CMS20150501 Data Run:

TK's Report Genrated by SAS run: Rpt_Extraction_Log_13Q3_14Q2.html

Data Checks Generated by Talend and SQL Checks:

Batch_id like 'CMS20150501%'

2015-05-20:

Patches introduced for the last two CMS batches that include information on missing benchmarks and calculations. These patches are included in the following batch_ids:

CMS20150101patch
CMS20150501patch

2015-05-18:

Benchmark issues persist with TKs Data. Full upload requested for additional benchmarks. Issues with original data noted:

(Taken from Martina Dolan's data report titled Data check on WNTB QA site)

No data in any measure group for following:

National Average for Academic Medical Center

Nat Avg for Profit Hospital

Nat Avg Govt Fed Hospital

Nat Avg Govt Non-Fed Hopsital

Nat Avg Not-for-profit Hospital

Nat Avg Rural Hospital

Nat Avg Safety Net Hospital

Nat Avg Teaching Hospital

B. Check state averages for Maryland - missing data for Maryland in majority of the measuresets. May just be Maryland had low data volume for these measures but worth checking just in case

Results by Measure groups

1. Quality - Overall Recommended Care

- No Top 10% Govt data for measures: Overall Recommended Care and Overall HA Care

- No Top 10% Rural Hospital data for measures: Overall Recommended Care, Overall HA, Overall HF, Overall Surgical Care

2. Recommended Heart Attack Care

- No data for AMI_7a 'Fibrinolytic Therapy Received within 30 minutes of hospital arrival'

- No Maryland state average for all mesaures in this set

- No data for Top 10% Government for all measures in this set

3. Recommended Heart Failure Care

- No Maryland state average for Overall HF Care, Discharge last, ACEI or ARB for LVSD measures

4. Surgical Care

- No data for SCIP-INF-4 ' Cardiac Surgery Patient with Controlled 6AM Post Operative Blood Glucose'

- No Maryland state average for Overall Surgical Care (has data for NY average)

- No MD or Maine state averages for measure 'Surgery Patient with Perioperative Temperature Management

- No Top 10% data (Academic medical center, For Profile, Govt, Govt-non-fed, not-for-profit, rural, safety-net, teaching) for following measure: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis ordered

5. HCAHPS

- All data fine except for missing data for national averages - see A above

6. Emergency Care

- no HRR dta for following measures: 'Time for ED arrival to ED departure for admitted ED patient', 'Admit decision time to ED departure time for admitted patients', 'CT scan results in a timely manner'

- No Top 1%, Top 5%, Top 10% , Top 25% data for 2 measures: 'Time for ED arrival to ED departure for admitted ED patient', 'Admit decision time to ED departure time for admitted patients',

- For 2 measures ( 'Time for ED arrival to ED departure for admitted ED patient', 'Admit decision time to ED departure time for admitted patients',): No Top 10% Academic Med Center, Top 10% For Profit, Top 10% Govt-(no data for 4 measures), Top 10% Govt non-fed, Top 10% not-for-profit private, Top 10% Rural, Top 10% Safety Net, Top 10% Teaching

- No health system data for 'Time for ED arrival to ED departure for admitted ED patient', 'Admit decision time to ED departure time for admitted patients'

7. Immunization Rates

- For one measure: 'Immunization for Influenza' - No data for national averages - see A above

8. Timely & Effective Stroke Care

- No Maryland state average for any measure in this gropu

- No data for Top 10% Govt, Top 10% Rural

9. Blood Clot Prevention & Treatment

- No Maryland state average for all measures

- No Top 10% Govt data for following 4 measures: 'Patient with bloodclots who got recommended treatment which includes using two different blood thinner medicines at same time', 'Patient with blood clots who were treated with an intravenous blood thinner and they were checked to determine if blood thinner was putting the patient at increased risk of bleeding', 'Patient with blood clots who were discharged on blood thinner medicine and received written instructions about that medicine', 'Patients who developed blood clot while in hospital and did not get treatment which would have prevented it'

10. Readmission Rates

- only missing data same as A above

11. Readmission Payment Adjustment Factor

- reporting time period 09Q3_12Q2 - what is data source for this measure? as not seeing it on Hosp Compare so could not check if correct reporting time period)

- only data displayed for individual hospitals

12. Mortality Rates / Effective Elective Delivery Rates / HAI
- All data fine except for missing data for national averages - see A above

Part 2:

1. Spending per medicare beneficiary

-- displaying data for individual hospitals (no state, HRR or health system data)

Response:

SPP measure is a case-mixed adjusted 'ratio'. We do not have sufficient data to calculate this ratio for a subset of hospitals. Therefore, there is no SPP measure at the HRR or Health System levels.
State- and National-level SPP measures (measure_id: 12321) were in the data file I uploaded.
CMS did not update SPP measures. The latest SPP measure is still based on Year 2013 data. Because there was no update, current data will simply overwrite the existing records in Pellucid.

2. Health care costs - cardiac, Joint, Other (2011 data)

-- displaying data for individual hospitals (no state, HRR or health system data)

Response:

CMS no longer report cost measures (see: https://www.medicare.gov/hospitalcompare/Data/Measures-Displayed.html)

3. H.I.T (2012 data)
-- displaying data for individual hospitals (no state, HRR or health system data)

Response:

HIT measures (OP_12, OP_17, OP_25) are structural measures with responses of 'Yes' and 'No'. They are 'attribute', not scores. Therefore, no benchmark can be calculated (actually, nothing can be calculated for these measures).

4. IQI hospital, IQI Maternity, PSI
-- displaying data for individual hospitals, state and HRR (no health system data)

Response:

CMS no longer report IQI measures (see: https://www.medicare.gov/hospitalcompare/Data/Measures-Displayed.html)

CMS20150101 Data Run:

TK's Report Genrated by SAS run: Rpt_Extraction_Log_13Q2_14Q1.html

Sample of Data Checks:

Batch_id = 'CMS20150101'

2015-01-22:

Found that data was missing for many state and national benchmarks. Was added with the batch_id = 'CMS20150101_benchmarks'

TKs File about additions here: Benchmarks.xlsx

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