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Quality Data on Core Measures
Here is how to interpret the data on each chart:Percentages listed in each column tell you how often a care process was put into practice during the indicated time period. For example, the Baylor University Medical Center (BUMC) table may list the AMI Core Measure, "Aspirin within 24 Hours of Arrival," along with the following percentages: 92% for Texas, 93% for National and 100% for BUMC. This means that aspirin was administered within 24 hours of arrival for AMI patients 92% of the time in Texas hospitals, 93% of the time in hospitals nationwide, and 100% of the time at BUMC.
Acute Myocardial Infarction (AMI) Core Measures
Cardiovascular disease, including AMI (commonly called heart attack), is the leading cause of death in the United States. Each year, 900,000 Americans are diagnosed with AMI and 225,000 cases lead to death. For patients who are admitted with symptoms of heart attack, the following Core Measures are recommended care processes:
Acute Myocardial Infarction
State of Texas
National (Centers for Medicare and Medicaid
Baylor University Medical Center at Dallas
Aspirin within 24 Hours of Arrival
92%
93%
100%
Aspirin at Discharge
Heart attacks occur when blood clots cut off the blood supply to vital organs. Aspirin makes blood less likely to clot by working against blood cells that cause clots. Aspirin can reduce the risk of stroke, another heart attack or other cardiovascular events by 20% to 30%. It should be given on arrival at the emergency department and with discharge prescriptions.
88%
90%
97%
Beta Blockers within 24 Hours of Arrival
Beta blocker therapy reduces damage from a heart attack and decreases the chances of another heart attack. Also, there is some evidence that long-term beta blocker therapy decreases the incidences of cardiac death.
86%
88%
96%
Beta Blockers at Discharge
89%
91%
97%
ACE Inhibitors For Left Ventricular Systolic Dysfunction
LVSD or weakness of the heart's pumping action is the most common cause of heart failure. An angiotensin-converting enzyme (ACE) inhibitor is a type of heart medication that prevents the body from creating angiotensin, a substance that raises blood pressure and increases the workload on the heart. ACE inhibitors improve long-term survival when they are begun after a patient has recovered from a heart attack. Patients with LVSD or weak heart muscles benefit the most from this treatment.
88%
85%
91%
Adult Smoking Cessation Counseling/Advice
Patients who receive even brief advice about quitting smoking from their health care providers are more likely to quit than those who receive no advice or counseling. Quitting smoking reduces a patient’s risk of having another heart attack.
92%
91%
100%
Primary PCI Received Within 90 Minutes of Hospital Arrival
Percutaneous coronary intervention (PCI) is a procedure that opens the blocked blood vessels in the heart and improves blood circulation to the heart muscle after a heart attack. This procedure should be done as soon as possible after arrival to the hospital. PCI performed less than 90 minutes after hospital arrival reduces the risk of complications and death from a heart attack.
56%
59%
86%
Community Acquired Pneumonia (CAP) Core Measures
Community-acquired pneumonia (CAP) is the sixth most common cause of death in the United States. Every year, there are an estimated two to three million cases of CAP resulting in 500,000 hospitalizations and 45,000 deaths. The following are the Core Measures recommended to treat this condition.
Community Acquired Pneumonia (CAP)
State of Texas
National (Centers for Medicare and Medicaid Services)
Baylor University Medical Center at Dallas
Oxygenation Assessment
Oxygenation assessment is a quick, easy, non-invasive procedure that allows care givers to determine the level of oxygen in a patient's blood.
99%
100%
100%
Antibiotic Within 4 Hours of Arrival
Pneumonia is a lung infection caused by a bacteria or virus. Pneumonia severe enough to result in hospitalization is often caused by bacteria, which can be killed with antibiotics. The timing of antibiotic administration is an important factor in reducing the likelihood of death from pneumonia. Studies performed by the CMS have indicated that administration of antibiotics to Medicare patients with pneumonia within 4 hours of hospital arrival is associated with improved survival rates.
93%
93%
93%
Pneumococcal Vaccination if Needed
Streptococcus pneumoniae is among the leading infectious causes of illness and death worldwide for young children. It also can cause illness and death among the elderly and other high risk populations, including people with serious chronic health problems such as heart disease and diabetes, and those with a weakened immune system. The pneumonia vaccine is not only highly effective in preventing pneumonia in persons age 65 years and older, but it also reduces the risk of death in vaccinated patients who develop pneumonia.
77%
75%
89%
Blood Cultures for Pneumonia Patients Admitted Through the Emergency Department
Different bacteria are treated with different antibiotics, so blood samples are taken to test for the type of infection before antibiotics are given. This measure reports the percent of pneumonia patients who received this test before antibiotics were given.
90%
90%
90%
Adult Smoking Cessation Advice/ Counseling
Smoking damages the lungs’ defenses against respiratory infections. Patients who quit smoking are less likely to get pneumonia again. Patients who receive even brief advice about quitting smoking from their health care providers are more likely to quit than those who receive no advice or counseling.
85%
84%
96%
Initial Antibiotic Selection for CAP in Immuno-competent Patients
Patients with CAP are more likely to survive when they are given the correct antibiotic. The number indicates the percent of patients with pneumonia who were given the recommended antibiotic.
84%
86%
94%
Heart Failure (HF) Core Measures
Heart failure is a condition in which the heart muscle weakens and can't pump blood efficiently. About five million patients in the United States have HF, and more than 550,000 patients are newly diagnosed with HF each year. It is primarily a condition of the elderly; more Medicare dollars are spent for the diagnosis and treatment of HF than for any other diagnosis. The following Core Measures are recommended to treat this condition.
Heart Failure (HF)
State of Texas
National (Centers for Medicare and Medicaid Services)
Baylor University Medical Center at Dallas
Assessment of Left Ventricular Function
Measuring left ventricular function or the pumping action of the heart is an important step in evaluating and managing patients with HF. This assessment can shed light on how serious the condition is and help care providers determine the necessary treatment. There are several different ways to measure this function.
84%
85%
99%
ACE Inhibitors for Left Ventricular Systolic Dysfunction
LVSD or weakness of the heart's pumping action is the most common cause of heart failure. An angiotensin-converting enzyme (ACE) inhibitor is a type of heart medication that prevents the body from creating angiotensin, a substance that raises blood pressure and contributes to increased workload on the heart. ACE inhibitors improve long-term survival when they are begun after a patient has recovered from a heart attack. Patients with LVSD or weak heart muscles benefit the most from this treatment.
85%
84%
89%
Discharge Instructions
When heart failure patients follow care instructions, they have a lower risk of experiencing complications or being re-hospitalized. Discharge instructions may include recommended dietary restrictions, activity restrictions, directions about how and when to take prescribed medications and when to follow-up with the doctor, and a list of signs of worsening heart failure that should signal a call to the doctor.
66%
66%
86%
Adult Smoking Cessation Counseling/Advice
In patients with heart failure, smoking increases the risk of symptom relapse and the risk of death. Patients who receive even brief advice about quitting smoking are more likely to quit than those who receive no advice or counseling.
85%
86%
99%
Surgical Care Improvement Project (SCIP) Core Measures
Surgical site infections account for 15% of all hospital-acquired infections. Patients who develop surgical site infections are twice as likely to die as other surgical patients. The following Core Measures are recommended to treat this condition.
Surgical Infection Prevention
State of Texas
National (Centers for Medicare and Medicaid Services)
Baylor University Medical Center at Dallas
Antibiotic Within 1 Hour of Incision
Studies have shown that patients given antibiotics within one hour before surgery, rather than during or after the operation, have a reduced risk of wound infection.
74%
82%
94%
Recommended Preventive Antibiotics Given
When giving antibiotics to a surgical patient, a doctor selects a medication that is safe and cost-effective, as well as one that will kill the potential bacteria for the specific surgery being performed. National guidelines list which antibiotics should be given for which surgeries.
85%
90%
92%
Antibiotic Discontinued Within 24 Hours
For certain surgeries, it has been found there is no increased benefit to keeping patients on antibiotics for more than 24 hours after surgery. In fact, continuing antibiotics for more than 24 hours may increase a patient's risk of developing antibiotic-resistant bacteria.
74%
78%
96%
References