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Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00459-01-C-IRFQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Inpatient Rehabilitation Facility Quality Reporting
CMS Program History
  • Finalized for inclusion in the Inpatient Rehabilitation Facility Quality Reporting program in 2012. 
  • Implemented in the Inpatient Rehabilitation Facility Quality Reporting program in 2014.
  • Also active in the Long-Term Care (LTC) Hospital Quality Reporting program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program. 
Description

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CAUTIs by the number of predicted CAUTIs.   

Numerator

Number of annually observed catheter-associated urinary tract infections (CAUTI) in hospital inpatients.

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

The denominator for both the SIR and the ARM is the total number of predicted CAUTI during hospitalization for patients within the unit of study (i.e., location under surveillance). The predicted number of infections for a facility is calculated based on the reported number of catheter days at the location-level using a negative binomial regression that accounts for the following risk factors:

ACHs: CDC-defined location within a facility (e.g., critical ICUs, SCAs, step-down units, etc.), bed size, medical school affiliation, and facility type

CAHs: medical school affiliation

IRFs: setting type, proportion of admissions with traumatic and non-traumatic spinal cord dysfunction, proportion of admissions with stroke

LTACHs: average length of stay, setting type, and location type.

Denominator Exclusions

The following are not considered indwelling catheters by NHSN definitions:

  • Suprapubic catheters
  • Condom catheters
  • “In and out” catheterizations
  • Nephrostomy tubes
  • Ileoconduits 
Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Hospital: Inpatient Acute Care Facility
PPS-Exempt Cancer Hospital
Inpatient Rehabilitation Facility
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed with Conditions
CBE Endorsement History

Endorsement History: 

  • Initial endorsement, 2012.
  • New measure endorsed with conditions Spring 2025.

Link to Endorsement Measure Record: National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

About this Analysis (Measure Score by PY)

Impact Summary: This measure supports the Inpatient Rehabilitation Facility Quality Reporting Program by assessing health care-associated catheter-associated urinary tract infections (CAUTI) among patients in bedded inpatient rehabilitation facilities, an outcome directly associated with patient safety and quality of care. 

Based on the most recent data, the total estimated number of CAUTIs across all deciles is approximately 1,400. If inpatient rehabilitation facilities with higher CAUTI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that up to about 1,400 CAUTIs could potentially be avoided, indicating a substantial opportunity for improved patient outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Inpatient Rehabilitation Facility - Provider Data | Provider Data Catalog (cms.gov):

  • Inpatient_rehabilitation_facilities_03_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “I_006_01” not marked as “Not Available” from the corresponding Inpatient_Rehabilitation_Facility-Provider_Data.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: There is no discernible change across the 4 years. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.

Table 1 (Score Distro)

Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

1.060 (1.089)

0

0

0

0

0.117

0.688

1.142

1.706

2.326

3.562

Average Raw Rate (Standard Deviation)

0.200 (0.328)

0

0

0

0

0.006

0.099

0.194

0.291

0.450

0.957

Entities

1,123

113

112

112

113

112

112

113

112

112

112

Patients

790,630

50,594

48,918

58,134

49,690

77,282

167,930

116,230

100,352

82,073

39,427

Interpretation (Score Distro)

Table 1 Interpretation: To estimate the number of negative outcomes (CAUTIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,400. If the average performance of Decile 3 (0%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 1,400 fewer measured patients would contract CAUTIs. This translates to about one patient per entity.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00459-01-C-LTCHQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Long-Term Care Hospital Quality Reporting
CMS Program History
  • Finalized for inclusion in the Long-Term Care Hospital Quality Reporting Program in 2011. 
  • Implemented in the Long-Term Care Hospital Quality Reporting Program in 2013.
  • Also active in the Inpatient Rehabilitation Facility Quality Reporting Program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.
Description

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CAUTIs by the number of predicted CAUTIs.

Numerator

Number of annually observed catheter-associated urinary tract infections (CAUTI) in hospital inpatients. 

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

Number of annually predicted catheter-associated urinary tract infections (CAUTI) in hospital inpatients.  

Denominator Exclusions

The following are not considered indwelling catheters by NHSN definitions:

  • Suprapubic catheters
  • Condom catheters
  • “In and out” catheterizations
  • Nephrostomy tubes
  • Ileoconduits 
Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Hospital: Inpatient Acute Care Facility
PPS-Exempt Cancer Hospital
Hospital: Outpatient
Inpatient Rehabilitation Facility
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed with Conditions
CBE Endorsement History

Endorsement History: 

  • Initial endorsement, 2012.
  • New measure endorsed with conditions Spring 2025.

Link to Endorsement Measure Record: National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

About this Analysis (Measure Score by PY)

Impact Summary: This measure supports the Long-Term Care Hospital Quality Reporting Program by assessing health care-associated catheter-associated urinary tract infections (CAUTI) among patients in bedded long-term care hospitals, an outcome directly associated with patient safety and quality of care. 

There was no discernible change in performance among entities reporting on this measure during the years examined. Based on the most recent data, the total estimated number of CAUTIs across all deciles is approximately 1,400. If long-term care hospitals with higher CAUTI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that up to about 1,000 CAUTIs could potentially be avoided, representing a meaningful opportunity for improved patient outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov): 

  • long-term_care_hospitals_03_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • long-term_care_hospitals_03_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • long-term_care_hospitals_03_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • long-term_care_hospitals_03_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “L_006_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: There is no discernible change across the 4 years; the median score had a range between a minimum of 0.57 to a maximum of 0.61. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores (standardized infection ratios [SIRs]), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.

For this measure, Decile 1 represents a group of 32 hospitals with the highest measure scores and Decile 10 shows those with the lowest measure scores. 

Table 1 (Score Distro)

Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

0.760 (0.730)

0

0

0.233

0.425

0.515

0.651

0.902

1.19

1.409

2.217

Average Raw Rate (Standard Deviation)

0.130 (0.122)

0

0

0.037

0.067

0.089

0.111

0.147

0.192

0.241

0.394

Entities

312

32

31

31

31

31

32

31

31

31

31

Patients

1,058,542

76,535

74,451

125,653

106,053

125,180

115,518

110,660

101,551

107,002

115,939

Interpretation (Score Distro)

Table 1 Interpretation: To estimate the number of negative outcomes (CAUTIs), the number of patients is multiplied by the average raw rate for each decile. In 2024, the total estimated number of negative outcomes across all deciles is about 1,400. If the average performance of Decile 3 (0.037%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 1,000 fewer negative outcomes could occur. This translates to about three patients per entity and means that improving performance on this measure could help ensure that several hundred fewer patients contract CAUTIs, potentially leading to better health outcomes.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00459-01-C-PCHQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting
CMS Program History
  • Finalized for inclusion in the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program in 2012. 
  • Implemented in the PCHQR Program in 2013.
  • Also active in the Inpatient Rehabilitation Facility Quality Reporting Program and the Long-Term Care Hospital Quality Reporting Program.
Description

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CAUTIs by the number of predicted CAUTIs.   

Numerator

Number of annually observed catheter-associated urinary tract infections (CAUTI) in hospital inpatients.   

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

Number of annually predicted catheter-associated urinary tract infections (CAUTI) in hospital inpatients.  

Denominator Exclusions

The following are not considered indwelling catheters by NHSN definitions:

  • Suprapubic catheters
  • Condom catheters
  • “In and out” catheterizations
  • Nephrostomy tubes
  • Ileoconduits 
Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Hospital: Inpatient Acute Care Facility
PPS-Exempt Cancer Hospital
Inpatient Rehabilitation Facility
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed with Conditions
CBE Endorsement History

Endorsement History: 

  • Initial endorsement, 2012.
  • New measure endorsed with conditions Spring 2025. 

Link to Endorsement Measure Record: National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

About this Analysis (Measure Score by PY)

Impact Summary: This measure aligns with Prospective Payment System-Exempt Cancer Hospital Quality Reporting (PCHQR) Program goals by delivering outcome-based, facility-level data to inform consumer choice and promote accountability. It encourages hospitals and clinicians to improve inpatient care for Medicare beneficiaries by tracking and reporting best practices across varied care settings. 

Performance change over time was difficult to assess as only 11 entities reported on this measure during the years assessed. Drawing from Table 1, if all hospitals improved their infection rates to match the average score found in Decile 3, there could be about 50 fewer CAUTI infections overall. On average, each hospital would see four fewer patients affected. Improving performance to achieve this average could help more patients avoid infections and lead to better health outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:

  • Hospitals_02_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • Hospitals_02_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • Hospitals_01_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • Hospitals_01_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “PCH_5” not marked as “Not Available” from the corresponding PCH_HEALTHCARE_ASSOCIATED_INFECTIONS_HOSPITAL.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: There are only 11 entities per year, so any apparent trend may just as likely be attributed to random error, indicating little discernible change across the 4 years. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores (standardized infection ratio [SIR]), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller entity size may be associated with lower performance scores.

Table 1 (Score Distro)

Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

0.851 (0.361)

N/A

0.260

0.574

0.729

0.654

0.906

1.223

1.216

1.248

N/A

Average Raw Rate (Standard Deviation)

0.102 (0.114)

0

0.032

0.050

0.066

0.072

0.081

0.122

0.138

0.147

0.410

Entities

11

2

1

1

1

1

1

1

1

1

1

Patients

119,667

974

21,860

2,017

31,633

12,421

12,326

4,911

11,564

21,717

244



 

Interpretation (Score Distro)

Table 1 Interpretation: Note that there are data for only 11 entities, and that the SIR is not available (N/A) for three of them due to an expected value less than 1. To estimate the number of negative outcomes (CAUTI infections), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 100. If the average performance of Decile 3 (0.574%) is considered a plausible, achievable rate, and the entities in Deciles 4 through 10 improved to reach that rate, about 50 fewer negative outcomes could occur. This translates to about four patients per entity and means that improving performance on this measure could help ensure that fewer patients contract CAUTI infections, potentially leading to better health outcomes.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio

Annual risk-adjusted standardized infection ratio (SIR) of catheter-associated urinary tract infections (CAUTI) among adults and children hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.   SIR is reported annually and is calculated by dividing the number of observed CAUTIs into the number of predicted CAUTIs. 

 

CBE ID
0138

Central Line-Associated Bloodstream Infection (CLABSI) Standardized Infection Ratio

Annual risk-adjusted standardized infection ratio (SIR) of central line-associated bloodstream infections (CLABSI) among adults and children hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, and long-term acute care hospitals. SIR is reported annually and is calculated by dividing the number of observed CLABSIs by the number of predicted CLABSIs.   

 

CBE ID
0139

Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00462-01-C-IRFQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Inpatient Rehabilitation Facility Quality Reporting
CMS Program History
  • Finalized for inclusion in the Inpatient Rehabilitation Facility Quality Reporting Program in 2014. 
  • Implemented in the Inpatient Rehabilitation Facility Quality Reporting Program in 2016.
  • Also active in the Long-Term Care Hospital Quality Reporting Program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.
Description

Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs

Numerator

Number of annually observed Clostridioides difficile (CDI) LabID events in hospital inpatients. 

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

Number of annually predicted Clostridioides difficile (CDI) LabID events in hospital inpatients.    

Denominator Exclusions

Baby based locations such as, neonatal ICU, special care nursery and well-baby nurseries, are excluded from the denominator count. In LDRP locations, moms and babies must each be counted separately (as two patients). Any locations that predominantly house infants, including NICU, SCN, or well-baby locations (for example, nurseries, babies in LDRP) are excluded. 

Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Hospital: Inpatient Acute Care Facility
Hospital: Critical Access
Inpatient Rehabilitation Facility
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed
CBE Endorsement History

Endorsement History: The measure was last endorsed in 2025 and is up for re-endorsement in 2029 

Link to Endorsement Measure Record: Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio | Partnership for Quality Measurement

About this Analysis (Measure Score by PY)

Impact Summary: This measure supports the Inpatient Rehabilitation Facility Quality Reporting Program by assessing facility-wide hospital-onset Clostridioides difficile infections (CDIs) among patients in inpatient rehabilitation facilities, an outcome closely tied to patient safety and infection prevention. 

Based on the most recent data, the total estimated number of CDIs across all deciles is approximately 1,500. If inpatient rehabilitation facilities with higher CDI rates improved their performance to levels observed among better-performing facilities, this would result in about one less CDI per facility, indicating limited opportunity to improve patient outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Inpatient Rehabilitation Facility - Provider Data | Provider Data Catalog (cms.gov):

  • Inpatient_rehabilitation_facilities_03_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • Inpatient_rehabilitation_facilities_03_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “I_015_01” not marked as “Not Available” from the corresponding Inpatient_Rehabilitation_Facility-Provider_Data.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: Figure 1 shows a decreasing trend from a median standardized infection ratio (SIR) of 0.34 in 2022 to a median SIR of 0.17 in 2024. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores (SIRs), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, this smaller group size may be associated with lower performance scores.

Table 1 (Score Distro)

Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

0.320 (0.440)

0

0

0

0

0.002

0.178

0.326

0.490

0.743

1.330

Average Raw Rate (Standard Deviation)

0.013 (0.020)

0

0

0

0

0

0.007

0.013

0.020

0.030

0.060

Entities

1,122

113

112

112

112

112

113

112

112

112

112

Patients

10,840,927

793,952

722,084

664,810

688,265

716,002

2,010,023

1,862,498

1,374,188

1,203,579

805,526

Interpretation (Score Distro)

Table 1 Interpretation: To estimate the number of negative outcomes (CDIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,500. If the average performance of Decile 3 (0%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated number of eligible patients with CDIs would go down by about 1,500. This translates to about one patient per entity.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00462-01-C-LTCHQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Long-Term Care Hospital Quality Reporting
CMS Program History
  • Finalized for inclusion in the Long-Term Care Hospital Quality Reporting Program in 2013. 
  • Implemented in the Long-Term Care Hospital Quality Reporting Program in 2016.
  • Also active in the Inpatient Rehabilitation Facility Quality Reporting Program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.
Description

Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.  SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs.  

Numerator

Number of annually observed Clostridioides difficile (CDI) LabID events in hospital inpatients. 

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

Number of annually predicted Clostridioides difficile (CDI) LabID events in hospital inpatients.    

Denominator Exclusions

Baby based locations such as neonatal ICU, special care nursery and well-baby nurseries, are excluded from the denominator count. In LDRP locations, moms and babies must each be counted separately (as two patients). Any locations that predominantly house infants, including NICU, SCN, or well-baby locations (for example, nurseries, babies in LDRP) are excluded. 

Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Facility
Care Setting
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed
CBE Endorsement History

Endorsement History: The measure was last endorsed in 2025 and is up for re-endorsement in 2029 

Link to Endorsement Measure Record: Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio | Partnership for Quality Measurement

About this Analysis (Measure Score by PY)

Impact Summary: This measure supports the Long-Term Care Hospital Quality Reporting Program by assessing facility-wide hospital-onset Clostridioides difficile infections (CDIs) among patients in long-term care hospitals, an outcome closely associated with patient safety and infection prevention. 

Based on the most recent data, the total estimated number of CDIs across all deciles is approximately 1,000. If long-term care hospitals with higher CDI rates improved their performance to levels observed among better-performing facilities, the analysis suggests that several hundred CDIs could potentially be avoided, indicating a meaningful opportunity for improved patient outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):

  • long-term_care_hospitals_03_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • long-term_care_hospitals_03_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • long-term_care_hospitals_03_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • long-term_care_hospitals_03_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “L_014_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: Although there was no discernible change from 2021 to 2022, Figure 1 shows a decreasing trend from a median standardized infection ratio (SIR) of 0.3 in 2022 to a median SIR of 0.2 in 2024. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores (SIRs), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller group size may be associated with lower performance scores.

Table 1 (Score Distro)

Table 1. Importance (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

0.300 (0.335)

0

0

0.036

0.110

0.173

0.241

0.317

0.461

0.655

1.049

Average Raw Rate (Standard Deviation)

0.030 (0.030)

0

0

0.003

0.011

0.016

0.021

0.029

0.042

0.059

0.095

Entities

312

32

31

31

31

31

32

31

31

31

31

Patients

4,207,696

304,536

206,866

852,566

449,200

482,814

466,775

363,369

434,037

325,420

322,113

Interpretation (Score Distro)

Table 1 Interpretation: To estimate the number of negative outcomes (CDIs), the number of patients is multiplied by the average raw rate for each decile. Right now, the total estimated number of negative outcomes across all deciles is about 1,000. If the average performance of Decile 3 (0.003%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 900 fewer negative outcomes could occur. This translates to about three patients per entity and means that improving performance on this measure could help ensure that several hundred fewer patients contract CDIs, potentially leading to better health outcomes.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio

CMS Measures Inventory Tool (CMIT) ID
00462-01-C-PCHQR
Steward Organization Group
Centers for Disease Control and Prevention
Committee
MSR Recommendation Group
Measure Overview
Use in CMS Programs
Current Program Use
Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting
CMS Program History
  • Finalized for inclusion in the Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program in 2015. 
  • Implemented in the Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program in 2017.
  • Also active in the Long-Term Care Hospital Quality Reporting Program and the Inpatient Rehabilitation Facility Quality Reporting Program.
Description

Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals.  SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs.  

Numerator

Number of annually observed Clostridioides difficile (CDI) LabID events in hospital inpatients. 

Numerator Exclusions

N/A

Numerator Exceptions

N/A

Denominator

Number of annually predicted Clostridioides difficile (CDI) LabID events in hospital inpatients.    

Denominator Exclusions

Baby based locations such as, neonatal ICU, special care nursery and well-baby nurseries, are excluded from the denominator count. In LDRP locations, moms and babies must each be counted separately (as two patients). Any locations that predominantly house infants, including NICU, SCN, or well-baby locations (for example, nurseries, babies in LDRP) are excluded. 

Denominator Exceptions

N/A

Cascade of Meaningful Measures Priority
Safety
Measure Type
Outcome
Level of Analysis
Other
Care Setting
Hospital: Inpatient Acute Care Facility
PPS-Exempt Cancer Hospital
Inpatient Rehabilitation Facility
Long-Term Acute Care Facility
CBE Endorsement Status
Endorsed with Conditions
CBE Endorsement History

Endorsement History: Endorsed with conditions, 2025 

Conditions for maintenance review in 3 years, the developer will have: Explored the possibility of using other all-payer data sources to expand the use of patient-level factors in the risk adjustment model and reduce reliance on facility-level factors.

Link to Endorsement Measure Record: Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio

About this Analysis (Measure Score by PY)

Impact Summary: By assessing the difference between observed and expected hospital-onset CDI LabID events among inpatients—accounting for facility characteristics such as bed size, academic affiliation, diagnostic method, and patient prevalence—this measure supports PCH goals by giving consumers meaningful, setting-specific quality-of-care data and encouraging hospitals to improve inpatient care quality for Medicare beneficiaries through transparent reporting and benchmarking against best practices. 

Overall, the limited number of PPS-exempt cancer hospitals participating and reporting in this program makes it difficult to analyze overall performance trends. Based on the performance shown in Table 1, if all entities reporting performed at least at the average score, improving performance on this measure could help ensure that 11 fewer patients per entity contract CDI, potentially leading to better health outcomes.

For this measure, Battelle reviewed the following publicly available datasets available at  Hospitals data archive | Provider Data Catalog:

  • Hospitals_02_2026.zip (which contains data from April 2024-March 2025 and is referred to as year 2024 in this assessment)
  • Hospitals_02_2025.zip (which contains data from April 2023-March 2024 and is referred to as year 2023 in this assessment)
  • Hospitals_01_2024.zip (which contains data from April 2022-March 2023 and is referred to as year 2022 in this assessment)
  • Hospitals_01_2023.zip (which contains data from April 2021-March 2022 and is referred to as year 2021 in this assessment)

Battelle analyzed all values for “PCH_26” not marked as “Not Available” from the corresponding PCH_HEALTHCARE_ASSOCIATED_INFECTIONS_HOSPITAL.csv file.

 

About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.

Figure 1 (Measure Score by PY)
boxplot

 

Figure 1. Boxplot of Measure Score by Year

Interpretation (Measure Score by PY)

Figure 1 Interpretation: Overall, the limited number of PPS-Exempt Cancer Hospitals participating and reporting in this program makes it difficult to analyze overall performance trends. There are only 11 entities per year, so any apparent trend may just as likely be attributed to random error, indicating little discernible change across the 4 years. For this measure, a lower score indicates better quality of care.

About this Analysis (Score Distro)

About Table 1: Table 1 illustrates the distribution of scores (standardized infection ratios [SIRs]), raw rates, and the number of patients represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller entity size may be associated with lower performance scores.

Table 1 (Score Distro)

Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, FY2024) 

 OverallDecile 1Decile 2Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Average SIR (Standard Deviation)

0.652 (0.552)

0.225

0.471

0.311

0.363

0.374

0.743

0.641

0.810

2.167

0.846

Average Raw Rate (Standard Deviation)

0.064 (0.040)

0.026

0.030

0.038

0.043

0.043

0.062

0.089

0.091

0.105

0.148

Entities

11

2

1

1

1

1

1

1

1

1

1

Patients

806,679

325,898

23,356

10,608

121,827

170,519

6,460

17,922

76,790

6,681

46,618

Interpretation (Score Distro)

Table 1 Interpretation: To estimate the number of negative outcomes (CDI), the number of patients is multiplied by the average raw rate for each decile. In 2024, the total estimated number of negative outcomes across all deciles is about 400. If the average performance of Decile 3 (0.311%) is considered a plausible, achievable rate, and the entities in Deciles 4 through 10 improved to reach that rate, about 120 fewer negative outcomes could occur. This translates to about 11 patients per entity and means that improving performance on this measure could help ensure that fewer patients contract CDI, potentially leading to better health outcomes.

Importance Criterion Definition

The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

Criterion Definition

This criterion will be evaluated as part of the full Preliminary Assessment available in September. 

PA Type
Performance and Impact Analysis (PIA)

Clostridioides difficile (CDI) LabID Event Standardized Infection Ratio

Annual risk-adjusted standardized infection ratio (SIR) of Clostridioides difficile (CDI) LabID events among adults and pediatrics hospitalized as inpatients at acute care hospitals, critical access hospitals, oncology hospitals, long-term acute care hospitals, and acute care rehabilitation hospitals. SIR is reported annually and is calculated by dividing the number of observed CDIs into the number of predicted CDIs.  

CBE ID
1717

Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder

The Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.

CBE ID
3453