Information for Professionals

Information for Professionals on Data Collection

The data presented on this website comes from hospitals that volunteered to submit their data for public reporting. The clinical measures reported here focus on heart attack, heart failure, pneumonia, asthma (children only) and surgical care improvement project. Each rate calculation is based on the hospital's relevant discharges. Detailed information concerning measure specifications and calculation of the rates is available at www.QualityNet.org

This site displays data provided by acute care "general" hospitals, children's hospitals, and "critical access" hospitals, which are small, generally geographically remote rural hospitals.

Beginning with discharges in 2004, eligible acute care hospitals could elect to report quality data in order to receive the incentive payment established by Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). To obtain increased payment, the provision required eligible hospitals to report on an initial set of 10 quality performance measures (the "starter set") and to agree to have their data publicly displayed.

Initially, almost all hospitals eligible for the payment incentive provided data for the 10 "starter set" measures, reflecting care delivered during 2004. Under Section 5001(a) of the Deficit Reduction Act of 2005, the set of measures included in the incentive was expanded, the magnitude of the incentive was increased, and the time-limit for the provision removed. More information about these provisions is available at Reporting Hospital Quality Data for Annual Payment Update.

The majority of these acute care hospitals are voluntarily providing data on additional measures that have been identified by the Hospital Quality Alliance (HQA). The HQA measure set currently consists of 28 measures:

• the ten "starter set" measures first published in October 2003
• seven new measures first published in April 2005
• three new measures first published in September 2005
• one measure first published in December 2006
• one measure first published in June 2007
• two measures first published in December 2007
• two measures first published in August 2008
• two measures first published in December 2008
• one measure first published in September 2009

For a full listing of the measures see measures list.

Critical access hospitals, which also provide acute care, also participate in the HQA. The critical access hospitals do not receive any financial incentive to report since they are not eligible for the incentive payment established by Section 501(b) of the MMA or 5001(a) of the DRA. These hospitals may elect to submit data for any or all of the measures in the measure set, and may elect to report data but not have it displayed on the website. While critical access hospitals play an important role in care in rural areas, measure design may affect the number of eligible cases reported by these hospitals.

The data collection approach was primarily retrospective. Data sources for required data elements included administrative data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal and other ICD-9-CM diagnosis and procedure codes, which require retrospective data entry.

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