatient hospitalizations for patients age 18 and older who have been administered an opioid medication and are subsequently administered an opioid antagonist within 12 hours, an indication of an opioid-related adverse event

Initial Population

Inpatient hospitalizations for patients age 18 and older during which at least one opioid medication was administered outside of the operating room

Denominator

Equals Initial Population

Denominator Exclusions None
Numerator

Inpatient hospitalizations where an opioid antagonist was administered outside of the operating room and within 12 hours following administration of an opioid medication. The route of administration of the opioid antagonist must be by intranasal spray, inhalation, intramuscular, subcutaneous, or intravenous injection.

Only one numerator event is counted per encounter.

Numerator Exclusions

Not applicable

Denominator Exceptions

None

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Proportion measure
Measure Type Outcome measure
Improvement Notation

A lower proportion indicates higher quality

Guidance

To calculate the hospital-level measure result, divide the total numerator events by the total number of qualifying encounters (denominator).

Qualifying encounters (denominator) include all patients 18 years of age or older with at least one opioid medication administered outside of the operating room.

To create the numerator:

 

1. First, start with those encounters meeting denominator criteria.

2. Next, remove all events where an opioid or opioid antagonist was only administered in the operating room.

Opioid antagonist administrations in the operating room are excluded because they could be part of the sedation plan as administered by an anesthesiologist. Encounters that include use of opioid antagonists for procedures and recovery outside of the operating room (e.g., bone marrow biopsy and PACU) are included in the numerator, as it would indicate the patient was over-sedated. Note that should a facility not utilize temporary patient locations, alternative times may be used to determine whether a patient is in the operating room during opioid antagonist administration. Since anesthesia end time could represent the time the anesthesiologist signed off, and thus may include the patient’s time in the PACU, this should be avoided.

3. Next, remove all events where the opioid antagonist was administered via an enteral route. Only opioid antagonists given by a non-enteral (i.e., intravenous, intramuscular, subcutaneous, intranasal, inhalation) route are considered.

4. Finally, remove all administrations of opioid antagonist that were given greater than 12 hours following hospital administration of an opioid medication.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center https://ecqi.healthit.gov/qdm) for more information on the QDM.

Next Version No Version Available
Previous Version No Version Available

Header

  • Removed duplicative statement regarding opioid antagonist administration in the operating room from the description as it is already in the guidance.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Description

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Annual Update

  • Updated the rationale to reflect recent evidence supporting the importance of the measure.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the Clinical Recommendation Statement to reflect current evidence.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Revised the Initial Population narrative to clarify that only opioid medications administered outside of the operating room (OR) will be evaluated.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised the Initial Population narrative to reflect the updated age anchor to 18 years and older at the start of the inpatient hospitalization to harmonize with other hospital measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised the narrative to clarify the route of administration of the opioid antagonist must be by intranasal spray, inhalation, intramuscular, subcutaneous, or intravenous injection in order to be evaluated for the numerator.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised the narrative to remove 'Naloxone' when describing the opioid antagonists since it is no longer the only opioid antagonist medication in the measure.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Revised the age anchor to 18 years and older at the start of the inpatient hospitalization to harmonize with other hospital measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised the definition name to align with logic content.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated the Initial Population to exclude events where the opioid medication was given in the operating room.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated the Numerator definition to only evaluate opioid antagonists given by a non-enteral (i.e., intravenous, intramuscular, subcutaneous, intranasal, inhalation) route. Revised the definition name to align with logic content.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Definitions

    Source of Change: Standards/Technical Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Added nalmefene as a new type of opioid antagonist medication to the value set Opioid Antagonist (2.16.840.1.113762.1.4.1248.119) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Routes of Administration for Opioid Antagonists (2.16.840.1.113762.1.4.1248.187) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Opioids, All (2.16.840.1.113762.1.4.1196.226): Added 19 RxNorm codes based on review by technical experts, SMEs, and/or public feedback. Deleted 153 RxNorm codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Opioid Antagonist (2.16.840.1.113762.1.4.1248.119): Added 2 RxNorm codes (199059, 2592953) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations. Added 1 RxNorm code (2596175) based on terminology update. Deleted 2 RxNorm codes (1191212, 1191228) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jan 22, 2024