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MEASUREMENT SETS
  AQA – AQA Measures
  AQA – Cardiac Surgery
  AQA – Cardiology
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PERFORMANCE MEASURES
    CROSSWALK BY TOPIC

  Patient Safety
  CABG / Cardiac Surgery
  PCI (angioplasty)
  ACS / AMI


PERFORMANCE MEASURE
    CODING

  HIPAA Standard Codes


 

– PERFORMANCE MEASURE SETS –
Ambulatory Care Quality Alliance (AQA)
Cardiac Surgery Performance Measures
in Ambulatory Care

AQA Cardiac Surgery
Starter Set of 15 Measures [Word .Doc]
Adapted from NQF National Voluntary Consensus Standards for Cardiac Surgery [PDF]

Performance Measure
Clinical Topic
Measure Description
1. Participation in a Systematic Database for Cardiac Surgery STS
Numerator – Does the facility participate in a multicenter, data collection and feedback program that provides benchmarking relative to peers and uses process and outcome measures? (Yes/No)
Denominator – Not Applicable
2. Timing of Antibiotic Administration for Cardiac Surgery Patients CMS
Numerator – Cardiac surgery patients who received prophylactic antibiotics within one hour of surgical incision (two hours if vancomycin)
Denominator – Surgical patients with CABG ICD-9-CM procedure codes:
a.CABG (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19, 36.20)
b.Other cardiac surgery, (ICD-9 codes: 35.0x, 35.1x, 35.2x, 35.3x, 35.4x, 35.5x, 35.6x, 35.7x, 35.8x, 35.91-35.95, 35.98, 35.99)
Exclusions:
1.Principal or admission diagnosis suggestive of pre-operative infectious disease
Infectious diseases 001.0-139.8
Meningitis 320.0-326
Ear infection 380.0-380.23; 382.0-382.20
Endocarditis 421.0-422.99
Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1
Digestive 540-542; 575.0
Renal 590-590.9; 595.0
Prostate 601.0-601.9
Gynecologic 614-614.9; 616-616.4
Skin 680-686.9
Musculo-skeletal 711.9-711.99; 730.0-730.99
Fever of unknown origin 780.6
Septic shock 785.59
Bacteremia 790.7
Viremia 790.8
2.Receiving antibiotics at the time of admission
3.Medical records do not include antibiotic start date/time or incision date/time
4.Receiving antibiotics more than 24 hours prior to surgery
3. Selection of Antibiotic Administration for Cardiac Surgery Patients CMS
Numerator – Cardiac surgery patients who received prophylactic antibiotics recommended for the specific operation: cefazolin, cefuroxime, cefamandole, or vancomycin*
*Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactam, then vancomycin or clindamycin is an acceptable substitute
Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99
Exclusions:
1.Principal or admission diagnosis suggestive of pre-operative infectious disease
Infectious diseases 001.0-139.8
Meningitis 320.0-326
Ear infection 380.0-380.23; 382.0-382.20
Endocarditis 421.0-422.99
Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1
Digestive 540-542; 575.0
Renal 590-590.9; 595.0
Prostate 601.0-601.9
Gynecologic 614-614.9; 616-616.4
Skin 680-686.9
Musculo-skeletal 711.9-711.99; 730.0-730.99
Fever of unknown origin 780.6
Septic shock 785.59
Bacteremia 790.7
Viremia 790.8
2.Receiving antibiotics at the time of admission
3.Medical records do not include antibiotic start date/time or incision date/time
4.Receiving antibiotics more than 24 hours prior to surgery
5.No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics)
6.No antibiotics received during the hospitalization
4. Pre-operative Beta Blockade STS
Numerator – Number of patients coming to isolated CABG with documented pre-operative (24 hours) beta blockade
Denominator – All patients undergoing CABG surgery
Exclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
5. Use of Internal Mammary Artery (IMA) CMS/
QIO
Numerator – Patients who received an IMA graft (ICD-9 procedure codes 36.15 and 36.16)
Denominator – Surgical patients undergoing isolated CABG (ICD-9-CM procedure codes: 36.10 - 36.19) who were discharged, transferred, or expired
Exclusions:
Other heart procedures (IDC-9 procedure codes 37.32, 37.34, 37.35, 36.2, 35.0-35.99)
Repeat CABG (ICD-9 status code V45.81)
6. Duration of Prophylaxis for Cardiac Surgery Patients CMS
Numerator –Cardiac surgery patients whose prophylactic antibiotics were discontinued within 24 to 48 hours after surgery end time
Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99
Exclusions:
1.Principal or admission diagnosis suggestive of pre-operative infectious disease
Infectious diseases 001.0-139.8
Meningitis 320.0-326
Ear infection 380.0-380.23; 382.0-382.20
Endocarditis 421.0-422.99
Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1
Digestive 540-542; 575.0
Renal 590-590.9; 595.0
Prostate 601.0-601.9
Gynecologic 614-614.9; 616-616.4
Skin 680-686.9
Musculo-skeletal 711.9-711.99; 730.0-730.99
Fever of unknown origin 780.6
Septic shock 785.59
Bacteremia 790.7
Viremia 790.8
2.Receiving antibiotics at the time of admission
3.Medical records do not include antibiotic start date/time or incision date/time
4.Receiving antibiotics >24 hours prior to surgery
5.No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics)
6.Diagnosed with and treated for infections within two days after surgery date
7.No antibiotics received during the hospitalization
7. Prolonged Intubation (ventilation) STS
Numerator – Number of patients who undergo isolated CABG who require intubation >24 hours
Denominator – All patients undergoing isolated CABG
 
Inclusions:
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
Number of patients undergoing isolated CABG without pre-existing intubation / tracheostomy
 
Exclusions:
Patients intubated prior to isolated CABG; patients with tracheostomy prior to isolated CABG
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
8. Deep Sternal Wound Infection Rate STS
Numerator – Number of patients who developed deep sternal wound infections within 30 days post-operative
Definition of deep sternal wound infection:
Patient with a deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention. Must have all of the following conditions:
Wound opened with excision of tissue (I&D) or re-exploration of mediastinum
Positive culture
Treatment with antibiotics
 
Denominator – All patients undergoing isolated CABG
 
Inclusions:
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
All patients undergoing isolated CABG surgery who developed a deep sternal wound infection within 30 days post-operative
 
Exclusions:
Patients undergoing isolated CABG surgery with superficial wound site infections and no involvement of deeper tissue post-operative
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
9. Stroke/Cerebrovascular Accident STS
Numerator – Number of patients who undergo isolated CABG with post-operative neurologic deficit persisting >72 hours
Denominator – All patients undergoing isolated CABG
 
Inclusions:
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Exclusions:
Patients with pre-existing neurologic deficits
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
10. Post-operative Renal Insufficiency STS
Numerator – Number of patients undergoing isolated CABG who develop post-operative renal failure/dialysis requirement
Definition of renal failure/dialysis requirement:
Patients with acute or worsening renal failure resulting in one or more of the following:
Increase in serum creatinine to >2.0 and two times most recent pre-operative creatinine level
New requirement for dialysis post-operatively
 
Denominator – All patients undergoing isolated CABG
 
Inclusions:
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
Number of patients undergoing isolated CABG without pre-existing renal failure
 
Exclusions:
Patients with documented history of renal failure, baseline serum creatinine >2.0; prior renal transplants are not considered pre-operative renal failure unless since transplantation their Cr has been or is >2.0
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
11. Surgical Re-exploration STS
Numerator – Number of patients undergoing isolated CABG who require return to the operating room for bleeding/tamponade, graft occlusion, or other cardiac reason
 
Denominator – All patients undergoing isolated CABG
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
12. Anti-platelet Medication at Discharge STS
Numerator – Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel after isolated CABG
 
Denominator – All patients undergoing isolated CABG
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
13. Beta Blockade at Discharge STS
Numerator – Number of isolated CABG patients discharged on beta blockers
 
Denominator – All patients undergoing isolated CABG
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
14. Anti-lipid Treatment at Discharge STS
Numerator – Number of isolated CABG patients discharged on a statin or other pharmacologic lipid-lowering regimen
 
Denominator – All patients undergoing isolated CABG
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
15. Risk-Adjusted 30-day Operative Mortality for CABG STS
Numerator: Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation
 
Denominator – All patients undergoing isolated CABG
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
The following 6 NQF cardiac surgery measures are not AQA measures
16. Risk-Adjusted Inpatient Operative Mortality for CABG CCORP
Numerator – Number of patients from participating hospitals who had an isolated CABG surgery and died in hospital
Denominator – Number of patients from participating hospitals who had isolated CABG surgery
 
Exclusions:
Deaths are not counted after discharge even if the patient dies soon after the operation. If a patient is transferred post-operatively to a rehabilitation or transitional care facility and dies before going home, this death is not counted.
Procedures performed during the same surgery:
valve procedures
operations on structures adjacent to heart valves
ventriculectomy
repair of atrial and ventricular septa
excision of aneurysm of heart
head and neck, intracranial endarterectomy
other open heart surgeries, such as aortic arch repair, pulmonary endarterectomy
endarterectomy of aorta
thoracic endarterectomy
heart transplantation
repair of certain congenital cardiac anomalies
implantation of cardiomyostimulation system
any aortic aneurysm repair
aorta-subclavian-carotid bypass
aorta-renal bypass
aorta-iliac-femoral bypass
caval-pulmonary artery anastomosis extracranial-intracranial (EC-IC) vascular bypass
coronary artery fistula
resection of a portion of the lung does not include simple biopsy of lung nodule in which surrounding lung is not resected or biopsy of a thoracic lymph node
incisional (ventral) hernia repair
lumpectomy or mastectomy for breast cancer
maze procedures, surgical or catheter
total or partial excision of thymus
Inclusions:
The CABG cases with the following procedures performed concurrently will be considered isolated CABG:
transmyocardial laser revascularization (TMR)
pericardiectomy and excision of lesions of heart
repair/restoration of the heart or pericardium
coronary endarterectomy
pacemakers
internal cardiac defibrillators
fem-fem cardiopulmonary bypass
 
Risk adjustment:
Multivariate logistic regression. Adjusted for differences in the case mix across hospitals and accounted for the pre-operative condition of each patient, using California CABG Outcome Reporting Program risk model, which is available from CCORP at http://www.oshpd.cahwnet.gov/HQAD/
Outcomes/CCORP/index.htm
.
17. Risk-Adjusted 30-day Operative Mortality for Aortic Valve Replacement (AVR) STS
Numerator: Number of patients undergoing isolated AVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation
 
Denominator – All patients undergoing isolated AVR surgery
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Exclusions:
Patients receiving CABG or other valve or cardiac surgery during this admission
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
18. Risk-Adjusted 30-day Operative Mortality for Mitral Valve Replacement (MVR) STS
Numerator: Number of patients undergoing isolated MVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation
 
Denominator – All patients undergoing isolated MVR surgery
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Exclusions:
Patients receiving CABG or other valve or cardiac surgery during this admission
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
19. Risk-Adjusted 30-day Operative Mortality for AVR + CABG STS
Numerator: Number of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation
 
Denominator – All patients undergoing combined AVR + CABG surgery
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Exclusions:
Patients receiving CABG or other valve or cardiac surgery during this admission
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
20. Risk-Adjusted 30-day Operative Mortality for MVR + CABG STS
Numerator: Number of patients undergoing combined MVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation
 
Denominator – All patients undergoing combined MVR + CABG surgery
 
Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
 
Exclusions:
Patients receiving CABG or other valve or cardiac surgery during this admission
 
Risk adjustment:
Multivariate logistic regression and hierarchical modeling available for STS.
21. Surgical Volume CMS
Surgical Volume to include:
a.Isolated Coronary Artery Bypass Graft (CABG) Surgery
b.Valve Surgery
c.CABG + Valve Surgery
Numerator
a.Number of patients undergoing isolated CABG surgery, (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19)
b.Number of patients undergoing Valvuloplasty surgery, (ICD-9 codes: 35.10, 35.11, 35.12, 35.13, 35.14) or
Number of patients undergoing valve replacement surgery, (ICD-9 codes: 36.20, 36.21, 36.22, 36.23, 36.24, 36.25, 36.26, 36.27, 36.28)
c.Number of patients undergoing valve+CABG surgery, ICD-9 codes: 36.10-36.16, 36.19 and 35.10-35.14, 35.20-35.28)
Denominator – Not Applicable
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