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  • Measure Summary
  • NQMC:011305
  • Mar 2017
  • NQF-Endorsed Measure

Pneumonia: hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization.

Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2017 condition-specific measures updates and specifications report: hospital-level 30-day risk-standardized mortality measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017 Mar. 98 p. [29 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure estimates a hospital-level, 30-day risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal diagnosis of pneumonia or a principle discharge diagnosis of sepsis with a secondary discharge diagnosis of pneumonia. Mortality is defined as death from any cause within 30 days of the start of the index admission.

The Centers for Medicare & Medicaid Services (CMS) annually reports the measure for individuals who are 65 years and older and are Medicare Fee-for-Service (FFS) beneficiaries hospitalized in non-federal short-term acute care hospitals (including Indian Health Services hospitals) and critical access hospitals.

Rationale

Hospitalization for pneumonia is common and associated with considerable risk of morbidity and mortality. Many current hospital interventions are known to decrease the risk of death within 30 days of hospital admission. Current process-based performance measures, however, cannot capture all the ways that care within the hospital might influence outcomes. As a result, many stakeholders, including patient organizations, are interested in outcomes measures that would permit groups of providers to assess their relative outcomes performance for the purpose of internal quality improvement or public reporting.

Since the most commonly available data across hospitals in the United States are administrative billing data, a measure is most widely applicable if it makes use of these data. Because there are concerns about the adequacy of administrative data, the measures using these data should be, if possible, validated against measures based on higher quality data (e.g., chart data). The Centers for Medicare & Medicaid Services (CMS) also believes that an outcomes measure for public reporting should have the following properties: the method by which the measure is calculated and information about its performance are publicly available; the patient sample accurately reflects patients treated for the condition at each hospital (e.g., transfers out are included, patients likely not to have pneumonia despite their International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] code are excluded, etc.); the measure is adjusted for conditions present on admission, not those that develop during the hospitalization; the measure is based on a standard period of outcome assessment; the measure is adjusted for past health care utilization history; risk factors are clinically coherent (not just data driven); statistical methods take into account the structure of the data (e.g., patients within hospitals); and results are reported in a way that reflects the degree of certainty about a hospital's performance. In CMS's assessment, no popular outcomes measure for pneumonia satisfies all of these criteria. Accordingly, CMS has sought to develop a measure with these properties.

Evidence for Rationale

Yale University, under CMS contract through the Colorado Foundation for Medical Care, Mathematica Policy Research. Pneumonia 30-day mortality. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2006 Apr 28. 7 p.

Primary Health Components

Pneumonia; sepsis; 30-day mortality rate

Denominator Description

The measure cohort consists of admissions for Medicare Fee-for-Service (FFS) beneficiaries aged 65 years or older and discharged from non-federal acute care hospitals and critical access hospitals, having a principal discharge diagnosis of pneumonia or a principle discharge diagnosis of sepsis with a secondary discharge diagnosis of pneumonia.

The risk-standardized mortality rate (RSMR) is calculated as the ratio of the number of "predicted" deaths to the number of "expected" deaths at a given hospital, multiplied by the national observed mortality rate. For each hospital, the denominator is the number of deaths expected based on the nation's performance with that hospital's case mix.

See the related "Denominator Inclusions/Exclusions" field.

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure; thus, this field is used to define the measure cohort.

See the 2017 Condition-specific Measures Updates and Specifications Report. Hospital-level 30-day Risk-standardized Mortality Measures for more details.

Numerator Description

The measure counts death from any cause within 30 days of the start of the index admission.

The risk-standardized mortality rate (RSMR) is calculated as the ratio of the number of "predicted" deaths to the number of "expected" deaths at a given hospital, multiplied by the national observed mortality rate. For each hospital, the numerator of the ratio is the number of deaths within 30 days predicted based on the hospital's performance with its observed case mix.

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure; thus, this field is used to define the outcome.

See the 2017 Condition-specific Measures Updates and Specifications Report. Hospital-level 30-day Risk-standardized Mortality Measures for more details.

Type of Evidence Supporting the Criterion of Quality for the Measure

  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

More than one million hospitalizations each year in the United States are caused by pneumonia (Lindenauer et al., 2012; Centers for Disease Control and Prevention [CDC], 2017). The annual mortality rate (deaths per 100,000 population) is 16.9 (CDC, 2017). Among patients aged 65 years or over in the United States, pneumonia is the second leading cause of hospitalization, and is the leading infectious cause of death (Fry et al., 2005; Bratzler et al., 2011). Many current hospital interventions have been shown to be associated with lower risk of death within 30 days of hospital admission (Lee et al., 2014).

Evidence for Additional Information Supporting Need for the Measure

Bratzler DW, Normand SL, Wang Y, O'Donnell WJ, Metersky M, Han LF, Rapp MT, Krumholz HM. An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients. PLoS ONE. 2011 Apr 12;6(4):e17401. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). FastStats: pneumonia. [internet]. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2017 Jan 20 [10/31/2017].

Fry AM, Shay DK, Holman RC, Curns AT, Anderson LJ. Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988-2002. JAMA. 2005 Dec 7;294(21):2712-9. PubMed External Web Site Policy

Lee JS, Nsa W, Hausmann LR, Trivedi AN, Bratzler DW, Auden D, Mor MK, Baus K, Larbi FM, Fine MJ. Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to 2010. JAMA Intern Med. 2014 Nov;174(11):1806-14. PubMed External Web Site Policy

Lindenauer PK, Lagu T, Shieh MS, Pekow PS, Rothberg MB. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009. JAMA. 2012 Apr 4;307(13):1405-13. PubMed External Web Site Policy

Extent of Measure Testing

Assessment of Updated Models

The pneumonia measure estimates hospital-specific 30-day all-cause risk-standardized mortality rates (RSMRs) using a hierarchical logistic regression model. Refer to Section 2 in the original measure documentation for a summary of the measure methodology and model risk-adjustment variables. Refer to prior methodology and technical reports for further details.

The Centers for Medicare & Medicaid Services (CMS) evaluated and validated the performance of the models, using July 2013 to June 2016 data for the 2017 reporting period. They also evaluated the stability of the risk-adjustment model over the three-year measurement period by examining the model variable frequencies, model coefficients, and the performance of the risk-adjustment model in each year.

CMS assessed logistic regression model performance in terms of discriminant ability for each year of data and for the three-year combined period. They computed two summary statistics to assess model performance: the predictive ability and the area under the receiver operating characteristic (ROC) curve (c-statistic). CMS also computed between-hospital variance for each year of data and for the three-year combined period. If there were no systematic differences between hospitals, the between-hospital variance would be zero.

The results of these analyses are presented in Section 4.5 of the original measure documentation.

Pneumonia Mortality 2017 Model Results

Frequency of Pneumonia Model Variables

CMS examined the change in the frequencies of clinical and demographic variables. Frequencies of model variables were stable over the measurement period. The largest changes in the frequencies (those greater than 2% absolute change) include:

  • Increases in Asthma (10.9% to 14.0%), Respiratory arrest; Cardio-respiratory failure and shock (24.3% to 26.5%), and Septicemia, sepsis, systemic inflammatory response syndrome/shock (12.8% to 15.1%)
  • Decreases in Iron deficiency or other/unspecified anemias and blood disease (60.5% to 58.4%) and Cerebrovascular disease (25.4% to 23.0%)

Pneumonia Model Parameters and Performance

Table 4.5.2 in the original measure documentation shows hierarchical logistic regression model variable coefficients by individual year and for the combined three-year dataset. Table 4.5.3 in the original measure documentation shows the risk-adjusted odds ratios (ORs) and 95% confidence intervals for the pneumonia mortality model by individual year and for the combined three-year dataset. Overall, the variable effect sizes were relatively constant across years. In addition, model performance was stable over the three-year time period; the c-statistic increased slightly from 0.71 to 0.72.

Refer to the original measure documentation for additional information.

Evidence for Extent of Measure Testing

Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2017 condition-specific measures updates and specifications report: hospital-level 30-day risk-standardized mortality measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017 Mar. 98 p. [29 references]

State of Use

Current routine use

Current Use

Collaborative inter-organizational quality improvement

External oversight/Medicare

Internal quality improvement

Pay-for-performance

Pay-for-reporting

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than or equal to 65 years

Target Population Gender

Either male or female

IOM Care Need

Getting Better

IOM Domain

Safety

Case Finding Period

Discharges July 1, 2013 through June 30, 2016

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window precedes index event

Denominator Inclusions/Exclusions

Inclusions
An index admission is the hospitalization to which the mortality outcome is attributed and includes admissions for patients:

  • Having a principal discharge diagnosis of:
    • Pneumonia* (including aspiration pneumonia); or,
    • Sepsis (not including severe sepsis) with a secondary diagnosis of pneumonia (including aspiration pneumonia) coded as present on admission (POA) and no secondary diagnosis of severe sepsis coded as POA**
  • Enrolled in Medicare Fee-for-Service (FFS) Part A and Part B for the 12 months prior to the date of admission, and enrolled in Part A during the index admission
  • Aged 65 or over
  • Not transferred from another acute care facility

*International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes used to define the pneumonia cohort for discharges on or after October 1, 2015:

  • A48.1 Legionnaires' disease
  • J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia
  • J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia
  • J10.08 Influenza due to other identified influenza virus with other specified pneumonia
  • J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia
  • J11.08 Influenza due to unidentified influenza virus with specified pneumonia
  • J12.0 Adenoviral pneumonia
  • J12.1 Respiratory syncytial virus pneumonia
  • J12.2 Parainfluenza virus pneumonia
  • J12.3 Human metapneumovirus pneumonia
  • J12.81 Pneumonia due to SARS-associated coronavirus
  • J12.89 Other viral pneumonia
  • J12.9 Viral pneumonia, unspecified
  • J13 Pneumonia due to Streptococcus pneumoniae
  • J14 Pneumonia due to Hemophilus influenzae
  • J15.0 Pneumonia due to Klebsiella pneumoniae
  • J15.1 Pneumonia due to Pseudomonas
  • J15.20 Pneumonia due to staphylococcus, unspecified
  • J15.211 Pneumonia due to Methicillin susceptible Staphylococcus aureus
  • J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
  • J15.29 Pneumonia due to other staphylococcus
  • J15.3 Pneumonia due to streptococcus, group B
  • J15.4 Pneumonia due to other streptococci
  • J15.5 Pneumonia due to Escherichia coli
  • J15.6 Pneumonia due to other aerobic Gram-negative bacteria
  • J15.7 Pneumonia due to Mycoplasma pneumoniae
  • J15.8 Pneumonia due to other specified bacteria
  • J15.9 Unspecified bacterial pneumonia
  • J16.0 Chlamydial pneumonia
  • J16.8 Pneumonia due to other specified infectious organisms
  • J18.0 Bronchopneumonia, unspecified organism
  • J18.1 Lobar pneumonia, unspecified organism
  • J18.8 Other pneumonia, unspecified organism
  • J18.9 Pneumonia, unspecified organism
  • J69.0 Pneumonitis due to inhalation of food and vomit

**Principal discharge diagnosis codes included in cohort if combined with a secondary diagnosis of pneumonia coded as POA AND no secondary diagnosis of severe sepsis (R65.20 Severe sepsis without septic shock or R65.21 Severe sepsis with septic shock) coded as POA is present:

  • A02.1 Salmonella sepsis
  • A22.7 Anthrax sepsis
  • A26.7 Erysipelothrix sepsis
  • A32.7 Listerial sepsis
  • A40.0 Sepsis due to streptococcus, group A
  • A40.1 Sepsis due to streptococcus, group B
  • A40.3 Sepsis due to Streptococcus pneumoniae
  • A40.8 Other streptococcal sepsis
  • A40.9 Streptococcal sepsis, unspecified
  • A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
  • A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
  • A41.1 Sepsis due to other specified staphylococcus
  • A41.2 Sepsis due to unspecified staphylococcus
  • A41.3 Sepsis due to Hemophilus influenzae
  • A41.4 Sepsis due to anaerobes
  • A41.50 Gram-negative sepsis, unspecified
  • A41.51 Sepsis due to Escherichia coli (E. coli)
  • A41.52 Sepsis due to Pseudomonas
  • A41.53 Sepsis due to Serratia
  • A41.59 Other Gram-negative sepsis
  • A41.81 Sepsis due to Enterococcus
  • A41.89 Other specified sepsis
  • A41.9 Sepsis, unspecified organism
  • A42.7 Actinomycotic sepsis
  • A54.86 Gonococcal sepsis
  • B37.7 Candidal sepsis

Note: International Classification of Diseases, Ninth Revision (ICD-9) code lists for discharges prior to October 1, 2015 can be found in the 2016 Condition-specific Mortality Measures Updates and Specifications Report External Web Site Policy.

Exclusions

  • Discharged alive on the day of admission or the following calendar day who were not transferred to another acute care facility
  • Inconsistent or unknown vital status or other unreliable demographic (age and gender) data
  • Enrolled in the Medicare hospice program any time in the 12 months prior to the index admission, including the first day of the index admission
  • Discharged against medical advice

For patients with more than one eligible admission for pneumonia in a given year, only one index admission for that condition is randomly selected for inclusion in the cohort. Additional admissions within that year are excluded.

Exclusions/Exceptions

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
The measure counts death from any cause within 30 days of the start of the index admission.

The risk-standardized mortality rate (RSMR) is calculated as the ratio of the number of "predicted" deaths to the number of "expected" deaths at a given hospital, multiplied by the national observed mortality rate. For each hospital, the numerator of the ratio is the number of deaths within 30 days predicted based on the hospital's performance with its observed case mix.

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure; thus, this field is used to define the outcome.

See the 2017 Condition-specific Measures Updates and Specifications Report. Hospital-level 30-day Risk-standardized Mortality Measures External Web Site Policy for more details.

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Type of Health State

Death

Instruments Used and/or Associated with the Measure

None

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Case-mix adjustment

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

Risk-Adjustment Variables

In order to account for differences in case mix among hospitals, the measure adjusts for variables (for example, age, comorbid diseases, and indicators of patient frailty) that are clinically relevant and have relationships with the outcome. For each patient, risk-adjustment variables are obtained from inpatient, outpatient, and physician Medicare administrative claims data extending 12 months prior to, and including, the index admission.

The measure adjusts for case mix differences among hospitals based on the clinical status of the patient at the time of the index admission. Accordingly, only comorbidities that convey information about the patient at that time or in the 12 months prior, and not complications that arise during the course of the hospitalization, are included in the risk adjustment.

The measure does not adjust for socioeconomic status (SES) because the association between SES and health outcomes can be due, in part, to differences in the quality of healthcare that groups of patients with varying SES receive. The intent is for the measure to adjust for patient demographic and clinical characteristics while illuminating important quality differences. As part of the National Quality Forum's (NQF's) endorsement process for this measure, the Centers for Medicare & Medicaid Services (CMS) completed analyses for the two-year Sociodemographic Trial Period. Although univariate analyses found that the patient-level observed (unadjusted) mortality rates are higher for dual-eligible patients (for patients living in lower Agency for Healthcare Research and Quality [AHRQ] SES Index census block groups) and African-American patients compared with all other patients, analyses in the context of a multivariable model demonstrated that the effect size of these variables was small, and that the c-statistics for the models are similar with and without the addition of these variables.

Refer to Appendix D of the original measure documentation for the list of comorbidity risk-adjustment variables and the list of complications that are excluded from risk adjustment if they occur only during the index admission.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Hospital-level 30-day RSMR following pneumonia.

Measure Collection Name

National Hospital Inpatient Quality Measures

Measure Set Name

Mortality Measures

Submitter

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Developer

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Yale-New Haven Health Services Corporation/Center for Outcomes Research and Evaluation under contract to Centers for Medicare & Medicaid Services - Academic Affiliated Research Institute

Funding Source(s)

Centers for Medicare & Medicaid Services (CMS)

Composition of the Group that Developed the Measure

This measure was developed primarily by a team of clinical and statistical experts from the Centers for Medicare & Medicaid Services, Mathematica Policy Research, Colorado Foundation for Medical Care, Oklahoma Foundation for Medical Quality, and Yale University. The following experts helped to develop the measure:

  • Randy Poulsen, PhD, CMS
  • Lein Han, PhD, CMS
  • Mel Ingber, PhD, CMS
  • Neil Gittings, MA, CMS
  • Renee Mentnech, MS, CMS
  • Myles Maxfield, PhD, Mathematica Policy Research
  • Angela Merrill, PhD, Mathematica Policy Research
  • Eric M. Schone, PhD, Mathematica Policy Research
  • Risa Hayes, CPC, Colorado Foundation for Medical Care
  • Deb R. Chromik-Ralston, BS, Colorado Foundation for Medical Care
  • Dale W. Bratzler, DO, MPH, Oklahoma Foundation for Medical Quality
  • Wato Nsa, MD, PhD, Oklahoma Foundation for Medical Quality
  • Harlan M. Krumholz, MD, SM, Yale University School of Medicine
  • Amy S. Rich, MPH, Yale University School of Medicine
  • Yongfei Wang, MSc, Yale University School of Medicine
  • Jennifer A. Mattera, MPH, Yale University/Yale-New Haven Hospital
  • Yun Wang, PhD, Yale University/Yale-New Haven Hospital
  • Sharon-Lise T. Normand, PhD, MSc, Harvard School of Public Health
  • Hongyu Zhao, PhD, Yale University
  • Inyoung Kim, PhD, Yale University
  • Shih-Yieh Ho, PhD, Qualidigm

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

0468

Date of Endorsement

2017 Oct 3

Measure Initiative(s)

Hospital Compare

Hospital Inpatient Quality Reporting Program

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2017 Mar

Measure Maintenance

Annual

Date of Next Anticipated Revision

2018 Apr

Measure Status

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Source(s)

Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2017 condition-specific measures updates and specifications report: hospital-level 30-day risk-standardized mortality measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017 Mar. 98 p. [29 references]

Measure Availability

Source available from the QualityNet Web site External Web Site Policy.

Check the QualityNet Web site regularly for the most recent version of the specifications manual and for the applicable dates of discharge.

Companion Documents

The following are available:

  • Hospital compare: a quality tool provided by Medicare. [internet]. Washington (DC): U.S. Department of Health and Human Services; [accessed 2017 Oct 3]. This is available from the Medicare Web site External Web Site Policy.
  • Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2017 Medicare hospital quality chartbook. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017. Available from the Centers for Medicare & Medicaid Services (CMS) Web site External Web Site Policy.
  • Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2017 condition-specific mortality measures updates and specifications report: supplemental ICD-10 code lists for use with claims for discharges on or after October 1, 2015. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017. Available from the QualityNet Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on June 23, 2009. The information was verified by the measure developer on December 29, 2009.

This NQMC summary was updated by ECRI Institute on November 8, 2010. The information was verified by the measure developer on December 17, 2010.

This NQMC summary was retrofitted into the new template on May 18, 2011.

This NQMC summary was updated by ECRI Institute on August 23, 2012. The information was verified by the measure developer on October 19, 2012.

This NQMC summary was updated by ECRI Institute on December 4, 2013. The information was verified by the measure developer on January 10, 2014.

This NQMC summary was updated by ECRI Institute on July 20, 2015. The information was verified by the measure developer on September 23, 2015.

This NQMC summary was updated again by ECRI Institute on October 17, 2017. The information was verified by the measure developer on November 9, 2017.

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