| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety |
Measure Description
Percentage of patients undergoing open repair of small or moderate abdominal aortic aneurysms (AAA) who are discharged alive
Instruction
This measure is to be reported each time a repair of abdominal aortic aneurysms (AAA) is performed during the performance period. It is anticipated that eligible clinicians who provide services of the repair of abdominal aortic aneurysms (AAA), as described in the measure, based on the services provided and the measure-specific denominator coding will report this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Denominator
Patients aged 18 and older with all elective open repairs of small or moderate asymptomatic AAAs in men with < 6 cm diameter and women with < 5.5 cm diameter AAAs
Denominator Criteria (Eligible Cases):
Patients aged 18 and older
AND
Patient procedure during performance period (CPT): 35081, 35102
AND NOT
DENOMINATOR EXCLUSIONS:
For women:
Aortic aneurysm 5.5 – 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial
formatted CT: 9003F
OR
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F
OR
For men:
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F
OR
Symptomatic AAAs that required urgent/emergent (non-elective) repair: G9600
Numerator
Patients discharged alive/home following open repair of asymptomatic AAAs in men with < 6 cm diameter and women with < 5.5 cm diameter AAAs
Numerator Instructions: A higher calculated performance rate for this measure indicates better clinical care or control. Therefore the “Performance Met” numerator outcome option for this measure is the
representation of the better clinical quality or control. Reporting that numerator outcome option will produce a performance rate that trends closer to 100%, as quality increases.
Definition:
Home – For purposes of reporting this measure, home is the point of origin prior to hospital admission prior to procedure of AAA. For example, if the patient comes from a skilled facility and returns to the skilled facility post AAA repair, this would meet criteria for discharged to home.
Numerator Options:
Performance Met: Patient discharge to home no later than post-operative day #7 (G9601)
OR
Performance Not Met: Patient not discharged to home by post-operative day
#7 (G9602)