Hybrid Hospital-Wide Readmission*

Last updated: February 19, 2018

CMS Measure ID: CMS529v0
Version: 0
NQF Number: 2879
Measure Description:

This logic is intended to extract electronic clinical data. It is designed to extract the first captured set of vital signs and basic laboratory results obtained on adult Medicare fee-for-service patients admitted to acute care short stay hospitals. These data will be linked with administrative claims data to risk-adjust hospital-level hybrid outcome measures. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead it will produce a file containing the data that CMS will use to risk adjust the hybrid HWR measure.

Initial Patient Population:

All Medicare fee-for-service patients age 65 and older with an inpatient admission (length of stay <365 days) during the measurement period.

Denominator Statement:

Same as initial population

Denominator Exclusions:

None

Numerator Statement:

For patients in the denominator, report the FIRST value for vital signs captured within the 24 hours prior to the inpatient admission. If no values were captured in the 24 hours prior to the admission (for example, for patients directly admitted to the hospitals) report the first value captured within 2 hours after the start of the inpatient admission. For laboratory test results, report the first captured value in the 24 hours prior to admission. If there are no values in the 24 hours prior to admission, report the first values within 24 hours after the start of the inpatient admission. First values for the following data elements may be captured in the emergency department or other outpatient area within the hospital before a patient is subsequently admitted to the same hospital. First values for these data elements may also be captured on an inpatient unit for directly admitted patients who do not receive care in the emergency department or other hospital outpatient location before admission. The core clinical data elements are as follows: Heart rate Systolic blood pressure Respiratory rate Temperature Oxygen saturation Weight Hematocrit White blood cell count Potassium Sodium Bicarbonate Creatinine Glucose NOTE: Do not report ALL values on a patient during their entire admission. Only report the FIRST recorded value for EACH core clinical data element collected in the appropriate timeframe, if available.

Numerator Exclusions:

None

Denominator Exceptions:

None

Measure Steward: Centers for Medicare and Medicaid Services (CMS)
Measure Score: Proportion
Improvement Notation:

No actual measure score will be generated by hospitals. Instead hospitals will report the data values for each of the core clinical data elements for all patients in the denominator. These core clinical data elements will be linked to administrative claims data and used by CMS to calculate results for hospital-level hybrid outcome measures.

Guidance:

This logic guides the user to extract the FIRST captured core clinical data elements for all Medicare fee-for-service patients age 65 or older, (as described by Initial Population field) directly admitted to the hospital or admitted to the same facility after an emergency department stay or surgical procedure. The logic supports extraction of the FIRST set of core clinical data elements in two different ways, depending on if the patient was a direct admission: 1. If the patient was a direct admission, the logic supports extraction of the FIRST captured vital signs within 2 hours after the start of the inpatient admission, and the FIRST captured laboratory test results within 24 hours after the start of the inpatient admission. 2. If the patient has values captured prior to admission, for example from the emergency department or pre-operative or other outpatient area within the hospital, the logic supports extraction of the FIRST captured vital signs and laboratory test results within 24 hours PRIOR to the start of the inpatient admission. All clinical systems used in inpatient and outpatient locations within the hospital facility should be queried when looking for core clinical data element values related to a patient who is subsequently admitted. Value sets for the laboratory tests represent the LOINC codes currently available for these tests. If the institution is using local codes to capture and store relevant laboratory test data, those sites should map that information to the LOINC code for CCDE reporting. NOTE: Do not report ALL values on a patient during their entire admission. Only report the FIRST recorded value for EACH core clinical data element collected in the appropriate timeframe, if available.

Addendum Notes: None
Specialty Measure Set: *This is a voluntary measure and does not count toward eCQM submission

Specifications

External Resources