Compare eCQM Versions
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.
Measure Information | 2023 Reporting Period | 2024 Reporting Period |
---|---|---|
Title | Hospital Harm - Opioid-Related Adverse Events | Hospital Harm - Opioid-Related Adverse Events |
CMS eCQM ID | CMS819v1 | CMS819v2 |
Short Name | HH-03 | HH-ORAE |
NQF Number | 3501e | 3501e |
Description |
This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication and are subsequently administered an opioid antagonist (naloxone) within 12 hours, an indication of an opioid-related adverse event. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting. |
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 18 years or older during which at least one opioid medication was administered |
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 |
Equals Initial Population |
Denominator Exclusions | None | None |
Numerator |
Inpatient hospitalizations where an opioid antagonist (naloxone) was administered outside of the operating room and within 12 hours following administration of an opioid medication. Only one numerator event is counted per encounter. |
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 |
Not applicable |
Denominator Exceptions |
None |
None |
Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
Measure Scoring | Proportion measure | Proportion measure |
Measure Type | Outcome measure | Outcome measure |
Improvement Notation |
A lower proportion indicates higher quality |
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 at the start of the encounter with at least one opioid medication administered during the encounter. To create the numerator:
1. First, start with those encounters meeting denominator criteria 2. Next, remove all events where an opioid antagonist (naloxone) 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. Finally, remove all administrations of naloxone 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 QDM page for more information on the QDM. |
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 | CMS819v2 | No Version Available |
Previous Version | No Version Available |
Measure Information | |
---|---|
CMS eCQM ID | CMS819v1 |
Short Name | HH-03 |
NQF Number | 3501e |
Description |
This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication and are subsequently administered an opioid antagonist (naloxone) within 12 hours, an indication of an opioid-related adverse event. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting. |
Initial Population |
Inpatient hospitalizations for patients 18 years or older during which at least one opioid medication was administered |
Denominator |
Equals Initial Population |
Denominator Exclusions |
None |
Numerator |
Inpatient hospitalizations where an opioid antagonist (naloxone) was administered outside of the operating room and within 12 hours following administration of an opioid medication. Only one numerator event is counted per encounter. |
Numerator Exclusions |
Not applicable |
Denominator Exceptions |
None |
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 at the start of the encounter with at least one opioid medication administered during the encounter. To create the numerator:
1. First, start with those encounters meeting denominator criteria 2. Next, remove all events where an opioid antagonist (naloxone) 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. Finally, remove all administrations of naloxone 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 QDM page for more information on the QDM. |
Next Version |