Skip to main content
  • Measure Summary
  • NQMC:010159
  • Oct 2015
  • NQF-Endorsed Measure

Chronic obstructive pulmonary disease (COPD): hospital 30-day, all-cause, risk-standardized readmission rate following acute exacerbation of COPD hospitalization.

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.

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 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure estimates a hospital-level 30-day risk-standardized readmission rate (RSRR) for patients discharged from the hospital with either a principal diagnosis of chronic obstructive pulmonary disease (COPD) or a principal diagnosis of respiratory failure with a secondary diagnosis of an acute exacerbation of COPD (AECOPD). The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions.

The Centers for Medicare & Medicaid Services (CMS) annually reports the measure for individuals who are 65 years and over and are Medicare Fee-for-Service (FFS) beneficiaries hospitalized in non-federal hospitals.

Rationale

The Centers for Medicare & Medicaid Services (CMS) developed the chronic obstructive pulmonary disease (COPD) 30-day readmission measure to complement the existing COPD process of care and mortality measures. Risk-standardized readmission rates (RSRRs) can provide important additional information about quality of care that is currently not captured by the process and mortality measures and is currently unavailable to hospitals. Variation in readmission, after adjusting for case-mix, may reflect differences in hospitals' general environments (such as coordination of care, patient safety policies, and staffing) or variation in care processes not measured in the current core measure set. Outcome measures can focus attention on a broader set of healthcare activities that affect patients' well-being. Moreover, improving outcomes is the ultimate goal of quality improvement, and thus the inclusion of outcomes measures assists in attaining improvement goals.

Readmission of patients who were recently discharged after hospitalization with COPD represents an important, expensive, and often preventable adverse outcome. The risk of readmission can be modified by the quality and type of care provided to these patients. Improving readmission rates is the joint responsibility of hospitals and clinicians. Measuring readmission will create incentives to invest in interventions to improve hospital care, better assess the readiness of patients for discharge, and facilitate transitions to outpatient status.

Evidence for Rationale

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 Health Components

Chronic obstructive pulmonary disease (COPD); acute exacerbation of COPD (AECOPD); 30-day readmission rate

Denominator Description

The measure cohort consists of admissions for Medicare Fee-for-Service (FFS) beneficiaries aged 65 years and older discharged from non-federal acute care hospitals with a principal discharge diagnosis of chronic obstructive pulmonary disease (COPD), as well as those with a principal diagnosis of respiratory failure who had a secondary diagnosis of an acute exacerbation of COPD (AECOPD).

The risk-standardized readmission rate (RSRR) is calculated as the ratio of the number of "predicted" readmissions to the number of "expected" readmissions, multiplied by the national unadjusted readmission rate. The "denominator" is the number of readmissions expected on the basis of 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 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures External Web Site Policy for more details.

Numerator Description

The measure assesses unplanned readmissions to any acute care hospital within a 30-day period from the date of discharge from the index acute exacerbation of chronic obstructive pulmonary disease (COPD) admission.

The hospital-specific risk-standardized readmission rate (RSRR) is calculated as the ratio of the number of "predicted" readmissions to the number of "expected" readmissions, multiplied by the national unadjusted readmission rate. The "numerator" of the ratio is the number of readmissions within 30 days predicted on the basis of the hospital's performance with its observed case-mix.

See the related "Numerator 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 outcome.

See the 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures External Web Site Policy 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

  • In 2010, chronic obstructive pulmonary disease (COPD) was the 4th leading cause of death in the United States (U.S.) (Centers for Disease Control and Prevention, 2010) and projected care costs for direct and indirect health care expenditures were nearly $50 billion for 2010 (National Heart, Lung and Blood Institute [NHLBI], 2009).
  • COPD affects as many as 24 million individuals in the U.S. (NHLBI, 2009). Between 1998 and 2008, the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18% (Agency for Healthcare Research and Quality [AHRQ], 2011).
  • In 2008, COPD was one of the top 20 most expensive conditions treated in U.S. hospitals (AHRQ, 2011). It was also one of the top 20 most expensive conditions billed to Medicare, accounting for nearly $17 billion of total hospital charges billed to Medicare (AHRQ, 2011).
  • COPD is a leading cause of readmissions to the hospital (Jencks, Williams, & Coleman, 2009). The 30-day readmission rate among patients hospitalized for COPD is 22.6%, accounting for 4% of all 30-day readmissions (Jencks, Williams, & Coleman, 2009). In 2007 the Medicare Payment Advisory Committee (MedPAC) published a report to Congress in which it identified the seven conditions associated with the most costly potentially preventable readmissions. Among these seven, COPD ranked fourth (MedPAC, 2007).
  • The AHRQ has identified COPD as an ambulatory-care-sensitive condition (ACSC). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease (AHRQ, 2006). COPD is an ASCS that is associated with high readmission rates and high costs to Medicare (MedPAC, 2007). These facts underscore the need for developing strategies to reduce readmissions and subsequent costs associated with COPD admissions. COPD patients require ongoing care and treatment after discharge and are therefore at increased risk for readmission. A hospital-level, 30-day all-cause readmission measure will inform healthcare providers about opportunities to improve care, and strengthen incentives for quality improvement, particularly for care at the time of transitions (e.g., discharge to home or a skilled nursing facility). Improvements in inpatient care and care transitions for this common, costly condition are likely to reduce costly readmissions.
  • Readmission rates are influenced by the quality of inpatient and outpatient care, the availability and use of effective disease management programs, and the bed capacity of the local health care system. Some of the variation in readmissions may be attributable to delivery system characteristics (Fisher et al., 1994). Also, interventions during and after a hospitalization can be effective in reducing readmission rates in geriatric populations generally (Benbassat & Taragin, 2000; Naylor et al., 1999; Coleman et al., 2006). Tracking readmissions also emphasizes improvement in care transitions and care coordination. Although discharge planning is required by Medicare as a condition of participation for hospitals, transitional care focuses more broadly on "hand-offs" of care from one setting to another, and may have implications for quality and costs (Coleman, 2005).

Evidence for Additional Information Supporting Need for the Measure

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators. Fact sheet. Prevention quality indicators, 2006. [internet]. 2006 [accessed 2010 Dec 21].

Agency for Healthcare Research and Quality (AHRQ). Healthcare Cost and Utilization Project (HCUP). The national hospital bill: the most expensive conditions by payer, 2008. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2011 Mar. 12 p.

Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000 Apr 24;160(8):1074-81. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). National Center for Health Statistics chronic lower respiratory disease. FastStats 2010. [internet]. [accessed 2010 Sep 18].

Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822-8. PubMed External Web Site Policy

Coleman EA. Background paper on transitional care performance measurement. Appendix I. In: Institute of Medicine, performance measurement: accelerating improvement. Washington (DC): National Academy Press; 2005.

Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl J Med. 1994 Oct 13;331(15):989-95. PubMed External Web Site Policy

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. PubMed External Web Site Policy

Medicare Payment Advisory Commission. Report to the Congress: promoting greater efficiency in Medicare. [internet]. Washington (DC): Medicare Payment Advisory Commission (MedPac); 2007 Jun 15 [accessed 2012 Jun 13].

National Heart, Lung and Blood Institute. Morbidity and mortality: 2009 chartbook of cardiovascular, lung and blood diseases. Bethesda (MD): National Institutes of Health; 2009.

Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999 Feb 17;281(7):613-20. PubMed External Web Site Policy

Extent of Measure Testing

Each year, Centers for Medicare & Medicaid Services (CMS) evaluates the performance of the model. Over the most recent three year period, model performance was stable; the area under the ROC curve (c-statistic) remained constant at 0.64.

Refer to the 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures for additional information (see also the "Companion Documents" field).

Evidence for Extent of Measure Testing

Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2015 condition-specific measures updates and specifications report: hospital-level 30-day risk-standardized readmission measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Mar. 102 p.

State of Use

Current routine use

Current Use

Collaborative inter-organizational quality improvement

External oversight/Medicare

Monitoring and planning

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

Does not apply to this measure

Target Population Age

Age greater than or equal to 65 years

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Discharges July 1, 2011 through June 30, 2014

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
The target population for this measure includes admissions for Medicare Fee-for-Service (FFS) beneficiaries aged greater than or equal to 65 years discharged from non-federal acute care hospitals with a principal discharge diagnosis of chronic obstructive pulmonary disease (COPD), as well as those with a principal diagnosis of respiratory failure who had a secondary diagnosis of an acute exacerbation of COPD (AECOPD).*

Centers for Medicare & Medicaid Services (CMS) FFS beneficiaries hospitalized within a non-federal acute care hospital are included if they have been enrolled in Part A and Part B Medicare for the 12 months prior to the date of admission to ensure a full year of administrative data for risk-adjustment.

*International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes that define the patient cohort:

  • 491.21 Obstructive chronic bronchitis; With (acute) exacerbation; acute exacerbation of COPD, decompensated COPD, decompensated COPD with exacerbation
  • 491.22 Obstructive chronic bronchitis; with acute bronchitis
  • 491.8 Other chronic bronchitis. Chronic: tracheitis, tracheobronchitis
  • 491.9 Unspecified chronic bronchitis
  • 492.8 Other emphysema; emphysema (lung or pulmonary): Not Otherwise Specified (NOS), centriacinar, centrilobular, obstructive, panacinar, panlobular, unilateral, vesicular. MacLeod's syndrome; Swyer-James syndrome; unilateral hyperlucent lung
  • 493.20 Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, unspecified
  • 493.21 Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, with status asthmaticus
  • 493.22 Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, with (acute) exacerbation
  • 496 Chronic: nonspecific lung disease, obstructive lung disease, obstructive pulmonary disease (COPD) NOS. Note: This code is not to be used with any code from categories 491-493
  • 518.81** Other diseases of lung; acute respiratory failure; respiratory failure NOS
  • 518.82** Other diseases of lung; acute respiratory failure; other pulmonary insufficiency, acute respiratory distress
  • 518.84** Other diseases of lung; acute respiratory failure; acute and chronic respiratory failure
  • 799.1** Other ill-defined and unknown causes of morbidity and mortality; respiratory arrest, cardiorespiratory failure

**Patients with a principal diagnosis represented by these codes are included in the measure if the code is accompanied by a secondary diagnosis of AECOPD (491.21, 491.22, 493.21, or 493.22).

Exclusions

  • Admissions for patients with an in-hospital death are excluded because they are not eligible for readmission.
  • Admissions for patients without at least 30 days post-discharge enrollment in FFS Medicare are excluded because the 30-day readmission outcome cannot be assessed in this group.
  • Admissions for patients having a principal diagnosis of COPD during the index hospitalization and subsequently transferred to another acute care facility are excluded because we are focusing on discharges to non-acute care settings.
  • Admissions for patients who are discharged against medical advice (AMA) are excluded because providers did not have the opportunity to deliver full care and prepare the patient for discharge.

Exclusions/Exceptions

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
The measure assesses unplanned readmissions to any acute care hospital within a 30-day period from the date of discharge from the index acute exacerbation of chronic obstructive pulmonary disease (COPD) admission.

The hospital-specific risk-standardized readmission rate (RSRR) is calculated as the ratio of the number of "predicted" readmissions to the number of "expected" readmissions, multiplied by the national unadjusted readmission rate. The "numerator" of the ratio is the number of readmissions within 30 days predicted on the basis of 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 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures External Web Site Policy for more details.

Exclusions
Admissions identified as planned by the planned readmissions algorithm are not counted as readmissions. The "algorithm" is a set of criteria for classifying readmissions as planned using Medicare claims. The algorithm identifies admissions that are typically planned and may occur within 30 days of discharge from the hospital. The Centers for Medicare & Medicaid Services (CMS) based the planned readmission algorithm on three principles:

  1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance chemotherapy/immunotherapy, rehabilitation);
  2. Otherwise, a planned readmission is defined as a non-acute readmission for a scheduled procedure; and
  3. Admissions for acute illness or for complications of care are never planned

The planned readmission algorithm uses a flow chart and four tables of procedures and conditions to operationalize these principles and to classify readmissions as planned. The flow chart and tables are available in the 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures External Web Site Policy.

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Type of Health State

Proxy for Outcome

Instruments Used and/or Associated with the Measure

Planned Readmission Algorithm Version 3.0 Flowchart

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure 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

The approach to risk adjustment is tailored to and appropriate for a publicly reported outcome measure, as articulated in the American Heart Association (AHA) Scientific Statement, "Standards for Statistical Models Used for Public Reporting of Health Outcomes" (Krumholz et al., 2006).

The measure adjusts for key variables that are clinically relevant and have strong relationships with the outcome (e.g., age, sex, comorbid diseases, and indicators of frailty). For each patient, covariates are obtained from administrative data extending 12 months prior to, and including, the index admission. For all patients, information from Medicare inpatient claims, physician Part B claims and hospital outpatient claims are used for risk adjustment.

The model seeks to adjust for case differences 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 index hospitalization are included in the risk adjustment.

The final set of risk-adjustment variables included:

Demographics
  • Age
Cardiovascular/Respiratory
  • History of mechanical ventilation
  • Sleep apnea
  • Respirator dependence/respiratory failure
  • Cardio-respiratory failure and shock
  • Congestive heart failure
  • Acute coronary syndrome
  • Chronic atherosclerosis
  • Arrhythmias
  • Other and unspecified heart disease
  • Vascular or circulatory disease
  • Fibrosis of lung and other chronic lung disorder
  • Pneumonia
Comorbidity
  • History of infection
  • Metastatic cancer and acute leukemia
  • Lung, upper digestive tract, and other severe cancers
  • Lymphatic, head and neck, brain, and other major cancers; breast, colorectal and other cancers and tumors; other respiratory and heart neoplasms
  • Other digestive and urinary neoplasms
  • Diabetes and diabetes mellitus (DM) complications
  • Protein-calorie malnutrition
  • Disorders of fluid/electrolyte/acid-base
  • Other endocrine/metabolic/nutritional disorders
  • Pancreatic disease
  • Peptic ulcer, hemorrhage, other specified gastrointestinal disorders
  • Other gastrointestinal disorders
  • Severe hematological disorders
  • Iron deficiency and other/unspecified anemia and blood disease
  • Dementia or senility
  • Drug/alcohol induced dependence/psychosis
  • Major psychiatric disorders
  • Depression
  • Anxiety disorders
  • Other psychiatric disorders
  • Quadriplegia, paraplegia, paralysis, functional disability
  • Polyneuropathy
  • Hypertensive heart and renal disease or encephalopathy
  • Stroke
  • Renal failure
  • Decubitus ulcer or chronic skin ulcer
  • Cellulitis, local skin infection
  • Vertebral fractures

Hierarchical logistic regression modeling is used to calculate a hospital-specific risk-standardized readmission rate (RSRR). This approach is analogous to a ratio of "observed" to "expected" used in other types of statistical analyses. It conceptually allows for a comparison of a particular hospital's performance given its case-mix to an average hospital's performance with the same case-mix. Thus, a lower ratio indicates lower-than-expected readmission or better quality, and a higher ratio indicates higher-than-expected readmission or worse quality. To assess hospital performance in any reporting period, the model coefficients are re-estimated using the years of data in that period. Refer to the 2015 Condition-specific Measures Updates and Specifications Report: Hospital-level 30-day Risk-standardized Readmission Measures for additional information (see also the "Companion Documents" field).

Full details of the development of the risk-standardization model for this measure are available at www.qualitynet.org External Web Site Policy.

Standard of Comparison

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

External comparison of time trends

Internal time comparison

Original Title

READM-30-COPD: hospital 30-day, all-cause risk-standardized readmission rate (RSRR) following acute exacerbation of chronic obstructive pulmonary disease (COPD).

Measure Collection Name

National Hospital Inpatient Quality Measures

Measure Set Name

Readmission Measures

Submitter

Centers for Medicare & Medicaid Services

Developer

Centers for Medicare & Medicaid Services

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

Funding Source(s)

Centers for Medicare & Medicaid Services (CMS)

Composition of the Group that Developed the Measure

This measure was developed by a team of clinical and statistical experts from Yale University/Yale-New Haven Hospital Center for Outcomes Research and Evaluation (Yale-CORE) and Harvard University, under a contract with Centers for Medicare & Medicaid Services (CMS).

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

1891

Date of Endorsement

2014 Apr 8

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

2015 Oct

Measure Maintenance

Annual

Date of Next Anticipated Revision

Unspecified

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 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Source(s)

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.

Measure Availability

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

Information is also available from The Joint Commission Web site External Web Site Policy. Check the QualityNet Web site and The Joint Commission 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:

  • Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). 2015 condition-specific measures updates and specifications report: hospital-level 30-day risk-standardized readmission measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Mar. 102 p. This document is available from the QualityNet Web site External Web Site Policy.
  • Hospital compare: a quality tool provided by Medicare. [internet]. Washington (DC): U.S. Department of Health and Human Services; [accessed 2015 May 27]. This is available from the Medicare Web site External Web Site Policy. See the related QualityTools External Web Site Policy summary.
  • Yale New Haven Health Services Corporation (YNHHSC), Center for Outcomes Research and Evaluation (CORE). Medicare hospital quality chartbook: performance report on outcome measures. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2014 Sep. 107 p. This document is available from the CMS Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on December 5, 2014. The information was verified by the measure developer on January 21, 2015.

This NQMC summary was updated by ECRI Institute on July 21, 2015. The information was verified by the measure developer on September 23, 2015.

Copyright Statement

The Specifications Manual for National Hospital Inpatient Quality Measures [Version 5.0a, October, 2015] is the collaborative work of the Centers for Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services and The Joint Commission. Users of the Specifications Manual for National Hospital Inpatient Quality Measures must update their software and associated documentation based on the published manual production timelines.

NQMC Disclaimer

The National Quality Measures Clearinghouseâ„¢ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.

Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact the measure developer.