emeasure Title emeasure Identifier (Measure Authoring Tool) 621 emeasure Version number

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1 emeasure Title emeasure Identifier (Measure Authoring Tool) Measurement That Matters 621 emeasure Version number NQF Number GUID a81691e2-4be b279- a07448a74bcd Measurement Period Measure Steward Measure Developer Endorsed By Description Copyright Disclaimer Measure Scoring Measure Type Measure Item Count Stratification Risk Adjustment Rate Aggregation Rationale Clinical Recommendation Statement Improvement Notation January 1, 20XX through December 31, 20XX Joint Commission Joint Commission The measure estimates a hospital-level, risk-adjusted mortality rate (RAMR) for patients 18 years and older during or following a qualifying isolated coronary artery bypass graft (CABG) procedure. Mortality is defined as death anywhere from any cause within 30 days of the procedure date of an index CABG admission, or death at any time during the same admission for CABG surgery. Measure specifications are in the Public Domain. LOINC(R) is a registered trademark of the Regenstrief Institute. This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright International Health Terminology Standards Development Organization. All rights reserved. These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. Proportion Outcome Encounter, Performed: Encounter Inpatient The measure adjusts for variables (i.e., age, comordid diseases, and other patient risk factors) that are clinically relevant and have strong relationships with the outcome. A hospital-level, in-hospital/30-day all-cause mortality measure will provide hospitals with an incentive to reduce mortality through improved coordination of perioperative care and strengthen incentives for quality improvement, particularly for peri- and post-operative care and care at the time of transitions (e.g., discharge to home or a skilled nursing facility). Improvements in inpatient surgical and perioperative care and care transitions for this common, costly procedure are likely to reduce mortality rates. ` Lower risk-adjusted mortality equals better quality Reference Definition Guidance

2 Transmission Format Initial Population Exclusions Numerator Numerator Exclusions Exceptions Supplemental Data Elements TBD Patients age 18 years and older who had a CABG surgery. Patients who had an isolated CABG surgery. Isolated CABG is defined as having a CABG without any other major cardiac surgery done at the same time. Patients with pre-operative cardiogenic shock. Patients who died during the same hospital stay in which a patient underwent cardiac surgery and on deaths that occur after discharge but within 30 days of surgery. An in-hospital death is defined as a patient who died subsequent to CABG surgery during the same admission or was discharged to hospice care. For every patient evaluated by this measure also identify payer, race, ethnicity and sex Commented [AL1]: We are not able to model if patient is dc d to hospice but still living after 30 days, then they are considered living. We can only model if dc d to hospice, they are in the numerator. Table of Contents Population Criteria Data Criteria (QDM Variables) Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population = o AND: Age>= 18 year(s) at: Occurrence A of $EncounterInpatient365 o AND: "Occurrence A of starts during Occurrence A of $EncounterInpatient365 = o AND: Initial Population o AND NOT: Union of: "Occurrence A of Procedure, Performed: Other Cardiac Surgery_no valves" starts during Occurrence A of $EncounterInpatient365 "Occurrence A of Procedure, Performed: Cardiac Valve Procedures_Open or Percutaneous Approach" starts during Occurrence A of $EncounterInpatient365 Exclusions = o OR: AND: "Diagnosis: Cardiogenic Shock" starts before start of "Occurrence A of AND NOT: "Diagnosis: Cardiogenic Shock" ends before start of "Occurrence A of Numerator = o AND: OR: Intersection of: Occurrence A of $EncounterInpatient365 "Encounter, Performed: Encounter Inpatient" satisfies any: Commented [AL2]: Bonnie-177- AND NOT highlighting is not working correcting- measure calculation is correct- logic highlighting will not be fixed until CQL Commented [AL3]: Cardiogenic shock hard to capture due to large amount of human inference ecqm only uses ICD-9, ICD-10, and SNOMED codes- may not always be coded accurately so rates may not be reflective of true rates

3 (discharge status: Discharged to Health Care Facility for Hospice Care) (discharge status: Discharged to Home for Hospice Care) (discharge status: Patient Expired) OR: "Expired : Patient Characteristic Expired" satisfies all: starts after start of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" OR: "Expired : Patient Characteristic Expired" satisfies all: <= 30 day(s) starts after end of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" starts after end of Occurrence A of $EncounterInpatient365 Numerator Exclusions = o Exceptions = o Stratification = o Commented [AL4]: current measure states if a person is discharged to hospice, they are considered dead; but, if they are still living in 30 days after the procedure, then they are considered alive the ecqm has no way to model this; so for ecqm, we consider any patient discharged to hospice as mortality so rates may be higher than actual Commented [AL5]: ecqm does not have a good way to capture death after discharge from a hospital- source of truth is really vital statistics- would need to do a hybrid measure to link up the EHR data to vital statistics data Data Criteria (QDM Variables) $EncounterInpatient365 = o "Encounter, Performed: Encounter Inpatient" satisfies all: (length of stay <= 365 day(s)) ends during "Measurement Period" Data Criteria (QDM Data Elements) "Diagnosis: Cardiogenic Shock" using "Cardiogenic Shock Grouping Value Set ( )" "Diagnosis: Cirrhosis or other liver disease" using "Cirrhosis or other liver disease Grouping Value Set ( )" "Diagnostic Study, Performed: Ejection Fraction" using "Ejection Fraction Grouping Value Set ( )" "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set ( )" "Laboratory Test, Performed: Bilirubin" using "Bilirubin Grouping Value Set ( )" "Laboratory Test, Performed: Creatinine Level Lab Test Group" using "Creatinine Level Lab Test Group Grouping Value Set ( )" "Laboratory Test, Performed: Serum Albumin" using "Serum Albumin LOINC Value Set ( )" "Medication, Active: Insulin Medications" using "Insulin Medications RXNORM Value Set ( )" "Medication, Active: Oral Hypoglycemic Medications" using "Oral Hypoglycemic Medications RXNORM Value Set ( )" "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set ( )" "Physical Exam, Performed: Height" using "Height Grouping Value Set ( )" "Physical Exam, Performed: Weight" using "Weight Grouping Value Set ( )" "Procedure, Performed: Bone Marrow Transplant" using "Bone Marrow Transplant Grouping Value Set ( )" " using "CABG_Open and Endoscopic Grouping Value Set ( )"

4 "Procedure, Performed: Cardiac Valve Procedures_Open or Percutaneous Approach" using "Cardiac Valve Procedures_Open or Percutaneous Approach Grouping Value Set ( )" "Procedure, Performed: Organ transplant" using "Organ transplant Grouping Value Set ( )" "Procedure, Performed: Other Cardiac Surgery_no valves" using "Other Cardiac Surgery_no valves Grouping Value Set ( )" "Procedure, Performed: PCI" using "PCI Grouping Value Set ( )" Attribute: "Discharge status: Patient Expired" using "Patient Expired SNOMEDCT Value Set ( )" Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set ( )" Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set ( )" Supplemental Data Elements "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set ( )" "Patient Characteristic Payer: Payer" using "Payer SOP Value Set ( )" "Patient Characteristic Race: Race" using "Race CDCREC Value Set ( )" "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set ( )" Risk Adjustment Variables "Procedure, Performed: Other Cardiac Surgery_no valves" starts before start of "Occurrence A of Union of: o "Procedure, Performed: Organ transplant" starts before start of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" o "Procedure, Performed: Bone Marrow Transplant" starts before start of "Occurrence A of "Birthdate : Patient Characteristic Birthdate" Max: o "Occurrence A of Laboratory Test, Performed: Creatinine Level Lab Test Group" satisfies all: (result) starts before start of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" Union of: o "Medication, Active: Oral Hypoglycemic Medications" starts during Occurrence A of $EncounterInpatient365 o "Medication, Active: Insulin Medications" starts during Occurrence A of $EncounterInpatient365 Most Recent: o "Occurrence A of Diagnostic Study, Performed: Ejection Fraction" satisfies all: (result) starts before start of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" "Physical Exam, Performed: Height" satisfies all: o (result) Commented [AL6]: BONNIE- 175: Unable to test entire section in Bonnie- moved risk adjustment variables to the numerator section to test, then put back in this section MAT issue : unable to do AND s or OR s in the risk adjustment section- this is actually a standards issue, and will not be resolved until CQL-based HQMF- use cases sent to the standards team Commented [AL7]: BONNIE-189: MAX function not displaying in Bonnie- not able to fully test- fix tbd

5 "Diagnosis: Cirrhosis or other liver disease" starts before start of "Occurrence A of Procedure, Performed: CABG_Open and Endoscopic" "Laboratory Test, Performed: Bilirubin" satisfies all: o (result > 2 mg/dl) "Laboratory Test, Performed: Serum Albumin" satisfies all: o (result < 3500 mg/dl) " starts before start of "Occurrence A of "Procedure, Performed: PCI" satisfies all: "Procedure, Performed: Cardiac Valve Procedures_Open or Percutaneous Approach" starts before start of "Occurrence A of "Patient Characteristic Sex: ONC Administrative Sex" "Physical Exam, Performed: Weight" satisfies all: o (result) Commented [AL8]: MAT issue MAT missing g/dl as a unit of measurement will be added in a future release, no impact for measure, just converted it on our side Measure Set