Measure Category
Measure Name
Description
Technical Specifications
Risk Adjustment
Rate Explanation
Why is it Important to be Aware of This Event?
Chronic Disease Rate of admission for short-term diabetes complications Diabetes is when the amount of sugar in your blood is higher than it should be Admissions for principal diagnosis with short-term complications per 100,000 population in patients ages 18 and older Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. Diabetes is a serious disease. High blood sugar can lead to other problems with your health, including heart disease, stroke, eye problems, loss of feeling in hands and feet or gum disease or loss of teeth.
Chronic Disease Rate of admission for long-term diabetes complications Diabetes is when the amount of sugar in your blood is higher than it should be Admissions for principal diagnosis with short-term complications per 100,000 population in patients ages 18 and older Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. Diabetes is a serious disease. High blood sugar can lead to other problems with your health, including heart disease, stroke, eye problems, loss of feeling in hands and feet or gum disease or loss of teeth.
Chronic Disease Rate of admission for uncontrolled diabetes Diabetes is when the amount of sugar in your blood is higher than it should be Admissions for principal diagnosis that do not mention short-term or long-term complications per 100,000 population in patients ages 18 and older. Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. Diabetes is a serious disease. High blood sugar can lead to other problems with your health, including heart disease, stroke, eye problems, loss of feeling in hands and feet or gum disease or loss of teeth.
Chronic Disease Rate of admission for Chronic Obstructive Pulmonary Disease or adult asthma Chronic obstructive pulmonary disease makes breathing hard because of swelling and thickening of your airway. Management of chronic obstructive pulmonary disease includes admissions with a principal diagnosis of COPD or asthma per 100,000 population in patients ages 40 and older. Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. COPD is the third leading cause of death in the US. At this time there is no cure for COPD. COPD is often not found until the disease is very advanced because people do not know the early warning signs. Sometimes people think they are short of breath or less able to do the things they are used to doing because they are "just getting old". But shortness of breath is never normal (American Lung Association, 2015).
Chronic Disease Rate of admission for high blood pressure High blood pressure is a disease called hypertension. Management of hypertension includes admissions with a principal diagnosis of high blood pressure per 100,000 population in patients ages 18 and older. Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. Although someone with high blood pressure may not have symptoms, it can be very dangerous. Over time, the high force of blood flow will stretch arteries and damage them. (American Heart Association, 2015.)
Chronic Disease Rate of admission Congestive Heart Failure Heart failure means that the heart is not pumping like it should. Management of congestive heart failure includes admissions with a principal diagnosis of heart failure per 100,000 population in patients ages 18 and older. Age and sex These rates are reported by patient county, not per hospital. Lower rates are better. With heart failure, the weak heart cannot supply the cells with enough blood which causes exhaustion and shortness of breath. Normal activities such as carrying groceries, playing with children and climbing stairs are more difficult than they should be. (American Heart Association, 2015).
Infections Rate of urinary tract infections among patients with a urine tube placed during hospital stay An infection of the bladder caused by germs that enter through a patient’s urine tube, used to drain their bladder Catheter-associated urinary tract infections developed while patient is in the hospital Type of patient care location, hospital affiliation with medical school, bed size of the patient care location Lower is Better Catheter infections are the most common type of infection in hospitals in the United States.  Infections can add complications and endanger patients.  Research suggests infections of the bladder can be prevented and as many as 50 to 70 percent are completely avoidable (Agency for Healthcare Research and Quality. U.S. Department of Health and Human Services, 2012)
Infections Rate of blood-stream infections among patients with a tube placed in the vein during hospital stay Central line bloodstream infections are an infection in the blood caused by germs that entered the body through a line placed in the vein. Central venous catheter-related bloodstream infections as a primary or secondary diagnosis, per 1,000 medical and surgical discharges in patients ages 18 and older or obstetric cases. Type of patient care location, hospital affiliation with medical school, bed size of the patient care location Lower is Better CLABSIs are associated with significant morbidity, mortality and costs (Health Research & Educational Trust, 2009)
Infections Rate of surgical site infections after colon surgery An infection after surgery on the colon Surgical site infections in patients who had colon surgery as primary or secondary procedure Duration of surgery, surgical wound class, use of endoscopes, re-operation status, patient age, patient assessment at time of anesthesiology Lower is Better Infections of any kind can be dangerous for patients and lead to more treatments or surgery.
Infections Rate of surgical site infections following abdominal surgery to remove the uterus An infection after surgery to remove the uterus Surgical site infections in patients who had abdominal hysterectomy as primary or secondary procedure Duration of surgery, surgical wound class, use of endoscopes, re-operation status, patient age, patient assessment at time of anesthesiology Lower is Better Infections of any kind can be dangerous for patients and lead to more treatments or surgery.
Infections Rate of serious complications from infection following surgery Sepsis is an illness that affects the entire body because of an infection Sepsis rate in postoperative patients per 1,000 elective surgical discharges in patients ages 18 and older Age, gender and medical condition adjusted Lower is Better Sepsis is a serious illness that is difficult to predict, diagnose and treat. Patients who have sepsis have an increased risk of complications and death. Those patients also face longer treatments and higher health care costs (Centers for Disease Control and Prevention, 2015).
Infections Rate of Clostridium difficile (C.Diff) infections obtained during hospital stay Clostridium difficile is a bacterium that causes symptoms such as diarrhea. Clostridium difficile rate of infections acquired during hospitalization, 10,000 patient days. None Lower is Better C.Diff is considered one of the primary causes of infectious diarrhea in the United States (Health Research Funding, 2014). Clostridium difficile is very difficult to treat. Patients at highest risk are older adults taking antibiotics while in the hospital.
Infections Rate of Methicillin-resistant Staphylococcus aureus (MRSA) infections obtained during hospital stay Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a bacteria that lives on the skin Methicillin-resistant staphylococcus aureus rate of infections acquired during hospitalization per 100,000 patient days. None Lower is Better MRSA is important to prevent because it can be very difficult to treat.
Harm Falls with injury during hospital stay An unintended movement to the floor that causes an injury Injury rate from falls and other trauma in inpatients that was not present on admission. None Lower is Better Among adults 65 years and older, falls are the leading cause of injury death. They are also the most common cause of non-fatal injuries and hospital admissions for trauma (Partnership for Patients, 2014).
Harm Blood clot following surgery A blood clot in a deep vein after surgery Perioperative pulmonary embolism or deep vein thrombosis rate for patients ages 18 and over who had surgery, per 1,000 surgical discharges. Age group, sex and medical condition Lower is Better Pulmonary embolism is the most common cause of preventable death of hospitalized patients. Research shows that 95 percent of hospital patients are at risk for VTE (Missouri Hospital Engagement Network, 2014).
Harm Rate of unexpected patient deaths during hospital stay Patients who die within 30 days of being in the hospital for a condition that normally has a low death rate The rate of in-hospital deaths per 1,000 discharges for low mortality diagnoses in patients ages 18 and older or obstetric patients. Age group, sex and medical condition Lower is Better If quality of care is high, death rates will potentially be lower.
Harm Rate of major bedsores obtained during hospital stay An injury to the skin, typically over a boney area of the body, as a result of prolonged pressure. The rate of Stage III or IV pressure ulcers for patients ages 18 and older per 1,000 discharges. Age group, sex and medical condition Lower is Better Pressure ulcers reduce overall quality of life because of pain, treatments and increased length of stay (Missouri Hospital Engagement Network, 2014).
Readmissions Rate of rehospitalization within 30 days of leaving the hospital Patients with another hospital stay within 30 days of when they were last in the hospital. Hospital wide readmissions assess the amount of adult inpatients who were readmitted to the same hospital within 30 days for any reason. SDS - age, medical condition, Medicaid eligibility and poverty CMS/Yale - Age and Medical Condition Lower is Better Having to go back to the hospital so soon is inconvenient and costly for the patient and could also lead to additional complications.
Readmissions Rate of rehospitalization within 30 days of leaving the hospital for Congestive Heart Failure Heart failure patients with another hospital stay within 30 days of when they were last in the hospital Adult inpatients who were readmitted following hospitalization for congestive heart failure to a Missouri and/or St. Louis metropolitan area hospital within 30 days for any reason. SDS - age, medical condition, Medicaid eligibility and poverty CMS/Yale - Age and Medical Condition Lower is Better Having to go back to the hospital so soon is inconvenient and costly for the patient and could also lead to additional complications.
Readmissions Rate of rehospitalization within 30 days of leaving the hospital for a Heart Attack Heart attack patients with another hospital stay within 30 days of when they were last in the hospital. Adult inpatients who were readmitted following hospitalization for acute myocardial infarction to a Missouri and/or St. Louis metropolitan area hospital within 30 days for any reason. SDS - age, medical condition, Medicaid eligibility and poverty CMS/Yale - Age and Medical Condition Lower is Better Having to go back to the hospital so soon is inconvenient and costly for the patient and could also lead to additional complications.
Readmissions Rate of rehospitalization within 30 days of leaving the hospital for a serious lung infection (Pneumonia) Pneumonia patients with another hospital stay within 30 days of when they were last in the hospital Pneumonia causes more than a million hospitalizations and close to 50,000 deaths each year (American Lung Association, 2014). SDS - age, medical condition, Medicaid eligibility and poverty CMS/Yale - Age and Medical Condition Lower is Better Having to go back to the hospital so soon is inconvenient and costly for the patient and could also lead to additional complications.
Readmissions Rate of rehospitalization within 30 days of leaving the hospital for Chronic Obstructive Pulmonary Disease COPD patients with another hospital stay within 30 days of when they were last in the hospital. Adult inpatients who were readmitted following hospitalization for chronic obstructive pulmonary disease to a Missouri and/or St. Louis metropolitan area hospital within 30 days for any reason SDS - age, medical condition, Medicaid eligibility and poverty CMS/Yale - Age and Medical Condition Lower is Better Having to go back to the hospital so soon is inconvenient and costly for the patient and could also lead to additional complications.