Supporting Statement - Part B
Submission of Information for the Rural Emergency Hospital Quality Reporting (REHQR) Program
Collection of Information Employing Statistical Methods
1. Describe potential respondent universe.
Based on the actual number of acute care and critical access hospital conversions to REH status as of April 22, 2024, we estimate that 25 REHs would report data to the REHQR Program during the CY 2025 reporting period. While the exact number of REHs required to submit data may vary due to status changes to and from an REH, REHs are required by statute to submit quality data.
2. Describe procedures for collecting information.
Data have been collected from quality data codes (QDCs) entered on Medicare non-institutional claims via the CMS-1500 form and via on-line submission directly to CMS through a secure portal to CMS’ Hospital Quality Reporting system.
Data may be patient-level or summary or aggregate data submitted directly to CMS via a secure web portal (currently, the Hospital Quality Reporting (HQR) system) by either the hospital or their authorized vendor(s), as specified.
3. Describe methods to maximize response rates.
In an effort to reduce burden and thereby maximize response rates, REHs are allowed to sample for the Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients measure as it requires direct data entry. Sample size requirements per quarter per REH for this measure is based on an REH’s denominator population. REHs are at liberty to utilize sampling techniques of their choosing but are not required to do so.
4. Describe any tests of procedures or methods.
Sampling for Chart-Abstracted Data for the REHQR Program
For one measure under the REHQR Program, to reduce burden REHs may submit sample case sizes of their population of either a minimum of 63 cases for REHs with a population size between 0 and 900 or a minimum of 96 cases for REHs with a population size of greater than 900. REHs that choose to sample should ensure that the sampled data represents their outpatient population by using either the simple random sampling or systematic random sampling method and that the sampling techniques are applied consistently within a quarter. For example, quarterly samples for a sampling population should use consistent sampling techniques across the quarterly submission period. REHs may also submit measure data for the entire applicable patient population in lieu of sampling.
5. Provide name and telephone number of individuals consulted on statistical aspects.
Anita Bhatia, PhD, MPH Grace Snyder, JD, MPH
410-786-7236 410-786-0700
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2024-10-28 |