2021 HCPR20: Clostridium Difficile – Risk Assessment and Plan of Care

Measure Description

Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission

Denominator

• Any patient ≥ 18 years of age evaluated by the Eligible Professional (E/M Codes 99221- 99223, 99231- 99233, & 99291-99292 AND Place of Service Indicator: 21)
• Transferred, eloped or AMA patients are excluded

Numerator

Patients that had a risk assessment for C. difficile infection and, if high-risk, a plan of care documented on the day of or day after hospital admission

Definitions:

• Risk assessment (e.g., IDSA score, SHEA score, ZAR criteria):
  • Previous C. difficile infection
  • Recent antibiotic use (60-90 days prior to current admission)
  • Recent contact with healthcare facility (60-90 days prior to current admission)
  • Age ≥ 65
  • Recent use of proton pump inhibitor (PPI) or histamine receptor 2 antagonists (H2RA)
  • Diagnosis and procedure history (e.g., IBD, immunosuppression or hemodialysis)
• Plan of Care
  • Contact precautions if diarrhea is present
  • Stool assay
  • Initiation of antibiotics if indicated

Numerator Options:

• Performance Met (PRO13): Patients who did have a C. difficile infection risk assessment, AND if high-risk, a plan of care for C. difficile documented on the day of or day after hospital admission
• Medical Performance Exclusion (Denominator Exception) (PRO16): Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile for medical reasons documented by the Eligible Professional (e.g., C. difficile infection already documented prior to hospital admission, patients unable to provide history, patients on comfort measures)
• Performance Not Met (PRO14): Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile documented on the day of or day after hospital admission, no reason specified

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Patient Safety

High Priority Measure

Yes

Includes Telehealth?

Yes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No