– PERFORMANCE MEASURES –
Ambulatory Care Quality Alliance (AQA)

In September 2004, the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), America’s Health Insurance Plans (AHIP), and the Agency for Healthcare Research and Quality (AHRQ), joined together to lead an effort to improve performance measurement, data aggregation and reporting in the ambulatory care setting. The mission of this collaborative effort – named the AQA – is:

"improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician or group level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes."

In April 2006, the AQA Performance Measurement Workgroup announced the release of AQA-endorsed performance measures intended for use by physicians' offices, group practices, and other ambulatory care settings that included:

• ◊  Starter set of 26 AQA Clinical Measures for physician performance
• ◊  Starter set of 8 performance measures for cardiovascular care – Cardiology
• ◊  Starter set of 15 performance measures for Cardiac Surgery

Implementation of these measures included an announcement of a pilot project involving 6 national sites on March 1, 2006 [Word .Doc]. The AQA announced implementation of the Cardiology and Cardiac Surgery starter sets on June 16, 2006 [Word .Doc].

AQA Starter Set
Clinical Measures for Physician Performance
in Ambulatory Care
[Word .Doc]

Performance Measure Clinical Topic			Source of Measure		PVRP Measure		Description
Prevention Measures
1.	Breast Cancer Screening	NCQA	–	Percentage of women who had a mammogram during the measurement year or year prior to the measurement year.
2.	Colorectal Cancer Screening	NCQA	–	The percentage of adults who had an appropriate screening for colorectal cancer. One or more of the following: - FOBT (fecal cccult blood test) during measurement year; - Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year; - DCBE (double contrast barium enema) during the measurement year or the four years prior; - Colonoscopy during the measurement or nine years prior.
3.	Cervical Cancer Screening	NCQA	X	Percentage of women who had one or more Pap tests during the measurement year or the two prior years.
4.	Tobacco Use	CMS/ AMA	X	Percentage of patients who were queried about tobacco use one or more times during the two-year measurement period.
5.	Advising Smokers to Quit	NCQA	X	Percentage of patients who received advice to quit smoking.
6.	Influenza Vaccination	NCQA	X	Percentage of patients [50-64] who received an influenza vaccination.
7.	Pneumonia Vaccination	NCQA	X	Percentage of patients who ever received a pneumococcal vaccine.
Coronary Artery Disease (CAD)
8.	Drug Therapy for Lowering LDL Cholesterol	CMS/ AMA	X	Percentage of patients with CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines).
9.	Beta-Blocker Treatment after Heart Attack	NCQA	X	Percentage of patients hospitalized with acute myocardial infarction (AMI) who received an ambulatory prescription for beta-blocker therapy (within 7 days discharge).
10.	Beta-Blocker Therapy – Post MI	NCQA	X	Percentage patients hospitalized with AMI who received persistent beta-blocker treatment (6 months after discharge).
Heart Failure
11.	ACE Inhibitor /ARB Therapy	CMS/ AMA	X	Percentage of patients with heart failure who also have LVSD who were prescribed ACE inhibitor or ARB therapy.
12.	LVF Assessment	CMS/ AMA	X	Percentage of patients with heart failure with quantitative or qualitative results of LVF assessment recorded.
Diabetes
13.	HbA1C Management	NCQA	X	Percentage of patients with diabetes with one or more A1C test(s) conducted during the measurement year.
14.	HbA1C Management Control	NCQA	X	Percentage of patients with diabetes with most recent A1C level greater than 9.0% (poor control).
15.	Blood Pressure Management	CMS/ AMA	X	Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mm Hg.
16.	Lipid Measurement	NCQA	X	Percentage of patients with diabetes with at least one Low Density Lipoprotein cholesterol (LDL-C) test (or ALL component tests).
17.	LDL Cholesterol Level (<130mg/dL)	NCQA	X	Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dL or less than 130 mg/dL.
18.	Eye Exam	NCQA	X	Percentage of patients who received a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) during the reporting year or during the prior year if patient is at low risk for retinopathy. A patient is considered low risk if all three of the following criteria are met: (1) the patient is not taking insulin; (2) has an A1C less than 8.0%; and (3) has no evidence of retinopathy in the prior year.
Asthma
19.	Use of Appropriate Medications for People w/ Asthma	NCQA	X	Percentage of individuals who were identified as having persistent asthma during the year prior to the measurement year and who were appropriately prescribed asthma medications (e.g. inhaled corticosteroids) during the measurement year
20.	Asthma: Pharmacologic Therapy	CMS/ AMA	X	Percentage of all individuals with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.
Depression
21.	Antidepressant Medication Management, Acute Phase	NCQA	X	Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug during the entire 84-day (12-week) Acute Treatment Phase.
22.	Antidepressant Medication Management, Continuation Phase	NCQA	X	Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug for at least 180 days (6 months).
Prenatal Care
23.	Screening for Human Immunodeficiency Virus (HIV)	CMS/ AMA	X	Percentage of patients who were screened for HIV infection during the first or second prenatal visit.
24.	Anti-D Immune Globulin	CMS/ AMA	X	Percentage of D (Rh) negative, unsensitized patients who received anti-D immune globulin at 26-30 weeks gestation.
Quality Measures Addressing Overuse or Misuse
25.	Appropriate Treatment for Children with Upper Respiratory Infection (URI)	NCQA	X	Percentage of patients who were given a diagnosis of URI and were not dispensed an antibiotic prescription on or 3 days after the episode date.
26.	Appropriate Testing for Children with Pharyngitis	NCQA	X	Percentage of patients who were diagnosed with pharyngitis, prescribed an antibiotic and who received a group A streptococcus test for the episode.

AQA Starter Set
Cardiovascular Care Performance Measures
in Ambulatory Care [Word .Doc]

Performance Measure Clinical Topic			Source of Measure		PVRP Measure		Description
Coronary Artery Disease
CAD – Level 1 (Core) Measures
1.	CAD: Antiplatelet Therapy	CMS / AMA / ACC/AHA	–	Percentage of CAD patients who were prescribed antiplatelet therapy. • Numerator – Patients who were prescribed antiplatelet therapy • Denominator – All patients with CAD > 18 years of age   a. Antiplatelet therapy may include aspirin, clopidogrel, or combination of aspirin and dipyridamole. b. Denominator Exclusion – Medical reasons for not prescribing antiplatelet therapy: active bleeding in the previous six months which required hospitalization and/ or transfusion(s), patient on other antiplatelet therapy, etc. c. Denominator Exclusion – Patient reasons for not prescribing antiplatelet therapy: economic, social, and/or religious, etc.
2.	CAD: Beta-Blocker Therapy - Prior Myocardial Infarction (MI)	CMS / AMA / ACC/AHA	–	Percentage of CAD patients with prior MI who were prescribed beta-blocker therapy. • Numerator – Patients who were prescribed beta-blocker therapy • Denominator – All patients with CAD > 18 years of age with prior MI.   a. Denominator Exclusion – Medical reasons for not prescribing beta-blocker therapy: Document. b. Denominator Exclusion – Patient reasons for not prescribing beta-blocker therapy: Document.
CAD – Level 2 Measures
3.	CAD: Lipid Profile	CMS / AMA / ACC/AHA	–	Percentage of CAD patients who received at least one lipid profile (or ALL component tests) • Numerator – Patients who received at least one lipid profile (or ALL component tests) • Denominator – All patients with CAD > 18 years of age.   a. Component tests include total cholesterol, HDL-C, LDL-C, and triglycerides.
4.	CAD: ACE Inhibitor or Angiotensin Receptor (ARB) Therapy	CMS / AMA / ACC/AHA	–	Percentage of CAD patients with diabetes and/or LVSD who were prescribed ACE-I or ARB therapy. • Numerator – Patients who were prescribed ACE-I or ARB therapy • Denominator – All patients with CAD > 18 years of age age who also have diabetes and/or LVSD. Denominator Includes patients with CAD who also have diabetes and/or LVSD (LVEF <40% or with moderately or severely depressed LVSF)   a. Denominator Exclusion – Medical reasons for not prescribing ACE-I/ARB: allergy, angioedema due to ACE-I/ARB, anuric renal failure due to ACE-I/ARB, pregnancy, moderate or severe aortic stenosis, etc. b. Denominator Exclusion – Patient reasons for not prescribing ACE-I/ARB: economic, social, and/ or religious, etc.
Heart Failure
Heart Failure – Level 1 (Core) Measures
5.	HF: Left Ventricular Function (LVF) Assessment	CMS / AMA / ACC/AHA	–	Percentage of HF patients with quantitative or qualitative results of LVF assessment recorded. • Numerator – Patients with quantitative or qualitative results of LVF assessment recorded • Denominator – All patients with CAD > 18 years of age.   This measure requires only documentation of a previous LVF assessment anytime previous in the record and that reassessment should be based on a change in clinical status.
6.	HF: Beta-Blocker Therapy	CMS / AMA / ACC/AHA	–	Percentage of HF patients with left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy • Numerator – Patients who were prescribed beta-blocker therapy • Denominator – All patients with HF > 18 years of age with LVEF <40% or with moderately or severely depressed LVSF.   a. Denominator Exclusion – Medical reasons for not prescribing beta-blocker therapy: Document. b. Denominator Exclusion – Patient reasons for not prescribing beta-blocker therapy: economic, social, and/ or religious, etc.
7.	HF: ACE Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	CMS / AMA / ACC/AHA	–	Percentage of HF patients with LVSD who were prescribed ACE-I or ARB therapy. • Numerator – Patients who were prescribed ACE-I or ARB therapy • Denominator – All patients with HF > 18 years of age with LVEF <40% or with moderately or severely depressed LVSF.   a. Denominator Exclusion – Medical reasons for not prescribing ACE-I or ARB therapy: Document. b. Denominator Exclusion – Patient reasons for not prescribing ACE-I or ARB therapy: economic, social, and/ or religious, etc.
Heart Failure – Level 2 Measures
8.	HF: Warfarin Therapy for Patients with Atrial Fibrillation (AF)	CMS / AMA / ACC/AHA	–	Percentage of HF patients with paroxysmal or chronic AF who were prescribed warfarin therapy. • Numerator – Patients who were prescribed warfarin therapy • Denominator – All patients with Heart Failure > 18 years of age with paroxysmal or chronic AF.   a. Denominator Exclusion – Medical reasons for not prescribing warfarin therapy: Document. b. Denominator Exclusion – Patient reasons for not prescribing warfarin therapy: economic, social, and/ or religious, etc.

AQA Starter Set
Cardiac Surgery Performance Measures
in Ambulatory Care [Word .Doc]
Adapted from NQF National Voluntary Consensus Standards for Cardiac Surgery [PDF]

Performance Measure Clinical Topic			Measure		Description
1.	Participation in a Systematic Database for Cardiac Surgery	STS	Numerator – Does the facility participate in a multicenter, data collection and feedback program that provides benchmarking relative to peers and uses process and outcome measures? (Yes/No) Denominator – Not Applicable
2.	Timing of Antibiotic Administration for Cardiac Surgery Patients	CMS	Numerator – Cardiac surgery patients who received prophylactic antibiotics within one hour of surgical incision (two hours if vancomycin) Denominator – Surgical patients with CABG ICD-9-CM procedure codes: a. CABG (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19, 36.20) b. Other cardiac surgery, (ICD-9 codes: 35.0x, 35.1x, 35.2x, 35.3x, 35.4x, 35.5x, 35.6x, 35.7x, 35.8x, 35.91-35.95, 35.98, 35.99) Exclusions: 1. Principal or admission diagnosis suggestive of pre-operative infectious disease • Infectious diseases 001.0-139.8 • Meningitis 320.0-326 • Ear infection 380.0-380.23; 382.0-382.20 • Endocarditis 421.0-422.99 • Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 • Digestive 540-542; 575.0 • Renal 590-590.9; 595.0 • Prostate 601.0-601.9 • Gynecologic 614-614.9; 616-616.4 • Skin 680-686.9 • Musculo-skeletal 711.9-711.99; 730.0-730.99 • Fever of unknown origin 780.6 • Septic shock 785.59 • Bacteremia 790.7 • Viremia 790.8 2. Receiving antibiotics at the time of admission 3. Medical records do not include antibiotic start date/time or incision date/time 4. Receiving antibiotics more than 24 hours prior to surgery
3.	Selection of Antibiotic Administration for Cardiac Surgery Patients	CMS	Numerator – Cardiac surgery patients who received prophylactic antibiotics recommended for the specific operation: cefazolin, cefuroxime, cefamandole, or vancomycin* * Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactam, then vancomycin or clindamycin is an acceptable substitute Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99 Exclusions: 1. Principal or admission diagnosis suggestive of pre-operative infectious disease • Infectious diseases 001.0-139.8 • Meningitis 320.0-326 • Ear infection 380.0-380.23; 382.0-382.20 • Endocarditis 421.0-422.99 • Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 • Digestive 540-542; 575.0 • Renal 590-590.9; 595.0 • Prostate 601.0-601.9 • Gynecologic 614-614.9; 616-616.4 • Skin 680-686.9 • Musculo-skeletal 711.9-711.99; 730.0-730.99 • Fever of unknown origin 780.6 • Septic shock 785.59 • Bacteremia 790.7 • Viremia 790.8 2. Receiving antibiotics at the time of admission 3. Medical records do not include antibiotic start date/time or incision date/time 4. Receiving antibiotics more than 24 hours prior to surgery 5. No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics) 6. No antibiotics received during the hospitalization
4.	Pre-operative Beta Blockade	STS	Numerator – Number of patients coming to isolated CABG with documented pre-operative (24 hours) beta blockade Denominator – All patients undergoing CABG surgery Exclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
5.	Use of Internal Mammary Artery (IMA)	CMS/ QIO	Numerator – Patients who received an IMA graft (ICD-9 procedure codes 36.15 and 36.16) Denominator – Surgical patients undergoing isolated CABG (ICD-9-CM procedure codes: 36.10 - 36.19) who were discharged, transferred, or expired Exclusions: • Other heart procedures (IDC-9 procedure codes 37.32, 37.34, 37.35, 36.2, 35.0-35.99) • Repeat CABG (ICD-9 status code V45.81)
6.	Duration of Prophylaxis for Cardiac Surgery Patients	CMS	Numerator –Cardiac surgery patients whose prophylactic antibiotics were discontinued within 24 to 48 hours after surgery end time Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99 Exclusions: 1. Principal or admission diagnosis suggestive of pre-operative infectious disease • Infectious diseases 001.0-139.8 • Meningitis 320.0-326 • Ear infection 380.0-380.23; 382.0-382.20 • Endocarditis 421.0-422.99 • Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 • Digestive 540-542; 575.0 • Renal 590-590.9; 595.0 • Prostate 601.0-601.9 • Gynecologic 614-614.9; 616-616.4 • Skin 680-686.9 • Musculo-skeletal 711.9-711.99; 730.0-730.99 • Fever of unknown origin 780.6 • Septic shock 785.59 • Bacteremia 790.7 • Viremia 790.8 2. Receiving antibiotics at the time of admission 3. Medical records do not include antibiotic start date/time or incision date/time 4. Receiving antibiotics >24 hours prior to surgery 5. No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics) 6. Diagnosed with and treated for infections within two days after surgery date 7. No antibiotics received during the hospitalization
7.	Prolonged Intubation (ventilation)	STS	Numerator – Number of patients who undergo isolated CABG who require intubation >24 hours Denominator – All patients undergoing isolated CABG   Inclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report • Number of patients undergoing isolated CABG without pre-existing intubation / tracheostomy   Exclusions: • Patients intubated prior to isolated CABG; patients with tracheostomy prior to isolated CABG   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
8.	Deep Sternal Wound Infection Rate	STS	Numerator – Number of patients who developed deep sternal wound infections within 30 days post-operative Definition of deep sternal wound infection: Patient with a deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention. Must have all of the following conditions: • Wound opened with excision of tissue (I&D) or re-exploration of mediastinum • Positive culture • Treatment with antibiotics   Denominator – All patients undergoing isolated CABG   Inclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report • All patients undergoing isolated CABG surgery who developed a deep sternal wound infection within 30 days post-operative   Exclusions: • Patients undergoing isolated CABG surgery with superficial wound site infections and no involvement of deeper tissue post-operative   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
9.	Stroke/Cerebrovascular Accident	STS	Numerator – Number of patients who undergo isolated CABG with post-operative neurologic deficit persisting >72 hours Denominator – All patients undergoing isolated CABG   Inclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Exclusions: • Patients with pre-existing neurologic deficits   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
10.	Post-operative Renal Insufficiency	STS	Numerator – Number of patients undergoing isolated CABG who develop post-operative renal failure/dialysis requirement Definition of renal failure/dialysis requirement: Patients with acute or worsening renal failure resulting in one or more of the following: • Increase in serum creatinine to >2.0 and two times most recent pre-operative creatinine level • New requirement for dialysis post-operatively   Denominator – All patients undergoing isolated CABG   Inclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report • Number of patients undergoing isolated CABG without pre-existing renal failure   Exclusions: • Patients with documented history of renal failure, baseline serum creatinine >2.0; prior renal transplants are not considered pre-operative renal failure unless since transplantation their Cr has been or is >2.0   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
11.	Surgical Re-exploration	STS	Numerator – Number of patients undergoing isolated CABG who require return to the operating room for bleeding/tamponade, graft occlusion, or other cardiac reason   Denominator – All patients undergoing isolated CABG   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
12.	Anti-platelet Medication at Discharge	STS	Numerator – Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel after isolated CABG   Denominator – All patients undergoing isolated CABG   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
13.	Beta Blockade at Discharge	STS	Numerator – Number of isolated CABG patients discharged on beta blockers   Denominator – All patients undergoing isolated CABG   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
14.	Anti-lipid Treatment at Discharge	STS	Numerator – Number of isolated CABG patients discharged on a statin or other pharmacologic lipid-lowering regimen   Denominator – All patients undergoing isolated CABG   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report
15.	Risk-Adjusted 30-day Operative Mortality for CABG	STS	Numerator: Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation   Denominator – All patients undergoing isolated CABG   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS.
The following 6 NQF cardiac surgery measures are not AQA measures 16. Risk-Adjusted Inpatient Operative Mortality for CABG CCORP Numerator – Number of patients from participating hospitals who had an isolated CABG surgery and died in hospital Denominator – Number of patients from participating hospitals who had isolated CABG surgery   Exclusions: Deaths are not counted after discharge even if the patient dies soon after the operation. If a patient is transferred post-operatively to a rehabilitation or transitional care facility and dies before going home, this death is not counted. Procedures performed during the same surgery: • valve procedures • operations on structures adjacent to heart valves • ventriculectomy • repair of atrial and ventricular septa • excision of aneurysm of heart • head and neck, intracranial endarterectomy • other open heart surgeries, such as aortic arch repair, pulmonary endarterectomy • endarterectomy of aorta • thoracic endarterectomy • heart transplantation • repair of certain congenital cardiac anomalies • implantation of cardiomyostimulation system • any aortic aneurysm repair • aorta-subclavian-carotid bypass • aorta-renal bypass • aorta-iliac-femoral bypass • caval-pulmonary artery anastomosis extracranial-intracranial (EC-IC) vascular bypass • coronary artery fistula • resection of a portion of the lung does not include simple biopsy of lung nodule in which surrounding lung is not resected or biopsy of a thoracic lymph node • incisional (ventral) hernia repair • lumpectomy or mastectomy for breast cancer • maze procedures, surgical or catheter • total or partial excision of thymus Inclusions: The CABG cases with the following procedures performed concurrently will be considered isolated CABG: • transmyocardial laser revascularization (TMR) • pericardiectomy and excision of lesions of heart • repair/restoration of the heart or pericardium • coronary endarterectomy • pacemakers • internal cardiac defibrillators • fem-fem cardiopulmonary bypass   Risk adjustment: • Multivariate logistic regression. Adjusted for differences in the case mix across hospitals and accounted for the pre-operative condition of each patient, using California CABG Outcome Reporting Program risk model, which is available from CCORP at http://www.oshpd.cahwnet.gov/HQAD/ Outcomes/CCORP/index.htm. 17. Risk-Adjusted 30-day Operative Mortality for Aortic Valve Replacement (AVR) STS Numerator: Number of patients undergoing isolated AVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation   Denominator – All patients undergoing isolated AVR surgery   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Exclusions: • Patients receiving CABG or other valve or cardiac surgery during this admission   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS. 18. Risk-Adjusted 30-day Operative Mortality for Mitral Valve Replacement (MVR) STS Numerator: Number of patients undergoing isolated MVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation   Denominator – All patients undergoing isolated MVR surgery   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Exclusions: • Patients receiving CABG or other valve or cardiac surgery during this admission   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS. 19. Risk-Adjusted 30-day Operative Mortality for AVR + CABG STS Numerator: Number of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation   Denominator – All patients undergoing combined AVR + CABG surgery   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Exclusions: • Patients receiving CABG or other valve or cardiac surgery during this admission   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS. 20. Risk-Adjusted 30-day Operative Mortality for MVR + CABG STS Numerator: Number of patients undergoing combined MVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation   Denominator – All patients undergoing combined MVR + CABG surgery   Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report   Exclusions: • Patients receiving CABG or other valve or cardiac surgery during this admission   Risk adjustment: • Multivariate logistic regression and hierarchical modeling available for STS. 21. Surgical Volume CMS Surgical Volume to include: a. Isolated Coronary Artery Bypass Graft (CABG) Surgery b. Valve Surgery c. CABG + Valve Surgery Numerator a. Number of patients undergoing isolated CABG surgery, (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19) b. Number of patients undergoing Valvuloplasty surgery, (ICD-9 codes: 35.10, 35.11, 35.12, 35.13, 35.14) or Number of patients undergoing valve replacement surgery, (ICD-9 codes: 36.20, 36.21, 36.22, 36.23, 36.24, 36.25, 36.26, 36.27, 36.28) c. Number of patients undergoing valve+CABG surgery, ICD-9 codes: 36.10-36.16, 36.19 and 35.10-35.14, 35.20-35.28) Denominator – Not Applicable