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30-Day Post-Operative Colon Surgery (COLO) and Abdominal Hysterectomy (HYST) Surgical Site Infection (SSI) Standardized Infection Ratio (SIR)

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

CBE ID
0753

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

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

Days at Home for Patients with Complex, Chronic Conditions

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.

CBE ID
4555

Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

Percentage of adult non-ICU hospitalized patients with uncomplicated pneumonia that qualify for 5-day duration according to national guidelines who received excess antibiotic duration, defined as >/= 7 days of total antibiotic therapy including inpatient and discharge antibiotics. Measure is reported annually at the hospital level.

Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

The Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia who receive an excess antibiotic duration. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level for both quality improvement and pay-for-performance.

CBE ID
4540e

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Ischemic Stroke Hospitalization with Claims-Based Risk Adjustment for Stroke Severity

The measure estimates the hospital-level, risk-standardized mortality rate (RSMR) for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage[MA]) discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure includes the National Institutes of Health (NIH) Stroke Scale as an assessment of stroke severity upon admission in the risk-adjustment model.

CBE ID
4595