Appendix H Miscellaneous Tables Release Notes: Bleeding Inclusion Table Table 1.1 Bleeding Inclusion Table Version 1.0 Gastrointestinal (GI) Genitourinary (GU) Intracranial Other Types of Bleeding • anemia due to • blood in urine, • cerebral hemorrhage or • bleeding which occurred gastrointestinal unless noted only as bleeding as a result of trauma or bleeding laboratory or • hemorrhagic injury ONLY if medical • bleeding diverticulum dipstick finding cerebrovascular intervention required • bleeding from a peptic, • hematuria described accident (CVA) • epistaxis ONLY if gastric, esophageal, or as gross • hemorrhagic infarct of medical intervention duodenal ulcer the brain required • bleeding from colon • intracerebral • hematoma requiring • bleeding from gastritis Pulmonary bleeding/hemorrhage transfusion, stoppage of • bleeding hemorrhoid • bloody tinged • intracranial heparin or other ONLY if medical sputum bleeding/hemorrhage anticoagulant (e.g., Integrilin, Eptifibatide, intervention required • bloody sputum • ruptured intracranial Coumadin, Levonox), or • blood in vomitus, • coughing up blood aneurysm surgical intervention emesis, or stool • hemoptysis • subarachnoid • coffee ground emesis hemorrhage (SAH) (e.g., incision and • esophageal bleeding • subdural hematoma drainage) varices • post-procedure bleeding • hematemesis noted as abnormal or which required medical • hematochezia intervention • heme/guaiac positive vomitus, emesis, or • retinal hemorrhage/ bleeding stool • retroperitoneal (bleeding • hemoccult/occult into the abdomen) positive vomitus, emesis, or stool • vaginal bleeding, abnormal and • lower gastrointestinal nonmenstrual bleeding (LGI bleed, LGIB) • Mallory-Weiss Tear • melena • rectal bleeding (bright red blood [BRB] per rectum [BRBPR]) • upper gastrointestinal bleeding (UGI bleed, UGIB) Specifications Manual for National Appendix H-1 Hospital Quality Measures Release Notes: LVF Assessment Inclusion Table Version 1.0 Table 1.2 LVF Assessment Inclusion Table Cardiac Catheterization (cath) Nuclear Medicine Left Ventricular Echocardiogram (echo) with Left Tests Function (LVF) Ventriculogram (LV gram) • 2-D • adenosine • cardiac cath with • akinesis • cardiac ultrasound myocardial mention of LVF • biventricular heart failure • Doppler color flow perfusion stress test • cardiac/coronary • contractility mapping with mention of angiogram with LV • diastolic dysfunction • M-mode echo LVF gram • diastolic function • transesophageal • cardiac blood pool • cardiac/coronary • diastolic impairment echocardiogram (TEE) imaging angiogram with • dyskinesis • Cardiolite scan with mention of LVF • ejection fraction (EF) mention of LVF • cardiac/coronary • endstage cardiomyopathy • gated blood pool arteriogram with LV • hypocontractility imaging study gram • hypokinesis gated heart study cardiac/coronary • • • left ventricular diastolic arteriogram with • gated dysfunction ventriculogram mention of LVF • left ventricular diastolic • multiple gated • left ventriculogram function acquisition scan • left ventricular (MUGA) dysfunction (LVD) • radionuclide • left ventricular ejection ventriculography fraction (LVEF) Sestamibi scan with • • left ventricular systolic mention of LVF dysfunction (LVSD) • technetium scan • left ventricular systolic with mention of function (LVSF) LVF • systolic dysfunction • thallium stress test • systolic function with mention of LVF • wall motion study Specifications Manual for National Appendix H-2 Hospital Quality Measures Release Notes: Moderate/Severe Systolic Dysfunction Inclusion Table Version 1.0 Table 1.3 Moderate/Severe Systolic Dysfunction Inclusion Table Note: Moderate/severe biventricular heart failure and endstage cardiomyopathy are also inclusions. Contractility described Ejection fraction (EF) Hypokinesis described as: described as: as: • abnormal • abnormal • diffuse • compromised • compromised • generalized • decreased • decreased • global • depressed • depressed • involving the entire left • hypocontractility • impaired ventricle • impaired • low • low • poor • poor • reduced • reduced • very low • very low Left ventricular Left ventricular Left ventricular dysfunction (LVD) ejection fraction function (LVF) described as: (LVEF) described as: described as: • marked • abnormal • abnormal • moderate • compromised • compromised • moderate-severe • decreased • decreased • severe • depressed • depressed • significant • impaired • impaired • substantial • low • low • the severity is not • poor • poor specified • reduced • reduced • very severe • very low • very low Left ventricular Left ventricular Systolic dysfunction Systolic function systolic dysfunction systolic function described as: described as: (LVSD) described as: (LVSF) described as: • marked • abnormal • marked • abnormal • moderate • compromised • moderate • compromised • moderate-severe • decreased • moderate-severe • decreased • severe • depressed • severe • depressed • significant • impaired • significant • impaired • substantial • low • substantial • low • the severity is not • poor • the severity is not • poor specified • reduced specified • reduced • very severe • very low • very severe • very low Specifications Manual for National Appendix H-3 Hospital Quality Measures Table 1.4 - retired Release Notes: LVSD Notes Table Version 1.0 Table 1.5 LVSD Notes Table NUMERIC EFs • When the severity of systolic dysfunction is not • The numeric EF may be documented as a specified in the test report or other documentation percentage (%), whole number, or decimal. Convert (e.g., “LVD”), the inference is being made that the all decimals to percentages (e.g., 0.40 = 40). The degree of systolic dysfunction is clinically significant value should be between 5 and 80. – that is, the systolic dysfunction is moderate or severe • If the EF is documented as less than (<) or greater in degree. than (>) a given number, use the value one whole • The Moderate/Severe Systolic Dysfunction Inclusion number below or above the given number. E.g., Table is limited to moderate/severe systolic “EF< 40%” – Use 39%; “EF>40%” – Use 41%. dysfunction terms most commonly found in medical • If the EF is not documented as a whole number, record documentation. Abstractors may need to round fractions to the nearest whole number (e.g., exercise judgment in determining how to abstract 39.5% = 40%, 39.4% = 39%). terms that are not covered in the inclusion and • If both calculated and estimated values are exclusion lists (e.g., “mildly reduced EF” = ‘No’). It is documented on an LVF assessment test report, use recommended that organizations establish a systemic the calculated value. way of tracking such decisions so that future cases • If the EF is documented as a range, use the midpoint with similar terms can be abstracted in a consistent and consider this an estimated value. E.g., LVEF of manner. “35-45%.” Use 40% as an estimated EF value. • The LVF inclusion terms from the LVF Assessment • If the EF is documented as “about 40%” or variable should not automatically be considered “approximately 40%”, use 40% and consider this an synonyms of the LVF inclusion terms in the estimated value. Moderate/Severe Systolic Dysfunction Inclusion Table (e.g., Diastolic dysfunction is an inclusion for LVF in the LVF Assessment variable. “Impaired LVF” is an inclusion for LVSD. “Impaired diastolic dysfunction” should not be considered LVSD.). • When there are two or more documented LVFs, use the LVF closest to discharge (or closest to hospital arrival, if ONLY pre-arrival LVFs are documented). • The intent of this variable is to capture the most recent known LVF. In cases where there are no LVF results documented from a recent LVF assessment test, but there is an LVF documented from an earlier time period, use that earlier LVF, as it is the most recent known LVF. E.g., MUGA was done in the hospital and there are no LVF results documented (no numeric EF, no qualitative description), but an echo from 3 months prior to arrival showed an EF of 35% - Select “Yes” for LVSD). • If unable to determine which LVF is closest to discharge (or closest to arrival, in the case where only pre-arrival LVFs are documented), or if there is conflicting documentation, select “Yes” if any of the documented LVFs is an EF less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. In the following examples, “Yes” should be selected: o EF 50% per MUGA report from previous hospital stay included in chart, “Recent echo showed moderate LVD” per consultation report. Specifications Manual for National Appendix H-4 Hospital Quality Measures NUMERIC EFs o “EF 35%” per echo report, “Echo indicates normal systolic function” per progress note. o “Moderate LV dysfunction with EF 45%” noted on MUGA report. o Findings of “reduced EF” and “mild left ventricular dysfunction” are noted on MUGA report. o Echo findings noted as “global hypokinesis” and “EF 44%” in discharge summary. o “Echo last March showed preserved systolic function” per consultation report, “LVSD” noted in history section of H&P. o “Patient admitted with known LVSD” per H&P, “Hx mild biventricular heart failure” per consultation report. Specifications Manual for National Appendix H-5 Hospital Quality Measures Tables 1.6-1.8 - Retired Release Notes: Surgery Performed During Stay (SIP) Version 1.0 Table 1.9 Surgery Performed During Stay (SIP) Inclusion/Exclusion Table for Surgical Procedures Procedure Inclusions Exclusion CABG Surgery Coronary Artery Bypass Graft Any surgery other than CABG performed on