All SOMC employee injuries requiring treatment beyond First Aid and sharps injuries.
Exposure Rate of Sharps Injuries and DART Rate are subsets of this indicator.
This is the number of recordable injuries per 100 FTEs.
Sharps Injuries include needlesticks, lacerations, punctures, etc. with an exposure of blood or body fluid from another person.
Failure to Rescue: (ie, prevent a clinically important deterioration, such as death or permanent disability) from a complication of an underlying illness (eg, cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (eg, major hemorrhage after thrombolysis for acute myocardial infarction). Failure to rescue thus provides a measure of the degree to which providers responded to adverse occurrences (eg, hospital-acquired infections, cardiac arrest or shock) that developed on their watch, It may reflect the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both.
Initial studies of mortality and complication rates after surgical procedures indicated that lower rates of failure to rescue correlated with other plausible quality measures. Rates of failure to rescue have since served as outcome measures in prominent studies of the impacts of nurse-staffing ratios and nurse educational levels on the quality of care. Examples of the specific “rescue-able” adverse occurrences in such studies include pneumonia, shock, cardiac arrest, upper gastrointestinal bleeding, sepsis, and deep venous thrombosis. Death after any of these in-hospital occurrences would count as failure to rescue, on the view that early identification by providers can influence the risk of death.
The number of patients with surgical site infections, as defined by CDC (Centers for Disease Control), with the following types of procedures:
Occurrences of unintended retention of objects any point after the surgery ends, regardless of setting or of whether the object is removed.
This measure excludes:
Selected infections due to medical care/1000 discharges (excluding immunocompromised and cancer patients and neonates) (PSI 7)
Wound dehiscence is the premature “bursting” open of a wound along surgical suture. It is a surgical complication that results from poor wound healing. Risk factors are age, diabetes, obesity, poor knotting/grabbing of stitches and trauma to the wound after surgery.
SOMC uses The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators as the benchmark for Safety. These indicators help us identify potential adverse events occuring during hospitalization.
AHRQ is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decisionmaking.
The 30-day Risk-adjusted Death (mortality) Rates are produced using a complex statistical model, that relies on Medicare claims and enrolment information. The model predicts patient deaths for any cause within 30 days of hospital admission for AMI, whether the patients die while still in the hospital or after discharge. Thirty-day mortality is used because this is the time periods when deaths are most likely to be related to the care patients received in the hospital. Deaths that occur outside the hospital within 30 days are included along with deaths that occur in the hospital, because some hospitals discharge patients sooner than others.
The 30-day Risk-adjusted Death (mortality) Rates are produced using a complex statistical model, that relies on Medicare claims and enrolment information. The model predicts patient deaths for any cause within 30 days of hospital admission for HF, whether the patients die while still in the hospital or after discharge. Thirty-day mortality is used because this is the time periods when deaths are most likely to be related to the care patients received in the hospital. Deaths that occur outside the hospital within 30 days are included along with deaths that occur in the hospital, because some hospitals discharge patients sooner than others.
The 30-day Risk-adjusted Death (mortality) Rates are produced using a complex statistical model, that relies on Medicare claims and enrolment information. The model predicts patient deaths for any cause within 30 days of hospital admission for PN, whether the patients die while still in the hospital or after discharge. Thirty-day mortality is used because this is the time periods when deaths are most likely to be related to the care patients received in the hospital. Deaths that occur outside the hospital within 30 days are included along with deaths that occur in the hospital, because some hospitals discharge patients sooner than others.
A puncture wound is caused by an object piercing an internal organ and creating a small hole. Some punctures are just on the surface. Others can be very deep, depending on the source and cause.
A laceration is a cut in an organ caused by a sharp object such as a scalpel or blade.
Hyperglycemia and hypoglycemia are extremely common laboratory findings in hospitalized patients and can be complicating features of underlying diseases and some therapies. Extreme manifestations of poor glycemic control are reasonably preventable through the application of evidence-based guidelines and sound medical practice while in the hospital setting; specifically, that they are preventable through the use of routine serum glucose measurement and control which are basic elements of good hospital care.
1. Presence of vascular catheter within the last 48 hr.
2. Must meet one of the following:
a. Recognized pathogen isolated from blood culture and pathogen not related to infection at another site.
b. Temperature at least 38.0°C (100.4°F) or hypotension, and common skin contaminate isolated from two blood culture samples drawn on separate occasions, with 24 hr. and organism is, not related to infection at another site.
Mediastinitis is swelling and irritation (inflammation) of the area between the lungs (mediastinum). This area contains the heart, large blood vessels, windpipe (trachea, esophagus, thymus gland, lymph nodes, and connective tissues.
Mediastinitis may occur suddenly (acute) or may develop slowly and get worse over time (chronic). Most cases occur in patients who have had open chest surgery. Less than 5 percent of patients develop mediastinitis after having chest surgery.
The urinary tract is the most common site of nosocomial infection, accounting for more than 40% of the total number reported by acute-care hospital and affecting an estimated 600,00- patients per year.
Most of these infections follow instrumentation of the urinary tract, mainly urinary catheterization. Although not all catheter-associated urinary tract infections can be prevented, it is believed that a large number could be avoided by the proper management of the indwelling catheter. Determination of the optimal catheter care for these and other patients with different drainage systems requires separate evaluation.
As recent studies have shown, over 20% of patients catheterized and maintained on closed drainage on busy hospital wards may be expected to become infected. In these studies, errors in maintaining sterile closed drainage were common and predisposed patients to infection. Host factors which appear to increase the risk of acquiring catheter-associated urinary tract infections include advanced age, debilitation, and the postpartum state.
Catheter-associated urinary tract infections are generally assumed to be benign. Such infection in otherwise healthy patients is often asymptomatic and is likely to resolve spontaneously with the removal of the catheter. Occasionally, infection persists and leads to such complications as prostatitis, epididymitis, cystitis, pyelonephritis, and gram-negative bacteremia, particularly in high-risk patients. The last complication is serious since it is associated with a significant mortality, but fortunately occurs in fewer than 1% of catheterized patients.
Includes, but is not limited to, catheters, drains and other specialized tubes, infusion pumps, and ventilators.
This event is intended to capture occurrences whether or not the use is intended or described by the device manufactures’ literature.
An air embolism, or more generally gas embolism, is a medical condition caused by gas bubbled in the bloodstream (embolism in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures (for example a bubble entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism that shows any symptoms, is very rare.
Excludes death or serious disability associated with neurosurgical procedures known to present a high risk of intravascular air embolism.
High-risk procedures, other than neurosurgical procedures that include a small but known risk of air embolism are reportable under this event, including, but not limited to, those involving the head and neck, vaginal delivery and cesarean section, spinal instrumentation procedures and liver transplantation.
Stedman’s Online Medical Dictionary defines an infant as a child under the age of one year.
Excludes events involving competent adults.
The Term competent adult should be interpreted in accordance with prevailing legal standards.
This event is not intended to capture death or serious disability that occurs due to circumstances unrelated to the elopement (after the patient is located).
Defined as events that result from patient actions after admission to a healthcare facility. Excludes deaths resulting from self-inflicted injuries that were the reason for admission to the healthcare facility.
This event is not intended to capture patient suicide or attempted suicide when the patient is not physically present in the “healthcare facility.”
This measure includes errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administrations.
This measure also includes administration of a medication to which a patient has a known allergy and drug-drug interactions for which there is know potential for death or serious disability.
This measure excludes reasonable differences in clinical judgment involving drug selection and dose.
Hemolytic transfusion reactions are the result of antibodies in the recipient’s plasma directed against antigens in the donor’s erythrocytes. This results in rapid intravascular hemolysis of the donor red blood cells. ABO incompatibility clerical error is the most frequent cause. This results in hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation (DIC), renal failure, and complement-medicated cardiovascular collapse.
Hemolytic transfusion reactions occur in 1 per 40,000 transfused units of packed RBC’s.
Hemolytic transfusion reactions result in death in 1 per 100,000 units transfused.
Hemolytic transfusion reactions are associated with the following signs, which usually occur after a small amount of blood has been transfused and almost always before the unit is transfused completely:
In unconscious or obtunded patient, the diagnosis of hemolysis is suggested by development of the following:
This event is not intended to capture:
A low-risk pregnancy is defined as a pregnancy occurring in a woman aged 18-39 who has no previous diagnosis of essential hypertension, renal disease, collagen-vascular disease, liver disease, cardiovascular disease, Placenta previa, multiple gestation, intrauterine growth retardation, smoking, pregnancy – induced hypertension, premature rupture of membranes, or other previously documented condition that poses a high risk of poor pregnancy outcome.
Includes events that occur within 42 days postdelivery.
Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.
Hypoglycemia is defined as blood glucose levels <60 mgdl.
Hyperbilirubinemia is defined as bilirubin levels >30 mg/dl.
Neonate refers to the first 28 days of life.
Kernicterus is a condition of newborns that leads to severely disabling brain damage or death. It results from hyperbilirubinemia that can be caused by a number of factors. Kernicterus is preventable with techniques currently available.
Hyperbilirubinemia is characterized by jaundice, and while jaundice in the newborn is common, extreme hyperbilirubinemia that caused kernicterus is rare.
The risk factors for severe hyperbilirubinemia are:
This measure is also a Joint Commission Sentinel Event issued 4/1/2001.
The organization’s obligation is to report the event when it is made aware of the death or serious disability either by re-admittance or by the patient’s family.
Definition: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Definition: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (fascia, tendon, or joint capsule) making osteomylitis possible. Exposed bone/tendon is visible or directly palpable.
Excludes progression from Stage 2 to Stage 3, if Stage 2 was recognized upon admission.
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Spinal manipulative therapy encompasses all types of manual techniques, including spinal mobilization (movement of a joint within its physiologic range of motion) and manipulation (movement beyond its physiologic range of motion), regardless of their precise anatomic and physiologic focus or their discipline of origin.
Patient death or disability associated with unintended electric shock during the course of care or treatment.
Patient death or disability associated with emergency defibrillation during ventricular fibrillation or electroconvulsive therapies.
Excludes events involving planned treatments such as electric countershock/elective cardioversion.
Includes but is not limited to fractures, head injuries, and intracranial hemorrhage.
Restraint is currently defined by the Joint commission, by the Center for Medicare and Medicaid services, and by some states. If none of those definitions apply to an institution, the following definition, which is intended to comprise definitions from the named organizations, is offered: restraint is defined as any method of restricting a patient's freedom of movement that; is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his or her legal representative has consented; that is not indicated to treat the patient’s Medical condition or symptoms; or that does not promote the patient’s independent functioning.
The event is intended to capture instances in which restraints are implicated in the death; for example, the use led to strangulation/entrapment. Death/disability resulting from falls caused by lack of restraints would be captured under falls.
The carrying away of any person by luring, by force or by fraud. This is crime punishable by indictment. A near synonym in criminal law is kidnapping but it is restrictive in its meaning as it refers to abduction by force or the threat of force.
Language and definitions may vary based on state statute (e.g., many states have existing statutes that may use the terms sexual assault or simple assault or criminal sexual conduct); However, the principle and intent remain regardless of the language required based on jurisdiction.
Sexual assault as used in this indicator shall mean any unwanted or unauthorized touching by one or more persons, using any part of their bodies or any instrument, of an erogenous zone of any other person for the purpose of sexual gratification of the perpetrator.
Language and definitions may vary based on state statute (e.g., many states have existing statutes that may use the terms first degree assault or second degree assault or battery).
Significant Injury – A permanent disability or loss of function.
The aorta is the largest artery in your body, an it carries oxygen-rich blood pumped our of, or away from, your heart. Your aorta runs through your chest, where it is called the thoracic aorta. When it reaches your abdomen, it is called the abdominal aorta. The abdominal aorta supplies blood to the lower part of the body, In the abdomen, just below the navel, the aorta splits into two branches, called the iliac arteries. Which carry blood in to each leg.
When a weak area of the abdominal aorta expands or bulges, it is called an abdominal aortic aneurysm (AAA). The pressure from blood flowing through your abdominal aorta can cause a weakened part of the aorta to bulge, much like a balloon. A normal aorta in about 1 inch (or about 2 centimeters) in diameter. However, an AAA can stretch the aorta beyond its safety margin as it expands. Aneurysms are a health risk because they can burst or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or even death.
Less commonly, AAA can cause another serious health problem called embolization. Clots or debris can form inside the aneurysm and travel to blood vessels leading to other organs in your body. If one of these blood vessels becomes blocked, it can cause severe pain or even more serious problems, such as limb loss.
This data includes all Medicare patients who are admitted with any diagnosis and expire during the same admission. The data excludes Hospice patients.
The target was determined by reducing the previous fiscal year’s rate by 10%
This data includes all Medicare patients admitted with Acute Myocardial Infarction who expire within 30 days of discharge. This data excludes patients that have had Hospice services within the previous 12 months. Data does not exclude patients that expire with Hospice services and have not been under Hospice for the previous 12 months. Thirty days following discharge the case manager makes a follow up telephone call to the patient’s residence to determine if the patient has expired unless there is documentation that the patient has expired within the 30 days of discharge.
The target was determined by reducing the previous fiscal year’s rate by 10%.
This data includes all Medicare patients admitted with heart failure who expire within 30 days of discharge. This data excludes patients that have had Hospice services within the previous 12 months. Data does not exclude patients that expire with Hospice services and have not been under Hospice for the previous 12 months. Thirty days following discharge the case manager makes a follow up telephone call to the patient’s residence to determine if the patient has expired unless there is documentation that the patient has expired within the 30 days of discharge.
The target was determined by reducing the previous fiscal year’s rate by 10%.
This data includes all Medicare patients admitted with Pneumonia who expire within 30 days of discharge. This data excludes patients that have had Hospice services within the previous 12 months. Data does not exclude patients that expire with Hospice services and have not been under Hospice for the previous 12 months. Thirty days following discharge the case manager makes a follow up telephone call to the patient’s residence to determine if the patient has expired unless there is documentation that the patient has expired within the 30 days of discharge.
The target was determined by reducing the previous fiscal year’s rate by 10%.
For the HF readmission the measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of HF who were discharged from the hospital. For each hospital, CMS estimated the risk-standardized readmission rate (RSRR) to any hospital, from all causes, within 30 days of admission. This measure will complement the process measures and the mortality measure for HF currently posted on the consumer website, Hospital Compare, by providing a more complete assessment of HF care.
As for the publicly reported 30-day mortality measures, CMS uses a model based on administrative claims data validated by comparing the results to those from a model based on clinical (chart review) data. The model adjusts for each hospital’s patient mix, so that hospitals that care for older, sicker patients are on a “level playing field” with those hospitals serving healthier patients. The measure has been endorsed by National Quality Forum and supported by the Hospital Quality Alliance.
This measure focuses on HF because it is a common condition with substantial readmission and morbidity and because both process and mortality measures for HF are currently reported on Hospital Compare. Heart failure is the second most common cause of hospitalization of the elderly and accounts for approximately 770,000 admissions annually among patients 65 years of age or older in the United States. Hospitalization rates for heart failure have increased by 20% from 1988-1990 to 2000-2002 for patients aged 65 to 84 years. All-cause 30-day readmission rates per thousand patients discharged with HF increased by 11% between 1992 and 2001.
An adverse condition caused by treatment by any health professional where a leak in the lung caused air to accumulate in the space around the lung (pleural cavity). This prevents the lung from expanding fully and hence a partial lung collapse occurs. For example, a doctor may accidentally puncture the lung during a surgical operation.
Numerator: All discharges with a disposition of “deceased” (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator
Denominator: All surgical discharges age 18 years and older or MCD 14 (pregnancy, childbirth, and puerperium) defined by specific DRGs pr MS-DRGs and am ICD-9-CM code for an operating room procedure, principal procedure within 2 days of admission or admission type of elective (ATYPE=3) with potential complications of care listed in Death among surgical definition (e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer
The goal in developing composite measures that could be used to monitor performance over time or across regions and populations using a method that applied at the national, regional, state or provider/area level. Potential benefits of composite measures are to: summarize quality across multiple indicator, improve the ability to detect differences, identify important domains and drivers of quality, prioritize action for quality improvement.
Discharges with ICD-9-CM code of pressure ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the denominator All medical and surgical discharges age 18 years and older defined by specific DRGs or MS-DRGs
Definition: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Definition: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (fascia, tendon, or joint capsule) making osteomylitis possible. Exposed bone/tendon is visible or directly palpable.
Excludes progression from Stage 2 to Stage 3, if Stage 2 was recognized upon admission.
Includes detectable contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product.
The term detectable is intended to capture contaminations that can be seen with the naked eye or with the use of detection mechanisms that are in general use; these contaminations are to be reported when they become known to the provider or healthcare facility. Detection mechanisms may include cultures and tests that signal changes in pH or glucose levels.
Displacement of an organ or any part; specifically a disturbance or disarrangement of the normal relation of the bones at a joint in which there is complete loss of contact between the two articular surfaces. The direction of the dislocation is determined by the position of the distal part of the articulation.
The sum of immediate and delayed pathophysiologic responses of living tissue to a current of electricity of sufficient magnitude to induce abnormal sensations (paresthesia, pain) or objective changes (muscle spasm, cardiac arrhythmia, neurologic impairment including coma, tissue damage).
Any injury within the cranium, usually meaning within the cranial cavity.
A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy objects.
A burn is damage to the body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.
Fracture of the femoral neck; requires surgical repair with internal fixation and can lead to prolonged or permanent loss of mobility and shortened life span.
Non-Risk adjusted Acute Myocardial Infarction (AMI) readmission rate measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of AMI who were discharged from the hospital and then readmitted within 30 days from all causes. This is reported as a raw rate, meaning that this rate is not adjusted to account for the acuity or any co-morbidities of the patients included in this measure.
Non-Risk adjusted Heart Failure (HF) readmission rate measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of HF who were discharged from the hospital and then readmitted within 30 days from all causes. This is reported as a raw rate, meaning that this rate is not adjusted to account for the acuity or any co-morbidities of the patients included in this measure.
Non-Risk adjusted Pneumonia (PN) readmission rate measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of PN who were discharged from the hospital and then readmitted within 30 days from all causes. This is reported as a raw rate, meaning that this rate is not adjusted to account for the acuity or any co-morbidities of the patients included in this measure.
Risk adjusted Acute Myocardial Infarction (AMI) readmission rate measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of AMI who were discharged from the hospital and then readmitted within 30 days from all causes.
For each hospital, CMS estimated the risk-standardized readmission rate (RSRR) to any hospital, from all causes, within 30 days of admission.
As for the publicly reported 30-day mortality measures, CMS uses a model based on administrative claims data validated by comparing the results to those from a model based on clinical (chart review) data. The model adjusts for each hospital’s patient mix, so that hospitals that care for older, sicker patients are on a “level playing field” with those hospitals serving healthier patients. The measure has been endorsed by National Quality Forum and supported by the Hospital Quality Alliance.
Risk adjusted Pneumonia (PN) readmission rate measure includes Fee-for-Service Medicare beneficiaries of at least 65 years of age with a principal discharge diagnosis of AMI who were discharged from the hospital and then readmitted within 30 days from all causes.
For each hospital, CMS estimated the risk-standardized readmission rate (RSRR) to any hospital, from all causes, within 30 days of admission.
As for the publicly reported 30-day mortality measures, CMS uses a model based on administrative claims data validated by comparing the results to those from a model based on clinical (chart review) data. The model adjusts for each hospital’s patient mix, so that hospitals that care for older, sicker patients are on a “level playing field” with those hospitals serving healthier patients. The measure has been endorsed by National Quality Forum and supported by the Hospital Quality Alliance.
This indicator measures the number of deaths among cases who underwent a Percutaneous Transluminal Coronary Angioplasty (PTCA) or “balloon treatment”, who were discharged and age 18 years and older.
This number includes inpatient procedures only
This indicator measures the number of deaths among cases who underwent a Coronary Artery Bypass Graft (CABG) or Open Heart Surgery, who were discharged and age 40 years and older.
This number includes CABG procedures who may have also had a valve replacement procedure
This measure estimates the percentage of people who had an MRI of the Lumbar Spine with a diagnosis of low back pain without claims based evidence of antecedent conservative therapy
This measure calculates the percentage of patients with mammography screening studies that are followed by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting. An abnormally high rate of “call-backs” form indeterminate screening studies may be an indication of the inability of the reader to adequately determine when additional imaging is necessary (high false positive rate). This points to the experience and confidence of the interpreting physician and indicates both quality and efficiency, although a recent survey of 1.570 women concluded that “a substantial fraction of women in this study would have preferred the inconvenience of and anxiety associated with a higher recall rate if it resulted in the possibility of detecting breast cancer earlier”. Recall rates with follow-up “diagnostic” mammography studies greater than 10 to 14 percent are generally felt to be unusual unless explained by the morbidity of the underlying population.
Estimate the ratio of combined (with and without) studies to total studies performed. A high value would indicate a high use of combination studies and raise the question of inefficient examination protocols. Results to be segmented based upon data availability by facility. This measure calculates the percentage of abdomen studies that are performed with and without contrast out of all abdomen studies performed (those with contrast, those without contrast, and those with both). Current literature clearly defines indications for the use of combined studies, that is , examinations performed without contrast followed by contrast enhancement. The intent of this measure is to assess questionable utilization of contrast agents that carry an element of risk and significantly increase examination cost. While there may be a direct financial benefit to the service provider for the use of contrast agents due to increased reimbursements for “combined” studies, this proposed measure is directed at the identification of those providers who typically employ interdepartmental/facility protocols that call for its use in nearly all cases. The mistaken concept is that more information is always better than not enough.
Estimate the ratio of combined (with and without) studies to total studies performed. A high value would indicate a high use of combination studies. Results to be segmented based upon data availability by facility. This measure calculates the percentage of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both). Current literature clearly defines indications for the use of combined studies, that is, examinations performed without contrast followed by contrast enhancement. The intent of this measure is to assess questionable utilization of contrast agents that carry an element of risk and significantly increase examination cost. While there may be a direct financial benefit to the service provider for the use of contrast agents due to increased reimbursements for “combined” studies, this proposed measure is directed at the identification of those providers who typically employ interdepartmental/facility protocols that call for its use in nearly all cases. The mistaken concept is that more information is always better than not enough. The focus of this measure is one of the specific body parts where the indications for contrast material are more specifically defined.