Within Measurement Period Trends

2023 Measure Reporting Year

April 2019 - June 2022

Evaluating trends over time is necessary to identify patterns, changes, and potential unintended consequences in measure results. Users can examine national results for individual years within the current public reporting measurement period. More information on the measurement period can be found in the Notes section below. The visualization can be organized by condition/procedure or by type of measure outcome. Please note that while the graphs present exact data, the sparklines in the default views represent a general shape of changes over time.

To begin exploring the data, please do the following:

  1. Select up to 17 measures (all 17 are selected by default)

  2. Create up to 4 hospital profiles (in addition to the default profile of all hospitals).

  3. Click on the sparklines in the table below to explore percent change from the first year of the three-year measurement period.

Choose conditions/procedures

{[{vizh.year}]} Measure Reporting Year

Group By:

Years:

2023 2022 2021 2020 2019 2018

Table View

How This Is Calculated

To calculate three-year trends, we examined the national measure results for each year of the three-year public reporting measurement periods. The dates for each year of data collection in the public reporting measurement period are listed in the notes section below. We allow users to view the results by hospital characteristic profiles with 5 or more hospitals.

  1. For each year of the three-year measurement period, all hospitals are ranked in order of performance and the median is determined.

  2. The graphs use units of percent change, with the first year of the performance period fixed at zero and subsequent years located relative to the first. The following formula is used to calculate percent change:

The image shows calculation of percent change from the first year; the difference between the median measure results of the second and first years divided by the first year, multiplied by 100.

The image shows calculation of percent change from the first year; the difference between the median measure results of the third and first years divided by the first year, multiplied by 100.

  1. For each year of the three-year measurement period, the 25th and 75th percentiles determine the  interquartile ranges for the results.

Notes

Data Sources

  • Medicare Part A and B administrative claims and enrollment databases (2018-2021)

  • Inpatient Prospective Payment System (IPPS) Improving Medicare Post-Acute Care Transformation (IMPACT) Act File 2021

Beginning with the 2019 reporting year, the stroke readmission measure was removed from this data visualization because this measure is no longer reported in the Inpatient Quality Reporting Program (IQR). This measure’s results are still available in reporting years prior to 2019.

Table 1. Included Measures

Outcome 

Condition/Procedure

Measurement Period

Mortality

Acute Myocardial Infarction, Coronary Artery Bypass Graft Surgery, Chronic Obstructive Pulmonary Disease, Heart Failure, Pneumonia, Stroke

Year 1: 7/1/2018 – 6/30/2019

Year 2: 7/1/2019 – 6/30/2020

Year 3: 7/1/2020 – 6/30/2021

 

Complication

Total hip arthroplasty and/or total knee arthroplasty

4/2018 - 3/2021

Readmission

Acute Myocardial Infarction, Coronary Artery Bypass Graft Surgery, Chronic Obstructive Pulmonary Disease, Heart Failure, Pneumonia, Stroke, Total hip arthroplasty and/or total knee arthroplasty

Year 1: 7/1/2018 – 6/30/2019

Year 2: 7/1/2019 – 6/30/2020

Year 3: 7/1/2020 – 6/30/2021

Payment

Acute Myocardial Infarction, Heart Failure, Pneumonia

Year 1: 7/1/2018 – 6/30/2019

Year 2: 7/1/2019 – 6/30/2020

Year 3: 7/1/2020 – 6/30/2021

 

Methodology Sources

AMI, COPD, Heart Failure, and Pneumonia Readmission Measures Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Condition-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures: Acute Myocardial Infarction – Version 16.0, Chronic Obstructive Pulmonary Disease – Version 12.0, Heart Failure – Version 16.0, Pneumonia – Version 16.0. https://qualitynet.cms.gov/inpatient/measures/readmission/resources Available as of Spring 2023.

 

CABG and Hip/Knee Arthroplasty Readmission Measures Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Procedure-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures: Isolated Coronary Artery Bypass Graft (CABG) Surgery – Version 10.0, Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) – Version 12.0. https://qualitynet.cms.gov/inpatient/measures/readmission/methodology  Available as of Spring 2023.

 

AMI, COPD, Heart Failure, Pneumonia, and Stroke Mortality Measures Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Condition-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Mortality Measures: Acute Myocardial Infarction – Version 17.0, Chronic Obstructive Pulmonary Disease – Version 12.0, Heart Failure – Version 17.0, Pneumonia – Version 17.0, Stroke – Version 12.0. https://qualitynet.cms.gov/inpatient/measures/mortality/resources.  Available as of Spring 2023.

 

CABG Mortality Measure Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Procedure-Specific Measure Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Mortality Measure: Isolated Coronary Artery Bypass Graft (CABG) Surgery – Version 10.0. https://qualitynet.cms.gov/inpatient/measures/mortality/methodology. Available as of Spring 2023.

 

Hip/Knee Arthroplasty Complication Measure Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Procedure-Specific Measure Updates and Specifications Report Hospital-Level Risk-Standardized Complication Measure: Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) – Version 12.0. https://qualitynet.cms.gov/inpatient/measures/complication/resources Available as of Spring 2023.

 

AMI, Heart Failure, Pneumonia, and Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Payment Measures Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Measure Updates and Specifications Report Hospital-Level Risk-Standardized Payment Measures: Acute Myocardial Infarction – Version 12.0, Heart Failure – Version 10.0, Pneumonia – Version 10.0, Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) – Version 9.0. https://qualitynet.cms.gov/inpatient/measures/payment/resources Available as of Spring 2023.

 

AMI, Heart Failure, Pneumonia Excess Days in Acute Care Measure Methodology: DeBuhr J, McDowell K, Grady J, et al. 2023 Condition-Specific Measures Updates and Specification Report Hospital-Level 30-Day Risk-Standardized Excess Days in Acute Care Measures: Acute Myocardial Infarction – Version 8.0, Heart Failure – Version 8.0, Pneumonia – Version 7.0. https://qualitynet.cms.gov/inpatient/measures/edac/resources Available as of Spring 2023.

 

Hospital-Wide Readmission Measure Methodology: DeBuhr J, McDowell K, Grady J, et al. 2020 All-Cause Hospital-Wide Measure Updates and Specifications Report: Hospital-Level 30-Day Risk-Standardized Readmission Measure – Version 12.0 https://qualitynet.cms.gov/inpatient/measures/readmission/methodology Available as of Spring 2023.

 

 

 

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