including prevention, healthy lifestyle behaviors, populations at risk & disparities (age, race/ ethnicity, gender, geographic & socioeconomic)

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1 Endorsement Maintenance 2010 Identification of Gap Areas for which Evidence-based Surgery-related Measures are Needed Cardiac, General, Other Surgical Subspecialties The table below is a tool that identifies NQF-endorsed surgery-, cidate measures, the domain into which they best fit. Surgery Endorsement Maintenance Committee members should review the tool add any new topic areas a description of measures that should be sought to fill measurement gaps. This includes suggesting new measures within existing topic areas or adaptation of existing measures to target additional domains. Rows for suggested measures are provided for new topic areas near top of the tool as well as within each of the identified topic areas. Surgery Add new topic areas below recovery Domains Note: identifies domain targeted by the measure. Please identify domain for any additions suggested. risk geographic morbidity / patient Cardiac Surgery 0125 Timing of antibiotic prophylaxis for cardiac surgery patients Selection of antibiotic prophylaxis for cardiac surgery patients Duration of prophylaxis for cardiac

2 surgery patients Venous thromboembolism (VTE) prophylaxis Beta blocker therapy prior to admission who received a beta blocker during the perioperative period Venous thromboembolism (VTE) prophylaxis Intensive care unit (ICU) VTE prophylaxis Participation in a systematic national database for general thoracic surgery Cardiac stress imaging not meeting appropriate use criteria: Preoperative evaluation in low risk surgery patients Hospital risk-stardized complication rate following implantation of implantable cardioverter-defibrillator (ICD) day post-hospital HF discharge care transition composite measure the above topic area (cardiac surgery) below recovery risk geographic morbidity / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

3 recovery risk geographic morbidity / patient CABG Participation in systematic database for cardiac surgery 0114 Post-operative renal failure 0115 Surgical re-exploration 0116 Anti-platelet at discharge Beta blockade at discharge 0118 Anti-lipid treatment at discharge Operative mortality for CABG Pre-operative beta blockade Prolonged intubation (ventilation) Deep sternal wound infection rate Stroke/cerebrovascular accident PCI mortality (risk-adjusted) IMA in CABG Percutaneous coronary intervention (PCI) volume Pre-op beta blocker in patient with isolated CABG (2) Anti-platelet on discharge Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

4 recovery Cardiac surgery patients with controlled postoperative blood glucose Discharged on antiplatelet therapy Cardiac rehabilitation patient referral from an inpatient setting Cardiac rehabilitation patient referral from an outpatient setting 695- Hospital 30-day risk-stardized readmission rates following percutaneous coronary intervention (PCI) The STS CABG composite score the above topic area (CABG) below risk geographic morbidity / patient AVR Operative mortality for AVR Operative mortality for AVR + CABG surgery the above topic area (AVR) below Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

5 recovery risk geographic morbidity / patient MVR Operative mortality for MVR Operative mortality MVR + CABG surgery Operative mortality for MV repair Operative mortality for MV repair + CABG surgery the above topic area (MVR) below AAA AAA volume AAA repair mortality rate In-hospital mortality following elective non-ruptured open AAA repair In-hospital mortality following EVAR the above topic area (AAA) below Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

6 recovery risk geographic morbidity / patient Abdominal Perforated appendicitis the above topic area (abdominal) below Admission/Transfers Hospital transfer/admission the above topic area (admission/transfers) below Cancer Post breast conserving surgery irradiation Needle biopsy to establish diagnosis of cancer precedes surgical excision/resection Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

7 recovery risk geographic morbidity s with early stage breast cancer who have evaluation of the axilla Adjuvant chemotherapy is considered or administered within 4 months (120 days) of surgery to patients under the age of 80 with AJCC III (lymph node positive) colon cancer Colorectal cancer resection pathology reporting- pt category (primary tumor) pn category (regional lymph nodes) with histologic grade Recording of clinical stage for lung cancer esophageal cancer resection Recording of performance status (zubrod, karnofsky, WHO or ECOG performance status) prior to lung or esophageal cancer resection Pulmonary function tests before major anatomic lung resection (pneumonectomy, lobectomy) Risk-adjusted morbidity after lobectomy for lung cancer Risk-adjusted morbidity mortality / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

8 recovery for esophagectomy for cancer Melanoma coordination of care Biopsy follow-up 706- Risk adjusted colorectal surgery outcome measure the above topic area (cancer) below risk geographic morbidity / patient Carotid 0465-Perioperative anti-platelet therapy for patients undergoing carotid endarterectomy Use of patch during conventional carotid endarterectomy Stent drug-eluting clopidogrel Postoperative stroke or death in asymptomatic patients undergoing carotid endarterectomy Postoperative stroke or death in asymptomatic patients undergoing carotid artery stenting (CAS) Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

9 the above topic area (carotid) below recovery risk geographic morbidity / patient Cataracts Complications within 30 days following cataract surgery requiring additional surgical procedures Cataracts: 20/40 or better visual acuity within 90 days following cataract surgery Cataracts: Improvement in patient s visual function within 90 days following cataract surgery the above topic area (cataracts) below Esophageal Esophageal resection mortality rate Esophageal resection volume Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

10 the above topic area (esophageal) below recovery risk geographic morbidity / patient General Percentage of ICU high-risk nursery patients, who over a certain amount of days acquired a central line catheterassociated blood stream infections over a amount of line-days fall rate Improvement in status of surgical wounds Pressure ulcer prevalence Falls with injury Restraint prevalence (vest limb only) Nursing care hours per patient day (RN, LPN, UAP) Hemodialysis vascular access - decision- by surgeon to maximize placement of autogenous arterial venous Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

11 recovery risk geographic morbidity fistula Prophylactic intravenous antibiotic timing fall Wrong site, wrong side, wrong patient, wrong procedure, wrong implant Selection of prophylactic antibiotic: first OR second generation cephalosporin Timing of prophylactic antibioticsadministering physician Timing of antibiotic prophylaxis: ordering physician Discontinuation of prophylactic antibiotics (non-cardiac procedures) Surgical site infection rate Appropriate hair removal (reserve status) LBP: Surgical timing LBP: education LBP: decision LBP: Post-surgical outcomes LBP: Mental health assessment Accidental puncture or laceration (PDI Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II / patient

12 recovery risk geographic morbidity 1) (risk adjusted) Accidental puncture or laceration (PSI 15) Latrogenic pneumothorax (PSI 6) (risk adjusted) Latrogenic pneumothorax in Non- Neonates (PDI 5) (risk adjusted) Death among surgical inpatients with serious, treatable Failure to rescue in-hospital mortality Failure to rescue 30-day mortality Foreign body left after procedure (PDI 3) Postoperative DVT or PE (PSI 12) Surgery patients with perioperative temperature management Urinary catheter removed on postoperative day 1 (POD1) or postoperative day 2 (POD2) with day of surgery being day zero Anesthesiology critical care: Perioperative temperature management Incidence of episiotomy / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

13 0472- Prophylactic antibiotic received within one hour prior to surgical Incision or at the time of delivery cesarean section Appropriate DVT prophylaxis in women undergoing cesarean delivery Nosocomial blood stream infections in neonates (NQI #3) Thirty-day all-cause risk stardized readmission rate following acute myocardial infarction (AMI) hospitalization Ambulatory surgery patients with appropriate method of hair Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP-Inf Prophylactic antibiotic selection for surgical patients Prophylactic antibiotic discontinued within 24 hours after surgery end time Postoperative respiratory failure (PSI #11) Hospital specific risk-adjusted measure of mortality or one or more major within 30 days of a lower recovery risk geographic morbidity / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

14 recovery extremity bypass (LEB) Ace inhibitor / angiotensin receptor blocker use persistence among members with coronary artery disease at high risk for coronary events Deep vein thrombosis anticoagulation >= 3 Months Pulmonary embolism anticoagulation >= 3 Months (s) that had a serum creatinine in last 12 reported months Heart failure - Use of ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy Atrial fibrillation - Warfarin therapy Discontinuation of prophylactic antibiotics (cardiac procedures) s with a transient ischemic event ER visit that had a follow up office visit Reconciled list received by discharged patients (inpatient discharges to home/self care or any other site of care) risk geographic morbidity / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

15 0647- Transition record with elements received by discharged patients (inpatient discharges to home/self care or any other site of care)(inpatient discharges to home/self care or any other site of care) Timely transmission of transition record (inpatient discharges to home/self care or any other site of care) Risk adjusted case mix adjusted elderly surgery outcomes measure Intensive care unit (ICU) length-ofstay (LOS) Intensive : In-hospital mortality rate Stardized mortality ratio for neonates undergoing non-cardiac surgery Stardized adverse event ratio for children adults undergoing cardiac catheterization for congenital heart disease the above topic area (general) below recovery risk geographic morbidity / patient Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

16 recovery risk geographic morbidity / patient Lower Extremity Lower extremity amputations among patients with diabetes (PQI 16) Statin therapy at discharge after LEB the above topic area (lower extremity) below Pancreatic Pancreatic resection mortality rate Pancreatic resection volume Call for a measure of glycemic control with intravenous insulin implementation Adult(s) taking insulin with evidence of self-monitoring blood glucose testing Adult(s) with diabetes mellitus that had a serum creatinine in last 12 reported months. the above topic area (pancreatic) below Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

17 recovery risk geographic morbidity / patient Pediatric Pediatric heart surgery mortality Pediatric heart surgery volume Ventriculoperitoneal (VP) shunt malfunction rate in children the above topic area (pediatric) below THA/TKA Hospital-level risk-stardized complication rate following elective THA TKA Hospital-level 30-day all-cause riskstardized readmission rate following elective THA TKA the above topic area (THA/TKA) below Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II

18 recovery risk geographic morbidity / patient VTE Prophylaxis Received appropriate VTE prophylaxis within 24 hours VTE patients unfractionated heparin (UFH) dosages/platelet count monitoring by protocol (or nomogram) receiving unfraction-ated heparin (UFH) with dosages/ platelet count monitored by protocol (or nomogram) VTE discharge instructions Incidence of potentially preventable VTE the above topic area (VTE) below Yellow highlight notes newly submitted measures those undergoing maintenance in Phases I or II