This document details the methodology for the Lower Gastrointestinal Hemorrhage measure and should be reviewed along with the Lower Gastrointestinal Hemorrhage Measure Codes List file, which contains the medical codes used in constructing the measure.
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 35 days after the trigger.
Gastrointestinal bleeding is the most common cause of hospitalizations among gastrointestinal diseases, with over 500,000 patients hospitalized annually. 3,4 Lower gastrointestinal bleeding is responsible for approximately 30 to 40% of all gastrointestinal bleeding cases, with an incidence of around 36 per 100,000 persons.5,6 Morbidity and mortality due to gastrointestinal (GI) bleeds increase significantly for patients who are older and for those with pre-existing medical conditions, leading to higher costs and resource use, including for Medicare patients.7 With application of an effective measurement tool, opportunities for improvement in care of lower gastrointestinal bleeding include better methods for characterizing patients at higher risk for rebleeding, better approaches to treatment and ongoing management to reduce the incidence of recurrent bleeding, and improving the use of early intervention strategies to mitigate the risk for catastrophic bleeding and other associated downstream complications. The Lower Gastrointestinal Hemorrhage episode-based cost measure was recommended for development by an expert clinician committee—the Gastrointestinal Disease Management - Medical and Surgical Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, and the opportunity for incentivizing cost-effective, high-quality clinical care in this area. Based on the initial recommendations from the Clinical Subcommittee, the subsequent measure-specific expert workgroup provided extensive, detailed input on this measure
The cost measure numerator is the sum of the ratio of observed to expected8 payment standardized cost to Medicare for all Lower Gastrointestinal Hemorrhage episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
The cost measure denominator is the total number of episodes from the Lower Gastrointestinal Hemorrhage episode group attributed to a clinician.
The Lower Gastrointestinal Hemorrhage cost measure uses the following data sources:
- Medicare Parts A and B claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)9
Methodologically, the Lower Gastrointestinal Hemorrhage cost measure can be triggered based on claims data from acute inpatient (IP) hospitals
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract that triggers a Lower Gastrointestinal Hemorrhage episode.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (see Appendix A).
1 Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Price (Payment) Standardization - Basics" and “CMS Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview page. (https://www.resdac.org/articles/cms-price-payment-standardization-overview)
2 Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts. Claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
3 Gralnek, Ian M, Ziv Neeman, and Lisa L Strate. “Acute Lower Gastrointestinal Bleeding.” The New England Journal of Medicine, no. 376, 2017, pp. 1054-1063.
4 Strate, Lisa L and Ian M Gralnek. “ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding.” The American Journal of Gastroenterology, vol. 111, 2016, pp. 459-474.
6 Parekh, Parth J, Ross C Buerlein, Rouzbeh Shams, Harlan Vingan, and David A Johnson. “Evaluation of Gastrointestinal Bleeding: Update of Current Radiologic Strategies.” World Journal of Gastrointestinal Pharmacology and Therapeutics, vol. 5, no. 4, 2014, pp. 200-208.
7 Jansen, Antje, Sabine Harenberg, Uwe Grenda, and Christoph Elsing. “Risk Factors for Colonic Diverticular Bleeding: A Westernized Community Based Hospital Study.” World Journal of Gastroenterology, vol. 15, no. 4, 2009, pp. 457-461.
8 Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section A.5.
9 For information on how LTC MDS data are used in risk adjustment, please refer to Section A.5.