April 1, 2024 Release Notes

Peer Groups are updated annually in QualityAdvisor, typically around the end of Q1. The updates included in this release are listed below:

Top Performers

2023 Top Performers are now available in each of the following categories:

Top Performer Peers – Overall by Focused Population

Top Performer Peers – by Outcome

Top Performer Peers – Overall

Please see Current Top Performer Peer Groups in chapter 11 of the Methodologies User Guide for details.

Notes:

All 2023 Top Performers are calculated based on data from the January - December 2022 timeframe

The Top Performers by Focused Population based on the CMS Readmission and Mortality methodologies were calculated using the FY24 focused population definitions

The update includes 2023 Outpatient Top Decile and Top Quartile Performers

2023 Readmission Top Performer peers are based on HWR v4.0 2022 readmission methodology

All 2019 Top Performer Peers are retired

Academic Peer Group Update

The Academic Peer Group is now updated. Each year, the new peer list completely replaces the previous year's list.

Note: The qualifying definition for the Academic Peer Group stipulates that the peer group only includes facilities that are active QualityAdvisor members who are published on the Association of American Medical Colleges (AAMC) website, and that meet minimum comparative publishing standards to the comparative warehouse. Since the Academic Peer Group is updated only once every 12 months, it is possible that the list may or may not include facilities whose status against the qualifying definition has changed in the ensuing 12 months.

Birth Volume Peers

All groups in the Birth Volume peer group have been recalculated to be based on calendar year 2022 values. The methodology used to identify birth volumes for each facility matches the CDC Birth Volume denominator methodology.

Blood Utilization Peer Group

A new 2023 Blood Utilization & Data Optimization peer group has been added to the Premier Initiatives folder.

The 2019 peer group is retired

Safety Net Peer Group

The Safety Net Hospitals Peer Group is now updated. Each year, the new peer list completely replaces the previous year's list.

A safety net hospital is a type of medical center (in the United States) that, by legal obligation or mission, provides healthcare for all individuals regardless of their insurance status or ability to pay. The Safety Net Hospitals peer group at Premier, includes active members of the America’s Essential Hospitals (AEH) trade group that helps ensure access to care for America’s medically under-served and uninsured populations, and are published on the AEH Website.

 

Two new peer groups are added to QualityAdvisor with this release:

• 2023 100 Top Benchmark Hospitals Peer Group

• Urban, Academic, & Level I Trauma (UALOT) Peer Group

2023 100 Top Benchmark Hospitals Peer Group

This peer group includes the Quality Enterprise and QualityAdvisor members that receive the 100 Top Hospitals award at Premier's annual Breakthroughs conference each summer.

• This is a static list and hospitals only populate if they are an active QualityAdvisor subscriber that has published data to the comparative warehouse

• This peer group will be updated annually. This initial list is being added with this year's annual peer group update, and then going forward the list is planned to be updated after the annual Breakthroughs conference each summer (including 2024)

• The peer group (folder and list) are added to the “Premier Initiatives” parent folder

Urban, Academic, & Level I Trauma (UALOT) Peer Group

The UALOT peer group includes Academic hospitals that are also part of an urban community and have a Level I Trauma center.

This initial UALOT list is based on the most recent Academic hospital list included in this release, and the facility self-identified "Community Status" and "Trauma Level" data from the QA Facility Profile. Going forward, this peer group will be part of the annual peer group update each year.

• The peer group selection is added to the “Academic” parent folder

 

This April release includes the following Core Measure (EBC) updates:

Four measures are removed from QualityAdvisor

The following measures were previously retired and are now being removed/deleted from QualityAdvisor. Data for these measures has either already been archived, or will be archived as part of the upcoming summer 2024 release:

OP-5 — CMS - OP-AMI-5- Median Time to ECG (EBC - CMS - OP-AMI Continuous Measures)

OP-5 — CMS - OP-CP-5- Median Time to ECG (EBC - CMS - OP-CP Continuous Measures)

SUB-1 — TJC - SUB-1 Alcohol Use Screening (EBC - TJC - SUB Measure Rates)

TOB-1 — TJC - TOB-1 Tobacco Use Screening (EBC - TJC - TOB Measure Rates)

12 measures are retired (but not removed)

The measure descriptions for the following measures now include the date the measure is retired. The measures remain in QualityAdvisor for reporting purposes:

CMS IPFQR HBIPS-5 — Multiple Antipsychotic Medications at Discharge with Appropriate Justification - Retired Dec 31, 2022(EBC - CMS IPFQR - HBIPS Measure Rates)

CMS IPFQR - TOB-2 — Tobacco Use Treatment Provided or Offered - Retired Dec 31, 2022

CMS IPFQR - TOB-2a — Tobacco Use Treatment Den - Retired Dec 31, 2022(EBC - CMS IPFQR - TOB Measure Rates)

CMS PC-01 — Elective Delivery - Retired Dec 31, 2023(EBC - CMS - PC Measure Rates)

TJC HBIPS-5a — Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate - Retired Dec 31, 2024*

TJC HBIPS-5b — Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Children (1 through 12 years) - Retired Dec 31, 2024*

TJC HBIPS-5c — Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adolescent (13 through 17 years) - Retired Dec 31, 2024*

TJC HBIPS-5d — Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through 64 years) - Retired Dec 31, 2024*

TJC HBIPS-5e — Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Older Adult (≥ 65 years) - Retired Dec 31, 2024*

TJC TOB-2 — Tobacco Use Treatment Provided or Offered - Retired Dec 31, 2024*

TJC TOB-2a — Tobacco Use Treatment Den - Retired Dec 31, 2024*(EBC - TJC - TOB Measure Rates)

TJC STK-OP-1c — Median Time to Door to Transfer Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) - Retired Jun 30, 2021(EBC - TJC - OP-STK Continuous Measures)

*Note: While these measures are being retired by TJC effective 1/1/2024, the measures will remain active in Quality Measures Reporter until 1/1/2025 for any members that want to continue to report internally. Therefore, QualityAdvisor is adding the Premier retired date in the description for these measures.

13 Measure Descriptions Updated

TJC PC-05 — *Exclusive Human Milk Feeding (Previously Exclusive Breast Milk Feeding)

TJC ACHF-OP-03 — *Hospital Outpatient Mineralocorticoid Receptor Antagonists (MRA) (Previously Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD)

TJC STK-VOL-1 — *Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy (Previously Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy)

ED-2a — **Median Time from Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate (Inserted "Median Time from")

ED-2b — **Median Time from Admit Decision Time to ED Departure Time for Admitted Patients - Reporting (Inserted "Median Time from")

ED-2c — **Median Time from Admit Decision Time to ED Departure Time for Admitted Patients - Psych (Inserted "Median Time from")

TJC STK-OP-1b — **Median Time Door to Transfer Hemorrhagic Stroke (Previously Hemorrhagic Stroke; Median Time ED Arrival to Transfer)

TJC STK-OP-1d — **Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible (Previously Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible; Median Time ED Arrival to Transfer)

TJC STK-OP-1e — **Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible (Previously Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible; Median Time ED Arrival to Transfer)

TJC STK-OP-1f — **Median Time Door to Transfer Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO (Previously Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO; Median Time ED Arrival to Transfer)

TJC STK-OP-1g — **Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible (Previously Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible; Median Time ED Arrival to Transfer)

TJC STK-OP-1h — **Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible (Previously Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible; Median Time ED Arrival to Transfer)

TJC STK-OP-1i — **Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO (Previously Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO; Median Time ED Arrival to Transfer)

*Note: While measure description updates are effective 1/1/2024, data from previous description will be aggregated under new description.

**Note: These updated descriptions differ from the TJC manual. Premier has updated these descriptions to add clarity in response to frequent questions received from our members. These descriptions were previously updated in Quality Measures Reporter and are updated in QualityAdvisor with this release. Data from previous description will be aggregated under new description.

Six Measures are Added

The following Social Drivers of Health measures are mandatory for CMS and voluntary for TJC. They are not tied to an initiative at this time:

SDOH-1 — Screening for Social Drivers of Health

SDOH-2a — Screen Positive Rate for Social Drivers of Health - Food Insecurity

SDOH-2b — Screen Positive Rate for Social Drivers of Health - Housing Instability

SDOH-2c — Screen Positive Rate for Social Drivers of Health - Transportation Needs

SDOH-2d — Screen Positive Rate for Social Drivers of Health - Utility Difficulties

SDOH-2e — Screen Positive Rate for Social Drivers of Health - Interpersonal Safety

 

The new HAC FY2024 reporting option has been added to the PSI-90 for CMS HAC Reduction Program - Facility standard analysis.

Summary Overview

• The performance period for this software is January 1, 2021 - June 30, 2022

• The SAS software is modified by CMS (recalibrated) for the Fee-For-Service reference patient population specifically for the FY2024 program and is called Version 13

• The recalibrated version 13.0 software is modified so that software parameters (i.e., risk-adjustment coefficients, signal variance, and component weights in the Recalibrated PSI 90 Composite) derived from the reference population for CMS PSIs based on 12 months of Medicare FFS discharge data (July 1, 2019 to December 31, 2019 and January 1, 2021 to June 30, 2021)

• CMS v13.0 PSI software incorporates updated measure technical specifications consistent with AHRQ PSI software v2022 and is compatible with fiscal year 2022 ICD-10-CM/PCS coding, but unlike AHRQ v2022, COVID-19 discharges are included in FY2024 v13.0

• Premier uses the CMS software and replication instructions to provide this reporting option in alignment with the program as closely as possible:

25 diagnosis and 25 procedure codes are passed through the software

Medicare only patients

• Premier population statistics are based on the same Winsorized z-scoring methodology documented by CMS for the performance period timeframe:

Premier Median

Premier 75th Percentile

• Updated measure descriptions for PSI-09 and PSI-15

PSI 09 Postoperative Hemorrhage or Hematoma Rate (Previously Perioperative Hemorrhage or Hematoma Rate)

PSI 15 Abdominopelvic Accidental Puncture/Laceration Rate (Previously Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate)

• Minimum Discharge Rule

For this v13 implementation only, there is a minimum discharge rule. A hospital will only receive a CMS PSI-90 composite value if it meets both of the following criteria:

1. Has 1 or more PSI component with at least 25 discharges

2. Has 7 or more component PSI measures with at least 3 discharges each

If a hospital does not meet both of these criteria, the CMS PSI-90 composite will display dashes ("--") as a null value. (Previously a value of 1.0000 was displayed)

Note: The FY2022 v11 option for this analysis remains available.

Please see PSI-90 for CMS HAC Reduction Program for more detailed information.