| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety | Obstetrics/Gynecology |
Measure Description
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery
Instruction
This measure is to be reported each time a pelvic organ prolapse repair surgery is performed during the performance period ending November 30th. There is no diagnosis associated with this measure. This measure may be reported by clinicians who performthe quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Denominator
All patients undergoing anterior, posterior or apical pelvic organ prolapse (POP) surgery
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 57106, 57110, 57120, 57250, 57260, 57265, 57268, 57270, 57280 , 57556, 58263, 58270, 58280, 58292, 58294, 58400
Numerator
The number of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within one month after surgery
Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
NUMERATOR NOTE: In order to meet the measure, bowel injury is sustained as a result ofthe prolapse surgery.
Numerator Options:
Performance Met: Patient sustained bowel injury at the time of surgery or discovered subsequently up to 1 month post-surgery (G9628)
OR
Denominator Exception: Documented medical reasons for not reporting bowel injury (e.g. gynecologic or other pelvic malignancy documented, planned (e.g. not due to an unexpected bowel injury) resection and/or re-anastomosis of bowel, or patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bowel injury) (G9629)
OR
Performance Not Met: Patient did not sustain a bowel injury at the time of surgery nor discovered subsequently up to 1 month post-surgery (G9630)