Skip to Main Content

Public Comment

 

Welcome to CMS Quality Measures Public Comment Page

This page serves as the designated site for CMS to solicit public comments on proposed quality measures that are included in the individual project pages. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Details of the Public Comment Period:

  • The public is encouraged to submit general comments relevant to both measures or comments specific to certain measures
  • Information about each measure is found in the Downloads section below
  • Do not include personal health information in your comments
  • At the end of the public comment period, all public comments will be posted on the website along with a public comment summary report

Instructions for Providing Comments:

  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information
  • If you are commenting as an individual, submit identifying or contact information
  • Please indicate which measure(s) you are commenting on
  • You may submit general comments on the entire set of measures or you may provide comments specific to individual measures

Public Comment Postings:

 

Project Title: End-Stage Renal Disease Evaluation of Potential Prevalent Comorbidity Adjustments in the Standardized Hospitalization Ratio (SHR) and the Standardized Mortality Ratio (SMR)

Dates:

  • The Call for Public Comment period opens on February 8, 2015 and closes February 22, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to evaluate the potential of including prevalent comorbidities in the SMR and SHR risk adjustment models. The contract name is End Stage Renal Disease (ESRD) Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I. As part of its measure development process, CMS requests interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to evaluate the potential of including prevalent comorbidities in the SMR and SHR risk adjustment models. Specific objectives included:

  • Review of the comorbidity adjustment in the current NQF endorsed SMR and SHR measures
  • Consideration of what, if any, prevalent comorbidities would be appropriate to include in each measure.

Documents and Measures for Comment:

The following documents are provided for your review and comment. The files are found below in the Download section.

  • Standardized Mortality Ratio Measure Information Form
  • Standardized Mortality Ratio Measure Justification Form
  • Standardized Hospitalization Ratio Measure Information Form
  • Standardized Hospitalization Ratio Measure Justification Form

Project Specific Instructions:

  • Do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Please indicate which measure (s) you are providing comments on.
  • Please send all comments to dialysisdata@umich.edu no later than February 22, 2016.

[Back to top]

 

Project Title:  Electronic Clinical Quality Measures (eCQM) Development and Maintenance for Eligible Professionals

Dates:

  • The Call for Public Comment period closed on November 20, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain electronic clinical quality measures for use in CMS quality reporting programs for eligible professionals. The name of the contract is Electronic Clinical Quality Measures Development and Maintenance for Eligible Professionals. The contract number is HHSM-500-2013-13011I. As part of its measure development process, CMS requested interested parties to submit comments on the draft eCQM, Non-Recommended Prostate-Specific Antigen (PSA)-Based Screening.

Project Objectives:

  • Develop, electronically specify and maintain electronic clinical quality measures for use in CMS quality reporting programs for eligible professionals.

Comment Summary:

The following document includes CMS’s response along with a summary of public comments for this measure. The document is found below in the Download section.

  • eCQM Development and Maintenance for Eligible Professionals_CMS_PSA_Response_Public Comment.pdf

[Back to top]

 

Project Title:  Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM)

Task: Electronic specification of an existing chart-based influenza immunization measure (IMM-2) and development of a new Advance Care Planning (ACP) measure

Dates:  

  • The Call for Public Comment period opens on January 25, 2016 and closes on February 24, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs—Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), PPS-Exempt Cancer Hospital Quality Reporting (PCHQR), and the EHR Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I, Task Order HHSM-500-T00003. As part of its measure development process, CMS requests interested parties to submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by providers in CMS quality reporting programs. In conjunction with developing new eCQMs, the project is also tasked to re-engineer existing chart- or claims-based measures as eCQMs. Mathematica is working with the National Committee for Quality Assurance to develop the new Access to Quality Advance Care Planning measure, and working with Telligen to re-engineer the IMM-2 measure. As part of the measure development process, we are soliciting feedback about the feasibility, usability, and face validity of these measures during a public comment period.

Documents and Measures for Comment:

CMS is currently requesting feedback on the following measures:

  • Influenza Immunization (IMM-2)
  • Access to Quality Advance Care Planning

The following documents are provided for each of the measures for your review and comment. The files are found below in the Download section.

  • Instructions for commenting on JIRA and searching VSAC for value sets
    • IMM-2 ACP JIRA and VSAC Instructions.pdf
  • Human-readable MAT output
    • ACP_v4_3_HumanReadable.pdf
    • InfluenzaImmunization_v4_3_HumanReadable.pdf 
  • A summary narrative of measure specifications for IMM-2
    • IMM-2 Narrative Description.pdf
  • Additional background on the measure intent and development process for Access to Quality Advance Care Planning measure
    • ACP Framing Document.pdf

Project Specific Instructions:

All comments are welcome, but we are particularly interested in feedback in the following areas:

For IMM2:

  • Whether the data elements can be captured in structured fields in an EHR;
  • Whether the current EHR specification records immunization status as accurately as possible given the possibility of conflicting documentation of immunization status and if not, how it might be improved;
  • Whether a lookback period for Guillain-Barre Syndrome (GBS) is necessary in the numerator;
  • Feasibility of data collection and submission for the purpose of public reporting under CMS’s quality reporting programs;
  • Usefulness of the measures to assess the quality of care for Medicare or Medicaid beneficiaries;
  • Appropriateness of the measure to assess performance of hospitals.

For ACP:

  • The appropriateness of the serious illness denominator value set for capturing patients who would most benefit from advance care planning during their hospitalization;
  • Whether the numerator criteria appropriately reflect and capture the features of high quality advance care planning for hospitalized, seriously ill patients; 
  • The current and future feasibility of capturing the necessary data elements in an enterprise EHR (a standard EHR or an EHR with an advance care planning component);
  • Whether advance care planning documentation in the EHR are accessible to hospital staff across service lines and units;
  • Feasibility of data collection and submission for the purpose of public reporting under CMS’s quality reporting programs;
  • Usefulness of the measure to assess the quality of care for Medicare or Medicaid beneficiaries;
  • Appropriateness of the measure to assess performance of hospitals.

How to Leave a Comment:

  • To participate in public comment please visit the eCQM Tracker JIRA website hosted by the Office of the National Coordinator for Health Information Technology: https://jira.oncprojectracking.org/browse/CQM
  • For instructions on accessing JIRA and creating an account, please see the guidance included in the Downloads section below. All comments should be submitted in JIRA.
  • For access to the Value Set Authority Center site, see the JIRA guidance in the Downloads section.
  • Please do NOT submit anything that would constitute protected health information or personally-identifiable information (e.g., Date of Birth, Social Security Number, Health Insurance Claim Number) in your comments.
  • If you are providing comments on behalf of an organization, include the organization’s name and contact information.
  • If you are commenting as an individual, please submit identifying or contact information.

[Back to top]

 

Project Title:  Medicare Spending Per Beneficiary – Post Acute Care (MSPB-PAC) Resource Use Measures

Dates:  

  • The Call for Public Comment period opens on January 13, 2016 and closes on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to develop the MSPB-PAC measures.  The contract name is Calculating Episode-Based Costs from the Medicare Episode Grouper for Physician FeedbackThe contract number is HHSM-500-2011-000121, and the task order number is HHSM-500-T0008.  As part of its measure development process, CMS encourages interested parties to submit comments on these draft measures mandated by the Improving Post-Acute Care Medicare Transformation Act of 2014 (IMPACT Act).  CMS asks that stakeholders provide comments regarding the overall episode construction methodology, exclusions, and the risk adjustment approach. CMS is also interested in stakeholders’ comments on the treatment of episodes with hospice.

Project Objectives:

The goal of this project is to develop resource use measures for PAC settings as mandated by the IMPACT Act of 2014.  These measures apply to skilled nursing facilities (SNFs), home health agencies (HHAs), long-term care hospitals (LTCHs), and inpatient rehabilitation facilities (IRFs).  The purpose of the measures is to provide actionable, transparent information to support PAC providers’ efforts to gauge and improve the efficiency and coordination of patient care.  A given PAC provider’s efficiency is evaluated relative to the efficiency of the national median PAC provider in the same setting. 

The objectives of the project are to:

  • Produce MSPB-PAC measures that use a framework similar to the hospital MSPB measure used in the Hospital Value-Based Purchasing program
  • Prepare the measure for SNF, HHA, LTCH, and IRF quality reporting programs (QRPs)

Documents and Measures for Comment:

The following documents are provided for your review and comment.  The files are found below in the Downloads section.

  • MSPB-PAC Measure Specifications_ Draft

Project Specific Instructions:

  • If you are providing comments on behalf of an organization, please include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Do not include personal health information in your comments.
  • You may submit general comments on the entire set of measures or you may provide comments specific to individual measures.  If you are commenting on individual measures, please indicate the measure(s) for which you are providing comments.
  • Send your comments to mspb-pac-measures-support@acumenllc.com
  • Comments are due by 11:59 pm ET, Wednesday, January 27, 2016.

[Back to top]

 

Project Title:  Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM).  Electronic specification for one set of three re-engineered Tobacco Treatment (TOB) measures.

Dates:

  • The Call for Public Comment period closed on December 4, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs—Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), PPS-Exempt Cancer Hospital Quality Reporting (PCHQR), and the EHR Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I Task Order HHSM-500-T0003. As part of its measure development process, CMS requested interested parties to submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by hospitals in CMS quality reporting programs. Along with developing new eCQMs, the project will be re-engineering existing chart- or claims-based measures as eCQMs. Mathematica is working with the TOB measure developer and steward, The Joint Commission, to re-engineer three TOB measures. As part of the measure development process, we solicited feedback about the feasibility, usability, face validity, and related/competing measures during a public comment period.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Hospital-MDM_TOB Public Comment Summary Report_FINAL

[Back to top]

 

Project Title: End-Stage Renal Disease Vascular Access Measure Development

Dates:

The Call for Public Comment period opens on January 6, 2016 and closes on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to review the NQF endorsed Vascular Access measures (Minimizing Use of Catheters as Chronic Dialysis Access, and Maximizing Placement of Arterial Venous Fistula) and consider possible revisions to the existing measures, including potential risk adjustment. The contract name is ESRD Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to evaluate the existing NQF-endorsed vascular access measures. Specific objectives included:

  • Review of the current NQF endorsed Vascular Access measures (Minimizing Use of Catheters as Chronic Dialysis Access, and Maximizing Placement of Arterial Venous Fistula)
  • Consider revisions to the vascular access measure set
  • Consider including potential risk adjustment

Documents and Measures for Comment:

The following documents are provided for your review and comment. The files are found below in the Download section.

  • Hemodialysis Vascular Access: Long-term Catheter Rate Measure Information Form
  • Hemodialysis Vascular Access: Long-term Catheter Rate Measure Justification Form
  • Hemodialysis Vascular Access: Standardized Fistula Rate Measure Information Form
  • Hemodialysis Vascular Access: Standardized Fistula Rate Measure Justification Form

Project Specific Instructions:

  • Do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Please indicate which measure (s) you are providing comments on.
  • Please send all comments to dialysisdata@umich.edu no later than February 5, 2016.

[Back to top]

 

Project Title: End-Stage Renal Disease Access to Kidney Transplantation Measure Development

Dates:

The Call for Public Comment period opens on January 6, 2016 and closes on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) develop Access to Kidney Transplantation measures (Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) and Percentage of Prevalent Patients Waitlisted (PPPW)). The contract name is ESRD Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to develop quality access to kidney transplantation measures. Specific objectives included:

  • Develop quality measures that address important quality gaps across the spectrum of the kidney transplantation process, such as transplant education, referral, waitlisting, and transplant
  • Provide input on relevant measures currently used as part of the provider feedback program Dialysis Facility Reports (DFR), including facility waitlisting rate and the Standardized Transplantation Ratio (STR).
  • Consider the degree to which performance on a potential measure is under the control of the dialysis facility, as well as the strength of the link between performance on a measure and outcomes that are valued by patients
  • Consider issues of data element availability and collection
  • Discuss the potential need for exclusion criteria and/or risk adjustment

Documents and Measures for Comment:

The following documents are provided for your review and comment. The files are found below in the Download section.

  • Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) Measure Information Form
  • Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) Measure Justification Form
  • Percentage of Prevalent Patients Waitlisted (PPPW) Measure Information Form
  • Percentage of Prevalent Patients Waitlisted (PPPW) Measure Justification Form

Project Specific Instructions:

  • Do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Please indicate which measure (s) you are providing comments on.
  • Please send all comments to dialysisdata@umich.edu no later than February 5, 2016.

[Back to top]

 

Project Title:  Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE)

Dates:

  • The Call for Public Comment period closed on September 24, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Econometrica, Inc., to adapt, implement, and maintain quality measures for the PACE programs nationwide. The contract name is Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE). The contract number is HHSM-500-2013-13006I.  As part of its measure development process, CMS encourages interested parties to submit comments on the proposed adapted measures and the suitability of these measures to the PACE program.

Project Objectives:

The primary objectives of this project are to:

  • Analyze existing quality measure sets to determine the extent to which they can be uniquely modified, refined, or enhanced for the PACE programs.
  • Focus on four areas of measurement developed during the first year of the project: 30-Day Readmissions, Falls, Falls With Injury, and Pressure Ulcers Prevalence (with prevention).
  • Conduct field testing to assess the feasibility of data collection for the four proposed adapted measures.
  • Develop an auditing and validation plan for each of the proposed measures.
  • Seek public comments throughout each stage of the measure development process.

Comment Summary:

CMS and Econometrica produced a Preliminary Public Comment Report based on comments received through a public comment period that closed on August 17, 2015.  A revised Preliminary Public Comment Report requesting comments and feedback on additional questions was shared as part of the second round of public comment period that closed on September 24, 2015.  This Final Public Comment Report summarizes all comments and questions posted during both rounds of public comment. It provides individual responses to these comments and questions.

The following document includes a summary of public comments and the original measures; this associated document is found below in the Download section.

  • Final Public Comment Report

[Back to top]

 

Project Title: IMPACT Act of 2014 Cross-Setting Quality Measure: Drug Regimen Review

Dates:

  • The Call for Public Comment period closed on October 6, 2015  

Project Overview:

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 was signed into law on October 6, 2014.1 This Act requires Post-Acute Care (PAC) providers to report standardized patient assessment data and quality measure data to the Secretary of the Department of Health and Human Services.
 

The Centers for Medicare & Medicaid Services (CMS) is working to ensure that data elements within PAC assessment instruments are standardized and interoperable. Current federal assessment instruments are setting-specific and contain assessment items with varying concepts, definitions, and measurement scales. The move towards standardized assessment data elements facilitates cross-setting data collection, quality measurement, outcome comparison, and interoperable data exchange.
 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Abt Associates and RTI International to develop a cross-setting PAC measure for the quality measure domain—medication reconciliation. The contract names are Development and Maintenance of Symptom Management Measures (contract number HHSM-500-2013-13015I) and Outcome and Assessment Information Set (OASIS) Quality Measure Development and Maintenance Project (contract number HHSM-500-2013-13001I, Task Order HHSM-500T0002). As part of its measure development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure contractor during measure development and maintenance.
 

In this measure, medication reconciliation and drug regimen review are defined as:
 

Medication Reconciliation – the process of comparing the medications a patient is taking (and should be taking) with newly ordered medications in order to identify and resolve discrepancies. (Reference: The Joint Commission, National Patient Safety Goals).

Drug Regimen Review – a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. (Reference: Home Health Conditions of Participation §484.55c).

Project Objectives:

  • Introduce drug regimen data elements for capturing data for a drug regimen measure in the medication reconciliation domain for PAC settings.
  • Refine measure specifications.
  • Identify setting-specific needs/concerns/barriers for capturing drug regimen review/medication reconciliation information using the data elements.
  • Gather feedback on importance, feasibility, usability and potential impact of adding drug regimen review data elements for quality measurement as new items to existing PAC assessment instruments in Home Health (HH), Inpatient Rehabilitation Facilities (IRF), Long Term Care Hospital (LTCH) and Skilled Nursing Facilities (SNF) settings.
  • Identify additional guidance required for the implementation in each setting of care.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Drug Regimen Review Public Comment Summary Report

             Within this document are sections that present the following:

    • Verbatim Comments
    • Appendix
    • Drug Regimen Review Measure Information Form
    • Drug Regimen Review Measure Justification Form

1https://www.govtrack.us/congress/bills/113/hr4994

[Back to top]

 

Project Title: Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM)

Task: Electronic specification of an existing chart-based cesarean section measure (PC-02)

Dates:

  • The Call for Public Comment period closed on October 12, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) engaged Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs. These programs are Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR), and the Electronic Health Record (EHR) Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I, task order HHSM-500-T00003. As part of its measure development process, CMS requested that interested parties submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by providers in CMS quality reporting programs. Along with developing new eCQMs, the project will be retooling up to 20 existing chart- or claims-based measures as eCQMs. Mathematica is working with the PC-02 measure developer and steward, The Joint Commission, to retool the PC-02 measure. As part of this process, we solicited feedback about the feasibility, usability, and face validity of this measure.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • “PC-02 Public Comment Summary Memo”
  • Public Comment Verbatim Weekly Summary Report (PDF)

[Back to top]

 

Project Title: Overall Hospital Quality Star Ratings on Hospital Compare

Dates:

  • The Call for Public Comment period closed on September 14, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale-New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) and Lantana Consulting Group to develop Overall Hospital Quality Star Ratings for the Hospital Compare website. The purpose of the project is to improve the usability and interpretability of quality measurement for patients, caregivers, and consumers using Hospital Compare to inform their healthcare decision making. The star ratings system will provide a clear and easy interpretation and summary of currently available data regarding hospital quality measurement. CORE’s contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I - T0001 Modification 000002. Lantana’s contract name is Hospital Quality Initiatives Option Year 1 Measure Implementation Support. The contract number is HHSM-500-2013-13010I- HHSM-500-T0001.

This second public comment period seeks input from a wide variety of stakeholders regarding several key decisions made during the development of the methodology including the analytic approach for summarizing individual measures, the use of weights to combine several aspects of quality into a single measure, and the approach to categorizing hospitals into star categories. CMS requests that interested parties submit comments on the methodology under development for the Overall Hospital Quality Star Ratings. CMS asks that stakeholders provide comments regarding the approaches to calculating hospital summary scores and translating summary scores to star ratings. The public may also offer general suggestions regarding the Overall Hospital Quality Star Ratings project.

Project Objectives:

  • To improve the usability and interpretability of Hospital Compare for patients and consumers; and
  • To develop a methodology designed to generate an overall star rating for hospitals with sufficient quality data using the existing measures on Hospital Compare.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Hospital Quality Star Ratings on Hospital Compare Public Comment 2 Summary Report (PDF)
  • Public Comment Verbatim Weekly Summary Report (PDF)

[Back to top]

 

Project Title: Development of Claims-Based and Hybrid Measures of 30-Day Mortality Following Acute Ischemic Stroke Hospitalization that Incorporate Risk Adjustment for Stroke Severity

Dates:

  • The Call for Public Comment period closed on August 26, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Systems Corporation/Center for Outcomes Research and Evaluation (CORE) to develop two types of hospital-level measures of mortality following hospitalization for ischemic stroke. These measures include risk adjustment for stroke severity. The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I- T0001 Modification 000002. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

To develop two types of hospital-level measures of risk-standardized mortality for ischemic stroke patients that include an assessment of stroke severity, as measured by the first captured National Institutes of Health Stroke Scale (NIHSS) score. One type of these measures is an updated claims-only stroke mortality measure that utilizes only Medicare administrative claims data. The other type of measure is “hybrid,” which utilizes both claims data and electronic clinical data extractable from electronic health record (EHR) data. We developed two hybrid measures, with two different risk-adjustment models both of which include the NIHSS as a risk factor. One risk-adjustment model is a hybrid model and includes additional risk factors derived from claims and electronic clinical data; the other risk-adjustment model is electronic clinical data-only and includes additional risk factors only from electronic clinical data.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Public Comment Summary Report

[Back to top]