The Centers for Disease Control and Prevention (CDC) has notified the Centers for Medicare & Medicaid Services (CMS) that two quarters of Clostridium difficile Infection (CDI) data were calculated with the incorrect risk-adjustment.
CDI (NQF #1717) is a risk-adjusted outcome measure, monitoring hospital onset of CDI events using the standardized infection ratio (SIR) among all inpatients in the facility. CDI data are reported via CDC’s National Healthcare Safety Network (NHSN), and CDC uses the CDI test type to adjust the measure calculation for risk in the predicted number of infections.
During the FY 2017 HAC Reduction Program Review and Corrections period, CDC notified CMS that 2014 Q1 and 2014 Q2 of CDI data were calculated with the incorrect risk-adjustment. The error occurred in hospitals that modified their CDI test type in either the first or second quarter of 2014 from what was reported on their 2013 NHSN Annual Survey.
Hospitals with changed CDI measure scores, Domain 2 scores, Total HAC Scores, or payment reduction statuses will receive more information via email. The FY 2018 Baseline Measures Reports, including the revised CDI measure results, are being made available through the QualityNet Secure Portal. CMS will update the archived databases on the CMS Hospital Compare website. The downloadable Hospital Compare archive files may be accessed here. CMS will include more information regarding the corrected CDI data in future communications. CMS intends to update facility, state, national report data for the first and second quarters of 2014.
Additional information for the HAC Reduction Program, measures, scoring methodology, resources, and applications used by healthcare providers and others can be found on the CMS QualityNet website here. Technical questions or issues related to accessing reports should be directed to the QualityNet Help Desk.