From 2908724163e7c4d2a51ea38d2edcf866bd010418 Mon Sep 17 00:00:00 2001 From: Kalvin Wang Date: Thu, 9 Nov 2017 18:42:57 -0800 Subject: [PATCH] [QPPA-1310] Set metricType to multiplePerformanceRate on some QCDR measures (#85) This PR sets `metricType` to `multiPerformanceRate` for QCDR measures with `Number of performance rates to be included in the XML` greater than 1, AND (proportional=Y, continuous=N, ratio=N). In order to include strata names and descriptions for multiPerformanceRate measures, we've manually modified the QCDR csv in these ways for each of the 27 affected measures (aka QCDR measures where the metricType is multiPerformanceRate): - For column N, `Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted`, we modify the values to strictly be one of: - the number of the rate that is the overall rate (e.g. `3`) instead of `Rate 3` or `Performance Rate 3`, or - `weighted average` or `sum numerators` (case-insensitive) - For rows where column N is filled out, in column E, `Measure Description`, we modify the values to strictly be in the format: - `*summary* Rate 1: description Rate 2: description Rate 3: description`, instead of e.g. - `*summary* A) description B) description C) description *more summary*` We plan to ask policy to make the above modifications prior to future updates to the QCDR csv. Testing: checked results manually and found 27 measures change from `singlePerformanceRate` to `multiPerformanceRate` which appears to be accurate. Added a unit test, tests pass. (This is a followup to #81, and includes a generated file that should have been added as part of that PR, `measures-data-with-qcdrs.json`) Jira: https://jira.cms.gov/browse/QPPA-1310 - [x] Include multiple strata name/descriptions and overallalgorithm field - [x] Include other strata data once policy responds - [x] Move strata names to a separate file Reviewer: @marimiyachi --- measures/measures-data.json | 3669 +-- measures/measures-data.xml | 2769 +- measures/measures-schema.yaml | 15 +- package.json | 1 + scripts/measures/build-measures | 5 +- scripts/measures/import-qcdr-measures.js | 100 +- staging/measures-data-with-qcdrs.json | 23645 ++++++++++++++++ .../measures/fixtures/expected-measures.json | 25 +- test/scripts/measures/fixtures/test-qcdr.csv | 1 + .../measures/import-qcdr-measures-spec.js | 12 +- ...0170911.csv => QCDR-Measures-20170911.csv} | 0 util/measures/QCDR-Measures-20171109.csv | 6788 +++++ util/measures/qcdr-measures-strata-names.json | 29 + 13 files changed, 31704 insertions(+), 5355 deletions(-) create mode 100644 staging/measures-data-with-qcdrs.json rename util/measures/{latest-QCDR-Measures-20170911.csv => QCDR-Measures-20170911.csv} (100%) create mode 100644 util/measures/QCDR-Measures-20171109.csv create mode 100644 util/measures/qcdr-measures-strata-names.json diff --git a/measures/measures-data.json b/measures/measures-data.json index ea7f7e80..02a596fb 100644 --- a/measures/measures-data.json +++ b/measures/measures-data.json @@ -12080,11 +12080,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12105,11 +12100,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12130,11 +12120,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12155,11 +12140,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12180,11 +12160,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12205,11 +12180,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12230,11 +12200,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12255,11 +12220,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12280,11 +12240,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12292,7 +12247,7 @@ { "measureId": "AAAAI19", "title": "Asthma: Pharmacologic Therapy for Persistent Asthma – Ambulatory Care Setting", - "description": "Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication\n\nThis measure will be calculated with three rates:\n\n1) Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication \n2) Patients prescribed alternative long-term control medications (non-ICS) \n3) Total patients prescribed long-term control medication", + "description": "Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication\n\nThis measure will be calculated with three rates:\n\nRate 1: Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication\nRate 2: Patients prescribed alternative long-term control medications (non-ICS)\nRate 3: Total patients prescribed long-term control medication", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -12305,19 +12260,29 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "ICS", + "description": "Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication" + }, + { + "name": "nonICS", + "description": "Patients prescribed alternative long-term control medications (non-ICS)" + }, + { + "name": "overall", + "description": "Total patients prescribed long-term control medication" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "AAD1", "title": "Psoriasis: Assessment of Psoriasis Disease Activity", - "description": "This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale. \n\n Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period.", + "description": "This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale.\n\n Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -12330,11 +12295,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12342,7 +12302,7 @@ { "measureId": "AAD2", "title": "Psoriasis: Screening for Psoriatic Arthritis", - "description": "Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life. \n\n Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period.", + "description": "Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life.\n\n Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, @@ -12355,11 +12315,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12367,7 +12322,7 @@ { "measureId": "AAD3", "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients", - "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) \n\n The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", + "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -12380,11 +12335,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12392,7 +12342,7 @@ { "measureId": "AAD4", "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk", - "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) \n\n The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", + "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -12405,11 +12355,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12417,7 +12362,7 @@ { "measureId": "AAD5", "title": "Biopsy Reporting Time - Clinician to Patient", - "description": "Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. \n\n Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.", + "description": "Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient.\n\n Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -12430,11 +12375,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12442,7 +12382,7 @@ { "measureId": "ARCO11", "title": "Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival", - "description": "This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio. \n\nHOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´", + "description": "This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio.\n\nHOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´", "nationalQualityStrategyDomain": "Effective Communication and Care Coordination", "measureType": "process", "isHighPriority": true, @@ -12455,11 +12395,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12480,11 +12415,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12492,7 +12422,7 @@ { "measureId": "ARCO13", "title": "Ischemic stroke patients management -", - "description": "o This measure will be calculated with 4 performance rates:\n1. The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;\n2. The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate; \n3. The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two; \n4. The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge", + "description": "o This measure will be calculated with 4 performance rates:\nRate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;\nRate 2: The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;\nRate 3: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;\nRate 4: The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge", "nationalQualityStrategyDomain": "Effective Communication and Care Coordination", "measureType": "process", "isHighPriority": false, @@ -12505,14 +12435,28 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "sumNumerators", "strata": [ { - "name": "overall" + "name": "antithrombotic", + "description": "The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;" + }, + { + "name": "anticoagulation", + "description": "The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;" + }, + { + "name": "antithrombotic2", + "description": "The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;" + }, + { + "name": "LDL", + "description": "The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "ARCO3", @@ -12530,11 +12474,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12555,11 +12494,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12580,11 +12514,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12605,11 +12534,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12630,11 +12554,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12655,11 +12574,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12680,11 +12594,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12705,11 +12614,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12717,7 +12621,7 @@ { "measureId": "ACCCath3", "title": "Vascular access site injury requiring treatment or major bleeding post PCI in patients without CABG or other major surgeries during admission.", - "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment. \n\nMajor access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge. \n\nMajor bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure. To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding.\n\nThis measure evaluates the occurrence of vascular site injury requiring treatment or major bleeding as outcomes of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment.\n\nMajor access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge.\n\nMajor bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure. To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding.\n\nThis measure evaluates the occurrence of vascular site injury requiring treatment or major bleeding as outcomes of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -12730,11 +12634,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12742,7 +12641,7 @@ { "measureId": "ACCCath4", "title": "Cardiac tamponade post PCI in patients without CABG or other major surgery during admission.", - "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure. \n\nThis measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure.\n\nThis measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -12755,11 +12654,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12780,11 +12674,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12805,11 +12694,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12830,11 +12714,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12855,11 +12734,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12880,11 +12754,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -12905,11 +12774,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -12930,11 +12794,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -12955,11 +12814,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -12980,11 +12834,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13005,11 +12854,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13030,11 +12874,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13055,11 +12894,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13067,7 +12901,7 @@ { "measureId": "AAN8", "title": "Exercise and Appropriate Physical Activity Counseling for Patients with MS", - "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate \n physical activity for patients with MS in the past 12 months.", + "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate\n physical activity for patients with MS in the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -13080,11 +12914,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13105,11 +12934,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13130,11 +12954,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13155,11 +12974,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13180,11 +12994,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13205,11 +13014,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13230,11 +13034,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13255,11 +13054,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13280,11 +13074,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13305,11 +13094,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13330,11 +13114,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13355,11 +13134,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13380,11 +13154,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13405,11 +13174,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13430,11 +13194,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13455,11 +13214,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13480,11 +13234,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13505,11 +13254,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13530,11 +13274,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13555,11 +13294,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13580,11 +13314,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13605,11 +13334,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13630,11 +13354,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13655,11 +13374,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13680,11 +13394,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13692,7 +13401,7 @@ { "measureId": "Q416", "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", - "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury \n (INVERSE Measure: Lower score indicates better performance)", + "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury\n (INVERSE Measure: Lower score indicates better performance)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -13705,11 +13414,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13717,7 +13421,7 @@ { "measureId": "ACEP21", "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", - "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider \n (INVERSE Measure: Lower score indicates better performance)", + "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider\n (INVERSE Measure: Lower score indicates better performance)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -13730,11 +13434,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13755,11 +13454,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13780,11 +13474,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13805,11 +13494,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13830,11 +13514,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13855,11 +13534,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13880,11 +13554,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13905,11 +13574,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13930,11 +13594,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13955,11 +13614,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -13967,7 +13621,7 @@ { "measureId": "ACEP32", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -13980,11 +13634,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -13992,7 +13641,7 @@ { "measureId": "ACEP33", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +)", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14005,11 +13654,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14017,7 +13661,7 @@ { "measureId": "ACEP35", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999)", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14030,11 +13674,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14042,7 +13681,7 @@ { "measureId": "ACEP36", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999)", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14055,11 +13694,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14067,7 +13701,7 @@ { "measureId": "ACEP37", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999)", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14080,11 +13714,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14092,7 +13721,7 @@ { "measureId": "ACEP38", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less)", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14105,11 +13734,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14117,7 +13741,7 @@ { "measureId": "ACEP39", "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Eds", - "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients \n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -14130,11 +13754,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14155,11 +13774,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14180,11 +13794,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14205,11 +13814,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14230,11 +13834,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14255,11 +13854,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14280,11 +13874,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14305,11 +13894,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14330,11 +13914,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14355,11 +13934,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14380,11 +13954,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14405,11 +13974,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14430,11 +13994,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14455,11 +14014,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14480,11 +14034,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14505,11 +14054,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14517,7 +14061,7 @@ { "measureId": "ACRad26", "title": "Appropriate venous access for hemodialysis", - "description": "Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access \n\nInverse measure", + "description": "Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access\n\nInverse measure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, @@ -14530,11 +14074,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14555,11 +14094,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14580,11 +14114,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14592,7 +14121,7 @@ { "measureId": "ACRad23", "title": "Lung Cancer Screening Abnormal Interpretation Rate", - "description": "The percentage of screening lung cancer interpreted \nas positive (Lung-RADS Category 3 or 4).", + "description": "The percentage of screening lung cancer interpreted\nas positive (Lung-RADS Category 3 or 4).", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, @@ -14605,11 +14134,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14617,7 +14141,7 @@ { "measureId": "ACRad21", "title": "Lung Cancer Screening Cancer Detection Rate (CDR)", - "description": "The percentage of screenings of lung cancer that \nwere interpreted as positive (Lung-RADS category 3 \nor 4) and result in a tissue diagnosis of cancer within \n12 months.", + "description": "The percentage of screenings of lung cancer that\nwere interpreted as positive (Lung-RADS category 3\nor 4) and result in a tissue diagnosis of cancer within\n12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -14630,11 +14154,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14642,7 +14161,7 @@ { "measureId": "ACRad22", "title": "Lung Cancer Screening Positive Predictive Value (PPV)", - "description": "The percentage of screenings for lung cancer with \nabnormal interpretation (Lung-RADS 3 or 4) that \nresult in a tissue diagnosis of cancer within 12 \nmonths.", + "description": "The percentage of screenings for lung cancer with\nabnormal interpretation (Lung-RADS 3 or 4) that\nresult in a tissue diagnosis of cancer within 12\nmonths.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -14655,11 +14174,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14680,11 +14194,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14705,11 +14214,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14730,11 +14234,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14742,7 +14241,7 @@ { "measureId": "ACRad30", "title": "Rate of Inadequate Percutaneous Image-Guided Biopsy", - "description": "The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report. \n\nInverse measure", + "description": "The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report.\n\nInverse measure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "isHighPriority": true, @@ -14755,11 +14254,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14767,7 +14261,7 @@ { "measureId": "ACRad28", "title": "Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement", - "description": "Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement \n\nInverse measure", + "description": "Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement\n\nInverse measure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -14780,11 +14274,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14792,7 +14281,7 @@ { "measureId": "ACRad29", "title": "Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement", - "description": "Percentage of percutaneous nephrostomy tube \nreplacement within 30 days following initial \nplacement. \n\nInverse measure", + "description": "Percentage of percutaneous nephrostomy tube\nreplacement within 30 days following initial\nplacement.\n\nInverse measure", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -14805,11 +14294,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14830,11 +14314,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14842,7 +14321,7 @@ { "measureId": "ACRad25", "title": "Report Turnaround Time: Mammography", - "description": "Mean mammography report turnaround time (RTAT). \nInverse measure \nContinuous measure scoring", + "description": "Mean mammography report turnaround time (RTAT).\nInverse measure\nContinuous measure scoring", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, @@ -14855,11 +14334,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14880,11 +14354,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14905,11 +14374,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14917,7 +14381,7 @@ { "measureId": "ACRad15", "title": "Report Turnaround Time: Radiography (modified)\n(Inverse Measure)", - "description": "Mean radiography report turnaround time (RTAT). \n(Does not include mammography.)", + "description": "Mean radiography report turnaround time (RTAT).\n(Does not include mammography.)", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, @@ -14930,11 +14394,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14955,11 +14414,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -14980,11 +14434,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -14992,7 +14441,7 @@ { "measureId": "ACRad3", "title": "Screening Mammography Cancer Detection Rate (CDR)", - "description": "The fraction of all screening mammograms that are \ninterpreted as positive (abnormal) and have a tissue \ndiagnosis of cancer within 12 months (expressed per \n1000 exams, not as a percentage)", + "description": "The fraction of all screening mammograms that are\ninterpreted as positive (abnormal) and have a tissue\ndiagnosis of cancer within 12 months (expressed per\n1000 exams, not as a percentage)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -15005,11 +14454,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15030,11 +14474,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15042,7 +14481,7 @@ { "measureId": "ACRad7", "title": "Screening Mammography Node Negativity Rate", - "description": "The percentage of invasive cancers detected at \nscreening mammography that are node negative", + "description": "The percentage of invasive cancers detected at\nscreening mammography that are node negative", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -15055,19 +14494,14 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" }, { "measureId": "ACRad6", - "title": "Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy \nRecommended)", - "description": "The percentage of screening mammograms where \nbiopsy was recommended that have a tissue \ndiagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening", + "title": "Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy\nRecommended)", + "description": "The percentage of screening mammograms where\nbiopsy was recommended that have a tissue\ndiagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -15080,11 +14514,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15105,11 +14534,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15130,11 +14554,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15155,11 +14574,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15180,11 +14594,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15205,11 +14614,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15230,11 +14634,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15255,11 +14654,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15280,11 +14674,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15305,11 +14694,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15330,11 +14714,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15355,11 +14734,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15380,11 +14754,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15405,11 +14774,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15430,11 +14794,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15455,11 +14814,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15480,11 +14834,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15505,11 +14854,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15517,7 +14861,7 @@ { "measureId": "ASNC13", "title": "SPECT-MPI studies meeting appropriate use criteria", - "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion \n Imaging (MPI) studies performed that are appropriate.", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion\n Imaging (MPI) studies performed that are appropriate.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, @@ -15530,11 +14874,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15542,7 +14881,7 @@ { "measureId": "ASNC14", "title": "PET-MPI studies meeting appropriate use criteria", - "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies \n performed that are appropriate.", + "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are appropriate.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, @@ -15555,11 +14894,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15580,11 +14914,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15592,7 +14921,7 @@ { "measureId": "ASNC18", "title": "PET-MPI studies not Equivocal", - "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies \n performed that are not equivocal.", + "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are not equivocal.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "isHighPriority": true, @@ -15605,11 +14934,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15630,11 +14954,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15642,7 +14961,7 @@ { "measureId": "ASNC20", "title": "SPECT-MPI studies performed without the use of thallium", - "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion \n Imaging (MPI) studies performed without the use of thallium.", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion\n Imaging (MPI) studies performed without the use of thallium.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -15655,11 +14974,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15680,11 +14994,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15705,11 +15014,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15730,11 +15034,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15755,11 +15054,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15780,11 +15074,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15805,11 +15094,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15830,11 +15114,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15855,11 +15134,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15880,11 +15154,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15905,11 +15174,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15930,11 +15194,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15955,11 +15214,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -15980,11 +15234,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16005,11 +15254,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16030,11 +15274,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16055,11 +15294,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16080,11 +15314,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16105,11 +15334,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16130,11 +15354,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16155,11 +15374,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16180,11 +15394,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16205,11 +15414,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16230,11 +15434,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16255,11 +15454,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16280,11 +15474,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16305,11 +15494,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16330,11 +15514,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16355,11 +15534,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16380,11 +15554,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16405,11 +15574,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16430,11 +15594,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16455,11 +15614,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16480,11 +15634,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16505,11 +15654,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16517,7 +15661,7 @@ { "measureId": "AHSQC6", "title": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period", - "description": "Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.\n\nThis measure is reported as three performance rates stratified by hernia width:\n1) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)\n2) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm\n3) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm", + "description": "Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.\n\nThis measure is reported as three performance rates stratified by hernia width:\nRate 1: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)\nRate 2: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm\nRate 3: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -16530,14 +15674,24 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "hernia", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)" + }, + { + "name": "overall", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm" + }, + { + "name": "hernia>10cm", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "AHSQC7", @@ -16555,11 +15709,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16580,11 +15729,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16592,7 +15736,7 @@ { "measureId": "AHSQC9", "title": "Ventral Hernia Repair: Pain and Functional Status Assessment", - "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email. \nThis measure is reported as two performance rates: \n1) Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate\n2) Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate", + "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email.\nThis measure is reported as two performance rates:\nRate 1: Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate\nRate 2: Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -16605,14 +15749,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate" + }, + { + "name": "email", + "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "ABG28", @@ -16630,11 +15780,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16655,11 +15800,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16680,11 +15820,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16705,11 +15840,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16730,11 +15860,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16755,11 +15880,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16780,11 +15900,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16805,11 +15920,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16830,11 +15940,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16855,11 +15960,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16880,11 +15980,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16905,11 +16000,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16930,11 +16020,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16955,11 +16040,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -16980,11 +16060,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17005,11 +16080,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17030,11 +16100,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17042,7 +16107,7 @@ { "measureId": "AQI49", "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite", - "description": "This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below:\n\n1. Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used\n2. Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used\n3. Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used\n4. Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used\n5. Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met\n\nFor MIPS performance purposes, the overall performance score is the 5th composite performance score for this measure.", + "description": "This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below:\n\nRate 1: Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used\nRate 2: Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used\nRate 3: Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used\nRate 4: Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used\nRate 5: Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -17055,14 +16120,32 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "lysine", + "description": "Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used" + }, + { + "name": "mini", + "description": "Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used" + }, + { + "name": "redcell", + "description": "Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used" + }, + { + "name": "transfusion", + "description": "Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used" + }, + { + "name": "overall", + "description": "Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "AQI50", @@ -17080,11 +16163,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17105,11 +16183,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17130,11 +16203,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17155,11 +16223,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17180,11 +16243,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17205,11 +16263,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17230,11 +16283,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17255,11 +16303,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17280,11 +16323,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17305,11 +16343,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17330,11 +16363,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17355,11 +16383,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17380,11 +16403,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17405,11 +16423,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17430,11 +16443,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17455,11 +16463,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17480,11 +16483,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17505,11 +16503,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17530,11 +16523,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17555,11 +16543,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17580,11 +16563,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17605,11 +16583,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17630,11 +16603,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17655,11 +16623,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17680,11 +16643,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17705,11 +16663,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17730,11 +16683,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17755,11 +16703,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17780,11 +16723,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17805,11 +16743,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17830,11 +16763,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17855,11 +16783,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17880,11 +16803,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17905,11 +16823,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17930,11 +16843,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17955,11 +16863,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -17980,11 +16883,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18005,11 +16903,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18030,11 +16923,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18055,11 +16943,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18080,11 +16963,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18105,11 +16983,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18130,11 +17003,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18142,7 +17010,7 @@ { "measureId": "CESQIP5", "title": "Related readmission for adrenal related problems", - "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: \n 1. Hematoma \n 2. Adrenal Insufficiency \n 3. Hypertension \n 4. Pain \n 5. Wound Infection \n 6. Pneumonia \n 7. Dehydration \n 8. Respiratory Distress", + "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hematoma\n 2. Adrenal Insufficiency\n 3. Hypertension\n 4. Pain\n 5. Wound Infection\n 6. Pneumonia\n 7. Dehydration\n 8. Respiratory Distress", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -18155,11 +17023,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18167,7 +17030,7 @@ { "measureId": "CESQIP2", "title": "Related readmission for thyroid or parathyroid related problems", - "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: \n 1. Hypocalcemia \n 2. Hematoma \n 3. Seroma \n 4. Wound infection \n 5. Rash \n 6. Dehydration \n 7. Lymphatic or thoracic duct leak \n 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness \n 9. Dysphagia \n 10. Pain \n 11. Tracheal injury or perforation \n 12. Esophageal injury or perforation \n 13. Lower extremity complication (Phlebitis) \n 14. Deep venous thrombosis \n 15. Pulmonary embolism (including respiratory distress) \n 16. Pulmonary (asthma, URI, pneumonia) \n 17. Gastrointestinal (diarrhea, constipation, SBO) \n 18. Nausea and/or vomiting \n 19. Genitourinary (UTI, urinary retention) \n 20. Myocardial Event (Atrial fib, CHF, MI, CVA) \n 21. Psychiatric/Neurological (anxiety, syncope, dizziness)", + "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hypocalcemia\n 2. Hematoma\n 3. Seroma\n 4. Wound infection\n 5. Rash\n 6. Dehydration\n 7. Lymphatic or thoracic duct leak\n 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness\n 9. Dysphagia\n 10. Pain\n 11. Tracheal injury or perforation\n 12. Esophageal injury or perforation\n 13. Lower extremity complication (Phlebitis)\n 14. Deep venous thrombosis\n 15. Pulmonary embolism (including respiratory distress)\n 16. Pulmonary (asthma, URI, pneumonia)\n 17. Gastrointestinal (diarrhea, constipation, SBO)\n 18. Nausea and/or vomiting\n 19. Genitourinary (UTI, urinary retention)\n 20. Myocardial Event (Atrial fib, CHF, MI, CVA)\n 21. Psychiatric/Neurological (anxiety, syncope, dizziness)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -18180,11 +17043,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18192,7 +17050,7 @@ { "measureId": "CUHSM3", "title": "CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)", - "description": "•Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients. \n Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. \n Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. \n Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians", + "description": "•Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients.\n Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients.\n Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients.\n Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "isHighPriority": true, @@ -18205,11 +17063,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18230,11 +17083,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18255,11 +17103,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18280,11 +17123,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18305,11 +17143,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18330,11 +17163,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18355,11 +17183,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18380,11 +17203,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18405,11 +17223,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18430,11 +17243,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18455,11 +17263,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18480,11 +17283,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18505,11 +17303,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18530,11 +17323,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18555,11 +17343,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18580,11 +17363,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18605,11 +17383,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18630,11 +17403,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18655,11 +17423,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18680,11 +17443,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -18705,11 +17463,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18730,11 +17483,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18742,7 +17490,7 @@ { "measureId": "HF3", "title": "Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder", - "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. \n\nEligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1] \n\nDefining the population: \nCPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability. \n\nLabral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460). \n\nSurgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure. \nTime-period for data collection and reporting: \nThis measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. \n\nMeasures: \nTwo surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. \nUnadjusted measure: Average Shoulder Measure Change Score", + "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level.\n\nEligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1]\n\nDefining the population:\nCPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability.\n\nLabral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460).\n\nSurgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure.\nTime-period for data collection and reporting:\nThis measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available.\n\nMeasures:\nTwo surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon.\nUnadjusted measure: Average Shoulder Measure Change Score", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -18755,11 +17503,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18780,11 +17523,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18805,11 +17543,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18817,7 +17550,7 @@ { "measureId": "HF6", "title": "Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair", - "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscal repair. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]Defining the population:\nCPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscal repair. Meniscal repair during the reporting period CPT-4 Codes: 29882, 29883. Excluding concurrent procedures including Anterior Cruciate Ligament Reconstruction (29888). Surgeons who performed a minimum of 25 meniscal repair procedures a year will be eligible to submit this measure.Time period for data collection and reporting:\nThis measure will be calculated using all patients who underwent meniscal repair during the observation period. Patients receiving meniscal repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscal repair patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscal repair patients in the denominator. DENOMINATOR: The number of all patients who received meniscal repair during the observation window from the surgeon. Type of score: Validated knee measure change score average; Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscal repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscal repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model.\nType of score: Ratio score\nInterpretation of score:\nSurgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions:\nPatient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. \nPatient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months.Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient.Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient.The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", + "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscal repair. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]Defining the population:\nCPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscal repair. Meniscal repair during the reporting period CPT-4 Codes: 29882, 29883. Excluding concurrent procedures including Anterior Cruciate Ligament Reconstruction (29888). Surgeons who performed a minimum of 25 meniscal repair procedures a year will be eligible to submit this measure.Time period for data collection and reporting:\nThis measure will be calculated using all patients who underwent meniscal repair during the observation period. Patients receiving meniscal repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscal repair patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscal repair patients in the denominator. DENOMINATOR: The number of all patients who received meniscal repair during the observation window from the surgeon. Type of score: Validated knee measure change score average; Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscal repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscal repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model.\nType of score: Ratio score\nInterpretation of score:\nSurgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions:\nPatient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal.\nPatient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months.Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient.Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient.The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -18830,11 +17563,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18855,11 +17583,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18880,11 +17603,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18905,11 +17623,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18917,7 +17630,7 @@ { "measureId": "M2S16", "title": "Absence of unplanned reoperation after major lower extremity amputation", - "description": "The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision. \n\n Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique.", + "description": "The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision.\n\n Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -18930,11 +17643,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18942,7 +17650,7 @@ { "measureId": "M2S17", "title": "Absence of serious technical complications during peripheral arterial intervention", - "description": "The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment. \n\n Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue.", + "description": "The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment.\n\n Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -18955,11 +17663,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18967,7 +17670,7 @@ { "measureId": "M2S18", "title": "Venous clinical severity score (VCSS) assessment before varicose vein treatment", - "description": "The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment. \n Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement.", + "description": "The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment.\n Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -18980,11 +17683,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -18992,7 +17690,7 @@ { "measureId": "M2S19", "title": "Proper patient selection for perforator vein ablation", - "description": "The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease. \n\n Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction.", + "description": "The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease.\n\n Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -19005,11 +17703,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19030,11 +17723,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19055,11 +17743,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19080,11 +17763,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19105,11 +17783,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19130,11 +17803,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19155,11 +17823,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19180,11 +17843,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19205,11 +17863,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19230,11 +17883,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19255,11 +17903,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19280,11 +17923,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19305,11 +17943,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19330,11 +17963,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19342,7 +17970,7 @@ { "measureId": "BIVARUS27", "title": "Patient Reported Comprehensive Assessment of Safety", - "description": "A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. \nNote: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. \n Items: \n Bivarus 1: Hand Sanitation Performed By My Provider \n Bivarus 2: Medication Reconciliation Performed At My Visit \n Bivarus 3: Practice Asked Me About Allergies \n Bivarus 5: Practice Explained Medications Before Giving Them \n Bivarus 10: Overall Assessment Of Safety", + "description": "A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\nNote: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n Items:\n Bivarus 1: Hand Sanitation Performed By My Provider\n Bivarus 2: Medication Reconciliation Performed At My Visit\n Bivarus 3: Practice Asked Me About Allergies\n Bivarus 5: Practice Explained Medications Before Giving Them\n Bivarus 10: Overall Assessment Of Safety", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "patientEngagementExperience", "isHighPriority": true, @@ -19355,11 +17983,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19367,7 +17990,7 @@ { "measureId": "BIVARUS28", "title": "Patient Reported Experience and Care Coordination", - "description": "A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. \n\nItems: \n\nBivarus 16: My Doctor Listened To Me \nBivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions \nBivarus 19: My Doctor Explained My Final Diagnosis \nBivarus 22: My Doctor Informed Me of My Treatment Options \nBivarus 23: My Doctor Told Me How Longs Things Would Take \nBivarus 24: My Doctor Did Not Seem Rushed With Me \nBivarus 25: While In My Room, My Doctor Was Focused On My Issues \nBivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends", + "description": "A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\nItems:\n\nBivarus 16: My Doctor Listened To Me\nBivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions\nBivarus 19: My Doctor Explained My Final Diagnosis\nBivarus 22: My Doctor Informed Me of My Treatment Options\nBivarus 23: My Doctor Told Me How Longs Things Would Take\nBivarus 24: My Doctor Did Not Seem Rushed With Me\nBivarus 25: While In My Room, My Doctor Was Focused On My Issues\nBivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes/Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, @@ -19380,11 +18003,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19392,7 +18010,7 @@ { "measureId": "BIVARUS32", "title": "Patient Reported Care Team Communication", - "description": "A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. \n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. \n\n Items: \n\n Bivarus 7: Coordination of Care Among Physicians And Nurses \n Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care \n Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand \n Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan", + "description": "A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Items:\n\n Bivarus 7: Coordination of Care Among Physicians And Nurses\n Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care\n Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand\n Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientEngagementExperience", "isHighPriority": true, @@ -19405,11 +18023,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19417,7 +18030,7 @@ { "measureId": "BIVARUS30", "title": "Patient Reported Pain Treatment Effectiveness", - "description": "This measure is a patient reported outcome measure. \n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. \n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. \n\n Item: \n\n Bivarus 13: My Pain Was Treated Effectively", + "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Item:\n\n Bivarus 13: My Pain Was Treated Effectively", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -19430,11 +18043,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19442,7 +18050,7 @@ { "measureId": "BIVARUS31", "title": "Patient Reported Communication and Care Coordination", - "description": "This measure is a patient reported outcome measure. \n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. \n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. \n\n Item: \n\n Bivarus 20: I Understood What the Physician Told Me", + "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Item:\n\n Bivarus 20: I Understood What the Physician Told Me", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, @@ -19455,19 +18063,14 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" }, { - "measureId": "MOA 1", + "measureId": "MOA1", "title": "Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment.", - "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either: \n a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). \n b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. \n c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. \n\n Measure explanation: \n a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). \n b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). \n\n 1) Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain. \n2) Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain.", + "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either:\n a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6).\n b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present.\n c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\n Measure explanation:\n a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n\nRate 1: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain.\nRate 2: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -19480,19 +18083,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", "strata": [ { - "name": "overall" + "name": "back", + "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain." + }, + { + "name": "neck", + "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "MOA 2", "title": "Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology.", - "description": "Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year. \n\n Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending.", + "description": "Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year.\n\n Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, @@ -19505,11 +18114,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19517,7 +18121,7 @@ { "measureId": "MOA 7", "title": "Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur.", - "description": "Successful Reporting: \n a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically. \n b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. \n c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.). \n\nMeasure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation.", + "description": "Successful Reporting:\n a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically.\n b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year.\n c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.).\n\nMeasure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -19530,11 +18134,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19542,7 +18141,7 @@ { "measureId": "MOA 13", "title": "Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders.", - "description": "Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure. \n\nMeasure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period.", + "description": "Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure.\n\nMeasure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, @@ -19555,11 +18154,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19567,7 +18161,7 @@ { "measureId": "MOA 14", "title": "Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety.", - "description": "Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified. \n\n Measure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines.", + "description": "Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified.\n\n Measure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -19580,11 +18174,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19592,7 +18181,7 @@ { "measureId": "MOA 15", "title": "Weight loss in pain patients with BMI >30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control.", - "description": "Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy. \n\nMeasure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management.", + "description": "Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy.\n\nMeasure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -19605,11 +18194,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19617,7 +18201,7 @@ { "measureId": "MOA 12", "title": "Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities.", - "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. \n\nProviders would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code). \n\nMeasure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment.", + "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\nProviders would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code).\n\nMeasure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, @@ -19630,11 +18214,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19655,11 +18234,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19680,11 +18254,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19692,7 +18261,7 @@ { "measureId": "ECPR43", "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", - "description": "Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR); multiple performance rates include: \n• Rate - Emergency Department (ED) \n• Rate – Urgent Care (UC)", + "description": "multiple performance rates include:\nRate 1: In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)\nRate 2: In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "isHighPriority": true, @@ -19705,14 +18274,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)" + }, + { + "name": "urgentcare", + "description": "In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "ECPR2", @@ -19730,11 +18305,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19755,11 +18325,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19780,11 +18345,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19805,11 +18365,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19830,11 +18385,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19855,11 +18405,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19880,11 +18425,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -19905,11 +18445,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19930,11 +18465,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19955,11 +18485,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -19980,11 +18505,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20005,11 +18525,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20030,11 +18545,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20055,11 +18565,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20080,11 +18585,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20105,11 +18605,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20130,11 +18625,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20155,11 +18645,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20180,11 +18665,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20205,11 +18685,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20230,11 +18705,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20255,11 +18725,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20267,7 +18732,7 @@ { "measureId": "MICS1", "title": "General Health Postoperative Improvement", - "description": "Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery. \n \nPerformance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.\n \nInstructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery. \n\nRationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "description": "Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery.\n\nRationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "isHighPriority": false, @@ -20280,11 +18745,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20292,7 +18752,7 @@ { "measureId": "MICS2", "title": "Surgery Specific Postoperative Improvement in Pain Levels", - "description": "Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery. \n \nPerformance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels. \n\nRationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "description": "Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels.\n\nRationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -20305,11 +18765,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20317,7 +18772,7 @@ { "measureId": "MICS3", "title": "Surgery Specific Postoperative Improvement in Function Levels", - "description": "Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery. \n \nPerformance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.\n \nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks. \n\nRationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "description": "Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks.\n\nRationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -20330,11 +18785,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20342,7 +18792,7 @@ { "measureId": "MEX1", "title": "Heel Pain Treatment Outcomes for Adults", - "description": "DESCRIPTION: \n Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year \n\n INSTRUCTIONS: \n This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. \n\n Measure Reporting via Registry: \n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. \n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", + "description": "DESCRIPTION:\n Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year\n\n INSTRUCTIONS:\n This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -20355,11 +18805,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20367,7 +18812,7 @@ { "measureId": "MEX2", "title": "Heel Pain Treatment Outcomes for Pediatric Patients", - "description": "DESCRIPTION: \nPercentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain. \n\nINSTRUCTIONS: \n This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. \n\n Measure Reporting via Registry: \n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. \n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", + "description": "DESCRIPTION:\nPercentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain.\n\nINSTRUCTIONS:\n This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -20380,11 +18825,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20392,7 +18832,7 @@ { "measureId": "MEX3", "title": "Identification of Flat Foot in Pediatric Patients", - "description": "DESCRIPTION: \nPercentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year \n\nINSTRUCTIONS: \nThis measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient. \n\n Measure Reporting via Registry: \n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.", + "description": "DESCRIPTION:\nPercentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year\n\nINSTRUCTIONS:\nThis measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -20405,11 +18845,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20417,7 +18852,7 @@ { "measureId": "MBSAQIP1", "title": "Risk standardized rate of patients who experienced a postoperative complication within 30 days", - "description": "Risk standardized rate of patients who experienced a postoperative complication within 30 days \n following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, \n performed as a primary (not revisional) procedure.", + "description": "Risk standardized rate of patients who experienced a postoperative complication within 30 days\n following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation,\n performed as a primary (not revisional) procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -20430,11 +18865,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20455,11 +18885,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20480,11 +18905,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20505,11 +18925,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20530,11 +18945,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20555,11 +18965,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20580,11 +18985,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -20605,11 +19005,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20630,11 +19025,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20655,11 +19045,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20680,11 +19065,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20692,7 +19072,7 @@ { "measureId": "MSSIC8", "title": "Percent of patients achieving MCID for back or neck pain", - "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. \n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -20705,11 +19085,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20717,7 +19092,7 @@ { "measureId": "MSSIC9", "title": "Percent of patients achieving MCID for leg or arm pain", - "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. \n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -20730,11 +19105,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20742,7 +19112,7 @@ { "measureId": "MSSIC10", "title": "Percent of patients achieving MCID for pain-related disability (ODI/NDI)", - "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. \n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -20755,11 +19125,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20780,11 +19145,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20805,11 +19165,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20830,11 +19185,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20855,11 +19205,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20867,7 +19212,7 @@ { "measureId": "MSSIC12", "title": "Risk-adjusted rate of hospital readmission", - "description": "The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned \"readmissions\" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions. \n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "description": "The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned \"readmissions\" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions.\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -20880,11 +19225,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20892,7 +19232,7 @@ { "measureId": "MSSIC13", "title": "Risk-adjusted rate of surgical site infection", - "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment. \n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -20905,11 +19245,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20917,7 +19252,7 @@ { "measureId": "MSSIC14", "title": "Risk-adjusted rate of urinary retention", - "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period. \n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -20930,11 +19265,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20955,11 +19285,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -20980,11 +19305,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21005,11 +19325,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21030,11 +19345,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21055,11 +19365,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21080,11 +19385,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21105,11 +19405,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21130,11 +19425,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21155,11 +19445,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21180,11 +19465,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21205,11 +19485,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21230,11 +19505,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21255,11 +19525,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21280,11 +19545,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21305,11 +19565,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21330,11 +19585,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21355,11 +19605,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21380,11 +19625,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21405,11 +19645,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21430,11 +19665,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21442,7 +19672,7 @@ { "measureId": "MNCM1", "title": "Optimal Diabetes Care", - "description": "The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following: \n>HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present \n>Non‐tobacco user >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present", + "description": "The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:\n>HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present\n>Non‐tobacco user >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, @@ -21455,11 +19685,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21467,7 +19692,7 @@ { "measureId": "MNCM2", "title": "Optimal Vascular Care", - "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following: \n* Blood Pressure less than 140/90 mmHg \n* On a statin medication, unless allowed contraindications or exceptions are present \n* Non-tobacco user \n*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present", + "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:\n* Blood Pressure less than 140/90 mmHg\n* On a statin medication, unless allowed contraindications or exceptions are present\n* Non-tobacco user\n*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, @@ -21480,11 +19705,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21492,7 +19712,7 @@ { "measureId": "MNCM3", "title": "Optimal Asthma Control", - "description": "The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period \n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months\n\nThe percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period \n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months", + "description": "Rate 1: The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months\n\nRate 2: The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": true, @@ -21505,14 +19725,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", "strata": [ { - "name": "overall" + "name": "pediatric", + "description": "The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months" + }, + { + "name": "adult", + "description": "The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "MNCM4", @@ -21530,11 +19756,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21555,11 +19776,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21580,11 +19796,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21605,11 +19816,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21630,11 +19836,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21655,11 +19856,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21680,11 +19876,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21705,11 +19896,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21730,11 +19916,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21755,11 +19936,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21780,11 +19956,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21805,11 +19976,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21817,7 +19983,7 @@ { "measureId": "MHAN1", "title": "Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate", - "description": "Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) \nor asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions \nand transfers from other institutions.", + "description": "Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD)\nor asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions\nand transfers from other institutions.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -21830,11 +19996,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21855,11 +20016,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -21880,11 +20036,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21892,7 +20043,7 @@ { "measureId": "NHBPC15", "title": "A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure)", - "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received basic ADL assessments and IADL assessments at enrollment and annually.\n \nThis measure will be calculated with three rates:\n \n1) Percentage of patients who received a basic ADL assessment\n2) Percentage of patients who received an IADL assessment\n3) Percentage of patients who received both a basic ADL and IADL assessment (overall rate)", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received basic ADL assessments and IADL assessments at enrollment and annually.\n\nThis measure will be calculated with three rates:\n\nRate 1: Percentage of patients who received a basic ADL assessment\nRate 2: Percentage of patients who received an IADL assessment\nRate 3: Percentage of patients who received both a basic ADL and IADL assessment (overall rate)", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -21905,17 +20056,27 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" - }, - { - "measureId": "NHBPC2", + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "ADL", + "description": "Percentage of patients who received a basic ADL assessment" + }, + { + "name": "IADL", + "description": "Percentage of patients who received an IADL assessment" + }, + { + "name": "overall", + "description": "Percentage of patients who received both a basic ADL and IADL assessment (overall rate)" + } + ] + }, + { + "measureId": "NHBPC2", "title": "Alcohol Problem Use Assessment for Home-Based Primary Care and Palliative Care Patients", "description": "Percentage of newly enrolled and active home-based primary care and palliative care patients who were assessed for a problem with alcohol use at enrollment.", "nationalQualityStrategyDomain": "Community/Population Health", @@ -21930,11 +20091,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21955,11 +20111,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -21967,7 +20118,7 @@ { "measureId": "NHBPC7", "title": "Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure)", - "description": "Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates:\n \n1) Percentage of patients whose medications lists were reviewed for possible offending medications.\n2) Percentage of patients with offending medications whose use of offending medications was discontinued or justified.", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates:\n\nRate 1: Percentage of patients whose medications lists were reviewed for possible offending medications.\nRate 2: Percentage of patients with offending medications whose use of offending medications was discontinued or justified.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -21980,14 +20131,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "reviewed", + "description": "Percentage of patients whose medications lists were reviewed for possible offending medications." + }, + { + "name": "overall", + "description": "Percentage of patients with offending medications whose use of offending medications was discontinued or justified." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NHBPC3", @@ -22005,11 +20162,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22030,11 +20182,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22055,11 +20202,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22080,11 +20222,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22105,11 +20242,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22130,11 +20262,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22155,11 +20282,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22180,11 +20302,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22205,11 +20322,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22230,11 +20342,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22255,11 +20362,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22280,11 +20382,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22305,11 +20402,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -22330,11 +20422,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -22355,11 +20442,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22380,11 +20462,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22405,11 +20482,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22430,11 +20502,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22455,11 +20522,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22480,11 +20542,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22505,11 +20562,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22530,11 +20582,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22555,11 +20602,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22580,11 +20622,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22605,11 +20642,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22617,7 +20649,7 @@ { "measureId": "NPA3", "title": "Functional Outcome Assessment for Spine Intervention", - "description": "Percentage of patients aged 18 years and older undergoing index spine therapy (-ies) who completed baseline and 3-month follow-up (patient-reported) functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates:\n1) Rate 1: Patient population with Follow-up/Patient population with baseline\n2) Rate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up. \nOverall Rate = Rate 2", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy (-ies) who completed baseline and 3-month follow-up (patient-reported) functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22630,19 +20662,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in functional status after Follow-up/Patient population with Follow-up." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPA4", "title": "Quality-of-Life Assessment for Spine Intervention", - "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed baseline and 3-month follow-up (patient-reported) quality-of-life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates:\n1) Rate 1: Patient population with Follow-up/Patient population with baseline\n2) Rate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up. \nOverall Rate = Rate 2", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed baseline and 3-month follow-up (patient-reported) quality-of-life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22655,19 +20693,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPA5", "title": "Patient Satisfaction with Spine Care", - "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed 3-month follow-up (patient-reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates:\n1) Rate 1: Patient population with Follow-up/Patient population with baseline\n2) Rate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up. \nOverall Rate = Rate 2", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed 3-month follow-up (patient-reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22680,14 +20724,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPAGSC6", @@ -22705,11 +20755,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22730,11 +20775,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22742,7 +20782,7 @@ { "measureId": "NPAGSC3", "title": "Functional Outcome Assessment for Spine Intervention", - "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment with at least 10% improvement in the functional status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: \nRate 1: Patient population with Follow-up/Patient population with baseline \nRate 2: Patient population with improvement in functional status (at least 10% improvement) from the baseline. \nThus Rate 2 =< Rate 1 \nOverall Rate = Rate 1", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment with at least 10% improvement in the functional status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in functional status (at least 10% improvement) from the baseline.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22755,19 +20795,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in functional status (at least 10% improvement) from the baseline." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPAGSC7", "title": "Narcotic Pain Medicine Management Prior to and Following Spine Therapy", - "description": "Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: \nRate 1: Patient population with Follow-up/Patient population with baseline \nRate 2: Patient population with improvement in pain status from the baseline.\nThus Rate 2 =< Rate 1 \nOverall Rate = Rate 1", + "description": "Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in pain status from the baseline.\nThus Rate 2 =< Rate 1\nOverall Rate = Rate 1", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, @@ -22780,11 +20826,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -22805,11 +20846,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22817,7 +20853,7 @@ { "measureId": "NPAGSC4", "title": "Quality-of-Life Assessment for Spine Intervention", - "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment with an improvement in the quality of life status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline \nRate 2: Patient population with improvement in Quality of life status from the baseline\nThus Rate 2 =< Rate 1 \nOverall Rate = Rate 1", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment with an improvement in the quality of life status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in Quality of life status from the baseline", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22830,19 +20866,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in Quality of life status from the baseline" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPAGSC5", "title": "Patient Satisfaction with Spine Care", - "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed satisfaction with care assessment prior to the treatment and at 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment with an improvement in the satisfaction with care status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline \nRate 2: Patient population with improvement in satisfaction with care status from the baseline\nThus Rate 2 =< Rate 1 \nOverall Rate = Rate 1", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed satisfaction with care assessment prior to the treatment and at 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment with an improvement in the satisfaction with care status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in satisfaction with care status from the baseline", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22855,19 +20897,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in satisfaction with care status from the baseline" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NPAGSC10", "title": "Spine/Extremity Pain Assessment", - "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s)AND/ OR Leg or arm pain tool(s) at baseline and 2 +/-1 month following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms with an improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline \nRate 2: Patient population with improvement in the pain status from the baseline\nThus Rate 2 =< Rate 1 \nOverall Rate = Rate 1", + "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s)AND/ OR Leg or arm pain tool(s) at baseline and 2 +/-1 month following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms with an improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in the pain status from the baseline", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -22880,14 +20928,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in the pain status from the baseline" } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NHCR5", @@ -22905,11 +20959,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22930,11 +20979,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22955,11 +20999,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -22980,11 +21019,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23005,11 +21039,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23030,11 +21059,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23055,11 +21079,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23080,11 +21099,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23105,11 +21119,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23130,11 +21139,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23155,11 +21159,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23180,11 +21179,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23205,11 +21199,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23230,11 +21219,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23255,11 +21239,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23280,11 +21259,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23305,11 +21279,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23330,11 +21299,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23355,11 +21319,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23380,11 +21339,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23405,11 +21359,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23430,11 +21379,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23442,7 +21386,7 @@ { "measureId": "NNEPTN1", "title": "Substance Use Screening", - "description": "This measure produces two rates of substance use screening:\na) Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year.\n\nb) Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year.", + "description": "This measure produces two rates of substance use screening:\nRate 1: Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year.\nRate 2: Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, @@ -23455,14 +21399,20 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", "strata": [ { - "name": "overall" + "name": "12to18", + "description": "Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year." + }, + { + "name": "18", + "description": "Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "NNEPTN2", @@ -23480,11 +21430,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23492,7 +21437,7 @@ { "measureId": "NNEPTN3", "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team", - "description": "Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: \n 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: \n a. Patient communication \n b. Health professional assessments; \n 2. Identify gaps in the achievement of health and life plan; \n 3. Health status evaluations, interventions, and outcomes; \n 4. Action plans: \n a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. \n 5. Medication Management; \n 6. Identify community/social services and family support; \n 7. Advanced directives", + "description": "Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements:\n 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by:\n a. Patient communication\n b. Health professional assessments;\n 2. Identify gaps in the achievement of health and life plan;\n 3. Health status evaluations, interventions, and outcomes;\n 4. Action plans:\n a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals.\n 5. Medication Management;\n 6. Identify community/social services and family support;\n 7. Advanced directives", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "isHighPriority": true, @@ -23505,11 +21450,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23517,7 +21457,7 @@ { "measureId": "NNEPTN4", "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 02: Referral of At-Risk Patients to Community Based Prevention and Support Resources", - "description": "This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes: \n• BMI range >26; \n• Pre-diabetes; \n• Metabolic syndrome; \n• Behavioral/mental health ; \n• Substance use disorder.", + "description": "This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes:\n• BMI range >26;\n• Pre-diabetes;\n• Metabolic syndrome;\n• Behavioral/mental health ;\n• Substance use disorder.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "isHighPriority": false, @@ -23530,11 +21470,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23555,11 +21490,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23580,11 +21510,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23605,11 +21530,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23630,11 +21550,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23655,11 +21570,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23680,11 +21590,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23705,11 +21610,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23730,11 +21630,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23755,11 +21650,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23780,11 +21670,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23805,11 +21690,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23830,11 +21710,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23855,11 +21730,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23867,7 +21737,7 @@ { "measureId": "WCHQ32", "title": "Controlling High Blood Pressure: eGFR Test Annually", - "description": "The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period: \n\n An eGFR (Estimated Glomerular Filtration Rate) test annually", + "description": "The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period:\n\n An eGFR (Estimated Glomerular Filtration Rate) test annually", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -23880,11 +21750,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23892,7 +21757,7 @@ { "measureId": "WCHQ10", "title": "Diabetes Care All or None Outcome Measure: Optimal Control", - "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <140/90, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.", + "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <140/90, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -23905,11 +21770,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23917,7 +21777,7 @@ { "measureId": "WCHQ9", "title": "Diabetes Care All or None Process Measure: Optimal Testing", - "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \nAll or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test", + "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\nAll or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -23927,14 +21787,9 @@ "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23942,7 +21797,7 @@ { "measureId": "WCHQ13", "title": "Ischemic Vascular Disease Care Blood Pressure Control", - "description": "The percentage of patients age 18 through 75 with one of the following conditions: \n 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or \n 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year: \n Most recent Blood pressure controlled to a level of less than 140/90 mm Hg", + "description": "The percentage of patients age 18 through 75 with one of the following conditions:\n 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or\n 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year:\n Most recent Blood pressure controlled to a level of less than 140/90 mm Hg", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -23955,11 +21810,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -23980,11 +21830,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24005,11 +21850,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24017,7 +21857,7 @@ { "measureId": "ACCPin2", "title": "CAD: Blood Pressure Control", - "description": "Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure \n< 140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during the most recent office visit", + "description": "Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure\n< 140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during the most recent office visit", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -24030,11 +21870,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24055,11 +21890,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24080,11 +21910,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24105,11 +21930,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24130,11 +21950,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24155,11 +21970,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24180,11 +21990,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24205,11 +22010,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24230,11 +22030,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24255,11 +22050,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24280,11 +22070,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24305,11 +22090,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24330,11 +22110,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24355,11 +22130,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24380,11 +22150,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24405,11 +22170,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24430,11 +22190,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24455,11 +22210,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24480,11 +22230,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24505,11 +22250,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24530,11 +22270,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24555,11 +22290,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24580,11 +22310,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -24605,11 +22330,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24630,11 +22350,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24642,7 +22357,7 @@ { "measureId": "PP1", "title": "Annual Monitoring for Patients on Persistent Medications (MPM)", - "description": "This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report the following three rates and a total rate: \n - Rate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.\n - Rate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year. \n - Rate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. \nThis measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics.", + "description": "This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics.\nRate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.\nRate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year.\nRate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": true, @@ -24655,14 +22370,24 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "sumNumerators", "strata": [ { - "name": "overall" + "name": "ace", + "description": "Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." + }, + { + "name": "digoxin", + "description": "Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year." + }, + { + "name": "diuretics", + "description": "Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "PP2", @@ -24680,11 +22405,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24705,11 +22425,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24730,11 +22445,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24755,11 +22465,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24780,11 +22485,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24805,11 +22505,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24830,11 +22525,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24855,11 +22545,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24880,11 +22565,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24892,7 +22572,7 @@ { "measureId": "AAO8", "title": "Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use", - "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants \n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications. \n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. \n\n Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. \n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016)\"", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications.\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016)\"", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -24905,11 +22585,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24917,7 +22592,7 @@ { "measureId": "AAO9", "title": "Otitis Media with Effusion: Systemic Corticosteroids – Avoidance of Inappropriate Use", - "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids \n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects. \n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. \n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. \n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -24930,11 +22605,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24942,7 +22612,7 @@ { "measureId": "AAO10", "title": "Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use", - "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials \n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. \n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. \n\n Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. \n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -24955,11 +22625,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -24967,7 +22632,7 @@ { "measureId": "AAO11", "title": "Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids", - "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids \n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects. \n\n The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. \n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. \n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects.\n\n The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "isHighPriority": false, @@ -24980,11 +22645,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25005,11 +22665,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25030,11 +22685,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25055,11 +22705,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25080,11 +22725,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25105,11 +22745,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25130,11 +22765,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25155,11 +22785,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25180,11 +22805,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25205,11 +22825,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25230,11 +22845,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25255,11 +22865,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25280,11 +22885,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25305,11 +22905,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25330,11 +22925,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25355,11 +22945,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -25380,11 +22965,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25405,11 +22985,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25430,11 +23005,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25455,11 +23025,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25480,11 +23045,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25505,11 +23065,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25530,11 +23085,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25555,11 +23105,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25567,7 +23112,7 @@ { "measureId": "ICLOPS15", "title": "Excess Days Rate and Degree of Excess (Including Physician Response)", - "description": "This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. Performance Rate 1 is the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older. Performance Rate 2 is the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days. The final performance rate is calculated as follows: Overall Performance Rate = (Part 1 Performance Met + Part 2 Performance Met) / (Part 1 Performance Eligible + Part 2 Performance Eligible). This measure was previously qualified as \"ICLOPS 15.\"", + "description": "This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "outcome", "isHighPriority": true, @@ -25580,19 +23125,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", "strata": [ { - "name": "overall" + "name": "withoutexcess", + "description": "the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older." + }, + { + "name": "withexcess", + "description": "the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "ICLOPS17", "title": "Rate of Follow Up Visits Within 7 Days of Discharge (Including Physician Response)", - "description": "This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. Performance Rate 1 the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older. Performance Rate 2 is the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older. The final performance rate is calculated as follows: Overall Performance Rate = (Part 1 Performance Met + Part 2 Performance Met) / (Part 1 Performance Eligible + Part 2 Performance Eligible). This measure was previously qualified as \"ICLOPS 17.\"", + "description": "This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "isHighPriority": true, @@ -25605,19 +23156,25 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", "strata": [ { - "name": "overall" + "name": "withfollowup", + "description": "the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older." + }, + { + "name": "withoutfollowup", + "description": "the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "RHI1", "title": "Diabetic patients with significant change in HgbA1C level or overall change in HgbA1C", - "description": "This measure examines changes in Hemoglobin A1c using 3 Performance Rates: Performance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%. Performance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "description": "This measure examines changes in Hemoglobin A1c using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -25630,19 +23187,29 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "<9", + "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance" + }, + { + "name": ">=9", + "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "RHI2", "title": "Hypertensive patients with significant change in systolic blood pressure or overall change in systolic pressure", - "description": "This measure examines changes in systlic blood pressure using 3 Performance Rates: Performance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg. Performance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "description": "This measure examines changes in systlic blood pressure using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "isHighPriority": true, @@ -25655,14 +23222,24 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": ">=160", + "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance" + }, + { + "name": "<160", + "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "RHI3", @@ -25680,11 +23257,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25692,7 +23264,7 @@ { "measureId": "RHI4", "title": "Patients with Change in BMI", - "description": "This measure examines BMI changes using 3 Performance Rates: Performance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35. Performance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "description": "This measure examines BMI changes using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "isHighPriority": false, @@ -25705,14 +23277,24 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "decreased", + "description": "The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance" + }, + { + "name": "increased", + "description": "The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "RHI5", @@ -25730,11 +23312,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25755,11 +23332,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25780,11 +23352,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25805,11 +23372,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25830,11 +23392,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25855,11 +23412,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25880,11 +23432,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25905,11 +23452,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25930,11 +23472,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25955,11 +23492,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -25980,11 +23512,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26005,11 +23532,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26030,11 +23552,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26055,11 +23572,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26080,11 +23592,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26105,11 +23612,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26130,11 +23632,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26155,11 +23652,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26180,11 +23672,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26203,13 +23690,8 @@ "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], + "nqfEMeasureId": null, + "nqfId": null, "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26230,11 +23712,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26255,11 +23732,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26280,11 +23752,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26305,11 +23772,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26330,11 +23792,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -26355,11 +23812,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -26380,11 +23832,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -26405,11 +23852,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26430,11 +23872,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26455,11 +23892,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26480,11 +23912,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26505,11 +23932,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26530,11 +23952,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26555,11 +23972,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26580,11 +23992,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26605,11 +24012,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26630,11 +24032,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26655,11 +24052,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26667,7 +24059,7 @@ { "measureId": "CAP3", "title": "Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin Completed", - "description": "Cancer checklist used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures – \n\n• Partial Nephrectomy\n• Radical Nephrectomy", + "description": "Cancer checklist used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures –\n\n• Partial Nephrectomy\n• Radical Nephrectomy", "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", "measureType": "outcome", "isHighPriority": false, @@ -26680,11 +24072,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26705,11 +24092,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26730,11 +24112,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26742,7 +24119,7 @@ { "measureId": "CAP6", "title": "Cancer Protocol Elements for Carcinoma of the Pancreas Completed", - "description": "Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The checklist covers the following procedures – \n• Partial Pancreatectomy \n• Pancreaticoduodenectomy (Whipple Resection) \n• Total Pancreatectomy", + "description": "Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The checklist covers the following procedures –\n• Partial Pancreatectomy\n• Pancreaticoduodenectomy (Whipple Resection)\n• Total Pancreatectomy", "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", "measureType": "outcome", "isHighPriority": false, @@ -26755,11 +24132,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26767,7 +24139,7 @@ { "measureId": "SPINEIQ1", "title": "Change in Functional Outcomes", - "description": "Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain. \n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", + "description": "Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -26780,11 +24152,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -26792,7 +24159,7 @@ { "measureId": "SPINEIQ2", "title": "Change in Pain Intensity", - "description": "Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain. \n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", + "description": "Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -26805,11 +24172,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "nonProportion" @@ -26830,11 +24192,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26855,11 +24212,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26880,11 +24232,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26905,11 +24252,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26930,11 +24272,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26955,11 +24292,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -26980,11 +24312,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27005,11 +24332,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27030,11 +24352,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27042,7 +24359,7 @@ { "measureId": "USWR15", "title": "Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT", - "description": "Percentage diabetic foot ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has achieved healing or closure 6 months after completion of a course of HBOT, stratified by the Wound Healing Index. Healing or closure is defined as an ulcer with epithelial coverage and no continued drainage requiring a dressing.\n \nThere are four rates reported for this measure. \nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: \n1. 0.00-62.42\n2. 62.42-73.19\n3. 73.19-93.45\n4. The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", + "description": "Percentage diabetic foot ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has achieved healing or closure 6 months after completion of a course of HBOT, stratified by the Wound Healing Index. Healing or closure is defined as an ulcer with epithelial coverage and no continued drainage requiring a dressing.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00-62.42\nRate 2: 62.42-73.19\nRate 3: 73.19-93.45\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "isHighPriority": false, @@ -27055,14 +24372,28 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "bucket1", + "description": "0.00-62.42" + }, + { + "name": "bucket2", + "description": "62.42-73.19" + }, + { + "name": "bucket3", + "description": "73.19-93.45" + }, + { + "name": "overall", + "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "USWR16", @@ -27080,11 +24411,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27092,7 +24418,7 @@ { "measureId": "USWR20", "title": "Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers", - "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool. \n\nUsing the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure.", + "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool.\n\nUsing the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "isHighPriority": true, @@ -27105,11 +24431,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27117,7 +24438,7 @@ { "measureId": "USWR22", "title": "Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers", - "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) within the 12-month reporting period. \n\nUsing the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Implementation of an intervention plan based on nutritional screening is CDR measure 20.", + "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) within the 12-month reporting period.\n\nUsing the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Implementation of an intervention plan based on nutritional screening is CDR measure 20.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -27130,19 +24451,14 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" }, { "measureId": "USWR13", - "title": "Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen \nTherapy (HBOT) Treatment", - "description": "Percentage of HBOT treatments of patients aged 18 years and older who have their vital signs and blood glucose level assessed prior to undergoing hyperbaric oxygen therapy\n(HBOT). Three rates are reported for this measure.\n \n1. Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken.\n2. Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check.\n3. Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check.", + "title": "Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen\nTherapy (HBOT) Treatment", + "description": "Percentage of HBOT treatments of patients aged 18 years and older who have their vital signs and blood glucose level assessed prior to undergoing hyperbaric oxygen therapy\n(HBOT). Three rates are reported for this measure.\n\nRate 1: Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken.\nRate 2: Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check.\nRate 3: Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "isHighPriority": false, @@ -27155,14 +24471,24 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "vital", + "description": "Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken." + }, + { + "name": "glucose", + "description": "Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check." + }, + { + "name": "overall", + "description": "Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "CDR3", @@ -27180,11 +24506,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27205,11 +24526,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27230,11 +24546,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27242,7 +24553,7 @@ { "measureId": "CDR6", "title": "Venous Leg Ulcer outcome measure: Healing or Closure", - "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n \nThere are four rates reported for this measure. \nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: \n1. 0.00-73.24\n2. 73.24-80.26\n3. 80.26-87.21\n4. The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", + "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00-73.24\nRate 2: 73.24-80.26\nRate 3: 80.26-87.21\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "isHighPriority": true, @@ -27255,14 +24566,28 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", "strata": [ { - "name": "overall" + "name": "bucket1", + "description": "0.00-73.24" + }, + { + "name": "bucket2", + "description": "73.24-80.26" + }, + { + "name": "bucket3", + "description": "80.26-87.21" + }, + { + "name": "overall", + "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." } - ], - "measureSets": [], - "isRegistryMeasure": true, - "metricType": "singlePerformanceRate" + ] }, { "measureId": "USWR21", @@ -27280,11 +24605,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" @@ -27305,11 +24625,6 @@ "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "strata": [ - { - "name": "overall" - } - ], "measureSets": [], "isRegistryMeasure": true, "metricType": "singlePerformanceRate" diff --git a/measures/measures-data.xml b/measures/measures-data.xml index b8ae5a43..52edb81a 100644 --- a/measures/measures-data.xml +++ b/measures/measures-data.xml @@ -10535,9 +10535,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10557,9 +10554,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10579,9 +10573,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10601,9 +10592,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10623,9 +10611,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10645,9 +10630,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10667,9 +10649,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10689,9 +10668,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10711,9 +10687,6 @@ b. Percentage of patients who were ordered at least two different high-risk medi - - overall - true singlePerformanceRate @@ -10724,9 +10697,9 @@ b. Percentage of patients who were ordered at least two different high-risk medi This measure will be calculated with three rates: -1) Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication -2) Patients prescribed alternative long-term control medications (non-ICS) -3) Total patients prescribed long-term control medication +Rate 1: Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication +Rate 2: Patients prescribed alternative long-term control medications (non-ICS) +Rate 3: Total patients prescribed long-term control medication Effective Clinical Care process false @@ -10739,16 +10712,26 @@ This measure will be calculated with three rates: + true + multiPerformanceRate + overallStratumOnly + + ICS + Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication + + + nonICS + Patients prescribed alternative long-term control medications (non-ICS) + overall + Total patients prescribed long-term control medication - true - singlePerformanceRate AAD1 Psoriasis: Assessment of Psoriasis Disease Activity - This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale. + This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale. Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period. Effective Clinical Care @@ -10763,16 +10746,13 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate AAD2 Psoriasis: Screening for Psoriatic Arthritis - Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life. + Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life. Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period. Person and Caregiver-Centered Experience and Outcomes @@ -10787,16 +10767,13 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate AAD3 Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients - This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) + This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery. Efficiency and Cost Reduction @@ -10811,16 +10788,13 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate AAD4 Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk - This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) + This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller on the trunk (chest, back, abdomen) who are treated with Mohs surgery. Efficiency and Cost Reduction @@ -10835,16 +10809,13 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate AAD5 Biopsy Reporting Time - Clinician to Patient - Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. + Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed. Efficiency and Cost Reduction @@ -10859,16 +10830,13 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate ARCO11 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival - This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio. + This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio. HOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´ Effective Communication and Care Coordination @@ -10883,9 +10851,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -10905,9 +10870,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -10915,10 +10877,10 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp ARCO13 Ischemic stroke patients management - o This measure will be calculated with 4 performance rates: -1. The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge; -2. The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate; -3. The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two; -4. The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge +Rate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge; +Rate 2: The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate; +Rate 3: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two; +Rate 4: The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge Effective Communication and Care Coordination process false @@ -10931,11 +10893,25 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp + true + multiPerformanceRate + sumNumerators - overall + antithrombotic + The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge; + + + anticoagulation + The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate; + + + antithrombotic2 + The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two; + + + LDL + The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge - true - singlePerformanceRate ARCO3 @@ -10953,9 +10929,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -10975,9 +10948,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -10997,9 +10967,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -11019,9 +10986,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -11041,9 +11005,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -11063,9 +11024,6 @@ HOQR is a quality data-reporting program, implemented by CMS for outpatient hosp - - overall - true singlePerformanceRate @@ -11087,9 +11045,6 @@ This measure evaluates the occurrence of stroke as an outcome of a percutaneous - - overall - true singlePerformanceRate @@ -11111,18 +11066,15 @@ This measure evaluates the occurrence of the new need for dialysis as an outcome - - overall - true singlePerformanceRate ACCCath3 Vascular access site injury requiring treatment or major bleeding post PCI in patients without CABG or other major surgeries during admission. - The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment. + The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment. -Major access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge. +Major access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge. Major bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure. To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding. @@ -11139,16 +11091,13 @@ This measure evaluates the occurrence of vascular site injury requiring treatmen - - overall - true singlePerformanceRate ACCCath4 Cardiac tamponade post PCI in patients without CABG or other major surgery during admission. - The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure. + The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure. This measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care. Patient Safety @@ -11163,9 +11112,6 @@ This measure evaluates the occurrence of cardiac tamponade as an outcome of a pe - - overall - true singlePerformanceRate @@ -11187,9 +11133,6 @@ This measure reflects the processes of care and current guidelines associated wi - - overall - true singlePerformanceRate @@ -11209,9 +11152,6 @@ This measure reflects the processes of care and current guidelines associated wi - - overall - true singlePerformanceRate @@ -11233,9 +11173,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true singlePerformanceRate @@ -11255,9 +11192,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true singlePerformanceRate @@ -11277,9 +11211,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true singlePerformanceRate @@ -11299,9 +11230,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true nonProportion @@ -11321,9 +11249,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true nonProportion @@ -11343,9 +11268,6 @@ This metric evaluates the process of care associated with the multi-society guid - - overall - true nonProportion @@ -11367,9 +11289,6 @@ when seen for an initial evaluation for distal symmetric polyneuropathy. - - overall - true nonProportion @@ -11391,9 +11310,6 @@ when seen for an initial evaluation for distal symmetric polyneuropathy. - - overall - true nonProportion @@ -11414,9 +11330,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -11436,16 +11349,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion AAN8 Exercise and Appropriate Physical Activity Counseling for Patients with MS - Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate + Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months. Effective Clinical Care process @@ -11459,9 +11369,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -11481,9 +11388,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11503,9 +11407,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11525,9 +11426,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11547,9 +11445,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11569,9 +11464,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11591,9 +11483,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11613,9 +11502,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11635,9 +11521,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11657,9 +11540,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11679,9 +11559,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11701,9 +11578,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11723,9 +11597,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11745,9 +11616,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11767,9 +11635,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11789,9 +11654,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11811,9 +11673,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11833,9 +11692,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11855,9 +11711,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11877,9 +11730,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11899,9 +11749,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11921,9 +11768,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11943,9 +11787,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11965,9 +11806,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -11987,16 +11825,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate Q416 Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years - Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury + Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury (INVERSE Measure: Lower score indicates better performance) Efficiency and Cost Reduction process @@ -12010,16 +11845,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate ACEP21 Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding - Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider + Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider (INVERSE Measure: Lower score indicates better performance) Efficiency and Cost Reduction process @@ -12033,9 +11865,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12055,9 +11884,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12077,9 +11903,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12099,9 +11922,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12121,9 +11941,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12143,9 +11960,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12165,9 +11979,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12187,9 +11998,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12209,9 +12017,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12231,16 +12036,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate ACEP32 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12262,16 +12064,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP33 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +) - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12293,16 +12092,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP35 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999) - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12324,16 +12120,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP36 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999) - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12355,16 +12148,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP37 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999) - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12386,16 +12176,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP38 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less) - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12417,16 +12204,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion ACEP39 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Eds - Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients + Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer Patients) 2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients @@ -12448,9 +12232,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12478,9 +12259,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12508,9 +12286,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12538,9 +12313,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12568,9 +12340,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12598,9 +12367,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12628,9 +12394,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12658,9 +12421,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true nonProportion @@ -12680,9 +12440,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12702,9 +12459,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12724,9 +12478,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12746,9 +12497,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12768,9 +12516,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12790,9 +12535,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12812,9 +12554,6 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate @@ -12834,16 +12573,13 @@ recommended medication for acute migraine attacks within the 12 month measuremen - - overall - true singlePerformanceRate ACRad26 Appropriate venous access for hemodialysis - Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access + Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access Inverse measure Patient Safety @@ -12858,9 +12594,6 @@ Inverse measure - - overall - true singlePerformanceRate @@ -12880,9 +12613,6 @@ Inverse measure - - overall - true singlePerformanceRate @@ -12902,16 +12632,13 @@ Inverse measure - - overall - true singlePerformanceRate ACRad23 Lung Cancer Screening Abnormal Interpretation Rate - The percentage of screening lung cancer interpreted + The percentage of screening lung cancer interpreted as positive (Lung-RADS Category 3 or 4). Efficiency and Cost Reduction outcome @@ -12925,18 +12652,15 @@ as positive (Lung-RADS Category 3 or 4). - - overall - true singlePerformanceRate ACRad21 Lung Cancer Screening Cancer Detection Rate (CDR) - The percentage of screenings of lung cancer that -were interpreted as positive (Lung-RADS category 3 -or 4) and result in a tissue diagnosis of cancer within + The percentage of screenings of lung cancer that +were interpreted as positive (Lung-RADS category 3 +or 4) and result in a tissue diagnosis of cancer within 12 months. Effective Clinical Care outcome @@ -12950,18 +12674,15 @@ or 4) and result in a tissue diagnosis of cancer within - - overall - true singlePerformanceRate ACRad22 Lung Cancer Screening Positive Predictive Value (PPV) - The percentage of screenings for lung cancer with -abnormal interpretation (Lung-RADS 3 or 4) that -result in a tissue diagnosis of cancer within 12 + The percentage of screenings for lung cancer with +abnormal interpretation (Lung-RADS 3 or 4) that +result in a tissue diagnosis of cancer within 12 months. Effective Clinical Care outcome @@ -12975,9 +12696,6 @@ months. - - overall - true singlePerformanceRate @@ -12997,9 +12715,6 @@ months. - - overall - true singlePerformanceRate @@ -13019,9 +12734,6 @@ months. - - overall - true singlePerformanceRate @@ -13041,16 +12753,13 @@ months. - - overall - true singlePerformanceRate ACRad30 Rate of Inadequate Percutaneous Image-Guided Biopsy - The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report. + The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report. Inverse measure Patient Safety @@ -13065,16 +12774,13 @@ Inverse measure - - overall - true singlePerformanceRate ACRad28 Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement - Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement + Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement Inverse measure Patient Safety @@ -13089,18 +12795,15 @@ Inverse measure - - overall - true singlePerformanceRate ACRad29 Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement - Percentage of percutaneous nephrostomy tube -replacement within 30 days following initial -placement. + Percentage of percutaneous nephrostomy tube +replacement within 30 days following initial +placement. Inverse measure Patient Safety @@ -13115,9 +12818,6 @@ Inverse measure - - overall - true singlePerformanceRate @@ -13138,17 +12838,14 @@ Inverse measure - - overall - true nonProportion ACRad25 Report Turnaround Time: Mammography - Mean mammography report turnaround time (RTAT). -Inverse measure + Mean mammography report turnaround time (RTAT). +Inverse measure Continuous measure scoring Communication and Care Coordination outcome @@ -13162,9 +12859,6 @@ Continuous measure scoring - - overall - true nonProportion @@ -13185,9 +12879,6 @@ Continuous measure scoring - - overall - true nonProportion @@ -13208,9 +12899,6 @@ Continuous measure scoring - - overall - true nonProportion @@ -13218,7 +12906,7 @@ Continuous measure scoring ACRad15 Report Turnaround Time: Radiography (modified) (Inverse Measure) - Mean radiography report turnaround time (RTAT). + Mean radiography report turnaround time (RTAT). (Does not include mammography.) Communication and Care Coordination outcome @@ -13232,9 +12920,6 @@ Continuous measure scoring - - overall - true nonProportion @@ -13255,9 +12940,6 @@ Continuous measure scoring - - overall - true nonProportion @@ -13278,18 +12960,15 @@ Continuous measure scoring - - overall - true singlePerformanceRate ACRad3 Screening Mammography Cancer Detection Rate (CDR) - The fraction of all screening mammograms that are -interpreted as positive (abnormal) and have a tissue -diagnosis of cancer within 12 months (expressed per + The fraction of all screening mammograms that are +interpreted as positive (abnormal) and have a tissue +diagnosis of cancer within 12 months (expressed per 1000 exams, not as a percentage) Effective Clinical Care outcome @@ -13303,9 +12982,6 @@ diagnosis of cancer within 12 months (expressed per - - overall - true singlePerformanceRate @@ -13325,16 +13001,13 @@ diagnosis of cancer within 12 months (expressed per - - overall - true singlePerformanceRate ACRad7 Screening Mammography Node Negativity Rate - The percentage of invasive cancers detected at + The percentage of invasive cancers detected at screening mammography that are node negative Effective Clinical Care outcome @@ -13348,18 +13021,15 @@ screening mammography that are node negative - - overall - true singlePerformanceRate ACRad6 - Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy + <title>Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy Recommended) - The percentage of screening mammograms where -biopsy was recommended that have a tissue + The percentage of screening mammograms where +biopsy was recommended that have a tissue diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening Effective Clinical Care outcome @@ -13373,9 +13043,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13395,9 +13062,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13420,9 +13084,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13442,9 +13103,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13464,9 +13122,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13486,9 +13141,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13510,9 +13162,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13536,9 +13185,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13560,9 +13206,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13582,9 +13225,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13604,9 +13244,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13626,9 +13263,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13648,9 +13282,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13670,9 +13301,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13692,9 +13320,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13714,9 +13339,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13736,9 +13358,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13758,16 +13377,13 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate ASNC13 SPECT-MPI studies meeting appropriate use criteria - Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion + Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed that are appropriate. Efficiency and Cost Reduction efficiency @@ -13781,16 +13397,13 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate ASNC14 PET-MPI studies meeting appropriate use criteria - Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies + Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed that are appropriate. Efficiency and Cost Reduction efficiency @@ -13804,9 +13417,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13826,16 +13436,13 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate ASNC18 PET-MPI studies not Equivocal - Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies + Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed that are not equivocal. Efficiency and Cost Reduction efficiency @@ -13849,9 +13456,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13871,16 +13475,13 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate ASNC20 SPECT-MPI studies performed without the use of thallium - Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion + Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed without the use of thallium. Patient Safety outcome @@ -13894,9 +13495,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13916,9 +13514,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13938,9 +13533,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13960,9 +13552,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -13982,9 +13571,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14004,9 +13590,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14026,9 +13609,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14048,9 +13628,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14070,9 +13647,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14092,9 +13666,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14114,9 +13685,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14136,9 +13704,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14158,9 +13723,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14180,9 +13742,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14202,9 +13761,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14224,9 +13780,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14246,9 +13799,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14268,9 +13818,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14290,9 +13837,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14312,9 +13856,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14334,9 +13875,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14356,9 +13894,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14378,9 +13913,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14400,9 +13932,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14422,9 +13951,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14444,9 +13970,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14466,9 +13989,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14488,9 +14008,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14510,9 +14027,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14532,9 +14046,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14554,9 +14065,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14576,9 +14084,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14598,9 +14103,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14620,9 +14122,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14642,9 +14141,6 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad - - overall - true singlePerformanceRate @@ -14654,9 +14150,9 @@ diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be mad Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal. This measure is reported as three performance rates stratified by hernia width: -1) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate) -2) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm -3) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm +Rate 1: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate) +Rate 2: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm +Rate 3: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm Patient Safety outcome true @@ -14669,11 +14165,21 @@ This measure is reported as three performance rates stratified by hernia width: + true + multiPerformanceRate + overallStratumOnly + + hernia + Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate) + overall + Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm + + + hernia>10cm + Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm - true - singlePerformanceRate AHSQC7 @@ -14691,9 +14197,6 @@ This measure is reported as three performance rates stratified by hernia width: - - overall - true singlePerformanceRate @@ -14713,19 +14216,16 @@ This measure is reported as three performance rates stratified by hernia width: - - overall - true singlePerformanceRate AHSQC9 Ventral Hernia Repair: Pain and Functional Status Assessment - Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email. -This measure is reported as two performance rates: -1) Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate -2) Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate + Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email. +This measure is reported as two performance rates: +Rate 1: Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate +Rate 2: Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate Person and Caregiver-Centered Experience and Outcomes outcome true @@ -14738,11 +14238,17 @@ This measure is reported as two performance rates: + true + multiPerformanceRate + overallStratumOnly overall + Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate + + + email + Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate - true - singlePerformanceRate ABG28 @@ -14760,9 +14266,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14782,9 +14285,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14804,9 +14304,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14826,9 +14323,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14848,9 +14342,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14870,9 +14361,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14892,9 +14380,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14914,9 +14399,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14936,9 +14418,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14958,9 +14437,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -14980,9 +14456,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15002,9 +14475,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15024,9 +14494,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15046,9 +14513,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15068,9 +14532,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15090,9 +14551,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15112,9 +14570,6 @@ This measure is reported as two performance rates: - - overall - true singlePerformanceRate @@ -15123,13 +14578,11 @@ This measure is reported as two performance rates: Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below: -1. Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used -2. Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used -3. Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used -4. Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used -5. Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met - -For MIPS performance purposes, the overall performance score is the 5th composite performance score for this measure. +Rate 1: Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used +Rate 2: Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used +Rate 3: Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used +Rate 4: Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used +Rate 5: Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met Effective Clinical Care outcome false @@ -15142,11 +14595,29 @@ For MIPS performance purposes, the overall performance score is the 5th composit + true + multiPerformanceRate + overallStratumOnly + + lysine + Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used + + + mini + Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used + + + redcell + Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used + + + transfusion + Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used + overall + Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met - true - singlePerformanceRate AQI50 @@ -15164,9 +14635,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15186,9 +14654,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15208,9 +14673,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15230,9 +14692,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15252,9 +14711,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15274,9 +14730,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15296,9 +14749,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15318,9 +14768,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15340,9 +14787,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15362,9 +14806,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15384,9 +14825,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15406,9 +14844,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15428,9 +14863,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15450,9 +14882,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15472,9 +14901,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15494,9 +14920,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15516,9 +14939,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15538,9 +14958,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15560,9 +14977,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15582,9 +14996,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15604,9 +15015,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15626,9 +15034,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15648,9 +15053,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15670,9 +15072,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15692,9 +15091,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15714,9 +15110,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15736,9 +15129,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15758,9 +15148,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15780,9 +15167,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15802,9 +15186,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15824,9 +15205,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15846,9 +15224,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15868,9 +15243,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15890,9 +15262,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15912,9 +15281,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15934,9 +15300,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15956,9 +15319,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -15978,9 +15338,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16000,9 +15357,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16022,9 +15376,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16044,9 +15395,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16066,9 +15414,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16088,23 +15433,20 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate CESQIP5 Related readmission for adrenal related problems - Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: - 1. Hematoma - 2. Adrenal Insufficiency - 3. Hypertension - 4. Pain - 5. Wound Infection - 6. Pneumonia - 7. Dehydration + Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: + 1. Hematoma + 2. Adrenal Insufficiency + 3. Hypertension + 4. Pain + 5. Wound Infection + 6. Pneumonia + 7. Dehydration 8. Respiratory Distress Effective Clinical Care outcome @@ -16118,36 +15460,33 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate CESQIP2 Related readmission for thyroid or parathyroid related problems - Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: - 1. Hypocalcemia - 2. Hematoma - 3. Seroma - 4. Wound infection - 5. Rash - 6. Dehydration - 7. Lymphatic or thoracic duct leak - 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness - 9. Dysphagia - 10. Pain - 11. Tracheal injury or perforation - 12. Esophageal injury or perforation - 13. Lower extremity complication (Phlebitis) - 14. Deep venous thrombosis - 15. Pulmonary embolism (including respiratory distress) - 16. Pulmonary (asthma, URI, pneumonia) - 17. Gastrointestinal (diarrhea, constipation, SBO) - 18. Nausea and/or vomiting - 19. Genitourinary (UTI, urinary retention) - 20. Myocardial Event (Atrial fib, CHF, MI, CVA) + Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: + 1. Hypocalcemia + 2. Hematoma + 3. Seroma + 4. Wound infection + 5. Rash + 6. Dehydration + 7. Lymphatic or thoracic duct leak + 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness + 9. Dysphagia + 10. Pain + 11. Tracheal injury or perforation + 12. Esophageal injury or perforation + 13. Lower extremity complication (Phlebitis) + 14. Deep venous thrombosis + 15. Pulmonary embolism (including respiratory distress) + 16. Pulmonary (asthma, URI, pneumonia) + 17. Gastrointestinal (diarrhea, constipation, SBO) + 18. Nausea and/or vomiting + 19. Genitourinary (UTI, urinary retention) + 20. Myocardial Event (Atrial fib, CHF, MI, CVA) 21. Psychiatric/Neurological (anxiety, syncope, dizziness) Effective Clinical Care outcome @@ -16161,18 +15500,15 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate CUHSM3 CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys) - •Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients. - Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. - Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. + •Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients. + Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. + Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians Person and Caregiver-Centered Experience and Outcomes patientEngagementExperience @@ -16186,9 +15522,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16208,9 +15541,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16230,9 +15560,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16252,9 +15579,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16274,9 +15598,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16296,9 +15617,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16318,9 +15636,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16340,9 +15655,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16362,9 +15674,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16384,9 +15693,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16406,9 +15712,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16428,9 +15731,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16450,9 +15750,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16472,9 +15769,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16494,9 +15788,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16516,9 +15807,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16538,9 +15826,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16560,9 +15845,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16582,9 +15864,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16604,9 +15883,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true singlePerformanceRate @@ -16626,9 +15902,6 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion @@ -16648,30 +15921,27 @@ For MIPS performance purposes, the overall performance score is the 5th composit - - overall - true nonProportion HF3 Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder - The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. + The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. -Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1] +Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1] -Defining the population: -CPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability. +Defining the population: +CPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability. -Labral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460). +Labral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460). -Surgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure. -Time-period for data collection and reporting: -This measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. +Surgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure. +Time-period for data collection and reporting: +This measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. -Measures: -Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. +Measures: +Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score Effective Clinical Care outcome @@ -16685,9 +15955,6 @@ Unadjusted measure: Average Shoulder Measure Change Score - - overall - true nonProportion @@ -16707,9 +15974,6 @@ Unadjusted measure: Average Shoulder Measure Change Score - - overall - true nonProportion @@ -16729,9 +15993,6 @@ Unadjusted measure: Average Shoulder Measure Change Score - - overall - true nonProportion @@ -16744,7 +16005,7 @@ This measure will be calculated using all patients who underwent meniscal repair Type of score: Ratio score Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: -Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. +Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months.Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient.Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient.The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references. Effective Clinical Care outcome @@ -16758,9 +16019,6 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion @@ -16780,9 +16038,6 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion @@ -16802,9 +16057,6 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion @@ -16824,16 +16076,13 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion M2S16 Absence of unplanned reoperation after major lower extremity amputation - The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision. + The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision. Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique. Patient Safety @@ -16848,16 +16097,13 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion M2S17 Absence of serious technical complications during peripheral arterial intervention - The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment. + The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment. Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue. Patient Safety @@ -16872,16 +16118,13 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion M2S18 Venous clinical severity score (VCSS) assessment before varicose vein treatment - The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment. + The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment. Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement. Effective Clinical Care process @@ -16895,16 +16138,13 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion M2S19 Proper patient selection for perforator vein ablation - The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease. + The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease. Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction. Effective Clinical Care @@ -16919,9 +16159,6 @@ Patient’s Knee Measure Change Score: A patient’s change score is calculated - - overall - true nonProportion @@ -16942,9 +16179,6 @@ Supra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, C - - overall - true nonProportion @@ -16965,9 +16199,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -16987,9 +16218,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17009,9 +16237,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17031,9 +16256,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17053,9 +16275,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17075,9 +16294,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17097,9 +16313,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17119,9 +16332,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17141,9 +16351,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17163,9 +16370,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17185,9 +16389,6 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion @@ -17207,22 +16408,19 @@ after Infra-Inguinal Bypass for intermittent claudication. - - overall - true nonProportion BIVARUS27 Patient Reported Comprehensive Assessment of Safety - A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. -Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. - Items: - Bivarus 1: Hand Sanitation Performed By My Provider - Bivarus 2: Medication Reconciliation Performed At My Visit - Bivarus 3: Practice Asked Me About Allergies - Bivarus 5: Practice Explained Medications Before Giving Them + A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. +Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Items: + Bivarus 1: Hand Sanitation Performed By My Provider + Bivarus 2: Medication Reconciliation Performed At My Visit + Bivarus 3: Practice Asked Me About Allergies + Bivarus 5: Practice Explained Medications Before Giving Them Bivarus 10: Overall Assessment Of Safety Patient Safety patientEngagementExperience @@ -17236,26 +16434,23 @@ Note: Limiting the composite measure score to the highest response category prov - - overall - true nonProportion BIVARUS28 Patient Reported Experience and Care Coordination - A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. -Items: +Items: -Bivarus 16: My Doctor Listened To Me -Bivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions -Bivarus 19: My Doctor Explained My Final Diagnosis -Bivarus 22: My Doctor Informed Me of My Treatment Options -Bivarus 23: My Doctor Told Me How Longs Things Would Take -Bivarus 24: My Doctor Did Not Seem Rushed With Me -Bivarus 25: While In My Room, My Doctor Was Focused On My Issues +Bivarus 16: My Doctor Listened To Me +Bivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions +Bivarus 19: My Doctor Explained My Final Diagnosis +Bivarus 22: My Doctor Informed Me of My Treatment Options +Bivarus 23: My Doctor Told Me How Longs Things Would Take +Bivarus 24: My Doctor Did Not Seem Rushed With Me +Bivarus 25: While In My Room, My Doctor Was Focused On My Issues Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends Person and Caregiver-Centered Experience and Outcomes/Communication and Care Coordination patientEngagementExperience @@ -17269,24 +16464,21 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr - - overall - true nonProportion BIVARUS32 Patient Reported Care Team Communication - A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. - Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. - Items: + Items: - Bivarus 7: Coordination of Care Among Physicians And Nurses - Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care - Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand + Bivarus 7: Coordination of Care Among Physicians And Nurses + Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care + Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan Communication and Care Coordination patientEngagementExperience @@ -17300,22 +16492,19 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr - - overall - true nonProportion BIVARUS30 Patient Reported Pain Treatment Effectiveness - This measure is a patient reported outcome measure. + This measure is a patient reported outcome measure. - This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. - Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. - Item: + Item: Bivarus 13: My Pain Was Treated Effectively Person and Caregiver-Centered Experience and Outcomes @@ -17330,22 +16519,19 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr - - overall - true nonProportion BIVARUS31 Patient Reported Communication and Care Coordination - This measure is a patient reported outcome measure. + This measure is a patient reported outcome measure. - This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. - Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. - Item: + Item: Bivarus 20: I Understood What the Physician Told Me Communication and Care Coordination @@ -17360,26 +16546,23 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr - - overall - true nonProportion - MOA 1 + MOA1 Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment. - Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either: - a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). - b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. - c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. + Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either: + a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). + b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. + c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. - Measure explanation: - a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). - b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). + Measure explanation: + a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). + b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). - 1) Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain. -2) Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain. +Rate 1: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain. +Rate 2: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain. Effective Clinical Care outcome false @@ -17392,16 +16575,22 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr + true + multiPerformanceRate + weightedAverage - overall + back + Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain. + + + neck + Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain. - true - singlePerformanceRate MOA 2 Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology. - Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year. + Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year. Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending. Efficiency and Cost Reduction @@ -17416,19 +16605,16 @@ Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Fr - - overall - true singlePerformanceRate MOA 7 Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur. - Successful Reporting: - a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically. - b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. - c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.). + Successful Reporting: + a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically. + b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. + c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.). Measure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation. Patient Safety @@ -17443,16 +16629,13 @@ Measure explanation: Chronic Pain medication prescribed (prescribed for greater - - overall - true singlePerformanceRate MOA 13 Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders. - Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure. + Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure. Measure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period. Patient Safety @@ -17467,16 +16650,13 @@ Measure explanation: Controlled substance agreement (CSA) or opiate agreement (O - - overall - true singlePerformanceRate MOA 14 Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety. - Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified. + Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified. Measure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines. Patient Safety @@ -17491,16 +16671,13 @@ Measure explanation: Controlled substance agreement (CSA) or opiate agreement (O - - overall - true singlePerformanceRate MOA 15 Weight loss in pain patients with BMI >30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control. - Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy. + Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy. Measure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management. Patient Safety @@ -17515,18 +16692,15 @@ Measure explanation: Pain conditions that can be treated definitively to avoid o - - overall - true singlePerformanceRate MOA 12 Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities. - Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. + Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. -Providers would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code). +Providers would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code). Measure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment. Efficiency and Cost Reduction @@ -17541,9 +16715,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17563,9 +16734,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17585,18 +16753,15 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate ECPR43 Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding - Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR); multiple performance rates include: -• Rate - Emergency Department (ED) -• Rate – Urgent Care (UC) + multiple performance rates include: +Rate 1: In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) +Rate 2: In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) Efficiency and Cost Reduction process true @@ -17609,11 +16774,17 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s + true + multiPerformanceRate + overallStratumOnly overall + In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) + + + urgentcare + In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) - true - singlePerformanceRate ECPR2 @@ -17634,9 +16805,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17659,9 +16827,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17681,9 +16846,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17703,9 +16865,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17725,9 +16884,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17747,9 +16903,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17769,9 +16922,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17794,9 +16944,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17819,9 +16966,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17845,9 +16989,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17867,9 +17008,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17889,9 +17027,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17911,9 +17046,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -17933,9 +17065,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17955,9 +17084,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17977,9 +17103,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -17999,9 +17122,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -18021,9 +17141,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -18043,9 +17160,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -18065,9 +17179,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true nonProportion @@ -18087,9 +17198,6 @@ Measure explanation: Spinal stenosis typically is conservatively managed until s - - overall - true singlePerformanceRate @@ -18110,20 +17218,17 @@ procedure. - - overall - true singlePerformanceRate MICS1 General Health Postoperative Improvement - Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery. - + Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery. + Performance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval. - -Instructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery. + +Instructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery. Rationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns. Community/Population Health @@ -18138,20 +17243,17 @@ Rationale: Understanding a patient’s mental and general physical improvement a - - overall - true nonProportion MICS2 Surgery Specific Postoperative Improvement in Pain Levels - Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery. - + Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery. + Performance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval. -Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels. +Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels. Rationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns. Effective Clinical Care @@ -18166,20 +17268,17 @@ Rationale: Understanding the change in a patient’s pain levels from before to - - overall - true nonProportion MICS3 Surgery Specific Postoperative Improvement in Function Levels - Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery. - + Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery. + Performance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval. - -Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks. + +Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks. Rationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns. Effective Clinical Care @@ -18194,23 +17293,20 @@ Rationale: Understanding the change in a patient’s function levels from before - - overall - true nonProportion MEX1 Heel Pain Treatment Outcomes for Adults - DESCRIPTION: - Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year + DESCRIPTION: + Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year - INSTRUCTIONS: - This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. + INSTRUCTIONS: + This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. - Measure Reporting via Registry: - ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. + Measure Reporting via Registry: + ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure. Effective Clinical Care outcome @@ -18224,23 +17320,20 @@ Rationale: Understanding the change in a patient’s function levels from before - - overall - true nonProportion MEX2 Heel Pain Treatment Outcomes for Pediatric Patients - DESCRIPTION: -Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain. + DESCRIPTION: +Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain. -INSTRUCTIONS: - This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. +INSTRUCTIONS: + This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. - Measure Reporting via Registry: - ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. + Measure Reporting via Registry: + ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure. Effective Clinical Care outcome @@ -18254,22 +17347,19 @@ INSTRUCTIONS: - - overall - true nonProportion MEX3 Identification of Flat Foot in Pediatric Patients - DESCRIPTION: -Percentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year + DESCRIPTION: +Percentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year -INSTRUCTIONS: -This measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient. +INSTRUCTIONS: +This measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient. - Measure Reporting via Registry: + Measure Reporting via Registry: ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. Effective Clinical Care process @@ -18283,17 +17373,14 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion MBSAQIP1 Risk standardized rate of patients who experienced a postoperative complication within 30 days - Risk standardized rate of patients who experienced a postoperative complication within 30 days - following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, + Risk standardized rate of patients who experienced a postoperative complication within 30 days + following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. Effective Clinical Care outcome @@ -18307,9 +17394,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18329,9 +17413,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18351,9 +17432,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18373,9 +17451,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18395,9 +17470,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18417,9 +17489,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18439,9 +17508,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true nonProportion @@ -18461,9 +17527,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18483,9 +17546,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18505,9 +17565,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18527,16 +17584,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC8 Percent of patients achieving MCID for back or neck pain - The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) Person and Caregiver-Centered Experience and Outcomes @@ -18551,16 +17605,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC9 Percent of patients achieving MCID for leg or arm pain - The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) Person and Caregiver-Centered Experience and Outcomes @@ -18575,16 +17626,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC10 Percent of patients achieving MCID for pain-related disability (ODI/NDI) - The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard "Minimum Clinically Important Difference" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) Person and Caregiver-Centered Experience and Outcomes @@ -18599,9 +17647,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18621,9 +17666,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18643,9 +17685,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18665,9 +17704,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18687,16 +17723,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC12 Risk-adjusted rate of hospital readmission - The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned "readmissions" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions. + The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned "readmissions" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Patient Safety outcome @@ -18710,16 +17743,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC13 Risk-adjusted rate of surgical site infection - The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment. + The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Patient Safety @@ -18734,16 +17764,13 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate MSSIC14 Risk-adjusted rate of urinary retention - The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period. + The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period. Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Patient Safety @@ -18758,9 +17785,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18780,9 +17804,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18802,9 +17823,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18824,9 +17842,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18846,9 +17861,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18868,9 +17880,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18890,9 +17899,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18912,9 +17918,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18934,9 +17937,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18956,9 +17956,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -18978,9 +17975,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19000,9 +17994,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19022,9 +18013,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19044,9 +18032,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19066,9 +18051,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19088,9 +18070,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19110,9 +18089,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19132,9 +18108,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19154,9 +18127,6 @@ This measure is to be reported a minimum of once per reporting period for eligib - - overall - true singlePerformanceRate @@ -19177,9 +18147,6 @@ meeting established criteria, notified of need for follow-up from the provider.< - - overall - true singlePerformanceRate @@ -19199,17 +18166,14 @@ meeting established criteria, notified of need for follow-up from the provider.< - - overall - true singlePerformanceRate MNCM1 Optimal Diabetes Care - The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following: ->HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present + The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following: +>HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present >Non‐tobacco user >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present Effective Clinical Care outcome @@ -19223,19 +18187,16 @@ meeting established criteria, notified of need for follow-up from the provider.< - - overall - true singlePerformanceRate MNCM2 Optimal Vascular Care - The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following: -* Blood Pressure less than 140/90 mmHg -* On a statin medication, unless allowed contraindications or exceptions are present -* Non-tobacco user + The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following: +* Blood Pressure less than 140/90 mmHg +* On a statin medication, unless allowed contraindications or exceptions are present +* Non-tobacco user *On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present Effective Clinical Care outcome @@ -19249,21 +18210,18 @@ meeting established criteria, notified of need for follow-up from the provider.< - - overall - true singlePerformanceRate MNCM3 Optimal Asthma Control - The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: -•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period + Rate 1: The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period •Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months -The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: -•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period +Rate 2: The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period •Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months Effective Clinical Care outcome @@ -19277,11 +18235,21 @@ The percentage of adult (18-50 years of age) patients who had a diagnosis of ast + true + multiPerformanceRate + weightedAverage - overall + pediatric + The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period +•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months + + + adult + The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period +•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months - true - singlePerformanceRate MNCM4 @@ -19300,9 +18268,6 @@ The percentage of adult (18-50 years of age) patients who had a diagnosis of ast - - overall - true singlePerformanceRate @@ -19324,9 +18289,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true singlePerformanceRate @@ -19346,9 +18308,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19368,9 +18327,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19390,9 +18346,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19412,9 +18365,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19434,9 +18384,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19456,9 +18403,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19479,9 +18423,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19502,9 +18443,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19524,9 +18462,6 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion @@ -19546,17 +18481,14 @@ On daily aspirin or anti-platelets, unless allowed contraindications or exceptio - - overall - true nonProportion MHAN1 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate - Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) -or asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions + Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) +or asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions. Patient Safety outcome @@ -19570,9 +18502,6 @@ and transfers from other institutions. - - overall - true nonProportion @@ -19592,9 +18521,6 @@ and transfers from other institutions. - - overall - true nonProportion @@ -19617,9 +18543,6 @@ and transfers from other institutions. - - overall - true singlePerformanceRate @@ -19627,12 +18550,12 @@ and transfers from other institutions. NHBPC15 A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure) Percentage of actively enrolled home-based primary care and palliative care patients who received basic ADL assessments and IADL assessments at enrollment and annually. - + This measure will be calculated with three rates: - -1) Percentage of patients who received a basic ADL assessment -2) Percentage of patients who received an IADL assessment -3) Percentage of patients who received both a basic ADL and IADL assessment (overall rate) + +Rate 1: Percentage of patients who received a basic ADL assessment +Rate 2: Percentage of patients who received an IADL assessment +Rate 3: Percentage of patients who received both a basic ADL and IADL assessment (overall rate) Effective Clinical Care process false @@ -19645,11 +18568,21 @@ This measure will be calculated with three rates: + true + multiPerformanceRate + overallStratumOnly + + ADL + Percentage of patients who received a basic ADL assessment + + + IADL + Percentage of patients who received an IADL assessment + overall + Percentage of patients who received both a basic ADL and IADL assessment (overall rate) - true - singlePerformanceRate NHBPC2 @@ -19667,9 +18600,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19689,9 +18619,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19699,9 +18626,9 @@ This measure will be calculated with three rates: NHBPC7 Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure) Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates: - -1) Percentage of patients whose medications lists were reviewed for possible offending medications. -2) Percentage of patients with offending medications whose use of offending medications was discontinued or justified. + +Rate 1: Percentage of patients whose medications lists were reviewed for possible offending medications. +Rate 2: Percentage of patients with offending medications whose use of offending medications was discontinued or justified. Effective Clinical Care process false @@ -19714,11 +18641,17 @@ This measure will be calculated with three rates: + true + multiPerformanceRate + overallStratumOnly + + reviewed + Percentage of patients whose medications lists were reviewed for possible offending medications. + overall + Percentage of patients with offending medications whose use of offending medications was discontinued or justified. - true - singlePerformanceRate NHBPC3 @@ -19736,9 +18669,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19758,9 +18688,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19780,9 +18707,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19802,9 +18726,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19824,9 +18745,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19846,9 +18764,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19868,9 +18783,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19890,9 +18802,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19912,9 +18821,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19934,9 +18840,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19956,9 +18859,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -19978,9 +18878,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20000,9 +18897,6 @@ This measure will be calculated with three rates: - - overall - true nonProportion @@ -20022,9 +18916,6 @@ This measure will be calculated with three rates: - - overall - true nonProportion @@ -20044,9 +18935,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20066,9 +18954,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20088,9 +18973,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20110,9 +18992,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20132,9 +19011,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20154,9 +19030,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20176,9 +19049,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20198,9 +19068,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20220,9 +19087,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20242,9 +19106,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20264,9 +19125,6 @@ This measure will be calculated with three rates: - - overall - true singlePerformanceRate @@ -20274,9 +19132,8 @@ This measure will be calculated with three rates: NPA3 Functional Outcome Assessment for Spine Intervention Percentage of patients aged 18 years and older undergoing index spine therapy (-ies) who completed baseline and 3-month follow-up (patient-reported) functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates: -1) Rate 1: Patient population with Follow-up/Patient population with baseline -2) Rate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up. -Overall Rate = Rate 2 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up. Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20289,19 +19146,24 @@ Overall Rate = Rate 2 + true + multiPerformanceRate + overallStratumOnly + + baseline + Patient population with Follow-up/Patient population with baseline + overall + Patient population with improvement in functional status after Follow-up/Patient population with Follow-up. - true - singlePerformanceRate NPA4 Quality-of-Life Assessment for Spine Intervention Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed baseline and 3-month follow-up (patient-reported) quality-of-life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates: -1) Rate 1: Patient population with Follow-up/Patient population with baseline -2) Rate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up. -Overall Rate = Rate 2 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up. Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20314,19 +19176,24 @@ Overall Rate = Rate 2 + true + multiPerformanceRate + overallStratumOnly + + baseline + Patient population with Follow-up/Patient population with baseline + overall + Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up. - true - singlePerformanceRate NPA5 Patient Satisfaction with Spine Care Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed 3-month follow-up (patient-reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates: -1) Rate 1: Patient population with Follow-up/Patient population with baseline -2) Rate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up. -Overall Rate = Rate 2 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up. Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20339,11 +19206,17 @@ Overall Rate = Rate 2 + true + multiPerformanceRate + overallStratumOnly + + baseline + Patient population with Follow-up/Patient population with baseline + overall + Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up. - true - singlePerformanceRate NPAGSC6 @@ -20361,9 +19234,6 @@ Overall Rate = Rate 2 - - overall - true singlePerformanceRate @@ -20383,20 +19253,15 @@ Overall Rate = Rate 2 - - overall - true singlePerformanceRate NPAGSC3 Functional Outcome Assessment for Spine Intervention - Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment with at least 10% improvement in the functional status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: -Rate 1: Patient population with Follow-up/Patient population with baseline -Rate 2: Patient population with improvement in functional status (at least 10% improvement) from the baseline. -Thus Rate 2 =< Rate 1 -Overall Rate = Rate 1 + Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment with at least 10% improvement in the functional status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in functional status (at least 10% improvement) from the baseline. Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20409,19 +19274,25 @@ Overall Rate = Rate 1 + true + multiPerformanceRate + overallStratumOnly overall + Patient population with Follow-up/Patient population with baseline + + + improvement + Patient population with improvement in functional status (at least 10% improvement) from the baseline. - true - singlePerformanceRate NPAGSC7 Narcotic Pain Medicine Management Prior to and Following Spine Therapy - Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: -Rate 1: Patient population with Follow-up/Patient population with baseline + Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: +Rate 1: Patient population with Follow-up/Patient population with baseline Rate 2: Patient population with improvement in pain status from the baseline. -Thus Rate 2 =< Rate 1 +Thus Rate 2 =< Rate 1 Overall Rate = Rate 1 Communication and Care Coordination process @@ -20435,9 +19306,6 @@ Overall Rate = Rate 1 - - overall - true nonProportion @@ -20457,9 +19325,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20467,10 +19332,8 @@ Overall Rate = Rate 1 NPAGSC4 Quality-of-Life Assessment for Spine Intervention Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment with an improvement in the quality of life status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: -Rate 1: Patient population with Follow-up/Patient population with baseline -Rate 2: Patient population with improvement in Quality of life status from the baseline -Thus Rate 2 =< Rate 1 -Overall Rate = Rate 1 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in Quality of life status from the baseline Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20483,20 +19346,24 @@ Overall Rate = Rate 1 + true + multiPerformanceRate + overallStratumOnly overall + Patient population with Follow-up/Patient population with baseline + + + improvement + Patient population with improvement in Quality of life status from the baseline - true - singlePerformanceRate NPAGSC5 Patient Satisfaction with Spine Care Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed satisfaction with care assessment prior to the treatment and at 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment with an improvement in the satisfaction with care status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: -Rate 1: Patient population with Follow-up/Patient population with baseline -Rate 2: Patient population with improvement in satisfaction with care status from the baseline -Thus Rate 2 =< Rate 1 -Overall Rate = Rate 1 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in satisfaction with care status from the baseline Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20509,20 +19376,24 @@ Overall Rate = Rate 1 + true + multiPerformanceRate + overallStratumOnly overall + Patient population with Follow-up/Patient population with baseline + + + improvement + Patient population with improvement in satisfaction with care status from the baseline - true - singlePerformanceRate NPAGSC10 Spine/Extremity Pain Assessment Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s)AND/ OR Leg or arm pain tool(s) at baseline and 2 +/-1 month following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms with an improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up: -Rate 1: Patient population with Follow-up/Patient population with baseline -Rate 2: Patient population with improvement in the pain status from the baseline -Thus Rate 2 =< Rate 1 -Overall Rate = Rate 1 +Rate 1: Patient population with Follow-up/Patient population with baseline +Rate 2: Patient population with improvement in the pain status from the baseline Person and Caregiver-Centered Experience and Outcomes outcome true @@ -20535,11 +19406,17 @@ Overall Rate = Rate 1 + true + multiPerformanceRate + overallStratumOnly overall + Patient population with Follow-up/Patient population with baseline + + + improvement + Patient population with improvement in the pain status from the baseline - true - singlePerformanceRate NHCR5 @@ -20557,9 +19434,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20579,9 +19453,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20601,9 +19472,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20623,9 +19491,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20645,9 +19510,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20667,9 +19529,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20689,9 +19548,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20711,9 +19567,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20733,9 +19586,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20755,9 +19605,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20777,9 +19624,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20799,9 +19643,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20821,9 +19662,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20843,9 +19681,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20865,9 +19700,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20887,9 +19719,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20909,9 +19738,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20931,9 +19757,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20953,9 +19776,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20975,9 +19795,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -20997,9 +19814,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -21019,9 +19833,6 @@ Overall Rate = Rate 1 - - overall - true singlePerformanceRate @@ -21029,9 +19840,8 @@ Overall Rate = Rate 1 NNEPTN1 Substance Use Screening This measure produces two rates of substance use screening: -a) Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year. - -b) Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year. +Rate 1: Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year. +Rate 2: Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year. Community/Population Health process false @@ -21044,11 +19854,17 @@ b) Percentage of patients age 18 years and older screened for substance use usin + true + multiPerformanceRate + weightedAverage - overall + 12to18 + Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year. + + + 18 + Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year. - true - singlePerformanceRate NNEPTN2 @@ -21066,25 +19882,22 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate NNEPTN3 Transforming Clinical Practice Initiative Common Measure Name: TCPI 01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team - Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: - 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: - a. Patient communication - b. Health professional assessments; - 2. Identify gaps in the achievement of health and life plan; - 3. Health status evaluations, interventions, and outcomes; - 4. Action plans: - a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. - 5. Medication Management; - 6. Identify community/social services and family support; + Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: + 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: + a. Patient communication + b. Health professional assessments; + 2. Identify gaps in the achievement of health and life plan; + 3. Health status evaluations, interventions, and outcomes; + 4. Action plans: + a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. + 5. Medication Management; + 6. Identify community/social services and family support; 7. Advanced directives Communication and Care Coordination process @@ -21098,20 +19911,17 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate NNEPTN4 Transforming Clinical Practice Initiative Common Measure Name: TCPI 02: Referral of At-Risk Patients to Community Based Prevention and Support Resources - This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes: -• BMI range >26; -• Pre-diabetes; -• Metabolic syndrome; -• Behavioral/mental health ; + This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes: +• BMI range >26; +• Pre-diabetes; +• Metabolic syndrome; +• Behavioral/mental health ; • Substance use disorder. Community/Population Health process @@ -21125,9 +19935,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21147,9 +19954,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21169,9 +19973,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21191,9 +19992,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21213,9 +20011,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21235,9 +20030,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21257,9 +20049,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21279,9 +20068,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21301,9 +20087,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21323,9 +20106,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21345,9 +20125,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21367,9 +20144,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21389,9 +20163,6 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate @@ -21411,16 +20182,13 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate WCHQ32 Controlling High Blood Pressure: eGFR Test Annually - The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period: + The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period: An eGFR (Estimated Glomerular Filtration Rate) test annually Effective Clinical Care @@ -21435,16 +20203,13 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate WCHQ10 Diabetes Care All or None Outcome Measure: Optimal Control - The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: + The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <140/90, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD. Effective Clinical Care process @@ -21458,16 +20223,13 @@ b) Percentage of patients age 18 years and older screened for substance use usin - - overall - true singlePerformanceRate WCHQ9 Diabetes Care All or None Process Measure: Optimal Testing - The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: + The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test Effective Clinical Care process @@ -21481,18 +20243,15 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate WCHQ13 Ischemic Vascular Disease Care Blood Pressure Control - The percentage of patients age 18 through 75 with one of the following conditions: - 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or - 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year: + The percentage of patients age 18 through 75 with one of the following conditions: + 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or + 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year: Most recent Blood pressure controlled to a level of less than 140/90 mm Hg Effective Clinical Care process @@ -21506,9 +20265,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21528,9 +20284,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21550,16 +20303,13 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate ACCPin2 CAD: Blood Pressure Control - Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure + Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure < 140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during the most recent office visit Effective Clinical Care process @@ -21573,9 +20323,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21595,9 +20342,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21617,9 +20361,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21639,9 +20380,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21661,9 +20399,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21683,9 +20418,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21705,9 +20437,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21727,9 +20456,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21749,9 +20475,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21771,9 +20494,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21793,9 +20513,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21815,9 +20532,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21837,9 +20551,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21859,9 +20570,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -21881,9 +20589,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -21903,9 +20608,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -21925,9 +20627,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -21947,9 +20646,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -21969,9 +20665,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -21991,9 +20684,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -22013,9 +20703,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -22035,9 +20722,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -22057,9 +20741,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true nonProportion @@ -22079,9 +20760,6 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate @@ -22101,20 +20779,16 @@ All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidn - - overall - true singlePerformanceRate PP1 Annual Monitoring for Patients on Persistent Medications (MPM) - This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report the following three rates and a total rate: - - Rate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. - - Rate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year. - - Rate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. -This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics. + This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics. +Rate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. +Rate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year. +Rate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. Patient Safety process true @@ -22127,11 +20801,21 @@ This measure assesses the percentage of patients 18 years of age and older who r + true + multiPerformanceRate + sumNumerators - overall + ace + Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. + + + digoxin + Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year. + + + diuretics + Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. - true - singlePerformanceRate PP2 @@ -22151,9 +20835,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22173,9 +20854,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22195,9 +20873,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22217,9 +20892,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22239,9 +20911,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22261,9 +20930,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22283,9 +20949,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22305,9 +20968,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22327,20 +20987,17 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate AAO8 Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use - "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants - Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications. - The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. + "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants + Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications. + The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. - Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. + Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016)" Effective Clinical Care @@ -22355,22 +21012,19 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate AAO9 Otitis Media with Effusion: Systemic Corticosteroids – Avoidance of Inappropriate Use - "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids + "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids - Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects. + Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects. - The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. + The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. - Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. + Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)" Effective Clinical Care @@ -22385,22 +21039,19 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate AAO10 Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use - "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials + "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials - Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. + Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. - The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. + The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. - Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. + Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)" Effective Clinical Care @@ -22415,22 +21066,19 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate AAO11 Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids - "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids + "Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids - Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects. + Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects. - The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. + The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. - Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. + Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)" Effective Clinical Care @@ -22445,9 +21093,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true singlePerformanceRate @@ -22467,9 +21112,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true nonProportion @@ -22489,9 +21131,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true nonProportion @@ -22511,9 +21150,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true nonProportion @@ -22533,9 +21169,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true nonProportion @@ -22555,9 +21188,6 @@ This measure assesses the percentage of patients 18 years of age and older who r - - overall - true nonProportion @@ -22583,9 +21213,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22605,9 +21232,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22627,9 +21251,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22649,9 +21270,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22671,9 +21289,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22693,9 +21308,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22715,9 +21327,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22737,9 +21346,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22759,9 +21365,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22781,9 +21384,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true nonProportion @@ -22803,9 +21403,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22825,9 +21422,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22847,9 +21441,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22869,9 +21460,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22891,9 +21479,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22913,9 +21498,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22935,9 +21517,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -22957,16 +21536,15 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate ICLOPS15 Excess Days Rate and Degree of Excess (Including Physician Response) - This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. Performance Rate 1 is the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older. Performance Rate 2 is the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days. The final performance rate is calculated as follows: Overall Performance Rate = (Part 1 Performance Met + Part 2 Performance Met) / (Part 1 Performance Eligible + Part 2 Performance Eligible). This measure was previously qualified as "ICLOPS 15." + This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. +Rate 1: the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older. +Rate 2: the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days. Efficiency and Cost Reduction outcome true @@ -22979,16 +21557,24 @@ CKD 5 Patients with 8 or more visits/yr. + true + multiPerformanceRate + weightedAverage - overall + withoutexcess + the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older. + + + withexcess + the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days. - true - singlePerformanceRate ICLOPS17 Rate of Follow Up Visits Within 7 Days of Discharge (Including Physician Response) - This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. Performance Rate 1 the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older. Performance Rate 2 is the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older. The final performance rate is calculated as follows: Overall Performance Rate = (Part 1 Performance Met + Part 2 Performance Met) / (Part 1 Performance Eligible + Part 2 Performance Eligible). This measure was previously qualified as "ICLOPS 17." + This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation. +Rate 1: the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older. +Rate 2: the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older. Communication and Care Coordination outcome true @@ -23001,16 +21587,25 @@ CKD 5 Patients with 8 or more visits/yr. + true + multiPerformanceRate + weightedAverage - overall + withfollowup + the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older. + + + withoutfollowup + the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older. - true - singlePerformanceRate RHI1 Diabetic patients with significant change in HgbA1C level or overall change in HgbA1C - This measure examines changes in Hemoglobin A1c using 3 Performance Rates: Performance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%. Performance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. + This measure examines changes in Hemoglobin A1c using 3 Performance Rates: +Performance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%. +Performance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%. +Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. Effective Clinical Care outcome false @@ -23023,16 +21618,31 @@ CKD 5 Patients with 8 or more visits/yr. + true + multiPerformanceRate + overallStratumOnly + + <9 + The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%. +Performance + + + >=9 + The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%. +Performance + overall + The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. - true - singlePerformanceRate RHI2 Hypertensive patients with significant change in systolic blood pressure or overall change in systolic pressure - This measure examines changes in systlic blood pressure using 3 Performance Rates: Performance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg. Performance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. + This measure examines changes in systlic blood pressure using 3 Performance Rates: +Performance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg. +Performance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg. +Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. Patient Safety outcome true @@ -23045,11 +21655,23 @@ CKD 5 Patients with 8 or more visits/yr. + true + multiPerformanceRate + overallStratumOnly + + >=160 + The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg. +Performance + + + <160 + The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg. +Performance + overall + The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. - true - singlePerformanceRate RHI3 @@ -23067,16 +21689,16 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate RHI4 Patients with Change in BMI - This measure examines BMI changes using 3 Performance Rates: Performance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35. Performance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35. Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. + This measure examines BMI changes using 3 Performance Rates: +Performance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35. +Performance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35. +Performance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. Community/Population Health outcome false @@ -23089,11 +21711,23 @@ CKD 5 Patients with 8 or more visits/yr. + true + multiPerformanceRate + overallStratumOnly + + decreased + The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35. +Performance + + + increased + The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35. +Performance + overall + The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure. - true - singlePerformanceRate RHI5 @@ -23111,9 +21745,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23133,9 +21764,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23155,9 +21783,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23177,9 +21802,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23199,9 +21821,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23221,9 +21840,6 @@ CKD 5 Patients with 8 or more visits/yr. - - overall - true singlePerformanceRate @@ -23253,9 +21869,6 @@ assessment - - overall - true singlePerformanceRate @@ -23275,9 +21888,6 @@ assessment - - overall - true singlePerformanceRate @@ -23297,9 +21907,6 @@ assessment - - overall - true singlePerformanceRate @@ -23319,9 +21926,6 @@ assessment - - overall - true singlePerformanceRate @@ -23341,9 +21945,6 @@ assessment - - overall - true singlePerformanceRate @@ -23363,9 +21964,6 @@ assessment - - overall - true singlePerformanceRate @@ -23385,9 +21983,6 @@ assessment - - overall - true singlePerformanceRate @@ -23407,9 +22002,6 @@ assessment - - overall - true singlePerformanceRate @@ -23429,9 +22021,6 @@ assessment - - overall - true singlePerformanceRate @@ -23451,9 +22040,6 @@ assessment - - overall - true singlePerformanceRate @@ -23473,9 +22059,6 @@ assessment - - overall - true singlePerformanceRate @@ -23495,9 +22078,6 @@ assessment - - overall - true singlePerformanceRate @@ -23517,9 +22097,6 @@ assessment - - overall - true singlePerformanceRate @@ -23539,9 +22116,6 @@ assessment - - overall - true singlePerformanceRate @@ -23561,9 +22135,6 @@ assessment - - overall - true singlePerformanceRate @@ -23583,9 +22154,6 @@ assessment - - overall - true singlePerformanceRate @@ -23605,9 +22173,6 @@ assessment - - overall - true singlePerformanceRate @@ -23627,9 +22192,6 @@ assessment - - overall - true singlePerformanceRate @@ -23649,9 +22211,6 @@ assessment - - overall - true nonProportion @@ -23671,9 +22230,6 @@ assessment - - overall - true nonProportion @@ -23693,9 +22249,6 @@ assessment - - overall - true nonProportion @@ -23715,9 +22268,6 @@ assessment - - overall - true singlePerformanceRate @@ -23737,9 +22287,6 @@ assessment - - overall - true singlePerformanceRate @@ -23759,9 +22306,6 @@ assessment - - overall - true singlePerformanceRate @@ -23783,9 +22327,6 @@ assessment - - overall - true singlePerformanceRate @@ -23805,9 +22346,6 @@ assessment - - overall - true singlePerformanceRate @@ -23829,9 +22367,6 @@ assessment - - overall - true singlePerformanceRate @@ -23851,9 +22386,6 @@ assessment - - overall - true singlePerformanceRate @@ -23873,9 +22405,6 @@ assessment - - overall - true singlePerformanceRate @@ -23895,9 +22424,6 @@ assessment - - overall - true singlePerformanceRate @@ -23917,9 +22443,6 @@ assessment - - overall - true singlePerformanceRate @@ -23939,16 +22462,13 @@ assessment - - overall - true singlePerformanceRate CAP3 Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin Completed - Cancer checklist used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures – + Cancer checklist used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures – • Partial Nephrectomy • Radical Nephrectomy @@ -23964,9 +22484,6 @@ assessment - - overall - true singlePerformanceRate @@ -23986,9 +22503,6 @@ assessment - - overall - true singlePerformanceRate @@ -24008,18 +22522,15 @@ assessment - - overall - true singlePerformanceRate CAP6 Cancer Protocol Elements for Carcinoma of the Pancreas Completed - Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The checklist covers the following procedures – -• Partial Pancreatectomy -• Pancreaticoduodenectomy (Whipple Resection) + Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The checklist covers the following procedures – +• Partial Pancreatectomy +• Pancreaticoduodenectomy (Whipple Resection) • Total Pancreatectomy Clinical Process/Effectiveness outcome @@ -24033,16 +22544,13 @@ assessment - - overall - true singlePerformanceRate SPINEIQ1 Change in Functional Outcomes - Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain. + Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain. NOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction. Effective Clinical Care @@ -24057,16 +22565,13 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true nonProportion SPINEIQ2 Change in Pain Intensity - Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain. + Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain. NOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction. Effective Clinical Care @@ -24081,9 +22586,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true nonProportion @@ -24103,9 +22605,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24125,9 +22624,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24147,9 +22643,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24169,9 +22662,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24191,9 +22681,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24213,9 +22700,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24235,9 +22719,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24257,9 +22738,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24279,9 +22757,6 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa - - overall - true singlePerformanceRate @@ -24289,13 +22764,13 @@ NOTE: Negative decreases (or increases in pain inference) for a provider's overa USWR15 Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT Percentage diabetic foot ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has achieved healing or closure 6 months after completion of a course of HBOT, stratified by the Wound Healing Index. Healing or closure is defined as an ulcer with epithelial coverage and no continued drainage requiring a dressing. - -There are four rates reported for this measure. -Three of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: -1. 0.00-62.42 -2. 62.42-73.19 -3. 73.19-93.45 -4. The average of the three risk stratified buckets which will be the performance rate in the XML submitted. + +There are four rates reported for this measure. +Three of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: +Rate 1: 0.00-62.42 +Rate 2: 62.42-73.19 +Rate 3: 73.19-93.45 +Rate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted. Effective Clinical Care outcome false @@ -24308,11 +22783,25 @@ Three of the rates will be risk stratified into three buckets (minimum-maximum) + true + multiPerformanceRate + overallStratumOnly + + bucket1 + 0.00-62.42 + + + bucket2 + 62.42-73.19 + + + bucket3 + 73.19-93.45 + overall + The average of the three risk stratified buckets which will be the performance rate in the XML submitted. - true - singlePerformanceRate USWR16 @@ -24330,16 +22819,13 @@ Three of the rates will be risk stratified into three buckets (minimum-maximum) - - overall - true singlePerformanceRate USWR20 Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers - The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool. + The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool. Using the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Person and Caregiver-Centered Experience and Outcomes @@ -24354,16 +22840,13 @@ Using the MNA Short Form algorithm, if a patient at risk of malnutrition has an - - overall - true singlePerformanceRate USWR22 Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers - The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) within the 12-month reporting period. + The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) within the 12-month reporting period. Using the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Implementation of an intervention plan based on nutritional screening is CDR measure 20. Person and Caregiver-Centered Experience and Outcomes @@ -24378,22 +22861,19 @@ Using the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA - - overall - true singlePerformanceRate USWR13 - Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen + <title>Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen Therapy (HBOT) Treatment Percentage of HBOT treatments of patients aged 18 years and older who have their vital signs and blood glucose level assessed prior to undergoing hyperbaric oxygen therapy (HBOT). Three rates are reported for this measure. - -1. Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken. -2. Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check. -3. Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check. + +Rate 1: Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken. +Rate 2: Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check. +Rate 3: Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check. Patient Safety process false @@ -24406,11 +22886,21 @@ Therapy (HBOT) Treatment + true + multiPerformanceRate + overallStratumOnly + + vital + Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken. + + + glucose + Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check. + overall + Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check. - true - singlePerformanceRate CDR3 @@ -24428,9 +22918,6 @@ Therapy (HBOT) Treatment - - overall - true singlePerformanceRate @@ -24450,9 +22937,6 @@ Therapy (HBOT) Treatment - - overall - true singlePerformanceRate @@ -24472,9 +22956,6 @@ Therapy (HBOT) Treatment - - overall - true singlePerformanceRate @@ -24482,13 +22963,13 @@ Therapy (HBOT) Treatment CDR6 Venous Leg Ulcer outcome measure: Healing or Closure Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required. - -There are four rates reported for this measure. -Three of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: -1. 0.00-73.24 -2. 73.24-80.26 -3. 80.26-87.21 -4. The average of the three risk stratified buckets which will be the performance rate in the XML submitted. + +There are four rates reported for this measure. +Three of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: +Rate 1: 0.00-73.24 +Rate 2: 73.24-80.26 +Rate 3: 80.26-87.21 +Rate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted. Person and Caregiver-Centered Experience and Outcomes outcome true @@ -24501,11 +22982,25 @@ Three of the rates will be risk stratified into three buckets (minimum-maximum) + true + multiPerformanceRate + overallStratumOnly + + bucket1 + 0.00-73.24 + + + bucket2 + 73.24-80.26 + + + bucket3 + 80.26-87.21 + overall + The average of the three risk stratified buckets which will be the performance rate in the XML submitted. - true - singlePerformanceRate USWR21 @@ -24523,9 +23018,6 @@ Three of the rates will be risk stratified into three buckets (minimum-maximum) - - overall - true singlePerformanceRate @@ -24545,9 +23037,6 @@ Three of the rates will be risk stratified into three buckets (minimum-maximum) - - overall - true singlePerformanceRate diff --git a/measures/measures-schema.yaml b/measures/measures-schema.yaml index c29ebcd3..f37a635f 100644 --- a/measures/measures-schema.yaml +++ b/measures/measures-schema.yaml @@ -111,7 +111,7 @@ definitions: type: boolean default: false overallAlgorithm: - description: Formula to determine the overall performance rate, given multiple strata of performance rates. + description: Formula to determine the overall performance rate, given multiple strata of performance rates. Only applicable to multiPerformanceRate measures. enum: [simpleAverage, weightedAverage, sumNumerators, overallStratumOnly] strata: description: Population segments for which the measure requires reporting data. Only applicable to multiPerformanceRate measures. @@ -142,7 +142,18 @@ definitions: cpcPlusGroup: description: CPC+ group which the measure belongs type: string - required: [nationalQualityStrategyDomain, measureType, eMeasureId, nqfEMeasureId, nqfId, isHighPriority, isInverse, strata, primarySteward, measureSets, isRegistryMeasure] + oneOf: [ + { + properties: { + metricType: { enum: [multiPerformanceRate] } + }, + required: [overallAlgorithm, strata] + },{ + properties: { + metricType: { enum: [singlePerformanceRate, nonProportion, cahps] } + } + }] + required: [nationalQualityStrategyDomain, measureType, eMeasureId, nqfEMeasureId, nqfId, isHighPriority, isInverse, primarySteward, measureSets, isRegistryMeasure] performanceStrata: type: object diff --git a/package.json b/package.json index eb6c777e..c0d03516 100644 --- a/package.json +++ b/package.json @@ -1,6 +1,7 @@ { "name": "qpp-measures-data", "version": "1.0.0-alpha.15", + "version": "1.0.0-alpha.16", "description": "Quality Payment Program Measures Data Repository", "repository": { "type": "git", diff --git a/scripts/measures/build-measures b/scripts/measures/build-measures index 2fd7b2b3..c70ffa66 100755 --- a/scripts/measures/build-measures +++ b/scripts/measures/build-measures @@ -1,13 +1,14 @@ #!/usr/bin/env bash -qcdr_csv='../../util/measures/latest-QCDR-Measures-20170911.csv' +qcdr_csv='../../util/measures/QCDR-Measures-20171109.csv' +qcdr_strata_names='../../util/measures/qcdr-measures-strata-names.json' staging_measures='../../staging/measures-data.json' staging_measures_with_qcdrs='../../staging/measures-data-with-qcdrs.json' final_measures='../../measures/measures-data.json' # 0. Add QCDR measures to the 'staging/measures-data.json' file: node scripts/measures/import-qcdr-measures.js \ - $staging_measures $qcdr_csv $staging_measures_with_qcdrs + $staging_measures $qcdr_csv $qcdr_strata_names $staging_measures_with_qcdrs # 1. Enrich `measures-data.json` file, run: node scripts/measures/enrich-measures-data.js \ diff --git a/scripts/measures/import-qcdr-measures.js b/scripts/measures/import-qcdr-measures.js index 45ed1728..7942e255 100644 --- a/scripts/measures/import-qcdr-measures.js +++ b/scripts/measures/import-qcdr-measures.js @@ -27,11 +27,6 @@ const config = { eMeasureId: null, nqfEMeasureId: null, nqfId: null, - strata: [ - { - name: 'overall' - } - ], measureSets: [], isRegistryMeasure: true }, @@ -86,15 +81,70 @@ const config = { } }; +const addMultiPerformanceRateDetails = function(newMeasure, record, qcdrStrataNamesDataPath) { + // Parse the names for qcdr measures with multiple strata/performance rates + // { measureId: [name of 1st performance rate, name of 2nd performance rate, etc.] } + // + // In the strata names file, note that the order of the array values matter. + // Also, unlike the descriptions for each of the strata/performance rates, + // the names do not come from a source outside of this codebase. They were + // created by manually selecting distinct keywords from the associated + // performance rate description and are used when submitting to the API. + const strataNames = fs.readFileSync(path.join(__dirname, qcdrStrataNamesDataPath), 'utf8'); + const qcdrStrataNames = JSON.parse(strataNames); + + newMeasure['metricType'] = 'multiPerformanceRate'; + + const overallPerformanceRate = _.lowerCase(_.trim(record[12])); + const nthPerformanceRate = _.parseInt(overallPerformanceRate); + if (_.isInteger(nthPerformanceRate)) { + newMeasure['overallAlgorithm'] = 'overallStratumOnly'; + } else if (overallPerformanceRate === 'sum numerators') { + newMeasure['overallAlgorithm'] = 'sumNumerators'; + } else if (overallPerformanceRate === 'weighted average') { + newMeasure['overallAlgorithm'] = 'weightedAverage'; + } + + // Add the names and descriptions of strata + let strataName; + const measureId = _.trim(record[2]); + const measureDescription = _.trim(record[4]); + + // Measure description column contains performance rate description + // Split '*summary* Rate 1: text Rate 2: text' into [text, text] + const strata = _.split(measureDescription, /\s*[Rr]ate [0-9]+:\s*/); + // Drop anything before 'Rate 1' (usually a description of the measure) + strata.shift(); + + newMeasure['strata'] = []; + _.each(strata, function(stratum, index) { + strataName = qcdrStrataNames[measureId][index]; + // i + 1 because Rates in the csv are numbered starting from 1 + if (_.lowerCase(strataName) === 'overall' && + index + 1 !== nthPerformanceRate) { + throw TypeError('"Overall" strata for ' + measureId + ' in QCDR ' + + 'CSV doesn\'t match the name in the strata details file'); + } + newMeasure['strata'].push({ + 'name': strataName, + 'description': strata[index] + }); + }); + + return newMeasure; +}; + /** * [convertCsvToMeasures description] * @param {array of arrays} records each array in the outer array represents a new measure, each inner array its attributes * @param {object} config object defining how to build a new measure from this csv file, including mapping of measure fields to column indices * @return {array} Returns an array of measures objects * - * We trim all data sourced from CSVs because people sometimes unintentionally include spaces or linebreaks + * Notes: + * 1. The terms [performance rate] 'strata' and 'performance rates' are used interchangeably + * 2. We trim all data sourced from CSVs because people sometimes unintentionally include spaces or linebreaks */ -const convertCsvToMeasures = function(records, config) { +const convertCsvToMeasures = function(records, config, qcdrStrataNamesDataPath) { const sourcedFields = config.sourced_fields; const constantFields = config.constant_fields; @@ -120,15 +170,19 @@ const convertCsvToMeasures = function(records, config) { // If the 'proportion' column (col 17) is Y and the other two columns // (continuous and ratio, cols 18 and 19) are N, metricType should be - // 'singlePerformanceRate'. Otherwise it should be 'nonProportion' - // - // Note: if the 'proportion' column is Y *and* there are multiple - // strata, then the metricType should be 'multiPerformanceRate' - // TODO(kalvin): implement multiPerformanceRate; - if (record[17] === 'Y' && - record[18] === 'N' && - record[19] === 'N') { - newMeasure['metricType'] = 'singlePerformanceRate'; + // 'singlePerformanceRate', or 'multiPerformanceRate' if there are multiple + // strata/performance rates. Otherwise it should be 'nonProportion' + const proportion = _.trim(record[17]); + const continuous = _.trim(record[18]); + const ratio = _.trim(record[19]); + if (proportion === 'Y' && continuous === 'N' && ratio === 'N') { + // returns an integer if passed string '3', NaN if passed 'N/A' + const numPerformanceRates = _.parseInt(_.trim(record[11])); + if (_.isInteger(numPerformanceRates) && numPerformanceRates > 1) { + addMultiPerformanceRateDetails(newMeasure, record, qcdrStrataNamesDataPath); + } else { + newMeasure['metricType'] = 'singlePerformanceRate'; + } } else { newMeasure['metricType'] = 'nonProportion'; } @@ -201,18 +255,19 @@ function addMissingRegistryFlags(measures) { return measures; } -function importMeasures(measuresDataPath, qcdrMeasuresDataPath, outputPath) { +function importMeasures(measuresDataPath, qcdrMeasuresDataPath, qcdrStrataNamesDataPath, outputPath) { const qpp = fs.readFileSync(path.join(__dirname, measuresDataPath), 'utf8'); const allMeasures = JSON.parse(qpp); const csv = fs.readFileSync(path.join(__dirname, qcdrMeasuresDataPath), 'utf8'); - const records = parse(csv, 'utf8'); + const qcdrCsv = parse(csv, 'utf8'); // remove header - records.shift(); + qcdrCsv.shift(); + // If there's more than one QCDR measure with the same measure, we can // arbitrarily pick one and ignore the others (they should all be // identical except for the QCDR Organization Name which we don't care about) - const qcdrMeasures = _.uniqBy(convertCsvToMeasures(records, config), 'measureId'); + const qcdrMeasures = _.uniqBy(convertCsvToMeasures(qcdrCsv, config, qcdrStrataNamesDataPath), 'measureId'); const mergedMeasures = mergeMeasures(allMeasures, qcdrMeasures, outputPath); return JSON.stringify(addMissingRegistryFlags(mergedMeasures), null, 2); @@ -220,7 +275,8 @@ function importMeasures(measuresDataPath, qcdrMeasuresDataPath, outputPath) { const measuresDataPath = process.argv[2]; const qcdrMeasuresDataPath = process.argv[3]; -const outputPath = process.argv[4]; +const qcdrStrataNamesDataPath = process.argv[4]; +const outputPath = process.argv[5]; -const newMeasures = importMeasures(measuresDataPath, qcdrMeasuresDataPath, outputPath); +const newMeasures = importMeasures(measuresDataPath, qcdrMeasuresDataPath, qcdrStrataNamesDataPath, outputPath); fs.writeFileSync(path.join(__dirname, outputPath), newMeasures); diff --git a/staging/measures-data-with-qcdrs.json b/staging/measures-data-with-qcdrs.json new file mode 100644 index 00000000..b322594a --- /dev/null +++ b/staging/measures-data-with-qcdrs.json @@ -0,0 +1,23645 @@ +[ + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PCMH", + "cehrtEligible": false, + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "title": "Patient Centered Medical Home Attestation", + "weight": null, + "subcategoryId": null + }, + { + "measureId": "ACI_INFBLO_1", + "category": "aci", + "title": "Prevention of Information Blocking Attestation", + "description": "I have not knowingly and willfully take action to limit or restrict the interoperability of certified EHR technology.\nI have responded to requests to retrieve or exchange information—including requests from patients and other health care providers regardless of the requestor's affiliation or technology.\nI have implemented appropriate standards and processes to ensure that its certified EHR technology was connected in accordance with applicable law and standards, allowed patients timely access to their electronic health information; and supported exchange of electronic health information with other health care providers.", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": 0, + "isRequired": true, + "isBonus": false, + "measureSets": [], + "objective": null, + "reportingCategory": "preAttestation", + "substitutes": [] + }, + { + "measureId": "ACI_ONCDIR_1", + "category": "aci", + "title": "ONC Direct Review Attestation", + "description": "I have (1) acknowledged the requirement to cooperate in good faith with ONC direct review health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received;\nAND (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": 0, + "isRequired": true, + "isBonus": false, + "measureSets": [], + "objective": null, + "reportingCategory": "preAttestation", + "substitutes": [] + }, + { + "measureId": "ACI_ONCACB_1", + "category": "aci", + "title": "ONC-ACB Surveillance Attestation (Optional)", + "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC–ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC–ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": 0, + "isRequired": false, + "isBonus": false, + "measureSets": [], + "objective": null, + "reportingCategory": "preAttestation", + "substitutes": [] + }, + { + "measureId": "ACI_IACEHRT_1", + "category": "aci", + "title": "CEHRT Used", + "description": "I attest that I have submitted an eligible Improvement Activity using Certified Electronic Health Record Technology (CEHRT).", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": 10, + "isRequired": false, + "isBonus": true, + "measureSets": [], + "objective": null, + "reportingCategory": "cehrtBonus", + "substitutes": [] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_LVPP_1", + "title": "E-Prescribing Exclusion", + "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", + "isRequired": false, + "weight": 0, + "measureSets": [], + "isBonus": false, + "objective": "electronicPrescribing", + "reportingCategory": "base", + "substitutes": [ + "ACI_EP_1", + "ACI_TRANS_EP_1", + "ACI_TRANS_LVPP_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_LVPP_1", + "title": "E-Prescribing Exclusion", + "description": "A MIPS eligible clinician (EC) who writes fewer than 100 permissible prescriptions during the performance period is eligible for exclusion from the required e-prescribing measure.", + "isRequired": false, + "weight": 0, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "electronicPrescribing", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_EP_1", + "ACI_LVPP_1", + "ACI_EP_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_LVOTC_1", + "title": "Send a Summary of Care Exclusion", + "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", + "isRequired": false, + "weight": 0, + "measureSets": [], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_HIE_1", + "ACI_TRANS_HIE_1", + "ACI_TRANS_LVOTC_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_LVOTC_1", + "title": "Health Information Exchange Exclusion", + "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient less than 100 times during the performance period.", + "isRequired": false, + "weight": 0, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_HIE_1", + "ACI_HIE_1", + "ACI_LVOTC_1", + "ACI_HIE_2", + "ACI_LVITC_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_LVITC_1", + "title": "Request/Accept Summary of Care Exclusion", + "description": "Any MIPS eligible clinician who does not receive any transitions of care or referrals or have patient encounters in which the MIPS eligible clinician has never before encountered the patient during the performance period.", + "isRequired": false, + "weight": 0, + "measureSets": [], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_HIE_2", + "ACI_TRANS_HIE_1", + "ACI_TRANS_LVOTC_1" + ] + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_1", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: How Well Providers Communicate", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_2", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Patient's Rating of Provider", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_3", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Access to Specialists", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_4", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Health Promotion and Education", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_5", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Shared Decision-Making", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_6", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Health Status and Functional Status", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_7", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Care Coordination", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_8", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Courteous and Helpful Office Staff", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_9", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Helping You Take Medications as Directed", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_10", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Stewardship of Patient Resources", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_11", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "cahps", + "title": "CAHPS for MIPS SSM: Between Visit Communication", + "description": "", + "nationalQualityStrategyDomain": null, + "measureType": "patientEngagementExperience", + "measureId": "CAHPS_12", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Diabetes Mellitus (DM) Composite (All or Nothing Scoring) ", + "description": "Composite of DM-2 (NQF 0059): Diabetes: Homoglobin A1c (HbA1c) Poor Control (<9%) & DM-7 (NQF 0055): Diabetes: Eye Exam ", + "nationalQualityStrategyDomain": "ECC", + "measureType": "intermediateOutcomeAndProcess", + "measureId": "dmComposite", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0055 & 0059", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients 18 - 75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period and who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period", + "name": "A1c>9.0%" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "cmsWebInterface" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [], + "isBonus": true, + "objective": "publicHealthAndClinicalDataRegistryReporting", + "reportingCategory": "registryBonus", + "substitutes": [ + "ACI_TRANS_PHCDRR_3" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_HIE_3", + "title": "Clinical Information Reconciliation", + "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician performs clinical information reconciliation. The MIPS eligible clinician must implement clinical information reconciliation for the following three clinical information sets: (1) Medication. Review of the patient's medication, including the name, dosage, frequency, and route of each medication. (2) Medication allergy. Review of the patient's known medication allergies. (3) Current Problem list. Review of the patient's current and active diagnoses.", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_TRANS_MR_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [], + "isBonus": true, + "objective": "publicHealthAndClinicalDataRegistryReporting", + "reportingCategory": "registryBonus", + "substitutes": [] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", + "isRequired": true, + "weight": 0, + "measureSets": [], + "isBonus": false, + "objective": "electronicPrescribing", + "reportingCategory": "base", + "substitutes": [ + "ACI_LVPP_1", + "ACI_TRANS_EP_1", + "ACI_TRANS_LVPP_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "publicHealthAndClinicalDataRegistryReporting", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_TRANS_PHCDRR_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_CCTPE_3", + "title": "Patient-Generated Health Data", + "description": "Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient seen by the MIPS eligible clinician during the performance period.", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "coordinationOfCareThroughPatientEngagement", + "reportingCategory": "performanceBonus", + "substitutes": [] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_PEA_2", + "title": "Patient-Specific Education", + "description": "The MIPS eligible clinician must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician.", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "patientElectronicAccess", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_TRANS_PSE_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_PEA_1", + "title": "Provide Patient Access", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's certified EHR technology.", + "isRequired": true, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "patientElectronicAccess", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_PEA_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [], + "isBonus": true, + "objective": "publicHealthAndClinicalDataRegistryReporting", + "reportingCategory": "registryBonus", + "substitutes": [] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_HIE_2", + "title": "Request/Accept Summary of Care", + "description": "For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient's record an electronic summary of care document.", + "isRequired": true, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_LVITC_1", + "ACI_TRANS_HIE_1", + "ACI_TRANS_LVOTC_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_CCTPE_2", + "title": "Secure Messaging", + "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "coordinationOfCareThroughPatientEngagement", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_TRANS_SM_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "isRequired": true, + "weight": 0, + "measureSets": [], + "isBonus": false, + "objective": "protectPatientHealthInformation", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_PPHI_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_HIE_1", + "title": "Send a Summary of Care", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider-(1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_LVOTC_1", + "ACI_TRANS_HIE_1", + "ACI_TRANS_LVOTC_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from a urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [], + "isBonus": true, + "objective": "publicHealthAndClinicalDataRegistryReporting", + "reportingCategory": "registryBonus", + "substitutes": [ + "ACI_TRANS_PHCDRR_2" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_CCTPE_1", + "title": "View, Download and Transmit (VDT)", + "description": "During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either-(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician's certified EHR technology; or (3) a combination of (1) and (2).", + "isRequired": false, + "weight": 10, + "measureSets": [], + "isBonus": false, + "objective": "coordinationOfCareThroughPatientEngagement", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_TRANS_PEA_2" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.", + "isRequired": true, + "weight": 0, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "electronicPrescribing", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_LVPP_1", + "ACI_LVPP_1", + "ACI_EP_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_HIE_1", + "title": "Health Information Exchange", + "description": "The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving health care clinician for at least one transition of care or referral.", + "isRequired": true, + "weight": 20, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "healthInformationExchange", + "reportingCategory": "base", + "substitutes": [ + "ACI_TRANS_LVOTC_1", + "ACI_HIE_1", + "ACI_LVOTC_1", + "ACI_HIE_2", + "ACI_LVITC_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data.", + "isRequired": false, + "weight": 10, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "publicHealthReporting", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_PHCDRR_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_MR_1", + "title": "Medication Reconciliation", + "description": "The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.", + "isRequired": false, + "weight": 10, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "medicationReconciliation", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_HIE_3" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_PSE_1", + "title": "Patient-Specific Education", + "description": "The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS eligible clinician.", + "isRequired": false, + "weight": 10, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "patientSpecificEducation", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_PEA_2" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_PEA_1", + "title": "Provide Patient Access", + "description": "At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician's discretion to withhold certain information.", + "isRequired": true, + "weight": 20, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "patientElectronicAccess", + "reportingCategory": "base", + "substitutes": [ + "ACI_PEA_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_SM_1", + "title": "Secure Messaging", + "description": "For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the performance period.", + "isRequired": false, + "weight": 10, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "secureMessaging", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_CCTPE_2" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "isRequired": true, + "weight": 0, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "protectPatientHealthInformation", + "reportingCategory": "base", + "substitutes": [ + "ACI_PPHI_1" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_PHCDRR_3", + "title": "Specialized Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to specialized registry. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [ + "transition" + ], + "isBonus": true, + "objective": "publicHealthReporting", + "reportingCategory": "registryBonus", + "substitutes": [ + "ACI_PHCDRR_5" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "ACI_TRANS_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data. Earn a 5 % bonus in the advancing care information performance category score for submitting to one or more public health or clinical data registries.", + "isRequired": false, + "weight": 5, + "measureSets": [ + "transition" + ], + "isBonus": true, + "objective": "publicHealthReporting", + "reportingCategory": "registryBonus", + "substitutes": [ + "ACI_PHCDRR_2" + ] + }, + { + "category": "aci", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "proportion", + "measureId": "ACI_TRANS_PEA_2", + "title": "View, Download, or Transmit (VDT)", + "description": "At least one patient seen by the MIPS eligible clinician during the performance period (or patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.", + "isRequired": false, + "weight": 10, + "measureSets": [ + "transition" + ], + "isBonus": false, + "objective": "patientElectronicAccess", + "reportingCategory": "performanceBonus", + "substitutes": [ + "ACI_CCTPE_1" + ] + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_EPA_4", + "cehrtEligible": false, + "description": "As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).", + "title": "Additional improvements in access as a result of QIN/QIO TA", + "weight": "medium", + "subcategoryId": "expandedPracticeAccess" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_4", + "cehrtEligible": false, + "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html)", + "title": "Administration of the AHRQ Survey of Patient Safety Culture", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_5", + "cehrtEligible": false, + "description": "Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.", + "title": "Annual registration in the Prescription Drug Monitoring Program", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_2", + "cehrtEligible": true, + "description": "MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: \nPatients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nPatients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;\n\nFor rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or\n\nFor patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinicians would attest that, 60 percent for first year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.\n\n\n", + "title": "Anticoagulant management improvements", + "weight": "high", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_12", + "cehrtEligible": false, + "description": "Establish effective care coordination and active referral management that could include one or more of the following:\n\nEstablish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;\n\nTrack patients referred to specialist through the entire process; and/or\nSystematically integrate information from referrals into the plan of care.\n\n", + "title": "Care coordination agreements that promote improvements in patient tracking across settings", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_10", + "cehrtEligible": false, + "description": "Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).", + "title": "Care transition documentation practice improvements", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_11", + "cehrtEligible": false, + "description": "Establish standard operations to manage transitions of care that could include one or more of the following: \n\nEstablish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or\n\nPartner with community or hospital-based transitional care services.\n", + "title": "Care transition standard operational improvements", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_13", + "cehrtEligible": true, + "description": "Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following: \nProvide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning;\nUse condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;\nUse pre-visit planning to optimize preventive care and team management of patients with chronic conditions;\nUse panel support tools (registry functionality) to identify services due; \nUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or\nRoutine medication reconciliation.", + "title": "Chronic care and preventative care management for empanelled patients", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_5", + "cehrtEligible": false, + "description": "Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.", + "title": "CMS partner in Patients Hospital Improvement Innovation Networks", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_6", + "cehrtEligible": false, + "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. ", + "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement", + "weight": "high", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_EPA_3", + "cehrtEligible": false, + "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. ", + "title": "Collection and use of patient experience and satisfaction data on access", + "weight": "medium", + "subcategoryId": "expandedPracticeAccess" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_9", + "cehrtEligible": false, + "description": "Completion of the American Medical Association's STEPS Forward program.", + "title": "Completion of the AMA STEPS Forward program", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_10", + "cehrtEligible": false, + "description": "Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.", + "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_6", + "cehrtEligible": false, + "description": "Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days. ", + "title": "Consultation of the Prescription Drug Monitoring program", + "weight": "high", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_4", + "cehrtEligible": false, + "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", + "title": "Depression screening", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_1", + "cehrtEligible": false, + "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.", + "title": "Diabetes screening ", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_8", + "cehrtEligible": true, + "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", + "title": "Electronic Health Record Enhancements for BH data capture", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_5", + "cehrtEligible": false, + "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund. ", + "title": "Engagement of community for health status improvement", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_AHE_1", + "cehrtEligible": false, + "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. ", + "title": "Engagement of new Medicaid patients and follow-up", + "weight": "high", + "subcategoryId": "achievingHealthEquity" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_15", + "cehrtEligible": true, + "description": "Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.", + "title": "Engagement of patients, family and caregivers in developing a plan of care ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_4", + "cehrtEligible": true, + "description": "Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.", + "title": "Engagement of patients through implementation of improvements in patient portal", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_3", + "cehrtEligible": false, + "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.", + "title": "Engagement with QIN-QIO to implement self-management training programs", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_14", + "cehrtEligible": false, + "description": "Engage patients and families to guide improvement in the system of care.", + "title": "Engage patients and families to guide improvement in the system of care.", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_5", + "cehrtEligible": false, + "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973", + "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_16", + "cehrtEligible": false, + "description": "Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.", + "title": "Evidenced-based techniques to promote self-management into usual care", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_4", + "cehrtEligible": true, + "description": "For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:\nFor the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:\na) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and\nb) Is reassessed at least annually.\n\nThe performance threshold will increase to 75 percent for the second performance year and onward.\nClinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.\n\n", + "title": "Glycemic management services", + "weight": "high", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_3", + "cehrtEligible": false, + "description": "Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.", + "title": "Implementation of additional activity as a result of TA for improving care coordination", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_17", + "cehrtEligible": false, + "description": "Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following:\n\nTrain appropriate staff on interpretation of cost and utilization information; and/or\n\nUse available data regularly to analyze opportunities to reduce cost through improved care.\n", + "title": "Implementation of analytic capabilities to manage total cost of care for practice population", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_15", + "cehrtEligible": false, + "description": "Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics", + "title": "Implementation of antibiotic stewardship program", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_6", + "cehrtEligible": false, + "description": "Integration facilitation, and promotion of the colocation of mental health services in primary and/or non-primary clinical care settings.", + "title": "Implementation of co-location PCP and MH services", + "weight": "high", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_20", + "cehrtEligible": false, + "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.", + "title": "Implementation of condition-specific chronic disease self-management support programs", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_8", + "cehrtEligible": true, + "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", + "title": "Implementation of documentation improvements for practice/process improvements", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_15", + "cehrtEligible": true, + "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:\nRoutine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or\nManaging care intensively through new diagnoses, injuries and exacerbations of illness.\n", + "title": "Implementation of episodic care management practice improvements", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_21", + "cehrtEligible": false, + "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", + "title": "Implementation of fall screening and assessment programs", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_19", + "cehrtEligible": false, + "description": "Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: \nTrain all staff in quality improvement methods; \nIntegrate practice change/quality improvement into staff duties;\nEngage all staff in identifying and testing practices changes;\nDesignate regular team meetings to review data and plan improvement cycles;\nPromote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or\nPromote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.\n", + "title": "Implementation of formal quality improvement methods, practice changes or other practice improvement processes", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_2", + "cehrtEligible": false, + "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", + "title": "Implementation of improvements that contribute to more timely communication of test results", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_7", + "cehrtEligible": true, + "description": "Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:\nUse evidence-based treatment protocols and treatment to goal where appropriate;\nUse evidence-based screening and case finding strategies to identify individuals at risk and in need of services;\nEnsure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;\nConduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;\nUse of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or\nIntegrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.\n", + "title": "Implementation of integrated PCBH model", + "weight": "high", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_16", + "cehrtEligible": true, + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: \nReconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; \nIntegrate a pharmacist into the care team; and/or\nConduct periodic, structured medication reviews.\n", + "title": "Implementation of medication management practice improvements", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_14", + "cehrtEligible": true, + "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:\nUse a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;\nUse a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or\nUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.\n", + "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_9", + "cehrtEligible": true, + "description": "Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). ", + "title": "Implementation of practices/processes for developing regular individual care plans", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_1", + "cehrtEligible": true, + "description": "Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.", + "title": "Implementation of use of specialist reports back to referring clinician or group to close referral loop", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_21", + "cehrtEligible": false, + "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.", + "title": "Improved practices that disseminate appropriate self-management materials", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_22", + "cehrtEligible": false, + "description": "Provide a pre-visit development of a shared visit agenda with the patient.", + "title": "Improved practices that engage patients pre-visit", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_23", + "cehrtEligible": false, + "description": "Provide coaching between visits with follow-up on care plan and goals.", + "title": "Integration of patient coaching practices between visits", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_20", + "cehrtEligible": false, + "description": "Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: \n\nMake responsibility for guidance of practice change a component of clinical and administrative leadership roles; \n\nAllocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or\n\nIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.\n", + "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_AHE_4", + "cehrtEligible": false, + "description": "Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).", + "title": "Leveraging a QCDR for use of standard questionnaires", + "weight": "medium", + "subcategoryId": "achievingHealthEquity" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_AHE_3", + "cehrtEligible": false, + "description": "Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).", + "title": "Leveraging a QCDR to promote use of patient-reported outcome tools", + "weight": "medium", + "subcategoryId": "achievingHealthEquity" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_AHE_2", + "cehrtEligible": true, + "description": "Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.", + "title": "Leveraging a QCDR to standardize processes for screening", + "weight": "medium", + "subcategoryId": "achievingHealthEquity" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_5", + "cehrtEligible": false, + "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions. ", + "title": "MDD prevention and treatment interventions", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_18", + "cehrtEligible": false, + "description": "Measure and improve quality at the practice and panel level that could include one or more of the following:\n\nRegularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or\nUse relevant data sources to create benchmarks and goals for performance at the practice level and panel level.\n\n", + "title": "Measurement and improvement at the practice and panel level", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_3", + "cehrtEligible": false, + "description": "For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R)", + "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_ERP_2", + "cehrtEligible": false, + "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.", + "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.", + "weight": "high", + "subcategoryId": "emergencyResponseAndPreparedness" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_1", + "cehrtEligible": false, + "description": "Participation in an AHRQ-listed patient safety organization. ", + "title": "Participation in an AHRQ-listed patient safety organization. ", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_8", + "cehrtEligible": false, + "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ", + "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive. ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_10", + "cehrtEligible": false, + "description": "Participation in a QCDR, that promotes implementation of patient self-action plans. ", + "title": "Participation in a QCDR, that promotes implementation of patient self-action plans. ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_7", + "cehrtEligible": false, + "description": "Participation in a QCDR, that promotes use of patient engagement tools. ", + "title": "Participation in a QCDR, that promotes use of patient engagement tools. ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_11", + "cehrtEligible": false, + "description": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ", + "title": "Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan. ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_14", + "cehrtEligible": false, + "description": "Participation in other quality improvement programs such as Bridges to Excellence", + "title": "Participation in Bridges to Excellence or other similar program", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_11", + "cehrtEligible": false, + "description": "Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).", + "title": "Participation in CAHPS or other supplemental questionnaire", + "weight": "high", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_8", + "cehrtEligible": false, + "description": " Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model", + "title": "Participation in CMMI models such as Million Hearts Campaign", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_13", + "cehrtEligible": false, + "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative", + "title": "Participation in Joint Commission Evaluation Initiative", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_2", + "cehrtEligible": false, + "description": "Participation in Maintenance of Certification (MOC) Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.", + "title": "Participation in MOC Part IV", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_9", + "cehrtEligible": false, + "description": "Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.", + "title": "Participation in population health research", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_12", + "cehrtEligible": false, + "description": "Participation in designated private payer clinical practice improvement activities.", + "title": "Participation in private payer CPIA", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_1", + "cehrtEligible": false, + "description": " Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program)for 60 percent of practice patients in year 1 and 75 percent of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors). ", + "title": "Participation in systematic anticoagulation program", + "weight": "high", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_ERP_1", + "cehrtEligible": false, + "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.", + "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.", + "weight": "medium", + "subcategoryId": "emergencyResponseAndPreparedness" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_12", + "cehrtEligible": false, + "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.\n\nEmpanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. \n\nEmpanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the \"active population\" of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define \"active patients\" operationally, but generally, the definition of \"active patients\" includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.", + "title": "Population empanelment", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_13", + "cehrtEligible": true, + "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: \n\nParticipate in a Health Information Exchange if available; and/or\n\nUse structured referral notes.\n", + "title": "Practice improvements for bilateral exchange of patient information", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_14", + "cehrtEligible": false, + "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: \n\nMaintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or\n\nProvide a guide to available community resources.\n", + "title": "Practice improvements that engage community resources to support patient health goals", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_EPA_1", + "cehrtEligible": true, + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:\nExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);\n\nUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or\n\nProvision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management\n\n", + "title": "Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record", + "weight": "high", + "subcategoryId": "expandedPracticeAccess" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_18", + "cehrtEligible": false, + "description": "Provide peer-led support for self-management.", + "title": "Provide peer-led support for self-management.", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_13", + "cehrtEligible": false, + "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", + "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_11", + "cehrtEligible": false, + "description": "Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.", + "title": "Regular review practices in place on targeted patient population needs", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_7", + "cehrtEligible": false, + "description": "Implementation of regular care coordination training. ", + "title": "Regular training in care coordination", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_3", + "cehrtEligible": false, + "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.", + "title": "RHC, IHS or FQHC quality improvement activities", + "weight": "high", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_4", + "cehrtEligible": false, + "description": "Participation in the CMS Transforming Clinical Practice Initiative.", + "title": "TCPI participation", + "weight": "high", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_2", + "cehrtEligible": false, + "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", + "title": "Tobacco use", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BMH_3", + "cehrtEligible": false, + "description": "Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions. ", + "title": " Unhealthy alcohol use", + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_12", + "cehrtEligible": false, + "description": "Use evidence-based decision aids to support shared decision-making.", + "title": "Use evidence-based decision aids to support shared decision-making.", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_19", + "cehrtEligible": false, + "description": "Use group visits for common chronic conditions (e.g., diabetes).", + "title": "Use group visits for common chronic conditions (e.g., diabetes).", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_1", + "cehrtEligible": true, + "description": "In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.", + "title": "Use of certified EHR to capture patient reported outcomes", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_16", + "cehrtEligible": true, + "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", + "title": "Use of decision support and standardized treatment protocols", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_8", + "cehrtEligible": false, + "description": " Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator. ", + "title": "Use of patient safety tools", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PSPA_7", + "cehrtEligible": false, + "description": "Use of QCDR data, for ongoing practice assessment and improvements in patient safety. ", + "title": "Use of QCDR data for ongoing practice assessment and improvements", + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_10", + "cehrtEligible": false, + "description": "Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome). ", + "title": "Use of QCDR data for quality improvement such as comparative analysis reports across patient populations", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_7", + "cehrtEligible": false, + "description": " Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.", + "title": "Use of QCDR for feedback reports that incorporate population health ", + "weight": "high", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_9", + "cehrtEligible": false, + "description": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ", + "title": " Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. ", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_CC_6", + "cehrtEligible": false, + "description": "Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).", + "title": "Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination", + "weight": "medium", + "subcategoryId": "careCoordination" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_2", + "cehrtEligible": false, + "description": "Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.", + "title": "Use of QCDR to support clinical decision making", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_EPA_2", + "cehrtEligible": false, + "description": "Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients. ", + "title": "Use of telehealth services that expand practice access", + "weight": "medium", + "subcategoryId": "expandedPracticeAccess" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_PM_6", + "cehrtEligible": false, + "description": "Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", + "title": "Use of toolsets or other resources to close healthcare disparities across communities", + "weight": "medium", + "subcategoryId": "populationManagement" + }, + { + "category": "ia", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "boolean", + "measureId": "IA_BE_17", + "cehrtEligible": false, + "description": "Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How's My Health).", + "title": "Use of tools to assist patient self-management", + "weight": "medium", + "subcategoryId": "beneficiaryEngagement" + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use", + "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "093", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0654", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy", + "name": "AOE" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "emergencyMedicine", + "otolaryngology", + "generalPracticeFamilyMedicine", + "pediatrics" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Acute Otitis Externa (AOE): Topical Therapy", + "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "091", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0653", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations", + "name": "AOE" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "emergencyMedicine", + "otolaryngology", + "pediatrics" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication", + "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. \na. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.\nb. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.\n", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "366", + "eMeasureId": "CMS136v6", + "nqfEMeasureId": null, + "nqfId": "0108", + "isInverse": false, + "strata": [ + { + "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD.", + "eMeasureUuids": { + "initialPopulationUuid": "4DF80BC3-980B-465E-8591-616C7DB74FBD", + "denominatorUuid": "815F709E-9703-4A6E-860F-CB0096A98B71", + "numeratorUuid": "341DBA96-D1CC-409F-99D9-8AB80D03B4A8", + "denominatorExclusionUuid": "FE028D3B-7AB5-418B-A90C-CCFE76F25078" + }, + "name": "visitWithin30Days" + }, + { + "description": "Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.", + "eMeasureUuids": { + "initialPopulationUuid": "9FC61BF5-1EBD-44DE-ADCB-64E70FD3C0A5", + "denominatorUuid": "62FDAE01-000B-40A0-9C74-4A803BA37A96", + "numeratorUuid": "5097B983-9C47-4F28-9194-C795F42053AF", + "denominatorExclusionUuid": "425772D2-6437-4F33-9B1E-349E1C6587D9" + }, + "name": "visitAndFollowups" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "mentalBehavioralHealth", + "pediatrics" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-22a639d81762", + "overallAlgorithm": "simpleAverage", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", + "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", + "nationalQualityStrategyDomain": "PS", + "measureType": "intermediateOutcome", + "measureId": "383", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1879", + "isInverse": false, + "strata": [ + { + "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)", + "name": "schizophrenia" + } + ], + "isHighPriority": true, + "primarySteward": "Health Services Advisory Group ", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "mentalBehavioralHealth" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Adult Kidney Disease: Blood Pressure Management", + "description": "Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care", + "nationalQualityStrategyDomain": "ECC", + "measureType": "intermediateOutcome", + "measureId": "122", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patient visits with blood pressure results < 140/90 mmHg", + "name": "<140/90mmHg" + }, + { + "description": "Percentage of patient visits with blood pressure results ≥ 140/90 mmHg and plan of care", + "name": "planOfCare" + }, + { + "description": "Overall percentage of patient visits with blood pressure results < 140/90 mmHg and ≥ 140/90 mmHg with a documented plan of care Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.", + "name": "overall" + } + ], + "isHighPriority": true, + "primarySteward": "Renal Physicians Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "overallAlgorithm": "overallStratumOnly", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis", + "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "329", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated", + "name": "ESRD" + } + ], + "isHighPriority": true, + "primarySteward": "Renal Physicians Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days", + "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "330", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter", + "name": "ESRD" + } + ], + "isHighPriority": true, + "primarySteward": "Renal Physicians Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Kidney Disease: Referral to Hospice", + "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "403", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care", + "name": "ESRD" + } + ], + "isHighPriority": true, + "primarySteward": "Renal Physicians Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions", + "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "325", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition", + "name": "comorbid" + } + ], + "isHighPriority": true, + "primarySteward": "American Psychiatric Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "mentalBehavioralHealth" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment", + "description": "Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "107", + "eMeasureId": "CMS161v5", + "nqfEMeasureId": null, + "nqfId": "0104", + "isInverse": false, + "strata": [ + { + "description": "Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified", + "eMeasureUuids": { + "initialPopulationUuid": "9CDC88D7-31DA-44F1-9348-CFDD29F4B20B", + "denominatorUuid": "1EC810C4-E6D2-4ED6-AE02-A0BF4D675F05", + "numeratorUuid": "693493EC-2E8E-447C-88A3-FC93AD771AB9" + }, + "name": "assessedSuicideRisk" + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [], + "eMeasureUuid": "40280381-503f-a1fc-0150-de8350a220c3", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery", + "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "384", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery", + "name": "retinalDetachment" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Ophthalmology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "ophthalmology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", + "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "385", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye", + "name": "retinalDetachment" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Ophthalmology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "ophthalmology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)", + "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "331", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": true, + "strata": [ + { + "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms", + "name": "sinusitis" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "otolaryngology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", + "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "332", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis", + "name": "sinusitis" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "otolaryngology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)", + "description": "Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis", + "nationalQualityStrategyDomain": "ECR", + "measureType": "efficiency", + "measureId": "333", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": true, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis", + "name": "sinusitis" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "otolaryngology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)", + "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis", + "nationalQualityStrategyDomain": "ECR", + "measureType": "efficiency", + "measureId": "334", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": true, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after date of diagnosis", + "name": "sinusitis" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology-Head and Neck Surgery", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "otolaryngology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Age Appropriate Screening Colonoscopy", + "description": "The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31", + "nationalQualityStrategyDomain": "ECR", + "measureType": "efficiency", + "measureId": "439", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31", + "name": "colonoscopy" + } + ], + "isHighPriority": true, + "primarySteward": "American Gastroenterological Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "gastroenterology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement", + "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "140", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0566", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD", + "name": "AMD" + } + ], + "isHighPriority": false, + "primarySteward": "American Academy of Ophthalmology", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "ophthalmology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Age-Related Macular Degeneration (AMD): Dilated Macular Examination", + "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "014", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0087", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage the level of macular degeneration severity during one or more office visits within 12 months", + "name": "AMD" + } + ], + "isHighPriority": false, + "primarySteward": "American Academy of Ophthalmology", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "ophthalmology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "All-cause Hospital Readmission", + "description": "The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "458", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1789", + "isInverse": false, + "strata": [], + "isHighPriority": false, + "primarySteward": "Yale University", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", + "description": "Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "386", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually", + "name": "ALS" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Neurology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "neurology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Anastomotic Leak Intervention", + "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "354", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery", + "name": "colectomy" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalSurgery" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Anesthesiology Smoking Abstinence", + "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure", + "nationalQualityStrategyDomain": "ECC", + "measureType": "intermediateOutcome", + "measureId": "404", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure", + "name": "cigarettes" + } + ], + "isHighPriority": true, + "primarySteward": "American Society of Anesthesiologists", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "anesthesiology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", + "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "387", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period", + "name": "HCV" + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "internalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Anti-Depressant Medication Management", + "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. \na. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). \nb. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).\n", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "009", + "eMeasureId": "CMS128v5", + "nqfEMeasureId": null, + "nqfId": "0105", + "isInverse": false, + "strata": [ + { + "description": "Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date", + "eMeasureUuids": { + "initialPopulationUuid": "220EBFDC-C2DF-431B-B14A-8982026B10F1", + "denominatorUuid": "50E80E87-0A09-4914-8632-BD0797460B34", + "numeratorUuid": "02A8409A-7B63-4FE9-B865-87C650DD7459", + "denominatorExclusionUuid": "BA926F92-CA87-43B3-A5C4-FD9FF8B59BB5" + }, + "name": ">=84Days" + }, + { + "description": "Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date", + "eMeasureUuids": { + "initialPopulationUuid": "1E041190-8EE7-46B0-A735-B416C5FA76FC", + "denominatorUuid": "B1C6949E-6854-4182-8BC9-C0EE75B705A2", + "numeratorUuid": "3A4FA8BB-D8BC-4F66-9367-A71DF03A868D", + "denominatorExclusionUuid": "8C51C326-AE19-462B-9745-6C8ABE92AE27" + }, + "name": ">=180Days" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "internalMedicine", + "mentalBehavioralHealth", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-22a112d2172a", + "overallAlgorithm": "simpleAverage", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal", + "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "421", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts", + "name": "IVC" + } + ], + "isHighPriority": false, + "primarySteward": "Society of Interventional Radiology ", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Appropriate Follow-up Imaging for Incidental Abdominal Lesions", + "description": "Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended:\n
  • Liver lesion <= 0.5 cm\n
  • Cystic kidney lesion < 1.0 cm\n
  • Adrenal lesion <= 1.0 cm\n\n\n
", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "405", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm", + "name": "abdominalImaging" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Radiology", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "diagnosticRadiology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients", + "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "406", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended", + "name": "CT" + } + ], + "isHighPriority": true, + "primarySteward": 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"name": "endometrialAblation" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "obstetricsGynecology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + 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}, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use", + "description": "Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "367", + "eMeasureId": "CMS169v5", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis", + "eMeasureUuids": { + "initialPopulationUuid": "AB5E9E84-65FB-4566-8254-D3488CA9A169", + "denominatorUuid": 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null, + "nqfEMeasureId": null, + "nqfId": "0391", + "isInverse": false, + "strata": [ + { + "description": "Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade", + "name": "pTpN" + } + ], + "isHighPriority": false, + "primarySteward": "College of American Pathologists", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "pathology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Breast Cancer Screening", + "description": "Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "112", + "eMeasureId": "CMS125v5", + "nqfEMeasureId": null, + "nqfId": "2372", + "isInverse": false, + "strata": [ + { + "description": "Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period", + "name": "mammogram", + "eMeasureUuids": { + "initialPopulationUuid": "66FD640C-70BB-400F-9926-98EA1ACEBEBA", + "denominatorUuid": "40FB2D5F-7DEF-4D41-80C4-F3FBA0ED5851", + "numeratorUuid": "0AB40D2B-08CE-4185-8A54-336C3140644D", + "denominatorExclusionUuid": "EC5CC49E-42A7-4DD8-BD40-A6258E71DCB9" + } + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "internalMedicine", + "obstetricsGynecology", + "preventiveMedicine", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-229c4ea3170c", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "CAHPS for MIPS Clinician/Group Survey", + "description": "
  • Getting timely care, appointments, and information;\n
  • How well providers Communicate;\n
  • Patient's Rating of Provider;\n
  • Access to Specialists;\n
  • Health Promotion & Education;\n
  • Shared Decision Making;\n
  • Health Status/Functional Status;\n
  • Courteous and Helpful Office Staff;\n
  • Care Coordination;\n
  • Between Visit Communication;\n
  • Helping Your to Take Medication as Directed; and\n
  • Stewardship of Patient Resources
", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "patientEngagementExperience", + "measureId": "321", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0006 & 0005", + "isInverse": false, + "strata": [], + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", + "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "243", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0643", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program Definition: Referral - A referral is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA). Note: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.", + "name": "outpatient" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Cardiology Foundation", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients", + "description": "Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic 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"lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", + "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status", + "nationalQualityStrategyDomain": "ECR", + "measureType": "efficiency", + "measureId": "323", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": true, + "strata": [ + { + "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status", + "name": "PCI" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Cardiology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "cardiology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients", + "description": "Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in 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This includes diabetics who had one of the following:\r\nA retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period", + "name": "diabetes", + "eMeasureUuids": { + "initialPopulationUuid": "321FB2D3-477E-41B7-8BB1-02EE94D08417", + "denominatorUuid": "98CE7ECC-1F09-4F52-906C-E53EAB545F00", + "numeratorUuid": "3F48A9B6-7B99-4BF4-AB1E-50DC1FFB9D1A" + } + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "cmsWebInterface", + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "internalMedicine", + "ophthalmology", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-22a24cdd1740", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Diabetes: Foot Exam", + "description": "The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "163", + "eMeasureId": "CMS123v5", + "nqfEMeasureId": null, + "nqfId": "0056", + "isInverse": false, + "strata": [ + { + "description": "Patients who received visual, pulse and sensory foot examinations during the measurement period", + "eMeasureUuids": { + "initialPopulationUuid": "9AB84D25-5883-4D85-A868-0D702403F250", + "denominatorUuid": "61B09878-32B3-4ECB-8E78-D1093E1FDDF9", + "numeratorUuid": "60EC6098-950A-40E5-994F-E9A62CFF6FC2", + "denominatorExclusionUuid": "02D13BF4-EF77-4DF4-A436-834AEDBE043C" + }, + "name": "receivedFootExams" + } + ], + "isHighPriority": false, + "primarySteward": "National 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This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "130", + "eMeasureId": "CMS68v6", + "nqfEMeasureId": null, + "nqfId": "0419", + "isInverse": false, + "strata": [ + { + "description": "Eligible professional attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administration", + "name": "document", + "eMeasureUuids": { + "initialPopulationUuid": "D412322D-11F1-4573-893E-E6A05855DE10", + "denominatorUuid": "375D0559-C749-4BB9-9267-81EDF447650B", + "numeratorUuid": "EFFE261C-0D57-423E-992C-7141B132768C", + "denominatorExceptionUuid": "3C100EC4-2990-4D79-AE14-E816F5E78AC8" + } + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "anesthesiology", + "cardiology", + "dermatology", + "emergencyMedicine", + "gastroenterology", + "generalSurgery", + "generalOncology", + "hospitalists", + "neurology", + "obstetricsGynecology", + "ophthalmology", + 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Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", + "nationalQualityStrategyDomain": "ECR", + "measureType": "efficiency", + "measureId": "415", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", + "name": "headTrauma" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Emergency Physicians", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "emergencyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": 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validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "414", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record", + "name": "opioidRisk" + } + ], + "isHighPriority": false, + "primarySteward": "American Academy of Neurology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "internalMedicine", + "neurology", + "physicalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Falls: Plan of Care", + "description": "Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "155", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0101", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months", + "name": "falls" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "internalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Falls: Risk Assessment", + "description": "Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "154", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0101", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months", + "name": "falls" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "internalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Falls: Screening for Future Fall Risk", + "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "318", + "eMeasureId": "CMS139v5", + "nqfEMeasureId": null, + "nqfId": "0101", + "isInverse": false, + "strata": [ + { + "description": "Patients who were screened for future fall risk at least once within the measurement period", + "eMeasureUuids": { + "initialPopulationUuid": "0175F89E-9CD7-4CD8-8D7F-38CB825D2BDD", + "denominatorUuid": "A3F77B7C-2398-470D-A359-E2A31539DF91", + "numeratorUuid": "F0F4094E-CE53-44EE-8CEF-0555479E37B2", + "denominatorExceptionUuid": "CF7E1913-CB4E-42F7-BAEC-0EFFF01ECB17" + }, + "name": "screenedForFallRisk" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord", + "cmsWebInterface" + ], + "measureSets": [], + "eMeasureUuid": "40280381-51f0-825b-0152-22aae8a21778", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Follow-Up After Hospitalization for Mental Illness (FUH)", + "description": "The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:\n
  • The percentage of discharges for which the patient received follow-up within 30 days of discharge.\n
  • The percentage of discharges for which the patient received follow-up within 7 days of discharge\n\n
", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "391", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0576", + "isInverse": false, + "strata": [ + { + "description": "The percentage of discharges for which the patient received follow-up within 30 days of discharge", + "name": "30days" + }, + { + "description": "The percentage of discharges for which the patient received follow-up within 7 days of discharge", + "name": "overall" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "mentalBehavioralHealth", + "pediatrics" + ], + "overallAlgorithm": "overallStratumOnly", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Outcome Assessment", + "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "182", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "2624", + "isInverse": false, + "strata": [ + { + "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies", + "name": "functionalOutcome" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "physicalMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Assessment for Total Hip Replacement", + "description": "Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "376", + "eMeasureId": "CMS56v5", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36,PROMIS-10-Global Health, PROMIS-29, HOOS) not more than 180 days prior to the primary THA procedure, and at least 60 days and not more than 180 days after THA procedure", + "eMeasureUuids": { + "initialPopulationUuid": "642D0090-BEAB-410B-B3B3-8D1A5EC5B919", + "denominatorUuid": "FFA80359-2E09-48C8-8862-DD6E1F5F5428", + "numeratorUuid": "7D021618-E1EE-4C2F-AD6A-F74E03D69E43", + "denominatorExclusionUuid": "65458ECD-6573-4203-8C56-515063BAFE19" + }, + "name": "functionalStatus" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-227617db152e", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Assessment for Total Knee Replacement", + "description": "Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "375", + "eMeasureId": "CMS66v5", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients with patient-reported functional status assessment results (eg, VR-12, VR-36, PROMIS-10 Global Health, PROMIS-29, KOOS) not more than 180 days prior to the primary TKA procedure, and at least 60 days and not more than 180 days after TKA procedure", + "eMeasureUuids": { + "initialPopulationUuid": "F0D80FC4-5E5E-46F3-A519-1B99013E2761", + "denominatorUuid": "D795B824-0575-47B3-93DB-D48CD5643677", + "numeratorUuid": "0DD7EF36-2B1D-4447-8E52-BF9C4A3E7ED3", + "denominatorExclusionUuid": "0E8BFC37-A4BA-4DE6-A6F3-DF4C188AB129" + }, + "name": "functionalStatus" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-227ce2c81597", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Assessments for Congestive Heart Failure", + "description": "Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "377", + "eMeasureId": "CMS90v6", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients with patient reported functional status assessment results (eg, VR-12; VR-36; MLHF-Q; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHR within two weeks before or during the initial encounter and the follow-up encounter during the measurement year", + "eMeasureUuids": { + "initialPopulationUuid": "AD37C6FE-2537-4A9B-8AD9-A372E3215F76", + "denominatorUuid": "19ECF222-71EF-4D75-9CC2-19ED201107EA", + "numeratorUuid": "F9B4C929-8F37-48D1-953C-489C028AE725", + "denominatorExclusionUuid": "32DBECF3-11EC-40FB-B35D-FA1BF7366492" + }, + "name": "functionalStatus" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [], + "eMeasureUuid": "40280381-52fc-3a32-0153-1f3f70ca0eff", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", + "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "222", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0427", + "isInverse": false, + "strata": [ + { + "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "name": "armImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Foot or Ankle Impairments", + "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "219", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0424", + "isInverse": false, + "strata": [ + { + "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO’s (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "name": "footImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with General Orthopaedic Impairments", + "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "223", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0428", + "isInverse": false, + "strata": [ + { + "description": "A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS assessed using FOTO (general orthopedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", + "name": "orthoImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Hip Impairments", + "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "218", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0423", + "isInverse": false, + "strata": [ + { + "description": "A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO’s (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "name": "hipImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Knee Impairments", + "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "217", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0422", + "isInverse": false, + "strata": [ + { + "description": "A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO’s (knee) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "name": "kneeImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Lumbar Impairments", + "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "220", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0425", + "isInverse": false, + "strata": [ + { + "description": "A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality", + "name": "lumbarImpairment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Functional Status Change for Patients with Shoulder Impairments", + "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "221", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0426", + "isInverse": false, + "strata": [ + { + "description": "A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO’s (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality", + "name": "shoulderImpariment" + } + ], + "isHighPriority": true, + "primarySteward": "Focus on Therapeutic Outcomes, Inc.", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", + "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "005", + "eMeasureId": "CMS135v5", + "nqfEMeasureId": "2907", + "nqfId": "0081", + "isInverse": false, + "strata": [ + { + "description": "Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", + "name": "LVEF<40%", + "eMeasureUuids": { + "initialPopulationUuid": "F3000871-B8FD-4F74-8892-281C250C11EA", + "denominatorUuid": "C1E20830-ADFE-4D88-B979-166FA0820D5C", + "numeratorUuid": "49E476F4-E8A1-48A6-B800-A8172073DBFB", + "denominatorExceptionUuid": "41E08783-4358-4E0D-81BE-9616A8F58319" + } + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "internalMedicine", + "cardiology", + "hospitalists", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-52fc-3a32-0153-62239c5d1ef6", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", + "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "008", + "eMeasureId": "CMS144v5", + "nqfEMeasureId": "2908", + "nqfId": "0083", + "isInverse": false, + "strata": [ + { + "description": "Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge", + "name": "HF", + "eMeasureUuids": { + "initialPopulationUuid": "5ED1A428-A266-47E5-AE4F-DB97A65BB1D4", + "denominatorUuid": "1E6C181E-91F6-4A61-82E0-7360C81CE3B0", + "numeratorUuid": "ABBFFB54-E629-4520-875E-F6D18BC651B1", + "denominatorExceptionUuid": "E9280685-6046-438D-AE45-0F7EDBA29C33" + } + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "cardiology", + "hospitalists", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-52fc-3a32-0153-1a3981870b45", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry", + "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "070", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0379", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart", + "name": "CLL" + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hematology: Multiple Myeloma: Treatment with Bisphosphonates", + "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "069", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0380", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.", + "name": "MM" + } + ], + "isHighPriority": false, + "primarySteward": "American Society of Hematology", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow", + "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "067", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0377", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow", + "name": "MDS" + } + ], + "isHighPriority": false, + "primarySteward": "American Society of Hematology", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "068", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0378", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy", + "name": "MDS" + } + ], + "isHighPriority": false, + "primarySteward": "American Society of Hematology", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options", + "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment\n", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "390", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment", + "name": "hepC" + } + ], + "isHighPriority": true, + "primarySteward": "American Gastroenterological Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "gastroenterology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", + "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "401", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period", + "name": "hepC" + } + ], + "isHighPriority": false, + "primarySteward": "American Gastroenterological Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "internalMedicine", + "gastroenterology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies", + "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "449", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1857", + "isInverse": false, + "strata": [ + { + "description": "Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies", + "name": "breastCancer" + } + ], + "isHighPriority": true, + "primarySteward": "American Society of Clinical Oncology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalOncology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis", + "description": "Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "160", + "eMeasureId": "CMS52v5", + "nqfEMeasureId": null, + "nqfId": "0405", + "isInverse": false, + "strata": [ + { + "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 200 cells/mm3", + "eMeasureUuids": { + "initialPopulationUuid": "E681DBF8-F827-4586-B3E0-178FF19EC3A2", + "denominatorUuid": "04BF53CE-6993-4EA2-BFE5-66E36172B388", + "numeratorUuid": "631C0B49-83F4-4A54-96C4-7E0766B2407C", + "denominatorExceptionUuid": "58347456-D1F3-4BBB-9B35-5D42825A0AB3" + }, + "name": "CD4<200/mm3" + }, + { + "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 500 cells/mm3 or a CD4 percentage below 15%", + "eMeasureUuids": { + "initialPopulationUuid": "AAC578DB-1900-43BD-BBBF-50014A5457E5", + "denominatorUuid": "1574973E-EB52-40C7-9709-25ABEDBA99A3", + "numeratorUuid": "5B7AC4EC-547A-47E5-AC5E-618401175511", + "denominatorExceptionUuid": "B7CCA1A6-F352-4A23-BC89-6FE9B60DC0C6" + }, + "name": "CD4<500/mm3OrCD4<15%" + }, + { + "description": "Patients who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis at the time of diagnosis of HIV", + "eMeasureUuids": { + "initialPopulationUuid": "AF36C4A9-8BD9-4E21-838D-A47A1845EB90", + "denominatorUuid": "B95BC0D3-572E-462B-BAA2-46CD33A865CD", + "numeratorUuid": "86F74F07-D593-44F6-AA12-405966400963" + }, + "name": "atDiagnosis" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "allergyImmunology", + "pediatrics" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-2273af5a150b", + "overallAlgorithm": "weightedAverage", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis", + "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "205", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0409", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection", + "name": "HIV/AIDS" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "pediatrics" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "HIV Medical Visit Frequency", + "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "340", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "2079", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits", + "name": "HIV" + } + ], + "isHighPriority": true, + "primarySteward": "Health Resources and Services Administration", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "HIV Viral Load Suppression", + "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "338", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "2082", + "isInverse": false, + "strata": [ + { + "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year", + "name": "HIV" + } + ], + "isHighPriority": true, + "primarySteward": "Health Resources and Services Administration", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", + "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender:\n
  • Reporting Age Criteria 1: Females 18-64years of age\n
  • Reporting Age Criteria 2: Males 18-64 years of age\n
  • Reporting Age Criteria 3: Females 65 years of age and older\n
  • Reporting Age Criteria 4: Males 65 years of age and older\n
", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "392", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "2474", + "isInverse": false, + "strata": [ + { + "description": "Females 18-64 years of age", + "name": "18-64F" + }, + { + "description": "Males 18-64 years of age", + "name": "18-64M" + }, + { + "description": "Females 65 years of age and older", + "name": "65+F" + }, + { + "description": "Males 65 years of age and older", + "name": "65+M" + }, + { + "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.", + "name": "overall" + } + ], + "isHighPriority": true, + "primarySteward": "The Heart Rhythm Society", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "electrophysiologyCardiacSpecialist" + ], + "overallAlgorithm": "overallStratumOnly", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate", + "description": "Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "348", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients with first time implants with one or more complications or mortality within 30 days", + "name": "30" + }, + { + "description": "Patients with first time implants with one or more complications within 90 days", + "name": "90" + } + ], + "isHighPriority": true, + "primarySteward": "The Heart Rhythm Society", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "electrophysiologyCardiacSpecialist" + ], + "overallAlgorithm": "weightedAverage", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", + "description": "Infection rate following CIED device implantation, replacement, or revision\n", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "393", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Infection rate following CIED device implantation, replacement, or revision", + "name": "CIED" + } + ], + "isHighPriority": true, + "primarySteward": "The Heart Rhythm Society", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "electrophysiologyCardiacSpecialist" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Hypertension: Improvement in Blood Pressure", + "description": "Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.", + "nationalQualityStrategyDomain": "ECC", + "measureType": "intermediateOutcome", + "measureId": "373", + "eMeasureId": "CMS65v6", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.\r\n\r\nIf a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed \"not improved.\"", + "eMeasureUuids": { + "initialPopulationUuid": "78CD5ACE-054C-43DF-A743-5F1E5BA4C099", + "denominatorUuid": "CE973C7A-B867-422B-8408-83538E236039", + "numeratorUuid": "F67DCC8F-4F0F-491B-957F-B21E721B040B", + "denominatorExclusionUuid": "74F900B9-65DA-4E6C-BB2D-592189ABDDE5" + }, + "name": "lowerFollowupBP" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [], + "eMeasureUuid": "40280381-51f0-825b-0152-227c2f851589", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Image Confirmation of Successful Excision of Image-Localized Breast Lesion", + "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "262", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy", + "name": "imageConfirmation" + } + ], + "isHighPriority": true, + "primarySteward": "American Society of Breast Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Immunizations for Adolescents", + "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday", + "nationalQualityStrategyDomain": "CPH", + "measureType": "process", + "measureId": "394", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1407", + "isInverse": false, + "strata": [ + { + "description": "Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays", + "name": "meningococcal" + }, + { + "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays", + "name": "Tdap" + }, + { + "description": "Patients who had at least three HPV vaccines with different dates of service on or between the patient’s 9th and 13th birthdays", + "name": "HPV" + }, + { + "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes.", + "name": "overall" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalPracticeFamilyMedicine", + "pediatrics" + ], + "overallAlgorithm": "overallStratumOnly", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "275", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy", + "name": "IBD" + } + ], + "isHighPriority": false, + "primarySteward": "American Gastroenterological Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "gastroenterology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment", + "description": "Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "271", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year", + "name": "IBD" + } + ], + "isHighPriority": false, + "primarySteward": "American Gastroenterological Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "gastroenterology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", + "description": "Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.\na. Percentage of patients who initiated treatment within 14 days of the diagnosis.\nb. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.\n", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "305", + "eMeasureId": "CMS137v5", + "nqfEMeasureId": null, + "nqfId": "0004", + "isInverse": false, + "strata": [ + { + "description": "Patients who initiated treatment within 14 days of the diagnosis", + "eMeasureUuids": { + "initialPopulationUuid": "EC2C5F63-AF76-4D3C-85F0-5423F8C28541", + "denominatorUuid": "BC948E65-B908-493B-B48B-04AC342D3E6C", + "numeratorUuid": "0BBF8596-4CFE-47F4-A0D7-9BEAB94BA4CD", + "denominatorExclusionUuid": "56BC7FA2-C22A-4440-8652-2D3568852C60" + }, + "name": "14DaysOfDiagnosis" + }, + { + "description": "Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", + "eMeasureUuids": { + "initialPopulationUuid": "1511AD34-240C-4F3E-A87B-73511AABFC5C", + "denominatorUuid": "4A09AB89-D9B8-4DD1-BC4E-78BCFD1C5873", + "numeratorUuid": "7FFA49C4-D708-491E-85FE-6855F0A725DF", + "denominatorExclusionUuid": "206A891D-C3E1-4660-BF2C-6CDBDF9282FB" + }, + "name": "30DaysOfVisit" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [], + "eMeasureUuid": "40280381-528a-60ff-0152-8e089ed20376", + "overallAlgorithm": "simpleAverage", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", + "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: \n
  • Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And \n
  • Most recent tobacco status is Tobacco Free -- And \n
  • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And \n
  • Statin Use\n
", + "nationalQualityStrategyDomain": "ECC", + "measureType": "intermediateOutcome", + "measureId": "441", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: • Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And • Most recent tobacco status is Tobacco Free -- And • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And • Statin Use", + "name": "IVDAllOrNone" + } + ], + "isHighPriority": true, + "primarySteward": "Wisconsin Collaborative for Healthcare Quality", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet", + "description": "Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "204", + "eMeasureId": "CMS164v5", + "nqfEMeasureId": null, + "nqfId": "0068", + "isInverse": false, + "strata": [ + { + "description": "Patients who had an active medication of aspirin or another antiplatelet during the measurement year", + "name": "AMI", + "eMeasureUuids": { + "initialPopulationUuid": "C3E458D8-8ED4-4F09-A661-6221A2B9355D", + "denominatorUuid": "FE6E1AA0-EE26-4F9E-A2FD-8E36058DCB47", + "numeratorUuid": "0A3C80F4-A9FF-4BDF-B018-D647E7D777EB", + "denominatorExclusionUuid": "D564DEEE-17E7-4442-921D-436E5113788A" + } + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "internalMedicine", + "cardiology", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-52fc-3a32-0153-5736a9401b9f", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy", + "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "451", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1859", + "isInverse": false, + "strata": [ + { + "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed", + "name": "KRASGeneMutation" + } + ], + "isHighPriority": false, + "primarySteward": "American Society of Clinical Oncology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalOncology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", + "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "395", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report", + "name": "lungCancer" + } + ], + "isHighPriority": true, + "primarySteward": "College of American Pathologists", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "pathology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Lung Cancer Reporting (Resection Specimens)", + "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "396", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type", + "name": "lungCarcinoma" + } + ], + "isHighPriority": true, + "primarySteward": "College of American Pathologists", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "pathology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Maternal Depression Screening", + "description": "The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.\n", + "nationalQualityStrategyDomain": "CPH", + "measureType": "process", + "measureId": "372", + "eMeasureId": "CMS82v4", + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Children with documentation of maternal screening or treatment for postpartum depression for the mother.", + "eMeasureUuids": { + "initialPopulationUuid": "D3ADB281-2F53-4BE6-89A9-124480DE787D", + "denominatorUuid": "6B845134-C1B7-4383-AFB3-1FFB7EAD359B", + "numeratorUuid": "D2A5FF72-DE5E-413A-829E-C763FC07DF4A" + }, + "name": "screeningOrTreatment" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [], + "eMeasureUuid": "40280381-51f0-825b-0152-2295c55c16aa", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)", + "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at\n>= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication\n", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "335", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication", + "name": "birth" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Maternity Care: Post-Partum Follow-Up and Care Coordination", + "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "336", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning", + "name": "postPartum" + } + ], + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Medication Management for People with Asthma", + "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "444", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "1799", + "isInverse": false, + "strata": [ + { + "description": "The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period", + "name": "asthma" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "generalPracticeFamilyMedicine", + "pediatrics" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Medication Reconciliation Post-Discharge", + "description": "The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.\nThis measure is reported as three rates stratified by age group:\n
  • Reporting Criteria 1: 18-64 years of age\n
  • Reporting Criteria 2: 65 years and older\n
  • Total Rate: All patients 18 years of age and older\n
", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "046", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0097", + "isInverse": false, + "strata": [ + { + "description": "Performance Rate 1: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18-64 years of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on- going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", + "name": "18-64" + }, + { + "description": "Performance Rate 2: Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 65 years and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on- going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", + "name": "65+" + }, + { + "description": "Total Rate (Overall Performance Rate): Percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record", + "name": "overall" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "cmsWebInterface", + "registry" + ], + "measureSets": [], + "overallAlgorithm": "overallStratumOnly", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Melanoma: Continuity of Care - Recall System", + "description": "Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:\n
  • A target date for the next complete physical skin exam, AND\n
  • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment\n
", + "nationalQualityStrategyDomain": "CCC", + "measureType": "structure", + "measureId": "137", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0650", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment", + "name": "melanoma" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Dermatology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "dermatology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Melanoma: Coordination of Care", + "description": "Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "138", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis", + "name": "melanoma" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Dermatology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "dermatology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Melanoma: Overutilization of Imaging Studies in Melanoma", + "description": "Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "224", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0562", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one- year measurement period, for whom no diagnostic imaging studies were ordered", + "name": "melanoma" + } + ], + "isHighPriority": true, + "primarySteward": "American Academy of Dermatology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "dermatology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Melanoma Reporting", + "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate", + "nationalQualityStrategyDomain": "CCC", + "measureType": "outcome", + "measureId": "397", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate", + "name": "melanoma" + } + ], + "isHighPriority": true, + "primarySteward": "College of American Pathologists", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "pathology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females", + "description": "The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "443", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer", + "name": "cervicalCancer" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "obstetricsGynecology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy", + "description": "Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed", + "nationalQualityStrategyDomain": "CCC", + "measureType": "process", + "measureId": "147", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed", + "name": "scintigraphy" + } + ], + "isHighPriority": true, + "primarySteward": "Society of Nuclear Medicine and Molecular Imaging", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "diagnosticRadiology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Oncology: Medical and Radiation - Pain Intensity Quantified", + "description": "Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "143", + "eMeasureId": "CMS157v5", + "nqfEMeasureId": null, + "nqfId": "0384", + "isInverse": false, + "strata": [ + { + "description": "Patient visits in which pain intensity is quantified", + "name": "cancer", + "eMeasureUuids": { + "initialPopulationUuid": "8494E3CD-7119-4471-9F2F-42540A797498", + "denominatorUuid": "D1358E7F-9C53-414C-9D4D-DEF7AE9B6E68", + "numeratorUuid": "95484C04-C98A-4A77-B2A7-9FE583060582" + } + } + ], + "isHighPriority": true, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "generalOncology", + "radiationOncology" + ], + "eMeasureUuid": "40280381-52fc-3a32-0153-1a4425a90b6c", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Oncology: Medical and Radiation - Plan of Care for Pain", + "description": "Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "144", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0383", + "isInverse": false, + "strata": [ + { + "description": "Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain", + "name": "cancer" + } + ], + "isHighPriority": true, + "primarySteward": "American Society of Clinical Oncology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "radiationOncology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Oncology: Radiation Dose Limits to Normal Tissues", + "description": "Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "156", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0382", + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues", + "name": "cancer" + } + ], + "isHighPriority": true, + "primarySteward": "American Society for Radiation Oncology", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "radiationOncology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk", + "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "400", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection", + "name": "HCV" + } + ], + "isHighPriority": false, + "primarySteward": "Physician Consortium for Performance Improvement", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "internalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Operative Mortality Stratified by the Five STS-EACTS Mortality Categories", + "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "446", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0733", + "isInverse": false, + "strata": [ + { + "description": "Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool", + "name": "heartSurgery" + } + ], + "isHighPriority": true, + "primarySteward": "Society of Thoracic Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Opioid Therapy Follow-up Evaluation", + "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "408", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record", + "name": "opiates" + } + ], + "isHighPriority": false, + "primarySteward": "American Academy of Neurology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "internalMedicine", + "neurology", + "physicalMedicine", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Optimal Asthma Control", + "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "398", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation.", + "name": "overall" + }, + { + "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation.", + "name": "5-17" + }, + { + "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation.", + "name": "18-50" + }, + { + "description": "Asthma well-controlled (take the most recent ACT) for patients 5 to 17 with Asthma", + "name": "ACT5-17" + }, + { + "description": "Asthma well-controlled (take the most recent ACT) for patients 18 to 50 with Asthma", + "name": "ACT18-50" + }, + { + "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma", + "name": "lowRisk5-17" + }, + { + "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma", + "name": "lowRisk18-50" + } + ], + "isHighPriority": true, + "primarySteward": "Minnesota Community Measurement", + "submissionMethods": [ + "registry" + ], 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diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well", + "name": "stroke" + } + ], + "isHighPriority": false, + "primarySteward": "American Heart Association", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Surgical Site Infection (SSI)", + "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI)", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "357", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI)", + "name": "SSI" + } + ], + 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measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user", + "name": "tobacco" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "internalMedicine", + "cardiology", + "dermatology", + "emergencyMedicine", + "gastroenterology", + "generalSurgery", + "generalOncology", + "hospitalists", + "neurology", + "obstetricsGynecology", + "ophthalmology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "preventiveMedicine", + "rheumatology", + "thoracicSurgery", + "urology", + "vascularSurgery", + "mentalBehavioralHealth", + "plasticSurgery", + "generalPracticeFamilyMedicine", + "pediatrics" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Total 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patients regardless of age undergoing a total knee replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure", + "name": "kneeReplacement" + } + ], + "isHighPriority": true, + "primarySteward": "American Association of Hip and Knee Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", + "description": "Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "351", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)", + "name": "kneeReplacement" + } + ], + "isHighPriority": true, + "primarySteward": "American Association of Hip and Knee Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 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Clinical Oncology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalOncology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier", + "description": "Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "337", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test", + "name": "tuberculosis" + } + ], + "isHighPriority": false, + "primarySteward": "American Academy of Dermatology", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "dermatology", + "rheumatology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", + "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "254", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0651", + "isInverse": false, + "strata": [ + { + "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location", + "name": "ED" + } + ], + "isHighPriority": false, + "primarySteward": "American College of Emergency Physicians", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "emergencyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", + "description": "Percentage of patients aged 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postoperative period", + "nationalQualityStrategyDomain": "PS", + "measureType": "outcome", + "measureId": "355", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period", + "name": "reoperation" + } + ], + "isHighPriority": true, + "primarySteward": "American College of Surgeons", + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "generalSurgery" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", + "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months", + "nationalQualityStrategyDomain": "ECC", + "measureType": "process", + "measureId": "048", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months", + "name": "UTI" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "obstetricsGynecology", + "preventiveMedicine", + "urology" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", + "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months", + "nationalQualityStrategyDomain": "PCCEO", + "measureType": "process", + "measureId": "050", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months", + "name": "UTI" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "internalMedicine", + "obstetricsGynecology", + "urology", + "generalPracticeFamilyMedicine" + ], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Use of High-Risk Medications in the Elderly", + "description": "Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.\na. Percentage of patients who were ordered at least one high-risk medication. \nb. Percentage of patients who were ordered at least two different high-risk medications.", + "nationalQualityStrategyDomain": "PS", + "measureType": "process", + "measureId": "238", + "eMeasureId": "CMS156v5", + "nqfEMeasureId": null, + "nqfId": "0022", + "isInverse": true, + "strata": [ + { + "description": "Patients with an order for at least one high-risk medication during the measurement period.", + "name": "overall", + "eMeasureUuids": { + "initialPopulationUuid": "C7BCE5A3-AC0D-440E-AA29-C98239F37A8B", + "denominatorUuid": "07F04D61-0383-487E-942C-690BBBC6437D", + "numeratorUuid": "7A0001AC-4BE0-4FAA-94AE-4843C9FFFCA8" + } + }, + { + "description": "Patients with an order for at least two different high-risk medications during the measurement period.", + "name": "2+", + "eMeasureUuids": { + "initialPopulationUuid": "BC02D7CE-7133-46C6-8592-658668B09948", + "denominatorUuid": "00401314-1B01-4896-A9FC-E991CDF29B6B", + "numeratorUuid": "FA7BF805-C21E-4077-B43E-C63F8D17B5CF" + } + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [], + "overallAlgorithm": "overallStratumOnly", + "eMeasureUuid": "40280381-52fc-3a32-0153-56d2b4f01ae5", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Use of Imaging Studies for Low Back Pain", + "description": "Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.", + "nationalQualityStrategyDomain": "ECR", + "measureType": "process", + "measureId": "312", + "eMeasureId": "CMS166v6", + "nqfEMeasureId": null, + "nqfId": "0052", + "isInverse": false, + "strata": [ + { + "description": "Patients without an imaging study conducted on the date of the outpatient or emergency department visit or in the 28 days following the outpatient or emergency department visit", + "eMeasureUuids": { + "initialPopulationUuid": "45D3A3ED-A7D6-45B9-AC95-647BFFE7018E", + "denominatorUuid": "0E27156C-B8EB-48E7-A588-4AB97A0914E1", + "numeratorUuid": "13C60632-9CF4-491B-82E9-A06118111C44", + "denominatorExclusionUuid": "0E9E3C94-6AA0-4C3C-A311-72CB0F2698B6" + }, + "name": "noStudy28Days" + } + ], + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "orthopedicSurgery", + "physicalMedicine", + "generalPracticeFamilyMedicine" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-22ba7621182e", + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "singlePerformanceRate", + "title": "Varicose Vein Treatment with Saphenous Ablation: Outcome Survey", + "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment", + "nationalQualityStrategyDomain": "ECC", + "measureType": "outcome", + "measureId": "420", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "isInverse": false, + "strata": [ + { + "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment", + "name": "CEAP_C2-S" + } + ], + "isHighPriority": false, + "primarySteward": "Society of Interventional Radiology ", + "submissionMethods": [ + "registry" + ], + "measureSets": [], + "isRegistryMeasure": false + }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents", + "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.\n\n - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation\n - Percentage of patients with counseling for nutrition\n - Percentage of patients with counseling for physical activity", + "nationalQualityStrategyDomain": "CPH", + "measureType": "process", + "measureId": "239", + "eMeasureId": "CMS155v5", + "nqfEMeasureId": null, + "nqfId": "0024", + "isInverse": false, + "strata": [ + { + "description": "Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period", + "eMeasureUuids": { + "initialPopulationUuid": "0ADE9325-3FB7-402F-AD89-34C9F2753D03", + "denominatorUuid": "933D86C8-2C2B-4AFF-AE81-DF2F9882A3A4", + "numeratorUuid": "61887626-5457-484C-A02D-75EF8547F559", + "denominatorExclusionUuid": "6938F4DD-D5AB-4C40-BA03-EB0F0959615C" + }, + "name": "BMI" + }, + { + "description": "Patients who had counseling for nutrition during a visit that occurs during the measurement period", + "eMeasureUuids": { + "initialPopulationUuid": "25286925-4221-4396-9DE0-60EA606924DF", + "denominatorUuid": "CFB8E3E2-FF4F-4D25-B613-7EC142BAE8A9", + "numeratorUuid": "EEAD441F-B3B2-4DC9-A890-B35E14B38EA7", + "denominatorExclusionUuid": "A399FA9C-48CF-41E5-812A-3445188B8301" + }, + "name": "nutrition" + }, + { + "description": "Patients who had counseling for physical activity during a visit that occurs during the measurement period", + "eMeasureUuids": { + "initialPopulationUuid": "48747E9D-674C-4013-9585-268114190119", + "denominatorUuid": "208B74F2-6592-4381-BEC1-EB136004C3B2", + "numeratorUuid": "21409D88-B5E3-4745-8DE2-D99DBB9F4DF0", + "denominatorExclusionUuid": "507F7EC3-D380-48BE-B920-ABB1EB258256" + }, + "name": "physicalActivity" + } + ], + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "pediatrics" + ], + "eMeasureUuid": "40280381-51f0-825b-0152-22b695b217dc", + "overallAlgorithm": "simpleAverage", + "isRegistryMeasure": false + }, + { + "measureId": "AAAAI2", + "title": "Asthma: Assessment of Asthma Control – Ambulatory Care Setting", + "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI5", + "title": "Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment", + "description": "Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI6", + "title": "Documentation of Clinical Response to Allergen Immunotherapy within One Year", + "description": "Percentage of patients aged 5 years and older who were evaluated for clinical improvement and efficacy within one year after initiating allergen immunotherapy AND assessment documented in the medical record. National Quality Strategy Domain: Communication and Care Coordination Process Measure", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI8", + "title": "Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year", + "description": "Proportion of patients receiving subcutaneous allergen immunotherapy that contains at least one standardized extract (mite, ragweed, grass, and/or cat) who achieved the projected effective dose for all included standardized allergen extract(s) after at least one year of treatment. National Quality Strategy Domain: Effective Clinical Care Outcome Measure", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI9", + "title": "Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s)", + "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who are receiving subcutaneous allergen immunotherapy with a documented assessment of asthma symptoms prior to administration of allergen immunotherapy injections. National Quality Strategy Domain: Patient Safety Process Measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI11", + "title": "Asthma Assessment and Classification", + "description": "Percentage of patients aged 5 years and older with asthma and documentation of an asthma assessment and classification. National Quality Strategy Domain: Effective Clinical Care Process Measure", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI12", + "title": "Lung Function/Spirometry Evaluation", + "description": "Percentage of patients aged 5 years and older with asthma and documentation of a spirometry evaluation. National Quality Strategy Domain: Effective Clinical Care Process Measure", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI17", + "title": "Asthma Control: Minimal Important Difference Improvement", + "description": "Percentage of patients aged 12 years and older whose asthma is not well-controlled as indicated by the Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire and who demonstrated a minimal important difference improvement upon a subsequent office visit during the 12-month reporting period. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Outcome Measure", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI18", + "title": "Penicillin Allergy: Appropriate Removal or Confirmation", + "description": "Percentage of patients, regardless of age, with a primary diagnosis of penicillin or ampicillin/amoxicillin allergy, who underwent elective skin testing or antibiotic challenge that resulted in the removal of the penicillin or ampicillin/amoxicillin allergy label from the medical record if negative or confirmation of the penicillin or ampicillin/amoxicillin allergy label if positive. National Quality Strategy Domain: Communication and Care Coordination Outcome Measure", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAAAI19", + "title": "Asthma: Pharmacologic Therapy for Persistent Asthma – Ambulatory Care Setting", + "description": "Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication\n\nThis measure will be calculated with three rates:\n\nRate 1: Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication\nRate 2: Patients prescribed alternative long-term control medications (non-ICS)\nRate 3: Total patients prescribed long-term control medication", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "ICS", + "description": "Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication" + }, + { + "name": "nonICS", + "description": "Patients prescribed alternative long-term control medications (non-ICS)" + }, + { + "name": "overall", + "description": "Total patients prescribed long-term control medication" + } + ] + }, + { + "measureId": "AAD1", + "title": "Psoriasis: Assessment of Psoriasis Disease Activity", + "description": "This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale.\n\n Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAD2", + "title": "Psoriasis: Screening for Psoriatic Arthritis", + "description": "Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life.\n\n Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAD3", + "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients", + "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAD4", + "title": "Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk", + "description": "This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance)\n\n The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller on the trunk (chest, back, abdomen) who are treated with Mohs surgery.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAD5", + "title": "Biopsy Reporting Time - Clinician to Patient", + "description": "Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient.\n\n Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "AAD’s DataDerm™ (American Academy of Dermatology)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO11", + "title": "Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival", + "description": "This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio.\n\nHOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´", + "nationalQualityStrategyDomain": "Effective Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO12", + "title": "Venous Thromboembolism (VTE) Prophylaxis", + "description": "This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission. This measure is a part of a set of eight nationally implemented measures that address stroke care (STK-2: Discharged on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-4: Thrombolytic Therapy, STK-5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin Medication, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are used in The Joint Commission’s hospital accreditation and Disease-Specific Care certification programs.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO13", + "title": "Ischemic stroke patients management -", + "description": "o This measure will be calculated with 4 performance rates:\nRate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;\nRate 2: The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;\nRate 3: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;\nRate 4: The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge", + "nationalQualityStrategyDomain": "Effective Communication and Care Coordination", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "sumNumerators", + "strata": [ + { + "name": "antithrombotic", + "description": "The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge;" + }, + { + "name": "anticoagulation", + "description": "The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate;" + }, + { + "name": "antithrombotic2", + "description": "The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two;" + }, + { + "name": "LDL", + "description": "The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge" + } + ] + }, + { + "measureId": "ARCO3", + "title": "Antipsychotic Use in Persons with Dementia", + "description": "The percentage of individuals 65 years of age and older with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.", + "nationalQualityStrategyDomain": "Affordable Care: Overuse/Waste, Person- and Family-Centered Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NOF12", + "title": "Median Time to Pain Management for Long Bone Fracture", + "description": "Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO7", + "title": "Laboratory Investigation for Secondary Causes of Fracture", + "description": "Percentage of patients age 50 and over with fragility fracture who have had appropriate laboratory investigation for secondary causes of fracture ordered or performed prior to discharge from inpatient status.", + "nationalQualityStrategyDomain": "Prevention and Treatment of Cardiovascular Disease: Healthy Lifestyle Behaviors", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACR7", + "title": "Gout: Serum Urate Target", + "description": "Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Rheumatology - RISE Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO14", + "title": "Gout: ULT Therapy", + "description": "Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)", + "nationalQualityStrategyDomain": "Effective Communication and Care Coordination: Quality of Life/Functional Status", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ARCO10", + "title": "Risk Standardized Mortality Rate within 30 days following Trauma Operation", + "description": "Percentage of patients evaluated as part of a trauma activation or trauma consultation who are taken to the operating room for an abdominal operation who expired prior to hospital discharge.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath1", + "title": "Stroke intra or post PCI procedure in patients without CABG or other major surgeries during admission.", + "description": "Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure stroke (i.e., any confirmed a loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms) lasting at least 24 hours after onset or leading to death.\n\nThis measure evaluates the occurrence of stroke as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath2", + "title": "New requirement for dialysis post PCI in patients without CABG or other major surgeries during admission.", + "description": "Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a new requirement for renal dialysis intra or post PCI procedure.\n\nThis measure evaluates the occurrence of the new need for dialysis as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath3", + "title": "Vascular access site injury requiring treatment or major bleeding post PCI in patients without CABG or other major surgeries during admission.", + "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment.\n\nMajor access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge.\n\nMajor bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure. To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding.\n\nThis measure evaluates the occurrence of vascular site injury requiring treatment or major bleeding as outcomes of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath4", + "title": "Cardiac tamponade post PCI in patients without CABG or other major surgery during admission.", + "description": "The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure.\n\nThis measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath5", + "title": "STEMI patients receiving immediate PCI within 90 minutes.", + "description": "Percentage of patients diagnosed with a STEMI and treated with a PCI who have the first reperfusion device deployed within 90 minutes or less of their arrival to the hospital, or diagnosis with STEMI.\n\nThis measure reflects the processes of care and current guidelines associated with the treatment of patients experiencing ST elevated myocardial infarctions (STEMI).", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath6", + "title": "ACE-I or ARB prescribed at discharge for patients with an ejection fraction < 40% who had a PCI during the episode of care.", + "description": "Percentage of patients, age 18 years and older, with a left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB at hospital discharge.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath8", + "title": "Percutaneous Coronary Intervention (PCI): Post-procedural Optimal Medical Therapy", + "description": "Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge.\n\nThis metric evaluates the process of care associated with the multi-society guidelines recommendations.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath9", + "title": "PCI procedures that were inappropriate for patients with Acute Coronary Syndrome (ACS).", + "description": "Proportion of PCI procedures for patients with Acute Coronary Syndrome, that were evaluated as “Inappropriate”, meaning coronary revascularization is not generally acceptable and is not a reasonable approach for the indication and is unlikely to improve the patients’ health outcomes or survival.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCCath13", + "title": "Cardiac Rehabilitation Patient Referral From an Inpatient Setting", + "description": "Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone a percutaneous coronary intervention (PCI), who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF CathPCI Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAN4", + "title": "Screening for Psychiatric or Behavioral Health Disorders", + "description": "Percent of all visits for patients with a diagnosis of epilepsy where the patient was screened for psychiatric or behavioral disorders", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN9", + "title": "Querying about Symptoms of Autonomic Dysfunction", + "description": "Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN10", + "title": "Falls screening", + "description": "Percentage of patients with Parkinson’s disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia who were screened for falls at least annually", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN1", + "title": "Diabetes/Pre-Diabetes Screening for Patients with DSP", + "description": "Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for\ndiabetes (eg fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered\nwhen seen for an initial evaluation for distal symmetric polyneuropathy.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN2", + "title": "Screening for Unhealthy Alcohol Use", + "description": "Percentage of patients age 18 years and older with a diagnosis of DSP who were screened with a validated screening instrument for unhealthy alcohol use* at their initial evaluation, and if screening was positive, brief counseling provided.\n\n*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN5", + "title": "MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK", + "description": "Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline\nrecommended medication for acute migraine attacks within the 12 month measurement period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN11", + "title": "Overuse of Opioid and Barbiturate Containing Medications for Primary Headache Disorders.", + "description": "Percentage of patients age 12 years and older with a diagnosis of primary headache who were prescribed opioid or barbiturate containing medications assessed for medication overuse headache within the 12-month measurement period, and if identified as overusing opioid or barbiturate containing medication, treated or referred for treatment.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "AAN8", + "title": "Exercise and Appropriate Physical Activity Counseling for Patients with MS", + "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate\n physical activity for patients with MS in the past 12 months.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Neurology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "IRIS1", + "title": "Corneal Graft Surgery - Post-operative improvement in visual acuity of 20/40 or greater", + "description": "Percentage of corneal graft surgery patients with a visual acuity of 20/40 or greater within 90 days following surgery.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS2", + "title": "Glaucoma -  Intraocular Pressure (IOP)Reduction", + "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS3", + "title": "Glaucoma - Visual Field Progression", + "description": "Percentage of eyes, in patients with a diagnosis of glaucoma, with a mean deviation loss of more than 3dB from their baseline value", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS4", + "title": "Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty", + "description": "Percentage of patients underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level Rationale: Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS5", + "title": "Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance", + "description": "Percentage of surgical ptosis patients with an improvement of MRD postoperatively within 90 days following the surgical procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS6", + "title": "Acquired Involutional Entropion -  Normalized Lid Position After Surgical Repair", + "description": "Percentage of surgical entropion patients with postoperative normalized lid position .", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS7", + "title": "Amblyopia - Interocular Visual Acuity", + "description": "Percentage of newly diagnosed amblyopic patients with a corrected interocular visual acuity difference of less than 0.23 logMAR within 6 months of first diagnosis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS8", + "title": "Surgical Esotropia - Postoperative Alignment", + "description": "Percentage of surgical esotropia patients with a postoperative alignment of 15 prism diopters (PD) or less", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS9", + "title": "Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS10", + "title": "Exudative Age-Related Macular Degeneration - Loss of Visual Acuity", + "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with of loss of less than 0.3 logMar of visual acuity within the past 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS11", + "title": "Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity", + "description": "Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with of loss of less than 0.3 logMar of visual acuity within the past 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS13", + "title": "Diabetic Macular Edema - Loss of Visual Acuity", + "description": "Percentage of patients with a diagnosis of diabetic macular edema with of loss of less than 0.3 logMar of visual acuity within the past 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS16", + "title": "Acute Anterior Uveitis - Post-treatment visual acuity", + "description": "Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS17", + "title": "Acute Anterior Uveitis - Post-treatment Grade 0 anterior chamber cells", + "description": "Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS18", + "title": "Chronic Anterior Uveitis -  Post-treatment visual acuity", + "description": "Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS19", + "title": "Chronic Anterior Uveitis -  Post-treatment Grade 0 anterior chamber cells", + "description": "Percentage of patients with chronic anterior uveitis post-treatment with Grade 0 anterior chamber cells", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS20", + "title": "Idiopathic Intracranial Hypertension:  No worsening or improvement of mean deviation", + "description": "Percentage of patients with no worsening of perimetric mean deviation by > 3dB at 6 months or improvement in mean deviation at 6 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS21", + "title": "Ocular Myasthenia Gravis:  Improvement of ocular deviation or absence of diplopia or functional improvement", + "description": "Percentage of patients with improvement of ocular deviation or absence of diplopia in primary gaze after treatment or functional improvement of ptosis at 6 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS22", + "title": "Giant Cell Arteritis:  Absence of fellow eye involvement after corticosteroid treatment", + "description": "Percentage of patients without fellow eye involvement 1-26 weeks after initiating corticosteroids in patients with unilateral visual loss", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS23", + "title": "Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better", + "description": "Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better", + "nationalQualityStrategyDomain": "Outcome", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS24", + "title": "Refractive Surgery:  Postoperative correction within + 0.5 Diopter of the Intended Correction", + "description": "Percentage of patients with a postoperative spherical equivalent (SE) within + 0.5 Diopter (D) of the intended correction or SE", + "nationalQualityStrategyDomain": "Outcome", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS25", + "title": "Adenoviral Conjunctivitis:  Avoidance of Antibiotics", + "description": "Percentage of patients who received antibiotic treatment for adenoviral conjunctivitis", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "IRIS26", + "title": "Intravitreal Injections:  Avoidance of Routine Antibiotic Use", + "description": "The percentage of patients who received antibiotics before or after intravitreal injections", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Academy of Ophthalmology IRIS® Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Q415", + "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", + "description": "Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Q416", + "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", + "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury\n (INVERSE Measure: Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP21", + "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", + "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider\n (INVERSE Measure: Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP22", + "title": "Appropriate Emergency Department Utilization of CT for Pulmonary Embolism", + "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP24", + "title": "Pregnancy Test for Female Abdominal Pain Patients", + "description": "Percentage of all female patients ages 14 through 50 years old who present to the ED with a chief complaint of abdominal pain who have had a pregnancy test (urine or serum) ordered", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP25", + "title": "Tobacco Use: Screening and Cessation Intervention", + "description": "Percentage of asthma or COPD patients aged 18 years and older who were screened for tobacco use AND who received cessation counseling intervention if identified as a tobacco user", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP26", + "title": "Sepsis Management: Septic Shock: Lactate Level Measurement", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a serum lactate level ordered during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP27", + "title": "Sepsis Management: Septic Shock: Antibiotics Ordered", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for antibiotics during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP28", + "title": "Sepsis Management: Septic Shock: Fluid Resuscitation", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for ≥ 1 L of crystalloids during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP29", + "title": "Sepsis Management: Septic Shock: Repeat Lactate Level Measurement", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock and an elevated serum lactate result (>2mmol/L) with a second serum lactate measurement ordered following the elevated serum lactate result during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP30", + "title": "Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10%", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a second serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥ 10% during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP31", + "title": "Emergency Medicine: Appropriate Foley Catheter Use in the Emergency Department", + "description": "Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP32", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP33", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP35", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP36", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP37", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP38", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP39", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Eds", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients\n(Excluding Psych and Mental Health, and Transfer Patients)\n\n2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients\n\n3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED)\n\n4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients)\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP40", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP41", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP43", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP44", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP45", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP46", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less)", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP47", + "title": "ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding Eds", + "description": "Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)\n\n2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients\n\n3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED)\n\n4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients\n\n (Lower score indicates better performance)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACEP48", + "title": "Sepsis Management: Septic Shock: Blood Cultures Ordered", + "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a blood culture ordered during the emergency department visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACEP49", + "title": "Emergency Medicine: Appropriate Use of Imaging for Recurrent Renal Colic", + "description": "Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACPGR1", + "title": "High Risk Pneumococcal Vaccination", + "description": "The percentage of patients aged 19 through 64 with a high risk condition, who either received a pneumococcal vaccination OR who reported previous receipt of a pneumococcal vaccination.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Physicians Genesis Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET20", + "title": "Herpes Zoster (Shingles) Vaccination", + "description": "The percentage of patients 60 years of age and older who have a Varicella Zoster (shingles) vaccination", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACPGR2", + "title": "Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination", + "description": "Percentage of patients aged 19 or older who received a primary vaccine series of tetanus/diphtheria/acellular pertussis (tdap) vaccine OR who reported previous receipt of Tdap vaccination.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Physicians Genesis Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACPGR3", + "title": "Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) and a current or prior ejection fraction (EF) <40% who are self-identified Black or African Americans and receiving ACEI or ARB and Beta-blocker therapy who were prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Physicians Genesis Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Q408", + "title": "Opioid Therapy Follow-up Evaluation (Q408)", + "description": "All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Physicians Genesis Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Q414", + "title": "Evaluation or Interview for Risk of Opioid Misuse (Q414)", + "description": "All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Physicians Genesis Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad26", + "title": "Appropriate venous access for hemodialysis", + "description": "Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access\n\nInverse measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad2", + "title": "CT Colonography Clinically Significant Extracolonic Findings (Inverse Measure)", + "description": "Percentage of exams resulting in recommendations for clinical correlation or additional imaging on the basis of the CTC report", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad1", + "title": "CT Colonography True Positive Rate", + "description": "Percentage of exams with a ≥ 10mm polyp detected by CTC that was with confirmed by colonoscopy (True Positive Rate)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad23", + "title": "Lung Cancer Screening Abnormal Interpretation Rate", + "description": "The percentage of screening lung cancer interpreted\nas positive (Lung-RADS Category 3 or 4).", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad21", + "title": "Lung Cancer Screening Cancer Detection Rate (CDR)", + "description": "The percentage of screenings of lung cancer that\nwere interpreted as positive (Lung-RADS category 3\nor 4) and result in a tissue diagnosis of cancer within\n12 months.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad22", + "title": "Lung Cancer Screening Positive Predictive Value (PPV)", + "description": "The percentage of screenings for lung cancer with\nabnormal interpretation (Lung-RADS 3 or 4) that\nresult in a tissue diagnosis of cancer within 12\nmonths.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad31", + "title": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.", + "description": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad32", + "title": "Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.", + "description": "Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad33", + "title": "Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level", + "description": "Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad30", + "title": "Rate of Inadequate Percutaneous Image-Guided Biopsy", + "description": "The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report.\n\nInverse measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad28", + "title": "Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement", + "description": "Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement\n\nInverse measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad29", + "title": "Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement", + "description": "Percentage of percutaneous nephrostomy tube\nreplacement within 30 days following initial\nplacement.\n\nInverse measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad18", + "title": "Report Turnaround Time: CT\n(Inverse Measure)", + "description": "Mean CT report turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad25", + "title": "Report Turnaround Time: Mammography", + "description": "Mean mammography report turnaround time (RTAT).\nInverse measure\nContinuous measure scoring", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad17", + "title": "Report Turnaround Time: MRI\n(Inverse Measure)", + "description": "Mean MRI report turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad19", + "title": "Report Turnaround Time: PET\n(Inverse Measure)", + "description": "Mean PET report turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad15", + "title": "Report Turnaround Time: Radiography (modified)\n(Inverse Measure)", + "description": "Mean radiography report turnaround time (RTAT).\n(Does not include mammography.)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad16", + "title": "Report Turnaround Time: Ultrasound (Excluding Breast US)\n(Inverse Measure)", + "description": "Mean Ultrasound report turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ACRad5", + "title": "Screening Mammography Abnormal Interpretation Rate (Recall Rate)\n(inverse Measure)", + "description": "The percentage of screening mammograms interpreted as positive (abnormal)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad3", + "title": "Screening Mammography Cancer Detection Rate (CDR)", + "description": "The fraction of all screening mammograms that are\ninterpreted as positive (abnormal) and have a tissue\ndiagnosis of cancer within 12 months (expressed per\n1000 exams, not as a percentage)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad8", + "title": "Screening Mammography Minimal Cancer Rate", + "description": "The percentage of cancers detected at screening mammography that are invasive carcinoma ≤ 10mm or DCIS", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad7", + "title": "Screening Mammography Node Negativity Rate", + "description": "The percentage of invasive cancers detected at\nscreening mammography that are node negative", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad6", + "title": "Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy\nRecommended)", + "description": "The percentage of screening mammograms where\nbiopsy was recommended that have a tissue\ndiagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACRad27", + "title": "Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries", + "description": "Documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Radiology National Radiology Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS15", + "title": "Preoperative Composite", + "description": "Percentage of patients who are taken to the operating room for an elective surgical procedure under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care:\n1. The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record.\n2. An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date.\n3. An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and documentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS16", + "title": "Preventative Care and Screening: Tobacco Screening and Cessation Intervention", + "description": "Percentage of patients age 18 or older who are active tobacco users who receive tobacco screening AND are offered cessation counseling at least 2 months prior to elective surgical procedure in order to delay the procedure until smoking cessation is possibly achieved.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS17", + "title": "Preoperative Key Medications Review for Anticoagulation Medication", + "description": "Percentage of patients who take anticoagulation medication who are taken to the operating room for an elective intervention under regional anesthesia, monitored anesthesia care (MAC), and/or general anesthesia who have a peri-operative management plan for anticoagulation medications documented in the medical record", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS18", + "title": "Patient Frailty Evaluation", + "description": "Percentage of patients age 80 and older who have been evaluated for frailty prior to an elective operation.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS19", + "title": "Intraoperative Composite", + "description": "Percentage of patients age 18 or older who are taken to the operating room for an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia who have been documented for having all two intraoperative components addressed during the intraoperative phase of care:\n1. An intraoperative safety checklist is performed prior to incision that includes the verification of patient’s name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging.\n2. An intraoperative surgical debriefing takes place at the end of the case by the surgeon confirming wound classification, correct counts, procedure performed, specimen review, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and Foley catheter.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS20", + "title": "Optimal Postoperative Communication Plan and Patient Care Coordination Composite", + "description": "Percentage of patients, age 18 years or older, who are brought from their home or normal living environment and who are taken to the operating room for an elective surgical intervention under regional anesthesia, MAC, and/or general anesthesia who have been documented for having all four of the following patient care communication and care coordination planning components addressed at the beginning of the postoperative phase of care:\n1. A postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care.\n2. A postoperative review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate.\n3. A postoperative care coordination with the patient’s primary/referring provider regarding the surgery within 30 days following surgery.\n4. A postoperative patient care communication plan with the patient and/or patient’s family regarding the surgery and plan for care after discharge.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS21", + "title": "Post-Acute Recovery Composite", + "description": "Percentage of patients age 18 or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care:\n1. A post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date.\n2. A post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains, IV lines, etc).", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS22", + "title": "Unplanned Reoperation within the 30 Day Postoperative Period", + "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACS23", + "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", + "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Pinc51", + "title": "Surgical Site Infection (SSI)", + "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "APMA1", + "title": "Comprehensive Diabetic Foot Examination", + "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus that had a comprehensive diabetic foot examination with risk categorization based on exam findings during one or more office visits within 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Podiatric Medical Association, Inc. (APMA Registry)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR2", + "title": "Diabetic Foot Ulcer (DFU) Healing or Closure", + "description": "Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC1", + "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients", + "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on low-risk surgery patients 18 years or older for preoperative evaluation.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC2", + "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)", + "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC3", + "title": "Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients", + "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC4", + "title": "Utilization of standardized nomenclature and reporting for nuclear cardiology imaging studies", + "description": "Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients where standardized nomenclature and reporting was used and the standardized nomenclature was used in the institution’s computer systems.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC13", + "title": "SPECT-MPI studies meeting appropriate use criteria", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion\n Imaging (MPI) studies performed that are appropriate.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC14", + "title": "PET-MPI studies meeting appropriate use criteria", + "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are appropriate.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC17", + "title": "SPECT-MPI studies not Equivocal", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed that are not equivocal.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC18", + "title": "PET-MPI studies not Equivocal", + "description": "Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies\n performed that are not equivocal.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC19", + "title": "Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed where the imaging protocol used was stress only.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC20", + "title": "SPECT-MPI studies performed without the use of thallium", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion\n Imaging (MPI) studies performed without the use of thallium.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC21", + "title": "SPECT-MPI study appropriate imaging protocol selection for morbidly obese patients", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed on morbidly obese patients where the Imaging Protocol included two days.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC22", + "title": "SPECT and PET MPI studies reporting Left Ventricular Ejection Fraction", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the Left Ventricle Ejection Fraction was calculated and included in the report.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC23", + "title": "SPECT-MPI study clinical utilization of Attenuation Correction image acquisition", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC24", + "title": "SPECT-MPI study utilization of exercise as a stressor", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using a Stress Test Type that includes exercise.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASNC25", + "title": "SPECT-MPI study adequate exercise testing performed", + "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "efficiency", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Society of Nuclear Cardiology ImageGuide", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR1", + "title": "Adequate Off-loading of Diabetic Foot Ulcer at each treatment visit", + "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and older received adequate off-loading during a 12-month reporting period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPS5", + "title": "Breast Reconstruction: Return to OR", + "description": "Percentage of female patients aged 18 years and older who had breast reconstruction who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Society of Plastic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPS6", + "title": "Breast Reconstruction: Flap Loss", + "description": "Percentage of female patients aged 18 years or older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who present with flap loss within 30 days of the primary breast reconstruction procedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Society of Plastic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS1", + "title": "Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair", + "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of pelvic organ prolapse in each vaginal compartment using one of the accepted, objective measurement systems (POP‐Q or Baden/Walker).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS2", + "title": "Preoperative utilization of pessary prior to Pelvic Organ Prolapse surgery", + "description": "The percentage of patients who have attempted pessary placement or the treatment of pelvic organ prolapse prior to surgical intervention.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS3", + "title": "Preoperative assessment of sexual function prior to pelvic organ prolapse repair", + "description": "Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS4", + "title": "Performing an intraoperative rectal examination at the time of prolapse repair", + "description": "Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior pelvic organ prolapse.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS5", + "title": "Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse", + "description": "Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS6", + "title": "Route of Hysterectomy", + "description": "Percentage of patients who underwent vaginal hysterectomy.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "intermediateOutcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS7", + "title": "Documentation that conservative management was offered prior to fecal incontinence surgery or procedures.", + "description": "The percentage of patients offered non-surgical treatment options for fecal incontinence prior to surgery.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS8", + "title": "Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women", + "description": "Percentage of obese patients having documented weight loss counseling prior to undergoing anti-urinary incontinence procedures.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AUGS9", + "title": "Over-utilization of synthetic mesh in the posterior compartment", + "description": "Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.", + "nationalQualityStrategyDomain": "Patient Safety Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA5", + "title": "Benign Prostate Hyperplasia: Do not order creatinine lab for patients", + "description": "Percentage of patients with NEW diagnosis of BPH who had creatinine lab order placed", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA6", + "title": "Benign Prostate Hyperplasia: Do not order upper-tract imaging", + "description": "Percentage of patients with NEW diagnosis of BPH who had CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA12", + "title": "Benign Prostate Hyperplasia: IPSS improvement after diagnosis", + "description": "Percentage of patients with NEW diagnosis of clinically significant BPH who had IPSS (international prostate symptoms score) or AUASS (American urological association symptom score) improvement by ≥20%.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA3", + "title": "Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys", + "description": "Percentage of patients (boys) =< 18 yrs. of age newly diagnosed with undescended testis or retractile testis with an order for ultrasound (scrotal or groin) placed.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA8", + "title": "Hospital re-admissions/complications within 30 days of TRUS Biopsy", + "description": "Percentage of patients who had TRUS biopsy performed who had ≥24h after the biopsy): infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA4", + "title": "Hypogonadism: Testosterone lab ordered/reported within 6 months of starting testosterone replacement", + "description": "Percentage of patients with hypogonadism, starting testosterone medication (any formulation of testosterone) or rec’d testosterone injection in clinic have testosterone level ordered within 6 months of first testosterone Rx or injection", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA11", + "title": "Prostate Cancer: Patient Report of Sexual function after treatment", + "description": "Patient report of sexual function 24 months after treatment, adjusting for nerve sparing, age/baseline, RT approach", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA10", + "title": "Prostate Cancer: Patient Report of Urinary function after treatment", + "description": "Patient report of urinary function 12months after treatment , adjusting for age/baseline", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC4", + "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients", + "description": "Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA14", + "title": "Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment", + "description": "Percentage of patients who underwent endoscopic procedures following SWL", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA13", + "title": "Stress Urinary Incontinence (SUI): Revision surgery within 12 months of incontinence procedure", + "description": "Percentage of women who undergo surgery for stress incontinence who require revision surgery within 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA15", + "title": "Stones: Urinalysis documented 30 days before surgical stone procedures", + "description": "Percentage of patients with a documented urinalysis 30 days before surgical stone procedures", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA16", + "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethal Resection of Bladder Tumor (TURBT) for T1 disease", + "description": "Percentage of patients with T1 disease, that had a second TURBTwithin 6 weeks fo the initial TURBT", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA17", + "title": "Non-Muscle Invasive Bladder Cancer: Initiation of BCG 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS", + "description": "Percentage of patients who initiate BCG treatment within 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQUA18", + "title": "Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis", + "description": "Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "American Urological Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AHSQC1", + "title": "Ventral Hernia Repair: Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period", + "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AHSQC2", + "title": "Unplanned Hospital Readmission or Observation Visit within the 30 Day Postoperative Period", + "description": "Percentage of patients aged 18 years and older who had any unplanned hospital readmission or 23 hour observation visit within the 30 day postoperative period", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AHSQC6", + "title": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period", + "description": "Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.\n\nThis measure is reported as three performance rates stratified by hernia width:\nRate 1: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)\nRate 2: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm\nRate 3: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "hernia", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)" + }, + { + "name": "overall", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm" + }, + { + "name": "hernia>10cm", + "description": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm" + } + ] + }, + { + "measureId": "AHSQC7", + "title": "Abdominal Wall Reconstruction Preoperative Diabetes Assessment", + "description": "Percentage of diabetic patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) with hemoglobin A1C assessment within 6 months prior to operation", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AHSQC8", + "title": "Ventral Hernia Repair: Biologic Mesh Prosthesis Use in Low Risk Patients", + "description": "Percentage of patients aged 18 years and older who have undergone low risk (elective, class I wound, no active skin infection, no stoma present) ventral hernia repair using biologic mesh placement", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AHSQC9", + "title": "Ventral Hernia Repair: Pain and Functional Status Assessment", + "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email.\nThis measure is reported as two performance rates:\nRate 1: Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate\nRate 2: Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Americas Hernia Society Quality Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate" + }, + { + "name": "email", + "description": "Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate" + } + ] + }, + { + "measureId": "ABG28", + "title": "Pre-Operative Screening for GERD", + "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about symptoms of Gastroesophageal Reflux Disease during their pre-anesthetic evaluation", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG29", + "title": "Pre-Operative Screening for Glaucoma", + "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about a history of Glaucoma or elevated eye pressures during their pre-anesthetic evaluation", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG30", + "title": "Pre-Operative Screening for PONV Risk", + "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about Post-operative Nauesa and Vomiting risk factors during their pre-anesthetic evaluation", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG31", + "title": "Pre-Operative Screening for Excessive Alcohol and Recreational Drug Use", + "description": "Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about alcohol and recreational drug use during their pre-anesthetic evaluation", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG32", + "title": "Pain Related Quality of Life Interference", + "description": "Percentage of patients with a diagnosis of chronic pain whose pain related quality of life (QOL) interference is addressed during at least two office visits throughout the calendar year.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG33", + "title": "Lower Body Functional Impairment (LBI)", + "description": "Percentage of patients with a diagnosis of chronic pain whose functional status was assessed with a tool(s) during at least two office visits throughout the calendar year and whose pain related functional status stayed the same or improved.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG34", + "title": "Mood Assessment Screening and treatment", + "description": "Percentage of patients with a diagnosis of chronic pain who were assessed for depression and anxiety with a standardized tool at least twice in the calendar year and who are treated for mood disorders during the calendar year as a result of their elevated assessment scores.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG1", + "title": "Intra-operative anesthesia safety", + "description": "Percentage of patients with no significant anesthesia adverse events in the operating room/procedure room.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI35", + "title": "Perioperative Mortality Rate - INVERSE MEASURE", + "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG4", + "title": "PACU tracheal intubation Rate", + "description": "The rate of tracheal intubation in the PACU for all patients who have anesthesia in the operating room/procedure room.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG5", + "title": "Composite Procedural Safety for All Vascular Access Procedures", + "description": "Percentage of adults under anesthesia care who experience a serious injury from an attempt at securing vascular access of any type (arterial, central venous, peripheral venous) in the operating room/procedure room or PACU.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG7", + "title": "Immediate Adult Post-Operative Pain Management", + "description": "The percentage of patients 18 or older admitted to the PACU after an anesthetic with a maximum pain score <7/10 within 15 minutes of arrival.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI48", + "title": "Anesthesia: Patient Experience Survey", + "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG14", + "title": "Corneal Abrasion", + "description": "Percentage of patients having an anesthetic in the operating room/procedure room who experience any ocular surface injury requiring evaluation, follow up, or treatment prior to discharge from PACU", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG15", + "title": "Dental Injury", + "description": "Percentage of patients who have general anesthesia and have an unintended change in dental status that is identified prior to PACU discharge", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG16", + "title": "Planned use of difficult airway equipment", + "description": "For all patients on whom difficult airway equipment is used in the operating room/procedure room, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG21", + "title": "Pre-operative OSA assessment", + "description": "Percentage of patients who undergo a surgical procedure in the operating room/procedure room that have a pre-operative assessment for Obstructive Sleep Apnea (OSA)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Business Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI49", + "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite", + "description": "This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below:\n\nRate 1: Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used\nRate 2: Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used\nRate 3: Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used\nRate 4: Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used\nRate 5: Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "lysine", + "description": "Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used" + }, + { + "name": "mini", + "description": "Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used" + }, + { + "name": "redcell", + "description": "Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used" + }, + { + "name": "transfusion", + "description": "Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used" + }, + { + "name": "overall", + "description": "Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met" + } + ] + }, + { + "measureId": "AQI50", + "title": "Application of Lung-Protective Ventilation during General Anesthesia", + "description": "Percentage of patients, aged 18 years and older, who undergo general anesthesia care that includes an endotracheal tube who had a median exhaled tidal volume less than or equal to 10 mL/kg of predicted-body-weight (PBW) during positive pressure ventilation (PPV).", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "intermediateOutcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI51", + "title": "Assessment of Patients for Obstructive Sleep Apnea", + "description": "Percentage of patients, aged 18 years and older, who underwent an elective procedure under anesthesia who were screened preoperatively for Obstructive Sleep Apnea (OSA) using a standardized tool prior to the procedure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI42", + "title": "Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure - INVERSE MEASURE", + "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI18", + "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation - INVERSE MEASURE", + "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI41", + "title": "Coronary Artery Bypass Graft (CABG): Stroke - INVERSE MEASURE", + "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke that did not resolve within 24 hours", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI28", + "title": "New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care", + "description": "Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to anesthesia end time.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI34", + "title": "Perioperative Cardiac Arrest - INVERSE MEASURE", + "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI31", + "title": "Postanesthesia Care Unit (PACU) Re-intubation Rate - INVERSE MEASURE", + "description": "Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI29", + "title": "Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)", + "description": "Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post- operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI32", + "title": "Procedural Safety for Central Line Placement", + "description": "Percentage of patients, regardless of age, who underwent a central venous cannulation insertion and did not experience a central line placement injury.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI37", + "title": "Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia", + "description": "Percentage of patients, regardless of age, who undergo a surgical procedure under general anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of general anesthesia.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI52", + "title": "Treatment of Hyperglycemia with Insulin", + "description": "The percentage of patients, aged 18 years and older, who undergo elective inpatient surgery and who have a blood glucose level of > 200 mg/dL and who receive insulin prior to anesthesia end time.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "intermediateOutcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE4", + "title": "Administration of insulin or glucose recheck for patients with hyperglycemia", + "description": "The percentage of cases with a perioperative glucose >200 mg/dL with administration of insulin or glucose recheck within 90 minutes of original elevated glucose measurement.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE3", + "title": "Administration of Neostigmine before Extubation for Cases with Nondepolarizing Neuromuscular Blockade", + "description": "The percentage of cases with administration of neostigmine, Sugammadex, and/or edrophonium before extubation for cases with non-depolarizing neuromuscular blockade.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE19", + "title": "Avoiding acute kidney injury", + "description": "The percentage of cases that the baseline creatinine does not increase more than 1.5 times within 7 days post-op or the baseline creatinine level does not increase by ≥ 0.3 mg/dL within 48 hours post-operatively.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE6", + "title": "Avoiding excessively high tidal volumes during positive pressure ventilation", + "description": "The percentage of cases with median tidal volumes less than 10mL/kg.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE16", + "title": "Avoiding intraoperative hypotension", + "description": "The percentage of cases that sustained intraoperative hypotension was avoided.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE22", + "title": "Avoiding medication overdose", + "description": "The percentage of cases where either naloxone or flumazenil was not administered to treat a medication overdose.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE18", + "title": "Avoiding myocardial Injury", + "description": "The percentage of cases without a Troponin I > 1.00 within 72 hours postoperatively.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE8", + "title": "Core temperature measurement for all general anesthetics", + "description": "The percentage of cases with increased risk of hypothermia that the anesthesia provider documented core temperature.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE2", + "title": "Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker", + "description": "The percentage of cases with a documented Train of Four after the last dose of a non-depolarizing neuromuscular blocker.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASPIRE13", + "title": "Transfusion goal of hematocrit less than 30 or hemoglobin less than 10.", + "description": "The percentage of cases where post-transfusion hematocrit is less than 30%, or hemoglobin less than 10.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "BNS1", + "title": "Preoperative notification of risk of developing ischemic optic neuropathy (ION) during prone spine procedures", + "description": "Percentage of postoperative development of ischemic optic neuropathy (ION) in prone spinal procedures with preoperative notification of risk factors", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Blue Nine Systems, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CCOME1", + "title": "1-Year Patient-Reported Pain and Function Improvement after Total Knee Arthroplasty", + "description": "Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL).", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Cleveland Clinic OME", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CCOME2", + "title": "1-Year Patient-Reported Pain and Function Improvement after Total Hip Arthroplasty", + "description": "Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in hip pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total hip arthroplasty (THA) surgery. PROMs include hip-related measures of pain and function (HOOS-Pain, HOOS-PS, HOOS-JR).", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Cleveland Clinic OME", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CCOME3", + "title": "1-Year Patient-Reported Pain and Function Improvement after Total Shoulder Arthroplasty", + "description": "Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in shoulder pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include shoulder-related measures of pain and function (PSS-Pain, PSS-Function, PSS-Satisfaction).", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Cleveland Clinic OME", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CCOME4", + "title": "1-Year Patient-Reported Pain and Function Improvement after ACLR Surgery", + "description": "Percentage of patients 13 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL).", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Cleveland Clinic OME", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CCOME5", + "title": "Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy", + "description": "Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Cleveland Clinic OME", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE6", + "title": "Improved Functional Outcome Assessment for Hip Replacement", + "description": "Percentage of patients aged 18 years and older with primary hip replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE7", + "title": "Improved Functional Outcome Assessment for Knee Replacement", + "description": "Percentage of patients aged 18 years and older with primary knee replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE1", + "title": "Improved Global Physical Health Outcome Assessment for Shoulder Replacement", + "description": "Percentage of patients aged 18 years and older with primary shoulder replacement who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE3", + "title": "Improved Functional Outcome Assessment for Foot/Ankle Repair", + "description": "Percentage of patients aged 18 years and older with primary foot/ankle repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE8", + "title": "Improved Global Physical Health Outcome Assessment for Cervical Surgery", + "description": "Percentage of patients aged 18 years and older with cervical surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE9", + "title": "Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair", + "description": "Percentage of patients aged 18 years and older with primary hand/wrist/elbow repair who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE5", + "title": "Improved Global Physical Health Outcome Assessment for Spine Surgery", + "description": "Percentage of patients aged 18 years and older with spine surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE10", + "title": "Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy", + "description": "Percentage of patients aged 18 years and older with primary shoulder arthroscopy who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE11", + "title": "Improved Functional Outcome Assessment for Knee Arthroscopy", + "description": "Percentage of patients aged 18 years and older with primary knee arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE2", + "title": "Improved Functional Outcome Assessment for ACL Repair", + "description": "Percentage of patients aged 18 years and older with primary anterior cruciate ligament repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CODE12", + "title": "Improved Functional Outcome Assessment for Hip Arthroscopy", + "description": "Percentage of patients aged 18 years and older with primary hip arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Code Technology", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP6", + "title": "Evaluation and Integration of anti-coagulant medication prior to surgery", + "description": "Patients with Documented Evaluation and Integration of Anti-coagulant Medication Prior to Surgery", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP4", + "title": "Persistent hypercalcemia", + "description": "Patients with persistent elevated calcium after surgery", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP1", + "title": "Post operative hypocalcemia after thyroidectomy surgery", + "description": "The number or percent of patients with low calcium levels or negligible parathyroid hormone values reported at 30 days or more post op", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP3", + "title": "Pre operative ultrasound exam of patients with thyroid cancer", + "description": "Documentation of use and efficacy of complete pre op cervical ultrasound exam in cancer patients", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP5", + "title": "Related readmission for adrenal related problems", + "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hematoma\n 2. Adrenal Insufficiency\n 3. Hypertension\n 4. Pain\n 5. Wound Infection\n 6. Pneumonia\n 7. Dehydration\n 8. Respiratory Distress", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CESQIP2", + "title": "Related readmission for thyroid or parathyroid related problems", + "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of:\n 1. Hypocalcemia\n 2. Hematoma\n 3. Seroma\n 4. Wound infection\n 5. Rash\n 6. Dehydration\n 7. Lymphatic or thoracic duct leak\n 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness\n 9. Dysphagia\n 10. Pain\n 11. Tracheal injury or perforation\n 12. Esophageal injury or perforation\n 13. Lower extremity complication (Phlebitis)\n 14. Deep venous thrombosis\n 15. Pulmonary embolism (including respiratory distress)\n 16. Pulmonary (asthma, URI, pneumonia)\n 17. Gastrointestinal (diarrhea, constipation, SBO)\n 18. Nausea and/or vomiting\n 19. Genitourinary (UTI, urinary retention)\n 20. Myocardial Event (Atrial fib, CHF, MI, CVA)\n 21. Psychiatric/Neurological (anxiety, syncope, dizziness)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CUHSM3", + "title": "CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)", + "description": "•Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients.\n Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients.\n Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients.\n Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Consortium for Universal Health System Metrics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "CUHSM4", + "title": "CAHPS Health Plan Survey v 4.0 - Adult questionnaire", + "description": "30-question core survey of adult health plan members that assesses the quality of care and services they receive. Level of analysis: health plan – HMO, PPO, Medicare, Medicaid, commercial", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Consortium for Universal Health System Metrics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "CUHSM6", + "title": "Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder", + "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Consortium for Universal Health System Metrics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "CUHSM8", + "title": "Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications", + "description": "The percentage of individuals 25 to 75 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Consortium for Universal Health System Metrics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "EPREOP4", + "title": "Short-term Pain Management/Maximum Pain Score", + "description": "The percentage of patients aged 18 years and older, admitted to the postoperative recovery area after undergoing a surgical procedure that required an anesthetic and had a maximum pain score of <8 out of 10.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ePreop Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "EPREOP9", + "title": "Prophylactic Antibiotic Administration", + "description": "Percentage of patients for whom the administration of an indicated and ordered prophylactic antibiotic is initiated within one hour (or two hours for fluoroquinolone or vancomycin) prior to surgical incision.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ePreop Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "EPREOP14", + "title": "Dental Injury", + "description": "Percentage of anesthesia patients who experience chipped, broken, loose, or dislodged teeth following insertion or removal of any of the following airway devices (laryngoscope, video laryngoscopy, supraglottic devices or fiberoptic intubating device).", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "ePreop Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "EPREOP26", + "title": "Ultrasound Guidance for Central Venous Catheter Placement", + "description": "Percentage of patients who undergo central venous catheterization for whom ultrasound guidance is used for vessel localization and venipuncture, and documented in the medical record.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ePreop Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "EPREOP27", + "title": "Ultrasound Guidance for Peripheral Nerve Block", + "description": "Percentage of patients, aged 18 years and older, who undergo upper or lower extremity peripheral nerve blockade, and for whom ultrasound guidance is used and documented in the medical record.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ePreop Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "FORCE4", + "title": "Improvement in Function after Knee Replacement", + "description": "Percentage of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or KOOS physical function score.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE5", + "title": "Improvement in Pain after Knee Replacement", + "description": "Percentage of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who had with a KOOS pain assessment score greater than 70 post-operatively, measured by the KOOS pain assessment score.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE9", + "title": "Improvement in Function after Hip Replacement", + "description": "Percentage of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or HOOS physical function score.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE10", + "title": "Measure Improvement in Pain after Hip Replacement", + "description": "Percentage of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who had with a HOOS pain assessment score greater than 70 post-operatively, measured by the HOOS pain assessment score.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE17", + "title": "Functional Status Assessment for Patients with musculoskeletal disease", + "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported functional status assessments", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE18", + "title": "Pain Status Assessment for Patients with musculoskeletal disease", + "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported pain status assessments", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "FORCE19", + "title": "Mental Health Assessment for Patients with orthopedic conditions", + "description": "Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported Mental Health assessments", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "FORCE-QI", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "GIQIC15", + "title": "Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients", + "description": "Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas, Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component), Sessile serrated polyp ≥ 10 mm OR sessile serrate polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "GI Quality Improvement Consortium (GIQuIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "GIQIC12", + "title": "Appropriate indication for colonoscopy", + "description": "Percentage of colonoscopy procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documented", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "GI Quality Improvement Consortium (GIQuIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "GIQIC10", + "title": "Appropriate management of anticoagulation in the peri-procedural period rate – EGD", + "description": "Percentage of patients undergoing an EGD on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "GI Quality Improvement Consortium (GIQuIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHCR4", + "title": "Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation", + "description": "Percentage of patients recommended for repeat screening or surveillance colonoscopy within one year or less due to inadequate/poor bowel preparation quality", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "GI Quality Improvement Consortium (GIQuIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "HF1", + "title": "Knee Arthroscopy for Meniscectomy", + "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscectomy. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscectomy. Isolated Meniscectomy during the reporting period CPT-4 Codes: 29880, 29881. Excluding concurrent with Anterior Cruciate Ligament Reconstruction (29888) and other concomitant procedures. Surgeons who performed a minimum of 25 meniscectomy procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent meniscectomy during the observation period. Patients receiving meniscectomy during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscectomy patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscectomy patients in the denominator. DENOMINATOR: The number of all patients who received meniscectomy during the observation window from the surgeon. Type of score: Validated knee measure change score average. Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscectomy patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscectomy patients treated by surgeon. Risk adjustment methods and variables: The predicted 6 month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscectomy surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline; 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months; 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score; Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure:  5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See attached for references...", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF2", + "title": "Surgical Reconstruction for Anterior Cruciate Ligament (ACL) Injury", + "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing ACL reconstruction. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 procedure codes will be used to identify patients who received ACL reconstruction without treatment of chondral injury. ACL reconstruction during the reporting period CPT-4 Codes: 29888. Surgeons who performed a minimum of 25 ACL reconstructions a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent ACL reconstruction during the observation period. Patients receiving ACL reconstruction during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all ACL reconstruction patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all ACL reconstruction patients in the denominator. DENOMINATOR: The number of all patients who received ACL reconstruction during the observation window from the surgeon. Type of score: Validated knee measure change score average. Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. Risk adjustment methods and variables: The predicted 6 month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to ACL reconstruction surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline; 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months; 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score; Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure:  5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See attached for references...", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF3", + "title": "Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder", + "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level.\n\nEligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1]\n\nDefining the population:\nCPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability.\n\nLabral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460).\n\nSurgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure.\nTime-period for data collection and reporting:\nThis measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available.\n\nMeasures:\nTwo surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon.\nUnadjusted measure: Average Shoulder Measure Change Score", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF4", + "title": "Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy", + "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroscopy which includes rotator cuff debridement, biceps tenodesis and acromioplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroscopy surgery. Shoulder arthroscopy during the reporting period CPT-4 Codes: 29822, 29823, 29826, 29828, 23430, 29999. Surgeons who performed a minimum of 25 shoulder arthroscopy procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroscopy during the observation period. Patients receiving shoulder arthroscopy during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroscopy patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score. NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroscopy patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroscopy during the observation window from the surgeon. Type of score: Validated shoulder measure change score average. Risk adjusted measure: Shoulder Measure Change Score Ratio. NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroscopy surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5.A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See Attachment for References.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF5", + "title": "Shoulder Arthroplasty: Change in a Validated Shoulder Patient Reported Outcome Measure Following Shoulder Arthroplasty", + "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroplasty which includes hemiarthroplasty, total anatomical and reverse arthroplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroplasty surgery. Shoulder arthroplasty during the reporting period CPT-4 Codes: 23470, 23472 (excluding 23 473 and 23474). Surgeons who performed a minimum of 25 shoulder arthroplasty procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroplasty during the observation period. Patients receiving shoulder arthroplasty during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroplasty patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroplasty patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroplasty during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroplasty surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF6", + "title": "Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair", + "description": "The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscal repair. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]Defining the population:\nCPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscal repair. Meniscal repair during the reporting period CPT-4 Codes: 29882, 29883. Excluding concurrent procedures including Anterior Cruciate Ligament Reconstruction (29888). Surgeons who performed a minimum of 25 meniscal repair procedures a year will be eligible to submit this measure.Time period for data collection and reporting:\nThis measure will be calculated using all patients who underwent meniscal repair during the observation period. Patients receiving meniscal repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscal repair patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscal repair patients in the denominator. DENOMINATOR: The number of all patients who received meniscal repair during the observation window from the surgeon. Type of score: Validated knee measure change score average; Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscal repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscal repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model.\nType of score: Ratio score\nInterpretation of score:\nSurgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions:\nPatient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal.\nPatient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months.Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient.Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient.The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HF7", + "title": "Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair", + "description": "The change in a validated shoulder measure score will be used as a performance measure for surgeons performing rotator cuff repair. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received a rotator cuff repair surgery. Arthroscopic rotator cuff repair during the reporting period CPT-4 Codes: 29827, 29826 Surgeons who performed a minimum of 25 rotator cuff repair procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent rotator cuff repair during the observation period. Patients receiving rotator cuff repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6 month shoulder measure change score across all rotator cuff repair patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6 month post-surgery across all rotator cuff repair patients in the denominator. DENOMINATOR: The number of all patients who received rotator cuff repair during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research In Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from the literature and American Academy of Orthopaedic Surgeons (AAOS) and peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. [2, 3] Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 month. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to rotator cuff repair surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Hawkins Foundation", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HAdv1", + "title": "Use of high risk sleep medications in the elderly", + "description": "Percentage of patients aged 65 years and older for whom a high risk sleep aid medication was prescribed for more than 30 days during the performance period", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "HealthAdvanta", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HAdv2", + "title": "Atrial fibrillation (afib) prevention and treatment: Patients with afib who are assessed for lifestyle and disease factors that contribute to uncontrolled afib", + "description": "Percentage of patients diagnosed with atrial fibrillation (afib) who are assessed for lifestyle and disease factors that contribue to uncontrolled atrial fibrillation at least once in the past 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "HealthAdvanta", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S16", + "title": "Absence of unplanned reoperation after major lower extremity amputation", + "description": "The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision.\n\n Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S17", + "title": "Absence of serious technical complications during peripheral arterial intervention", + "description": "The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment.\n\n Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S18", + "title": "Venous clinical severity score (VCSS) assessment before varicose vein treatment", + "description": "The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment.\n Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S19", + "title": "Proper patient selection for perforator vein ablation", + "description": "The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease.\n\n Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S1", + "title": "Procedures with statin and antiplatelet agents prescribed at discharge", + "description": "This measure estimates the frequency of procedures where a statin and antiplatelet agent was prescribed at discharge for any of the following procedures: Infra-Inguinal Bypass,\nSupra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, Carotid Endarterectomy, Thoracic and Complex EVAR, Endovascular AAA Repair, and Open AAA Repair", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S2", + "title": "Amputation-free survival assessed at least 9 months following Infra-Inguinal Bypass for intermittent claudication", + "description": "This measure estimates freedom from amputation or death at least 9 months\nafter Infra-Inguinal Bypass for intermittent claudication.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S3", + "title": "Infra-inguinal bypass for claudication patency assessed at least 9 months following surgery", + "description": "This measure estimates the frequency of graft patency assessment one year Infra-Inguinal Bypass.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S4", + "title": "Amputation-free survival assessed at least 9 months following Supra-Inguinal Bypassfor claudication", + "description": "This measure estimates freedom from amputation or death at least 9 months after Supra-Inguinal Bypassfor claudication.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S5", + "title": "Amputation-free survival at assessed at least 9 months following Peripheral Vascular Interventionfor intermittent claudication", + "description": "This measure estimates freedom from amputation or death at least 9 months after Peripheral Vascular Intervention for intermittent claudication.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S6", + "title": "Peripheral Vascular Intervention patency assessed at least 9 months following infrainguinal PVI for claudication", + "description": "This measure estimates the frequency of patency assessment at least 9 months following infrainguinal Peripheral Vascular Interventionfor claudication.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S7", + "title": "Ipsilateral stroke-free survival at assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures", + "description": "This measure estimates freedom from stroke or death at least 9 months after carotid artery stenting for asymptomatic carotid stenosis.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S8", + "title": "Ipsilateral stroke-free survival assessed at least 9 months following isolated Carotid Endarterectomy for asymptomatic procedures", + "description": "This measure estimates freedom from stroke or death at least 9 months after carotid endarterectomy for asymptomatic carotid artery stenosis.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S9", + "title": "Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures", + "description": "This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Thoracic and Complex EVAR procedures.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S10", + "title": "Survival at least 9 months after elective repair of small thoracic aortic aneurysms", + "description": "This measure estimates freedom from death at least 9 months after elective repair of small thoracic aortic aneurysms in patients without a known connective tissue disorder.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S11", + "title": "Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures", + "description": "This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Endovascular AAA Repair procedures.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S12", + "title": "Survival at least 9 months after elective repair Endovascular AAA Repair of small abdominal aortic aneurysms", + "description": "This measure estimates freedom from death at least 9 months after elective repair of small abdominal aortic aneurysms.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "M2S13", + "title": "Survival at least 9 months after elective Open AAA repair of small abdominal aortic aneurysms", + "description": "This measure estimates freedom from death at least 9 months after elective open repair of small abdominal aortic aneurysms.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "M2S Inc. (Vascular Quality Initiative QCDR)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "BIVARUS27", + "title": "Patient Reported Comprehensive Assessment of Safety", + "description": "A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\nNote: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n Items:\n Bivarus 1: Hand Sanitation Performed By My Provider\n Bivarus 2: Medication Reconciliation Performed At My Visit\n Bivarus 3: Practice Asked Me About Allergies\n Bivarus 5: Practice Explained Medications Before Giving Them\n Bivarus 10: Overall Assessment Of Safety", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SAPE QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "BIVARUS28", + "title": "Patient Reported Experience and Care Coordination", + "description": "A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\nItems:\n\nBivarus 16: My Doctor Listened To Me\nBivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions\nBivarus 19: My Doctor Explained My Final Diagnosis\nBivarus 22: My Doctor Informed Me of My Treatment Options\nBivarus 23: My Doctor Told Me How Longs Things Would Take\nBivarus 24: My Doctor Did Not Seem Rushed With Me\nBivarus 25: While In My Room, My Doctor Was Focused On My Issues\nBivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes/Communication and Care Coordination", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SAPE QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "BIVARUS32", + "title": "Patient Reported Care Team Communication", + "description": "A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Items:\n\n Bivarus 7: Coordination of Care Among Physicians And Nurses\n Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care\n Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand\n Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SAPE QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "BIVARUS30", + "title": "Patient Reported Pain Treatment Effectiveness", + "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Item:\n\n Bivarus 13: My Pain Was Treated Effectively", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "SAPE QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "BIVARUS31", + "title": "Patient Reported Communication and Care Coordination", + "description": "This measure is a patient reported outcome measure.\n\n This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure.\n\n Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level.\n\n Item:\n\n Bivarus 20: I Understood What the Physician Told Me", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "SAPE QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MOA1", + "title": "Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment.", + "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either:\n a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6).\n b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present.\n c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\n Measure explanation:\n a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication).\n\nRate 1: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain.\nRate 2: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", + "strata": [ + { + "name": "back", + "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain." + }, + { + "name": "neck", + "description": "Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain." + } + ] + }, + { + "measureId": "MOA 2", + "title": "Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology.", + "description": "Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year.\n\n Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MOA 7", + "title": "Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur.", + "description": "Successful Reporting:\n a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically.\n b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year.\n c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.).\n\nMeasure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MOA 13", + "title": "Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders.", + "description": "Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure.\n\nMeasure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MOA 14", + "title": "Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety.", + "description": "Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified.\n\n Measure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MOA 15", + "title": "Weight loss in pain patients with BMI >30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control.", + "description": "Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy.\n\nMeasure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MOA 12", + "title": "Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities.", + "description": "Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure.\n\nProviders would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code).\n\nMeasure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Maine Osteopathic Association in Collaboration with Patient 360", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MeHC1", + "title": "Hemoglobin A1c Test for Pediatric Patients", + "description": "Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Massachusetts eHealth Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ECPR39", + "title": "Avoid Head CT for Patients with Uncomplicated Syncope", + "description": "Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ECPR43", + "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", + "description": "multiple performance rates include:\nRate 1: In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)\nRate 2: In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)" + }, + { + "name": "urgentcare", + "description": "In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR)" + } + ] + }, + { + "measureId": "ECPR2", + "title": "Door to Diagnostic Evaluation by a Provider – Emergency Department (ED) Patients", + "description": "Risk-adjusted Mean Time from ED Arrival to Provider Contact for ED Patients Evaluated by the Eligible Professional; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ECPR44", + "title": "Door to Diagnostic Evaluation by a Provider – Urgent Care Patients", + "description": "Risk-adjusted Mean Time from Urgent Care Clinic (UCC) Arrival to Provider Contact for Urgent Care Patients Evaluated by the Eligible Professional; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ECPR40", + "title": "Initiation of the Initial Sepsis Bundle", + "description": "Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ECPR6", + "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients", + "description": "Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Higher Acuity Patients Discharged from the ED", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ECPR5", + "title": "Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients", + "description": "Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Lower Acuity Patients Discharged from the ED", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ECPR42", + "title": "Restrictive Use of Blood Transfusions", + "description": "Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ECPR41", + "title": "Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure", + "description": "Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ECPR11", + "title": "Three Day All Cause Return ED Visit Rate – All Patients", + "description": "Risk-adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ECPR38", + "title": "Three Day All Cause Return ED Visit Rate with Admission on Re-Visit", + "description": "Risk-Adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service with Admission on Re-Visit; multiple performance rates include:\n• Time - Overall\n• Time - Adult (≥ 18 years of age)\n• Time - Pediatric (< 18 years of age)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-E-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HCPR19", + "title": "30 Day All Cause Readmission Rate for Discharged Inpatients", + "description": "Risk-Standardized Rate of All-cause Readmission to the Discharging Hospital and Hospitalist Physician Group within 30 Days of Initial Hospital Discharge; multiple performance rates include:\n• Readmission Rate – All Discharged Patients\n• Readmission Rate – Discharged Pneumonia Patients\n• Readmission Rate – Discharged CHF Patients\n• Readmission Rate – Discharged COPD Patients", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HCPR4", + "title": "Mean Length of Stay for Inpatients – CHF", + "description": "Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Congestive Heart Failure (CHF)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HCPR5", + "title": "Mean Length of Stay for Inpatients – COPD", + "description": "Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HCPR3", + "title": "Mean Length of Stay for Inpatients – Pneumonia", + "description": "Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "HCPR16", + "title": "Physician’s Orders for Life-Sustaining Treatment (POLST) Form", + "description": "Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "HCPR17", + "title": "Pressure Ulcers – Risk Assessment and Plan of Care", + "description": "Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "HCPR13", + "title": "Stroke Venous Thromboembolism (VTE) Prophylaxis", + "description": "Percentage of Adult Ischemic and Hemorrhagic Stroke Patients Who Had VTE Prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "HCPR18", + "title": "Unintentional Weight Loss – Risk Assessment and Plan of Care", + "description": "Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "HCPR14", + "title": "Venous Thromboembolism (VTE) Prophylaxis", + "description": "Percentage of Adult Patients Who Had VTE prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedAmerica-H-CPR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AQI30", + "title": "Anesthesia Safety", + "description": "Percentage of patients, regardless of age, who undergo a procedure under anesthesia without the occurrence of a major adverse event prior to completion of anesthesia care.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Medaxion", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MA1", + "title": "Case Delay", + "description": "Percentage of cases marked as delayed from scheduled start with a reason indicated", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Medaxion", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MA2", + "title": "Corneal Abrasion", + "description": "Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Medaxion", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED3", + "title": "Dental Injury", + "description": "Percentage of patients experiencing dental trauma due to intubation during an anesthetic\nprocedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MICS1", + "title": "General Health Postoperative Improvement", + "description": "Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery.\n\nRationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedTrak, Inc. CareSense QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MICS2", + "title": "Surgery Specific Postoperative Improvement in Pain Levels", + "description": "Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels.\n\nRationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedTrak, Inc. CareSense QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MICS3", + "title": "Surgery Specific Postoperative Improvement in Function Levels", + "description": "Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery.\n\nPerformance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.\n\nInstructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks.\n\nRationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedTrak, Inc. CareSense QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MEX1", + "title": "Heel Pain Treatment Outcomes for Adults", + "description": "DESCRIPTION:\n Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year\n\n INSTRUCTIONS:\n This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedXpress Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MEX2", + "title": "Heel Pain Treatment Outcomes for Pediatric Patients", + "description": "DESCRIPTION:\nPercentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain.\n\nINSTRUCTIONS:\n This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.\n Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedXpress Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MEX3", + "title": "Identification of Flat Foot in Pediatric Patients", + "description": "DESCRIPTION:\nPercentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year\n\nINSTRUCTIONS:\nThis measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient.\n\n Measure Reporting via Registry:\n ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MedXpress Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP1", + "title": "Risk standardized rate of patients who experienced a postoperative complication within 30 days", + "description": "Risk standardized rate of patients who experienced a postoperative complication within 30 days\n following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation,\n performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP2", + "title": "Risk standardized rate of patients who experienced an unplanned readmission within 30 days", + "description": "Risk standardized rate of patients who experienced an unplanned readmission (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP3", + "title": "Risk standardized rate of patients who experienced a reoperation within 30 days", + "description": "Risk standardized rate of patients who experienced a reoperation (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP4", + "title": "Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days", + "description": "Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP6", + "title": "Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) within 30 days", + "description": "Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) (superficial incisional, deep incisional, or organ/space SSI) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP7", + "title": "Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days", + "description": "Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MBSAQIP8", + "title": "Risk standardized rate of patients who experienced extended length of stay (> 7 days)", + "description": "Risk standardized rate of patients who experienced extended length of stay (> 7 days) following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSSIC2", + "title": "Assessment of back or neck pain", + "description": "The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of back or neck pain (depending on the location of the spine probem) was done prior to surgery using a standard 0-10 numeric pain rating scale.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC3", + "title": "Assessment of leg or arm pain", + "description": "The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of leg or arm pain (depending on the location of the spine problem) was done prior to surgery using a standard 0-10 numeric pain rating scale.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC4", + "title": "Assessment of pain-related disability (ODI/NDI)", + "description": "The measure reflects the percent of patients receiving cervical spine surgery for whom a formal assessment pain-related disability was done, using either the Oswestry Disability Index (lumbar spine patients) or the Neck Disability Index (cervical spine patients).", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC5", + "title": "Follow-up (90 day) assessment of myelopathy (cervical only)", + "description": "The measure reflects the percent of patients receiving spine surgery who were formally assessed for myelopathy 90 days after surgery, using the mJOA scale. Ideally, this rate would be 100%. Surgical practices in MSSIC have rates generally ranging from 40% at the low end to 85% at the high end.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC8", + "title": "Percent of patients achieving MCID for back or neck pain", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC9", + "title": "Percent of patients achieving MCID for leg or arm pain", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC10", + "title": "Percent of patients achieving MCID for pain-related disability (ODI/NDI)", + "description": "The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard \"Minimum Clinically Important Difference\" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.)", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC6", + "title": "Percent same-day ambulation", + "description": "The measures reflects the percent of patients receiving spine surgery for whom there is medical record evidence of ambulation (actual movement out of the bed, not just feet dangling out of bed) on the day of surgery. Analysis of MSSIC data in 2016 showed the early ambulation is a significant protective factor for a variety of complications, and that there is currently significant variability among hospitals and surgeons in terms of the percent of patients who do have ambulation on the day of surgery.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC11", + "title": "Percent Satisfied with Result", + "description": "The measure reflects the percent of patients receiving spine surgery who report being satisfied with the result of surgery, either in terms of having received the benefit they wanted and expected, or having achieved enough benefit that they would be willing to do the procedure again to achieve the same benefit.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC1", + "title": "Pre-surgical screening for depression", + "description": "The measure reflects the percent of surgical cases that received a formal pre-surgical screening for depression. MSSIC uses the PHQ-2 brief screening instrument", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC7", + "title": "Rate of use of Pre-op skin preparation/wash", + "description": "The measures reflects the percent of patients receiving spine surgery for whom there is medical record evidence of use of evidence-based interventions to prevent surgical site infection (SSI). SSI is a relatively rare but serious complication of surgery, and is preventable to some extent by specific pre-surgical site preparation done by patients the day before surgery. Data from MSSIC suggests significant variability among surgeons and among hospitals in terms of the percent of patients for whom a formal pre-surgical wash preparation is used.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC12", + "title": "Risk-adjusted rate of hospital readmission", + "description": "The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned \"readmissions\" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions.\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC13", + "title": "Risk-adjusted rate of surgical site infection", + "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC14", + "title": "Risk-adjusted rate of urinary retention", + "description": "The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period.\n\n Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSSIC15", + "title": "Unplanned Return to OR Rate", + "description": "The measure reflects the percent of patients receiving spine surgery who had an unplanned return to the operating room, either during the index admission (or equivalent outpatient stay for outpatient procedures) or during the 90-day period post-discharge. Unplanned return to the OR reflects a quality problem of some kind, and rates vary significantly from surgeon to surgeon and from hospital to hospital.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Michigan Spine Surgery Improvement Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC1", + "title": "Prostate Biopsy Antibiotic Compliance", + "description": "Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC6", + "title": "Prostate Cancer: Unplanned Hospital Readmission After Radical Prostatectomy", + "description": "Percentage of patients aged 30 years and older who had an unplanned hospital readmission within 30 days of principal procedure", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC5", + "title": "Prostate Cancer: Radical Prostatectomy Cases LOS", + "description": "Percentage of radical prostatectomy cases with a length of stay > 2 days", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC3", + "title": "Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients", + "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a CT scan performed at any time since diagnosis of prostate cancer", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC2", + "title": "Prostate Biopsy: Unplanned Hospital Admission within 30 Days of TRUS Biopsy", + "description": "Percentage of biopsies where patients aged 30 years and older had an unplanned hospital admission within 30 days of biopsy", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC9", + "title": "Prostate Biopsy: Repeat Biopsy for Patients with Atypical Small Acinar Proliferation (ASAP)", + "description": "Proportion of patients undergoing a repeat prostate biopsy within 12 months of their initial biopsy in the registry as a result of a finding of atypical small acinar proliferation (ASAP) as per the NCCN guidelines", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC10", + "title": "Prostate Cancer: Confirmation Testing in low risk AS eligible patients", + "description": "Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MUSIC11", + "title": "Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months", + "description": "Percentage of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED5", + "title": "Adult PACU Pain Management", + "description": "The rate of all patients, 18 or older, transferred to the postanesthesia care unit (PACU) after care under an anesthesia provider with a maximum pain score greater than 7/10 within 1 hour of arrival to the PACU.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED9", + "title": "Case Delay Rate", + "description": "Percentage of scheduled anesthesia cases or pain procedures which are delayed greater than 15 minutes after the scheduled start time due to the surgeon being late, anesthesia staff late, or room not ready.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED7", + "title": "New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care", + "description": "Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to anesthesia end time.**", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ABG12", + "title": "Patient Experience Survey", + "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED4", + "title": "Perioperative Mortality Rate", + "description": "Percentage of patients, regardless of age, who undergo a procedure* under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.**", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED16", + "title": "Perioperative Pain Plan", + "description": "Percentage of patients with signed documentation that a perioperative pain plan using a multimodal, narcotic sparing technique was discussed", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED13", + "title": "Screening and patient education for high risk patients meeting guidelines for Abdominal Aortic Ultrasound Screening", + "description": "Percentage of patients receiving an abdominal aortic aneurysm screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED14", + "title": "Screening and patient education for high risk patients meeting guidelines for Breast Cancer screening with MRI", + "description": "Percentage of patients received a breast cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED12", + "title": "Screening and patient education for high risk patients meeting guidelines for Lung Cancer Screening with CT", + "description": "Percentage of patients receiving a lung cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED15", + "title": "Screening and patient education for high risk patients meeting guidelines for osteoporosis screening", + "description": "Percentage of patients received an osteoporosis risk assessment via a patient portal, and if\nmeeting established criteria, notified of need for follow-up from the provider.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MIRAMED11", + "title": "Screening and patient education for patients meeting guidelines for Colorectal Cancer screening", + "description": "Percentage of patients receiving a colon cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow up from the provider.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MiraMed", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MNCM1", + "title": "Optimal Diabetes Care", + "description": "The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:\n>HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present\n>Non‐tobacco user >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MN Community Measurement", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MNCM2", + "title": "Optimal Vascular Care", + "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:\n* Blood Pressure less than 140/90 mmHg\n* On a statin medication, unless allowed contraindications or exceptions are present\n* Non-tobacco user\n*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MN Community Measurement", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MNCM3", + "title": "Optimal Asthma Control", + "description": "Rate 1: The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months\n\nRate 2: The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MN Community Measurement", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", + "strata": [ + { + "name": "pediatric", + "description": "The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months" + }, + { + "name": "adult", + "description": "The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following:\n•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period\n•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months" + } + ] + }, + { + "measureId": "MNCM4", + "title": "Diabetes Hemoglobin A1c Poor Control (>9.0%)", + "description": "The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose A1c (HbA1c) was in poor control (> 9.0%)\n*HbA1c greater than 9.0 mg/dL", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MN Community Measurement", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MNCM5", + "title": "Ischemic (IVD): Use of Aspirin or Another Antiplatelet", + "description": "The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and are on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present.\n\nOn daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "MN Community Measurement", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "MSN6", + "title": "Report Turnaround Time: Facility CT", + "description": "Mean CT report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN11", + "title": "Report Turnaround Time: Non-Facility CT", + "description": "Mean CT report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN5", + "title": "Report Turnaround Time: Facility MRI", + "description": "Mean MRI report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN10", + "title": "Report Turnaround Time: Non-Facility MRI", + "description": "Mean MRI report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN7", + "title": "Report Turnaround Time: Facility PET", + "description": "Mean PET report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN12", + "title": "Report Turnaround Time: Non-Facility PET", + "description": "Mean PET report turnaround time (RTAT).", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN8", + "title": "Report Turnaround Time: Non-Facility Radiography (Excluding Mammography)", + "description": "Mean radiography report turnaround time (RTAT).\n (Does not include mammography.)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN3", + "title": "Report Turnaround Time: Facility Radiography (Excluding Mammography)", + "description": "Mean radiography report turnaround time (RTAT).\n (Does not include mammography.)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN4", + "title": "Report Turnaround Time: Facility Ultrasound (Excluding Breast US)", + "description": "Mean Ultrasound turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MSN9", + "title": "Report Turnaround Time: Non-Facility Ultrasound (Excluding Breast US)", + "description": "Mean Ultrasound turnaround time (RTAT)", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "MSN Healthcare Solutions, LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MHAN1", + "title": "Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate", + "description": "Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD)\nor asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions\nand transfers from other institutions.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MyHealth Access Network", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MHAN2", + "title": "Heart Failure Admission Rate", + "description": "Admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MyHealth Access Network", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "MHAN3", + "title": "Plan All Cause Readmissions", + "description": "For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:\n1. Count of Index Hospital Stays* (denominator)\n2. Count of 30-Day Readmissions (numerator)\n3. Average Adjusted Probability of Readmission", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "MyHealth Access Network", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC15", + "title": "A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure)", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received basic ADL assessments and IADL assessments at enrollment and annually.\n\nThis measure will be calculated with three rates:\n\nRate 1: Percentage of patients who received a basic ADL assessment\nRate 2: Percentage of patients who received an IADL assessment\nRate 3: Percentage of patients who received both a basic ADL and IADL assessment (overall rate)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "ADL", + "description": "Percentage of patients who received a basic ADL assessment" + }, + { + "name": "IADL", + "description": "Percentage of patients who received an IADL assessment" + }, + { + "name": "overall", + "description": "Percentage of patients who received both a basic ADL and IADL assessment (overall rate)" + } + ] + }, + { + "measureId": "NHBPC2", + "title": "Alcohol Problem Use Assessment for Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of newly enrolled and active home-based primary care and palliative care patients who were assessed for a problem with alcohol use at enrollment.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC14", + "title": "Cognitive Assessment for Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who received an assessment of their cognitive ability.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC7", + "title": "Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure)", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients with new diagnosis of altered mental status, delirium, or new or unexpected cognitive decline whose medication lists were reviewed for possible offending medications and whose use of medications was discontinued or justified. This measure will be calculated with two rates:\n\nRate 1: Percentage of patients whose medications lists were reviewed for possible offending medications.\nRate 2: Percentage of patients with offending medications whose use of offending medications was discontinued or justified.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "reviewed", + "description": "Percentage of patients whose medications lists were reviewed for possible offending medications." + }, + { + "name": "overall", + "description": "Percentage of patients with offending medications whose use of offending medications was discontinued or justified." + } + ] + }, + { + "measureId": "NHBPC3", + "title": "Depression Symptom Assessment for Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who were screened for the presence of depression symptoms at enrollment and annually.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC5", + "title": "Depression Treatment Plan for Home-Based Primary Care and Palliative Care Patients Who Screen Positive for Depression", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who screen positive for depression symptoms and have a treatment plan** for depression.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC13", + "title": "Interdisciplinary Team Assessment for Home-Based Primary care and Palliative Care Patients", + "description": "Percentage of newly enrolled and active home-based primary care and palliative care patients who were discussed by an interdisciplinary team** at enrollment. **Interdisciplinary team must include, at minimum, the following disciplines: MD or NP or PA, nursing, and social work.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC11", + "title": "Medication Reconciliation Within 2 Weeks of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of hospitalizations in which actively enrolled home-based primary care and palliative care patients are discharged home and medications were reconciled in the practice medical record within 2 weeks of hospital discharge.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC4", + "title": "Pain Screen for Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of home-based primary care and palliative care visits at which a patient was screened for the presence of pain.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC16", + "title": "Patient Reported Outcome for Home-Based Primary Care and Palliative Care Practices", + "description": "Percentage of actively enrolled home-based primary and palliative care patients who report that their provider is caring and inspires trust.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC9", + "title": "Referral to Hospice for Appropriate Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients with a prognosis of 6 months or less who were offered referral to hospice.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC6", + "title": "Screen for Risk of Future Fall for Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who were screened for risk of future fall at enrollment and annually.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NHBPC10", + "title": "Telephone Contact, Virtual, or In-person Visit Within 48 Hours of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients", + "description": "Percentage of actively enrolled home-based primary care and palliative care patients who had a telephone contact, virtual, or in-person visit within 48 hours of hospital discharge.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Home Based Primary Care and Palliative Care Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NOF6", + "title": "Hip Fracture Mortality Rate (IQI 19)", + "description": "In-hospital deaths per 1,000 hospital discharges with hip fracture as a principal diagnosis for patients ages 65 years and older. Excludes periprosthetic fracture discharges, obstetric discharges, and transfers to another hospital.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NOF7", + "title": "Osteoporosis: percentage of patients, any age, with a diagnosis of osteoporosis who are either receiving both calcium & vitamin D intake, & exercise at least once within 12 months.", + "description": "This measure is used to assess the percentage of patients regardless of age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NOF13", + "title": "Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older", + "description": "Percentage of patients aged 50 years or older with fracture of the hip, spine or distal radius that had a central DXA measurement ordered or performed or pharmacologic therapy prescribed", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "National Osteoporosis Foundation and National Bone Health Alliance", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA6", + "title": "Spine-Related Procedure Site Infection", + "description": "Percentage of patients aged 18 years and older who had a surgical-site infection (SSI) within 30 days of the index spine procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "NPA7", + "title": "Complication Following Spine-Related Procedure", + "description": "Proportion of patients undergoing spine-related procedures who have a complication (specifically, deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, urinary tract infection [UTI], or unexpected new neurological deficit) in the 30-day post-procedure period. Modification of NQF #0705.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "NPA9", + "title": "Referral for Post-Acute Care Rehabilitation Following Spine Procedure", + "description": "Percentage of patients undergoing spine procedure who are prescribed physical therapy and clinician followed up with patient to confirm whether the appointment was made in the 3-month period following the index procedure", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA11", + "title": "Unplanned Readmission Following Spine Procedure within the 30-day Postoperative Period", + "description": "Percentage of patients aged 18 years and older who had any unplanned readmission for spine-related procedure within the 30-day postoperative period.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA12", + "title": "Selection of Prophylactic Antibiotic Prior to Spine Procedure", + "description": "Percentage of patients aged 18 years and older undergoing an index spine-related procedure with the indications for prophylactic antibiotics who had an order for antimicrobial prophylaxis.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA14", + "title": "Medicine Reconciliation Following Spine Related Procedure", + "description": "Percentage of patients aged 18 years and older undergoing spine-related procedures, discharged from operative facility, and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, who had a reconciliation of the discharge medications with the current medication list documented in the outpatient medical record.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA15", + "title": "Risk Assessment for Elective Spine Procedure", + "description": "Percentage of patients who underwent elective therapy(-ies) for spine-related disorders with documentation of risk factor assessment by their treatment team prior to therapy and who received personal discussion of those documented risks with the healthcare provider.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA16", + "title": "Depression and Anxiety Assessment Prior to Spine-Related Therapies", + "description": "Percentage of patients aged 18 years and older with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to index therapy(-ies) for treatment of spine-related pain symptoms.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA17", + "title": "Narcotic Pain Medicine Management Following Elective Spine Procedure", + "description": "Percentage of patients aged 18 years and older who underwent elective therapies for spine-related pain who were assessed for narcotic use/requirements at the time of discharge. The performance measure was met if the patient 1) was not receiving narcotics post-discharge or 2) was receiving narcotics for pain for less than 2 weeks post-discharge or 3) was expected to require narcotics for more than 2 weeks after the index procedure and a narcotic use management plan was documented.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA18", + "title": "Smoking Assessment and Cessation Coincident with Spine-Related Therapies", + "description": "Percentage of patients aged 18 years and older who were assessed for tobacco use prior to spine-related therapy(-ies) and who received cessation counseling intervention if identified as a tobacco user.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA19", + "title": "Body Mass Assessment and Follow-up Coincident with Spine-Related Therapies", + "description": "Percentage of patients aged 18 years and older with a weight and height recorded in the medical record at the time of initial evaluation and/or treatment of spine-related disorder and, if the most recent body mass index (BMI) is outside of normal parameters (BMI ≥ 23 and < 30 for patients 65 years and older; BMI ≥ 18.5 and < 25 for patients 18-64 years of age), a follow-up plan is documented (example: “Patient referred to nutrition counseling for BMI above normal parameters”).", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA20", + "title": "Unhealthy Alcohol Use Assessment Coincident with Spine Care", + "description": "Percentage of patients aged 18 years and older being treated for spine-related disorders who were assessed for unhealthy alcohol use prior to index therapy(-ies) for treatment of spine-related pain symptoms.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA22", + "title": "Spine/Extremity Pain Assessment", + "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) AND/ OR Leg or arm pain tool(s) at baseline and 3 months following index therapy (-ies) for treatment of spine-related pain symptoms and documentation of follow-up plan.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPA3", + "title": "Functional Outcome Assessment for Spine Intervention", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy (-ies) who completed baseline and 3-month follow-up (patient-reported) functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in functional status after Follow-up/Patient population with Follow-up.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in functional status after Follow-up/Patient population with Follow-up." + } + ] + }, + { + "measureId": "NPA4", + "title": "Quality-of-Life Assessment for Spine Intervention", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed baseline and 3-month follow-up (patient-reported) quality-of-life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in quality of life status after Follow-up/Patient population with Follow-up." + } + ] + }, + { + "measureId": "NPA5", + "title": "Patient Satisfaction with Spine Care", + "description": "Percentage of patients aged 18 years and older undergoing index spine therapy(-ies) who completed 3-month follow-up (patient-reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance Quality Outcomes Database", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "baseline", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "overall", + "description": "Patient population with improvement in satisfaction with care status after Follow-up/Patient population with Follow-up." + } + ] + }, + { + "measureId": "NPAGSC6", + "title": "Depression and Anxiety Assessment Prior to Spine-Related Therapies", + "description": "Percentage of patients aged 18 years and older with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to therapy(-ies) for treatment of spine-related pain symptoms.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPAGSC9", + "title": "Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-procedure Period", + "description": "Percentage of patients aged 18 years and older who had any unplanned admission following percutaneous spine-related procedure within the 30-day post-procedure period", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPAGSC3", + "title": "Functional Outcome Assessment for Spine Intervention", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment with at least 10% improvement in the functional status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in functional status (at least 10% improvement) from the baseline.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in functional status (at least 10% improvement) from the baseline." + } + ] + }, + { + "measureId": "NPAGSC7", + "title": "Narcotic Pain Medicine Management Prior to and Following Spine Therapy", + "description": "Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and documentation of decreased narcotic use/requirements at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms with an improvement in pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in pain status from the baseline.\nThus Rate 2 =< Rate 1\nOverall Rate = Rate 1", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "NPAGSC8", + "title": "Complication Following Percutaneous Spine-Related Procedure", + "description": "Proportion of patients undergoing percutaneous spine-related procedures who have a complication (specifically, CSF leak, deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, procedure related infection or unexpected new neurological deficit) in the 30-day post-procedure period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NPAGSC4", + "title": "Quality-of-Life Assessment for Spine Intervention", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment with an improvement in the quality of life status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in Quality of life status from the baseline", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in Quality of life status from the baseline" + } + ] + }, + { + "measureId": "NPAGSC5", + "title": "Patient Satisfaction with Spine Care", + "description": "Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed satisfaction with care assessment prior to the treatment and at 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment with an improvement in the satisfaction with care status from the baseline. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in satisfaction with care status from the baseline", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in satisfaction with care status from the baseline" + } + ] + }, + { + "measureId": "NPAGSC10", + "title": "Spine/Extremity Pain Assessment", + "description": "Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s)AND/ OR Leg or arm pain tool(s) at baseline and 2 +/-1 month following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms with an improvement in the pain status from the baseline and documentation of follow-up plan. This measure will be calculated using two performance rates. Two rates can be reported for baseline and follow-up:\nRate 1: Patient population with Follow-up/Patient population with baseline\nRate 2: Patient population with improvement in the pain status from the baseline", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "NeuroPoint Alliance, - AAPM&R-AANS's Spine Quality Outcomes Database (SQOD)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Patient population with Follow-up/Patient population with baseline" + }, + { + "name": "improvement", + "description": "Patient population with improvement in the pain status from the baseline" + } + ] + }, + { + "measureId": "NHCR5", + "title": "Colonoscopy: Repeat colonoscopy recommended due to piecemeal resection", + "description": "Percentage of exams with polyps removed by piecemeal excision who are told to return in appropriate interval ≤1 year", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Hampshire Colonoscopy Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD7", + "title": "Critical test: Aortic Dissection", + "description": "Adherence to Critical Test Protocol: Aortic Dissection.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD6", + "title": "Critical test: Intracranial Hemorrhage", + "description": "Adherence to Critical Test Protocol: Intracranial Hemorrhage.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD4", + "title": "Critical test: OR Foreign Body", + "description": "Adherence to Critical Test Protocol: OR Foreign Body.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD5", + "title": "Critical test: Stroke", + "description": "Adherence to Critical Test Protocol: Stroke.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD22", + "title": "Critical Finding: Acute Ocular injury", + "description": "Efficiency of reporting Critical Result: Acute Ocular Injury diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD3", + "title": "Critical Result: Aortic Dissection", + "description": "Efficiency of reporting Critical Result: Aortic Dissection diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD19", + "title": "Critical Finding: Cord Compression", + "description": "Efficiency of reporting Critical Result: Cord Compression diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD12", + "title": "Critical Result: Ectopic Pregnancy", + "description": "Efficiency of reporting Critical Result: Ectopic Pregnancy diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD20", + "title": "Critical Finding: CTA of GI bleed", + "description": "Efficiency of reporting Critical Result: GI Bleed diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD2", + "title": "Critical Result: ICH", + "description": "Efficiency of reporting Critical Result: ICH diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD11", + "title": "Critical Result: New Deep Venous Thrombosis (DVT)", + "description": "Efficiency of reporting Critical Result: New DVT diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD8", + "title": "Critical Result: Occlusive Intracranial Stroke", + "description": "Efficiency of reporting Critical Result: Occlusive intracranial stroke diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD9", + "title": "Critical Result: Placental abruption", + "description": "Efficiency of reporting Critical Result: Placental abruption diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD21", + "title": "Critical Finding: Positive bleeding scan", + "description": "Efficiency of reporting Critical Result: Positive Bleeding Scan", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD1", + "title": "Critical Result: Pulmonary Embolism", + "description": "Efficiency of reporting Critical Result: Pulmonary Embolism diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD10", + "title": "Critical Result: Ruptured Ectopic Pregnancy", + "description": "Efficiency of reporting Critical Result: Ruptured ectopic pregnancy diagnosed on radiology exams", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD14", + "title": "Critical Result Protocol", + "description": "Timeliness of notification in cases of Critical Results", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD17", + "title": "Result Requiring Follow Up Protocol", + "description": "Timeliness of notification in cases of diagnostic exams when there is a recommendation to obtain a follow up exam.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD16", + "title": "Unexpected Result Protocol", + "description": "Timeliness of notification in cases of Unexpected Results", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD15", + "title": "Urgent Result Protocol", + "description": "Timeliness of notification in cases of Urgent Results", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NJIISMD13", + "title": "Critical Test Protocol", + "description": "Timeliness of procedure performance, interpretation and report delivery for diagnostic tests ordered as Critical Tests.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "New Jersey Innovation Institute", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NNEPTN1", + "title": "Substance Use Screening", + "description": "This measure produces two rates of substance use screening:\nRate 1: Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year.\nRate 2: Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", + "strata": [ + { + "name": "12to18", + "description": "Percentage of patients age > 12 and <18 years screened for substance use using an age appropriate evidence based standardized tool within the measurement year." + }, + { + "name": "18", + "description": "Percentage of patients age 18 years and older screened for substance use using an evidence based standardized tool within the measurement year." + } + ] + }, + { + "measureId": "NNEPTN2", + "title": "Transforming Clinical Practice Initiative Common Measure Name: Substance Use Screening and Intervention Composite", + "description": "Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results. The following two measures are encompassed in this composite measure: NQF 2152, Preventive Care and Screening: Unhealthy Alcohol Use – Screening and Brief Counseling and NQF 0028 Preventive Care and Screening: Tobacco Use – Screening and Intervention.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NNEPTN3", + "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team", + "description": "Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements:\n 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by:\n a. Patient communication\n b. Health professional assessments;\n 2. Identify gaps in the achievement of health and life plan;\n 3. Health status evaluations, interventions, and outcomes;\n 4. Action plans:\n a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals.\n 5. Medication Management;\n 6. Identify community/social services and family support;\n 7. Advanced directives", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NNEPTN4", + "title": "Transforming Clinical Practice Initiative Common Measure Name: TCPI 02: Referral of At-Risk Patients to Community Based Prevention and Support Resources", + "description": "This is a measure to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measures includes:\n• BMI range >26;\n• Pre-diabetes;\n• Metabolic syndrome;\n• Behavioral/mental health ;\n• Substance use disorder.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Northern New England Practice Transformation Network in Collaboration with Mingle Analytics", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS1", + "title": "Optimal vascular care", + "description": "This measure is a composite score of appropriate vascular care measures for treatment of PAD. This measure is a composite result of 1: Antiplatelet Therapy; 2: Preventive Care and Screening: Tobacco Use; and 3: Lipid-Lowering Medications (Statin) for Patients with PAD", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS2", + "title": "Emergent transfer from an outpatient, ambulatory surgical center, or office setting", + "description": "Rate of emergent transfer from an outpatient, ASC, or office setting to an acute care facility as a result of an invasive peripheral vascular intervention.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS3", + "title": "Antiplatelet Therapy", + "description": "Percentage of patients with PAD that have been prescribed an antiplatelet medication at the reported encounter.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS4", + "title": "Lipid-Lowering Medications for Patients with PAD", + "description": "The rate at which patients with documented peripheral artery disease have documentation of a currently prescribed antihyperlipidemic medication treatment. This may include one of the following, Statin, Bile acid sequestrants, Niacin, Ezetemibe, Fibrates, PCSK9 Inhibitors.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS5", + "title": "Appropriate non-invasive arterial testing for patients with critical limb ischemia who are undergoing a LE peripheral vascular intervention", + "description": "Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with critical limb ischemia.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "structure", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OEIS6", + "title": "Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention", + "description": "Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with intermittent claudication.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Outpatient Endovascular and Interventional Society- OEIS National Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR15", + "title": "Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment", + "description": "Percentage of patients aged 18 years and older with a diagnosis of cancer who are assessed for psychosocial distress, and if moderately to severely distressed, have a documented intervention during the measurement period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR16", + "title": "Recommendation for Exercise to Adult Cancer Survivors", + "description": "Percentage of patients aged 18 years or older with a diagnosis of cancer who received a documented recommendation for 150 minutes of cardio, resistence and/or flexibility exercise at any visit during the measurement period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR17", + "title": "Assessment and Intervention for Sleep-Wake Disturbance During Cancer Treatment", + "description": "Percentage of chemotherapy cycles for patients aged 18 years and older with a diagnosis of cancer where a sleep-wake disturbance assessment is documented, and if moderate to severe disturbance is reported, an intervention for sleep-wake disturbance is documented.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR6", + "title": "Education on Neutropenia Precautions", + "description": "Percentage of patients aged 18 years and older receiving intravenous chemotherapy who received education on neutropenia precautions prior to or at the time of the first chemotherapy administration. Instructions include hand washing and to contact health care provider of a fever of 101.0 or greater.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR18", + "title": "Goal Setting and Attainment for Cancer Survivors", + "description": "Percentage of patients aged 18 years and older who completed the final component of cancer treatment that have at least one post-treatment goal documented and progress of goal attainment documented within 12 months of completing the final component of cancer treatment.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR19", + "title": "Post-Treatment Education", + "description": "Percentage of patients aged 18 years and older for whom four critical areas of patient education regarding lifestyle, late effects and cancer recurrence have been provided or reinforcement of prior education has occurred.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ONSQIR20", + "title": "Fatigue Improvement", + "description": "Percentage of patients aged 18 years and older who had moderate or greater fatigue at baseline (end of cancer treatment) and report improvement in fatigue from baseline to most recent visit in during the 12 month period after completing the final component of the treatment plan.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Oncology Nursing Society", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCHQ32", + "title": "Controlling High Blood Pressure: eGFR Test Annually", + "description": "The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period:\n\n An eGFR (Estimated Glomerular Filtration Rate) test annually", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Physician Compass", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCHQ10", + "title": "Diabetes Care All or None Outcome Measure: Optimal Control", + "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <140/90, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Physician Compass", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCHQ9", + "title": "Diabetes Care All or None Process Measure: Optimal Testing", + "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:\nAll or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Physician Compass", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCHQ13", + "title": "Ischemic Vascular Disease Care Blood Pressure Control", + "description": "The percentage of patients age 18 through 75 with one of the following conditions:\n 1) Two diagnoses related visits with Coronary Artery Disease (CAD) or a CAD risk-equivalent condition, or\n 2) Acute Coronary Event consisting of an acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) from a hospital visit, who had each of the following during the one year measurement year:\n Most recent Blood pressure controlled to a level of less than 140/90 mm Hg", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Physician Compass", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCHQ15", + "title": "Screening For Osteoporosis", + "description": "The percentage of women age 65 through 85 who had a minimum of one bone densitometry test at age 60 or above or have a diagnosis of osteoporosis or osteopenia.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Physician Compass", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCPin1", + "title": "Hypertension: Blood Pressure Control", + "description": "Percentage of patients aged ≥18 years with a diagnosis of hypertension seen within a 12-month period who have a blood pressure <140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during their most recent office visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCPin2", + "title": "CAD: Blood Pressure Control", + "description": "Percentage of patients aged ≥18 years with a diagnosis of coronary artery disease seen within a 12-month period who have a blood pressure\n< 140/90 mm Hg, OR who have a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications during the most recent office visit", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCPin3", + "title": "HF: Patient Self Care Education", + "description": "Patients, age 18 and older, with a principle diagnosis of heart failure (LVEF <40) who received educational counseling on weight monitoring, sodium restriction, physical activity and medication instruction.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ACCPin4", + "title": "AFIB: CHA2DS2–VASc Score Risk Score Documented", + "description": "Percent of patients, age 18 and older, with nonvalvular atrial fibrillation or atrial flutter for whom a CHA2DS2-VASc risk score is documented.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "ACCF-PINNACLE registry and Diabetes Collaborative Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET8", + "title": "Antiplatelet Medication for High Risk Patients", + "description": "The percentage of high risk patients who are prescribed an antiplatelet medication. High risk patients include those patients ages 50-69 years with ≥ 10% 10-year CVD risk", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET32", + "title": "Screening for albuminuria in patients at risk for CKD (DM and/or HTN)", + "description": "Test for albuminuria or urine protein in adults with Diabetes Mellitus or Hypertension and without CKD", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET13", + "title": "Chronic Kidney Disease (CKD): eGFR Monitoring", + "description": "The percentage of adult patients with Stage 3 or 4 CKD who have had a eGFR or serum creatinine in the past 6 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET14", + "title": "Chronic Kidney Disease (CKD): Hemoglobin Monitoring", + "description": "The percentage of adult patients with Stage 3B-Stage 5 CKD who have had a serum hemoglobin measured in the past 12 months", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET31", + "title": "Screening for Type 2 Diabetes", + "description": "The percentage of patients 40 to 70 years of age who are overweight or obese and have been screened for type 2 diabetes in the past 3 years", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET33", + "title": "Avoiding Use of CNS Depressants in Patients on Long-Term Opioids", + "description": "The percentage of patients on long-term opioid prescriptions without a concurrent prescription for an CNS depressant", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET27", + "title": "Use of Benzodiazepines in the Elderly", + "description": "The percentage of patients 65 years and older who are prescribed a benzodiazepine and are on an appropriate dose", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET28", + "title": "NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF) or Chronic Kidney Disease (CKD)", + "description": "The percentage of adult patients with HF, HTN or CKD who are not prescribed an NSAID or COX 2 inhibitor. The CQM is aligned with a 2015 FDA Drug Safety Communication and corresponding NSAID label changes: “the risk of heart attack or stroke can occur as early as the first weeks.” Evidence from observational studies suggest that high risk patients (i.e. those eligible for the CQM) are at highest risk of harm in the first month of exposure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET29", + "title": "Monitoring Serum Creatinine", + "description": "The percentage of adult patients prescribed an ACEI, ARB, digoxin, diuretic or metformin who have had a serum creatinine measured in the past 12 months", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET30", + "title": "Treatment of Hypokalemia", + "description": "The percentage of adult patients prescribed a thiazide diuretic who have had a serum potassium measured in the past 12 months who have a serum potassium level ≥ 3.5 meq/L", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PPRNET24", + "title": "Appropriate Treatment for Adults with Upper Respiratory Infection", + "description": "The percentage of adult patients seen within the past month and diagnosed with a common cold, pharyngitis or acute bronchitis who were not prescribed an antibiotic", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PPRNet", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Pinc1", + "title": "Risk-adjusted 30 day Readmission for Acute Myocardial Infarction", + "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Acute Myocardial Infarction (AMI) admission", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc2", + "title": "Risk-adjusted 30 day Readmission for Heart Failure", + "description": "Readmission to the same hospital for all causes within 30 days from the date of discharge of the index Heart Failure (HF) admission.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc3", + "title": "Risk-adjusted 30 day Readmission for Pneumonia", + "description": "Readmission for all causes within 30 days from the date of discharge of the index Pneumonia (PN) admission", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc4", + "title": "Risk-adjusted Mortality for Acute Myocardial Infarction", + "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Acute Myocardial Infarction (AMI).", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc5", + "title": "Risk-adjusted Mortality for Heart Failure", + "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Heart Failure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc6", + "title": "Risk-adjusted Mortality for Pneumonia", + "description": "Mortality during hospital admission for patients with a Principal Diagnosis of Pneumonia.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc33", + "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction (AMI)", + "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the AMI population of inpatients for the measurement year.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc34", + "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure (HF)", + "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the HF population of inpatients for the measurement year.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc35", + "title": "Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia (PN)", + "description": "The average (geometric mean) hospital length of stay in days relative to the expected geometric mean length of stay of the PN population of inpatients for the measurement year.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "Pinc53", + "title": "Postoperative Sepsis Rate", + "description": "Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges, and cases with missing values as listed in denominator section.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "Pinc54", + "title": "Iatrogenic Pneumothorax", + "description": "Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Premier Healthcare Solutions, Inc.", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "PP1", + "title": "Annual Monitoring for Patients on Persistent Medications (MPM)", + "description": "This measure assesses the percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. The total rate includes the sum of persons with a therapeutic monitoring test at least once during the measurement year for angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB); serum potassium and a serum creatinine; digoxin and diuretics.\nRate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.\nRate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year.\nRate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PsychPro", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "sumNumerators", + "strata": [ + { + "name": "ace", + "description": "Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." + }, + { + "name": "digoxin", + "description": "Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year." + }, + { + "name": "diuretics", + "description": "Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year." + } + ] + }, + { + "measureId": "PP2", + "title": "Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)", + "description": "The percentage of discharges for individuals 18 – 85 years of age who were hospitalized for treatment of schizophrenia and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported.\n•The percentage of individuals who received follow-up within 30 days of discharge\n•The percentage of individuals who received follow-up within 7 days of discharge", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "PsychPro", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QOPI5", + "title": "Chemotherapy administered to patients with metastatic solid tumors and performance status of 3,4, or undocumented (lower score-better)", + "description": "Percentage of adult patients with metastatic solid tumors and performance status of 3, 4, or undocumented who receive chemotherapy (Lower score – better)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "QOPI (ASCO)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QOPI11", + "title": "Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer", + "description": "Percentage of adult women under 70 with a diagnosis of AJCC stage IA (T1c) to III ER/PR negative breast cancer, who receive combination chemotherapy within 4 months of diagnosis", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "QOPI (ASCO)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QOPI15", + "title": "GCSF administered to patients who received chemotherapy for metastatic cancer (Lower score-better)", + "description": "Percentage of adult patients with metastatic cancer who are administered chemotherapy and who receive a colony stimulating factor (Lower score-better)", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "QOPI (ASCO)", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QUANTUM41", + "title": "Case Cancellation on Day of Surgery", + "description": "Surgical case cancellation occurring after care has been initiated by the anesthesia care team on the day of surgery. The cause of cancellation must relate to an issue related to the care of the anesthesiology clinician. Because the measure applies to the anesthesia care team, this measure can only be reported by groups who are reporting MIPS under the Group Reporting Option. This is an Inverse Measure.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Quantum Clinical Navigation System", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QUANTUM31", + "title": "Central Line Ultrasound Guidance", + "description": "Percentage of patients, regardless of age, in whom ultrasound guidance is used by the anesthesia clinician when placing a central line for those central lines that are placed in the internal jugular location.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Quantum Clinical Navigation System", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QUANTUM37", + "title": "Gastric Aspiration", + "description": "Any patient who aspirates gastric material into the lungs while sedated with general anesthesia or other sedative hypnotic agents administered by the anesthesia clinician, as determined by the anesthesia clinician and/or radiologic imaging up through anesthesia end time. Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. This is an Inverse Measure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Quantum Clinical Navigation System", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QUANTUM42", + "title": "Unplanned Hospital Admission After An Intended Outpatient Procedure", + "description": "Patients who were scheduled for an outpatient surgical procedure who were subsequently admitted to an inpatient status related to the provision of anesthesia care.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Quantum Clinical Navigation System", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "QUANTUM51", + "title": "Unplanned ICU Admission", + "description": "Any patient who requires an unanticipated escalation in care necessitating a transfer to an ICU related to the provision of anesthesia care up through the time of PACU discharge. Reasons for admission may include a need for postoperative ventilation, ongoing vasopressor support, unanticipated unstable airway, unanticipated potential for apnea, unplanned prolonged anesthetic action or neuromuscular blockade. This is an Inverse Measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Quantum Clinical Navigation System", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAO8", + "title": "Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed or recommended to receive either antihistamines or decongestants\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. No data exists to support antihistamines and decongestants in treating OME. As a result, physicians should not prescribe or recommend the over-the-counter use of these medications.\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8c. ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016)\"", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAO9", + "title": "Otitis Media with Effusion: Systemic Corticosteroids – Avoidance of Inappropriate Use", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAO10", + "title": "Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects.\n\n The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AAO11", + "title": "Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids", + "description": "\"Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed topical intranasal corticosteroids\n\n Rationale: OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. In children aged 4 to 11 years, there was no difference in the resolution of effusion or hearing loss over 3 months between children treated with nasal mometasone or placebo; in fact, there was an economic disadvantage in the group treated with mometasone, considering the high rate of spontaneous resolution in the placebo group. Furthermore, 7% to 22% of study group patients experienced minor adverse effects.\n\n The purpose of the corresponding guideline action statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.\n\n Evidence: STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit.\n\n Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngoly Head Neck Surg. (2016)\"", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "REG-ENT The American Academy of Otolaryngology - Head and Neck Surgery Foundation Clinical Data Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR11", + "title": "Hospitalization Rate Following Procedures Performed under Procedure Sedation Analgesia", + "description": "Percentage of inpatient hospitalizations immediately following procedures performed under procedure sedation analgesia.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RPAQIR12", + "title": "Arterial Complication Rate Following Arteriovenous Access Intervention", + "description": "Percentage of arterial complications following angiography, angioplasty or thrombectomy procedures.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RPAQIR13", + "title": "Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician", + "description": "Percentage of patients aged 18 years and older for whom documentation is sent to the dialysis unit or referring physician within two days of the procedure completion or consultation.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RPAQIR14", + "title": "Arteriovenious Graft Thrombectomy Success Rate", + "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RPAQIR15", + "title": "Arteriovenous Fistulae Thrombectomy Success Rate", + "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR1", + "title": "CKD 3-5 Patients Seen at the Recommended Frequency Levels", + "description": "CKD 3-5 Patients Seen at Recommended Frequency Levels is the percentage of patients aged 18 years and older with a diagnosis for CKD 3-5 that have been seen by the nephrologist or nephrologist’s team member in the office setting within the lowest value of the suggested frequency range per the Kidney Disease: Improving Global Outcomes (KDIGO).\n\nMeasure Rates to be Reported:\n\nCKD 3 Patients with 2 or more visits/yr.\nCKD 4 Patients with 3 or more visits/yr.\nCKD 5 Patients with 8 or more visits/yr.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR2", + "title": "Patients with a Visit to a Nephrologists Prior to 6 Months of Dialysis Onset", + "description": "Patients with a Visit to a Nephrologists Prior to 6 Months of Dialysis Onset is the percent of patients aged 18 years and older that had an office visit with a nephrologist 6 months prior to the onset of dialysis.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR3", + "title": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test", + "description": "CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test is the percentage of patients aged 18 years and older with a diagnosis for CKD 3-5 and not receiving Renal Replacement Treatment that have had a urine albumin to creatinine ratio lab test (ACR) or urine protein to creatinine ratio lab test (PCR) performed within the measurement period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR4", + "title": "CKD 4-5 Patients with Transplant Referral", + "description": "CKD 4-5 Patients with Transplant Referral is the percentage of patients aged 18 years and older with a diagnosis for CKD 4-5 who are referred to a transplant center for kidney transplant evaluation within a 24 month period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR5", + "title": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care", + "description": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care is the percentage of all adult ESRD patients on peritoneal dialysis (PD) or home hemodialysis.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR6", + "title": "End Stage Renal Disease (ESRD) Missed Dialysis Treatments", + "description": "End Stage Renal Disease (ESRD) Missed Dialysis Treatments is the percentage of adult ESRD patients that completed all scheduled dialysis treatments during the most recent calendar month.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR7", + "title": "Improved Access Site Bleeding", + "description": "Improved Access Site Bleeding is the percentage of patients with ESRD and a vascular access site that presented for prolonged bleeding, received an intervention, and subsequently reported a reduction in post-dialysis bleeding.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR8", + "title": "Post Procedure Bleeding", + "description": "Post Procedure Bleeding is the percentage of patients with ESRD that had any peripheral vascular intervention performed and reported no post procedural bleeding complications.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR9", + "title": "Post Procedure Infection", + "description": "Post Procedure Infection is the percentage of patients with ESRD that had any peripheral vascular intervention performed and reported no post procedural signs or symptoms of infection as defined as fever, chills, localized erythema or active draining of pus or new abscess formation.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RCOIR10", + "title": "Upper Extremity Edema Improvement", + "description": "Upper Extremity Edema Improvement is the percentage of patients with ESRD that present with upper extremity edema and report an improvement within 48 hours after an intervention has been performed.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal and Cardiovascular Outcome Improvement Program, powered by Forward Health Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "RPAQIR1", + "title": "Angiotensin Converting Enzyme (ACE) Inhibitor or AngiotensinReceptor Blocker (ARB) Therapy", + "description": "Percentage of patients aged 18 years and older with a diagnosis of CKD (Stages 1-5, not receiving RRT) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR2", + "title": "Adequacy of Volume Management", + "description": "Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of ESRD undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR4", + "title": "Arteriovenous Fistula Rate", + "description": "Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of ESRD and receiving maintenance hemodialysis are using an autogenous arteriovenous (AV) fistula with two needles.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR5", + "title": "Transplant Referral", + "description": "Percentage of patients aged 18 years and older with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for 90 days or longer who are referred to a transplant center for kidney transplant evaluation within a 12-month period.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR9", + "title": "Advance Care Planning (Pediatric Kidney Disease)", + "description": "Percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding advance care planning.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR16", + "title": "Peritoneal Dialysis Catheter Success Rate", + "description": "Percentage of clinically successful peritoneal dialysis (PD) catheter placements.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR17", + "title": "Peritoneal Dialysis Catheter Exit Site Infection Rate", + "description": "Percentage of patients aged 18 years and older with an exit site infection within 2 weeks of a peritoneal dialysis (PD) catheter invasive intervention.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RPAQIR18", + "title": "Advance Directives Completed", + "description": "Percentage of patients aged 18 years and older with a diagnosis of Stage 3, 4 & 5 chronic kidney disease (CKD) or ESRD who have advance directives or end of life medical orders completed based on their preferences.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Renal Physicians Association", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ICLOPS15", + "title": "Excess Days Rate and Degree of Excess (Including Physician Response)", + "description": "This is a two-part measure, measuring rate of discharges with no excess days and, where excess days occur, the rate of overly excess days. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", + "strata": [ + { + "name": "withoutexcess", + "description": "the percentage of discharges without excess days out of the total of all-cause discharges for patients aged 18 years and older." + }, + { + "name": "withexcess", + "description": "the percentage of discharges with excess days where clinician provided the required feedback AND where excess days numbered less than 3, out of the total number of discharges with excess days." + } + ] + }, + { + "measureId": "ICLOPS17", + "title": "Rate of Follow Up Visits Within 7 Days of Discharge (Including Physician Response)", + "description": "This is a two-part measure, measuring whether patients were seen in a timely fashion in the ambulatory setting after discharge. Physician feedback is required to satisfy requirements. Patients will be assigned to a physician’s Registry based on identification within the Hospital Quality dataset. The patient will be matched to existing patient data within this physician’s source system using the standard Roji Health Intelligence patient-matching algorithm (utilizing the data elements listed previously). Patients within the data who cannot be matched to patients within the physician source system data will be displayed, but flagged for review and validation.\nRate 1: the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older.\nRate 2: the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "weightedAverage", + "strata": [ + { + "name": "withfollowup", + "description": "the percentage of discharges where there is a subsequent office visit within seven days out of the total number of of all-cause discharges for patients aged 18 years and older." + }, + { + "name": "withoutfollowup", + "description": "the percentage of discharges without subsequent office visits within 7 days where clinician provided required feedback AND where re-admission within 30 days did not occur, out of the total number of all-cause discharges for patients aged 18 years and older." + } + ] + }, + { + "measureId": "RHI1", + "title": "Diabetic patients with significant change in HgbA1C level or overall change in HgbA1C", + "description": "This measure examines changes in Hemoglobin A1c using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance rate 2: The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "<9", + "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has decreased by at least 1% from the highest level to the most recent level out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemgolobin A1c greater than or equal to 9%.\nPerformance" + }, + { + "name": ">=9", + "description": "The percentage of patients aged 18-75 years whose most recent Hemoglobin A1c has increased by at least 1% from the lowest level to the most Hemoglobin A1c, out of all patients with at least 2 Hemoglobin A1c levels in the measurement year or year prior to the measurement year with at least one Hemoglobin A1c less than 9%.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." + } + ] + }, + { + "measureId": "RHI2", + "title": "Hypertensive patients with significant change in systolic blood pressure or overall change in systolic pressure", + "description": "This measure examines changes in systlic blood pressure using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance rate 2: The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": ">=160", + "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has decreased by at least 20 mmHg from the highest level to the most recent level out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure greater than or equal to 160 mmHg.\nPerformance" + }, + { + "name": "<160", + "description": "The percentage of patients aged 50-75 years whose most recent systolic blood pressure has increased by at least 20 mmHg from the lowest level to the most systolic blood pressure, out of all patients with at least 2 systolic blood pressure readings in the measurement year or year prior to the measurement year with at least one systolic blood pressure less than 160 mmHg.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." + } + ] + }, + { + "measureId": "RHI3", + "title": "Patients who have a change in tobacco use status (Improvement)", + "description": "The percent of patients whose most recent tobacco use status is not smoking and at least one of the prior responses is currently smoking over the number of patients with no change in smoking status or smoking status changed from not a current smoker to smoker. This measure is for patient >2 office visits in the measurement year and the prior year (at least 1 must be in the measurement year) AND have an assessment of smoking status at least twice.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RHI4", + "title": "Patients with Change in BMI", + "description": "This measure examines BMI changes using 3 Performance Rates:\nPerformance Rate 1: The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance rate 2: The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance Rate 3: The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "decreased", + "description": "The percentage of patients 18 years and older whose most recent BMI has decreased by at least 5 from the highest level to the most recent BMI out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI greater than or equal to 35.\nPerformance" + }, + { + "name": "increased", + "description": "The percentage of patients 18 years and older whose most recent BMI has increased by at least 5 from the lowest level to the most recent BMI, out of all patients with at least 2 BMI levels in the measurement year or year prior to the measurement year with at least one BMI less than 35.\nPerformance" + }, + { + "name": "overall", + "description": "The difference between Performance Rate 1 and Performance Rate 2, divided by the total denominator. Performance Rate 3 is the final performance rate for this measure." + } + ] + }, + { + "measureId": "RHI5", + "title": "Low back pain patients who undergo an operative procedure on the spine within 12 weeks after a referral from a primary care physician", + "description": "Percent of patients with a diagnosis of low back pain who undergo an operative procedure on the spine within 12 weeks of an initial consultation", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RHI6", + "title": "Breast Mass Follow Up: Percent of patients with a breast mass who do not have follow-up physician contact", + "description": "The percentage of patients with a breast mass who are lost to follow-up", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "RHI7", + "title": "Uncontrolled chronic disease patients without a follow-up office visit", + "description": "Patients with hypertension OR diabetes mellitus OR CHF OR Asthma OR COPD who have not been seen in the office within six months of an encounter where there was evidence that the condition was uncontrolled", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "Roji Health Intelligence LLC", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SCG1", + "title": "Evaluation of High Risk Pain Medications for Morphine Milligram Equivalents (MME)", + "description": "Percentage of patients aged 18 years and older prescribed and actively taking one or more high risk pain medications and evaluated for clinical appropriateness of morphine milligram equivalents (MME)", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Searfoss Consulting Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SCG2", + "title": "Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement", + "description": "Percentage of patients 18 years and older who had at least two medical visits during the performance period, and for whom an ankle orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the performance period", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Searfoss Consulting Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SCG3", + "title": "Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement", + "description": "Percentage of patients 18 years and older with a deformity of the foot or forefoot, who had at least two medical visits during the performance period, and for whom a foot orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the reporting period", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Searfoss Consulting Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SCG4", + "title": "Prevention of Antibiotic or Natural Herbal Supplement Impairment of Anesthesia", + "description": "Percentage of patients, regardless of age, who are were prescribed antibiotics or taking natural herbal supplements and undergoing a surgical, therapeutic or diagnostic procedures\nunder anesthesia during the performance period and who have a documented use of a preoperative\nassessment for anesthesia impairment, documented cross activity and/or\ncontraindication where appropriate AND there was no impairment of the effectiveness of\nanesthesia\nThree rates are reported.\n1) Percentage of patients who were screened using a pre-operative assessment of antibiotic\ndrug combination or natural/herbal supplement usage\n2) Percentage of patients identified with a cross activity or contraindication in the\nassessment\n3) Percentage of patients experiencing no impairment of the effectiveness of anesthesia", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Searfoss Consulting Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SCG05", + "title": "Improvement in Quality of Life from Partial Foot, Prosthetics", + "description": "Percentage of patients 18 years and older with a prescription for a partial foot, prosthetic to assist with ambulation whose health related quality of life (HRQoL) was assessed during at least two visits during the performance period AND whose health related quality of life score stayed the same or improved", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "Searfoss Consulting Group", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SDPAD1", + "title": "Education of patients with inflammatory diseases regarding increased cardiovascular risk and the need for PCP evaluation", + "description": "Percentage of patients, regardless of age, with a current diagnosis of psoriasis or hidradenitis suppurativa who were seen for an office visit during the one-year measurement period and who have a documented discussion regarding increased risk for cardiovascular comorbidities including a referral to their PCP for that screening", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SDPAD2", + "title": "HCV testing in Lichen Planus", + "description": "Percentage of patients, regardless of age with a current diagnosis of lichen planus who were seen for an office visit during the one year measurement period and for whom a HCV antibody and liver function tests have been performed or documented", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SDPAD3", + "title": "Avoiding antibiotic use in ruptured epidermal inclusion cyst", + "description": "Percentage of patients with a diagnosis of inflamed epidermal cyst and no signs of infection and who were not prescribed antibiotics", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "efficiency", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SDPAD4", + "title": "Appropriate Testing and Treatment of Nail tinea infection", + "description": "Percentage of patients, regardless of age, with a current diagnosis of tinea unguium who were seen for an office visit during the one-year measurement period, for whom appropriate testing for tinea was accomplished prior to systemic fungal treatment", + "nationalQualityStrategyDomain": "Effective clinical care or Patient safety", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Society of Dermatology Physician Assistants Dermatology PA QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "STS1", + "title": "Prolonged Length of Stay Following Coronary Artery Bypass Grafting", + "description": "Percentage of patients aged 18 years and older undergoing isolated CABG with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Society of Thoracic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "STS3", + "title": "Prolonged Length of Stay for Coronary Artery Bypass Grafting (CABG) + Valve Replacement", + "description": "Percentage of patients aged 18 years and older undergoing CABG + valve replacement with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Society of Thoracic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "STS5", + "title": "Prolonged Length of Stay following Valve Surgery", + "description": "Percentage of patients aged 18 years and older undergoing isolated valve surgery with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": true, + "primarySteward": "Society of Thoracic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "STS7", + "title": "Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery", + "description": "Percentage of patients age 18 and older undergoing a non-emergency risk modeled cardiac surgery procedure that had personalized risk assessment using the STS risk calculator and discussed those risks with the surgeon.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Society of Thoracic Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SMX1", + "title": "Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia", + "description": "The percentage of patients 25 – 75 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the program year", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SpectraMedix eMeasures360 QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SMX2", + "title": "Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications", + "description": "The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the program year.", + "nationalQualityStrategyDomain": "Community/Population Health", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SpectraMedix eMeasures360 QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SMX3", + "title": "Use of Multiple Concurrent Antipsychotics in Children and Adolescents", + "description": "The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SpectraMedix eMeasures360 QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SMX4", + "title": "Metabolic Monitoring for Children and Adolescents on Antipsychotics", + "description": "The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "SpectraMedix eMeasures360 QCDR", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AJRR4", + "title": "Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation", + "description": "Percentage of patients undergoing a hip arthroplasty who are evaluated for the presence or absence of cardiovascular risk factors within 30 days prior to the procedure (e.g. history of deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), arrhythmia, and stroke).", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Joint Replacement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AJRR2", + "title": "Hip Arthroplasty: Health and Functional Improvement", + "description": "Percentage of patients undergoing a hip arthroplasty who reported functional status based on the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR,) AND either the NIH PROMIS-10 Global instrument OR the VR-12 during the preoperative visit within 3 months prior to the procedure and at the postoperative visit between 180 and 365 days following the procedure.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Joint Replacement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AJRR3", + "title": "Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", + "description": "Percentage of patients undergoing a hip arthroplasty with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g. NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Joint Replacement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "AJRR1", + "title": "Hip Arthroplasty: Postoperative Complications within 90 Days Following the Procedure", + "description": "Percentage of patients undergoing an elective primary total hip arthroplasty who did not have a secondary procedure on the operative hip for any of the following reasons: periprosthetic fracture, dislocation, mechanical failure of the implant, irrigation/debridement of deep infection or a debridement of a superficial infection or hematoma within 90 days following the procedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Joint Replacement Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "ASBS10", + "title": "Management of the axilla in breast cancer patients undergoing breast conserving surgery with a positive sentinel node biopsy", + "description": "ASBS10: Percent of Z0011 eligible breast cancer patients who do not undergo completion axillary dissection", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Society of Breast Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ASBS1", + "title": "Surgeon assessment for hereditary cause of breast cancer", + "description": "Percent of newly diagnosed invasive and ductal carcinoma in situ (DCIS) breast cancer patients (Stage 0 - Stage 4) seen by surgeon that undergo risk assessment for a hereditary cause of breast cancer. Patients with Lobular Carcinoma in situ (LCIS) are excluded from this Quality Measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Society of Breast Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "ASBS7", + "title": "Unplanned 30 day re-operation after mastectomy", + "description": "Percent of patients undergoing mastectomy who do not require an unplanned secondary breast or axillary operation within 30 days of the initial procedure.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The American Society of Breast Surgeons", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "NIPM4", + "title": "APPROPRIATE PATIENT SELECTION FOR DIAGNOSTIC FACET JOINT PROCEDURES", + "description": "Measurement of proportion of patients aged 18 years or older meeting appropriate patient selection criteria for diagnostic facet joint procedures.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM5", + "title": "APPROPRIATE PATIENT SELECTION FOR TRIAL SPINAL CORD STIMULATION", + "description": "Measurement of proportion of patients aged 18 years or older meeting appropriate patient selection criteria for trial spinal cord stimulation.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM6", + "title": "APPROPRIATE PATIENT SELECTION FOR USE OF EPIDURAL INJECTIONS IN MANAGING PAIN ORIGINATING IN THE SACRAL, LUMBAR, THORACIC OR CERVICAL SPINE", + "description": "Measurement of proportion of patients aged 18 years and older meeting appropriate patient selection criteria for therapeutic epidural injections.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM8", + "title": "AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE CERVICAL AND THORACIC SPINE\n\n(Measure 18)", + "description": "Measurement of percentage of patients aged 18 years and older receiving therapeutic cervical/thoracic epidural injections that do not receive an excessive number of injections during the measurement period.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM1", + "title": "AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE LUMBOSACRAL SPINE", + "description": "Measurement of percentage of patients aged 18 years and older receiving therapeutic lumbosacral epidural injections that do not receive an excessive number of injections during the measurement period.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM9", + "title": "AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC CERVICAL AND THORACIC SPINAL PAIN\n\n(Measure 19)", + "description": "Measurement of percentage of patients aged 18 years and older receiving cervical/thoracic facet joint interventions that do not receive an excessive number of procedures during the measurement period, based on the recommendations of the American Society of Interventional Pain Physicians, multiple Medicare carriers, or private insurers.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM3", + "title": "AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC LUMBAR SPINAL PAIN", + "description": "Measurement of percentage of patients aged 18 years and older receiving lumbar facet joint interventions that do not receive an excessive number of procedures during the measurement period, based on the recommendations of the American Society of Interventional Pain Physicians, multiple Medicare carriers, or private insurers.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM2", + "title": "RATE OF CAUDAL AND INTERLAMINAR EPIDURAL INJECTIONS WITHOUT DURAL PUNCTURE", + "description": "Measurement of percentage of patients aged 18 years and older undergoing epidural injections with a caudal approach or lumbar, thoracic or cervical interlaminar approach during the reporting period who have not experienced dural puncture during the procedure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "NIPM7", + "title": "SHARED DECISION MAKING REGARDING ANTICOAGULANT AND ANTITHROMBOTIC USE IN THE SETTING OF CAUDAL OR INTERLAMINAR EPIDURAL INJECTIONS", + "description": "Measurement of percentage of patients aged 18 years and older undergoing caudal or interlaminar epidural injections with documentation of appropriate discussion, risk/benefit analysis, and shared decision making regarding continuation or discontinuation of their anticoagulation or antithrombotic regimen.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP1", + "title": "Topic: Turnaround time (TAT) for standard biopsies", + "description": "Measurement of the TAT for surgical pathology biopsy reports that meet a minimum 2 day requirement which is an indicator of a laboratory’s efficiency and can also effect coordination of patient care.", + "nationalQualityStrategyDomain": "Communication and Care Coordination", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP2", + "title": "Cancer Protocol Elements for Carcinoma of the Endometrium Completed", + "description": "Cancer checklist used for all eligible Carcinoma of the Endometrium specimens and all required data elements are included. The checklist covers the following procedure – Hysterectomy with/without salpingoophorectomy", + "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP3", + "title": "Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin Completed", + "description": "Cancer checklist used for all eligible kidney resections and all required data elements are included. The checklist covers the following procedures –\n\n• Partial Nephrectomy\n• Radical Nephrectomy", + "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP4", + "title": "Cancer Protocol Elements for Carcinoma of the Intrahepatic Bile Ducts Completed", + "description": "• Cancer checklist used for all patients with carcinoma of the intrahepatic bile ducts and all required data elements are included. The checklist covers the following procedures – Hepatic Resection, Partial or Complete", + "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP5", + "title": "Cancer Protocol Elements for Hepatocellular Carcinoma Completed", + "description": "Cancer checklist used for all eligible hepatic resection specimens from patients with hepatocellular carcinoma and all required data elements are included. The checklist covers the following procedures – Hepatic Resection, Partial or Complete", + "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CAP6", + "title": "Cancer Protocol Elements for Carcinoma of the Pancreas Completed", + "description": "Cancer checklist used for all eligible all epithelial tumors of the pancreas, including high-grade neuroendocrine carcinomas. The checklist covers the following procedures –\n• Partial Pancreatectomy\n• Pancreaticoduodenectomy (Whipple Resection)\n• Total Pancreatectomy", + "nationalQualityStrategyDomain": "Clinical Process/Effectiveness", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The College of American Pathologists", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "SPINEIQ1", + "title": "Change in Functional Outcomes", + "description": "Average percentage decrease in PROMIS Pain Interference Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The Spine Institute for Quality", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "SPINEIQ2", + "title": "Change in Pain Intensity", + "description": "Average percentage decrease in PROMIS Pain Intensity Score for all episodes of care for back or neck pain.\n\nNOTE: Negative decreases (or increases in pain inference) for a provider's overall score are reported as a 0% reduction.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "The Spine Institute for Quality", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "nonProportion" + }, + { + "measureId": "SPINEIQ3", + "title": "Repeated X-ray Imaging", + "description": "Percent of patients with back or neck pain who receive two or more of the same x-ray imaging studies within the measurement period. (inverse Measurement)", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": true, + "isRiskAdjusted": false, + "primarySteward": "The Spine Institute for Quality", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OBERD22", + "title": "Post-Stroke Outcome and Follow-up", + "description": "This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the \"baseline\" measurement) ; and must have completed the same PRO between 90 and 120 days after the baseline (the \"follow-up\" measurement)", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Universal Research Solutions - OBERD", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OBERD23", + "title": "Health Related Quality of Life: Patient Defined Outcomes", + "description": "The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life. intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Universal Research Solutions - OBERD", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OBERD24", + "title": "Inflamatory Bowel Disease: Follow-up and Outcomes", + "description": "This measure is a translation of the recommendations of ICHOM for optimum IBD patient follow-up using an appropriate patient reported outcome (PRO) instrument to to measure symptoms and activities of daily living. IBD-Control is such an instrument, available without license or fees provided the original paper is cited in any publication (see Bodger, et al, Gut 2014;63(7):1092-102). This measure requires that adequate disease control is demonstrated.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Universal Research Solutions - OBERD", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OBERD12", + "title": "Patient Satisfaction: CG-CAHPS Composite Tracking v", + "description": "Patient Satisfaction has become a recognized responsibility of the healthcare community that ultimately resides with the EC. This measure is intended to encourage the administration of CG-CAHPS to all patients at each visit and to ensure that attention is focused on the actionable items in the instrument, as summarized in four of the composites: Getting Timely Appointments, Care, and Information;How Well Providers Communicate With Patients; Helpful, Courteous, and Respectful Office Staff; and Follow-up on Test Results. This questionnaire is collected like any other patient reported outcome by the QCDR; it differs from the \"CAHPS for MIPS\" in that it is much shorter and does not require a special vendor.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Universal Research Solutions - OBERD", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "OBERD25", + "title": "Patient Satisfaction: Tracking Satisfaction Improvement with CG-CAHPS", + "description": "This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Universal Research Solutions - OBERD", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR5", + "title": "Adequate Compression of Venous Leg Ulcers at each treatment visit", + "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older received adequate compression within the 12-month reporting period.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR9", + "title": "Appropriate use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcers (VLUs)", + "description": "Percent of patients 18 or older with venous or diabetic foot ulcer who receive cellular and/or tissue derived products appropriately as demonstrated by meeting all of the numerator targets of this problem and patient level composite measure: venous ulcer or diabetic foot ulcer did not achieve 30% closure within 4 weeks, patient underwent vascular screening, wound bed preparation with debridement of necrotic tissue, venous ulcer had adequate compression at each visit and diabetic foot ulcer had adequate off-loading at each visit.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR8", + "title": "Appropriate use of hyperbaric oxygen therapy for patients with diabetic foot ulcers", + "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and older received adequate off-loading during a 12-month reporting period.", + "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", + "measureType": "efficiency", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "USWR15", + "title": "Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT", + "description": "Percentage diabetic foot ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has achieved healing or closure 6 months after completion of a course of HBOT, stratified by the Wound Healing Index. Healing or closure is defined as an ulcer with epithelial coverage and no continued drainage requiring a dressing.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00-62.42\nRate 2: 62.42-73.19\nRate 3: 73.19-93.45\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "bucket1", + "description": "0.00-62.42" + }, + { + "name": "bucket2", + "description": "62.42-73.19" + }, + { + "name": "bucket3", + "description": "73.19-93.45" + }, + { + "name": "overall", + "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." + } + ] + }, + { + "measureId": "USWR16", + "title": "Major Amputation in Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT", + "description": "Percentage of ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5 diabetic foot ulcer (DFU) whose ulcer has an outcome of major amputation 6 months after completion of a course of HBOT, stratified by the Wound Healing Index.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "USWR20", + "title": "Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers", + "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12-month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool.\n\nUsing the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "USWR22", + "title": "Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers", + "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) within the 12-month reporting period.\n\nUsing the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. Implementation of an intervention plan based on nutritional screening is CDR measure 20.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "USWR13", + "title": "Patient Vital Sign Assessment and Blood Glucose Check Prior to Hyperbaric Oxygen\nTherapy (HBOT) Treatment", + "description": "Percentage of HBOT treatments of patients aged 18 years and older who have their vital signs and blood glucose level assessed prior to undergoing hyperbaric oxygen therapy\n(HBOT). Three rates are reported for this measure.\n\nRate 1: Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken.\nRate 2: Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check.\nRate 3: Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check.", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "vital", + "description": "Percentage of patients undergoing a hyperbaric treatment (HBOT) whose vital signs are taken." + }, + { + "name": "glucose", + "description": "Percentage of diabetic patients undergoing a hyperbaric treatment (HBOT) who had a blood glucose check." + }, + { + "name": "overall", + "description": "Percentage of patients undergoing HBOT with vital signs taken and those with diabetes had a blood glucose check." + } + ] + }, + { + "measureId": "CDR3", + "title": "Plan of Care Creation for Diabetic Foot Ulcers (DFU) not Achieving 30% Closure at 4 Weeks", + "description": "Percentage of diabetic foot ulcers of patients aged 18 years or from whom a plan of care was not created if they failed to achieve 30% of wound closure within 4 weeks. The plan of care will include a review of whether appropriate usual care has been implemented as well as whether an advanced therapeutic is indicated.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR7", + "title": "Plan of Care for Venous Leg Ulcers not Achieving 30% Closure at 4 Weeks", + "description": "Percentage of patients aged 18 years or older with a diagnosis of venous leg ulcer for whom a plan of care was not created if they failed to achieve 30% of wound closure within 4 weeks. The plan of care will include a review of whether appropriate usual care has been implemented as well as whether an advanced therapeutic is indicated.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR10", + "title": "Vascular Assessment of patients with chronic leg ulcers", + "description": "Percentage of patients aged 18 years or older with a non healing lower extremity Diabetic Foot Ulcer (DFU), Venous Leg UIcer (VLU), or pressure ulcer of the lower extremity that underwent a non-invasive baseline vascular assessment once in a 12 month period", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "CDR6", + "title": "Venous Leg Ulcer outcome measure: Healing or Closure", + "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\nRate 1: 0.00-73.24\nRate 2: 73.24-80.26\nRate 3: 80.26-87.21\nRate 4: The average of the three risk stratified buckets which will be the performance rate in the XML submitted.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": true, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "multiPerformanceRate", + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "bucket1", + "description": "0.00-73.24" + }, + { + "name": "bucket2", + "description": "73.24-80.26" + }, + { + "name": "bucket3", + "description": "80.26-87.21" + }, + { + "name": "overall", + "description": "The average of the three risk stratified buckets which will be the performance rate in the XML submitted." + } + ] + }, + { + "measureId": "USWR21", + "title": "Wound Outcome", + "description": "Completion of Wound Outcome Questionnaire by eligible patients once during the 12-month reporting period by patients 18 years of age or older who are discharged or transferred to another site of care.", + "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", + "measureType": "outcome", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "U.S. Wound Registry", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + }, + { + "measureId": "WCQIC16", + "title": "Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers", + "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12 month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool. Using the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2 ), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure.", + "nationalQualityStrategyDomain": "Effective Clinical Care", + "measureType": "process", + "isHighPriority": false, + "isInverse": false, + "isRiskAdjusted": false, + "primarySteward": "Wound Care Collaborative", + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureSets": [], + "isRegistryMeasure": true, + "metricType": "singlePerformanceRate" + } +] \ No newline at end of file diff --git a/test/scripts/measures/fixtures/expected-measures.json b/test/scripts/measures/fixtures/expected-measures.json index 60cf4d5e..15a7da30 100644 --- a/test/scripts/measures/fixtures/expected-measures.json +++ b/test/scripts/measures/fixtures/expected-measures.json @@ -4,11 +4,6 @@ "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", - "strata": [ - { - "name": "overall" - } - ], "measureId": "AAAAI2", "title": "Asthma: Assessment of Asthma Control – Ambulatory Care Setting", "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure", @@ -19,16 +14,26 @@ "isRiskAdjusted": false, "isRegistryMeasure": true }, + { + "category": "quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "metricType": "multiPerformanceRate", + "measureId": "AAAAI4", + "title": "Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment", + "description": "Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure", + "nationalQualityStrategyDomain": "Patient Safety", + "measureType": "process", + "isHighPriority": true, + "isInverse": false, + "isRiskAdjusted": false, + "isRegistryMeasure": true + }, { "category": "quality", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "metricType": "singlePerformanceRate", - "strata": [ - { - "name": "overall" - } - ], "measureId": "AAAAI5", "title": "Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment", "description": "Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure", diff --git a/test/scripts/measures/fixtures/test-qcdr.csv b/test/scripts/measures/fixtures/test-qcdr.csv index 1928a6a1..b67099ab 100644 --- a/test/scripts/measures/fixtures/test-qcdr.csv +++ b/test/scripts/measures/fixtures/test-qcdr.csv @@ -1,4 +1,5 @@ QCDR Vendor ID,QCDR Organization Name,Measure ID,Measure Title,Measure Description,NQS Domain,Numerator,Denominator,Denominator Exclusions,Denominator Exceptions,Numerator Exclusion,Number of performance rates to be included in the XML,"Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted Specify which rate will represent an overall performance rate for the measure or how an overall performance rate could be calculated based on the data submitted in the XML [for example, simple average of the performance rates submitted or weighted average (sum the numerators divided by the sum of the denominators), etc].",Measure Types,High Priority,Outcome,Inverse Measure (Y/N),Proportional Measure (Y/N),Continuous Variable Measure (Y/N),Ratio Measure (Y/N),Risk-Adjusted (Y/N),Is accepted by more than one QCDR,Primary Steward 6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI2,Asthma: Assessment of Asthma Control – Ambulatory Care Setting,Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure ,Effective Clinical Care,Patients who were evaluated at least once during the measurement period for asthma control.,All patients aged 5 years and older with a diagnosis of asthma. ,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,Y,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI4,Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment,Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure ,Patient Safety,Patients who were assessed and had documentation of IgE sensitivity to allergens in the allergen immunotherapy prescription prior to initiating allergen immunotherapy.,Patients aged 5 years and older who initiated allergen immunotherapy during the reporting period. ,None,None,None,2,N/A,Process,High Priority,,N,Y,N,N,N,Y,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." 6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI5,Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment,Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure ,Patient Safety,Patients who were assessed and had documentation of IgE sensitivity to allergens in the allergen immunotherapy prescription prior to initiating allergen immunotherapy.,Patients aged 5 years and older who initiated allergen immunotherapy during the reporting period. ,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Y,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." 6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI5,Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment,Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure ,Patient Safety,Patients who were assessed and had documentation of IgE sensitivity to allergens in the allergen immunotherapy prescription prior to initiating allergen immunotherapy.,Patients aged 5 years and older who initiated allergen immunotherapy during the reporting period. ,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Y,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." diff --git a/test/scripts/measures/import-qcdr-measures-spec.js b/test/scripts/measures/import-qcdr-measures-spec.js index 8d43e6b6..d8ff3d13 100644 --- a/test/scripts/measures/import-qcdr-measures-spec.js +++ b/test/scripts/measures/import-qcdr-measures-spec.js @@ -4,12 +4,14 @@ const assert = chai.assert; const { execSync } = require('child_process'); const fs = require('fs'); const path = require('path'); +const _ = require('lodash'); // Test data const testMeasures = '../../test/scripts/measures/fixtures/test-measures-data.json'; const testMeasures2 = '../../test/scripts/measures/fixtures/test-measures-data2.json'; const testCsv = '../../test/scripts/measures/fixtures/test-qcdr.csv'; const testCsv2Cols = '../../test/scripts/measures/fixtures/test-qcdr-2cols.csv'; +const qcdrStrataNamesFile = '../../util/measures/qcdr-measures-strata-names.json'; const outputArg = '../../test/scripts/measures/fixtures/test-measures-data-output.json'; const output = '../' + outputArg; @@ -19,7 +21,7 @@ const expectedMeasures = require('./fixtures/expected-measures.json'); // Function which executes script and reads in output file to a JS object. const runTest = function(measuresFile, measuresCsv) { const cmd = 'node ./scripts/measures/import-qcdr-measures.js ' + - measuresFile + ' ' + measuresCsv + ' ' + outputArg; + measuresFile + ' ' + measuresCsv + ' ' + qcdrStrataNamesFile + ' ' + outputArg; console.log(execSync(cmd, {stdio: 'pipe'}).toString()); const qpp = fs.readFileSync(path.join(__dirname, output), 'utf8'); @@ -30,7 +32,7 @@ const runTest = function(measuresFile, measuresCsv) { describe('import measures', function() { it('should create new measures and ignore duplicate measureIds', () => { const measures = runTest(testMeasures, testCsv); - assert.equal(measures.length, 2); + assert.equal(measures.length, 3); }); it('should overwrite fields with the right csv data', () => { @@ -42,6 +44,12 @@ describe('import measures', function() { }); }); + it('should correctly identify multiPerformanceRate measures', () => { + const measures = runTest(testMeasures, testCsv); + const multiPerformanceRateMeasure = _.find(measures, {measureId: 'AAAAI4'}); + assert.equal(multiPerformanceRateMeasure.metricType, 'multiPerformanceRate'); + }); + it('throws an informative error when the column doesn\'t exist', function() { const errorMessage = /Column 2 does not exist in source data/; // assert.throws expects a function as its first parameter diff --git a/util/measures/latest-QCDR-Measures-20170911.csv b/util/measures/QCDR-Measures-20170911.csv similarity index 100% rename from util/measures/latest-QCDR-Measures-20170911.csv rename to util/measures/QCDR-Measures-20170911.csv diff --git a/util/measures/QCDR-Measures-20171109.csv b/util/measures/QCDR-Measures-20171109.csv new file mode 100644 index 00000000..5c4bf1a6 --- /dev/null +++ b/util/measures/QCDR-Measures-20171109.csv @@ -0,0 +1,6788 @@ +QCDR Vendor ID,QCDR Organization Name,Measure ID,Measure Title,Measure Description,NQS Domain,Numerator,Denominator,Denominator Exclusions,Denominator Exceptions,Numerator Exclusion,Number of performance rates to be included in the XML,"Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted +Specify which rate will represent an overall performance rate for the measure or how an overall performance rate could be calculated based on the data submitted in the XML [for example, simple average of the performance rates submitted or weighted average (sum the numerators divided by the sum of the denominators), etc].",Measure Types,High Priority,Outcome,Inverse Measure (Y/N),Proportional Measure (Y/N),Continuous Variable Measure (Y/N),Ratio Measure (Y/N),Risk-Adjusted (Y/N),Is accepted by more than one QCDR,Primary Steward +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI2,Asthma: Assessment of Asthma Control – Ambulatory Care Setting,Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure,Effective Clinical Care,Patients who were evaluated at least once during the measurement period for asthma control.,All patients aged 5 years and older with a diagnosis of asthma.,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI5,Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment,Percentage of patients aged 5 years and older who were assessed for IgE sensitivity to allergens prior to initiating allergen immunotherapy AND results documented in the medical record.National Quality Strategy Domain: Patient Safety Process Measure,Patient Safety,Patients who were assessed and had documentation of IgE sensitivity to allergens in the allergen immunotherapy prescription prior to initiating allergen immunotherapy.,Patients aged 5 years and older who initiated allergen immunotherapy during the reporting period.,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI6,Documentation of Clinical Response to Allergen Immunotherapy within One Year,Percentage of patients aged 5 years and older who were evaluated for clinical improvement and efficacy within one year after initiating allergen immunotherapy AND assessment documented in the medical record. National Quality Strategy Domain: Communication and Care Coordination Process Measure,Communication and Care Coordination,Patients who were evaluated for clinical improvement and efficacy at least once within the first year of treatment with assessment documented in the medical record.,All patients aged 5 years and older who initiated allergen immunotherapy within one year prior to the date of encounter.,"Patients who, at any point, discontinued the allergen immunotherapy regimen in the twelve months after initiation.",None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI8,Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year,"Proportion of patients receiving subcutaneous allergen immunotherapy that contains at least one standardized extract (mite, ragweed, grass, and/or cat) who achieved the projected effective dose for all included standardized allergen extract(s) after at least one year of treatment. National Quality Strategy Domain: Effective Clinical Care Outcome Measure ",Effective Clinical Care,Patients who achieved the projected effective dose for all standardized extracts included in the prescription.,All patients aged 5 years and older who received subcutaneous allergen immunotherapy for at least one year containing at least one standardized antigen.,None,"1. Documentation of medical reasons for not achieving the projected effective dose such as local or systemic reactions, interruptions in therapy due to co-morbid conditions (e.g. pregnancy) or patient intolerance to the projected effective dose. + +2. Documentation of patient reason(s) for not achieving the projected effective dose such as interruptions in therapy due to noncompliance. + +3. Patients receiving allergen immunotherapy prescribed and prepared by eligible professional by an outside entity (providing supervision only)",None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI9,Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s),Percentage of patients aged 5 years and older with a diagnosis of asthma who are receiving subcutaneous allergen immunotherapy with a documented assessment of asthma symptoms prior to administration of allergen immunotherapy injections. National Quality Strategy Domain: Patient Safety Process Measure,Patient Safety,Patients with documentation of an asthma symptom assessment prior to administration of allergen immunotherapy injection(s).,All patients aged 5 years and older with a diagnosis of asthma AND who are receiving subcutaneous allergen immunotherapy.,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI11,Asthma Assessment and Classification,Percentage of patients aged 5 years and older with asthma and documentation of an asthma assessment and classification. National Quality Strategy Domain: Effective Clinical Care Process Measure,Effective Clinical Care,Patients aged 5 years and older with a diagnosis of asthma and documentation of an asthma assessment and classification.,Patients aged 5 years and older with a documented diagnosis of asthma.,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI12,Lung Function/Spirometry Evaluation,Percentage of patients aged 5 years and older with asthma and documentation of a spirometry evaluation. National Quality Strategy Domain: Effective Clinical Care Process Measure ,Effective Clinical Care,"Patients aged 5 years and older with a diagnosis of asthma and documentation of a spirometry evaluation, unless a physical inability exists.",Patients aged 5 years and older with a documented diagnosis of asthma.,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI17,Asthma Control: Minimal Important Difference Improvement,"Percentage of patients aged 12 years and older whose asthma is not well-controlled as indicated by the Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire and who demonstrated a minimal important difference improvement upon a subsequent office visit during the 12-month reporting period. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Outcome Measure ",Person and Caregiver-Centered Experience and Outcomes,"Patients who demonstrate a minimal important difference (MID) improvement using one of the following three asthma assessment patient-completed questionnaires:
    +
  • Change in the Asthma Control Test (ACT) by ≥ 3 points Change in Asthma Control Questionnaire (ACQ) by ≥ 0.5 points Change in Asthma Therapy Assessment Questionnaire (ATAQ) by ≥ 1 point","All patients aged 12 years or older whose asthma is not well-controlled and who had at least one follow-up ACT, ACQ, or ATAQ within the 12-month reporting period. ",Patients with a diagnosis of COPD.," +• Medical reason(s) for patient not demonstrating MID improvement (e.g., respiratory infection within 4 weeks of follow-up visit). +",None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI18,Penicillin Allergy: Appropriate Removal or Confirmation,"Percentage of patients, regardless of age, with a primary diagnosis of penicillin or ampicillin/amoxicillin allergy, who underwent elective skin testing or antibiotic challenge that resulted in the removal of the penicillin or ampicillin/amoxicillin allergy label from the medical record if negative or confirmation of the penicillin or ampicillin/amoxicillin allergy label if positive. National Quality Strategy Domain: Communication and Care Coordination Outcome Measure ",Communication and Care Coordination,Patients who underwent elective skin testing or penicillin challenge AND who had the penicillin or ampicillin/amoxicillin allergy label removed from the medical record if results were negative or confirmed in the medical record if results were positive.,"All patients, regardless of age, with a diagnosis of primary penicillin or ampicillin/amoxicillin allergy seen during the reporting period. ",Patients with a diagnosis of Steven-John Syndrome or Serum-Sickness.,"1. Medical reason(s) for not documenting and reviewing results (e.g., previous positive penicillin skin test, patients with severe anaphylaxis to penicillin within the past 5 years, patients with penicillin reaction histories consistent with severe non-IgE-mediated reactions, significant comorbid disease and patients unable to discontinue medications with antihistaminic effects or beta-blockers). +2. Patient reason(s) for not documenting and reviewing results (e.g., patients who decline or are non-adherent with skin testing/challenge recommendations)",None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +6273354,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc.",AAAAI19,Asthma: Pharmacologic Therapy for Persistent Asthma – Ambulatory Care Setting,"Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication + +This measure will be calculated with three rates: + +Rate 1: Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication +Rate 2: Patients prescribed alternative long-term control medications (non-ICS) +Rate 3: Total patients prescribed long-term control medication +",Effective Clinical Care,Patients who were prescribed long-term control medication.,All patients aged 5 years and older with a diagnosis of persistent asthma.,None,"Patient reason(s) documented for not prescribing long-term control medication (e.g., patient declined, other patient reason)",None,3,3,Process,,,N,Y,N,N,N,No,"AAAAI American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by Premier, Inc." +4649789,AAD’s DataDerm™ (American Academy of Dermatology),"AAD1 +",Psoriasis: Assessment of Psoriasis Disease Activity,"This measure evaluates the percentage of patients with plaque psoriasis with documented assessment of disease activity using a validated scale. + + Percentage of patients with plaque psoriasis who have disease activity assessed by using one of the listed measures or validated instruments/ tools at least once during the performance period. ",Effective Clinical Care,A psoriasis patient’s disease activity is assessed and documented in the medical record using any of the listed measures or validated instruments/ tools at least once during the performance period.,All patients with a diagnosis of plaque psoriasis.,Patients with a psoriasis type other than plaque psoriasis (psoriasis vulgaris).,None,None,N/A,Current data for this measure has not been validated. Measures testing is in process and has not been finalized at this time.,Process,,,N,Y,N,N,N,No,AAD’s DataDerm™ (American Academy of Dermatology) +4649789,AAD’s DataDerm™ (American Academy of Dermatology),AAD2,Psoriasis: Screening for Psoriatic Arthritis,"Patients with psoriasis are at an increased risk of having psoriatic arthritis. This measure seeks for dermatologists to actively assess for psoriatic arthritis as to relieve symptoms, prevent structural damage, and improve quality of life. + + Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at least once during the performance period. ",Person and Caregiver-Centered Experience and Outcomes,Patients with psoriasis (any type) are screened for psoriatic arthritis by documenting in the medical record the presence or absence of joint symptoms at least once during the performance period.,All patients with a diagnosis of psoriasis.,Patients with existing diagnosis of psoriatic arthritis.,None,None,N/A,Current data for this measure has not been validated. Measures testing is in process and has not been finalized at this time.,Process,High Priority,,N,Y,N,N,N,No,AAD’s DataDerm™ (American Academy of Dermatology) +4649789,AAD’s DataDerm™ (American Academy of Dermatology),AAD3,Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients,"This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) + + The percentage of immune‐competent patients with pathologically‐proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) who are treated with Mohs surgery. ",Efficiency and Cost Reduction,Number of patients with pathologically‐proven primary superficial BCC of the trunk treated by the provider utilizing Mohs surgery [CPT 17313],"All pathologically-proven primary superficial basal cell carcinoma (BCC) lesions on the trunk (chest, back, abdomen) on immune-competent patients treated by the provider within the performance period. ","• Patients whose immune system is compromised by disease or active treatment of disease. + Examples of immunocompromised patients include but are not limited to HIV, organ transplant, hematologic malignancy, or pharmacologic immunosuppression. +",None,"Tumors that have a pathologically documented mixed histology including a more aggressive histologic subtype, or a more aggressive tumor is found on any stage if Mohs surgery is performed. +Examples of pathology report documentation for this exclusion include but are not limited to: +o Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample +o Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology",N/A,Current data for this measure has not been validated. Measures testing is in process and has not been finalized at this time.,Process,High Priority,,Y,Y,N,N,N,No,AAD’s DataDerm™ (American Academy of Dermatology) +4649789,AAD’s DataDerm™ (American Academy of Dermatology),AAD4,Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk,"This measure evaluates the number of inappropriately utilized Mohs surgeries to treat pathologically-proven primary squamous cell carcinomas in situ (SCCis) of any size on the trunk and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Inverse Measure: Low count indicates better performance) + + The percentage of immune‐competent patients with pathologically‐proven primary squamous carcinoma in situ (SCCis) lesions of any size on the trunk (chest, back, abdomen) or keratoacanthoma type squamous cell carcinoma (SCC‐KA) lesions 1 cm or smaller on the trunk (chest, back, abdomen) who are treated with Mohs surgery. ",Efficiency and Cost Reduction,Number of patients with pathologically‐proven primary SCCis or SCC‐KA lesions of the trunk treated by the provider utilizing Mohs surgery [CPT 17313],"All pathologically-proven primary SCCis or SCC-KA lesions on the trunk (chest, back, abdomen) that are 1 cm or smaller in immunocompetent patients treated by the provider within the performance period. ","* Patients whose immune system is compromised by disease or active treatment of disease. + Examples of immunocompromised patients include but are not limited to HIV, organ transplant, hematologic malignancy, or pharmacologic immunosuppression. + + *Patients who have a genetic syndrome that increases their risk for skin cancer due to decreased immune response or abnormalities in the skin cell cycle. + Examples of genetic syndromes include but are not limited to Basal Cell Nevus Syndrome, Muir Torre Syndrome, Xeroderma Pigmentosus, Li Fraumeni Syndrome, and Bazex Syndrome. + +* Tumors in areas of previous radiation therapy. ",None,"Squamous cell carcinoma in situ (SCCis) tumors that have pathologically documented areas of dermal invasion, or dermal invasion is found on any stage if Mohs surgery is performed. +Examples of pathology report documentation for this exclusion include but are not limited to: +o Pathology report states that it cannot exclude a deeper or more aggressive tumor histology for any reason other than because it is a partial biopsy sample +o Pathology report states that there is a collision tumor with another tumor that has a more aggressive histology",N/A,Current data for this measure has not been validated. Measures testing is in process and has not been finalized at this time.,Process,High Priority,,Y,Y,N,N,N,No,AAD’s DataDerm™ (American Academy of Dermatology) +4649789,AAD’s DataDerm™ (American Academy of Dermatology),AAD5,Biopsy Reporting Time - Clinician to Patient,"Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. + + Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed. ",Efficiency and Cost Reduction,Number of cutaneous biopsies by the clinician consistent with basal cell carcinoma or squamous cell carcinoma (to include in situ disease) for which the patient was notified of their final biopsy pathology findings within 14 business days from the time when the biopsy was performed.,All cutaneous biopsies by the clinician consistent with cutaneous basal or squamous cell carcinoma (including in situ disease).,Pathology reports for tissue specimens produced from excision.,None,None,N/A,Current data for this measure has not been validated. Measures testing is in process and has not been finalized at this time.,Process,High Priority,,N,Y,N,N,N,No,AAD’s DataDerm™ (American Academy of Dermatology) +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO11,Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival,"This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. This measure is included in the CMS Hospital Outpatient Quality Reporting (HOQR) system measure portfolio. + +HOQR is a quality data-reporting program, implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year 2009. To meet HOQR Program requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule). In the context of this quality measure reporting program, NQF #0661 is referred to as ´OP-23.´",Effective Communication and Care Coordination,"Number of emergency department acute ischemic stroke or hemorrhagic stroke patients arriving at the ED within 2 hours of the time last known well, with an order for a head CT or MRI scan whose time from ED arrival to interpretation of the Head CT scan is within 45 minutes of arrival.",Number of emergency department acute ischemic stroke or hemorrhagic stroke patients arriving at the ED within 2 hours of the time last known well with an order for a head CT or MRI scan.,"Patients who meet one or more of the following criteria should be excluded from the denominator: +• Patients less than 18 years of age + +(Refer to Measure Value Set Excel workbook, included in S.2b, for detailed information.)","Patients who meet one or more of the following criteria should be denominator exceptions: +• Patients who expired +• Patients who left the emergency department against medical advice or discontinued care + +(Refer to Measure Value Set Excel workbook, included in S.2b, for detailed information.)",None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO12,Venous Thromboembolism (VTE) Prophylaxis,"This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission. This measure is a part of a set of eight nationally implemented measures that address stroke care (STK-2: Discharged on Antithrombotic Therapy, STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-4: Thrombolytic Therapy, STK-5: Antithrombotic Therapy By End of Hospital Day 2, STK-6 Discharged on Statin Medication, STK-8: Stroke Education, and STK-10: Assessed for Rehabilitation) that are used in The Joint Commission’s hospital accreditation and Disease-Specific Care certification programs.",Patient Safety,Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.,Ischemic or hemorrhagic stroke patients,"• Less than 18 years of age +• Length of Stay < 2 days +• Length of Stay > 120 days +","• Comfort measures only documented on day of or day after hospital arrival +• Enrolled in clinical trials related to stroke +• Admitted for elective carotid intervention",None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO13,Ischemic stroke patients management - ,"o This measure will be calculated with 4 performance rates: +Rate 1: The percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge; +Rate 2: The percent of ischemic stroke patients prescribed anticoagulation therapy at hospital discharge Rate; +Rate 3: The percent of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two; +Rate 4: The percent of ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge +",Effective Communication and Care Coordination,"Rate 1: Anticoagulation for ischemic stroke: the number of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. +Rate 2: Anticoagulation for ischemic stroke: the number of ischemic stroke patients with documented atrial fibrillation/flutter who were prescribed anticoagulation therapy at hospital discharge +Rate 3: Anticoagulation for ischemic stroke: the number of ischemic stroke patients who had antithrombotic therapy administered by end of hospital day two. +Rate 4: Anticoagulation for ischemic stroke: the number if ischemic stroke patients with an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival who were prescribed statin medication at hospital discharge. +",Ischemic stroke patients,"• Less than 18 years of age +• Length of Stay > 120 days +","• Comfort measures only documented +• Enrolled in clinical trials related to stroke +• Admitted for elective carotid intervention +• Discharged to another hospital +• Left against medical advice +• Expired +• Discharged to home for hospice care +• Discharged to a health care facility for hospice care +• Documented reason for not prescribing (1) antithrombotic therapy at discharge; (2) anticoagulation therapy at hospital discharge; (3) antithrombotic therapy administered by end of hospital day two; (4) prescribed statin medication at hospital discharge",None,4,Sum Numerators,Process,,,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO3,Antipsychotic Use in Persons with Dementia,The percentage of individuals 65 years of age and older with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.,"Affordable Care: Overuse/Waste, Person- and Family-Centered Care","The number of patients in the denominator who had at least one prescription and > 30 days supply for any antipsychotic medication during the measurement period and do not have a diagnosis of schizophrenia, bipolar disorder, Huntington’s disease or Tourette’s Syndrome.",All patients 65 years of age and older continuously enrolled during the measurement period with a diagnosis of dementia and/or two or more prescription claims and >60 days supply for a cholinesterase inhibitor or an NMDA receptor antagonist.,None,None,None,N/A,N/A,Process,,,Y,Y,N,N,N,Yes,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",NOF12,Median Time to Pain Management for Long Bone Fracture,Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).,Effective Clinical Care,Time (in minutes) from emergency department arrival to time of initial oral or parenteral pain medication administration,Patients admitted to the emergency department with a diagnosis of long bone fracture who were administered oral or parenteral pain medications.,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,National Osteoporosis Foundation and National Bone Health Alliance +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO7,Laboratory Investigation for Secondary Causes of Fracture,Percentage of patients age 50 and over with fragility fracture who have had appropriate laboratory investigation for secondary causes of fracture ordered or performed prior to discharge from inpatient status.,Prevention and Treatment of Cardiovascular Disease: Healthy Lifestyle Behaviors,"Patients who have all the specified laboratory tests ordered or performed prior to discharge: + +1. Complete blood cell count (CBC) +2. Kidney function test +3. Liver function test +4. Serum calcium +5. 25(OH) Vitamin D level OR Oral Administration of Vitamin D","Patients age 50 and over discharged from inpatient status with an ICD-9-CM Principal or Other Diagnosis Code of selected fractures as defined in Table 3.1 Vertebral Fracture, Table 4.1 Hip Fracture, or Table 5.1 Other Fracture","Exclusions are those patients with: +• Age less than 50 years +","• “Comfort Measures Only” documented +• Enrollment in a clinical trial pertaining to osteoporosis +• Laboratory testing performed in the prior 12 months +• Expired",None,N/A,N/A,Process,,,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ACR7,Gout: Serum Urate Target,"Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.",Effective Clinical Care,Patients whose most recent serum urate level is less than 6.8 mg/dL,Adult patients aged 18 and older with a diagnosis of gout treated with urate lowering therapy (ULT) for at least 12 months,None,Patients with a history of solid organ transplant,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,American College of Rheumatology - RISE Registry +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO14,Gout: ULT Therapy,"Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)",Effective Communication and Care Coordination: Quality of Life/Functional Status,Patients who are prescribed urate lowering therapy (ULT),Adult patients aged 18 and older with a diagnosis of gout and a serum urate level > 6.0 mg/dL who have at least one of the following: presence of tophus/tophi or two or more gout flares (attacks) in the past year,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +5567664,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc.",ARCO10,Risk Standardized Mortality Rate within 30 days following Trauma Operation,Percentage of patients evaluated as part of a trauma activation or trauma consultation who are taken to the operating room for an abdominal operation who expired prior to hospital discharge.,Effective Clinical Care,"All patients evaluated as part of a trauma activation or trauma consultation who were taken to the operating room for an abdominal operation who died prior to discharge from the hospital. +Numerator Instructions: There must be documentation of death during the patient’s index admission to the hospital following their injury. +Numerator Note: A lower calculated performance rate for this measure indicates better clinical care. +Numerator Quality-Data Coding Options for Reporting Satisfactorily: +Documentation of death during the patient’s index admission to the hospital following their injury. +Performance Met: Documentation of death during the patient’s index admission to the hospital following injury. +OR +Documentation that patient arrived at the hospital with no signs life. +3 +Dead on Arrival Exclusion: Documentation of a presenting pulse of 0, a presenting systolic blood pressure of 0, and a presenting Glasgow Coma Scale motor score (GCS-M) of 1. +OR +Documentation that the patient survived to hospital discharge. +Performance Not Met: Documentation of patient survival at the time of hospital discharge from their index hospital admission following injury. +RISK ADJUSTMENT: +Risk adjusted in-hospital mortality will be calculated by adjusting for the variables listed in the following table. Thus, these patient characteristics must be reported. +Age +Gender (male/female) +Injury Severity Score (ISS) +Presenting Heart Rate +Presenting Systolic Blood Pressure +Presenting GCS Motor Score +Mechanism (blunt/gunshot/stab) +Traumatic Intracranial Hemorrhage (yes/no) +Spinal Cord Injury (yes/no) +>3 Rib Fractures (yes/no) +Transfer Status (yes/no)","This measure is to be reported for all patients taken to the operating room for an abdominal operation following trauma. There is no diagnosis associated with this measure. It is anticipated that clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure. +Measure Reporting via Registry: +CPT codes and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. +All patients evaluated by an eligible professional as part of a trauma activation or trauma consultation who were taken to the operating room for an abdominal operation. +Denominator Instructions: CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, ie, dual procedures) will be included in the denominator population. Both surgeons participating in PQRS will be fully accountable for the clinical action described in the measure. +Denominator Criteria (Eligible Cases): +Patients evaluated as part of a trauma activation or trauma consultation +AND +Patients taken to the operating room for abdominal operation +AND +One of the following CPT codes for the patient encounter during the reporting period: Listed below are surgical procedures that may occur during abdominal surgery following trauma. +SURGICAL PROCEDURE +CPT CODE +Spleen and Lymph Nodes +38100, 38101, 38115, 38120, 38571, 1 +38572, 38747, 38780 +Esophagus +43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43122, 43123, 43124, 43279, 43280, 43281, 43282, 43320, 43325, 43327, 43328, 43330, 43332, 43333, 43336, 43337, 43340, 43350, 43360, 43361, 43400, 43401, 43405, 43415, 43425, 43496 +Stomach +43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43800, 43810, 43820, 43825, 43830, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880 +Small Intestine +44005, 44010, 44020, 44021, 44050, 44055, 44110, 44111, 44120, 44125, 44126, 44127, 44130 44139 +Colon +44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44238, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 44799 +Rectum +45110, 45111, 45112, 45113, 45114, 45119, 45120, 45121, 45123, 45135, 45136, 45150, 45395, 45397, 45400, 45402, 45499, 45540, 45550, 45560, 45562, 45563, 45800, 45805, 45820, 45825 +Biliary +47400, 47420, 47425, 47460, 47480, 47560, 47561, 47562, 47563, 47564, 47570, 47579, 47600, 47605, 47610, 47612, 47620, 47701, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47802, 47900, 47999 +Pancreas +48000, 48001, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 48556 +Abdomen, Peritoneum, & Omentum +49000, 49002, 49010, 49020, 49040, 49060, 49250, 49255, 49320, 49321, 2 +49322, 49329, 49402, 49900, 49999 +Mediastinum and Diaphragm +39501, 39540, 39541, 39545, 39560, 39561, 39599 +Meckel’s Diverticulum, Mesentery, & Appendix +44800, 44820, 44850, 44899, 44900, 44950, 44955, 44960, 44970, 44979 +Liver +47100, 47120, 47122, 47125, 47130, 47350, 47360, 47361, 47362, 47379, 47399 +Vascular Surgery +34502, 34820, 34830, 34831, 34832, 34833, 35081, 35082, 35091, 35092, 35102, 35103, 35111, 35112, 35121, 35122, 35131, 35132, 35189, 35221, 35251, 35281, 35531, 35535, 35536, 35537, 35538, 35539, 35540, 35560, 35563, 35565, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35646, 35647, 35663, 35665, 35840, 37617, 37619, 37660 +Urologic Surgery +50010, 50220, 50225, 50240, 50500, 50650, 50750, 50760, 50770, 50780, 50785, 51045, 51550, 51565, 51820, 51860, 51865, 51880, +Gynecologic Surgery +57284, 57305, 57307, 58150, 58152, 58180, 58200, 58210, 58520, 58600, 58700, 58720, 58940",None,None,None,N/A,N/A,Outcome,,Outcome,N,Y,N,N,N,No,"Academic Research for Clinical Outcomes (ARCO) in Collaboration with ReportingMD, Inc." +3809307,ACCF CathPCI Registry,ACCCath1,Stroke intra or post PCI procedure in patients without CABG or other major surgeries during admission.,"Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure stroke (i.e., any confirmed a loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms) lasting at least 24 hours after onset or leading to death. + +This measure evaluates the occurrence of stroke as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care. +",Patient Safety,"Number of patients undergoing isolated PCI who have an intra or post procedure stroke (i.e., any confirmed a loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms) lasting at least 24 hours after onset or leading to death.","Denominator All patients age 18 and older, undergoing isolated (defined by no CABG or other major surgery during episode of care) percutaneous coronary intervention (PCI).","•Patients with CABG during admission +•Patients with Other Major Surgery during admission",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath2,New requirement for dialysis post PCI in patients without CABG or other major surgeries during admission.,"Percent of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a new requirement for renal dialysis intra or post PCI procedure. + +This measure evaluates the occurrence of the new need for dialysis as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care. +",Patient Safety,Number of patients undergoing isolated PCI who have a new need for dialysis intra or post PCI procedure.,"All patients age 18 and older, undergoing isolated (defined by no CABG or other major surgery during episode of care) percutaneous coronary intervention (PCI).","•Patients with CABG during admission +•Patients with Other Major Surgery during admission",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath3,Vascular access site injury requiring treatment or major bleeding post PCI in patients without CABG or other major surgeries during admission.,"The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have an intra or post procedure major bleeding event or an intra or post procedure vascular complication requiring treatment. + +Major access site related injury requiring treatment includes: access site occlusion, peripheral embolization, dissection, pseudo-aneurysm, AV fistulas requiring treatment anytime from the procedure until discharge. + +Major bleeding is defined as bleeding at access site, hematomas at access site, or retroperitoneal bleeds that occur within 72 hours of the procedure. To qualify the event must be associated with a hemoglobin drop of >3 g/dL; or transfusion of whole or packed red blood cells, or a procedural intervention/surgery at the bleeding site to reverse/stop or correct the bleeding. + +This measure evaluates the occurrence of vascular site injury requiring treatment or major bleeding as outcomes of a percutaneous coronary intervention (PCI) during a patient’s episode of care.",Patient Safety,"Number of patients undergoing isolated PCI with a bleeding event (bleeding at access site, hematomas at access site, and/or a retroperitoneal bleed) and/or major access site related injury requiring treatment (access site occlusion, peripheral embolization, dissection, pseudoaneurysm, AV fistulas).","All patients age 18 and older, undergoing isolated (defined by no CABG or other major surgery during episode of care) percutaneous coronary intervention (PCI).","•Patients with CABG during admission +•Patients with Other Major Surgery during admission",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath4,Cardiac tamponade post PCI in patients without CABG or other major surgery during admission.,"The number of patients, age 18 years and older, undergoing isolated PCI procedure (defined by no CABG or other major surgery during episode of care) who have a cardiac tamponade intra or post procedure. + +This measure evaluates the occurrence of cardiac tamponade as an outcome of a percutaneous coronary intervention (PCI) during a patient’s episode of care. +",Patient Safety,The number of patients age 18 and older undergoing an isolated PCI with a cardiac tamponade intra or post PCI procedure.,"All patients age 18 and older, undergoing isolated (defined by no CABG or other major surgery during episode of care) percutaneous coronary intervention (PCI).","•Patients with CABG during admission +•Patients with Other Major Surgery during admission",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath5,STEMI patients receiving immediate PCI within 90 minutes.,"Percentage of patients diagnosed with a STEMI and treated with a PCI who have the first reperfusion device deployed within 90 minutes or less of their arrival to the hospital, or diagnosis with STEMI. + +This measure reflects the processes of care and current guidelines associated with the treatment of patients experiencing ST elevated myocardial infarctions (STEMI). ",Effective Clinical Care,"Number of patients with PCI procedures with an admit source of “emergency department” or “other” with a date/time difference of <=90” from +1. Arrival to first device activation <=90” when ST elevation noted on first ECG; or +2. Subsequent ECG with STEMI or STEMI equivalent to first device deployment time when STE elevation first noted on subsequent ECG.",All patients with a PCI indication of “immediate PCI for STEMI”.,Patients transferred in from another acute care facility. These patients are represented in the Transfer Door - to Door - to Balloon time metrics.,"Patients with “Reasons for delay” equal to “difficult vascular access,” or “cardiac arrest and/or need for intubation before PCI ,” or “patient delays in providing consent for the procedure,” or “difficulty crossing the culprit lesion during the PCI,” or “other”. + +Patients with a Reason for Delay indicated are removed from the measure numerator and denominator. ",None,1,N/A,Process,,,N,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath6,ACE-I or ARB prescribed at discharge for patients with an ejection fraction < 40% who had a PCI during the episode of care.,"Percentage of patients, age 18 years and older, with a left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB at hospital discharge.",Effective Clinical Care,Patients with an EF < 40% who had a PCI during the episode of care and were discharged with a prescription of either an ACE Inhibitor or an ARB.,Patients with an EF < 40% who had a PCI during the episode of care,"•Transferred to another hospital +•Deceased at discharge +•Left against medical advice +•Discharged with hospice care",Patients enrolled in clinical trials and thus coded as “blinded” and patients with a documented reason and thus coded as “contraindicated” for ACEI and ARB at discharge are considered as “Performance Met” and included in the numerator.,None,1,N/A,Process,,,N,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath8,Percutaneous Coronary Intervention (PCI): Post-procedural Optimal Medical Therapy,"Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge. + +This metric evaluates the process of care associated with the multi-society guidelines recommendations.",Effective Clinical Care,Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge,"All patients aged 18 years and older for whom PCI is performed who are eligible for any of the following medications (ie, patient has no contraindication, allergy, intolerance): +• Aspirin +• P2Y12 inhibitor (only for PCIs with stenting) +• Statin","•Transferred to another hospital +•Deceased at discharge +•Left against medical advice +•Discharged with hospice care","Patients enrolled in clinical trials and thus coded as “blinded” and patients with a documented reason and thus coded as “contraindicated” for ACEI and ARB at discharge are considered as “Performance Met” and included in the numerator. + +",None,1,N/A,Process,,,N,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath9,PCI procedures that were inappropriate for patients with Acute Coronary Syndrome (ACS).,"Proportion of PCI procedures for patients with Acute Coronary Syndrome, that were evaluated as “Inappropriate”, meaning coronary revascularization is not generally acceptable and is not a reasonable approach for the indication and is unlikely to improve the patients’ health outcomes or survival. ",Efficiency and Cost Reduction,PCI Procedures evaluated as “inappropriate” according to appropriate use criteria guidance.,"All patients presenting with a coronary artery disease (CAD) presentation of STEMI, NSTEMI or Unstable Angina (USA) aged 18 years and older for whom PCI is performed.",PCIs not classifiable for AUC reporting,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,ACCF CathPCI Registry +3809307,ACCF CathPCI Registry,ACCCath13,Cardiac Rehabilitation Patient Referral From an Inpatient Setting,"Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone a percutaneous coronary intervention (PCI), who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.",Community/Population Health,"Number of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient Cardiac Rehabilitation/Secondary Prevention (CR/SP) program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made. + +(Note: The program may include a traditional CR/SP program based on face-to-face interactions and training sessions or may include other options such as home-based approaches. If alternative CR/SP approaches are used, they should be designed to meet appropriate safety standards and deliver effective, evidence-based services.)",All patients who had a PCI during the admission.,"• Patients who expired before discharge. +• Patients who leave against medical advice. ","Exceptions criteria require documentation with the medical record of one or more of the following factors that may prohibit cardiac rehabilitation participation: +• Patient factors (e.g., patient resides in a long-term nursing care facility). +• Medical factors (e.g., patient deemed by provider to have a medically unstable, life-threatening condition). +• Health care system factors (e.g., no cardiac rehabilitation/secondary prevention (CR/SP) program available within 60 min of travel time from the patient’s home). + +If a patient has a documented exception criteria within the medical record, the code of “Patient Ineligible” is used for data collection and identification of this scenario. + +Patients with Exceptions will be considered “Performance Met” for the purpose of reporting physician performance. +",None,1,N/A,Process,,,N,Y,N,N,N,No,ACCF CathPCI Registry +8933551,American Academy of Neurology,AAN4,Screening for Psychiatric or Behavioral Health Disorders,Percent of all visits for patients with a diagnosis of epilepsy where the patient was screened for psychiatric or behavioral disorders,Communication and Care Coordination,"Patient visits where patient was screened* for psychiatric or behavioral +health disorders.** +*Screened: Questioning by the individual provider to identify areas of +concern, may include standardized testing. +**Psychiatric or behavioral disorders may include, but are not limited to +anxiety, depression, suicidality, mood disorder, attention deficit hyperactive +disorder, cognitive dysfunction, or other neurobehavioral disorders.",All visits for patients with diagnosis of epilepsy.,None,"Caregiver is unavailable for a patient who is non-communicative +or has an intellectual disability. +x Patient has an existing diagnosis of psychiatric disorder and is being +actively treated. +x Patient declines screening.",None,N/A,N/A,Process,High Priority,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN9,Querying about Symptoms of Autonomic Dysfunction,"Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months.",Effective Clinical Care,"Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months. +*autonomic dysfunction is defined as: orthostatic hypotension or intolerance, constipation, urinary urgency, incontinence, and nocturia, fecal incontinence, urinary retention requiring catheterization, delayed gastric emptying, dysphagia, drooling, hyperhidrosis, or sexual dysfunction.",All patients with a diagnosis of Parkinson’s disease.,None,None,None,N/A,N/A,Process,,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN10,Falls screening,"Percentage of patients with Parkinson’s disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia who were screened for falls at least annually ",Patient Safety,Patients who are screened for falls at least annually.,"Patients with a current diagnosis of Parkinson’s disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia. ","Documentation of medical reason for not querying a patient (or caregiver) about falls (e.g., patient is unable to respond and no informant is available, patient is cognitively impaired and unable to communicate, patient is non-ambulatory) +· Documentation of a patient reason for not querying the patient about falls (e.g. patient declines to answer the query about falls)",None,None,N/A,N/A,Process,High Priority,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN1,Diabetes/Pre-Diabetes Screening for Patients with DSP,"Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for +diabetes (eg fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered +when seen for an initial evaluation for distal symmetric polyneuropathy.",Efficiency and Cost Reduction,"Patients who had screening tests for diabetes (eg, fasting blood sugar test, hemoglobin A1C, +or a 2 hour Glucose Tolerance Test) reviewed, requested, or ordered when seen for an initial +evaluation for distal symmetric polyneuropathy.",All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy.,None,"Documentation of a medical reason for not reviewing, requesting or ordering +diabetes screening tests (eg patient has a diagnosis of diabetes, patient has a known +medical condition to cause neuropathy, patient had previous diabetes screening) +x Documentation of a patient reason for not reviewing, requesting or ordering +diabetes screening tests (eg patient declines to undergo testing) +x Documentation of a system reason for not reviewing, requesting or ordering +diabetes screening tests (eg patient does not have insurance to pay for testing)",None,N/A,N/A,Process,High Priority,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN2,Screening for Unhealthy Alcohol Use,"Percentage of patients age 18 years and older with a diagnosis of DSP who were screened with a validated screening instrument for unhealthy alcohol use* at their initial evaluation, and if screening was positive, brief counseling provided. + +*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. +",Efficiency and Cost Reduction,"Patients screened with a validated screening instrument for unhealthy alcohol use* when seen for an initial evaluation and if positive, brief counseling provided + +*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. + +Unhealthy alcohol use can be assessed using one of a number of available valid and reliable instruments available from medical literature. Examples include, but are not limited to: +• CAGE-AID (Cut-down, Annoyed, Guilty, Eye-opener)46 +• AUDIT C (Alcohol Use Disorders Identification Test – Consumption)41 + +A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening methods.47 +",All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy.,None,"Documentation of a medical reason for not screening the patient with a validated screening instrument for unhealthy alcohol use (eg patient diagnosed with alcoholism) +x Documentation of a patient reason for not screening the patient with a validated screening instrument for unhealthy alcohol use (eg patient declines to answer questions/complete the screening)",None,N/A,N/A,Process,High Priority,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN5,MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK,"Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline +recommended medication for acute migraine attacks within the 12 month measurement period.",Effective Clinical Care,"Patients who were prescribed a guideline recommended medication for acute migraine +attacks*within the 12 month measurement period. +* Guideline recommended acute medications for acute migraine attack include the following +but are not limited to: triptans, dihydroergotamine (DHE). Triptans and DHE are only +examples of medications that may be used. The clinician should use his/her best judgment to +prescribe a medication for acute migraine attacks to meet the specific needs of the individual +patient. Note: There is an exception for this measure for patients whose migraines are +controlled with over the counter (OTC) medications. +Note: The above list of medications/drug names is based on clinical guidelines and other +evidence and may not be all-inclusive or current. Physicians and other health care +professionals should refer to the Food and Drug Administration’s (FDA) web site page +entitled “Drug Safety Communications” for up-to-date drug recall and alert information +when prescribing medications.",All patients age 12 years old and older with a diagnosis of migraine headache.,None,"Medical exception for not prescribing a guideline recommended acute migraine +medication (i.e., guideline recommended medication is medically contraindicated or +ineffective for the patient; migraines are effectively controlled with OTC medications +or with NSAIDs; patient is already on an effective acute migraine medication +prescribed by another clinician; patient has no pain with migraine) +x Patient exception for not prescribing a guideline recommended acute migraine +medication (i.e., patient declines a prescription for any acute migraine medication) +x System exception for not prescribing a guideline recommended acute migraine +medication (i.e., patient does not have insurance to cover the cost of prescribed +abortive migraine medication)",None,N/A,N/A,Process,,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN11,Overuse of Opioid and Barbiturate Containing Medications for Primary Headache Disorders.,"Percentage of patients age 12 years and older with a diagnosis of primary headache who were prescribed opioid or barbiturate containing medications assessed for medication overuse headache within the 12-month measurement period, and if identified as overusing opioid or barbiturate containing medication, treated or referred for treatment.",Efficiency and Cost Reduction,"Patients assessed for opioid or barbiturate containing medication overuse headache within the 12 month measurement period, and if barbiturate or opioid medication overuse headache is identified, treatment or referral for treatment was provided.",All patients aged 12 years and older diagnosed with a primary headache disorder and prescribed an opioid or barbiturate containing medication,None,"Medical exception for prescribing a barbiturate or opioid containing medications for primary +headache disorder (i.e., use as a last resort for a patient who has failed all other +guideline recommended medications for headache or who have contraindications; +may be considered for rescue therapy in a supervised setting for acute migraine when +sedation side effects will not put the patient at risk and when the risk abuse has been +addressed).",None,N/A,N/A,Process,High Priority,,N,N,Y,Y,N,No,American Academy of Neurology +8933551,American Academy of Neurology,AAN8,Exercise and Appropriate Physical Activity Counseling for Patients with MS,"Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate + physical activity for patients with MS in the past 12 months. ",Effective Clinical Care,"Patients with MS counseled* on the benefits of exercise and appropriate physical +activity for patients with MS in past 12 months. +*Counseled: to advise seriously and formally after consultation",All patients with a diagnosis of MS.,"None** +**All patients including those unable to exercise should be provided information +on appropriate range of motion and activity.","None** +**All patients including those unable to exercise should be provided information +on appropriate range of motion and activity.",None,N/A,N/A,Process,,,N,N,Y,Y,N,No,American Academy of Neurology +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS1,Corneal Graft Surgery - Post-operative improvement in visual acuity of 20/40 or greater,Percentage of corneal graft surgery patients with a visual acuity of 20/40 or greater within 90 days following surgery.,Effective Clinical Care,Patients who had a visual acuity of 20/40 or greater achieved within 90 days following corneal graft surgery.,"Patients aged 18 years or older who underwent a corneal graft procedure with one of the following indications for surgery: endothelial dystrophy, post cataract surgery edema, failed corneal graft, ectatic disease, anterior/stromal dystrophy, or corneal opacity.",None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS2,Glaucoma -  Intraocular Pressure (IOP)Reduction,Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis,Effective Clinical Care,"Visits where the eye(s) IOP was below a specified threshold based on the severity of their glaucoma: Mild stage: IOP < 22 mmHg, Moderate stage: IOP < 18 mmHg Severe stage: IOP < 15 mmHg","Patients aged between 40 and 85 years, with a minimum of 4 office visits during the prior 2 years, with a glaucoma diagnosis and documentation of the severity of their glaucoma","Exclusions: +· Patients with a diagnosis of low tension glaucoma. +· Eyes with a documented severity of indeterminate stage. +· Eyes with absolute glaucoma blindness. +· Eyes with a glaucoma incisional surgery. +· Visual acuity findings: Count fingers (CF or FC), Hand motion (HM), Light perception (LP), No light perception (NLP)",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS3,Glaucoma - Visual Field Progression,"Percentage of eyes, in patients with a diagnosis of glaucoma, with a mean deviation loss of more than 3dB from their baseline value",Effective Clinical Care,Eyes with a mean deviation loss of 3dB or more from ‘baseline’ VFs to the most recent test,"Patients aged between 40 and 85 years, with a minimum of 4 visual field tests during the prior 3 years, with a glaucoma diagnosis","Exclusions: +· Eyes with absolute glaucoma blindness. +· Eyes with a glaucoma incisional surgery performed within the last 90 days. +· Conditions that may results in visual field worsening independent of glaucoma. +· Visual acuity findings: Count fingers (CF or FC), Hand motion (HM), Light perception (LP), No light perception (NLP)",None,None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS4,Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty,Percentage of patients underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level Rationale: Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome,Effective Clinical Care,"Eye(s) with a reduction in IOP 20% or greater from the pretreatment level. +Percentage (%) change between pretreatment IOP (Do not include IOP values taken on the day of the procedure) and the lowest IOP measure recorded between 2 and 4 months postoperatively. Calculation is based on the IOP of the eye that underwent the procedure.",Patients aged between 40 and 85 years who underwent laser trabeculoplasty,"Exclusions: Eyes with absolute glaucoma blindness. + +Visual acuity findings: Count fingers (CF or FC), Hand motion (HM), Light perception (LP), No light perception (NLP)",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS5,Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance,Percentage of surgical ptosis patients with an improvement of MRD postoperatively within 90 days following the surgical procedure.,Effective Clinical Care,Patients who achieved an improvement in MRD postoperatively within 90 days following surgery,All patients aged 18 years or older with a diagnosis of acquired involutional ptosis who underwent a surgical procedure for the condition,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS6,Acquired Involutional Entropion -  Normalized Lid Position After Surgical Repair,Percentage of surgical entropion patients with postoperative normalized lid position .,Effective Clinical Care,Patients with normalized lid position postoperatively within 90 days following surgery,All patients aged 18 years or older with a diagnosis of involutional entropion who underwent a surgical procedure for the condition,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS7,Amblyopia - Interocular Visual Acuity,Percentage of newly diagnosed amblyopic patients with a corrected interocular visual acuity difference of less than 0.23 logMAR within 6 months of first diagnosis,Effective Clinical Care,Patients with interocular visual acuity difference of less than 0.23 logMar recorded 6 months after first use of amblyopia diagnosis code,All patients aged 3 to 7 years at diagnosis of amblyopia with recognized visual acuity difference of greater than 0.29 logMar,"Exclusions: Patients with diagnosis of deprivation amblyopia, cataract, aphakia, or pseudophakia",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS8,Surgical Esotropia - Postoperative Alignment,Percentage of surgical esotropia patients with a postoperative alignment of 15 prism diopters (PD) or less,Effective Clinical Care,Patients who achieved a postoperative alignment of 15 PD or less between 4 and 12 weeks after surgery.,All patients aged 18 years or less who underwent a surgical procedure for esotropia,"Exclusions: Patients with diagnosis codes of diplopia, CN 6 palsy, and Duane syndrome. + +Patients who have a reoperation within 30 days of the original surgical date",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS9,Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy,Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months,Effective Clinical Care,Patients who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months,All patients aged 18 years and older with a diagnosis of diabetic retinopathy,None,Exception Documentation of medical reason for not performing a dilated or fundus examination and documentation of patient reason for not performing a dilated macular or fundus examination,None,1,N/A,Process,,,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS10,Exudative Age-Related Macular Degeneration - Loss of Visual Acuity,"Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with of loss of less than 0.3 logMar of visual acuity within the past 12 months ",Effective Clinical Care,Patients with four or more recorded visual acuity values within the past 12 months and with loss of visual acuity less than 0.3 logMar,All patients aged 18 years of older with a diagnosis of exudative age-related macular degeneration currently receiving anti-VEGF treatment and with 4 or more visual acuity values recorded in the past 12 months,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS11,Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity,Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with of loss of less than 0.3 logMar of visual acuity within the past 12 months,Effective Clinical Care,Patients with four or more recorded visual acuity values within the past 12 months and loss of visual acuity less than 0.3 logMar,All patients aged 18 years of older with a diagnosis of nonexudative and currently taking antioxidant supplements with 4 or more visual acuity values recorded in the past 12 months,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS13,Diabetic Macular Edema - Loss of Visual Acuity,Percentage of patients with a diagnosis of diabetic macular edema with of loss of less than 0.3 logMar of visual acuity within the past 12 months,Effective Clinical Care,Patients with four or more recorded visual acuity values within the past 12 months; loss of visual acuity less than 0.3 logMar,"All patients aged 18 years or older with a diagnosis of diabetic macular edema, with four or more visual acuity values recorded in the last 12 months, who have received anti-VEGF injections, intravitreal steroid injections or laser photocoagulation therapy","Exclusions: Patients with ophthalmic complications of diabetic retinopathy including neovascular glaucoma, traction retinal detachment, vitreous hemorrhage, history of vitreous surgery, history of retinal surgery, development of retinopathy in fellow eye; ",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS16,Acute Anterior Uveitis - Post-treatment visual acuity,Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis,Effective Clinical Care,Patients with a best corrected visual acuity of 20/40 or greater within 90 days of treatment initiation or Patients whose visual acuity had returned to their baseline value prior to onset of acute uveitis within 90 days of treatment initiation,Patients aged 18 years or older who underwent treatment for acute anterior uveitis,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS17,Acute Anterior Uveitis - Post-treatment Grade 0 anterior chamber cells,Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells,Effective Clinical Care,Patients with Grade 0 anterior chamber cells after treatment at 30 days after onset of treatment and not on topical corticosteroids at 60 days after treatment,Patients aged 18 years or older who underwent treatment for acute anterior uveitis,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS18,Chronic Anterior Uveitis -  Post-treatment visual acuity,Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis,Effective Clinical Care,Patients with a best corrected visual acuity of 20/40 or greater within 90 days of treatment initiation or Patients whose visual acuity had returned to their baseline value prior to onset of acute uveitis within 90 days of treatment initiation,All patients aged 18 years or greater who underwent treatment for chronic anterior uveitis,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS19,Chronic Anterior Uveitis -  Post-treatment Grade 0 anterior chamber cells,Percentage of patients with chronic anterior uveitis post-treatment with Grade 0 anterior chamber cells,Effective Clinical Care,Patients with Grade 0 anterior chamber cells at 30 days after treatment or Patients managed at 60 days with dose of topical corticosteroids of prednisolone acetate 1% 3X/day or less (or equivalent),All patients aged 18 years or greater who underwent treatment for chronic anterior uveitis,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS20,Idiopathic Intracranial Hypertension:  No worsening or improvement of mean deviation,Percentage of patients with no worsening of perimetric mean deviation by > 3dB at 6 months or improvement in mean deviation at 6 months,Effective Clinical Care,Patients with no worsening of perimetric mean deviation by > 3dB at 6 months or improvement in mean deviation at 6 months,All patients aged 18 years or greater with idiopathic intracranial hypertension,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS21,Ocular Myasthenia Gravis:  Improvement of ocular deviation or absence of diplopia or functional improvement,Percentage of patients with improvement of ocular deviation or absence of diplopia in primary gaze after treatment or functional improvement of ptosis at 6 months,Effective Clinical Care,Patients with improvement of ocular deviation or absence of diplopia in primary gaze after treatment or functional improvement of ptosis at 6 months,All patients aged 18 years or greater with ocular myasthenia gravis,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS22,Giant Cell Arteritis:  Absence of fellow eye involvement after corticosteroid treatment,Percentage of patients without fellow eye involvement 1-26 weeks after initiating corticosteroids in patients with unilateral visual loss,Effective Clinical Care,Patients without fellow eye involvement 1-26 weeks after initiating corticosteroids in patients with unilateral visual loss,All patients aged 18 years or greater with giant cell arteritis in one eye,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS23,Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better,Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better,Outcome,Patients receiving refractive surgery with a postoperative uncorrected visual acuity of 20/20 or better,All patients aged 18 years or greater and diagnosis of myopia and receiving refractive surgery treatment,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS24,Refractive Surgery:  Postoperative correction within + 0.5 Diopter of the Intended Correction,Percentage of patients with a postoperative spherical equivalent (SE) within + 0.5 Diopter (D) of the intended correction or SE,Outcome,Patients receiving refractive surgery with a postoperative spherical equivalent (SE) within + 0.5D of the intended correction or SE,All patients aged 18 years or greater and diagnosis of myopia and receiving refractive surgery treatment,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS25,Adenoviral Conjunctivitis:  Avoidance of Antibiotics,Percentage of patients who received antibiotic treatment for adenoviral conjunctivitis,Efficiency and Cost Reduction,Patients who received antibiotic treatment for adenoviral conjunctivitis,All patients who are diagnosed with adenoviral conjunctivitis,None,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +3927141,American Academy of Ophthalmology IRIS® Registry,IRIS26,Intravitreal Injections:  Avoidance of Routine Antibiotic Use,The percentage of patients who received antibiotics before or after intravitreal injections,Efficiency and Cost Reduction,The percentage of patients who received antibiotics before or after intravitreal injections,"Patients aged 18 years or older who received intravitreal injections, except for endophthalmitis",None,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Academy of Ophthalmology IRIS® Registry +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),Q415,Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older,Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT,Efficiency and Cost Reduction,Emergency department visits for patients who have an indication for a head CT,All emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider,"Patients with any of the following: + - Ventricular shunt + - Brain tumor + - Multisystem trauma + - Pregnancy + - Currently taking antiplatelet medications ",,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),Q416,Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years,"Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the PECARN prediction rules for traumatic brain injury + (INVERSE Measure: Lower score indicates better performance) ",Efficiency and Cost Reduction,Emergency department visits for patients who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury,All emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider,"Patients with any of the following: + - Ventricular shunt + - Brain tumor + - Coagulopathy + - Thrombocytopenia ",,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP21,Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding,"Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider + (INVERSE Measure: Lower score indicates better performance) ",Efficiency and Cost Reduction,"Emergency department visits during which coagulation studies (PT, PTT, or INR tests) were ordered by an emergency care provider",All emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain,"Patients with any of the following clinical indications for ordering coagulation studies: + - End stage liver disease + - Coagulopathy + - Thrombocytopenia + - Currently taking or newly prescribed anticoagulant medications + - Pregnancy + - Pulmonary or gastrointestinal hemorrhage + - Atrial fibrillation + - Inability to obtain medical history + - Trauma + - Patients who left before treatment completion ",,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP22,Appropriate Emergency Department Utilization of CT for Pulmonary Embolism,"Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level ",Efficiency and Cost Reduction,"Emergency department visits for patients with either: +1. Moderate or high pre-test clinical probability for pulmonary embolism +OR +2. Positive result or elevated D-dimer level","All emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition ",Pregnancy," Medical reason for ordering a CTPA without moderate or high pre-test clinical probability for pulmonary embolism AND no positive result or elevated D-dimer level (eg, CT ordered for aortic dissection)",None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP24,Pregnancy Test for Female Abdominal Pain Patients,Percentage of all female patients ages 14 through 50 years old who present to the ED with a chief complaint of abdominal pain who have had a pregnancy test (urine or serum) ordered,Patient Safety,Patients who have had a pregnancy test (urine or serum) ordered,All female patients ages 14 through 50 years old who present to the ED with a chief complaint of abdominal pain.,,"Pregnancy test (urine or serum) not ordered for reasons documented by clinician (e.g., documentation of pregnancy or status post menopausal) ",None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP25,Tobacco Use: Screening and Cessation Intervention,Percentage of asthma or COPD patients aged 18 years and older who were screened for tobacco use AND who received cessation counseling intervention if identified as a tobacco user,Community/Population Health,Patients who were screened for tobacco use during the ED encounter AND who received tobacco cessation counseling intervention if identified as a tobacco user,All asthma and COPD patients aged 18 years and older,Current tobacco non-user," Documented medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reasons)",None,1,N/A,Process,,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP26,Sepsis Management: Septic Shock: Lactate Level Measurement,Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a serum lactate level ordered during the emergency department visit,Effective Clinical Care,Emergency department visits for patients who had a serum lactate level ordered during the emergency department visit,All emergency department visits for patients aged 18 years and older with septic shock,"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Toxicological emergencies +- Burn +- Seizures +- Secondary diagnosis of + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma +",None,None,1,N/A,Process,,,N,Y,N,N,N,Yes,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP27,Sepsis Management: Septic Shock: Antibiotics Ordered,Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for antibiotics during the emergency department visit,Effective Clinical Care,Emergency department visits for patients who had an order for antibiotics during the emergency department visit,All emergency department visits for patients aged 18 years and older with septic shock,"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Toxicological emergencies +- Burn +- Seizures +- Secondary diagnosis of + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma",None,None,1,N/A,Process,,,N,Y,N,N,N,Yes,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP28,Sepsis Management: Septic Shock: Fluid Resuscitation,Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an order for ≥ 1 L of crystalloids during the emergency department visit,Effective Clinical Care,Emergency department visits for patients who had an order for ≥ 1 L of crystalloids during the emergency department visit,All emergency department visits for patients aged 18 years and older with septic shock,"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Severe Heart Failure (LVEF < 20%) +- Left Ventricular Assist Device (LVAD) +- Acute pulmonary edema +- Toxicological emergencies +- Burn +- Seizures +- Anuria +- End stage renal disease +- Secondary diagnosis of + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma",None,None,1,N/A,Process,,,N,Y,N,N,N,Yes,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP29,Sepsis Management: Septic Shock: Repeat Lactate Level Measurement,Percentage of emergency department visits for patients aged 18 years and older with septic shock and an elevated serum lactate result (>2mmol/L) with a second serum lactate measurement ordered following the elevated serum lactate result during the emergency department visit,Effective Clinical Care,Emergency department visits for patients with a second serum lactate measurement ordered following the elevated serum lactate result during the emergency department visit,All emergency department visits for patients aged 18 years and older with septic shock and an elevated serum lactate result (>2mmol/L),"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- ED visit less than 2 hours following the serum lactate result (>2mmol/L) +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Toxicological emergencies +- Burn +- Seizures +- Secondary diagnosis of: + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma",,None,1,N/A,Process,,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP30,Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10%,Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a second serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥ 10% during the emergency department visit,Effective Clinical Care,"Emergency department visits for patients with a lactate clearance rate of +≥ 10% during the emergency department visit",All emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a second serum lactate level measurement performed following the elevated serum lactate result,"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- ED visit less than 2 hours following the serum lactate result (>2mmol/L) +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Burn +- Status Epilepticus +- Seizures +- Toxicological emergencies +- Receiving epinephrine +- Drug-related conflict with ability to clear lactate (ie, Nucleoside Reverse Transcriptase Inhibitors) +- Liver dysfunction or cirrhosis with decompensation +- Liver failure +- End-stage liver disease +- Secondary diagnosis of + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma",,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP31,Emergency Medicine: Appropriate Foley Catheter Use in the Emergency Department,Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter,Patient Safety,"Emergency department visits where the patient had at least one of the following indications for an indwelling Foley catheter: +-Acute urinary retention or bladder outlet obstruction +-Need for accurate measurement of urinary output with no reasonable alternative +-Pre-operative use for selected surgical procedures +-Open sacral or perineal wounds in incontinent patients +-Patient requires prolonged immobilization +-Comfort for end of life care +-Other institution-specific indication",All emergency department visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered,Patients who had an existing indwelling Foley catheter at ED arrival,,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP32,ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP33,ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +),"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP35,"ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP36,"ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP37,"ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP38,"ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP39,ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Eds,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients +(Excluding Psych and Mental Health, and Transfer Patients) + +2: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Psych and Mental Health Patients + +3: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients(Transfer from ED) + +4: ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients (All Eligible Patients) + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Adult patients,"Overall Rate: Reporting Rate for Adults= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Adults = Psych and Mental Health Patients + +3. Reporting Rate for Adults = Transfer from ED + +4. Reporting Rate for Adults = All Eligible patients"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Pediatric patients (0-17 years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients (Excluding Psych and Mental Health, and Transfer patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP40,ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP41,ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +),"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP43,"ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP44,"ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP45,"ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP46,"ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less)","Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP47,ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding Eds,"Overall Rate: Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients) + +2. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Psych and Mental Health Patients + +3. ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients (Transfer from ED) + +4. ED Median Time from ED arrival to ED departure for Discharged ED patients for Pediatric Patients (All Eligible Patients + + (Lower score indicates better performance) ",Person and Caregiver-Centered Experience and Outcomes,Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients,"Overall Rate: Reporting Rate for Pediatric= All ED encounters (excluding psych and transfers) + +2. Reporting Rate for Pediatric = Psych and Mental Health Patients + +3. Reporting Rate for Pediatric = Transfer from ED + +4. Reporting Rate for Pediatric = All Eligible Patients + +"," + +- Transfers + - Psychiatric and mental health pts + - Patients who expired in the emergency department + - Adult patients (18+ years) ",,None,4,"Overall Rate: Time (in minutes) from ED arrival to ED departure for Pediatric Patients (Excluding Psych and Mental Health, and Transfer Patients)",Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP48,Sepsis Management: Septic Shock: Blood Cultures Ordered,Percentage of emergency department visits for patients aged 18 years and older with septic shock who had a blood culture ordered during the emergency department visit,Effective Clinical Care,Emergency department visits for patients who had a blood culture ordered during the emergency department visit,All emergency department visits for patients aged 18 years and older with septic shock,"Patients with any of the following: +- Transferred into the emergency department from another acute care facility or other in-patient hospital setting +- Left before treatment was complete +- Died during the emergency department visit +- Cardiac arrest within the emergency department visit +- Patient or surrogate decision maker declined care +- Advanced directives present in patient medical record for comfort care +- Toxicological emergencies +- Burn +- Seizures +- Secondary diagnosis of + - Acute Gastrointestinal Hemorrhage + - Acute Pulmonary Hemorrhage + - Ischemic Stroke + - Hemorrhagic Stroke + - Acute myocardial infarction + - Acute trauma",,None,1,N/A,Process,,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +5133825,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR),ACEP49,Emergency Medicine: Appropriate Use of Imaging for Recurrent Renal Colic,"Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered ",Efficiency and Cost Reduction,"Emergency department visits for which no imaging is ordered OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered ",All emergency department visits for patients aged 18 – 50 years with flank pain with any history of kidney stones," + +- Infection (fever, elevated white blood cell count, laboratory confirmation of urinary tract infection) + - Cancer + - Known acute or chronic renal disease (i.e., transplant, creatinine >1.5 mg/dL, renal insufficiency, polycystic kidney disease, acute kidney failure) + - Patient on anticoagulants + - Stone episode duration >= 72 hours + - Pregnancy + - Trauma + - Persistent pain that cannot be controlled during the ED visit + - Urologic procedure performed in the past 48 hours ",,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Emergency Physicians (ACEP) Clinical Emergency Data Registry (CEDR) +1679109,American College of Physicians Genesis Registry,ACPGR1,High Risk Pneumococcal Vaccination,"The percentage of patients aged 19 through 64 with a high risk condition, who either received a pneumococcal vaccination OR who reported previous receipt of a pneumococcal vaccination.",Community/Population Health,Patients who received a pneumococcal vaccination OR who reported previous receipt of a pneumococcal vaccination.,"Patient aged 19 through 64 with a high risk condition (e.g., diabetes, heart failure, COPD, end-stage kidney disease, nephritic syndrome, chronic kidney disease, chronic dialysis, asplenia, malignancy, solid organ transplant, on immunosuppressive medications, HIV, cystic fibrosis) and a valid patient encounter code.",None,"Pneumococcal vaccination not received with patient reason(s) documented (e.g., patient refusal).",None,N/A,N/A,Process,,,N,Y,N,N,N,No,American College of Physicians Genesis Registry +1679109,American College of Physicians Genesis Registry,PPRNET20,Herpes Zoster (Shingles) Vaccination,The percentage of patients 60 years of age and older who have a Varicella Zoster (shingles) vaccination,Community/Population Health,Patients with a shingles vaccine ever recorded,Patients 60 years of age and older,None,"Herpes zoster vaccination not received with patient reason(s) documented (e.g., patient refusal, patient allergy, patient reported as having a history of cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma, patient having active, untreated tuberculosis, patient having a weaken immune system due to HIV/AIDS or another disease or medication (such as steroids, radiation and chemotherapy) that effects the immune system, or other documented patient reason).",None,1,N/A,Process,,,N,Y,N,N,N,Yes,PPRNet +1679109,American College of Physicians Genesis Registry,ACPGR2,"Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination",Percentage of patients aged 19 or older who received a primary vaccine series of tetanus/diphtheria/acellular pertussis (tdap) vaccine OR who reported previous receipt of Tdap vaccination.,Community/Population Health,Patients who received Tdap vaccination OR who reported previous receipt of Tdap vaccination.,Patients aged 19 or older with a valid patient encounter code.,None,"Tdap vaccination not received with reason(s) documented (e.g., vaccination not indicated/patient refusal).",None,N/A,N/A,Process,,,N,Y,N,N,N,No,American College of Physicians Genesis Registry +1679109,American College of Physicians Genesis Registry,ACPGR3,Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy,Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) and a current or prior ejection fraction (EF) <40% who are self-identified Black or African Americans and receiving ACEI or ARB and Beta-blocker therapy who were prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge,Effective Clinical Care,Patients prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge.,All patients aged 18 years and older with a diagnosis of heart failure and a current or prior EF <40% who are self-identified Black or African Americans and receiving ACEI or ARB and beta-blocker therapy.,None,"Hypotension (severe or symptomatic), +Severe lupus erythematosus, +Unstable angina, +Peripheral neuritis, +Patient actively taking Phosphodiesterase Type 5 (PDE5) Inhibitors",None,N/A,N/A,Process,,,N,Y,N,N,N,No,American College of Physicians Genesis Registry +1679109,American College of Physicians Genesis Registry,Q408,Opioid Therapy Follow-up Evaluation (Q408),All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record,Effective Clinical Care,Patients who had a follow-up evaluation conducted at least every three months during opioid therapy,All patients 18 and older prescribed opiates for longer than six weeks duration and a valid patient encounter code.,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,No,American College of Physicians Genesis Registry +1679109,American College of Physicians Genesis Registry,Q414,Evaluation or Interview for Risk of Opioid Misuse (Q414),"All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record",Effective Clinical Care,"Patients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool,Opioid Assessment for Patients with Pain, revised (SOAPP-R)) or patient interview at least once during opioid therapy",All patients 18 and older prescribed opiates for longer than six weeks duration and a valid patient encounter code.,None,None,None,N/A,N/A,Process,,,N,Y,N,N,N,No,American College of Physicians Genesis Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad26,Appropriate venous access for hemodialysis,"Percentage of patients undergoing tunneled (long-term) catheter access for hemodialysis via subclavian access as compared to internal jugular access + +Inverse measure",Patient Safety,Number of patients who underwent placement of tunneled catheters for dialysis via the subclavian veins.,"Number of patients receiving tunneled hemodialysis catheters placed via the upper body (internal jugular, external jugular/other collateral veins or subclavian veins)",None,Patients with occlusion of the internal jugular veins,None,1,N/A,Process,High Priority,Intermediate Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad2,CT Colonography Clinically Significant Extracolonic Findings (Inverse Measure),Percentage of exams resulting in recommendations for clinical correlation or additional imaging on the basis of the CTC report,Efficiency and Cost Reduction,"Number of exams with a clinically significant +extracolonic finding, not otherwise known based on +the history provided or based on a prior imaging +procedure at the institution. Note: The ACR Practice +Guideline For The Performance Of Computed +Tomography (CT) Colonography In Adults +recommends the use of a CT Colonography Reporting +and Data System (C-RADS) to document clinically +significant extracolonic findings. According to C- +RADS, a clinically significant extracolonic finding +would be a rating of E3 or E4 for extracolonic +findings. See Zalis ME, Barish MA, Choi JR, et al. CT +colonography reporting and data system: a +consensus proposal. Radiology 2005;236(1):3–9, +Figure 3","All CTC exams, either screening or diagnostic",None,None,None,1,,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad1,CT Colonography True Positive Rate,Percentage of exams with a ≥ 10mm polyp detected by CTC that was with confirmed by colonoscopy (True Positive Rate),Effective Clinical Care,"Number of exams with a confirmed ≥ 10mm polyp at +colonoscopy that corresponds to a polyp detected by +CTC. (A polyp confirmed by colonoscopy corresponds +to a polyp detected at CTC if it is within 1 segment and 50% of the size of the CTC polyp, e.g., a polyp of 12mm at CTC must have a measurement of at least 6mm at colonoscopy.",Number of CT colonography (CTC) exams with a ≥ 10mm polyp for which data on confirming colonoscopies is available,None,"Number of exams with confirming colonoscopies that did not reach the level of lesion, or with no confirming colonoscopy (Data elements: Level of lesion (<10mm); Confirming colonoscopy or surgery not available",None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad23,Lung Cancer Screening Abnormal Interpretation Rate,"The percentage of screening lung cancer interpreted +as positive (Lung-RADS Category 3 or 4).",Efficiency and Cost Reduction,"Number of screening exams with a Lung-RADS +assessment category of 3 or 4",Number of screening exams,None,None,None,1,,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad21,Lung Cancer Screening Cancer Detection Rate (CDR),"The percentage of screenings of lung cancer that +were interpreted as positive (Lung-RADS category 3 +or 4) and result in a tissue diagnosis of cancer within +12 months.",Effective Clinical Care,"Number of screening exams that had a Lung-RADS +assessment category of 3 or 4 and a tissue diagnosis +of cancer within 12 months. (Tissue diagnosis field = +2, 4 or 5)",Number of screening exams,None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad22,Lung Cancer Screening Positive Predictive Value (PPV),"The percentage of screenings for lung cancer with +abnormal interpretation (Lung-RADS 3 or 4) that +result in a tissue diagnosis of cancer within 12 +months.",Effective Clinical Care,"Number of screening exams with a Lung-RADS +assessment category of 3 or 4 that had a tissue +diagnosis of cancer within 12 months. (Tissue +diagnosis field = 2, 4 or 5)","Number of screening exams with a Lung-RADS +assessment category of 3 or 4",None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,"ACRad31 +",Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.,Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN.,Patient Safety,Number of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.,Number of CT Abdomen-pelvis exams with contrast (single phase scans),None,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad32,Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.,"Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN. +",Patient Safety,Number of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.,Number of CT Chest exams without contrast (single phase scans),None,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad33,Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level,"Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. Note: Calculated at facility/TIN level and assigned to all NPIs who read CT under that TIN. +",Patient Safety,Number of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.,Number of Head/Brain exams without contrast (single phase scans),None,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad30,Rate of Inadequate Percutaneous Image-Guided Biopsy,"The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was inadequate for diagnosis on the final pathology report. + +Inverse measure",Patient Safety,Number of percutaneous image-guided biopsy procedures performed associated with a specimen sample considered inadequate for pathological analysis.,Number of percutaneous image-guided biopsies performed,Repeat biopsy procedures performed following an initial inadequate sample – excluded from numerator / denominator.,None,None,1,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,"ACRad28 +",Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement,"Incidence of peristomal gastrostomy infection occurring within 14 days following initial tube placement + +Inverse measure",Patient Safety,Number of patients with peristomal infections no more than 14 days following percutaneous gastrostomy insertion,Number of patients undergoing primary fluoroscopically “push” type gastrostomy insertion or fluoroscopically guided “hybrid” gastrostomy insertion.,Evaluation:The patient returned on [date] for site evaluation/The patient did not return for site evaluation,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad29,Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement,"Percentage of percutaneous nephrostomy tube +replacement within 30 days following initial +placement. + +Inverse measure",Patient Safety,Number of percutaneous nephrostomy tubes requiring replacement of a percutaneous nephrostomy tube secondary to dislodgement within 30 days of initial placement,Number of percutaneous nephrostomy tubes placed primarily.,Patients undergoing an intervening procedure on the kidney. Malfunctioning tubes which are found to be appropriately positioned are included in the denominator but excluded from numerator; these tubes require exchange rather than replacement.,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad18,"Report Turnaround Time: CT +(Inverse Measure)",Mean CT report turnaround time (RTAT),Communication and Care Coordination,"Mean time from exam completion to final signature +on report, in hours",Total number of CT exams completed,None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad25,Report Turnaround Time: Mammography,"Mean mammography report turnaround time (RTAT). +Inverse measure +Continuous measure scoring",Communication and Care Coordination,"Mean time from exam completion to final signature on report, in hours",Total number of radiography exams completed,None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,N/A,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,"ACRad17 +","Report Turnaround Time: MRI +(Inverse Measure)",Mean MRI report turnaround time (RTAT),Communication and Care Coordination,"Mean time from exam completion to final signature +on report, in hours",Total number of MRI exams completed,None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad19,"Report Turnaround Time: PET +(Inverse Measure)",Mean PET report turnaround time (RTAT),Communication and Care Coordination,"Mean time from exam completion to final signature +on report, in hours",Total number of PET exams completed,None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,"ACRad15 +","Report Turnaround Time: Radiography (modified) +(Inverse Measure)","Mean radiography report turnaround time (RTAT). +(Does not include mammography.)",Communication and Care Coordination,"Mean time from exam completion to final signature on report, in hours",Total number of radiography exams completed,None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad16,"Report Turnaround Time: Ultrasound (Excluding Breast US) +(Inverse Measure)",Mean Ultrasound report turnaround time (RTAT),Communication and Care Coordination,"Mean time from exam completion to final signature +on report, in hours","Total number of ultrasound exams completed +(excluding breast Ultrasound)",None,"Records that have lowest 2.5% values, and highest 2.5% values of calculated measure, to eliminate outliers",None,1; continuous measure scoring,,Outcome,High Priority,Outcome,Y,N,Y,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad5,"Screening Mammography Abnormal Interpretation Rate (Recall Rate) +(inverse Measure)",The percentage of screening mammograms interpreted as positive (abnormal),Efficiency and Cost Reduction,"Number of screening mammograms with abnormal +interpretation (BI-RADS 0, 3, 4 or 5)",Number of screening mammograms,None,None,None,1,,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad3,Screening Mammography Cancer Detection Rate (CDR),"The fraction of all screening mammograms that are +interpreted as positive (abnormal) and have a tissue +diagnosis of cancer within 12 months (expressed per +1000 exams, not as a percentage)",Effective Clinical Care,"Number of screening mammograms with abnormal +interpretation (BI-RADS 0, 3, 4 or 5) that have a tissue diagnosis of cancer within 12 months",Number of screening mammograms,None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad8,Screening Mammography Minimal Cancer Rate,The percentage of cancers detected at screening mammography that are invasive carcinoma ≤ 10mm or DCIS,Effective Clinical Care,Number of cancers detected at screening mammography that are invasive carcinoma ≤ 10mm or DCIS,Number of cancers detected at screening mammography,None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad7,Screening Mammography Node Negativity Rate,"The percentage of invasive cancers detected at +screening mammography that are node negative",Effective Clinical Care,"Number of invasive cancers detected at screening +mammography that are node negative","Number of invasive cancers detected at screening +mammography",None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad6,"Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy +Recommended)","The percentage of screening mammograms where +biopsy was recommended that have a tissue +diagnosis of cancer within 12 months. Note: Recommendation for biopsy may be made on the basis of a diagnostic mammogram that was initiated by findings on the screening",Effective Clinical Care,"Number of screening mammograms with a +recommendation for biopsy (BI-RADS 4 or 5) that +have a tissue diagnosis of cancer within 12 months","Number of screening mammograms with a +recommendation for biopsy (BI-RADS 4 or 5)",None,None,None,1,,Outcome,,Outcome,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5303416,American College of Radiology National Radiology Data Registry,ACRad27,Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries,Documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.,Effective Clinical Care,"Number of patients undergoing uterine artery embolization for symptomatic leiomyomas and/or adenomyosis in whom embolization endpoints are documented separately for each embolized vessel AND ovarian artery angiography or embolization performed in the presence of variant uterine artery anatomy. + +Embolization endpoints: Complete stasis (static contrast column for at least 5 heartbeats) / Near-stasis (not static, but contrast visible for at least 5 heartbeats) / Slowed flow (contrast visible for fewer than 5 heartbeats) / Normal velocity flow with pruning of distal vasculature / Other [specify] / Not documented + +Embolization strategy options for variant uterine artery anatomy: Ovarian artery angiography, Ovarian artery embolization, Abdominal Aortic angiography, None ",All patients undergoing uterine artery embolization for symptomatic leiomyomas and/or adenomyosis.,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,American College of Radiology National Radiology Data Registry +5598408,American College of Rheumatology - RISE Registry,ACR7,Gout: Serum Urate Target,"Percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.8 mg/dL.",Effective Clinical Care,Patients whose most recent serum urate level is less than 6.8 mg/dL,Adult patients aged 18 and older with a diagnosis of gout treated with urate lowering therapy (ULT) for at least 12 months,Patients with a history of solid organ transplant.,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,American College of Rheumatology - RISE Registry +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS15,Preoperative Composite,"Percentage of patients who are taken to the operating room for an elective surgical procedure under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care: +1. The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record. +2. An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date. +3. An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and documentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.",Communication and Care Coordination,"All patients who are taken to the operating room for an elective surgical procedure under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care: +COMPONENT 1: The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record. +COMPONENT 2: An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date. +COMPONENT 3: An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and documentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.","All adults (18 years and older) evaluated by an eligible clinician who 1) are brought from their home or normal living environment on the day of surgery AND 2) Surgery must be an elective scheduled procedure, performed in an operating room under regional, MAC, or general anesthesia.","Patients who are inpatient at an acute care hospital +OR +Patients who are transferred from an ED +OR +Patients who are transferred from a clinic +OR +Patients who undergo an emergent/urgent surgical case +OR +Patients whose admission to the hospital was on any date prior to the date of the scheduled surgical procedure for any reason",None,None,1,N/A,Composite,,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS16,Preventative Care and Screening: Tobacco Screening and Cessation Intervention,Percentage of patients age 18 or older who are active tobacco users who receive tobacco screening AND are offered cessation counseling at least 2 months prior to elective surgical procedure in order to delay the procedure until smoking cessation is possibly achieved.,Community/Population Health,All patients who undergo an elective surgical procedure and who are active tobacco users and received cessation counseling at least 2 months prior to the scheduled elective procedure.,"All patients, aged 18 years and older, evaluated by an eligible clinician who are scheduled for an elective surgical procedure AND who are active tobacco users. ",None,Documentation in the patient’s medical record that the patient did not receive tobacco cessation counseling at least 2 months prior to the procedure due to the risk of delaying the elective surgical procedure being greater than the benefits of cessation of tobacco use.,None,1,N/A,Process,,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS17,Preoperative Key Medications Review for Anticoagulation Medication,"Percentage of patients who take anticoagulation medication who are taken to the operating room for an elective intervention under regional anesthesia, monitored anesthesia care (MAC), and/or general anesthesia who have a peri-operative management plan for anticoagulation medications documented in the medical record",Patient Safety,"All patients who undergo an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia for whom an intraoperative surgical debriefing takes place at the end of the case confirming correct counts, procedure and specimen review, wound class, fluids recorded, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and Foley. The debriefing must be documented in the medical record.","All patients, aged 18 years and older, who take anticoagulation medication who are taken to the operating room for an elective surgical intervention under regional, MAC, or general anesthesia. ",None,Documentation that the plan for pre-operative anticoagulation management was discussed with the physician responsible for managing the patient’s anticoagulation between 48 hours and 30 days prior to surgery.,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS18,Patient Frailty Evaluation,Percentage of patients age 80 and older who have been evaluated for frailty prior to an elective operation.,Effective Clinical Care,"All patients who are 1) brought from their home or normal living environment on the day of surgery and 2) undergo a non-emergent/non-urgent, scheduled surgical procedure, and 3) have documented frailty screening and outcome of screening in the medical record.","All patients 80 years and older who 1) are brought from their home or normal living environment on the day of surgery AND 2) undergo a non-emergent/non-urgent, scheduled surgical procedure. ",None,"Frailty screen could not be completed due to patient condition (cognitive impairment, physical disability preventing participation) ",None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS19,Intraoperative Composite,"Percentage of patients age 18 or older who are taken to the operating room for an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia who have been documented for having all two intraoperative components addressed during the intraoperative phase of care: +1. An intraoperative safety checklist is performed prior to incision that includes the verification of patient’s name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging. +2. An intraoperative surgical debriefing takes place at the end of the case by the surgeon confirming wound classification, correct counts, procedure performed, specimen review, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and Foley catheter.",Patient Safety,"All patients age 18 years or older who are taken to the operating room for an elective or emergent surgical intervention under regional, MAC, and/or general anesthesia who have been documented for having all two intraoperative components addressed during the intraoperative phase of care: + +COMPONENT 1: An intraoperative safety checklist was performed prior to incision that includes the verification of patient’s name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging. + +COMPONENT 2: An intraoperative surgical debriefing took place at the end of the case by the surgeon confirming wound classification, correct counts, procedure performed, specimen review, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and Foley catheter. +","All patients, aged 18 years and older, who undergo an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia.",None,None,None,1,N/A,Composite,,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS20,Optimal Postoperative Communication Plan and Patient Care Coordination Composite,"Percentage of patients, age 18 years or older, who are brought from their home or normal living environment and who are taken to the operating room for an elective surgical intervention under regional anesthesia, MAC, and/or general anesthesia who have been documented for having all four of the following patient care communication and care coordination planning components addressed at the beginning of the postoperative phase of care: +1. A postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care. +2. A postoperative review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate. +3. A postoperative care coordination with the patient’s primary/referring provider regarding the surgery within 30 days following surgery. +4. A postoperative patient care communication plan with the patient and/or patient’s family regarding the surgery and plan for care after discharge.",Communication and Care Coordination,"Patients, age 18 years or older, who are reported for having at least three out of five of the following patient care +communication and care coordination planning components addressed: +COMPONENT 1: Patient has had a postoperative care plan established, addressing mobilization, pain +management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, +and wound care. +COMPONENT 2: Patient has had a postoperative review of the patient’s goals of care that were expressed +preoperatively and who has had those goals of care updated as appropriate. +COMPONENT 3: Patient has had a postoperative care coordination with the patient’s primary/referring +provider regarding the surgery within 30 days following surgery. +COMPONENT 4: Patient has had a postoperative patient care communication plan established with the +patient and/or patient’s family regarding the surgery and plan for care after discharge.","All patients, aged 18 years and older, who are brought from their home or normal living environment on the day of surgery and who are taken to the operating room for an elective surgical intervention under regional, MAC, and/or general anesthesia who have postoperative and/or post-discharge communication regarding the goals of care discussion documented as one of the following: +1. Living as long as possible +2. Living independently +3. Keeping comfortable, symptom relief +4. Establishing a diagnosis or treating/curing a condition +5. Other (single sentence)","Patients who are inpatient at an acute care hospital at the time of their current operation +OR +Patients who are transferred from the Emergency Department (ED) +OR +Patients who are transferred from a clinic +OR +Patients who undergo an emergent/urgent surgical operation +OR +Patients whose admission to the hospital was on any date prior to the date of the scheduled surgical procedure for any reason + +","COMPONENT 3: +Documentation that the patient does not have a PCP or referring physician to communicate with post-operatively within 30 days following surgery.",None,1,N/A,Composite,High Priority,Composite,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS21,Post-Acute Recovery Composite,"Percentage of patients age 18 or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care: +1. A post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date. +2. A post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains, IV lines, etc).",Patient Safety,"All patients age 18 or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care: +COMPONENT 1: A post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date. +COMPONENT 2: A post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains, IV lines, etc).","All patients, aged 18 years and older, who undergo an elective procedure under regional, MAC, and/or general anesthesia who have a post-discharge communication regarding the goals of care discussion documented as one of the following: +1. Living as long as possible +2. Living independently +3. Keeping comfortable, symptom relief +4. Establishing a diagnosis or treating/curing a condition +5. Other (single sentence)","Patients who are inpatient at an acute care hospital at the time of their current operation +OR +Patients who are transferred from the Emergency Department (ED) +OR +Patients who are transferred from a clinic +OR +Patients who undergo an emergent/urgent surgical operation +OR +Patients whose admission to the hospital was on any date prior to the date of the scheduled surgical procedure for any reason",None,None,1,N/A,Composite,,,N,Y,N,N,N,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS22,Unplanned Reoperation within the 30 Day Postoperative Period,Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.,Patient Safety,"Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative procedure. ",Patients aged 18 years and older undergoing an operative procedure.,None,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,ACS23,Unplanned Hospital Readmission within 30 Days of Principal Procedure,Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.,Effective Clinical Care,"Inpatient readmission to the same hospital for any reason or an outside hospital (if known to the surgeon), within 30 days of the principal surgical procedure. ",Patients aged 18 years and older undergoing a surgical procedure.,None,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +5546391,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care,Pinc51,Surgical Site Infection (SSI),Percentage of patients aged 18 years and older who had a surgical site infection (SSI).,Effective Clinical Care,Number of patients with a surgical site infection,Patients aged 18 years and older who have undergone a surgical procedure.,None,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,American College of Surgeons Surgeon Specific Registry QCDR Surgical Phases of Care +1698029,"American Podiatric Medical Association, Inc. (APMA Registry)",APMA1,Comprehensive Diabetic Foot Examination,Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus that had a comprehensive diabetic foot examination with risk categorization based on exam findings during one or more office visits within 12 months,Effective Clinical Care,"Patients who had a comprehensive diabetic foot exam with risk categorization performed at least once within 12 months + +Definition: A comprehensive diabetic foot examination consists of the following components: +- General Inspection: Including evaluation of proper footwear +- Dermatologic: Including skin status, sweating, infection, ulceration, calluses, blistering +- Musculoskeletal: Including deformity and muscle wasting +- Neurological Assessment: Including 10 g monofilament and one of the four following: vibration using 128 Hz tuning fork, pinprick sensation, ankle reflexes or vibration perception threshold testing (VPT) +- Vascular Assessment: foot pulses and ankle brachial pressure +index (ABI) if indicated",All patients aged 18 years and older with a diagnosis of diabetes mellitus with a visit during the measurement period,"* Medical reasons + Includes: + - not indicated (absence of organ/limb, already received/performed, other) + - contraindicated (patient allergic history, potential adverse drug interaction, other) + +* Patient reasons + Includes: + - patient declined + - economic, social, or religious reasons + - other patient reasons + +* System reasons + Includes: + - resources to perform the services not available + - insurance coverage/payor-related limitations + - other reasons attributable to health care delivery system",None,None,1,single performance rate,Process,,,N,Y,N,N,N,No,"American Podiatric Medical Association, Inc. (APMA Registry)" +1698029,"American Podiatric Medical Association, Inc. (APMA Registry)",CDR2,Diabetic Foot Ulcer (DFU) Healing or Closure,"Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration.",Effective Clinical Care,Diabetic Foot Ulcers within the denominator that achieved healing or closure within 6 months of its initial encounter.,All Diabetic Foot Ulcers of patients aged 18 years and older.,"EXCLUSIONS: Palliative care patients, DFU patients seen fewer than 5 times over the reporting period. +",None,None,1,single performance rate,Outcome,,Outcome,N,Y,N,N,N,Yes,U.S. Wound Registry +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC1,Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients,Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on low-risk surgery patients 18 years or older for preoperative evaluation.,Efficiency and Cost Reduction,Number of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on low-risk surgery patients for preoperative evaluation within 30 days preceding low-risk non-cardiac surgery,"All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older during the reporting period. +",None,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC2,Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI),"Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status. ",Efficiency and Cost Reduction,Number of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on asymptomatic patients within 2 years of the most recent PCI.,All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older during the reporting period.,None,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC3,"Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients","Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment. ",Efficiency and Cost Reduction,"Number of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on asymptomatic, low CHD risk patients for initial detection and risk assessment. ",All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients aged 18 years and older during the reporting period.,None,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC4,Utilization of standardized nomenclature and reporting for nuclear cardiology imaging studies,Percentage of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients where standardized nomenclature and reporting was used and the standardized nomenclature was used in the institution’s computer systems.,Communication and Care Coordination,All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed on patients where standardized nomenclature and reporting was used and the standardized nomenclature was used in the institution’s computer systems.,All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed.,None,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC13,SPECT-MPI studies meeting appropriate use criteria,"Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion + Imaging (MPI) studies performed that are appropriate. ",Efficiency and Cost Reduction,Number of denominator eligible studies performed where studies performed were appropriate.,Number of SPECT-MPI studies performed.,None,None,None,1,N/A,Efficiency,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC14,PET-MPI studies meeting appropriate use criteria,"Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies + performed that are appropriate. ",Efficiency and Cost Reduction,Number of denominator eligible studies performed where studies performed were appropriate.,Number of PET-MPI studies performed.,None,None,None,1,N/A,Efficiency,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC17,SPECT-MPI studies not Equivocal,Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed that are not equivocal.,Efficiency and Cost Reduction,Number of denominator eligible studies performed where the results were not equivocal.,Number of SPECT-MPI studies performed.,None,None,None,1,N/A,Efficiency,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC18,PET-MPI studies not Equivocal,"Percentage of Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies + performed that are not equivocal. ",Efficiency and Cost Reduction,Number of denominator eligible studies performed where the results were not equivocal.,Number of PET-MPI studies performed.,None,None,None,1,N/A,Efficiency,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC19,Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol,Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies performed where the imaging protocol used was stress only.,Patient Safety,Number of denominator eligible studies performed where the imaging protocol used was stress only.,All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed.,None,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC20,SPECT-MPI studies performed without the use of thallium,"Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion + Imaging (MPI) studies performed without the use of thallium. ",Patient Safety,Number of denominator eligible studies performed where the radiopharmaceutical Thallium was not used.,Number of SPECT-MPI studies performed.,None,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC21,SPECT-MPI study appropriate imaging protocol selection for morbidly obese patients,Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed on morbidly obese patients where the Imaging Protocol included two days.,Effective Clinical Care,Number of denominator eligible studies performed where the imaging protocol used was Rest/Stress 2-Day or Stress/Rest 2-day.,Number of SPECT-MPI studies performed where the BMI >= 40,None,None,None,1,N/A,Process,High Priority,Outcome,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC22,SPECT and PET MPI studies reporting Left Ventricular Ejection Fraction,Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the Left Ventricle Ejection Fraction was calculated and included in the report.,Effective Clinical Care,Number of denominator eligible studies performed where the Left Ventricle Ejection Fraction was calculated and reported.,All instances of stress nuclear Myocardial Perfusion Imaging (MPI) studies performed.,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC23,SPECT-MPI study clinical utilization of Attenuation Correction image acquisition,Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction.,Efficiency and Cost Reduction,Number of denominator eligible studies performed where an Attenuation Correction of CT or Transmission was used or an Attenuation Correction of “Prone” was documented for patients.,Number of SPECT-MPI studies performed,None,None,None,1,N/A,Efficiency,,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC24,SPECT-MPI study utilization of exercise as a stressor,Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using a Stress Test Type that includes exercise.,Effective Clinical Care,Number of denominator eligible studies performed where the Stress Test Type was exercise.,Number of SPECT-MPI studies performed.,"Patients with Left Bundle Branch Block (LBBB), a pacemaker or who are unable to exercise. ",None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6034942,American Society of Nuclear Cardiology ImageGuide,ASNC25,SPECT-MPI study adequate exercise testing performed,Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies performed where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise.,Effective Clinical Care,Number of denominator eligible studies performed where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise.,Number of SPECT-MPI studies performed,None,None,None,1,N/A,Efficiency,,,N,Y,N,N,N,No,American Society of Nuclear Cardiology ImageGuide +6621356,American Society of Plastic Surgeons,CDR1,Adequate Off-loading of Diabetic Foot Ulcer at each treatment visit,Percentage of visits in which diabetic foot ulcers among patients aged 18 years and older received adequate off-loading during a 12-month reporting period.,Effective Clinical Care,All visits for DFU treatment in which adequate off-loading is documented within the 12-month reporting period.,All visits for patients 18 years and older in which a diabetic foot ulcer (DFU) is documented as treated within the 12-month reporting period.,None,"Adequate off-loading not Prescribed for Medical, Patient or System Reasons ",None,1,N/A,Process,,,N,Y,N,N,N,Yes,U.S. Wound Registry +6621356,American Society of Plastic Surgeons,ASPS5,Breast Reconstruction: Return to OR,Percentage of female patients aged 18 years and older who had breast reconstruction who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure.,Patient Safety,"Patients who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure. + +Definitions: +Unplanned second operation: For the purposes of this measure, an unplanned second operation may include revisions, corrective surgery, and/or surgery due to complications of the primary breast procedure. + +Captured by workflow within the ASPS QCDR.","Denominator All female patients aged 18 years and older who had breast reconstruction + +Female + +AND + +Age ≥ 18 years + +AND + +CPT and HCPCS Code for Encounter: + +19357, 19357-50, 19340, 19340-50,19342, 19342-50, 19361, 19361-50, 19364, 19364-50, 19367, 19367-50, 19368, 19368-50,19369, 19369-50, S2068 + +",None,None,None,1,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,No,American Society of Plastic Surgeons +6621356,American Society of Plastic Surgeons,ASPS6,Breast Reconstruction: Flap Loss,Percentage of female patients aged 18 years or older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant who present with flap loss within 30 days of the primary breast reconstruction procedure.,Patient Safety,"Patients who present with flap loss within 30 days of the primary breast reconstruction procedure. + +Definition: + +Flap loss: For the purposes of this measure, flap loss is a loss of tissue due to infection or vascular compromise, requiring removal of the tissue flap. Total flap loss is greater than 90% of a flap. Partial flap loss is less <10 -90% of a flap. + +Captured by workflow within the ASPS QCDR. +","Denominator All female patients aged 18 years and older who had breast reconstruction via autologous reconstruction (not including latissimus flap) with or without a tissue expander or implant + +Female + +AND + +Age ≥ 18 years + +AND + +CPT and HCPCS Code for Encounter: + +19340, 19340-50, 19364, 19364-50, 19367, 19367-50, 19368, 19368-50, 19369, 19369-50, S2068 + +",None,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,American Society of Plastic Surgeons +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS1,Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair,"Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of pelvic organ prolapse in each vaginal compartment using one of the accepted, objective measurement systems (POP‐Q or Baden/Walker).",Communication and Care Coordination,"The number of patients for whom there is documentation of vaginal support in the anterior, apical and posterior compartments using the POPQ, or Baden/Walker). These would be identified by chart review.","The denominator includes all patients entered into the registry undergoing pelvic organ prolapse (POP) surgery that includes any of the following CPT codes: +57280, 57282, 57283, 57425 (colpopexies) +57240, 57284, 57285, 57423 (anterior repairs) +45560, 57250, 57210 (posterior repairs) +57200, 57260, 57265 (colporrhaphy and combined) +57268, 57270, 57556 (enterocele repair) +58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) +58400, uterine suspension +57120 colpocleisis +57106, 57110 vaginectomy",None,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS2,Preoperative utilization of pessary prior to Pelvic Organ Prolapse surgery,The percentage of patients who have attempted pessary placement or the treatment of pelvic organ prolapse prior to surgical intervention.,Communication and Care Coordination,The number of patients that who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention.,"The denominator includes all patients undergoing pelvic organ prolapse (POP) surgery: All patients with any of the following prolapse surgery codes: +57280, 57282, 57283, 57425 (colpopexies) +57240, 57284, 57285, 57423 (anterior repairs) +45560, 57250, 57210 (posterior repairs) +57200, 57260, 57265 (colporrhaphy and combined) +57268, 57270, 57556 (enterocele repair) +58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) +58400, uterine suspension +57120 colpocleisis +57106, 57110 vaginectomy +",Patients requiring surgery for another gynecologic condition who are having concurrent prolapse surgery. For example a patient with endometrial cancer who has a concurrent prolapse surgery,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS3,Preoperative assessment of sexual function prior to pelvic organ prolapse repair,Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse.,Effective Clinical Care,The number of patients entered into the registry undergoing pelvic organ prolapse (POP) surgery who undergo a preoperative assessment of sexual function.,"The denominator includes all patients entered into the registry undergoing pelvic organ prolapse (POP) surgery that includes any of the following CPT codes: +57280, 57282, 57283, 57425 (colpopexies) +57240, 57284, 57285, 57423 (anterior repairs) +45560, 57250, 57210 (posterior repairs) +57200, 57260, 57265 (colporrhaphy and combined) +57268, 57270, 57556 (enterocele repair) +58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) +58400, uterine suspension +57120 colpocleisis ",,Patient is unable or unwilling to discuss her sexual function.,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS4,Performing an intraoperative rectal examination at the time of prolapse repair,Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior pelvic organ prolapse.,Patient Safety,The number of patients undergoing surgery for pelvic organ prolapse in whom an intraoperative rectal examination was performed and documented.,"The denominator includes all patients undergoing apical or posterior pelvic organ prolapse (POP) surgery. Patients with any of the following prolapse codes will be: +57280, 57282, 57283, 57425 (colpopexies) +45560, 57250, 57210 (posterior repairs) +57200, 57260, 57265 (colporrhaphy and combined) +57268, 57270, 57556 (enterocele repair) +58263, 58270, 58280, 58292, 58294 (hyst w/ enterocele repair) +58400, uterine suspension +57120 colpocleisis +56800, 56810 (introital repair/ perineoplasty) +57106, 57110 vaginectomy",Patients who have undergone prior total proctectomy.,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS5,Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse,"Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed. ",Effective Clinical Care,"The number of patients who have a concomitant vaginal apical suspension (i.e. enterocele repair, uterosacral-, iliococygeus-, sacrospinous-, or sacral-colpopexy) at the time of hysterectomy for pelvic organ prolapse. Procedures identified by the submission of CPT codes as below: +57280 Colpopexy, abdominal approach +57282 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) +57283 Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) +57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex) +58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele +58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele +58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele +58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele +58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele +","Hysterectomy performed for the indication of pelvic organ prolapse. The prolapse codes for ICD-10 are detailed below, respectively: +N81.10, Cystocele, midline +N81.12, Cystocele, lateral +N81.6, Rectocele +N81.2, Incomplete uterovaginal prolapse +N81.3, Complete uterovaginal prolapse +N81.4, Uterovaginal prolapse, unspecified +N81.5, Vaginal enterocele +N81.89, Old laceration of muscles of pelvic floor +N81.82, incompetence or weakening of pubocervical tissue +N81.83, incompetence or weakening of rectovaginal tissue +N81.84, pelvic muscle wasting + +CPT codes for hysterectomy are: +57530 Trachelectomy +58150 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) +58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo-Urethrocystopexy (e.g. Marshall-Marchetti-Krantz, Burch) +58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) +58260 Vaginal Hysterectomy, for Uterus 250 G or Less +58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s) +58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele +58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control +58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele +58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy +58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele +58290 Vaginal Hysterectomy, for Uterus Greater than 250 G +58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) +58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele +58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo-Urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra Type) +58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele +58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less +58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) +58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G +58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) +58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less +58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) +58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G +58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) +58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less +58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s) +58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G +58573 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s) +","• Patients with a gynecologic or other pelvic malignancy noted at the time of hysterectomy +• Patients undergoing a concurrent obliterative procedure (colpocleisis) (CPT 57106, 57110, 57120) +",None,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS6,Route of Hysterectomy,Percentage of patients who underwent vaginal hysterectomy.,Effective Clinical Care,"The number of patients undergoing vaginal hysterectomy (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554)","The denominator includes the total number of patients undergoing hysterectomy of any type. (CPT codes 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58260, 58262, 58263, 58267, 58553, 58550, 58552, 58554, 58544, 58570, 58571, 58572, 58573, 58541, 58542, 58543, 58150, 58152, 58180)","Patients with a preoperative diagnosis of cancer (applies to both numerator and denominator, ICD-10 codes)",None,None,1,N/A,Intermediate Outcome,,Intermediate Outcome,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS7,Documentation that conservative management was offered prior to fecal incontinence surgery or procedures.,The percentage of patients offered non-surgical treatment options for fecal incontinence prior to surgery.,Effective Clinical Care,"Number of patients offered conservative management for fecal incontinence prior to invasive surgical or procedural intervention. Conservative management includes high fiber diet, fiber supplementation, bulking agents, and anti-diarrheal medications for patients with diarrhea, +ICD 10 diagnoses include: +R15 Fecal Incontinence +R15.0 Incomplete defecation +R15.1 Fecal smearing +R15.2 Fecal urgency +R15.9 Full incontinence of feces +","The denominator includes the number of patients undergoing surgery for the indication of fecal incontinence. Fecal incontinence surgeries/procedures will include the following CPT codes: +0377T Anoscopy with directed submucosal injection of bulking agent for fecal incontinence +46750 Overlapping anal sphincteroplasty +46760 Sphincteroplasty for incontinence, muscle transplant +46761 Anal sphincteroplasty with levator plication +46762 Implantation of artificial anal sphincter +64561, 64581, 64590 for sacral neuromodulation +",None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS8,Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women,Percentage of obese patients having documented weight loss counseling prior to undergoing anti-urinary incontinence procedures.,Effective Clinical Care,The number of obese patients (BMI > 30) having documented weight loss counseling prior to undergoing anti-urinary incontinence procedures.,"The denominator includes the number of obese patients (BMI > 30) having an anti-urinary incontinence surgical procedure. Anti-incontinence procedures will be defined by the following CPT codes: 57288 (urethral sling), 51840/51841 (Anterior vesicourethropexy), 51990/51992 (Laparoscopic urethral suspension/laparoscopic sling), , 58267 (Vaginal hysterectomy with colpo-urethropexy), ",None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +1089281,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry,AUGS9,Over-utilization of synthetic mesh in the posterior compartment,Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized.,Patient Safety Effective Clinical Care,"The number of patients undergoing surgery for pelvic organ prolapse in the posterior compartment with a synthetic mesh augment (non-absorbable and absorbable) placed in the posterior compartment. +57267 posterior compartment only (exclude 57267 anterior compartment) +","The denominator includes the number of patients undergoing surgery for pelvic organ prolapse which includes the posterior compartment. The prolapse codes for ICD9 -> ICD-10 include: +618.04 -> N81.6, Rectocele +CPT codes 45560,57250,57260,57265, +",The numerator will subtract non-synthetic mesh and synthetic mesh placed in anterior compartment repair.,None,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Urogynecologic Society (AUGS) AUGS Quality Improvement Registry +8758330,American Urological Association,AQUA5,Benign Prostate Hyperplasia: Do not order creatinine lab for patients,Percentage of patients with NEW diagnosis of BPH who had creatinine lab order placed,Efficiency and Cost Reduction,Number of patients with a new diagnosis of benign prostatic hyperplasia(BPH) with a creatinine lab order placed,Number of patients with a new diagnosis of benign prostatic hyperplasia(BPH),None,Patients with known renal insufficiency (Cr >1.5 or documented in past medical history),None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA6,Benign Prostate Hyperplasia: Do not order upper-tract imaging,"Percentage of patients with NEW diagnosis of BPH who had CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed",Efficiency and Cost Reduction,"Number of patients with NEW diagnosis of BPH with CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed",Number of patients with NEW diagnosis of benign prostatic hyperplasia(BPH),None,Patients with known renal insufficiency (Cr >1.5 or documented in past medical history) or with documented flank pain or hematuria,None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA12,Benign Prostate Hyperplasia: IPSS improvement after diagnosis,Percentage of patients with NEW diagnosis of clinically significant BPH who had IPSS (international prostate symptoms score) or AUASS (American urological association symptom score) improvement by ≥20%.,Person and Caregiver-Centered Experience and Outcomes,"Number of patients with a new diagnosis of benign prostatic hyperplasia(BPH) with a a baseline IPSS/AUASS ≥8 (definiing at least ""moderate"" symptoms) who are documented to have an improvement (decrease) in IPSS/AUASS by at least 20% within 12 months of diagnosis.",Number of patients with a new diagnosis of benign prostatic hyperplasia(BPH) and baseline IPSS / AUASS ≥8.,IPSS<8,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,AQUA3,Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys,Percentage of patients (boys) =< 18 yrs. of age newly diagnosed with undescended testis or retractile testis with an order for ultrasound (scrotal or groin) placed.,Efficiency and Cost Reduction,Number of patients (boys) =< 18 yrs. of age newly diagnosed with undescended testis or retractile testis with a scrotal or groin ultrasound order placed,Number of patients (boys) =< 18 yrs. of age newly diagnosed with undescended testis or retractile testis,None,"1) Boys with hypospadias or other findings concerning for disorder of sexual differentiation; 2) Boys with bilateral nonpalpable testes; 3) Relative exclusion – obese/overweight boys with nonpalpable testis may benefit from ultrasound to identify an inguinal testis; 4) clinical concern of torsion of undescended testis, or to differentiate UDT from incarcerated hernia or other acute scrotal/inguinal process",None,1,N/A,Process,High Priority,,Y,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA8,Hospital re-admissions/complications within 30 days of TRUS Biopsy,"Percentage of patients who had TRUS biopsy performed who had ≥24h after the biopsy): infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days",Patient Safety,"Number of patients with a TRUS biopsy performed that had infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days","Number of patients with a TRUS biopsy performed that had infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days",None,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,AQUA4,Hypogonadism: Testosterone lab ordered/reported within 6 months of starting testosterone replacement,"Percentage of patients with hypogonadism, starting testosterone medication (any formulation of testosterone) or rec’d testosterone injection in clinic have testosterone level ordered within 6 months of first testosterone Rx or injection",Effective Clinical Care,Number of patients with a diagnosis of hypogonadism receiving testosterone replacement (medication or injection) with a testosterone level test ordered/reported within 6 months of first testosterone Rx or infection,Number of patients with a diagnosis of hypogonadism receiving testosterone replacement (medication or injection),None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA11,Prostate Cancer: Patient Report of Sexual function after treatment,"Patient report of sexual function 24 months after treatment, adjusting for nerve sparing, age/baseline, RT approach",Person and Caregiver-Centered Experience and Outcomes,Men completing EPIC-26 sexual function domain,All newly diagnosed prostate cancer patients,None,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,AQUA10,Prostate Cancer: Patient Report of Urinary function after treatment,"Patient report of urinary function 12months after treatment , adjusting for age/baseline",Person and Caregiver-Centered Experience and Outcomes,Men completing EPIC-26 urinary function domain,All newly diagnosed prostate cancer patients,None,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,MUSIC4,Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients,Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting,Effective Clinical Care,# of low-risk prostate cancer patients on active surveillance or watchful waiting,"Number of newly diagnosed Prostate Cancer patients 30 years or older with low-risk disease (GS ≤3+3, PSA<10, cT≤2)",Prostate cancer patients < 30 years of age; patients that have had prior treatment for prostate cancer,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,Yes,Michigan Urological Surgery Improvement Collaborative (MUSIC) +8758330,American Urological Association,AQUA14,Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment,Percentage of patients who underwent endoscopic procedures following SWL,Efficiency and Cost Reduction,Patients undergoing SWL twice on the ipsilateral side within 6 months (inverse measure),"Patients undergoing SWL followed by ipsilateral SWL, ureteroscopy, or percutaneous nephrolithotomy within 6 months",None,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,AQUA13,Stress Urinary Incontinence (SUI): Revision surgery within 12 months of incontinence procedure,Percentage of women who undergo surgery for stress incontinence who require revision surgery within 12 months,Effective Clinical Care,Women undergoing revision surgery within 12 months of primary surgery,Women undergoing incontinence surgery (one of 8 classes of procedure defined by CPT codes),None,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,American Urological Association +8758330,American Urological Association,AQUA15,Stones: Urinalysis documented 30 days before surgical stone procedures,Percentage of patients with a documented urinalysis 30 days before surgical stone procedures,Patient Safety,Patients with documented urinalysis within 30 days before surgery,"Patients undergoing surgical stone procedures (including cystoscopy stent placement, percutaneous nephrostomy tube placement, shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy)",None,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA16,Non-Muscle Invasive Bladder Cancer: Repeat Transurethal Resection of Bladder Tumor (TURBT) for T1 disease,"Percentage of patients with T1 disease, that had a second TURBTwithin 6 weeks fo the initial TURBT",Efficiency and Cost Reduction,"Percentage of patients with T1 disease, that had a second TURBTwithin 6 weeks fo the initial TURBT",Patients diagnosed with clinical stage T1 bladder cancer,None,Onset of systemic chemotherapy or radical cystectomy within 3 months of diagnosis,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA17,Non-Muscle Invasive Bladder Cancer: Initiation of BCG 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS,Percentage of patients who initiate BCG treatment within 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS,Effective Clinical Care,Patients starting BCG within 3 months of TURBT,Patients diagnosed with high-grade T1 bladder cancer and/or CIS,Non-urothelial histology,Onset of systemic chemotherapy or radical cystectomy within 3 months of diagnosis; prior completion of at least 6 weeks BCG,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urological Association +8758330,American Urological Association,AQUA18,Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis,Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer,Effective Clinical Care,Patients undergoing cystoscopy within 4 months of TURBT,Patients undergoing TURBT for any bladder cancer,None,Onset of systemic chemotherapy or radical cystectomy within 3 months of diagnosis,None,1,N/A,Process,,,N,Y,N,N,N,No,American Urological Association +9986051,Americas Hernia Society Quality Collaborative,"AHSQC1 +",Ventral Hernia Repair: Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period,"Percentage of patients aged 18 years and older who have undergone ventral hernia repair who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal.",Patient Safety,All patients in the cohort who have undergone ventral hernia repair and completed 30 day postoperative follow up and had a surgical site occurrence requiring procedural intervention as described in the measure description,All patients in the cohort who have undergone ventral hernia repair with 30 day postoperative follow up,"Patients under the age of 18 years, patients without completed 30 day postoperative follow up",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Americas Hernia Society Quality Collaborative +9986051,Americas Hernia Society Quality Collaborative,AHSQC2,Unplanned Hospital Readmission or Observation Visit within the 30 Day Postoperative Period,Percentage of patients aged 18 years and older who had any unplanned hospital readmission or 23 hour observation visit within the 30 day postoperative period,Efficiency and Cost Reduction,All patients in the cohort who have undergone operation and completed 30 day postoperative follow up and had a hospital readmission or 23 hour observation visit as described in the measure description,All patients in the cohort who have undergone elective ventral hernia operation with 30 day postoperative follow up,"Patients under the age of 18 years, patients without completed 30 day postoperative follow up",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Americas Hernia Society Quality Collaborative +9986051,Americas Hernia Society Quality Collaborative,AHSQC6,Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period,"Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal. + +This measure is reported as three performance rates stratified by hernia width: +Rate 1: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate) +Rate 2: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm +Rate 3: Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm +",Patient Safety,All patients in the cohort who have undergone ventral hernia repair with myofascial release and had a surgical site occurrence requiring procedural intervention as described in the measure description,"Performance Rate 1) All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up + +Performance Rate 2) All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up with hernia width ≤10cm + +Performance Rate 3) All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up with hernia width >10cm +","Patients under the age of 18 years, patients without completed 30 day postoperative follow up",None,None,3,2,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Americas Hernia Society Quality Collaborative +9986051,Americas Hernia Society Quality Collaborative,AHSQC7,Abdominal Wall Reconstruction Preoperative Diabetes Assessment,Percentage of diabetic patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) with hemoglobin A1C assessment within 6 months prior to operation,Effective Clinical Care,All diabetic patients in the cohort who have undergone ventral hernia repair with myofascial release with preoperative assessment of hemoglobin A1c as specified in the measure description,All diabetic patients in the cohort who have undergone ventral hernia repair with myofascial release,Patients under the age of 18 years,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Americas Hernia Society Quality Collaborative +9986051,Americas Hernia Society Quality Collaborative,AHSQC8,Ventral Hernia Repair: Biologic Mesh Prosthesis Use in Low Risk Patients,"Percentage of patients aged 18 years and older who have undergone low risk (elective, class I wound, no active skin infection, no stoma present) ventral hernia repair using biologic mesh placement",Efficiency and Cost Reduction,All patients in the cohort who have undergone low risk ventral hernia repair with placement of biologic mesh,All patients in the cohort who have undergone low risk ventral hernia repair with mesh,Patients under the age of 18 years,None,None,1,N/A,Efficiency,High Priority,,Y,Y,N,N,N,No,Americas Hernia Society Quality Collaborative +9986051,Americas Hernia Society Quality Collaborative,AHSQC9,Ventral Hernia Repair: Pain and Functional Status Assessment,"Percentage of patients aged 18 years and older who have undergone ventral hernia repair with completed preoperative (baseline) and at least one follow-up patient reported pain and functional status assessment (patient reported outcome). These patient reported outcomes can be completed with an in-person clinical visit, phone call, smartphone, or email. +This measure is reported as two performance rates: +Rate 1: Ventral Hernia Repair: Pain and Functional Status Assessment-Overall completion rate +Rate 2: Ventral Hernia Repair: Pain and Functional Status Assessment-Email engagement completion rate",Person and Caregiver-Centered Experience and Outcomes,"Performance Rate 1) All patients in the cohort who have undergone ventral hernia repair and completed both preoperative (baseline) and one postoperative pain and functional status assessment by any method as described in the measure description + +Performance Rate 2) All patients in the cohort who have undergone ventral hernia repair and completed both preoperative (baseline) and one postoperative pain and functional status assessment by email as described in the measure description ","Performance Rate 1) All patients in the cohort who have undergone elective ventral hernia repair and the operation date is at least 30 days ago + +Performance Rate 2) All patients in the cohort who have undergone elective ventral hernia repair, the operation date is at least 30 days ago, have a valid email address and have not opted out of email communication ",Patients under the age of 18 years,None,None,2,1,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Americas Hernia Society Quality Collaborative +5551268,Anesthesia Business Group,"ABG28 +",Pre-Operative Screening for GERD,Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about symptoms of Gastroesophageal Reflux Disease during their pre-anesthetic evaluation,Effective Clinical Care,All patients who have procedures in the operating room/procedure room under anesthesia care that are also questioned about symptoms of Gasgtroesophageal Reflux Disease during their pre-operative assessment.,"All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",ASA PS>4,"Patient, system or medical reason that prevents assessent, ASA PS=""E""",None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG29,Pre-Operative Screening for Glaucoma,Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about a history of Glaucoma or elevated eye pressures during their pre-anesthetic evaluation,Effective Clinical Care,All patients who have procedures in the operating room/procedure room under anesthesia care that are also questioned about symptoms of Glaucoma or elevated eye pressures during their pre-operative assessment,"All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",ASA PS>4,"Patient, system or medical reason that prevents assessent, ASA PS=""E""",None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG30,Pre-Operative Screening for PONV Risk,Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about Post-operative Nauesa and Vomiting risk factors during their pre-anesthetic evaluation,Effective Clinical Care,All patients who have procedures in the operating room/procedure room under anesthesia care that are also questioned about PONV risk factors during their pre-operative assessment,"All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",ASA PS>4,"Patient, system or medical reason that prevents assessent, ASA PS=""E""",None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG31,Pre-Operative Screening for Excessive Alcohol and Recreational Drug Use,Percentage of patients that undergo an anesthetic in the operating room/procedure room who are questioned about alcohol and recreational drug use during their pre-anesthetic evaluation,Effective Clinical Care,All patients who have procedures in the operating room/procedure room under anesthesia care that are also questioned about alcohol and recreational drug use during their pre-operative assessment,"All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",ASA PS>4,"Patient, system or medical reason that prevents assessent, ASA PS=""E""",None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG32,Pain Related Quality of Life Interference,Percentage of patients with a diagnosis of chronic pain whose pain related quality of life (QOL) interference is addressed during at least two office visits throughout the calendar year.,Effective Clinical Care,Patients with two or more office visits in the calendar year who receive a plan of care from their provider to improve their QOL,All patients seen by a pain provider in the calendar year,Patients with chronic pain for less than three months. Patients with less than three office visits in the calendar year.,"Patient, system or medical reason that prevents assessment.",None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG33,Lower Body Functional Impairment (LBI),Percentage of patients with a diagnosis of chronic pain whose functional status was assessed with a tool(s) during at least two office visits throughout the calendar year and whose pain related functional status stayed the same or improved.,Effective Clinical Care,"Patients with two or more office visits in the calendar year who report the same or improved lower body functional status + +Performance Met: ABG Observation 1042 (same or improved lower body pain after at least two visits) +Performance Not Met: ABG Observation 1043 (fails to report improved lower body pain after at least two visits)",All patients seen by a pain provider in the calendar year,Patients with chronic pain for less than three months. Patients with less than three office visits in the calendar year.," History of documented non-compliance. New pain initiator that compounds original initiator being managed. Patient, system or medical reason that prevents assessment.",None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG34,Mood Assessment Screening and treatment,Percentage of patients with a diagnosis of chronic pain who were assessed for depression and anxiety with a standardized tool at least twice in the calendar year and who are treated for mood disorders during the calendar year as a result of their elevated assessment scores.,Person and Caregiver-Centered Experience and Outcomes,Patients with two or more office visits in the calendar year whose mood assessment scores are the same or improved,All patients seen by a pain provider in the calendar year,Patients with chronic pain for less than three months. Patients with less than three office visits in the calendar year.," History of documented non-compliance. New pain initiator that compounds original initiator being managed. Patient, system or medical reason that prevents assessment. Normal initial mood assessment score.",None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG1,Intra-operative anesthesia safety,Percentage of patients with no significant anesthesia adverse events in the operating room/procedure room.,Effective Clinical Care,"All patients who have a procedure under anesthesia care and do not have an adverse event reported while in the operating room/procedure room with the exception of nausea or vomiting + +Performance Met: Any one of the following ABG Observations: 001 (no significant observations), 023 and 024 (nausea and vomiting), 033 (other observation), 036 (use of difficult airway equipment, planned) +Performance Not Met: Any ABG Observation NOT in the following set (Insignificant ABG observations: 001, 023, 024, 033, 036)","Patient with an encounter + +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) +AND +Excluding Labor Epidural (CPT codes 01960, 01967)",None,None,None,N/A,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,AQI35,Perioperative Mortality Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.",Patient Safety,"Patients who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** + +Definition: Death or mortality is defined as the irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration and brain activity; the end of life. + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. +","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 ",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +5551268,Anesthesia Business Group,ABG4,PACU tracheal intubation Rate,The rate of tracheal intubation in the PACU for all patients who have anesthesia in the operating room/procedure room.,Patient Safety,All patients who have a procedure under anesthesia care that subsequently undergo tracheal intubation in the PACU.,"All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",None,None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG5,Composite Procedural Safety for All Vascular Access Procedures,"Percentage of adults under anesthesia care who experience a serious injury from an attempt at securing vascular access of any type (arterial, central venous, peripheral venous) in the operating room/procedure room or PACU.",Patient Safety,"All patients who have a procedure under anesthesia care that experience a serious injury from an attempt at vascular access (including pneumothorax, arterial, venous or neurological injury) that is recognized while in the operating room/procedure room.","All patients who have procedures in the operating room/procedure room under anesthesia care AND +Excluding Labor Epidural (CPT codes 01960, 01967)",None,None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG7,Immediate Adult Post-Operative Pain Management,The percentage of patients 18 or older admitted to the PACU after an anesthetic with a maximum pain score <7/10 within 15 minutes of arrival.,Person and Caregiver-Centered Experience and Outcomes,"The number of lucid patients with a pain score less than 7 within 15 minutes of PACU arrival. + +Performance Met: ABG Observation 1001 (Pain score 0-6 on arrival to PACU) Reported +Performance Not Met: ABG Observation 1002 (Pain score 7-10 on arrival to PACU) Reported","Patient with an encounter + +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)","Denominator Exclusions: Patient Age < 18 OR ABG observation 1017 (patient not transferred to PACU) reported +",Denominator Exceptions: ABG observation 1003 (patient unable to report pain score) reported,None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,Yes,Anesthesia Business Group +5551268,Anesthesia Business Group,AQI48,Anesthesia: Patient Experience Survey,"Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who received a survey within 30 days of the procedure to assess their experience and satisfaction with anesthesia. +Definition: Practices and eligible clinicians may customize their patient experience and satisfaction with anesthesia surveys to meet local needs but, at a minimum, surveys must include a core set of questions that address three of the four following criteria related to patient experience and satisfaction and one mandatory question described below. +1. Pre-operative Education and Preparation +2. Patient and/or Family Communication +3. Care Team Response to Comfort and Well-Being +4. Post-operative pain control and/or management + +Mandatory question that must be included in each survey (practices should also include an option for patient to indicate “Not Applicable”): +1. On a scale of 1 to 5, where 1 indicates the worst anesthesia experience and where 5 indicates the best anesthesia experience, how would you rate your overall anesthesia experience? +Numerator Note: Practices and individual eligible clinicians who have contracted with or receive patient experience and satisfaction with anesthesia services via the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS®), CAHPS® Surgical Care Survey or other CAHPS survey fulfill the spirit of this measure and should report Performance Met for patients who received such surveys. +Numerator Note: Practices and eligible clinicians may wish to supplement these questions by taking into consideration the recommendations of the ASA Committee on Performance and Outcomes Measurement work product entitled “Patient Satisfaction and Experience with Anesthesia.” +Numerator Note: Depending on local practice, practices and eligible clinicians may wish to supplement survey questions by taking into consideration the recommendations developed as part of the Perioperative Surgical Home (PSH) that are structured in five distinct components. +1. Pre-Operative Education and Preparation (Four Indicators) +a. Patient comfort with instructions provided about eating better +b. Patient comfort with instructions provided about exercise or physical therapy +c. Patient comfort with instructions provided about stopping smoking (if applicable) +d. Patient comfort with instructions provided about what to do after surgery +2. Check-In and Pre-Procedure Experience +3. Caregiver and Family Communication during Surgery +4. Care Team Response to Comfort and Well-Being +5. Post-Operative Pain Management +For more information on these resources, visit https://www.asahq.org/psh. +","Patients, aged 18 and older, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic +","Denominator Exclusions: Organ Donors as designated with ASA Physical Status 6, Patient died within 30 days of the procedure "," Denominator Exception: +• Documentation of patient reason(s), process reason(s)or medical reason(s) for not receiving survey (i.e. patients who are non-verbal, who are unable to be surveyed due to a medical or psychiatric reason, who are unable to be surveyed due to a language barrier, have not provided contact information or who decline to be surveyed) ",None,1,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +5551268,Anesthesia Business Group,ABG14,Corneal Abrasion,"Percentage of patients having an anesthetic in the operating room/procedure room who experience any ocular surface injury requiring evaluation, follow up, or treatment prior to discharge from PACU",Patient Safety,"Patients with documented ocular surface injury identified prior to discharge from PACU + +Performance Met: ABG Observation 080 (Corneal Abrasion) Reported intraoperatively or in PACU +Performance Not Met: ABG Observation 080 NOT Reported intraoperatively or in PACU","Patient with an encounter +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",None,None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG15,Dental Injury,Percentage of patients who have general anesthesia and have an unintended change in dental status that is identified prior to PACU discharge,Patient Safety,"All patients who receive general anesthesia and have an unintended change in dental status observed prior to discharge from PACU + +Performance Met: ABG Observation 006 (Dental Injury) Reported intraoperatively or in PACU +Performance Not Met: ABG Observation 006 NOT Reported intraoperatively or in PACU","Patient with an encounter +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",Denominator Exclusions: Patient did not undergo General Anesthesia,None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG16,Planned use of difficult airway equipment,"For all patients on whom difficult airway equipment is used in the operating room/procedure room, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes.",Effective Clinical Care,"All patients on whom difficult airway equipment is used in the operating room/procedure room for whom use is planned prior to the induction of anesthesia for any reason. The word ""planned"" in this measure means that the equipment was physically present in the operating room/procedure room prior to the induction of anesthesia. + +Performance Met: ABG Observation 036 (use of difficult airway equipment, planned) Reported intraoperatively +Performance Not Met: ABG Observation 037, 38 or 4 (unplanned use of difficult airway equipment, unable to intubate or failed airway) Reported intraoperatively","Patient with an encounter +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",Denominator Exclusions: Difficult airway equipment not used,None,None,N/A,N/A,Process,,,N,Y,N,N,N,Yes,Anesthesia Business Group +5551268,Anesthesia Business Group,ABG21,Pre-operative OSA assessment,Percentage of patients who undergo a surgical procedure in the operating room/procedure room that have a pre-operative assessment for Obstructive Sleep Apnea (OSA),Effective Clinical Care,"All patients who have procedures in the operating room/procedure room under anesthesia care that also have a pre-operative assesment for Obstructive Sleep Apnea (OSA) + +Performance Met: ABG Observation 1014 (preoperative OSA assessment done) Reported +Performance Not Met: ABG Observation 1015 (preoperative OSA assessment not done) Reported","Patient with an encounter +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",None,"Denominator Exceptions: ABG observation 1016 (patient, system or medical reason for not performing OSA assessment) reported",None,N/A,N/A,Process,,,N,Y,N,N,N,No,Anesthesia Business Group +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI49,Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite,"This measure will have a total of five performance rates: one for each of the four selected blood conservation strategies as well as a fifth, overall performance rate. The rates are described below: + +Rate 1: Lysine Analogues: Percentage of denominator-eligible patients for whom lysine analogues were used +Rate 2: Mini-circuits, RAP, or ultrafiltration: Percentage of denominator-eligible patients for whom mini-circuits, or Retrograde Autologous Priming (RAP) or ultrafiltration were used +Rate 3: Red Cell Salvage using Centrifugation: Percentage of denominator-eligible patients for whom red cell salvage using centrifugation was used +Rate 4: Transfusion Algorithm with Point-of-Care Testing: Percentage of denominator-eligible patients for whom a transfusion algorithm supplemented with point-of-care testing was used +Rate 5: Composite Performance Score: Percentage of denominator-eligible patients for whom a cumulative score of 100% of blood conservation strategies was met + +",Effective Clinical Care,"Patients for whom selected blood conservation strategies were used. + Numerator Scoring: Each blood conservation strategy of this measure accounts for 25% of the total composite score. Each of the four blood conservation strategies must be reported to be included in the performance measurement. The total composite score will be calculated by the data source and not the individual practitioner. + 1. Use of Lysine analogues + Numerator Note: As indicated by Intraoperative Antifibrinolytic med: Aminocaproic Acid or Tranexamic Acid. + 2. Use of mini-circuits or Retrograde Autologous Priming (RAP) or Ultrafiltration (Minimize hemodilution caused by cardiopulmonary bypass pump priming solution) + Numerator Note: Record the usage of retrograde autologous priming or a miniaturized circuit volume by the cardiopulmonary perfusion team prior to the onset of cardiopulmonary bypass. + Numerator Note: Capture the total volume of ultrafiltrate removed by the cardiopulmonary perfusion team during cardiopulmonary bypass and during modified ultra-hemofiltration post-CPB. Record the data in milliliters. + 3. Use of red cell salvage using centrifugation +Numerator Note: Capture the volume of cell saver collected and given. Do not include autologous, allogeneic, pump-residual, or chest-tube recirculated blood. + 4. Use of transfusion algorithm supplemented with point-of-care testing + Numerator Note: Transfusion algorithm includes SCA/STS guideline recommendations or an evidence-based algorithm formulated at the local level. + Composite Performance Score + Performance Score Note: This performance score is calculated by the data source and not the individual practitioner. Eligible clinicians reporting this measure must submit numerator quality codes for each of the four blood conservation strategies identified in this measure. The performance score is the cumulative sum of performance met for each blood conservation strategy listed in the numerator of this measure. + + For example, for a single patient encounter, if the eligible clinician reports performance met coding for “Use of mini-circuits or RAP or Ultrafiltration”, “Use of red cell salvage using centrifugation”, and “Use of transfusion algorithm supplemented with point-of-care testing” and performance not met for “Use of lysine analogues”, the cumulative score would be calculated as 3 performance met divided by 4 possibilities of performance met that would equal 75%. This eligible clinician for this particular patient would be assessed as “Performance Not Met” because the eligible clinician had a cumulative score less than 100%. ","Patients, aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass. + +Denominator Note: Patients undergoing a re-operation are included in the denominator to the measure","Denominator Exclusions: +Emergent cases ",None,None,5,5,Composite,,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI48,Anesthesia: Patient Experience Survey,"Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who received a survey within 30 days of the procedure to assess their experience and satisfaction with anesthesia. + + Definition: Practices and eligible clinicians may customize their patient experience and satisfaction with anesthesia surveys to meet local needs but, at a minimum, surveys must include a core set of questions that address three of the four following criteria related to patient experience and satisfaction and one mandatory question described below. + 1. Pre-operative Education and Preparation + 2. Patient and/or Family Communication + 3. Care Team Response to Comfort and Well-Being + 4. Post-operative pain control and/or management + + Mandatory question that must be included in each survey (practices should also include an option for patient to indicate “Not Applicable”): +1. On a scale of 1 to 5, where 1 indicates the worst anesthesia experience and where 5 indicates the best anesthesia experience, how would you rate your overall anesthesia experience? + + Numerator Note: Practices and individual eligible clinicians who have contracted with or receive patient experience and satisfaction with anesthesia services via the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS®), CAHPS® Surgical Care Survey or other CAHPS survey fulfill the spirit of this measure and should report Performance Met for patients who received such surveys. + + Numerator Note: Practices and eligible clinicians may wish to supplement these questions by taking into consideration the recommendations of the ASA Committee on Performance and Outcomes Measurement work product entitled “Patient Satisfaction and Experience with Anesthesia.” + +Numerator Note: Depending on local practice, practices and eligible clinicians may wish to supplement survey questions by taking into consideration the recommendations developed as part of the Perioperative Surgical Home (PSH) that are structured in five distinct components. + + 1. Pre-Operative Education and Preparation (Four Indicators) + a. Patient comfort with instructions provided about eating better + b. Patient comfort with instructions provided about exercise or physical therapy + c. Patient comfort with instructions provided about stopping smoking (if applicable) + d. Patient comfort with instructions provided about what to do after surgery + 2. Check-In and Pre-Procedure Experience + 3. Caregiver and Family Communication during Surgery + 4. Care Team Response to Comfort and Well-Being + 5. Post-Operative Pain Management ","Patients, aged 18 and older, who undergo a procedure* under anesthesia. +Definition: *Any procedure including surgical, therapeutic or diagnostic","Denominator Exclusions: +• Organ Donors as designated with ASA Physical Status 6 +• Patient died within 30 days of the procedure "," Denominator Exception: +• Documentation of patient reason(s), process reason(s)or medical reason(s) for not receiving survey (i.e. patients who are non-verbal, who are unable to be surveyed due to a medical or psychiatric reason, who are unable to be surveyed due to a language barrier, have not provided contact information or who decline to be surveyed) ",None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI50,Application of Lung-Protective Ventilation during General Anesthesia,"Percentage of patients, aged 18 years and older, who undergo general anesthesia care that includes an endotracheal tube who had a median exhaled tidal volume less than or equal to 10 mL/kg of predicted-body-weight (PBW) during positive pressure ventilation (PPV). ",Effective Clinical Care,"Patients who had a median exhaled tidal volume less than or equal to 10 mL/kg of predicted-body-weight (PBW) during positive pressure ventilation (PPV). + + Numerator Note: Positive pressure ventilation strategies include conservative tidal volume, lower peak airway pressures, positive end-expiratory pressure (PEEP) and lung-recruitment interventions to prevent atelectasis. ","Number of patients, aged 18 years and older, who undergo general anesthesia care that includes an endotracheal tube. ","Denominator Exclusions +• Patients continuously receiving inhaled medications (e.g. inhaled epoprostenol or nitric oxide) +• Patients with a diagnosis of pulmonary hypertension +• Patients who require hyperventilation for therapeutic reasons (e.g. elevated intracranial pressure, malignant hyperthermia, or thyroid storm)",None,None,N/A,N/A,Intermediate Outcome,,Intermediate Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI51,Assessment of Patients for Obstructive Sleep Apnea,"Percentage of patients, aged 18 years and older, who underwent an elective procedure under anesthesia who were screened preoperatively for Obstructive Sleep Apnea (OSA) using a standardized tool prior to the procedure",Patient Safety,"Patients who are screened preoperatively for Obstructive Sleep Apnea (OSA) using a standardized tool prior to the surgical procedure. + Numerator Note: High-risk is defined by screening tool utilized. Standardized tools for Obstructive Sleep Apnea include STOP-Bang Questionnaire, Berlin Questionnaire, P-SAP Score and the ASA OSA Patient Screening Tool Checklist. Although it is preferable to use one of the standardized tools listed above, at a minimum an assessment tool must assess the following components: snoring, daytime tiredness, breathing obstruction and hypertension. + Numerator Note: Obstructive Sleep Apnea assessment can be conducted by a physician anesthesiologist, other qualified anesthesia provider or proxy. ","Patients, aged 18 years and older, who underwent an elective procedure* under anesthesia. + Definition: *Any procedure including surgical, therapeutic or diagnostic ","Denominator Exclusions +• Patients with previous diagnosis for Obstructive Sleep Apnea (OSA) +• Patients receiving CPAP treatment +• Mechanically ventilated patients +• Intubated patients",None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI42,Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure - INVERSE MEASURE,Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis,Effective Clinical Care,"Patients who develop postoperative renal failure or require dialysis. + + Definition: Kidney failure is defined as either: (1) a level of GFR to <15 mL/min/1.73 m2, which is accompanied in most cases by signs and symptoms of uremia, or (2) a need for initiation of kidney replacement therapy (dialysis or transplantation) for treatment for complications of decreased GFR, which would otherwise increase the risk of mortality and morbidity. ","All patients, aged 18 years and older, undergoing isolated CABG surgery ","Denominator Exclusions +• Organ donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI18,Coronary Artery Bypass Graft (CABG): Prolonged Intubation - INVERSE MEASURE,Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours,Effective Clinical Care,Patients undergoing isolated CABG who require intubation > 24 hours following exit from the operating room,"All patients, aged 18 years and older, undergoing isolated CABG surgery","Denominator Exclusions +• Organ donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI41,Coronary Artery Bypass Graft (CABG): Stroke - INVERSE MEASURE,Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke that did not resolve within 24 hours,Effective Clinical Care,"Patients undergoing isolated CABG surgery who have a postoperative stroke + + Definition: A stroke is the sudden death of neurons in a localized area of brain due to inadequate blood flow that produces motor, sensory, or cognitive dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory) that persists for more than 24 hours. ","All patients, aged 18 years and older, undergoing isolated CABG Surgery ","Denominator Exclusions +• Organ donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI28,New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care,"Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to anesthesia end time. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury prior to anesthesia end time**. + Definition: A corneal injury is either a corneal abrasion (a scratch or scrape on the cornea, the clear front window of the eye that transmits and focuses light into the eye) or exposure keratitis (inflammation of the cornea from drying of the corneal tear film). Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded. + ** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. ","All patients, aged 18 and older, who undergo anesthesia care*, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery. + +Definition: * Anesthesia care includes general, regional and monitored anesthesia care.","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury before anesthesia care. +• Patient is sedated pharmacologically at the time of PACU discharge +• Patient has a co-occurring condition that limits their ability to communicate at the time of PACU discharge (e.g. severe dementia, developmental delay, mechanical ventilation) +• Patient bypassed PACU care + + Denominator Note: Measure not applicable to anesthesia care described by code 00300 when the underlying surgical procedure is described by CPT Codes: 67800, 67801, 67805, 67808, 67810, 67840, 67850, 67875, 67900, or 67938. ",None,None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI34,Perioperative Cardiac Arrest - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time ",Patient Safety,"Patients who experienced an unanticipated cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time**. + + Definition: Cardiac arrest is the unplanned cessation of the mechanical activity of the heart as confirmed by the absence of signs of effective circulation. Cardiac compression and/or defibrillation may be required for treatment. + + ** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. ","All patients, regardless of age, who undergo a procedure* under anesthesia. +Definition: *Any procedure including surgical, therapeutic or diagnostic +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Cases with a documented planned cardiac arrest (i.e., use of CPT Code 99116 for deep hypothermia) ",None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI35,Perioperative Mortality Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time. ",Patient Safety,"Patients who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** + + Definition: Death or mortality is defined as the irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration and brain activity; the end of life. + + ** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. ","All patients, regardless of age, who undergo a procedure* under anesthesia. +Definition: *Any procedure including surgical, therapeutic or ","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI31,Postanesthesia Care Unit (PACU) Re-intubation Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge. ",Patient Safety,"Patients who required re-intubation in the postanesthesia care unit + + Definition: Reintubation is defined as the need to insert an endotracheal tube resulting from the inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway. ","All patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or postanesthesia care unit. ","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who bypassed PACU care +• Patient received a planned trial of extubation documented in the medical record prior to removal of the original airway device ",None,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI29,Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics),"Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post- operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively + + Definition: The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk of POV include (but may not be limited to): +• 5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for prophylaxis for POV in children) +• Dexamethasone +• Antihistamines +• Butyrophenones + + The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications. ","All patients, aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV. + + Denominator Definition: Risk factors for POV are: +• Surgery ≥ 30 minutes +• Age ≥ 3 years +• Strabismus surgery +• History of POV or PONV in parent or sibling","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Cases in which an inhalational anesthetic is used only for induction "," Denominator Exception: +• Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (e.g. intolerance or other medical reason) ",None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI32,Procedural Safety for Central Line Placement,"Percentage of patients, regardless of age, who underwent a central venous cannulation insertion and did not experience a central line placement injury. ",Patient Safety,"Patients who did not experience a central line placement injury. + + Definition: A Central Line Placement Injury includes a pneumothorax, hemothorax or thoracic duct, cardiac or vascular injury that results from an attempted or completed insertion of a central venous catheter. + + Numerator Note: The measure should be reported as “Performance Not Met” for patients whom central venous catheter (CVC) with documented arterial injury (from the medical record or PSI code) or pneumothorax (512.89) requiring thoracostomy placement. For this indicator, the trauma can only be attributed to the attempted placement of central venous line by the anesthesia team and cannot be attributed to other causes. ","All patients, regardless of age, who undergo central venous cannulation insertion.","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI37,Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia,"Percentage of patients, regardless of age, who undergo a surgical procedure under general anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of general anesthesia. ",Patient Safety,"Patients who have documentation that all applicable safety checks of the WHO Surgical Safety Checklist (or other surgical checklist that includes the safety checks for specific procedure) were performed before induction of general anesthesia. + + Definition: + The WHO Surgical Safety Checklist includes the following items + + Before Induction of Anesthesia +• Has the patient confirmed his/her identity, site, procedure and consent? +• Is the site marked? +• Is the anesthesia machine and medication check complete? +• Is the pulse oximeter on the Patient And Functioning? +• Does the Patient have a: + o Known Allergy? + o Difficult Airway/Aspiration Risk? + o Risk of >500 ml Blood Loss (7ml/kg in children)? ","All patients, regardless of age, who undergo a surgical procedure under general anesthesia ","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6169123,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR),AQI52,Treatment of Hyperglycemia with Insulin,"The percentage of patients, aged 18 years and older, who undergo elective inpatient surgery and who have a blood glucose level of > 200 mg/dL and who receive insulin prior to anesthesia end time. ",Effective Clinical Care,Patients who are administered insulin during anesthesia or PACU care after having a blood glucose level > 200 mg/dL,"Patients, aged 18 years and older, who undergo elective inpatient surgery under anesthesia and have a blood glucose level > 200 mg/dL prior to anesthesia end time*. + +*Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care.",None,"Denominator Exception: +• Patient did not receive insulin because of previous history of adverse reaction or documented allergy to insulin +",None,N/A,N/A,Intermediate Outcome,,Intermediate Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +8442265,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan),ASPIRE4,Administration of insulin or glucose recheck for patients with hyperglycemia,The percentage of cases with a perioperative glucose >200 mg/dL with administration of insulin or glucose recheck within 90 minutes of original elevated glucose measurement.,Effective Clinical Care,"1. Cases with administration of insulin within 90 minutes (either IV or sub Q routes) of glucose measurement greater than 200 mg/dL or +2. Cases with glucose level checks within 90 minutes of glucose measurement greater than 200 mg/dL ",All cases with glucose measurements greater than 200 mg/dL between Anesthesia Start time and Anesthesia End time.,"1. Outpatient cases with Anesthesia Start to Anesthesia end time less than 4 hours long +2. Glucose measurements > 200 mg/dL within 90 minutes before Anesthesia End. +3. Patients <12 years of age. +4. ASA 5 or 6 cases. +5. Obstetric Non-Operative Procedures- CPT 01958, 01960, 01967 +6. Obstetric Non-Operative Procedure Rooms (Rooms tagged as OB-GYN- Labor and Delivery) +7. Obstetric Non-Operative Procedures with Procedure Text: “Labor Epidural” +",None,None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan) +8442265,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan),ASPIRE3,Administration of Neostigmine before Extubation for Cases with Nondepolarizing Neuromuscular Blockade,"The percentage of cases with administration of neostigmine, Sugammadex, and/or edrophonium before extubation for cases with non-depolarizing neuromuscular blockade. ",Effective Clinical Care,"1. All cases with documentation of neostigmine, Sugammadex, and/or edrophonium BEFORE earliest extubation. +2. All cases with greater than 3 hours between last dose of non-depolarizing medication and extubation for patients >/= 12 years old. +3. All cases with greater than 2 hours between last dose of non-depolarizing medication and extubation for patients <12 years old. +4. All cases with acceleromyography ratio of >/=0.9 documented after last dose of NMB and before earliest extubation. +","All cases that received either by bolus or infusion a non-depolarizing neuromuscular blocker (NMB) AND were extubated post-operatively or in the PACU. The following NMBs were included: + 1. Atracurium + 2. Cisatracurium + 3. Pancuronium + 4. Rocuronium + 5. Vecuronium ","1. Cases that were not extubated in the immediate post-operative period +2. Cases where patients (age > 12) received only defasciculating doses of non-depolarizing neuromuscular blockers (Vecuronium 1 year old (CPT: 00562) +8. Cardiac surgery with hypothermic arrest (CPT: 00563) +9. CABG with pump (CPT: 00567) +10. Heart Transplant (CPT: 00580) +11. Cases where patients (age >12) received defasciculating doses of Vecuronium 1.00 within 72 hours postoperatively.,Effective Clinical Care,Cases without troponin I > 1.00 within 72 hours postoperatively,All anesthetic cases,"1. ASA 5 or 6 cases. +2. Outpatient Cases. +3. Cases with Troponin I >0.01 within 42 days prior to anesthesia start. +4. Cardiac cases (CPT: 00530, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00534). ",None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan) +8442265,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan),ASPIRE8,Core temperature measurement for all general anesthetics,The percentage of cases with increased risk of hypothermia that the anesthesia provider documented core temperature.,Effective Clinical Care,Cases with at least one core temperature documented between anesthesia start and anesthesia end.,Cases with primary anesthesia technique of general anesthesia,"1. Cases less than 30 minutes between Case Start and Case End. +2. ASA 5 or 6 cases. +3. MRI Cases (CPT: 01922). +4. Neuraxial anesthesia as primary technique. ",None,None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan) +8442265,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan),ASPIRE2,Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker,The percentage of cases with a documented Train of Four after the last dose of a non-depolarizing neuromuscular blocker.,Effective Clinical Care,"All cases with documentation of either a Train of Four count (1, 2, 3, or 4), sustained tetany, or TOF ratio provided by acceleromyography AFTER last dose or stopping of infusion of neuromuscular blocker. A Train of four value of '0' is accepted for cases in which Sugammadex is administered for reversal.","All cases that received either by bolus or infusion a non-polarizing neuromuscular blocker (NMB) AND were extubated post-operatively or in the PACU. The following NMBs were included: + 1. Atracurium + 2. Cisatracurium + 3. Pancuronium + 4. Rocuronium + 5. Vecuronium","1. Cases that were not extubated in the immediate post-operative period. + 2. ASA 5 or 6 cases. + 3. Cardiac cases (CPT: 00560, 00561, 00562, 00563, 00567, 00580). + 4. Any cardiac case with an intraoperative note mapped to one of the following MPOG Concepts: + * 50399 Cardiopulmonary bypass- aortic clamp on/off note + * 50409 Cardiopulmonary bypass terminated + * 50410 Cardiopulmonary bypass initiated (full) + * 50416 Cardiopulmonary bypass- crossclamp and circulatory arrest time totals + * 50417 Cardiopulmonary bypass- Access cannula removed note + * 50714 Cardiopulmonary bypass- Bypass start/stop event +5. Cases performed by cardiac surgical service: MPOG concept: 80005. +6. Patients not given NMBs. ",None,None,1,N/A,Process,,,N,Y,N,N,N,No,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan) +8442265,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan),ASPIRE13,Transfusion goal of hematocrit less than 30 or hemoglobin less than 10.,"The percentage of cases where post-transfusion hematocrit is less than 30%, or hemoglobin less than 10. ",Efficiency and Cost Reduction,Cases with documented hematocrit less than 30 or hemoglobin less than 10 after last transfusion of red blood cells OR no hematocrit or hemoglobin checked within 6 hours of anesthesia end.,Cases in which a red blood cell transfusion is administered.,"1. Cases with 4 or more units of intraoperative PRBC transfused +2. EBL > 2000 ML for patients >/=12 years old. +3. EBL or PRBC transfusion > 30cc/kg for patients <12 years old. +4. Patients < 2 years of age. +5. ASA 5 and 6 cases. +6. Patients <12 years old undergoing a cardiac procedure (CPT: 00560, 00561, 00562, 00563, 00567, 00580). +",None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) (Regents of the University of Michigan) +9520371,"Blue Nine Systems, LLC",BNS1,Preoperative notification of risk of developing ischemic optic neuropathy (ION) during prone spine procedures,Percentage of postoperative development of ischemic optic neuropathy (ION) in prone spinal procedures with preoperative notification of risk factors,Effective Clinical Care,Prone spinal surgeries reviewed preoperatively as high-risk for ION,"Prone spinal surgeries exhibiting one of the four risk factors for ION: +1. Vascular risk factors (HTN, CAD, smoking) +2. Procedures > 6.5 hours +3. Preoperative anemia (< 10 mg/dL) +4. Anticipated substantial intraoperative blood loss",Patients with preexisting visual loss,None,None,1,N/A,Process,,,Y,Y,N,N,N,No,"Blue Nine Systems, LLC" +2217612,Cleveland Clinic OME,"CCOME1 +",1-Year Patient-Reported Pain and Function Improvement after Total Knee Arthroplasty,"Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL). ",Person and Caregiver-Centered Experience and Outcomes,Patients whose knee pain or function scores improved by at least one MCID (10 points on a 100-point scale) after one year.,"All patients 18 years of age and older undergoing primary TKA surgery who completed knee-related PROMs (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL) to measure knee pain and function up to 90 days prior to and at least one year after the surgery. ",Patients under 18 years of age; revision TKA surgery; knee pain and function PROMs not completed up to 90 days prior to and at least one year after surgery.,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Cleveland Clinic OME +2217612,Cleveland Clinic OME,CCOME2,1-Year Patient-Reported Pain and Function Improvement after Total Hip Arthroplasty,"Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in hip pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total hip arthroplasty (THA) surgery. PROMs include hip-related measures of pain and function (HOOS-Pain, HOOS-PS, HOOS-JR). ",Person and Caregiver-Centered Experience and Outcomes,Patients whose hip pain or function scores improved by at least one MCID (10 points on a 100-point scale) after one year.,"All patients 18 years of age and older undergoing primary THA surgery who completed hip-related PROMs (HOOS-Pain, HOOS-PS, HOOS-JR) to measure hip pain and function up to 90 days prior to and at least one year after the surgery. ",Patients under 18 years of age; revision THA surgery; hip pain and function PROMs not completed up to 90 days prior to and at least one year after surgery.,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Cleveland Clinic OME +2217612,Cleveland Clinic OME,CCOME3,1-Year Patient-Reported Pain and Function Improvement after Total Shoulder Arthroplasty,"Percentage of patients 18 years of age and older who obtained at least a minimal clinically important difference (MCID) in shoulder pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include shoulder-related measures of pain and function (PSS-Pain, PSS-Function, PSS-Satisfaction). ",Person and Caregiver-Centered Experience and Outcomes,Patients whose shoulder pain or function scores improved by at least one MCID (10 points on a 100-point scale) after one year.,"All patients 18 years of age and older undergoing primary TSA surgery who completed shoulder-related PROMs (PSS-Pain, PSS-Function, PSS-Satisfaction) to measure shoulder pain and function up to 90 days prior to and at least one year after the surgery. ",Patients under 18 years of age; revision TSA surgery; shoulder pain and function PROMs not completed up to 90 days prior to and at least one year after surgery.,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Cleveland Clinic OME +2217612,Cleveland Clinic OME,CCOME4,1-Year Patient-Reported Pain and Function Improvement after ACLR Surgery,"Percentage of patients 13 years of age and older who obtained at least a minimal clinically important difference (MCID) in knee pain or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and at least one year after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include knee-related measures of pain and function (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL). ",Person and Caregiver-Centered Experience and Outcomes,Patients whose knee pain or function scores improved by at least one MCID (10 points on a 100-point scale) after one year.,"All patients 13 years of age and older undergoing primary ACLR surgery who completed knee-related PROMs (KOOS-Pain, KOOS-PS, KOOS-JR, KOOS-KRQoL) to measure knee pain and function up to 90 days prior to and at least one year after the surgery. ",Patients under 13 years of age; revision ACLR surgery; knee pain and function PROMs not completed up to 90 days prior to and at least one year after surgery.,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Cleveland Clinic OME +2217612,Cleveland Clinic OME,CCOME5,Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy,"Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher. ",Effective Clinical Care,Patients who do not have grade IV chondromalacia in more than one compartment.,All patients aged 45 and higher undergoing primary APM surgery.,Patients aged 44 and under; revision APM surgery; primary procedure other than APM.,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Cleveland Clinic OME +5688365,Code Technology,"CODE6 +",Improved Functional Outcome Assessment for Hip Replacement,Percentage of patients aged 18 years and older with primary hip replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary hip replacement procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary hip replacement procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE7,Improved Functional Outcome Assessment for Knee Replacement,Percentage of patients aged 18 years and older with primary knee replacement who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary knee replacement procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary knee replacement procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE1,Improved Global Physical Health Outcome Assessment for Shoulder Replacement,Percentage of patients aged 18 years and older with primary shoulder replacement who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary shoulder replacement procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.","Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary shoulder replacement procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE3,Improved Functional Outcome Assessment for Foot/Ankle Repair,Percentage of patients aged 18 years and older with primary foot/ankle repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary foot/ankle repair procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary foot/ankle repair procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE8,Improved Global Physical Health Outcome Assessment for Cervical Surgery,Percentage of patients aged 18 years and older with cervical surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary cervical surgery procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.","Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary cervical surgery procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE9,Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair,Percentage of patients aged 18 years and older with primary hand/wrist/elbow repair who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary hand/wrist/elbow repair procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.","Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary hand/wrist/elbow repair procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE5,Improved Global Physical Health Outcome Assessment for Spine Surgery,Percentage of patients aged 18 years and older with spine surgery who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary spine surgery procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.","Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary spine surgery procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE10,Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy,Percentage of patients aged 18 years and older with primary shoulder arthroscopy who completed baseline and follow-up (patient-reported) PROMIS Global 10 assessments that reported an improvement in global physical health.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary shoulder arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated an improvement of at least 10% in global physical health.","Patients with patient-reported PROMIS Global 10 assessment results not more than 180 days prior to the primary shoulder arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE11,Improved Functional Outcome Assessment for Knee Arthroscopy,Percentage of patients aged 18 years and older with primary knee arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary knee arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary knee arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE2,Improved Functional Outcome Assessment for ACL Repair,Percentage of patients aged 18 years and older with primary anterior cruciate ligament repair who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary anterior cruciate ligament repair procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary anterior cruciate ligament repair procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +5688365,Code Technology,CODE12,Improved Functional Outcome Assessment for Hip Arthroscopy,Percentage of patients aged 18 years and older with primary hip arthroscopy who completed baseline and follow-up (patient-reported) functional status assessments that reported a non-trivial improvement in functional status.,Person and Caregiver-Centered Experience and Outcomes,"Patients with patient-reported functional status assessment results not more than 180 days prior to the primary hip arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure that demonstrated at least a 10% increase in their functional outcomes.","Patients with patient-reported functional status assessment results not more than 180 days prior to the primary hip arthroscopy procedure, and at least 60 days and not more than 180 days after the procedure.",Patients with multiple traumas at the time of the procedure or patients with severe cognitive impairment.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Code Technology +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP6,Evaluation and Integration of anti-coagulant medication prior to surgery,Patients with Documented Evaluation and Integration of Anti-coagulant Medication Prior to Surgery,Patient Safety,Patients with complete evaluation of anti-coagulant medications prior to surgery documented in patient history,All cases in registry with documented surgery date,None,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP4,Persistent hypercalcemia,Patients with persistent elevated calcium after surgery,Effective Clinical Care,Patients with elevated Ca values (and unaltered pth values) designated by Clinical Concern for Persistent/Recurrent Hyperparathyroidism = Yes documented by 30 day post op,All cases of parathyoidectomy surgery for primary hyperparathyroidism as defined by preoperative disease characterstics diagnosis = Sporadic Primary Hyperparathyroidism,Hypercalcemia due to diagnoses other than hyperparathyroidism,None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP1,Post operative hypocalcemia after thyroidectomy surgery,The number or percent of patients with low calcium levels or negligible parathyroid hormone values reported at 30 days or more post op,Effective Clinical Care,"Cases with low lab values and/or need for replacement designated by ""Clinical Concern for Hypoparathyroidism = Yes"" present at 30 day post op or any longitudinal period following. Concern for hypoparathyroidism based on excess calcium and/or vitamin D supplementation that is increased in intensity or duration over routine prophylactic supplementation; low calcium and/or PTH levels. Low defined as below lower end of normal value. ",All cases of thyroid surgery,None,None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP3,Pre operative ultrasound exam of patients with thyroid cancer,Documentation of use and efficacy of complete pre op cervical ultrasound exam in cancer patients,Effective Clinical Care,Patients with documented cervical ultrasound exams completed preoperative,All patients with diagnosis of thyroid cancer seen preoperative,None,patients whose clinical course demands expedited operative intervention,None,N/A,N/A,Process,,,N,Y,N,N,N,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP5,Related readmission for adrenal related problems,"Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: + 1. Hematoma + 2. Adrenal Insufficiency + 3. Hypertension + 4. Pain + 5. Wound Infection + 6. Pneumonia + 7. Dehydration + 8. Respiratory Distress ",Effective Clinical Care,Patients where readmission within 30 days of index surgery is yes AND reason is an adrenal related problem,All cases of adrenalectomy surgery,None,None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +9978062,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix",CESQIP2,Related readmission for thyroid or parathyroid related problems,"Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: + 1. Hypocalcemia + 2. Hematoma + 3. Seroma + 4. Wound infection + 5. Rash + 6. Dehydration + 7. Lymphatic or thoracic duct leak + 8. Suspected recurrent laryngeal nerve neuropraxia or voice hoarseness + 9. Dysphagia + 10. Pain + 11. Tracheal injury or perforation + 12. Esophageal injury or perforation + 13. Lower extremity complication (Phlebitis) + 14. Deep venous thrombosis + 15. Pulmonary embolism (including respiratory distress) + 16. Pulmonary (asthma, URI, pneumonia) + 17. Gastrointestinal (diarrhea, constipation, SBO) + 18. Nausea and/or vomiting + 19. Genitourinary (UTI, urinary retention) + 20. Myocardial Event (Atrial fib, CHF, MI, CVA) + 21. Psychiatric/Neurological (anxiety, syncope, dizziness) ",Effective Clinical Care,Patients where readmission within 30 days of index surgery is yes AND reason is a thyroid OR parathyroid related problem,All cases of thyroid OR parathyroid surgery,None,None,None,N/A,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,"Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) QCDR, powered by ArborMetrix" +8906378,Consortium for Universal Health System Metrics,CUHSM3,"CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)","•Adult Primary Care Survey: 37 core and 64 supplemental question survey of adult outpatient primary care patients. + Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. + Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. + Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians ",Person and Caregiver-Centered Experience and Outcomes,"The top box numerator for the Overall Rating of Provider is the number of respondents who answered 9 or 10 for the item, with 10 indicating “Best provider possible”. ",The measure’s denominator is the number of survey respondents. The target populations for the surveys are patients who have had at least one visit to the selected provider in the target 12-month time frame. This time frame is also known as the look back period. The sampling frame is a person-level list and not a visit-level list.,"The following are excluded when constructing the sampling frame: +• Patients that had another member of their household already sampled. +• Patients who are institutionalized (put in the care of a specialized institution) or deceased.",None,None,1,N/A,Patient Engagement/Experience,High Priority,,N,N,N,N,Y,No,Consortium for Universal Health System Metrics +8906378,Consortium for Universal Health System Metrics,CUHSM4,CAHPS Health Plan Survey v 4.0 - Adult questionnaire,"30-question core survey of adult health plan members that assesses the quality of care and services they receive. Level of analysis: health plan – HMO, PPO, Medicare, Medicaid, commercial ",Person and Caregiver-Centered Experience and Outcomes,The top box numerator for each of the four Overall Ratings items is the number of respondents who answered 9 or 10 for the item; with a 10 indicating the “Best possible.”,The measure’s denominator is the number of survey respondents who answered the question. The target population for the survey includes all individuals who have been enrolled in a health plan for at least 6 (Medicaid) or 12 (Commercial) months with no more than one 30-day break in enrollment. Denominators will vary by item and composite.,"Individuals are excluded from the survey target population if: + 1) They were not continuously enrolled in the health plan (excepting an allowable enrollment lapse of less than 30 days). + 2) Their primary health coverage is not through the plan. + 3) Another member of their household has already been sampled. + 4) They have been institutionalized (put in the care of a specialized institution) or are deceased.",None,None,1,N/A,Patient Engagement/Experience,High Priority,,N,N,N,N,Y,No,Consortium for Universal Health System Metrics +8906378,Consortium for Universal Health System Metrics,CUHSM6,Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder,Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).,Patient Safety,Individuals with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and have a PDC of at least 0.8 for mood stabilizer medications.,Individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder and at least two prescription drug claims for mood stabilizer medications during the measurement period (12 consecutive months).,None,None,None,1,N/A,Process,High Priority,,N,N,N,N,Y,Yes,Consortium for Universal Health System Metrics +8906378,Consortium for Universal Health System Metrics,CUHSM8,Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications,The percentage of individuals 25 to 75 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year.,Patient Safety,Individuals who had one or more LDL-C screenings performed during the measurement year.,Individuals ages 25 to 75 years of age by the end of the measurement year with a diagnosis of schizophrenia or bipolar disorder who were prescribed any antipsychotic medication during the measurement year.,"Individuals are excluded from the denominator if they were discharged alive for a coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) (these events may occur in the measurement year or year prior to the measurement year), or diagnosed with ischemic vascular disease (IVD) (this diagnosis must appear in both the measurement year and the year prior to the measurement year), chronic heart failure, or had a prior myocardial infarction (identified in the measurement year or as far back as possible).",None,None,1,N/A,Process,High Priority,,N,N,N,N,Y,No,Consortium for Universal Health System Metrics +6775913,ePreop Inc.,AQI29,Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics),"Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively + +Definition: The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk of POV include (but may not be limited to): +• 5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for prophylaxis for POV in children) +• Dexamethasone +• Antihistamines +• Butyrophenones + +The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications. + +","All patients, aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV. + +Denominator Definition: Risk factors for POV are: +* Surgery ≥ 30 minutes +* Age ≥ 3 years +* Strabismus surgery +* History of POV or PONV in parent or sibling + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Cases in which an inhalational anesthetic is used only for induction ","Denominator Exception: +• Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (e.g. intolerance or other medical reason) ",None,1,1,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI34,Perioperative Cardiac Arrest,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time ",Patient Safety,"Patients who experienced an unanticipated cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time**. + +Definition: Cardiac arrest is the unplanned cessation of the mechanical activity of the heart as confirmed by the absence of signs of effective circulation. Cardiac compression and/or defibrillation may be required for treatment.i + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care.i + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +10A32 Patient experienced an unanticipated cardiac arrest +OR +Performance Not Met: +10A33 Patient did not experience unanticipated cardiac arrest","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic + +Denominator Criteria (Eligible Cases): +All patients, regardless of age +AND +Patient encounter during the reporting period (CPT): +00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00566, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Cases with a documented planned cardiac arrest (i.e., use of CPT Code 99116 for deep hypothermia)",None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI35,Perioperative Mortality Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure* under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.",Patient Safety,"Patients who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** + +Definition: Death or mortality is defined as the irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration and brain activity; the end of life. + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. + +","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6",None,None,1,1,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI31,Postanesthesia Care Unit (PACU) Re-intubation Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge.",Patient Safety,"Patients who required re-intubation in the postanesthesia care unit + +Definition: Reintubation is defined as the need to insert an endotracheal tube resulting from the inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway + +","All patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or postanesthesia care unit. + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who bypassed PACU care +• Patient received a planned trial of extubation documented in the medical record prior to removal of the original airway device",None,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI32,Procedural Safety for Central Line Placement,"Percentage of patients, regardless of age, who underwent a central venous cannulation insertion and did not experience a central line placement injury.",Patient Safety,"Patients who did not experience a central line placement injury. + + Definition: A Central Line Placement Injury includes a pneumothorax, hemothorax or thoracic duct, cardiac or vascular injury that results from an attempted or completed insertion of a central venous catheter. + + Numerator Note: The measure should be reported as “Performance Not Met” for patients whom central venous catheter (CVC) with documented arterial injury (from the medical record or PSI code) or pneumothorax (512.89) requiring thoracostomy placement. For this indicator, the trauma can only be attributed to the attempted placement of central venous line by the anesthesia team and cannot be attributed to other causes. ","All patients, regardless of age, who undergo central venous cannulation insertion.","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6",None,None,1,1,Intermediate Outcome,High Priority,Intermediate Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI48,Anesthesia: Patient Experience Survey,"Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care ",Person and Caregiver-Centered Experience and Outcomes,"Patients who received a survey within 30 days of the procedure to assess their experience and satisfaction with anesthesia. + +Definition: Practices and eligible clinicians may customize their patient experience and satisfaction with anesthesia surveys to meet local needs but, at a minimum, surveys must include a core set of questions that address three of the four following criteria related to patient experience and satisfaction and one mandatory question described below. +1.Pre-operative Education and Preparation +2.Patient and/or Family Communication +3.Care Team Response to Comfort and Well-Being +4.Post-operative pain control and/or management + +Mandatory question that must be included in each survey (practices should also include an option for patient to indicate “Not Applicable”): +1.On a scale of 1 to 5, where 1 indicates the worst anesthesia experience and where 5 indicates the best anesthesia experience, how would you rate your overall anesthesia experience? + +Numerator Note: Practices and individual eligible clinicians who have contracted with or receive patient experience and satisfaction with anesthesia services via the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS®), CAHPS® Surgical Care Survey or other CAHPS survey fulfill the spirit of this measure and should report Performance Met for patients who received such surveys. + +Numerator Note:Practices and eligible clinicians may wish to supplement these questions by taking into consideration the recommendations of the ASA Committee on Performance and Outcomes Measurement work product entitled “Patient Satisfaction and Experience with Anesthesia.” + +Numerator Note: Depending on local practice, practices and eligible clinicians may wish to supplement survey questions by taking into consideration the recommendations developed as part of the Perioperative Surgical Home (PSH) that are structured in five distinct components. 1.Pre-Operative Education and Preparation (Four Indicators) +a. Patient comfort with instructions provided about eating better +b. Patient comfort with instructions provided about exercise or physical therapy +c. Patient comfort with instructions provided about stopping smoking (if applicable) +d. Patient comfort with instructions provided about what to do after surgery +2.Check-In and Pre-Procedure Experience +3. Caregiver and Family Communication during Surgery +4. Care Team Response to Comfort and Well-Being +5. Post-Operative Pain Management +For more information on these resources, visit https://www.asahq.org/psh. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: 10A12 Patient provided with a survey within 30 days of the procedure to assess their experience and satisfaction with anesthesia +OR +Denominator Exception 10A13 Documentation of patient reason(s), process reason(s) or medical reason(s) for not receiving survey (i.e. patients who are non-verbal, who are unable to be surveyed due to a medical or psychiatric reason, who are unable to be surveyed due to a language barrier, have not provided contact information or who decline to be surveyed) +OR +Performance Not Met: 10A14 Patient was not provided with a survey within 30 days of the procedure to assess their experience and satisfaction with anesthesia","Patients, aged 18 and older, who undergo a procedure* under anesthesia. +Definition: * Any procedure including surgical, therapeutic or diagnostic. + +Denominator Criteria (Eligible Cases): +Patients, aged 18 years and older, on date of encounter AND Patient encounter during the reporting period (CPT): +00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145,00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214,00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410,00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534,00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580,00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750,00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830,00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880,00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926,00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130,01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220,01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392,01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482,01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638,01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740,01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840,01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936,01951, 01952, 01953, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992, 20526, 20550, 20551, 20552, 20553, 20600, 20604, 20605, 20606, 20610, 20611, 27096, 36555, 36556, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 62263, 62264, 62270, 62272, 62273, 62280, 62281, 62282, 62310, 62311, 62318, 62319, 62350, 62355, 62360, 62361, 62362, 62365, 62370, 63650, 63661, 63662, 63663, 63664, 63685, 63688, 64400, 64402, 64405, 64408, 64410, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 64461, 64462, 64463, 64479, 64480, 64483, 64484, 64486, 64487, 64488, 64489, 64490, 64491, 64492, 64493, 64494, 64495, 64505, 64508, 64510, 64517, 64520, 64530, 64600, 64605, 64610, 64620, 64630, 64633, 64634, 64635, 64636, 64640, 64680, 64681, 72275,93503, 95990, 95991","Denominator Exclusions: +• Organ Donors as designated with ASA Physical Status 6 +• Patient died within 30 days of the procedure","Denominator Exception: +• Documentation of patient reason(s), process reason(s)or medical reason(s) for not receiving survey (i.e. patients who are non-verbal, who are unable to be surveyed due to a medical or psychiatric reason, who are unable to be surveyed due to a language barrier, have not provided contact information or who decline to be surveyed)",None,1,1,Patient Engagement/Experience,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI37,Surgical Safety Checklist: Applicable Safety Checks Completed Before Induction of Anesthesia,"Percentage of patients, regardless of age, who undergo a surgical procedure under general anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of general anesthesia. ",Patient Safety,"Patients who have documentation that all applicable safety checks of the WHO Surgical Safety Checklist (or other surgical checklist that includes the safety checks for specific procedure) were performed before induction of general anesthesia. + + Definition: + The WHO Surgical Safety Checklist includes the following items + + Before Induction of Anesthesia +• Has the patient confirmed his/her identity, site, procedure and consent? +• Is the site marked? +• Is the anesthesia machine and medication check complete? +• Is the pulse oximeter on the Patient And Functioning? +• Does the Patient have a: + o Known Allergy? + o Difficult Airway/Aspiration Risk? + o Risk of >500 ml Blood Loss (7ml/kg in children)? ","All patients, regardless of age, who undergo a surgical procedure under general anesthesia ","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6",None,None,1,1,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,AQI28,New Corneal Injury Not Diagnosed in the PACU/Recovery Area after Anesthesia Care,"Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to anesthesia end time.",Person and Caregiver-Centered Experience and Outcomes,"Patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury prior to anesthesia end time**. + +Definition: A corneal injury is either a corneal abrasion (a scratch or scrape on the cornea, the clear front window of the eye that transmits and focuses light into the eye) or exposure keratitis (inflammation of the cornea from drying of the corneal tear film). Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded.i + +**Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care.i + +","All patients, aged 18 and older, who undergo anesthesia care*, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery. + +Definition: * Anesthesia care includes general, regional and monitored anesthesia care. + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury before anesthesia care. +• Patient is sedated pharmacologically at the time of PACU discharge +• Patient has a co-occurring condition that limits their ability to communicate at the time of PACU discharge (e.g. severe dementia, developmental delay, mechanical ventilation) +• Patient bypassed PACU care + +Denominator Note: Measure not applicable to anesthesia care described by code 00300 when the underlying surgical procedure is described by CPT Codes: 67800, 67801, 67805, 67808, 67810, 67840, 67850, 67875, 67900, or 67938.",None,None,1,1,Outcome,High Priority,Outcome,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +6775913,ePreop Inc.,EPREOP4,Short-term Pain Management/Maximum Pain Score,"The percentage of patients aged 18 years and older, admitted to the postoperative recovery area after undergoing a surgical procedure that required an anesthetic and had a maximum pain score of <8 out of 10.",Person and Caregiver-Centered Experience and Outcomes,Number of denominator eligible patients with a maximum pain score of <8 out of 10,All patients aged 18 years and older admitted to the postoperative recovery area after undergoing a surgical procedure requiring anesthesia.,None,Patient not lucid/chronic pain/major psychiatric disorder/language barrier,None,1,1,Outcome,High Priority,Outcome,N,Y,N,N,N,No,ePreop Inc. +6775913,ePreop Inc.,EPREOP9,Prophylactic Antibiotic Administration,Percentage of patients for whom the administration of an indicated and ordered prophylactic antibiotic is initiated within one hour (or two hours for fluoroquinolone or vancomycin) prior to surgical incision.,Patient Safety,Number of denominator eligible patients for whom the administration of the antibiotic is initiated within one hour (or two hours for fluoroquinolone or vancomycin) prior to surgical incision.,All patients undergoing a scheduled surgical procedure for which anesthesia is required and a prophylactic antibiotic is both indicated and ordered,Emergent anesthesia cases 99140,"Medical exclusion (allergy, etc.)",None,1,1,Process,High Priority,,N,Y,N,N,N,No,ePreop Inc. +6775913,ePreop Inc.,EPREOP14,Dental Injury,"Percentage of anesthesia patients who experience chipped, broken, loose, or dislodged teeth following insertion or removal of any of the following airway devices (laryngoscope, video laryngoscopy, supraglottic devices or fiberoptic intubating device).",Patient Safety,"Number of denominator eligible patients who experience chipped, broken, loose, or dislodged teeth","All patients undergoing a scheduled surgical procedure where any of the following airway devices (laryngoscope, video laryngoscopy, supraglottic devices or fiberoptic intubating device) are inserted and/or removed while under direct anesthesia supervision",Emergent anesthesia cases 99140,None,None,1,1,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,ePreop Inc. +6775913,ePreop Inc.,EPREOP26,Ultrasound Guidance for Central Venous Catheter Placement,"Percentage of patients who undergo central venous catheterization for whom ultrasound guidance is used for vessel localization and venipuncture, and documented in the medical record.",Patient Safety,Number of denominator eligible patients for whom ultrasound guidance is used for vessel localization and venipuncture and documented in the medical record.,All patient who undergo central venous catheterization,"Emergent anesthesia cases 99140, organ donors/ASAPS 6","Medical exclusion, equipment unavailable",None,1,1,Process,High Priority,,N,Y,N,N,N,No,ePreop Inc. +6775913,ePreop Inc.,EPREOP27,Ultrasound Guidance for Peripheral Nerve Block,"Percentage of patients, aged 18 years and older, who undergo upper or lower extremity peripheral nerve blockade, and for whom ultrasound guidance is used and documented in the medical record. ",Patient Safety,Number of denominator eligible patients for whom ultrasound guidance is used and documented in the medical record.,All patients aged 18 years and older who undergo upper or lower extremity peripheral nerve blockade.,"Emergent anesthesia cases 99140, organ donors/ASAPS 6","Medical exclusion, patient refusal, provider unfamiliar with technique",None,1,1,Process,High Priority,,N,Y,N,N,N,No,ePreop Inc. +1546118,FORCE-QI,FORCE4,Improvement in Function after Knee Replacement,"Percentage of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or KOOS physical function score. ",Effective Clinical Care,Number of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who completed a pre-operative and follow-up (patient reported) functional status assessment and had improvement greater than or equal to 5 point increase from pre-operative functional status measure.,Number of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year.,Emergent (non-elective) TKA,Patients with a date of surgery in the last 3 months of the year as there would be insufficient time to collect follow-up functional status assessment.,None,1,N/A,Outcome,,Outcome,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE5,Improvement in Pain after Knee Replacement,"Percentage of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who had with a KOOS pain assessment score greater than 70 post-operatively, measured by the KOOS pain assessment score. ",Effective Clinical Care,"Number of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year who completed a follow-up (patient reported) KOOS pain assessment score and that score was greater than 70 post-operatively, as measured by the KOOS pain assessment score. ",Number of patients aged 18 years or older with an elective primary total knee arthroplasty (TKA) in the first 9 months of the year.,Emergent (non-elective) TKA,Patients with a date of surgery in the last 3 months of the year as there would be insufficient time to collect follow-up functional status assessment.,None,1,N/A,Outcome,,Outcome,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE9,Improvement in Function after Hip Replacement," Percentage of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who had improvement (greater than or equal to 5 point increase from pre-operative functional status measure) in their functional status assessment post-operatively, measured by the PCS and/or HOOS physical function score. ",Effective Clinical Care,Number of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who completed a pre-operative and follow-up (patient reported) functional status assessment and had improvement greater than or equal to 5 point increase from pre-operative functional status measure.,Number of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year,Emergent (non-elective) THA,Patients with a date of surgery in the last 3 months of the year as there would be insufficient time to collect follow-up functional status assessment.,None,1,N/A,Outcome,,Outcome,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE10,Measure Improvement in Pain after Hip Replacement,"Percentage of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who had with a HOOS pain assessment score greater than 70 post-operatively, measured by the HOOS pain assessment score. ",Effective Clinical Care,"Number of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year who completed a follow-up (patient reported) HOOS pain assessment score and that score was greater than 70 post-operatively, as measured by the HOOS pain assessment score. ",Number of patients aged 18 years or older with an elective primary total hip arthroplasty (THA) in the first 9 months of the year,Emergent (non-elective) THA,Patients with a date of surgery in the last 3 months of the year as there would be insufficient time to collect follow-up functional status assessment.,None,1,N/A,Outcome,,Outcome,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE17,Functional Status Assessment for Patients with musculoskeletal disease,Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported functional status assessments,Person and Caregiver-Centered Experience and Outcomes,Number of patients aged 18 years or older with musculoskeletal disease who completed at least 1 (patient reported) functional status assessment in a given year.,Number of patients aged 18 years or older with musculoskeletal disease seen in a given year.,Patients being seen for an issue other than musculoskeletal disease,None,None,1,N/A,Process,High Priority,,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE18,Pain Status Assessment for Patients with musculoskeletal disease,Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported pain status assessments,Person and Caregiver-Centered Experience and Outcomes,Number of patients aged 18 years or older with musculoskeletal disease who completed at least 1 (patient reported) pain status assessment in a given year.,Number of patients aged 18 years or older with musculoskeletal disease seen in a given year.,Patients being seen for an issue other than musculoskeletal disease.,None,None,1,N/A,Process,High Priority,,N,N,N,Y,N,No,FORCE-QI +1546118,FORCE-QI,FORCE19,Mental Health Assessment for Patients with orthopedic conditions,Percentage of patients 18 years of age and older with musculoskeletal disease who completed baseline and follow-up patient-reported Mental Health assessments,Person and Caregiver-Centered Experience and Outcomes,"Number of patients aged 18 years or older with orthopedic conditions who completed at least 1 (patient reported) mental health assessment in a given year, measured by the MCS score. ",Number of patients aged 18 years or older with orthopedic conditions seen in a given year.,Patients being seen for an issue other than orthopedic conditions.,None,None,1,N/A,Process,High Priority,,N,N,N,Y,N,No,FORCE-QI +5846856,GI Quality Improvement Consortium (GIQuIC),GIQIC15,Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients,"Percentage of average-risk patients aged 50 years and older receiving a screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas, Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component), Sessile serrated polyp ≥ 10 mm OR sessile serrate polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy ",Communication and Care Coordination,"Number of average-risk patients aged 50 years and older receiving a complete and adequately prepped screening colonoscopy with biopsy or polypectomy and pathology findings of 3-10 adenomas OR Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component) OR Sessile serrated polyp ≥ 10 mm OR sessile serrated polyp with dysplasia OR + traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy ","All complete and adequately prepped screening colonoscopies of average-risk patients aged 50 years and older with biopsy or polypectomy and pathology findings of 3-10 adenomas, OR Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component) OR Sessile serrated polyp ≥ 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated + adenoma ",None,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,GI Quality Improvement Consortium (GIQuIC) +5846856,GI Quality Improvement Consortium (GIQuIC),GIQIC12,Appropriate indication for colonoscopy,Percentage of colonoscopy procedures performed for an indication that is included in a published standard list of appropriate indications and the indication is documented,Effective Clinical Care,Number of colonoscopies performed for an indication that is included in a published standard list of appropriate indications,All colonoscopies,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,GI Quality Improvement Consortium (GIQuIC) +5846856,GI Quality Improvement Consortium (GIQuIC),GIQIC10,Appropriate management of anticoagulation in the peri-procedural period rate – EGD,Percentage of patients undergoing an EGD on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication,Communication and Care Coordination,Number of patients on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication,All patients undergoing an EGD on an anti-platelet agent or an anticoagulant,None,None,None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,GI Quality Improvement Consortium (GIQuIC) +5846856,GI Quality Improvement Consortium (GIQuIC),NHCR4,Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation,Percentage of patients recommended for repeat screening or surveillance colonoscopy within one year or less due to inadequate/poor bowel preparation quality,Effective Clinical Care,Number of screening and surveillance colonoscopies with bowel preparation documented as inadequate/poor and whose recommended follow-up was ≤ 1 year,Number of screening and surveillance colonoscopies with bowel preparation documented as inadequate/poor,None,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,GI Quality Improvement Consortium (GIQuIC) +5657468,Hawkins Foundation,"HF1 +",Knee Arthroscopy for Meniscectomy,"The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscectomy. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscectomy. Isolated Meniscectomy during the reporting period CPT-4 Codes: 29880, 29881. Excluding concurrent with Anterior Cruciate Ligament Reconstruction (29888) and other concomitant procedures. Surgeons who performed a minimum of 25 meniscectomy procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent meniscectomy during the observation period. Patients receiving meniscectomy during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscectomy patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscectomy patients in the denominator. DENOMINATOR: The number of all patients who received meniscectomy during the observation window from the surgeon. Type of score: Validated knee measure change score average. Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscectomy patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscectomy patients treated by surgeon. Risk adjustment methods and variables: The predicted 6 month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscectomy surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline; 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months; 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score; Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure:  5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See attached for references...",Effective Clinical Care,Average 6-month knee measure change score for all meniscectomy patients treated by surgeon.,Average predicted 6-month knee measure change score for all meniscectomy patients treated by surgeon.,None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF2,Surgical Reconstruction for Anterior Cruciate Ligament (ACL) Injury,"The change in a validated knee measure score will be used as a performance measure for surgeons performing ACL reconstruction. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 procedure codes will be used to identify patients who received ACL reconstruction without treatment of chondral injury. ACL reconstruction during the reporting period CPT-4 Codes: 29888. Surgeons who performed a minimum of 25 ACL reconstructions a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent ACL reconstruction during the observation period. Patients receiving ACL reconstruction during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all ACL reconstruction patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all ACL reconstruction patients in the denominator. DENOMINATOR: The number of all patients who received ACL reconstruction during the observation window from the surgeon. Type of score: Validated knee measure change score average. Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all ACL reconstruction patients treated by surgeon. Risk adjustment methods and variables: The predicted 6 month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months. Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient. Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to ACL reconstruction surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline; 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months; 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score; Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure:  5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See attached for references...",Effective Clinical Care,Average 6-month knee measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient ACL reconstruction (CPT-4 code: 29888) treated by the surgeon.,Average predicted 6-month knee measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient ACL reconstruction (CPT-4 code: 29888) treated by the surgeon.,None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF3,Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder,"The change in a validated shoulder measure score will be used as a performance measure for surgeons performing labral reconstruction for shoulder instability. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. + +Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation (SANE) [1] + +Defining the population: +CPT-4 codes will be used to identify patients who received labral repair or reconstruction for shoulder instability. + +Labral repair or reconstruction for shoulder instability during the reporting period CPT-4 Codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662, excluding revisions (23450 and 23460). + +Surgeons who performed a minimum of 25 labral repair or reconstruction procedures a year will be eligible to submit this measure. +Time-period for data collection and reporting: +This measure will be calculated using all patients who underwent surgery for shoulder instability during the observation period. Patients receiving surgery for shoulder instability during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. + +Measures: +Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder instability patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. +Unadjusted measure: Average Shoulder Measure Change Score ",Effective Clinical Care,"Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: +Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient labral reconstruction for shoulder instability (CPT-4 codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662).Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient labral reconstruction for shoulder instability (CPT-4 codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662). + +Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: +Average 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient labral reconstruction for shoulder instability (CPT-4 codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662) treated by the surgeon.","Unadjusted measure: Average Shoulder Measure Change Score DENOMINATOR: +The total number of adult patients (>18 years of age) receiving inpatient or outpatient labral reconstruction for shoulder instability (CPT-4 codes 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662) from the surgeon during the observation window. + +Risk adjusted measure: Shoulder Measure Change Score Ratio DENOMINATOR: +Average predicted 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient labral reconstruction for shoulder instability (CPT-4 codes: 29806, 29807, 23450, 23455, 23460, 23462, 23465, 23466, 23462, 29806, 23455, 23466, 23662) treated by the surgeon.",None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF4,Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy,"The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroscopy which includes rotator cuff debridement, biceps tenodesis and acromioplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1]. Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroscopy surgery. Shoulder arthroscopy during the reporting period CPT-4 Codes: 29822, 29823, 29826, 29828, 23430, 29999. Surgeons who performed a minimum of 25 shoulder arthroscopy procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroscopy during the observation period. Patients receiving shoulder arthroscopy during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroscopy patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score. NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroscopy patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroscopy during the observation window from the surgeon. Type of score: Validated shoulder measure change score average. Risk adjusted measure: Shoulder Measure Change Score Ratio. NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroscopy patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6]. Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, concomitant shoulder procedures, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroscopy surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5.A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8.The ratio scores for all surgeons in the database are ranked. See Attachment for References.",Effective Clinical Care,"Unadjusted measure: Average Shoulder Measure Change Score +NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroscopy (CPT-4 codes: 29822, 29823, 29826, 29828, 23430, 29999). + +Risk adjusted measure: Shoulder Measure Change Score Ratio +NUMERATOR: Average 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroscopy (CPT-4 codes: 29822, 29823, 29826, 29828, 23430, 29999) treated by the surgeon.","Unadjusted measure: Average Shoulder Measure Change Score +DENOMINATOR: The total number of adult patients (>18 years of age) receiving inpatient or outpatient shoulder arthroscopy (CPT-4 codes: 29822, 29823, 29826, 29828, 23430, 29999) from the surgeon during the observation window. + +Risk adjusted measure: Shoulder Measure Change Score Ratio +DENOMINATOR: Average predicted 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroscopy (CPT-4 codes: 29822, 29823, 29826, 29828, 23430, 29999) treated by the surgeon.",None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF5,Shoulder Arthroplasty: Change in a Validated Shoulder Patient Reported Outcome Measure Following Shoulder Arthroplasty,"The change in a validated shoulder measure score will be used as a performance measure for surgeons performing shoulder arthroplasty which includes hemiarthroplasty, total anatomical and reverse arthroplasty procedures. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received shoulder arthroplasty surgery. Shoulder arthroplasty during the reporting period CPT-4 Codes: 23470, 23472 (excluding 23 473 and 23474). Surgeons who performed a minimum of 25 shoulder arthroplasty procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent shoulder arthroplasty during the observation period. Patients receiving shoulder arthroplasty during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month shoulder measure change score across all shoulder arthroplasty patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all shoulder arthroplasty patients in the denominator. DENOMINATOR: The number of all patients who received shoulder arthroplasty during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all shoulder arthroplasty patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. Type of score: Ratio score Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 months. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, fracture, glenoid type, arthroplasty type (reverse vs. traditional total, hemi), the baseline shoulder measure, and baseline measures of pain, shoulder function, and quality of life.[2-6] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to shoulder arthroplasty surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.",Effective Clinical Care,"Unadjusted measure: Average Shoulder Measure Change Score +NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroplasty (CPT-4 codes: 23470, 23472). + +Risk adjusted measure: Shoulder Measure Change Score Ratio +NUMERATOR: Average 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroplasty (CPT-4 codes: 23470, 23472) treated by the surgeon.","Unadjusted measure: Average Shoulder Measure Change Score +DENOMINATOR: The total number of adult patients (>18 years of age) receiving inpatient or outpatient shoulder arthroplasty (CPT-4 codes: 23470, 23472) from the surgeon during the observation window. + +Risk adjusted measure: Shoulder Measure Change Score Ratio +DENOMINATOR: Average predicted 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient shoulder arthroplasty (CPT-4 codes: 23470, 23472) treated by the surgeon.",None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF6,Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair,"The change in a validated knee measure score will be used as a performance measure for surgeons performing knee arthroscopy for meniscal repair. Two measures will be created and reported by each surgeon. Surgeons will report the average knee measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted knee measure change score ratio by dividing the average patient knee measure change score by the average predicted patient knee measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated knee patient reported outcome measures include: International Knee Documental Committee (IKDC) Subjective Knee Form (Pedi-IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE) [1]Defining the population: +CPT-4 procedure codes will be used to identify patients who received knee arthroscopy for meniscal repair. Meniscal repair during the reporting period CPT-4 Codes: 29882, 29883. Excluding concurrent procedures including Anterior Cruciate Ligament Reconstruction (29888). Surgeons who performed a minimum of 25 meniscal repair procedures a year will be eligible to submit this measure.Time period for data collection and reporting: +This measure will be calculated using all patients who underwent meniscal repair during the observation period. Patients receiving meniscal repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the knee measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6-month knee measure change score across all meniscal repair patients treated by the surgeon. The adjusted measure will be the ratio of the average knee measure change score divided by the average predicted knee measure change score for all patients treated by the surgeon. Unadjusted measure: Average Knee Measure Change Score. NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all meniscal repair patients in the denominator. DENOMINATOR: The number of all patients who received meniscal repair during the observation window from the surgeon. Type of score: Validated knee measure change score average; Risk adjusted measure: Knee Measure Change Score Ratio. NUMERATOR: Average 6-month knee measure change score for all meniscal repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month knee measure change score for all meniscal repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month knee measure change scores are estimated for each patient using the Center for Effectiveness Research in Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. +Type of score: Ratio score +Interpretation of score: +Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had knee change scores higher than average. Surgeons with ratios scores less than 1 had knee change scores lower than average given the characteristics of their patients. Definitions: +Patient’s Knee Measure Score: A knee measure score is produced when the patient answers a validated knee assessment administered in the clinic or through an online portal. +Patient’s Knee Measure Change Score: A patient’s change score is calculated by subtracting the patient’s knee measure score at baseline from the patient’s knee measure score at 6 months.Patient’s Knee Measure Predicted Adjusted Change Score: Knee measure change scores for patients are risk adjusted using a regression model that includes the following independent variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, history or prior knee surgery, sport participation/activity level, osteoarthritis, concomitant chondral injury, the baseline knee measure, and baseline measures of pain, knee function, and quality of life.[2-4] The patient’s predicted knee measure change score is the dependent variable. The regression model produces a risk-adjusted predicted knee measure change score for each patient.Risk-adjusted Knee Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted knee measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as knee measure change scores that were less than predicted given the risk-adjustment variables of the patient.The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to meniscal repair surgery the patient completes a baseline validated knee measure assessment which generates the patient’s knee measure score at baseline. 2. Six months after surgery, the patient completes the same validated knee measure assessment again, which generates the patient’s knee measure score at 6 months. 3. The patient’s raw, unadjusted knee measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ knee measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted knee measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted knee measure change scores are averaged by surgeon. 7. A risk-adjusted Knee Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. See attachment for references.",Effective Clinical Care,"Unadjusted measure: Average Knee Measure Change Score +NUMERATOR: Sum of knee measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient knee arthroscopy for meniscal repair (CPT-4 codes: 29882, 29883). + +Risk adjusted measure: Knee Measure Change Score Ratio +NUMERATOR: Average 6-month knee measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient knee arthroscopy for meniscal repair (CPT-4 codes: 29882, 29883) treated by the surgeon.","Unadjusted measure: Average Knee Measure Change Score +DENOMINATOR: The total number of adult patients (>18 years of age) receiving inpatient or outpatient knee arthroscopy for meniscal repair (CPT-4 codes: 29882, 29883) from the surgeon during the observation window. + +Risk adjusted measure: Knee Measure Change Score Ratio +DENOMINATOR: Average predicted 6-month knee measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient knee arthroscopy for meniscal repair (CPT-4 codes: 29882, 29883) treated by the surgeon. +",None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +5657468,Hawkins Foundation,HF7,Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair,"The change in a validated shoulder measure score will be used as a performance measure for surgeons performing rotator cuff repair. Two measures will be created and reported by each surgeon. Surgeons will report the average shoulder measure change score for patients treated during the observation period. In addition, surgeons will produce a risk-adjusted shoulder measure change score ratio by dividing the average patient shoulder measure change score by the average predicted patient shoulder measure change score calculated using the formula provided. These measures will serve as sports medicine performance measures at the eligible surgeon level. Eligible validated shoulder patient reported outcome measures include: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE) [1] Defining the population: CPT-4 codes will be used to identify patients who received a rotator cuff repair surgery. Arthroscopic rotator cuff repair during the reporting period CPT-4 Codes: 29827, 29826 Surgeons who performed a minimum of 25 rotator cuff repair procedures a year will be eligible to submit this measure. Time period for data collection and reporting: This measure will be calculated using all patients who underwent rotator cuff repair during the observation period. Patients receiving rotator cuff repair during the period 18 to 6 months prior to the reporting data will be included in the analysis to ensure 6 months of patient-reported follow-up in the shoulder measure score are available. Measures: Two surgeon-level performance measures will be reported. The unadjusted measure will be the average 6 month shoulder measure change score across all rotator cuff repair patients treated by the surgeon. The adjusted measure will be the ratio of the average shoulder measure change score divided by the average predicted shoulder measure change score for all patients treated by the surgeon. Unadjusted measure: Average Shoulder Measure Change Score NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6 month post-surgery across all rotator cuff repair patients in the denominator. DENOMINATOR: The number of all patients who received rotator cuff repair during the observation window from the surgeon. Type of score: Validated shoulder measure change score average Risk adjusted measure: Shoulder Measure Change Score Ratio NUMERATOR: Average 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. DENOMINATOR: Average predicted 6-month shoulder measure change score for all rotator cuff repair patients treated by surgeon. Risk adjustment methods and variables: The predicted 6-month shoulder measure change scores are estimated for each patient using the Center for Effectiveness Research In Orthopaedics’ (CERortho) risk adjustment regression model that includes the following patient variables: age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] Variables included in the current CERortho risk model are based on information in available databases. CERortho plans to constantly update these specified variables based on input from evaluated surgeons and specialty organizations. Appendix A contains the list of baseline concepts from the literature and American Academy of Orthopaedic Surgeons (AAOS) and peer-reviewed literature that are thought to affect outcomes of treatment and will be candidates for future inclusion in the model. [2, 3] Type of score: Ratio score; Interpretation of score: Surgeons with ratio scores equal to 1 have quality scores equal to the average surgeon given the characteristics of their patients. Surgeons with ratio scores greater than 1 had shoulder change scores higher than average. Surgeons with ratios scores less than 1 had shoulder change scores lower than average given the characteristics of their patients. Definitions: Patient’s Shoulder Measure Score: A shoulder measure score is produced when the patient answers a validated shoulder assessment administered in the clinic or through an online portal. Patient’s Shoulder Measure Change Score: A patient’s change score is calculated by subtracting the patient’s shoulder measure score at baseline from the patient’s shoulder measure score at 6 month. Patient’s Shoulder Measure Predicted Adjusted Change Score: Shoulder measure change scores for patients are risk adjusted using a regression model that includes the following independent variables age, gender, BMI, smoking status, comorbidities, worker’s compensation status, prior shoulder surgery, tear size, tendon quality, the baseline shoulder measure score, and baseline measures of pain, shoulder function, and quality of life. [2, 3] The patient’s predicted shoulder measure change score is the dependent variable. The regression model produces a risk-adjusted predicted shoulder measure change score for each patient. Risk-adjusted Shoulder Measure Change Score Ratio: The ratio between the actual change scores and the predicted change scores (after risk adjustment) is the ratio score. The risk-adjusted shoulder measure change score represents risk-adjusted change corrected for patient characteristics. A risk-adjusted ratio score of one or greater should be interpreted as change scores that were as good as or better than predicted given the risk-adjustment variables of the patient. Risk-adjusted ratio change scores less than one should be interpreted as shoulder measure change scores that were less than predicted given the risk-adjustment variables of the patient. The surgeon ratio scores can be used to make comparisons across surgeons. Steps: 1. Prior to rotator cuff repair surgery the patient completes a baseline validated shoulder measure assessment which generates the patient’s shoulder measure score at baseline. 2. Six months after surgery, the patient completes the same validated shoulder measure assessment again, which generates the patient’s shoulder measure score at 6 months. 3. The patient’s raw, unadjusted shoulder measure change score is generated by subtracting the baseline score from the 6-month score. Unadjusted measure: 4. Patients’ shoulder measure change scores are averaged by surgeon. Adjusted measure: 5. A risk-adjusted shoulder measure change score is predicted using the CERortho risk-adjustment regression model. 6. Patients’ unadjusted and adjusted shoulder measure change scores are averaged by surgeon. 7. A risk-adjusted Shoulder Measure Change Score Ratio is generated for each surgeon. 8. The ratio scores for all surgeons in the database are ranked. ",Effective Clinical Care,"Unadjusted measure: Average Shoulder Measure Change Score +NUMERATOR: Sum of shoulder measure change scores from pre-surgery to 6-months post-surgery across all adult patients (>18 years of age) undergoing inpatient or outpatient surgical rotator cuff repair (CPT-4 codes: 29827, 29826). + +Risk adjusted measure: Shoulder Measure Change Score Ratio +NUMERATOR: Average 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient surgical rotator cuff repair (CPT-4 codes: 29827, 29826) treated by the surgeon.","Unadjusted measure: Average Shoulder Measure Change Score +DENOMINATOR: The total number of adult patients (>18 years of age) receiving inpatient or outpatient surgical rotator cuff repair (CPT-4 codes: 29827, 29826) from the surgeon during the observation window. + +Risk adjusted measure: Shoulder Measure Change Score Ratio +DENOMINATOR: Average predicted 6-month shoulder measure change score for all adult patients (>18 years of age) undergoing inpatient or outpatient surgical rotator cuff repair (CPT-4 codes: 29827, 29826) treated by the surgeon.",None,None,None,1,N/A,Outcome,,Outcome,N,N,Y,Y,Y,No,Hawkins Foundation +9160056,HealthAdvanta,HAdv1,Use of high risk sleep medications in the elderly,Percentage of patients aged 65 years and older for whom a high risk sleep aid medication was prescribed for more than 30 days during the performance period,Patient Safety,"Patients aged 65 years and older who were prescribed one or more of the following sleep aid medications for more than 30 days during the performance period: +• Estazolam (ProSom) +• Eszopiclone (Lunesta) +• Ramelteon (Rozerem) +• Temazepam (Restoril) +• Triazolam (Halcion) +• Zaleplon (Sonata) +• Zolpidem (Ambien, Edluar, Intermezzo, Zolpimist) +• Zolpidem extended release (Ambien CR) + +Note: This is an inverse measure whereby the objective is to not prescribe high risk sleep medications to the elderly.","Age 65 years and older. +Ambulatory Evaluation and Management CPT code billed (99201 - 99215, 99341 ‑ 99350)",None,None,None,1,N/A,Process,High Priority,,Y,N,N,N,N,No,HealthAdvanta +9160056,HealthAdvanta,HAdv2,Atrial fibrillation (afib) prevention and treatment: Patients with afib who are assessed for lifestyle and disease factors that contribute to uncontrolled afib,Percentage of patients diagnosed with atrial fibrillation (afib) who are assessed for lifestyle and disease factors that contribue to uncontrolled atrial fibrillation at least once in the past 12 months,Effective Clinical Care,Patients for whom an afib lifestyle and contributing disease factor assessment was completed at least once during the previous 12 months,"Patients, regardless of age, diagnosed with atrial fibrillation during the performance year (ICD-10-CM codes: I48.0 Paroxysmal atrial fibrillation, I48.1 Persistent atrial fibrillation, I48.2 Chronic atrial fibrillation, I48.3 Typical atrial flutter, I48.4 Atypical atrial flutter, I48.91 Unspecified atrial fibrillation) seen for an ambulatory evalutaion and management service ( CPT 99201 - 99215, 99341 ‑ 99350)",None,None,None,1,N/A,Process,,,N,N,N,N,N,No,HealthAdvanta +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S16,Absence of unplanned reoperation after major lower extremity amputation,"The percentage of patients undergoing closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who do NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision. + + Rationale: Major closed amputations (below and above knee) can be complicated by infection, bleeding or failure to heal, resulting in unplanned reoperation, if the level and conduct of the initial procedure is not appropriate. This outcome measure appropriately identifies proper amputation level selection and proper surgical technique. ",Patient Safety,"All procedures captured in the Vascular Quality Initiative® Lower Extremity Amputation Registry where the patient was at least 18 years old at the time of the procedure and underwent closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease who did NOT have unplanned reoperation during the same admission for infection, bleeding or amputation revision during the reporting period. ","All procedures captured in the Vascular Quality Initiative® Lower Extremity Amputation Registry where the patient was at least 18 years old at the time of the procedure and underwent closed lower extremity major amputation (below, thru or above knee) for ischemic arterial disease during the reporting period.","To both numerator and denominator: Patients undergoing initial open amputation (who always require reoperation) and patients undergoing amputation for non-arterial etiologies, including trauma, neoplasm, infection and diabetic neuropathy without underlying arterial disease.",None,None,1,N/A,Outcome,High Priority,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S17,Absence of serious technical complications during peripheral arterial intervention,"The percentage of patients undergoing lower extremity interventional treatment for arterial occlusive disease (including balloon angioplasty, stenting and atherectomy) who do NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm, Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that require admission, or surgical or interventional treatment. + + Rationale: Avoiding technical complications is critical to patient safety during peripheral interventional procedures. The complications listed above can result in serious harm, so this outcome measure tracks an important safety issue. ",Patient Safety,"All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry where the patient was at least 18 years old at the time of the procedure and underwent peripheral arterial intervention (balloon angioplasty, stenting or atherectomy) of the lower extremity (abdominal aorta and more distal) arteries for treatment of occlusive disease who did NOT experience technical complications (Access site: stenosis, occlusion, AV fistula, hematoma or pseudoaneursm , Thrombosis, Embolization, Perforation, or Dissection (target lesion or other artery) that required hospital admission, or transfusion, surgical or interventional treatment prior to discharge during the reporting period. ","All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry where the patient was at least 18 years old at the time of the procedure and underwent peripheral arterial intervention (balloon angioplasty, stenting or atherectomy) of the lower extremity (abdominal aorta and more distal) arteries for treatment of occlusive disease during the reporting period.",To both numerator and denominator: Patients undergoing interventional treatment for aneurysm disease or trauma.,None,None,1,N/A,Outcome,High Priority,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S18,Venous clinical severity score (VCSS) assessment before varicose vein treatment,"The percentage of patients undergoing surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who have venous clinical severity score (VCSS) of the treated leg(s) assessed prior to treatment. + Rationale: Pre-treatment assessment using VCSS, which measures 10 clinical signs and symptoms is recommended in practice guidelines to ensure that treatment is not being recommended for patients with minimal venous disease and to allow post-treatment assessment of improvement. ",Effective Clinical Care,"All procedures captured in the Vascular Quality Initiative® Varicose Vein Registry where the patient was at least 18 years old at the time of the procedure and underwent surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins who had the venous clinical severity score (VCSS) of their treated leg(s) assessed prior to treatment during the reporting period. ","All procedures captured in the Vascular Quality Initiative® Varicose Vein Registry where the patient was at least 18 years old at the time of the procedure and underwent surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) of truncal, perforator or cluster veins during the reporting period. ",None,None,None,1,N/A,Process,,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S19,Proper patient selection for perforator vein ablation,"The percentage of patients undergoing treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who have CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer), and not less severe C1-4 disease. + + Rationale: Perforator vein treatment has only been shown to benefit patients with venous ulcers or a history of ulcers, but is often applied to patients with less severe disease unnecessarily. This measures documents appropriate patient selection and effective cost reduction. ",Effective Clinical Care,"All procedures captured in the Vascular Quality Initiative® Varicose Vein Registry where the patient was at least 18 years old at the time of the procedure and underwent treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) who had CEAP clinical severity of disease C5 or C6 (venous ulcer or history of ulcer) during the reporting period. ","All procedures captured in the Vascular Quality Initiative® Varicose Vein Registry where the patient was at least 18 years old at the time of the procedure and underwent treatment of incompetent lower extremity perforator veins with surgical or ablation treatment (radiofrequency, laser, mechanochemical, chemical, or embolic adhesive) during the reporting period.",None,None,None,1,N/A,Process,,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S1,Procedures with statin and antiplatelet agents prescribed at discharge,"This measure estimates the frequency of procedures where a statin and antiplatelet agent was prescribed at discharge for any of the following procedures: Infra-Inguinal Bypass, +Supra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, Carotid Endarterectomy, Thoracic and Complex EVAR, Endovascular AAA Repair, and Open AAA Repair",Effective Clinical Care,"All procedures captured in the Vascular Quality Initiative®Infra-Inguinal Bypass, Supra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, Carotid Endarterectomy, Thoracic and Complex EVAR, Endovascular AAA Repair, and Open AAA Repair Registries where the patient was at least 18 years old at the time of the procedure, and the patient was +discharged alive during the reporting period where a statin and antiplatelet agent were prescribed at discharge","All procedures captured in the Vascular Quality Initiative® Infra-Inguinal Bypass, Supra-Inguinal Bypass, Peripheral Vascular Intervention, Carotid Artery Stent, Carotid Endarterectomy, Thoracic and Complex EVAR, Endovascular AAA Repair, and Open AAA Repair Registries where the patient was at least 18 years old at the time of the procedure, and the patient was +discharged alive during the reporting period.",Exclude procedures associated with patients who were not discharged on statins or antiplatelets due to a documented medical reason,None,None,1,N/A,Process,,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S2,Amputation-free survival assessed at least 9 months following Infra-Inguinal Bypass for intermittent claudication,"This measure estimates freedom from amputation or death at least 9 months +after Infra-Inguinal Bypass for intermittent claudication. ",Patient Safety,All procedures captured in the Vascular Quality Initiative® Infra-Inguinal Bypass Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication for the leg undergoing treatment during the calendar year prior to the reporting interval with at least 9 month follow up and who were alive and without minor or major amputation reported at a follow-up visit at least 9 months after the treatment,All procedures captured in the Vascular Quality Initiative® Infra-Inguinal Bypass Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication for the leg undergoing treatment during the calendar year prior to the reporting interval with at least 9 month follow up.,Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,High Priority,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S3,Infra-inguinal bypass for claudication patency assessed at least 9 months following surgery,This measure estimates the frequency of graft patency assessment one year Infra-Inguinal Bypass.,Communication and Care Coordination,All Infra-inguinal bypass procedures performed for claudication in Vascular Quality Initiative®Infrainguinal Bypass Registry during the calendar year prior to the reporting interval associated with patients who were at least 18 years old at the time of the procedure and with at least 9 month follow upwhere graft patency was assessed at follow-up.,All Infra-inguinal bypass procedures performed for claudication in Vascular Quality Initiative®Infrainguinal Bypass Registry during the calendar year prior to the reporting interval associated with patients who were at least 18 years old at the time of the procedure.,Procedures associated with patients lost to follow up are excluded from this measure.,None,None,1,N/A,Process,High Priority,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S4,Amputation-free survival assessed at least 9 months following Supra-Inguinal Bypassfor claudication,This measure estimates freedom from amputation or death at least 9 months after Supra-Inguinal Bypassfor claudication.,Patient Safety,All procedures captured in the Vascular Quality Initiative®Supra-Inguinal Bypass Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication in at least one leg during the calendar year prior to the reporting interval with at least 9 month follow up who were alive and without minor or major amputation reported after the treatment.,All procedures captured in the Vascular Quality Initiative® Supra-Inguinal Bypass Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication in at least one leg duringthe calendar year prior to the reporting interval with at least 9 month follow up.,Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,High Priority,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S5,Amputation-free survival at assessed at least 9 months following Peripheral Vascular Interventionfor intermittent claudication,This measure estimates freedom from amputation or death at least 9 months after Peripheral Vascular Intervention for intermittent claudication.,Patient Safety,All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication for the treated leg(s) undergoing Peripheral Vascular Intervention below external iliac during the calendar year prior to the reporting interval with at least at least 9 month follow upassociated with patients who were alive and without minor or major amputation reported after the intervention.,All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry associated with patients who were at least 18 years old at the time of the procedure and with indication of claudication for the treated leg (s) undergoing Peripheral Vascular Intervention below external iliac during the calendar year prior to the reporting interval with at least at least 9 month follow up.,Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,High Priority,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S6,Peripheral Vascular Intervention patency assessed at least 9 months following infrainguinal PVI for claudication,This measure estimates the frequency of patency assessment at least 9 months following infrainguinal Peripheral Vascular Interventionfor claudication.,Communication and Care Coordination,All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry for claudication distal to the external iliac during the calendar year prior to the reporting interval with at least 9 month follow up where patency was assessed at follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,All procedures captured in the Vascular Quality Initiative® Peripheral Vascular Intervention Registry for claudication distal to the external iliac during the calendar year prior to the reporting interval. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,Procedures associated with patients lost to follow up are excluded from this measure.,None,None,1,N/A,Process,High Priority,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S7,Ipsilateral stroke-free survival at assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures,This measure estimates freedom from stroke or death at least 9 months after carotid artery stenting for asymptomatic carotid stenosis.,Effective Clinical Care,All procedures captured in the Vascular Quality Initiative® Carotid Artery Stenting Registry for asymptomatic carotid stenosis during the calendar year prior to the reporting interval with at least 9 month follow up which are free of either stroke or death (any cause) after index carotid artery stenting. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,All procedures captured in the Vascular Quality Initiative® Carotid Artery Stenting Registry for asymptomatic carotid stenosis during the calendar year prior to the reporting interval with at least 9 month follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S8,Ipsilateral stroke-free survival assessed at least 9 months following isolated Carotid Endarterectomy for asymptomatic procedures,This measure estimates freedom from stroke or death at least 9 months after carotid endarterectomy for asymptomatic carotid artery stenosis.,Effective Clinical Care,All procedures captured in the Vascular Quality Initiative® Carotid Endarterectomy Registry for carotid endarterectomy for asymptomatic disease during the calendar year prior to the reporting interval with at least 9 month follow up which are free of either stroke or death (any cause) after index carotid endarterectomy. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,All procedures captured in the Vascular Quality Initiative® Carotid Endarterectomy Registry for carotid endarterectomy for asymptomatic disease during the calendar year prior to the reporting interval with at least 9 month follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,"Procedures associated with patients lost to follow up are excluded from this measure. This measure also excludes combined Coronary Artery Bypass Graft procedures, and excludes combined proximal or distal intervention or other combined arterial procedures. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.",None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S9,Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures,This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Thoracic and Complex EVAR procedures.,Communication and Care Coordination,"All Thoracic and Complex EVAR procedures captured in Vascular Quality Initiative®Thoracic and Complex EVAR Registry during the calendar year prior to the reporting interval with at least 9 month follow up, where the follow up included a CT scan or MR documenting the maximum aortic diameter. All procedures are associated with patients who were at least 18 years old at the time of the procedure.",All Thoracic and Complex EVAR procedures captured in Vascular Quality Initiative® Thoracic and Complex EVAR Registry during the calendar year prior to the reporting interval. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,Procedures associated with patients lost to follow up are excluded from this measure. This measure also excludes conversion to open.,None,None,1,N/A,Process,High Priority,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S10,Survival at least 9 months after elective repair of small thoracic aortic aneurysms,This measure estimates freedom from death at least 9 months after elective repair of small thoracic aortic aneurysms in patients without a known connective tissue disorder.,Effective Clinical Care,"All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Thoracic and Complex EVAR Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 6 cm for women, or less than or equal to 6.5 cm for men at the index procedure, and with at least 9 month follow up and who are alive. All procedures are associated with patients who were at least 18 years old at the time of the procedure.","All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Thoracic and Complex EVAR Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 6 cm for women, or less than or equal to 6.5 cm for men at the index procedure, and with at least at least 9 month follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.",Procedures associated with patients lost to follow up that are not dead are excluded from this measure. Procedures associated with patients with a known connective tissue disorder are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S11,Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures,This measure estimates the frequency of imaging-based maximum aortic diameter assessment at least 9 months after Endovascular AAA Repair procedures.,Communication and Care Coordination,All Endovascular AAA Repair procedures captured in Vascular Quality Initiative® Endovascular AAA Repair Registry during the calendar year prior to the reporting where maximum aortic diameter was assessed during a follow up visit at least 9 months after surgery and who are alive. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,All Endovascular AAA Repair procedures captured in Vascular Quality Initiative® Endovascular AAA Repair Registry during the calendar year prior to the reporting interval. All procedures are associated with patients who were at least 18 years old at the time of the procedure.,Procedures associated with patients lost to follow up are excluded from this measure. This measure also excludes procedures that were converted to open.,None,None,1,N/A,Process,High Priority,,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S12,Survival at least 9 months after elective repair Endovascular AAA Repair of small abdominal aortic aneurysms,This measure estimates freedom from death at least 9 months after elective repair of small abdominal aortic aneurysms.,Effective Clinical Care,"All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Endovascular AAA Repair Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 5.5 cm for women, or less than or equal to 6.0 cm for men at the index procedure, and with at least 9 month follow up and who are alive. All procedures are associated with patients who were at least 18 years old at the time of the procedure.","All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Endovascular AAA Repair Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 5.5cm for women, or less than or equal to 6.0 cm for men at the index procedure, and with at least 9 month follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.",Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +8183896,M2S Inc. (Vascular Quality Initiative QCDR),M2S13,Survival at least 9 months after elective Open AAA repair of small abdominal aortic aneurysms,This measure estimates freedom from death at least 9 months after elective open repair of small abdominal aortic aneurysms.,Effective Clinical Care,"All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Open AAA Repair Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 5.5 cm for women, or less than or equal to 6.0 cm for men at the index procedure, and with at least 9 month follow up who are alive. All procedures are associated with patients who were at least 18 years old at the time of the procedure.","All elective procedures for aneurysm repair captured in the Vascular Quality Initiative® Open AAA Repair Registry during the calendar year prior to the reporting interval where maximum aortic diameter is less than or equal to 5.5 cm for women, or less than or equal to 6.0 cm for men at the index procedure, and with at least 9 month follow up. All procedures are associated with patients who were at least 18 years old at the time of the procedure.",Procedures associated with patients lost to follow up are excluded from this measure. Procedures associated with missing key data elements that are required to calculate the outcomes measure will be excluded from this measure.,None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,M2S Inc. (Vascular Quality Initiative QCDR) +6804302,Maine Health Management Coalition in collaboration with Mingle Analytics,BIVARUS27,Patient Reported Comprehensive Assessment of Safety,"A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. +Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Items: + Bivarus 1: Hand Sanitation Performed By My Provider + Bivarus 2: Medication Reconciliation Performed At My Visit + Bivarus 3: Practice Asked Me About Allergies + Bivarus 5: Practice Explained Medications Before Giving Them + Bivarus 10: Overall Assessment Of Safety + +",Patient Safety,"Numerator: The total number of responses to each administered item contained in the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score). +",Denominator: The total number of responses to each administered item contained in the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +6804302,Maine Health Management Coalition in collaboration with Mingle Analytics,BIVARUS28,Patient Reported Experience and Care Coordination,"A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + +Items: + +Bivarus 16: My Doctor Listened To Me +Bivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions +Bivarus 19: My Doctor Explained My Final Diagnosis +Bivarus 22: My Doctor Informed Me of My Treatment Options +Bivarus 23: My Doctor Told Me How Longs Things Would Take +Bivarus 24: My Doctor Did Not Seem Rushed With Me +Bivarus 25: While In My Room, My Doctor Was Focused On My Issues +Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends +",Person and Caregiver-Centered Experience and Outcomes/Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Experience and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Experience and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey (excluding responses of not applicable).,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Person and Caregiver-Centered Experience Component of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +6804302,Maine Health Management Coalition in collaboration with Mingle Analytics,BIVARUS32,Patient Reported Care Team Communication,"A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Items: + + Bivarus 7: Coordination of Care Among Physicians And Nurses + Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care + Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand + Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan  +",Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Care Coordination Component of the Structured Assessment of the Patient Experience of Care Survey Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +6804302,Maine Health Management Coalition in collaboration with Mingle Analytics,BIVARUS30,Patient Reported Pain Treatment Effectiveness,"This measure is a patient reported outcome measure. + + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Item: + + Bivarus 13: My Pain Was Treated Effectively ",Person and Caregiver-Centered Experience and Outcomes,Numerator: The total number of responses to Patient Reported Pain Treatment Effectiveness Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to Patient Reported Pain Treatment Effectiveness Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,N/A,Patient Reported Outcome,High Priority,Outcome,N,N,Y,N,Y,Yes,SAPE QCDR +6804302,Maine Health Management Coalition in collaboration with Mingle Analytics,BIVARUS31,Patient Reported Communication and Care Coordination,"This measure is a patient reported outcome measure. + + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Item: + + Bivarus 20: I Understood What the Physician Told Me ",Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Reported Outcome,High Priority,Outcome,N,N,Y,N,Y,Yes,SAPE QCDR +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA1,Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment.,"Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show either: + a. A two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). + b. If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. + c. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. + + Measure explanation: + a. Utilizes Quadruple Visual Analogue Scale (QVAS) or similarly validated tool for pain related patient encounters to assess and document efficacy, functional, clinical and/or pain improvement of at least two points (a two-point reduction to show improvement) or a functionality > 6 to show functional improvement is maintained with current treatment. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). + b. If provider changes manipulative technique at the previous visit he/she uses QVAS at the subsequent visit to assess impact of change in technique or intervention on current pain state where patient’s pain is above a 6 on a 0-10 scale with 0 being no pain and 10 greatest pain and/or functionality is < 6 on a 0- 10 scale with 10 most and 0 least functional. Pain scale maintained between 4-6 for good control with current treatment regimen and/or a two-point improvement in pain since last visit for treatment with or without treatment adjustments. If this fails to occur provider changes technique or considers other intervention (i.e.: further diagnostics, referral, injections, prescription medication). + +Rate 1: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for low back pain. +Rate 2: Percentage of patients receiving manipulative medicine with a QVAS score and treatment adjustment/maintenance for neck pain. + +",Effective Clinical Care,"Numerator data will equal total pain patients receiving manipulative medicine or therapy with a QVAS done with functionality less than or equal to a five (<5) or pain scale greater than or equal to seven (>7) points. Numerator quality data coding options for reporting satisfactorily are Measure +#1 4.a. and 4.b. (immediately below) in measure explanation: + +4. Treated Areas Assessed: Low Back (Lumbar Spine) and Neck (Cervical Spine) + +a. Low Back + +i. P360X01a if done +ii. P360X01a-1P if medical reason prevented exam +iii. P360X01a-2P if patient refused or prevented exam +iv. P360X01a-3P if medical system prevented exam +v. P360X01a-8P if not done and/or not documented and reason not documented or otherwise specified performance not done. + +OR + +b. Neck + +i. P360X01b if done +ii. P360X01b-1P if medical reason prevented exam +iii. P360X01b-2P if patient refused or prevented exam +iv. P360X01b-3P if medical system prevented exam +v. P360X01b-8P if not done and/or not and reason not documented or otherwise specified performance not done. +","Denominator will equal patients aged 18-75 years on date of encounter during the reporting period meeting the following ICD and HCPCS codes located in Measure #1 + 5. ICD Codes: + a. Biomechanical lesions NEC (M99) + b. Cervical disc disorder (M50) + c. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + d. Dislocation & sprain of joints & ligaments of thorax (S23) + e. Dorsopathies, deforming (M43) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Hemarthosis (M25) + i. Injuries (S66-T88) + j. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + k. Migraine (G43) + l. M25, Neurologic deficit (R29) + m. Nerve root and plexus disorders (G54) + n. Osteoarthritis (M15-M19) + o. Other disorders of muscle (M62) + p. Other headache syndromes (G44) + q. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + r. Porphyria (E80) + s. Rheumatologic conditions (M05-M14) + t. Scoliosis (M41) + u. Shoulder lesions (M75) + v. Spinal muscular atrophy and related syndromes (G12) + w. Spinal stenosis (M99) + x. Spondylosis & Spondylopathies, other (M47-M48) + y. Strains/sprains: Back (S39), Cervical (S16) + z. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) +aa. Vasculitis (I77.6) +bb. Headache (R51) + HCPCS (E.g., CPT): 98925-98929, 98940-98943, 99201-99205, 99211-99215, 99221-99223, 99231-99233, and + 99291-99292 CPT: New/Established E&M; Initial/Subsequent Hospital, Critical Care E&M ",Patients not getting OMT,Cognitive impairment,None,2,weighted average,Outcome,,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 2,Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology.,"Successful Reporting: Successful reporting would include >80% of encounters where advanced imaging was done only subsequent to an Evaluation and Management (E&M) encounter where the physical examination included appropriate and focal neurologic and/or musculoskeletal evaluations that support the imaging study(ies) being ordered. Correlative documentation of an oral corticosteroid (i.e. prednisone) prescription given in the face of pending advanced diagnostic imaging (i.e. CT or MRI) when documented symptoms or physical findings warrant utilization AND no contraindications to medications exist. Successful reporting of this measure would be the aforementioned medical record documentation with and at the time of the CPT/ICD combinations noted in the reporting year. + + Measure explanation: Neurologic examination and/or focused musculoskeletal examination relative to symptomatic complaints documented prior to ordering MRI or CT Scan of neck or lumbar/lumbosacral spine for low back pain complaint. Corticosteroids/glucocorticoids given for symptomatic radicular pain and/or paresthesias with neurologic examination positive or equivocal, while advanced diagnostic imaging (i.e.: CT or MRI) is pending. ",Efficiency and Cost Reduction,"Numerator data are patients receiving advanced imaging in the reporting year ordered by the reporting provider. Numerator quality data coding options for reporting satisfactorily are ""a-e"" below in measure explanation. + + Reporting: + a. P360X02 if done + b. P360X02-1P if medical reason prevented exam + c. P360X02-2P if patient refused or prevented exam + d. P360X02-3P if medical system prevented exam + e. XP360X02-8P if examine and subsequent treatment not done and/or not documented before MRI/CT or other advanced imaging ordered and reason not documented or otherwise specified why exam not done. ","Denominator data are patients 18-75 years of age with advanced imaging ordered and diagnoses used in the reporting year under 4.f (ICD codes below) and the patient encounters during the reporting year (CPT or HCPCS) in 4.g below. + + ICD Codes: + a. Biomechanical lesions NEC (M99) + b. Cervical disc disorder (M50) + c. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + d. Dislocation & sprain of joints & ligaments of thorax (S23) + e. Dorsopathies, deforming (M43) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Hemarthosis (M25) + i. Injuries (S66-T88) + j. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + k. Migraine (G43) + l. Nerve root and plexus disorders (G54) + m. Neurologic deficit (R29) + n. Osteoarthritis (M15-M19) + o. Other disorders of muscle (M62) + p. Other headache syndromes (G44) + q. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + r. Porphyria (E80) + s. Rheumatologic conditions (M05-M14) + t. Scoliosis (M41) + u. Shoulder lesions (M75) + v. Spinal muscular atrophy and related syndromes (G12) + w. Spinal stenosis (M99) + x. Spondylosis & Spondylopathies, other (M47-M48) + y. Strains/sprains: Back (S39), Cervical (S16) + z. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + aa. Vasculitis (I77.6) + bb. Dislocation and sprain of joints and ligaments of thorax (S23) + + HCPCS (e.g., CPT): 98925-98929, 98940-98943, 99201-99205, 99211-99215, 99221-99223, 99231-99233, and 99291-99292 CPT: New/Established E&M; Initial/Subsequent Hospital, Critical Care E&M + + +",Those without imaging,Emergency surgery within 24 hours of a stat advanced imaging study,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 7,Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur.,"Successful Reporting: + a. Documentation of definitive pathology (e.g., imaging, surgical report, serology, provider referral for addiction/substance use disorder, etc.) to warrant chronic pain and/or buprenorphine/naloxone medication chronically. + b. Provider must document signing of a Controlled Substance (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. + c. For all patients violating existing CSA/OA, such violations are documented with correlative adjustments in treatment (e.g.: shorter duration prescriptions (2 week to 4 week), increased frequency of urine drug screens (quarterly to monthly), random pill counts, more frequent visits, etc.). + +Measure explanation: Chronic Pain medication prescribed (prescribed for greater than one week or more than twice a year) only after a diagnosis and medical or surgical plan has been implemented. CSA or OA followed and, if actionable violation (i.e.: Urine Drug Screen inappropriate, pill counts off, multiple providers prescribing, polypharmacy, etc.) corrective action taken (i.e.: probation, escalated use of Urine Drug Screens, shorter prescriptions intervals, termination of controlled prescribing or similar actions) as result of the CSA/OA violation. + +",Patient Safety,"Numerator data are patients aged 18 and above with documented definitive pathology of ICD data below: + + a. P360X03 if done + b. P360X03-1P if medical reason prevented diagnostic findings, CSA/OA policy adherence + c. P360X03-2P if patient refused diagnostic work-up, CSA/OA + d. P360X03-3P if medical system prevented diagnostic findings, CSA/OA policy adherence + e. P360X03-8P if not done and/or not documented what the patient’s definitive diagnosis is, CSA/OA not in chart or reason not documented or otherwise specified why it was not documented. ","Denominator data are all patients aged 18 and above with any combination of the ICD and HCPCS data defined in this section 4 & 5, below. + + 4. ICD Codes: Biomechanical Lesions NEC (M99) + + a. Cervical disc disorder (M50) + b. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + c. Dislocation & sprain of joints & ligaments of thorax (S23) + d. Dorsopathies, deforming (M43) + e. Cervical disc disorder (M50) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Injuries (S66-T88) + i. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + j. Migraines (G43) + k. Nerve root and plexus disorders (G54) + l. Neurologic deficit (R29) + m. Osteoarthritis (M15-M19) + n. Other headache syndromes (G44) + o. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + p. Porphyria (E80) + q. Rheumatologic conditions (M05-M14) + r. Scoliosis (M41) + s. Spinal muscular atrophy and related syndromes (G12) + t. Spinal stenosis (M99) + u. Spondylosis & Spondylopathies, other (M47-M48) + v. Strains/sprains: Back (S39), Cervical (S16) + w. Shoulder lesions (M75) + x. Somatic dysfunction (M99) + y. Substance Use Disorders (F10-19) + z. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + aa. Vasculitis (I77.6) + + 5. HCPCS (e.g., CPT): 99201-99205, 99211-99215, 99221-99223, 99231-99233, and 99291-99292 CPT: New/Estab E&M; Initial/Subsequent +",Not on controlled meds,No CSA or OA in place at time of UDS or no violations,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 13,Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders.,"Successful Reporting: Provider must document signing of a Controlled Substance Agreement (CSA) or Opiate Agreement (OA) if more than two (2) Schedule II controlled substance prescriptions are provided to a patient in a 12-month period. Understandably, prescriptions may occur in the prior reporting year as well as in the current reporting year. Documented urine drug screens (UDS) performed no less than quarterly on all pain patients and monthly for all substance use disorder patients with documented evidence of additional UDS if suspected diversion, illicit activity, or other red flags noted during the reporting year. Failure to perform the above frequency of UDS at a minimum, results in failure of this measure. Additionally, failure to increase regulatory scrutiny for red flags, diversion and/or illicit behavior (i.e.: problematic urines or pill counts) in the form of increased performance of urine drug screens via probationary periods and/or shorter prescribing periods and/or pill counts will result in measure failure. + +Measure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period. ",Patient Safety,"Numerator data are patients aged 18 and above with a documented Controlled Substance or Opiate Agreement. + +Measure explanation: Controlled substance agreement (CSA) or opiate agreement (OA) utilized on all patients received greater than two Schedule II controlled substance prescriptions in a 12-month period. +a. P360X04 if done +b. P360X04-1P if medical reason prevented exam +c. P360X04-2P if patient refused or prevented exam +d. P360X04-3P if medical system prevented exam +e. P360X04-8P if not done and/or not documented and reason not documented or otherwise specified why an opiate agreement or controlled substance agreement was not done. ","Denominator data are all patients having received two (2) or more Schedule II controlled substances in (or around) the reporting period with the combination of HCPCS and ICD data detailed below. + +4. ICD Codes: + a. Biomechanical lesions (M99) + b. Cervical disc disorder (M50) + c. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + d. Dislocation & sprain of joints & ligaments of thorax (S23) + e. Dorsopathies, deforming (M43) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Injuries (S66-T88) + i. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + j. Migraines (G43) + k. Nerve root and plexus disorders (G54) + l. Neurologic deficit (R29) + m. Osteoarthritis (M15-M19) + n. Other headache syndromes (G44) + o. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + p. Porphyria (E80) + q. Rheumatologic conditions (M05-M14) + r. Scoliosis (M41) + s. Shoulder lesions (M75) + t. Spinal muscular atrophy and related syndromes (G12) + u. Spinal stenosis (M99) + v. Spondylosis & Spondylopathies, other (M47-M48) + w. Strains/sprains: Back (S39), Cervical (S16) + x. Somatic dysfunction (M99) + y. Substance Use Disorders (F10-19) + z. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + aa. Vasculitis (I77.6) + bb. Weakness of muscle (M62) + +5. HCPCS (E.g., CPT): 99201-99205, 99211-99215, 99221-99223, 99231-99233, and 99291-99292 ",No OA/CSA in place,None,None,1,N/A,Process,High Priority,,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 14,Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety.,"Successful Reporting: Chronic pain patients with anxiety symptoms will be provided an SNRI/SSRI prescription and not acutely given benzodiazepines as documented in the medical record and medication list. Patients with chronic pain on benzodiazepines will have those drugs serially weaned and replaced by SNRI/SSRI agents unless a defined anxiety syndrome exists, is documented by a psychiatric provider and this comorbid state is verified. + + Measure explanation: Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines. +",Patient Safety,"Numerator data are patients aged 18 and above with a documented complaint of or diagnosis of anxiety or sleep disorder and be provided SSRI/SNRI agents in lieu of benzodiazepines. If on benzodiazepines, these will be serially weaned unless a documented diagnosis of an anxiety syndrome exists from a psychiatric provider, and treated with SNRI/SSRI agents. + +Benzodiazepines are implicated in polypharmacy overdose deaths and are often prescribed for sleep or anxiety symptoms. Pain patients typically have deficits in serotonin (5-HT) and norepinephrine (NE) secondary to pain chronicity and physiologic response. NE and 5-HT block pain in the ascending spine and deficiencies are associated with increased pain and the primary presenting symptom of 5- HT deficiency is anxiety. As such, appropriate management warrants utilization of SNRI/SSRI agents in this setting in lieu of benzodiazepines. + a. P360X07 if done + b. P360X07-1P if medical reason prevented exam + c. P360X07-2P if patient refused or prevented exam + d. P360X07-3P if medical system prevented exam + e. P360X07-8P if not done and/or not documented and reason not documented or otherwise specified why an opiate agreement or controlled substance agreement was not done. ","Denominator data are patients aged 18 and meet the HCPCS/ICD data parameters defined below. + + 4. ICD Codes: + a. Anxiety (F41) + b. Biomechanical Lesions NEC (M99) + c. Cervical disc disorder (M50) + d. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + e. Dislocation & sprain of joints & ligaments of thorax (S23) + f. Dorsopathies, deforming (M43) + g. Enthesopathies, other (M77) + h. Headache (R51) + i. Injuries (S66-T88) + j. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + k. Migraines (G43) + l. Nerve root and plexus disorders (G54) + m. Neurologic deficit (R29) + n. Osteoarthritis (M15-M19) + o. Other headache syndromes (G44) + p. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + q. Porphyria (E80) + r. Rheumatologic conditions (M05-M14) + s. Scoliosis (M41) + t. Shoulder lesions (M75) + u. Sleep Disorder (G47) + v. Spinal muscular atrophy and related syndromes (G12) + w. Spinal stenosis (M99) + x. Spondylosis & Spondylopathies, other (M47-M48) + y. Strains/sprains: Back (S39), Cervical (S16) + z. Somatic dysfunction (M99) + aa. Substance Use Disorders (F10-19) + bb. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + cc. Vasculitis (I77.6) + dd. Weakness of muscle (M62) + + 5. HCPCS (E.g., CPT): 99201-99205, 99211-99215, 99221-99223, 99231-99233, and 99291-99292 +",No Anxiety Dx or Symptoms,Psychiatrist documentation of medical necessity for benzodiazapine over SNRI/SSRI,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 15,Weight loss in pain patients with BMI >30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control.,"Successful Reporting: In chronic pain patients with weight related or weight exacerbated pain conditions (i.e.: DJD, DDD, Hip Pain/OA, Knee Pain/OA, Foot/Ankle Pain/OA, Pes Planus related plantar fasciitis) BMI will be documented and monitored at scheduled visits with serial reduction in BMI over the reporting period with correlative dose reduction (24 hour MME) of opiate/opioid therapy. + +Measure explanation: Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management. ",Patient Safety,"Numerator data are patients aged 18 and above with a BMI >30 on opiates/opioids for chronic pain related to weight related pain conditions or pain conditions exacerbated by obesity with documented weight loss and BMI reduction AND dose reduction (24 hour MME) documented. + +Pain conditions that can be treated definitively to avoid or cease opiate/opioid utilization should engage such treatment. Obesity, if causally related to pain, disease progression, and/or the major etiologic event must be addressed. Dose escalation for BMI escalation or maintenance is harmful and potentially dangerous to patients categorized as obese due to respiratory suppression and opiate/opioid related systemic endocrine dysfunction. Obesity is treatable. Pain medication may be needed initially help patients exercise and function to address pain in both weight bearing and non-weight bearing joints affected by obesity. However, weight reduction should eventually reduce opiate need and dosing if monitored, addressed and treated as part of comprehensive pain management. + a. P360X08 if done + b. P360X08-1P if medical reason prevented exam + c. P360X08-2P if patient refused or prevented exam + d. P360X08-3P if medical system prevented exam + e. P360X08-8P if not done and/or not documented and reason not documented or otherwise specified why an opiate agreement or controlled substance agreement was not done. ","Denominator data are patients who 18 age and older on chronic opiate therapy with BMI >30 with weight related or weight exacerbated pain conditions and meet the HCPCS/ICD data parameters defined below. + + ICD Codes: + a. Biomechanical lesions NEC (M99) + b. Cervical disc disorder (M50) + c. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + d. Dislocation & sprain of joints & ligaments of thorax (S23) + e. Dorsopathies, deforming (M43) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Injuries (S66-T88) + i. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + j. Migraines (G43) + k. Nerve root and plexus disorders (G54) + l. Neurologic deficit (R29) + m. Obesity (E66) + n. Osteoarthritis (M15-M19) + o. Other headache syndromes (G44) + p. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + q. Porphyria (E80) + r. Rheumatologic conditions (M05-M14) + s. Scoliosis (M41) + t. Shoulder lesions (M75) + u. Sleep apnea (G47 & P28) + v. Spinal muscular atrophy and related syndromes (G12) + w. Spinal stenosis (M99) + x. Spondylosis & Spondylopathies, other (M47-M48) + y. Strains/sprains: Back (S39), Cervical (S16) + z. Somatic dysfunction (M99) + aa. Substance Use Disorders (F10-19) + bb. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + cc. Vasculitis (I77.6) + dd. Weakness of muscle (M62) + + HCPCS (E.g., CPT): 99201-99205, 99211-99215, 99221-99223, 99231-99233, and 99291-99292 ",No CSA or CSA & BMI>30,None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +4191207,Maine Osteopathic Association in Collaboration with Patient 360,MOA 12,Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities.,"Successful Reporting: Successful reporting would include a validated QVAS or similarly validated tool showing for pain and functionality show a two (2) point pain improvement since last clinical encounter with the treating provider or maintenance of a functional improvement greater than or equal to a six (>6). If functionality 5 or less and/or pain 7 or more, medical record documentation of treatment change or diagnostic work up is present. Failure to document these changes with continued treatment despite lessening functionality and/or increasing pain would result in measure failure. + +Providers would be providing manual medicine in addition to non-traditional, but literature proven alternative medicine modalities (i.e.: acupuncture) with patients who have imaging confirmed spinal stenosis (M99 ICD-10 Code). + +Measure explanation: Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment. ",Efficiency and Cost Reduction,"Numerator data will equal total imaging confirmed spinal stenosis (M99) patients receiving manipulative medicine or therapy for this complaint that was inadequate at providing pain relief and necessitated the addition of an alternative medicine therapy (i.e.: acupuncture) during the reporting period. As such patients with a QVAS done with functionality less than or equal to a five (<5) or pain scale greater than or equal to seven (>7) points would be candidates for this measure. Numerator quality data coding options for reporting satisfactorily are below. + + Spinal stenosis typically is conservatively managed until surgical fusion or foraminotomy is necessitated based upon pain or neuropathic progression necessitating spinal fusion and/or foraminotomy. These surgeries carry risk to the patient and major expense to the system. Moreover, once a spinal fusion occurs, typically the areas above and/or below this area are fused in another 5-10 years. Avoiding the initial surgery is the only means to avoid subsequent surgeries and the associated risks and costs. Manipulative medicine combined with alternative medical therapies have been shown to improve pain and avoid surgical intervention, thus, this measure is designed to report such treatment. + a. P360X09 if done + b. P360X09-1P if medical reason prevented exam + c. P360X09-2P if patient refused or prevented exam + d. P360X09-3P if medical system prevented exam + e. P360X09-8P if not done and/or not documented and reason not documented or otherwise specified why an opiate agreement or controlled substance agreement was not done. ","Denominator will equal patients aged 18-75 years with date of encounter during the reporting period meeting the following ICD (must contain M99) and HCPCS codes located below. + + ICD Codes: + a. Biomechanical lesions NEC (M99) + b. Cervical disc disorder (M50) + c. Dislocation & sprain of joints & ligaments of shoulder girdle (S43) + d. Dislocation & sprain of joints & ligaments of thorax (S23) + e. Dorsopathies, deforming (M43) + f. Enthesopathies, other (M77) + g. Headache (R51) + h. Injuries (S66-T88) + i. Injury of muscle, fascia, & tendon at shoulder & upper arm level (S46) + j. Migraines (G43) + k. Nerve root and plexus disorders (G54) + l. Neurologic deficit (R29) + m. Osteoarthritis (M15-M19) + n. Other headache syndromes (G44) + o. Pain: Back & Radiculopathy (M54), Chronic (including Cancer; G89), Joint (M25), & Limb (M79) + p. Porphyria (E80) + q. Rheumatologic conditions (M05-M14) + r. Scoliosis (M41) + s. Shoulder lesions (M75) + t. Spinal muscular atrophy and related syndromes (G12) + u. Spinal stenosis (M99) + v. Spondylosis & Spondylopathies, other (M47-M48) + w. Strains/sprains: Back (S39), Cervical (S16) + x. Somatic dysfunction (M99) + y. Substance Use Disorders (F10-19) + z. Thoracic, thoracolumbar, & lumbosacral intervertebral disc disorders (M51) + aa. Vasculitis (I77.6) + bb. Weakness of muscle (M62) + + HCPCS (E.g., CPT): 97140, 99201-99205, 99211-99215, 99221-99223, 99231-99233, 98925-98929, 98940-98943 and 99291-99292 +","No spinal stenosis, no acupuncture ",None,None,1,N/A,Outcome,High Priority,Outcome,N,Y,N,N,Y,No,Maine Osteopathic Association in Collaboration with Patient 360 +8773711,Massachusetts eHealth Collaborative,MeHC1,Hemoglobin A1c Test for Pediatric Patients,Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period,Effective Clinical Care,Patients with documentation of date and result for a HbA1c test during the measurement period,Patients 5 to 17 years of age with a diagnosis of diabetes and a face-to-face visit between the physician and the patient that predates the most recent visit by at least 12 months,None,None,None,1,There is only 1 performance rate which will reflect the percentage of patients 5-17 years of age with a diagnosis of diabetes that have evidence of a completed Hb A1c test performed during the measurement period.,Process,,,N,Y,N,N,N,No,Massachusetts eHealth Collaborative +1718371,MedAmerica-E-CPR,ECPR39,Avoid Head CT for Patients with Uncomplicated Syncope,Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider,Efficiency and Cost Reduction,"Syncope Patients Who Did Not Have a Head CT Ordered by the Provider +Numerator Options +• Performance Met: Patients who did not have a head CT ordered +• Medical Performance Exclusion: Patients who did have a head CT ordered for medical reason documented by the eligible professional (i.e. seizure, drug or alcohol intoxication, vomiting, altered mental status, or other documented medical reason) +• Performance Not Met: Patients who did have a head CT ordered, reason not given ","• Any patient ≥18 years of age evaluated by the Eligible Professional in the Emergency Department or Urgent Care Clinic (E/M Codes 99201-99205, 99212-99215, 99281-99285, & 99291-99292 AND Place of Service Indicator: 11, 19, 20, 22 or 23) PLUS +• Diagnosis of Syncope: PLUS +o ICD-10: R55 +• Disposition of Admitted or Discharged (does not include transferred, eloped or AMA patients) ",None,None,None,1,Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR43,Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding,"multiple performance rates include: +Rate 1: In Emergency Department (ED), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) +Rate 2: In Urgent Care (UC), Percentage of Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) +",Efficiency and Cost Reduction,"Patients Aged 18 Years and Older with a Diagnosis of Chest Pain Where the Provider Ordered Coagulation Studies (PT, PTT, or INR) +Numerator Options +• Performance Met: Patients who did not have coagulation studies ordered +• Performance Not Met: Patients who did have coagulation studies ordered, reason not given ","• Any patient > 18 years of age evaluated by the Eligible Professional in the Emergency Department or Urgent Care Clinic (E/M Codes 99201-99205, 99212-99215, 99281-99285, & 99291-99292 AND Place of Service Indicator: 11, 19, 20, 22, or 23) PLUS +• Diagnosis of Non-traumatic Chest Pain: PLUS +o ICD-10: I20.1, I20.8, I20.9, I25.111, I25.118, I25.119, I25.701, I25.708, I25.709, I25.711, I25.718, I25.719, I25.721, I25.728, I25.729, I25.731, I25.738, I25.739, I25.751, I25.758, I25.759, I25.761, I25.768, I25.769, I25.791, I25.798, I25.799, R07.1, R07.2, R07.81, R07.82, R07.89, R07.9 +• Disposition of Discharged (does not include admitted, transferred, eloped or AMA patients) ","• Patients with trauma, end stage liver disease, coagulopathy, thrombocytopenia, atrial fibrillation, pulmonary/GI hemorrhage, pregnancy, or for whom medical history is unable to be obtained OR +• Patients taking any of the following anticoagulation therapies: +o Apixaban +o Argatroban +o Bivalirudin +o Dalteparin +o Dateparin +o Desirudin +o Enoxaparin +o Fondaparinux +o Heparin +o Lepirudin +o Rivaroxaban +o Tinzaparin +o Warfarin ",None,None,2,1,Process,High Priority,,Y,Y,N,N,N,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR2,Door to Diagnostic Evaluation by a Provider – Emergency Department (ED) Patients,"Risk-adjusted Mean Time from ED Arrival to Provider Contact for ED Patients Evaluated by the Eligible Professional; multiple performance rates include: +• Time - Overall +• Time - Adult (≥ 18 years of age) +• Time - Pediatric (< 18 years of age) +",Patient Safety,"Time (in minutes) from ED Arrival to Provider (MD/DO/PA/NP) Contact for ED Patients +• Definition of Arrival Time: The earliest documented time the patient arrived at the ED +• Definition of Provider Contact Time: The time of the first direct, personal exchange between an ED patient and the Eligible Professional ",Any Patient Evaluated by the Eligible Professional (MD/DO/PA/NP) in the ED (E/M Codes 99281-99285 & 99291-99292 AND Place of Service Indicator: 23),None,None,None,3,Risk-adjusted Mean Time from ED Arrival to Provider Contact for ED Patients Evaluated by the Eligible Professional,Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR44,Door to Diagnostic Evaluation by a Provider – Urgent Care Patients,"Risk-adjusted Mean Time from Urgent Care Clinic (UCC) Arrival to Provider Contact for Urgent Care Patients Evaluated by the Eligible Professional; multiple performance rates include: +• Time - Overall +• Time - Adult (≥ 18 years of age) +• Time - Pediatric (< 18 years of age) +",Patient Safety,"Time (in Minutes) from Urgent Care Clinic Arrival to Provider (MD/DO/PA/NP) Contact for Urgent Care Patients +• Definition of Arrival Time: The earliest documented time the patient arrived at the Urgent Care Clinic +• Definition of Provider Contact Time: The time of the first direct, personal exchange between an Urgent Care patient and the Eligible Professional","Any Patient Evaluated by the Eligible Professional (MD/DO/PA/NP) in the Urgent Care Clinic (E/M Codes 99201-99205 & 99212-99215 AND Place of Service Indicator: 11, 19, 20 or 22) ",None,None,None,3,Risk-adjusted Mean Time from Urgent Care Clinic (UCC) Arrival to Provider Contact for Urgent Care Patients Evaluated by the Eligible Professional,Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR40,Initiation of the Initial Sepsis Bundle,Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle,Effective Clinical Care,"Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock Who Have Initiation of the Initial Sepsis Bundle +Definition of initiation of initial sepsis bundle: Provider order for (or protocol resulting in order for) ALL of the following: +• Lactate (venous or arterial) +• Blood cultures +• IV antibiotics +• IV fluid bolus +Numerator Options +• Performance Met: Patients who did have initiation of initial sepsis bundle (must include all components) +• Medical Performance Exclusion: Patients who did not have initiation of the initial sepsis bundle for documented medical reason(s) (i.e. IV fluids not ordered given patient is in congestive heart failure, or other medical reason) +• Patient Performance Exclusion: Patients who did not have initiation of the initial sepsis bundle for documented patient reason(s) (i.e. blood cultures not ordered because patient refused or other patient reason) +• Performance Not Met: Patients who did not have initiation of the initial sepsis bundle, reason not given","• Any patient > 18 years of age evaluated by the Eligible Professional in the Emergency Department (E/M Codes 99281-99285 & 99291-99292 AND Place of Service Indicator: 23) PLUS +• ED diagnosis of either of below: PLUS +o Severe Sepsis: +- ICD-10: A41.9, R65.20 +o Septic Shock: +- ICD-10: A41.9, R65.21 +• Disposition of Admitted or Discharged from ED (does not include transferred, eloped or AMA patients) +• Patients with Advanced Directives indicating preference for limited intervention are excluded",None,None,None,1,Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle,Process,,,N,Y,N,N,N,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR6,Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients,Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Higher Acuity Patients Discharged from the ED,Person and Caregiver-Centered Experience and Outcomes,"Time (in minutes) from ED arrival to ED departure for Patients +Discharged from the ED +• Definition of Arrival Time: The earliest documented time the patient arrived at the ED +• Definition of Departure Time: The time the patient departed from the ED ","• Any Higher Acuity Patient Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99283 AND Place of Service Indicator: 23) PLUS +• Disposition of Discharged (does not include transferred, eloped or AMA patients) ",None,None,None,1,Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Higher Acuity Patients Discharged from the ED,Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR5,Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients,Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Lower Acuity Patients Discharged from the ED,Person and Caregiver-Centered Experience and Outcomes,"Time (in minutes) from ED arrival to ED departure for Patients +Discharged from the ED +• Definition of Arrival Time: The earliest documented time the patient arrived at the ED +• Definition of Departure Time: The time the patient departed from the ED ","• Any Lower Acuity Patient Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99283 AND Place of Service Indicator: 23) PLUS +• Disposition of Discharged (does not include transferred, eloped or AMA patients) ",None,None,None,1,Risk-adjusted Mean Time from ED Arrival to Time of Departure from the ED for Lower Acuity Patients Discharged from the ED,Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR42,Restrictive Use of Blood Transfusions,Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines),Efficiency and Cost Reduction,"Patients Who Were Not Ordered a Transfusion of Packed Red Blood Cells (When Hgb>8g/dL) +Numerator Options: +• Performance Met: Patients who did not have a transfusion of packed red blood cells +• Medical Performance Exclusion: Patients who did have a transfusion of packed blood cells for medical reason(s) documented by the eligible professional [e.g., acute coronary syndrome (acute myocardial infarction, unstable angina), symptomatic patients, severe thrombocytopenia, chronic transfusion-dependent anemia, hemodynamic instability, severe hemorrhage, other documented medical reason] +Performance Not Met: Patients who did have a transfusion of packed red blood cells, reason not specified","• Any patient aged 18 and older evaluated by the Eligible Professional (CPT Codes 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935, 01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, 01991, 01992 99217-99220, 99221-99223, 99224-99226, 99231-99233, 99238-99239, 99234-99236, 99281-99285, 99291-99292) PLUS +• Diagnosis of Anemia PLUS +o ICD-10: D50.0, D50.1, D50.8, D50.9, D51.0, D51.1, D51.2, D51.3, D51.8, D51.9, D52.0, D52.1, D52.8, D52.9, D53.0, D53.1, D53.2, D53.8, D53.9, D55.0, D55.1, D55.2, D55.3, D55.8, D55.9, D58.0, D58.1, D58.2, D58.8, D58.9, D59.0, D59.1, D59.2, D59.3, D59.4, D59.5, D59.6, D59.8, D59.9, D61.01, D61.09, D61.1, D61.2, D61.3, D61.810, D61.811, D61.818, D61.82, D61.89, D61.9, D62, D63.0, D63.1, D63.8, D64.0, D64.1, D64.2, D64.3, D64.4, D64.81, D64.89, D64.9 +• Laboratory result of Hgb>8g/dL documented in the medical record PLUS +• Disposition of Admitted or Discharged (does not include transferred, eloped or AMA patients) +• Trauma patients excluded",None,None,None,1,Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines),Process,High Priority,,N,Y,N,N,N,Yes,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR41,Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure,Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative,Patient Safety,"Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the ED and Received Rh-Immunoglobulin (Rhogam) if Rh-negative + +Numerator Options +• Performance Met: Patients who had their Rh status evaluated and were confirmed Rh-positive OR Patients who had Rh status evaluated AND received an order for Rh-Immunoglobulin (Rhogam) if Rh-negative +o Definition of Rh status evaluated: Laboratory testing of Rh status or documented Rh status (e.g., “Patient known Rh+”) +• Medical Performance Exclusion: Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented medical reasons +• Patient Performance Exclusion: Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented patient reason(s) (e.g., patient refused Rh testing or Rhogam) +• Performance not Met: Patients who did not have Rh status evaluated or did not receive Rh-Immunoglobulin (Rhogam) if Rh-negative, reason not given","• Any Female Patient > 14 Years of Age and < 51 Years of Age Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99285 & 99291-99292) PLUS +• ED Diagnosis of high risk pregnancy complication: +o ICD-10: O00.8, O00.9, O02.1, O03.1, O03.6, O04.6, O07.1, O08.1, O20.0, O20.8, O20.9, O43.011, O43.019, O44.10, O44.11, O45.001, O45.009, O45.011, O45.019, O45.021, O45.029, O45.091, O45.099, O45.8X1, O45.8X9, O45.90, O45.91, O46.001, O46.011, O46.021, O46.8X1, O46.8X9, O46.90, O46.91 +• Disposition of Admitted or Discharged (does not include transferred, eloped or AMA patients)",None,None,None,1,Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR11,Three Day All Cause Return ED Visit Rate – All Patients,"Risk-adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service; multiple performance rates include: +• Time - Overall +• Time - Adult (≥ 18 years of age) +• Time - Pediatric (< 18 years of age) +",Communication and Care Coordination,Number of Eligible Professional’s ED Discharged Patients that Returned to the Same ED within Three Calendar Days of Prior ED Date of Service,"• Any Patient Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99285 & 99291-99292 AND Place of Service Indicator: 23) PLUS +• Disposition of Discharged on initial ED visit (does not include transferred, eloped or AMA patients) ",None,None,None,3,Risk-adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,ECPR38,Three Day All Cause Return ED Visit Rate with Admission on Re-Visit,"Risk-Adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service with Admission on Re-Visit; multiple performance rates include: +• Time - Overall +• Time - Adult (≥ 18 years of age) +• Time - Pediatric (< 18 years of age) +",Communication and Care Coordination,Number of Eligible Professional’s ED Discharged Patients that Returned to the Same ED within Three Calendar Days of Prior ED Date of Service with Admission on Re-Visit (Disposition of Admitted),"• Any Patient Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99285 & 99291-99292 AND Place of Service Indicator: 23) PLUS +• Disposition of Discharged on initial ED visit (does not include transferred, eloped or AMA patients) ",None,None,None,3,Risk-Adjusted Percentage of the Eligible Professional’s ED Discharged Patients that Returned to the Same Emergency Department (ED) within Three Calendar Days of Prior ED Visit Date of Service with Admission on Re-Visit,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,MedAmerica-E-CPR +1718371,MedAmerica-E-CPR,NOF12,Median Time to Pain Management for Long Bone Fracture,Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).,Effective Clinical Care,Time (in minutes) from emergency department arrival to time of initial oral or parenteral pain medication administration,Patients admitted to the emergency department with a diagnosis of long bone fracture who were administered oral or parenteral pain medications.,None,None,None,N/A,N/A,Process,,,Y,Y,N,N,N,Yes,National Osteoporosis Foundation and National Bone Health Alliance +8483899,MedAmerica-H-CPR,HCPR19,30 Day All Cause Readmission Rate for Discharged Inpatients,"Risk-Standardized Rate of All-cause Readmission to the Discharging Hospital and Hospitalist Physician Group within 30 Days of Initial Hospital Discharge; multiple performance rates include: +• Readmission Rate – All Discharged Patients +• Readmission Rate – Discharged Pneumonia Patients +• Readmission Rate – Discharged CHF Patients +• Readmission Rate – Discharged COPD Patients +",Communication and Care Coordination,"[Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we use this field to define the measure outcome.] +The Outcome for This Measure Is All-cause Readmission within 30 Days of Hospital Discharge","• Patients Admitted to Inpatient Status on Index Admission PLUS +• Patients Discharged by the Eligible Professional on Index Admission (E/M Codes 99238-99239 AND Place of Service Indicator: 21) +• Patients who expired, were discharged AMA or transferred to another acute care hospital during initial inpatient admission are excluded +• Patients with any planned readmission are excluded",None,None,None,4,Risk-Standardized Rate of All-cause Readmission to the Discharging Hospital and Hospitalist Physician Group within 30 Days of Initial Hospital Discharge,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR4,Mean Length of Stay for Inpatients – CHF,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Congestive Heart Failure (CHF)",Efficiency and Cost Reduction,"[Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we use this field to define the measure outcome.] +The outcome for this measure Is Mean Time (in Days) from Admission to Inpatient Status to Hospital Discharge for CHF Patients ","• Patients Evaluated by the Eligible Professional with E/M Codes 99221-99223, 99231-99233, 99238-99239, and 99291-99292 AND Place of Service Indicator: 21 (Note: please see weighting methodology below) PLUS +• LOS ≤ 120 days PLUS +• E/M admission code (99221, 99222 or 99223) AND E/M discharge code (99238 or 99239) by Eligible Professional or one of Eligible Professional’s associates treating these patients PLUS +• Provider of record (“AI”) modifier specified for Medicare patients with E/M Codes 99221-99223 or 99231-99233 PLUS +• Discharge diagnosis of CHF +o ICD-10: I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 +• Patients who expired during inpatient care or left AMA are excluded",None,None,None,1,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Congestive Heart Failure (CHF)",Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR5,Mean Length of Stay for Inpatients – COPD,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)",Efficiency and Cost Reduction,"[Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we use this field to define the measure outcome.] +The outcome for this measure Is Mean Time (in Days) from Admission to Inpatient Status to Hospital Discharge for COPD Patients ","• Patients Evaluated by the Eligible Professional with E/M Codes 99221-99223, 99231-99233, 99238-99239, and 99291-99292 AND Place of Service Indicator: 21 (Note: please see weighting methodology below) PLUS +• LOS ≤ 120 days PLUS +• E/M admission code (99221, 99222 or 99223) AND E/M discharge code (99238 or 99239) by Eligible Professional or one of Eligible Professional’s associates treating these patients PLUS +• Provider of record (“AI”) modifier specified for Medicare patients with E/M Codes 99221-99223 or 99231-99233 PLUS +• Discharge diagnosis of COPD +o ICD-10: J41.0, J41.1, J41.8, J42, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.9 +• Patients who expired during inpatient care or left AMA are excluded",None,None,None,1,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Chronic Obstructive Pulmonary Disease (COPD)",Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,"HCPR3 +",Mean Length of Stay for Inpatients – Pneumonia,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia",Efficiency and Cost Reduction,"[Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we use this field to define the measure outcome.] +The outcome for this measure Is Mean Time (in Days) from Admission to Inpatient Status to Hospital Discharge for Pneumonia Patients","• Patients Evaluated by the Eligible Professional with E/M Codes 99221-99223, 99231-99233, 99238-99239, and 99291-99292 AND Place of Service Indicator: 21 (Note: please see weighting methodology below) PLUS +• LOS ≤ 120 days PLUS +• E/M admission code (99221, 99222 or 99223) AND E/M discharge code (99238 or 99239) by Eligible Professional or one of Eligible Professional’s associates treating these patients PLUS +• Provider of record (“AI”) modifier specified for Medicare patients with E/M Codes 99221-99223 or 99231-99233 PLUS +• Discharge diagnosis of pneumonia +o ICD-10: J12.0, J12.1, J12.2, J12.81, J12.89, J12.9, J15.1, J14, J15.4, J15.4, J15.20, J15.211, J15.212, J15.29, J15.8, J15.5, J15.6, A48.1, J15.8, J15.9, J15.7, J16.0, J16.8, J18.0, J17, J11.00, J11.08 +• Patients who expired during inpatient care or left AMA are excluded",None,None,None,1,"Weighted, Risk-Adjusted Mean LOS for All Inpatients Diagnosed with Pneumonia",Outcome,High Priority,Outcome,Y,N,Y,Y,Y,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR16,Physician’s Orders for Life-Sustaining Treatment (POLST) Form,Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed,Communication and Care Coordination,"Patients with a completed Physician’s Orders for Life-Sustaining Treatment (POLST) form + +Definitions: +• Physician’s Orders for Life-Sustaining Treatment (POLST) form is defined as a legally recognized, transportable and actionable medical order – intended for seriously ill patients at high risk for mortality – that remains with the patient whether at home, in the hospital, or in a care facility; the form indicates patient-specified medical treatment preferences and is signed by the authorizing physician, physician assistant (PA), or nurse practitioner (NP) +• The following elements must be present and completed in the Physician’s Orders for Life-Sustaining Treatment (POLST) form: +o Legally recognized decision maker verification +o Cardiopulmonary Resuscitation (CPR) preferences (e.g., attempt CPR, DNR) +o Medical Intervention (e.g., full code, comfort measures, limited/selective treatments) +o Signed by eligible healthcare provider (e.g., physician, PA, or NP) +• NOTE: The approved version and title of the Physician’s Orders for Life-Sustaining Treatment (POLST) form may differ slightly from state to state; variations in forms are acceptable as long as the elements listed above are present + +Numerator Options +• Performance Met: +o Existing Physician’s Orders for Life-Sustaining Treatment (POLST) form was acknowledged and documented in the medical record OR +o Physician’s Orders for Life-Sustaining Treatment (POLST) form was completed or updated and documented in the medical record OR +o Documented reason for not acknowledging, completing or updating Physician’s Orders for Life-Sustaining Treatment (POLST) form (e.g., patient refuses, patient is unresponsive or does not have capacity to complete, legally recognized decision maker is not present) +• Performance Not Met: Physician’s Orders for Life-Sustaining Treatment (POLST) form was not acknowledged, completed or updated, reason not specified","• Adult patients aged ≥ 65 years evaluated by the Eligible Professional in the Post-acute Facility (E/M Codes 99304-99310, 99315, 99316)",None,None,None,1,Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR17,Pressure Ulcers – Risk Assessment and Plan of Care,Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed,Patient Safety,"Adult Post-acute Facility Patients that Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention OR Treatment Documented + +Definitions +• Pressure ulcer: Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. +• Risk assessment: +o Nationally recognized scale (e.g., Braden Scale or Braden Q Scale) +o Nutrition +o Activity and Mobility Limitations +o History of skin breakdown +o Cognition +• Plan of care – Prevention: +o Scheduled skin integrity assessments +o Minimize friction and shear +o Minimize pressure with off-loading +o Manage moisture +o Maintain adequate nutrition and hydration +• Plan of care – Treatment: +o Scheduled wound description/staging +o Etiology of pressure (e.g., dementia, diapering) +o Body repositioning +o Nutritional status +o Bacterial colonization/infection +o Wound management (e.g., wound dressings, barrier creams, medicated creams, antibiotics, gauze) + +Numerator Options +• Performance Met: Patients who did have pressure ulcer risk assessment AND a plan of care for pressure ulcer prevention or treatment documented +• Performance Not Met: Patients who did not have pressure ulcer risk assessment AND a plan of care for pressure ulcer prevention or treatment documented","• Adult patients aged ≥ 18 years evaluated by the Eligible Professional in the Post-acute Facility (E/M Codes 99304-99310, 99315, 99316)",None,None,None,1,Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,ECPR42,Restrictive Use of Blood Transfusions,Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines),Efficiency and Cost Reduction,"Patients Who Were Not Ordered a Transfusion of Packed Red Blood Cells (When Hgb>8g/dL) +Numerator Options: +• Performance Met: Patients who did not have a transfusion of packed red blood cells +• Medical Performance Exclusion: Patients who did have a transfusion of packed blood cells for medical reason(s) documented by the eligible professional [e.g., acute coronary syndrome (acute myocardial infarction, unstable angina), symptomatic patients, severe thrombocytopenia, chronic transfusion-dependent anemia, hemodynamic instability, severe hemorrhage, other documented medical reason] +Performance Not Met: Patients who did have a transfusion of packed red blood cells, reason not specified","• Any patient aged 18 and older evaluated by the Eligible Professional (CPT Codes 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935, 01936, 01951, 01952, 01958, 01961, 01963, 01965, 01966, 01991, 01992 99217-99220, 99221-99223, 99224-99226, 99231-99233, 99238-99239, 99234-99236, 99281-99285, 99291-99292) PLUS +• Diagnosis of Anemia PLUS +o ICD-10: D50.0, D50.1, D50.8, D50.9, D51.0, D51.1, D51.2, D51.3, D51.8, D51.9, D52.0, D52.1, D52.8, D52.9, D53.0, D53.1, D53.2, D53.8, D53.9, D55.0, D55.1, D55.2, D55.3, D55.8, D55.9, D58.0, D58.1, D58.2, D58.8, D58.9, D59.0, D59.1, D59.2, D59.3, D59.4, D59.5, D59.6, D59.8, D59.9, D61.01, D61.09, D61.1, D61.2, D61.3, D61.810, D61.811, D61.818, D61.82, D61.89, D61.9, D62, D63.0, D63.1, D63.8, D64.0, D64.1, D64.2, D64.3, D64.4, D64.81, D64.89, D64.9 +• Laboratory result of Hgb>8g/dL documented in the medical record PLUS +• Disposition of Admitted or Discharged (does not include transferred, eloped or AMA patients) +• Trauma patients excluded",None,None,None,1,Percentage of Adult Patients with a Diagnosis of Anemia Who Did Not Receive a Blood Transfusion When Hgb > 8g/dL (Restrictive Transfusion Guidelines),Process,High Priority,,N,Y,N,N,N,Yes,MedAmerica-E-CPR +8483899,MedAmerica-H-CPR,HCPR13,Stroke Venous Thromboembolism (VTE) Prophylaxis,Percentage of Adult Ischemic and Hemorrhagic Stroke Patients Who Had VTE Prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered,Patient Safety,"Ischemic or hemorrhagic stroke patients who had VTE prophylaxis ordered on the day of or the day after hospital admission OR have documentation why no VTE prophylaxis was ordered on the day of or the day after hospital admission +• Performance Met (either of below qualify): +o Acceptable VTE Prophylaxis (Note: This is not meant to be an inclusive list of all available prophylaxis; rather it represents current information available at the time of publication): +- Pharmacologic Prophylaxis: Low dose unfractionated heparin (LDUH), Low molecular weight heparin (LMWH), Warfarin/Coumadin, IV Factor Xa Inhibitor such as Arixtra/Fondaparinux, Oral Factor Xa Inhibitor such as Xarelto/Rivaroxaban (must document why oral factor Xa was used for VTE Prophylaxis [acceptable reasons are: Atrial fibrillation, Atrial flutter, Hip arthoplasty/replacement, Total knee arthoplasty/replacement, or history of treatment for VTE or current VTE treatment]) +- Mechanical Prophylaxis: Intermittent pneumatic compression devices (IPC), Graduated compression stockings (GCS), Venous foot pumps (VFP) +o Acceptable Reason(s) for No VTE Prophylaxis: +- There is explicit documentation indicating that the patient is at low risk for VTE (i.e. Patient at low risk for VTE, No VTE Prophylaxis needed) OR +- There is explicit documentation of a contraindication to both mechanical prophylaxis AND documentation of a contraindication to pharmacological prophylaxis. +• Performance Not Met: No VTE prophylaxis ordered on the day of or the day after hospital admission AND no documentation why no VTE prophylaxis was ordered on the day of or the day after hospital admission ","• Patients ≥ 18 years of age evaluated by the Eligible Professional (E/M Codes 99221-99223, 99231-99233, 99238-99239, and 99291-99292 AND Place of Service Indicator: 21) PLUS +• LOS ≥ 2 days and ≤ 120 days PLUS +• Provider of record (“AI”) modifier specified for Medicare patients with E/M Codes 99221-99223 or 99231-99233 PLUS +• Diagnosis of Ischemic or Hemorrhagic CVA +o ICD-10: I65.1, I65.21, I65.22, I65.23, I65.29, I63.23, I63.231, I63.232, I63.239, I65.0, I65.0, I65.01, I65.02, I65.03, I65.09, I63.21, I63.211, I63.212, I63.219, I65.8, I65.9, I66.9, I63.50, I63.40, I60.9, I61.9 +• Patients with Comfort Measures Only documented on day of or day after hospital arrival are excluded +• Patients enrolled in clinical trials are excluded +• Patients admitted for Elective Carotid Intervention are excluded",None,None,None,1,Percentage of Adult Ischemic and Hemorrhagic Stroke Patients Who Had VTE Prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR18,Unintentional Weight Loss – Risk Assessment and Plan of Care,Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider,Patient Safety,"Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented + +Definitions +• Weight loss episode: A loss of weight equal to or greater than 5% within a 30-day period or 10% within a 180-day period +o Starting with the patient’s weight closest to 30 days ago, the patient’s current weight is equal to or less than 95%. Starting with the patient’s weight closest to 180 days ago, the patient’s current weight is equal to or less than 90% +• Risk Assessment: +o Nationally recognized tool [e.g., Minimum Data Set (MDS) Swallowing/Nutritional Status, Mini Nutritional Assessment (MNA), Malnutrition Screening] +Tool (MST)] +o Weight +o Height +o Body Mass Index (BMI) +• Plan Of Care: +o Oral nutrition support (e.g., therapeutic diet, mechanically altered diet, condition specific diet, fortified foods, and/or supplements) +o Parenteral feeding +o Enteral feeding tube +o Patient-centered and/or condition-specific considerations (e.g., prescription of orexigenic alternatives to anorectic drugs, hydration and edema status, increased nutritional needs for patients at high risk of pressure ulcers, patient preferences and availability of choices for foods and fluids, feeding assistance by staff to enhance the resident’s self-feeding ability, social stimulation throughout meal or snack period) + + +Numerator Options +• Performance Met: Patients who did have a risk assessment for unintentional weight loss AND a plan of care for unintentional weight loss documented +• Performance Not Met: Patients who did not have a risk assessment for unintentional weight loss AND a plan of care for unintentional weight loss documented ","• Adult patients aged ≥ 18 years evaluated by the Eligible Professional in the Post-acute Facility (E/M Codes 99304-99310, 99315, 99316)",None,None,None,1,Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-H-CPR +8483899,MedAmerica-H-CPR,HCPR14,Venous Thromboembolism (VTE) Prophylaxis,Percentage of Adult Patients Who Had VTE prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered,Patient Safety,"Patients who had VTE prophylaxis ordered on the day of or the day after hospital admission OR have documentation why no VTE prophylaxis was ordered on the day of or the day after hospital admission +Numerator Options +• Performance Met (either of below qualify): +o Acceptable VTE Prophylaxis (Note: This is not meant to be an inclusive list of all available anticoagulants; rather it represents current information available at the time of publication): +- Pharmacologic Prophylaxis: Low dose unfractionated heparin (LDUH), Low molecular weight heparin (LMWH), Warfarin/Coumadin, IV Factor Xa Inhibitor such as Arixtra/Fondaparinux, Oral Factor Xa Inhibitor such as Xarelto/Rivaroxaban (must document why oral factor Xa was used for VTE Prophylaxis [acceptable reasons are: Atrial fibrillation, Atrial flutter, Hip arthoplasty/replacement, Total knee arthoplasty/replacement, or history of treatment for VTE or current VTE treatment]) +- Mechanical Prophylaxis: Intermittent pneumatic compression devices (IPC), Graduated compression stockings (GCS), Venous foot pumps (VFP) +o Acceptable Reason(s) For No VTE Prophylaxis: +- There is explicit documentation indicating that the patient is at low risk for VTE (i.e. Patient at low risk for VTE, No VTE Prophylaxis needed) OR +- There is explicit documentation of a contraindication to both mechanical prophylaxis AND documentation of a contraindication to pharmacological prophylaxis. +• Performance Not Met: No VTE prophylaxis ordered on the day of or the day after hospital admission AND no documentation why no VTE prophylaxis was ordered on the day of or the day after hospital admission ","• Inpatients ≥ 18 years of age evaluated by the Eligible Professional (E/M Codes 99221-99223, 99231-99233, 99238-99239, 99291-99292 AND Place of Service Indicator: 21) PLUS +• LOS ≥ 2 days and ≤ 120 days PLUS +• Provider of record (“AI”) modifier specified for Medicare patients with E/M Codes 99221-99223 or 99231-99233 +• Patients with Comfort Measures Only documented on day of or day after hospital arrival are excluded +• Patients enrolled in clinical trials are excluded ",None,None,None,1,Percentage of Adult Patients Who Had VTE prophylaxis Ordered on the Day Of or the Day After Hospital Admission OR Have Documentation of Why No VTE Prophylaxis Was Ordered,Process,High Priority,,N,Y,N,N,N,No,MedAmerica-H-CPR +7958754,Medaxion,AQI29,Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics),"Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively + +Definition: The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk of POV include (but may not be limited to): +• 5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for prophylaxis for POV in children) +• Dexamethasone +• Antihistamines +• Butyrophenones + +The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications. + +","All patients, aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV. + +Denominator Definition: Risk factors for POV are: +* Surgery ≥ 30 minutes +* Age ≥ 3 years +* Strabismus surgery +* History of POV or PONV in parent or sibling + +","• Organ Donors as designated by ASA Physical Status 6 +• Cases in which an inhalational anesthetic is used only for induction +",• Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (e.g. intolerance or other medical reason),None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +7958754,Medaxion,AQI30,Anesthesia Safety,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia without the occurrence of a major adverse event prior to completion of anesthesia care.",Effective Clinical Care,"Patients who did not experience a major adverse event prior to completion of anesthesia care. + +Definition: Major adverse events of anesthesia are defined according to the 2009 Committee of Performance and Outcomes Measurement work product “Development of the ASA Critical Incidents Reporting System. The adverse events and their definitions can be accessed here: http://www.aqihq.org/files/CPOM-registry-data-set.pdf. Adverse events include: +• Death +• Cardiac arrest +• Perioperative myocardial infarction +• Anaphylaxis +• Malignant hyperthermia +• Transfusion reaction +• Stroke, cerebral vascular accident, or coma following anesthesia +• Visual loss +• Operation on incorrect site +• Operation on incorrect patient +• Medication error +• Unplanned ICU admission +• Intraoperative awareness +• Unrecognized difficult airway +• Reintubation +• Dental trauma +• Perioperative aspiration +• Vascular access complication, including vascular injury or pneumothorax +• Pneumothorax following attempted vascular access or regional anesthesia +• Infection following epidural or spinal anesthesia +• Epidural hematoma following spinal or epidural anesthesia +• High Spinal +• Postdural puncture headache +• Major systemic local anesthetic toxicity +• Peripheral neurologic deficit following regional anesthesia +• Infection following peripheral nerve block + +Numerator Quality-Data Coding Options for Reporting Satisfactorily: +Performance Met: Advance 2A: Patient did not experience an adverse event prior to completion of anesthesia care. +OR +Performance Not Met: Advance 2B: Patient experienced an adverse event prior to completion of anesthesia care","All patients, regardless of age, who undergo a procedure under anesthesia + +Definition: Any procedure including surgical, therapeutic or diagnostic Denominator Criteria (Eligible Cases): +All patients, regardless of age +AND Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992",Organ Donors as designated by ASA Physical Status 6,None,None,N/A,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Medaxion +7958754,Medaxion,MA1,Case Delay,Percentage of cases marked as delayed from scheduled start with a reason indicated,Communication and Care Coordination,"Cases that are delayed from scheduled start and have a reason indicated. + +Definition: Any procedure that is delayed form the scheduled start time and has a reason indicated by the anesthesia provider of care. +Reporting of the delay may include, but is not limited to: +• Anesthesia Late +• Difficult Block +• Scheduling Error +• Pre-op Staff Delay +• Paperwork Incomplete +• Missing Labs +• Surgical Consent Missing +• Surgical H&P Missing +• OR Staff Delay +• Contamination of Case +• Missing Equipment/Instrumentation +• Surgeon Late +• Patient Delay +• Not NPO +• Previous Case Ran Over +• Previous Case at Another Facility Ran Over + +Numerator Quality-Data Coding Options for Reporting Satisfactorily: +Performance Met: +Advance 3B: Procedure delayed from scheduled start time +AND +Advance 3C: Reason for delay indicated +OR +Performance Not Met: Advance 3A: Procedure was not delayed from scheduled start","All patients, regardless of age, who undergo a procedure under anesthesia. + +Definition: Any procedure including surgical, therapeutic or diagnostic +Denominator Criteria (Eligible Cases): +All patients, regardless of age +AND +Procedure Delayed from Scheduled Start +AND +Patient encounter during the reporting period (CPT): +00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00532, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935, 01936, 01951, 01952, 01953, 01958, 01961, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992","• Cases that were not scheduled in advance and are add-ons the day of surgery. +• Emergent cases identified by ASA Physical Status indicating case is emergent by using ‘E’ designation +• Organ Donors as designated by ASA Physical Status 6",None,None,N/A,N/A,Efficiency,High Priority,,N,N,N,N,N,No,Medaxion +7958754,Medaxion,AQI34,Perioperative Cardiac Arrest - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time ",Patient Safety,"Patients who experienced an unanticipated cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time**. + + Definition: Cardiac arrest is the unplanned cessation of the mechanical activity of the heart as confirmed by the absence of signs of effective circulation. Cardiac compression and/or defibrillation may be required for treatment. + + ** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. ","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic +","• Organ Donors as designated by ASA Physical Status 6 +• Cases with a documented planned cardiac arrest (i.e., use of CPT Code 99116 for deep hypothermia) ",None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +7958754,Medaxion,AQI35,Perioperative Mortality Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who undergo a procedure* under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.",Patient Safety,"Patients who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** + +Definition: Death or mortality is defined as the irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration and brain activity; the end of life. + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. + +","All patients, regardless of age, who undergo a procedure under anesthesia. + +Definition: Any procedure including surgical, therapeutic or diagnostic + +",Organ Donors as designated by ASA Physical Status 6,None,None,N/A,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +7958754,Medaxion,AQI31,Postanesthesia Care Unit (PACU) Re-intubation Rate - INVERSE MEASURE,"Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge.",Patient Safety,"Patients who required re-intubation in the postanesthesia care unit + +Definition: Reintubation is defined as the need to insert an endotracheal tube resulting from the inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway + +","All patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or postanesthesia care unit. + +","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who bypassed PACU care +• Patient received a planned trial of extubation documented in the medical record prior to removal of the original airway device",None,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +7958754,Medaxion,ABG7,Immediate Adult Post-Operative Pain Management,The percentage of patients 18 or older admitted to the PACU after an anesthetic with a maximum pain score <7/10 within 15 minutes of arrival.,Person and Caregiver-Centered Experience and Outcomes,"The number of lucid patients with a pain score less than 7 within 15 minutes of PACU arrival. + +Performance Met: ABG Observation 1001 (Pain score 0-6 on arrival to PACU) Reported +Performance Not Met: ABG Observation 1002 (Pain score 7-10 on arrival to PACU) Reported","Patient with an encounter + +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",Patient Age < 18 OR ABG observation 1020 (patient transferred to location other than PACU) Reported,ABG observation 1003 (patient unable to report pain score) reported,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,N,Y,N,N,N,Yes,Anesthesia Business Group +7958754,Medaxion,AQI37,Surgical Safety Checklist: Applicable Safety Checks Completed Before Induction of Anesthesia,"Percentage of patients, regardless of age, who undergo a surgical procedure under general anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of general anesthesia. ",Patient Safety,"Patients who have documentation that all applicable safety checks of the WHO Surgical Safety Checklist (or other surgical checklist that includes the safety checks for specific procedure) were performed before induction of general anesthesia. + + Definition: + The WHO Surgical Safety Checklist includes the following items + + Before Induction of Anesthesia +• Has the patient confirmed his/her identity, site, procedure and consent? +• Is the site marked? +• Is the anesthesia machine and medication check complete? +• Is the pulse oximeter on the Patient And Functioning? +• Does the Patient have a: + o Known Allergy? + o Difficult Airway/Aspiration Risk? + o Risk of >500 ml Blood Loss (7ml/kg in children)? ","All patients, regardless of age, who undergo a surgical procedure under general anesthesia ",• Organ Donors as designated by ASA Physical Status 6,None,None,N/A,N/A,Process,High Priority,,N,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +7958754,Medaxion,MA2,Corneal Abrasion,"Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. ",Person and Caregiver-Centered Experience and Outcomes,"All patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area who are awake and able to be assessed. + +Definition: Corneal Injury: Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily: +Performance Met: ASA38A: Patient was NOT newly diagnosed with exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room and was awake and able to be assessed. +OR +Performance Not Met: ASA38B: Patient diagnosed with new exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room and was awake and able to be assessed.","All patients, aged 18 and older, who undergo anesthesia care, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery. + +Denominator Criteria (Eligible Cases): Patients aged 18 years or older on date of encounter AND Patient encounter during the reporting period (CPT): 00100, 00102, 00104, 00120, 00124, 00126, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00562, 00563, 00566, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992 + +Denominator Note: Measure not applicable to anesthesia care described by code 00300 when the underlying surgical procedure is described by CPT Codes: 67800, 67801, 67805, 67808, 67810, 67840, 67850, 67875, 67900, or 67938. ","• Patients who undergo ophthalmologic surgery or patients with a diagnosis of either eye trauma or corneal injury before anesthesia care. +• Organ Donors as designated by ASA Physical Status 6 ",None,None,N/A,N/A,Outcome,High Priority,Outcome,N,Y,N,N,N,No,Medaxion +7958754,Medaxion,MIRAMED3,Dental Injury,"Percentage of patients experiencing dental trauma due to intubation during an anesthetic +procedure.",Patient Safety,"All patients who undergo an anesthetic procedure resulting in chipped or otherwise damaged +teeth due to intubation. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily: +Performance Met: Advance 5A: Patient did not receive of diagnosis of new dental injury/trauma +OR +Performance Not Met: Advance 5B: Patient was diagnosed with a new dental injury/trauma","All patients who undergo an anesthetic procedure requiring intubation. + +Definition: Any procedure including surgical, therapeutic or diagnostic + +Denominator Criteria (Eligible Cases): All patients, regardless of age AND Patient encounter during the reporting period (CPT): Anesthesia codes which are commonly indicated for associated surgical procedure(s): 00100,00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00834, 00836, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01935, 01936, 01951, 01952, 01953, 01958, 01961, 01963, 01965, 01966, 01967, 01968, 01969, 01991, 01992 ","• Organ Donors as designated by ASA Physical Status 6 +• Patients not intubated for anesthetic procedure G22",None,None,N/A,simple average of the performance rates submitted,Intermediate Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,MiraMed +8458231,"MedTrak, Inc. CareSense QCDR",MICS1,General Health Postoperative Improvement,"Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery. + +Performance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval. + +Instructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery. + +Rationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns. ",Community/Population Health,Each individual patient improvement score is calculated by subtracting the preoperative survey score from the postoperative survey score. The numerator is calculated by summing all the improvement scores for each patient.,"The number of patients that have a postoperative score and a preoperative score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks). +Valid general health questionnaires include, but are not limited to, the VR-12, PROMIS, PROMIS-10, VR-6D, SF-12, SF-36, and EQ-5D.",Patients who did not receive surgery.,"Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent.",None,2,The overall percentage of patients that improve beyond a minimum threshold of 5% from preoperatively to 4 weeks postoperatively; 7% from preoperatively to 6 weeks postoperatively; 10% from preoperatively to 3 months postoperatively; and 15% from preoperatively to 6 months postoperatively.,Outcome,,Outcome,N,N,Y,Y,N,No,"MedTrak, Inc. CareSense QCDR" +8458231,"MedTrak, Inc. CareSense QCDR",MICS2,Surgery Specific Postoperative Improvement in Pain Levels,"Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery. + +Performance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval. + +Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels. + +Rationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns. ",Effective Clinical Care,Each individual patient improvement score is calculated by subtracting the preoperative surgery-specific pain score from the postoperative surgery-specific pain score. The numerator is calculated by summing all the improvement scores for each patient.,"The number of patients that have a postoperative surgery-specific pain score and a preoperative surgery-specific pain score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks). Valid questionnaires include, but are not limited to, the Neck Disability Index, the Quick DASH, the HOOS-JR, the KOOS-JR, and the Foot Function Index.",Patients who did not receive surgery.,"Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent.",None,2,The overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively.,Outcome,,Outcome,N,N,Y,Y,N,No,"MedTrak, Inc. CareSense QCDR" +8458231,"MedTrak, Inc. CareSense QCDR",MICS3,Surgery Specific Postoperative Improvement in Function Levels,"Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery. + +Performance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval. + +Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks. + +Rationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns. ",Effective Clinical Care,Each individual patient improvement score is calculated by subtracting the preoperative surgery-specific function score from the postoperative surgery-specific function score. The numerator is calculated by summing all the improvement scores for each patient.,"The number of patients that have a postoperative surgery-specific function score and a preoperative surgery-specific function score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks). Valid questionnaires include, but are not limited to, the Neck Disability Index, the Quick DASH, the HOOS-JR, the KOOS-JR, and the Foot Function Index.",Patients who did not receive surgery.,"Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent.",None,2,The overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively.,Outcome,,Outcome,N,N,Y,Y,N,No,"MedTrak, Inc. CareSense QCDR" +9437642,MedXpress Registry,"MEX1 +",Heel Pain Treatment Outcomes for Adults,"DESCRIPTION: + Percentage of patients aged 18 years and older with a diagnosis of heel pain who had two or more encounters in the past year + + INSTRUCTIONS: + This measure is to be reported each visit for patients with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. + + Measure Reporting via Registry: + ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. + Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure. ",Effective Clinical Care,"Patients in the denominator who had a visit with heel pain as a diagnosis within the past 12 months. + +Definition: +Heel Pain Evaluation – Consists of a documented evaluation of patient reported pain level utilizing a standardized pain scale + +Performance Met: +Heel Pain Decreased Mildly (MX003) +Heel Pain Decreased Moderately (MX004) +Heel Pain Decreased Significantly (MX005) +OR +Performance Not Met: +Heel Pain level not documented (MX006) +Heel Pain not decreased (MX007)","All patients aged 18 years and older on date of encounter +AND +Diagnosis for heel pain (ICD-10-CM): +M77.31, M77.32, M72.2 +AND +Patients who have had at least two visits during the reporting period +AND NOT +Clinician documented that patient was not an eligible candidate for evaluation of heel pain, for example patient has condition that would not allow them to accurately respond to a pain level exam (dementia, Alzheimer´s, etc.), patient has previously documented diabetic peripheral neuropathy with loss of protective sensation ","Clinician documented that the patient was not an eligible candidate for evaluation of heel pain. For example, the patient has a condition that would not allow them to accurately respond to a pain level exam (Dementia, Alzheimer's, patient has previously documented diabetic peripheral neuropathy with loss of protective senstation)",None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,MedXpress Registry +9437642,MedXpress Registry,MEX2,Heel Pain Treatment Outcomes for Pediatric Patients,"DESCRIPTION: +Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who experience a decrease in heel pain. + +INSTRUCTIONS: + This measure is to be reported each visit for patients in the cohort with heel pain seen during the reporting period. Documentation of pain level in patients with heel pain to evaluate change in reported heel pain over time with treatment of heel pain. The Pain Scale should be reported using the standard 1-10 Pain Scale. + + Measure Reporting via Registry: + ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. + Patients who are not able to communicate a pain level or have neuropathy are exclusions for this measure. ",Effective Clinical Care,"Patients who had a visit with heel pain as a diagnosis within the past 12 months. + +Definition: +Heel Pain Evaluation – Consists of a documented evaluation of patient reported pain level utilizing a standardized pain scale. + +Performance Met: +Heel Pain Decreased Mildly (MX010) +Heel Pain Decreased Moderately (MX011) +Heel Pain Decreased Significantly (MX012) +OR +Performance Not Met: +Heel Pain Level Not Documented (MX013) +Heel Pain Not Decreased (MX014)","All patients aged 6 to 18 years on the date of initial encounter. +AND +Diagnosis for heel pain (ICD-10-CM): +M77.31, M77.32, M72.2, Q66.0, Q66.1, Q66.21, Q66.22, Q66.3, Q66.4, Q66.7, Q66.50, Q66.51, Q66.81, Q66.82, M92.61, M92.62 +AND +Patients who have had at least two visits during the reporting period +AND NOT +Clinician documented that patient was not an eligible candidate for evaluation of heel pain.  For example, a patient has condition that would not allow them to accurately respond to a pain level exam or the patient has previously documented peripheral neuropathy with loss of protective sensation.","Clinician documented that the patient was not an eligible candidate for evaluation of heel pain. For example, the patient has condition that would not allow them to accurately respond to a pain level exam or the patient has previously documented peripheral neuropathy with loss of protective sensation.",None,None,1,N/A,Outcome,,Outcome,N,N,N,N,N,No,MedXpress Registry +9437642,MedXpress Registry,MEX3,Identification of Flat Foot in Pediatric Patients,"DESCRIPTION: +Percentage of patients aged 6 - 18 years with a diagnosis of flat foot who had an encounter and treatment for flexible flat foot in the past year + +INSTRUCTIONS: +This measure is to be reported a minimum of once per reporting period for eligible patients with a diagnosis of flat foot seen during the reporting period. Documentation of flat foot in patients to have appropriate foot and ankle care to ensure the treatment is appropriate based upon the age of the patient. + + Measure Reporting via Registry: + ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. ",Effective Clinical Care,"Patients in the denominator who had a visit with flat foot as a diagnosis within the past 12 months. + +Definition: Flat Foot Evaluation – Consists of a documented evaluation of patient with a diagnosis of flat foot. + +Performance Met: +Flat Foot Evaluation Documented and treatment provided (MX015) +OR +Performance Not Met: +Flat Foot Evaluation Not documented (MX016) +Flat Foot Evaluation documented treatment not provided (MX017) +","All patients aged 6 to 18 years on the date of initial encounter with a diagnosis of flat foot +Patients aged 6 to 18 on the date of initial encounter +AND +Diagnosis for Flat Foot (ICD-10-CM): +M21.41, M21.42, Q66.51, Q66.52, Q66.81, Q66.82",None,None,None,1,N/A,Process,,,N,N,N,N,N,No,MedXpress Registry +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),"MBSAQIP1 +",Risk standardized rate of patients who experienced a postoperative complication within 30 days,"Risk standardized rate of patients who experienced a postoperative complication within 30 days + following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, + performed as a primary (not revisional) procedure. ",Effective Clinical Care,"Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a +postoperative complication within 30 days ","Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), +(43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), +(43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), +(44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), +(43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), +(43999,43775), (43846, 43999), (43847, 43999), (43810, 43644) +",Emergent procedures,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP2,Risk standardized rate of patients who experienced an unplanned readmission within 30 days,"Risk standardized rate of patients who experienced an unplanned readmission (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. ",Efficiency and Cost Reduction,Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced an unplanned readmission (likely related to the initial operation) to any hospital within 30 days,"Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), (44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644)",Emergent procedures,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP3,Risk standardized rate of patients who experienced a reoperation within 30 days,"Risk standardized rate of patients who experienced a reoperation (likely related to the initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. ",Efficiency and Cost Reduction,Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced reoperation (likely related to the initial operation) within 30 days,"Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), (44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644) +",Emergent procedures,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP4,Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days,"Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. ",Effective Clinical Care,Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced an anastomotic/staple line leak within 30 days,"Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), (44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644) +",Emergent procedures,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP6,Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) within 30 days,"Risk standardized rate of patients who experienced a postoperative surgical site infection (SSI) (superficial incisional, deep incisional, or organ/space SSI) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. ",Effective Clinical Care,Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a postoperative surgical site infection within 30 days,"Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644),(44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644)",Emergent procedures. Patients who have PATOS (Present At Time Of Surgery) modifiers will also be excluded from the denominator.,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP7,"Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days","Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure.",Effective Clinical Care,"Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced a postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days","Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), (44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644)",Emergent procedures,None,None,1,N/A,Outcome,,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +5459222,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP),MBSAQIP8,Risk standardized rate of patients who experienced extended length of stay (> 7 days),"Risk standardized rate of patients who experienced extended length of stay (> 7 days) following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional) procedure. ",Patient Safety,Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy patients who experienced extended length of stay (> 7 days),"Patients with Primary CPT 43644, 43645 or 43775 + +The following combinations of Primary CPT by Other CPT will also be included in the denominator: +(43644,43644), (43644,43645), (43644,43846), (43644,43847), (43644,43999), (43645,43644), (43645,43645), (43645,43846), (43645,43847), (43645, 43999), (43659,43644), (43659,43645), (43846,43644), (43846,43645), (43847,43644), (43847,43645), (43633,43644), (43633,43645), (43840,43644), (43840,43645), (44602,43644), (44602,43645), (44603, 43644), (44603,43645), (43999,43644), (43999,43645), (43659,43775), (43775,43775), (43775,43842), (43775,43843), (43775, 43999), (43843,43775), (43840,43775), (44602,43775), (44603,43775), (43999,43775), (43846, 43999), (43847, 43999), (43810, 43644)",Emergent procedures,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,Y,Y,No,Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC2,Assessment of back or neck pain,The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of back or neck pain (depending on the location of the spine probem) was done prior to surgery using a standard 0-10 numeric pain rating scale.,Effective Clinical Care,Patients with both baseline and 90-day follow-up surveys completed that include a 0-10 rating of back or neck pain,All patients meeting MSSIC inclusion criteria (see appendix A) and entered into registry,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC3,Assessment of leg or arm pain,The measure reflects the percent of patients receiving spine surgery for whom a formal assessment of leg or arm pain (depending on the location of the spine problem) was done prior to surgery using a standard 0-10 numeric pain rating scale.,Effective Clinical Care,Patients with both baseline and 90-day surveys completed that include a 0-10 rating of neck or arm pain,All patients meeting MSSIC inclusion criteria (see appendix A) and entered into registry,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC4,Assessment of pain-related disability (ODI/NDI),"The measure reflects the percent of patients receiving cervical spine surgery for whom a formal assessment pain-related disability was done, using either the Oswestry Disability Index (lumbar spine patients) or the Neck Disability Index (cervical spine patients). ",Effective Clinical Care,Patients with both baseline and 90-day follow-up surveys completed that includes the ODI (lumbar) or NDI (cervical),All patients meeting MSSIC inclusion criteria (see appendix A) and entered into registry,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC5,Follow-up (90 day) assessment of myelopathy (cervical only),"The measure reflects the percent of patients receiving spine surgery who were formally assessed for myelopathy 90 days after surgery, using the mJOA scale. Ideally, this rate would be 100%. Surgical practices in MSSIC have rates generally ranging from 40% at the low end to 85% at the high end. ",Effective Clinical Care,"Patients in the denominator with a confirmed surgery date who are >120 days post-surgery for whom a follow-up survey is completed that includes a scorable mJOA scale. + + + + + + + +","All patients with cervical spine problems meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates + + + +",None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC8,Percent of patients achieving MCID for back or neck pain,"The measures reflects the percent of patients receiving spine surgery who report an improvement in back or neck pain that is equal to, or greater than, the standard ""Minimum Clinically Important Difference"" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) ",Person and Caregiver-Centered Experience and Outcomes,"Patients with an improvement of 1.5 points or more on the 0-10 rating of back pain or 2.5 points or more for neck pain, from baseline to 90-day followup ","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery an completion of both baseline and 90-day followup assessment + + + + +","Lumbar patients with baseline back pain score of 0 or 1. Cervical patients with baseline neck pain of 0, 1, or 2. ",None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC9,Percent of patients achieving MCID for leg or arm pain,"The measures reflects the percent of patients receiving spine surgery who report an improvement in leg or arm pain that is equal to, or greater than, the standard ""Minimum Clinically Important Difference"" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) ",Person and Caregiver-Centered Experience and Outcomes,"Patients with an improvement of 1.75 points or more on the 0-10 rating of leg pain or 2.5 points or more for arm pain, from baseline to 90-day followup ","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery an completion of both baseline and 90-day followup assessment + + + + +","Lumbar patients with baseline leg pain score of 0 or 1. Cervical patients with baseline arm pain of 0, 1, or 2. ",,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC10,Percent of patients achieving MCID for pain-related disability (ODI/NDI),"The measures reflects the percent of patients receiving spine surgery who report an improvement in pain-related disability that is equal to, or greater than, the standard ""Minimum Clinically Important Difference"" for the specific measures used in MSSIC to assess back or neck pain. The MCID values are standard values (e.g., 1.75 points or more on a 0-10 rating scale) obtained from published articles, and are specific to spine surgery. The ideal value for the measure is 100% (all patients got better), but actual values are lower than that and vary significantly from hospital to hospital and surgeon to surgeon. + + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. Although it is a rare situation, patients with baseline scores so low as to not allow for an improvement larger than the MCID are excluded from the rate calculation. (Patients with myelopathy as an indication for surgery, for example, may not have pain.) ",Person and Caregiver-Centered Experience and Outcomes,"Patients with an improvement of 13.5 points or more on the ODI (lumbar) or 15 points or more on the NDI (cervical), from baseline to 90-day followup ","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery an completion of both baseline and 90-day followup assessment + + + + +",Lumbar patients with baseline ODI score less than 14. Cervical patients with baseline NDI score of less than 15.,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC6,Percent same-day ambulation,"The measures reflects the percent of patients receiving spine surgery for whom there is medical record evidence of ambulation (actual movement out of the bed, not just feet dangling out of bed) on the day of surgery. Analysis of MSSIC data in 2016 showed the early ambulation is a significant protective factor for a variety of complications, and that there is currently significant variability among hospitals and surgeons in terms of the percent of patients who do have ambulation on the day of surgery. ",Effective Clinical Care,Patients with evidence in the medical record of ambulation on the day of surgery,"All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and who are >120 days post-surgery ",Patients with durotomy or CSF leak or other clinical contra-indication for ambulation,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC11,Percent Satisfied with Result,"The measure reflects the percent of patients receiving spine surgery who report being satisfied with the result of surgery, either in terms of having received the benefit they wanted and expected, or having achieved enough benefit that they would be willing to do the procedure again to achieve the same benefit. ",Person and Caregiver-Centered Experience and Outcomes,"Patients who responded either ""Surgery met my expectations"" or "" I did not improve as much as I had hoped but I would undergo the same operation for the same results"" to question on ""Were you satisfied with the results of your surgical procedure?"" on 90-day followup survey + + + + + + + + + + + + + + + + +","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery and completion of 90-day followup assessment + + + + + + +",None,None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,"MSSIC1 +",Pre-surgical screening for depression,The measure reflects the percent of surgical cases that received a formal pre-surgical screening for depression. MSSIC uses the PHQ-2 brief screening instrument,Effective Clinical Care,Patients with a baseline survey completed that includes the PHQ-2.,All patients meeting MSSIC inclusion criteria (see attached description of inclusion/exclusion criteria and entered into registry,None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC7,Rate of use of Pre-op skin preparation/wash,"The measures reflects the percent of patients receiving spine surgery for whom there is medical record evidence of use of evidence-based interventions to prevent surgical site infection (SSI). SSI is a relatively rare but serious complication of surgery, and is preventable to some extent by specific pre-surgical site preparation done by patients the day before surgery. Data from MSSIC suggests significant variability among surgeons and among hospitals in terms of the percent of patients for whom a formal pre-surgical wash preparation is used. ",Effective Clinical Care,Patients with medical record evidence of use of recommended or prescribed surgical site wash/preparation in the 24 hours preceding surgery,"All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and who are >120 days post-surgery ",None,None,None,1,N/A,Process,,,N,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC12,Risk-adjusted rate of hospital readmission,"The measure reflects the percent of patients receiving spine surgery who were readmitted to a hospital within 90 days of surgery. Planned ""readmissions"" for two-stage procedures or other reasons are not counted. Rates are reported for all-cause readmissions, although the registry allows for separate analysis of spine-related vs. unrelated readmissions. + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. ",Patient Safety,"Patients with confirmed dates of surgery who are >120 days post-surgery whose medical records indicate an inpatient hospital admission within 90 days of discharge + + + + + + + + + + + + + + + + + +","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery and completion of 90-day followup assessment + + + + + + +",Patients without surgeon office records available for medical abstraction. Patients with missing information for any of the included risk factors.,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC13,Risk-adjusted rate of surgical site infection,"The measure reflects the percent of patients receiving spine surgery who had a clinically significant surgical site infection following surgery, requiring treatment. + + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. ",Patient Safety,"Patients with confirmed dates of surgery who are >120 days post-surgery whose medical records indicate a surgical site infection as defined by CDC criteria, plus those with a superficial SSI in the 30-90 day time window + + + + + + + + + + + + + + + + + + +","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery and completion of 90-day followup assessment + + + + + + +",Patients without surgeon office records available for medical abstraction. Patients with missing information for any of the included risk factors.,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC14,Risk-adjusted rate of urinary retention,"The measure reflects the percent of patients receiving spine surgery who had a clinically significant issue of urinary retention (residual urine in bladder after voiding, or inability to void) in the immediate post-surgical period. + + Rates are reported on a risk-adjusted basis, with the risk adjustment model based on a set of demographic and clinical characteristics, as well as case-mix variables (e.g., fusion vs. non-fusion) so that rates are truly comparable from surgeon to surgeon. ",Patient Safety,"Patients with confirmed dates of surgery who are >120 days post-surgery whose medical records indicate a the presence of urinary retention as defined in the MSSIC manual of operations + + + + + + + + + + + + + + + + + + + +","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery and completion of 90-day followup assessment + + + + + + +",Patients without surgeon office records available for medical abstraction. Patients with missing information for any of the included risk factors.,None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Michigan Spine Surgery Improvement Collaborative +3799930,Michigan Spine Surgery Improvement Collaborative,MSSIC15,Unplanned Return to OR Rate,"The measure reflects the percent of patients receiving spine surgery who had an unplanned return to the operating room, either during the index admission (or equivalent outpatient stay for outpatient procedures) or during the 90-day period post-discharge. Unplanned return to the OR reflects a quality problem of some kind, and rates vary significantly from surgeon to surgeon and from hospital to hospital. ",Patient Safety,"Patients with confirmed dates of surgery who are >120 days post-surgery whose medical records indicate an unplanned return to the operating room for a procedure related to the index procedure, either during the original hospital admission or in the 90-day period after discharge + + + + + + + + + + + + + + + + + + + + +","All patients meeting MSSIC Inclusion criteria (see attached file) and entered into registry, with confirmed surgery dates and > 120 days elapsed since surgery and completion of 90-day followup assessment + + + + + + +","Patients without surgeon office records available for medical abstraction. + + + + + + + +",None,None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,Michigan Spine Surgery Improvement Collaborative +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC1,Prostate Biopsy Antibiotic Compliance,Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy,Patient Safety,# of biopsies where a compliant antibiotic regimen was given,# of prostate biopsies for patients aged 30 or older,Non-TRUS biopsies; biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO and that which have a local biopsy are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC6,Prostate Cancer: Unplanned Hospital Readmission After Radical Prostatectomy,Percentage of patients aged 30 years and older who had an unplanned hospital readmission within 30 days of principal procedure,Communication and Care Coordination,# of radical prostatectomies where a hospital admission resulted within 30 days of the procedure,# of radical prostatectomies for patients aged 30 or older,Prostatectomies performed in patients < 30 years of age; patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Outcome,High Priority,Outcome,Y,Y,N,N,Y,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC5,Prostate Cancer: Radical Prostatectomy Cases LOS,Percentage of radical prostatectomy cases with a length of stay > 2 days,Effective Clinical Care,# of patients with a length of stay > 2 days after radical prostatectomy,# of patients aged 30 or older who underwent a radical prostatectomy as treatment for prostate cancer,Prostate cancer patients < 30 years of age; patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC4,Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients,Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting,Effective Clinical Care,# of low-risk prostate cancer patients on active surveillance or watchful waiting,# of low-risk prostate cancer patients 30 or older,Prostate cancer patients < 30 years of age; patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,Yes,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC3,Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients,"Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a CT scan performed at any time since diagnosis of prostate cancer ",Efficiency and Cost Reduction,"# of low risk prostate cancer patients receiving brachytherapy, EBRT, RP, or cryotherapy who did not have a CT scan since diagnosis of prostate cancer ","# of low-risk prostate cancer patients 30 years or older receiving brachytherapy, EBRT, RP, or cryotherapy ",Prostate cancer patients < 30 years of age; prostate cancer patients receiving an alternate form of treatment from those specified; patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Process,High Priority,,N,Y,N,N,N,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC2,Prostate Biopsy: Unplanned Hospital Admission within 30 Days of TRUS Biopsy,Percentage of biopsies where patients aged 30 years and older had an unplanned hospital admission within 30 days of biopsy,Effective Clinical Care,# of biopsies where a hospital admission resulted within 30 days of the procedure,# of prostate biopsies for patients aged 30 or older,Biopsies performed in patients < 30 years of age; biopsies performed in patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO and that which have a local biopsy are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Outcome,,Outcome,Y,Y,N,N,Y,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC9,Prostate Biopsy: Repeat Biopsy for Patients with Atypical Small Acinar Proliferation (ASAP),Proportion of patients undergoing a repeat prostate biopsy within 12 months of their initial biopsy in the registry as a result of a finding of atypical small acinar proliferation (ASAP) as per the NCCN guidelines,Effective Clinical Care,# of patients undergoing a repeat prostate biopsy as a result of a finding of ASAP on their initial biopsy,# of patients aged 30 or older that had a finding of ASAP on their initial prostate biopsy,Patients < 30 years of age; patients that have had prior treatment for prostate cancer,"Prostatectomy patients enrolled in MUSIC PRO and that which have a local biopsy are included in the registry, and thus this measure, as appropriate, regardless if had have had prior treatment for Pca",None,1,N/A,Outcome,,Outcome,N,Y,N,N,Y,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC10,Prostate Cancer: Confirmation Testing in low risk AS eligible patients,Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis,Effective Clinical Care,"# of patients that underwent a second biopsy, MRI, or genomics test within 6 months after date of diagnosis (positive biopsy date) ",# of patients aged 30 or older with new diagnosis of low and low-intermediate prostate cancer (Gleason 6 or low volume Gleason 3+4),Prostate cancer patients < 30 years of age; Patients that have had prior treatment for prostate cancer; Patients on watchful waiting,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +5480464,Michigan Urological Surgery Improvement Collaborative (MUSIC),MUSIC11,Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months,Percentage of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis,Effective Clinical Care,# of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis,# of patients aged 30 or older with new diagnosis of low and low-intermediate prostate cancer (Gleason 6 or low volume Gleason 3+4),Prostate cancer patients < 30 years of age; Patients that have had prior treatment for prostate cancer,None,None,1,N/A,Outcome,,Outcome,N,Y,N,N,N,No,Michigan Urological Surgery Improvement Collaborative (MUSIC) +4019379,Mingle Analytics MUSE Collaborative,BIVARUS27,Patient Reported Comprehensive Assessment of Safety,"A composite score on this measure is derived from responses on 5 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. +Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + Items: + Bivarus 1: Hand Sanitation Performed By My Provider + Bivarus 2: Medication Reconciliation Performed At My Visit + Bivarus 3: Practice Asked Me About Allergies + Bivarus 5: Practice Explained Medications Before Giving Them + Bivarus 10: Overall Assessment Of Safety + +",Patient Safety,"Numerator: The total number of responses to each administered item contained in the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score). +",Denominator: The total number of responses to each administered item contained in the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Comprehensive Assessment of Safety Composite Measure of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +4019379,Mingle Analytics MUSE Collaborative,BIVARUS28,Patient Reported Experience and Care Coordination,"A composite score on this measure is derived from responses on 8 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + +Items: + +Bivarus 16: My Doctor Listened To Me +Bivarus 17: My Doctor Made Me Feel Comfortable about Asking Questions +Bivarus 19: My Doctor Explained My Final Diagnosis +Bivarus 22: My Doctor Informed Me of My Treatment Options +Bivarus 23: My Doctor Told Me How Longs Things Would Take +Bivarus 24: My Doctor Did Not Seem Rushed With Me +Bivarus 25: While In My Room, My Doctor Was Focused On My Issues +Bivarus 26: How Likely Are You to Recommend This Physician To Your Family And Friends +",Person and Caregiver-Centered Experience and Outcomes/Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Experience and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Experience and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey (excluding responses of not applicable).,"Excluding responses of not applicable from the denominator. + +Excluding patients who opt-out of the survey.",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Person and Caregiver-Centered Experience Component of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +4019379,Mingle Analytics MUSE Collaborative,BIVARUS32,Patient Reported Care Team Communication,"A composite score on this measure is derived from responses on 4 items (each item scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR composite measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Items: + + Bivarus 7: Coordination of Care Among Physicians And Nurses + Bivarus 9: I Was Told How to Arrange an Appointment for Follow-Up Care + Bivarus 11: The Doctor Provided Follow-Up Care Instructions in A Way I Could Understand + Bivarus 12: I Was Involved In Developing My Care or Follow-Up Plan  +",Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Care Coordination Component of the Structured Assessment of the Patient Experience of Care Survey Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Engagement/Experience,High Priority,,N,N,Y,N,N,Yes,SAPE QCDR +4019379,Mingle Analytics MUSE Collaborative,BIVARUS30,Patient Reported Pain Treatment Effectiveness,"This measure is a patient reported outcome measure. + + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Item: + + Bivarus 13: My Pain Was Treated Effectively ",Person and Caregiver-Centered Experience and Outcomes,Numerator: The total number of responses to Patient Reported Pain Treatment Effectiveness Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to Patient Reported Pain Treatment Effectiveness Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,N/A,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,N,Y,N,Y,Yes,SAPE QCDR +4019379,Mingle Analytics MUSE Collaborative,BIVARUS31,Patient Reported Communication and Care Coordination,"This measure is a patient reported outcome measure. + + This measure is derived from responses on 1 item (scored with a text-anchored 5-point Likert scale with 1 representing the lowest value and 5 representing the highest value). Subjects (patients) receive individual items for their response. These items are not identified to patients as a component of a QCDR outcome measure. + + Note: Limiting the composite measure score to the highest response category provides an opportunity for differentiation among providers in a meaningful way and provides an opportunity for performance improvement at a provider level. + + Item: + + Bivarus 20: I Understood What the Physician Told Me ",Communication and Care Coordination,Numerator: The total number of responses to each administered item contained in the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey which received a score of “5” (or the highest possible score).,Denominator: The total number of responses to each administered item contained in the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey.,"Excluding responses of not applicable from the denominator. + + Excluding patients who opt-out of the survey. ",None,None,1,Overall Score: Rate of responses with the highest score on each administered item of the Patient Reported Communication and Care Coordination Composite Measure of the Structured Assessment of the Patient Experience of Care Survey calculated using Numerator and Denominator as Defined above (weighted average method).,Patient Reported Outcome,High Priority,Patient Reported Outcome,N,N,Y,N,Y,Yes,SAPE QCDR +9181695,MiraMed,MIRAMED5,Adult PACU Pain Management,"The rate of all patients, 18 or older, transferred to the postanesthesia care unit (PACU) after care under an anesthesia provider with a maximum pain score greater than 7/10 within 1 hour of arrival to the PACU. ",Person and Caregiver-Centered Experience and Outcomes,"All patients, 18 or older that can be assessed for pain, with a pain score less than or equal to 7/10 within 1 hour of arrival to the PACU ",All patients age 18 or greater admitted to PACU after a surgical procedure under anesthesia care who can be assessed for pain,Patients not transferred directly to PACU from OR,"Patient not lucid, or unable to communicate pain level. Age 17 or less.",None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED9,Case Delay Rate,"Percentage of scheduled anesthesia cases or pain procedures which are delayed greater than 15 minutes after the scheduled start time due to the surgeon being late, anesthesia staff late, or room not ready. ",Efficiency and Cost Reduction,"All scheduled anesthetic cases or pain procedure that are delayed on the day of surgery due to: +• Surgeon late +• Anesthesia staff late +• Operating/Procedure room not ready +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM09A1 Scheduled surgical case was NOT delayed on DOS +OR +Performance Not Met: +MM09B1 Scheduled surgical case was DELAYED on DOS due to Surgeon +MM09B2 Scheduled surgical case was DELAYED on DOS due to +Anesthesia +MM09B3 Scheduled surgical case was DELAYED on DOS due to Room +readiness","All patients undergoing scheduled surgical cases who are under anesthesia care or scheduled +pain procedures. +Denominator Criteria (Eligible Cases): +All patients, regardless of age +AND +Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, +00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, +00170, 00172, 00174, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, +00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, +00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, +00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, +00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, +00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, +00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, +00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, +00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, +00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, +00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, +01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, +01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, +01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, +01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, +01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, +01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, +01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, +01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 11900, 20526, 20550, +20551, 20552, 20553, 20600, 20605, 20610, 20611, 22514, 22899, 27096, 62264, 62273, +62290, 62310, 62311, 62350, 62362, 62368, 62370, 63650, 63661, 64400, 64405, 64416, +64417, 64418, 64420, 64421, 64425, 64430, 64447, 64450, 64461, 64479, 64483, 64486, +64490, 64491, 64493, 64494, 64510, 64517, 64520, 64530, 64615, 64620, 64633, 64635, +64640, 64999, 80300, 95886, 95909, 95910, 96365, 99201, 99202, 99203, 99204, 99212, +99213, 99214, 99243, 99244","Delayed scheduled surgical cases or pain procedures due to any reason other than: +• Surgeon late +• Anesthesia staff late +• Operating/Procedure room not ready",None,None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED7,New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care,"Percentage of patients, aged 18 years or older, who undergo anesthesia care and did not have a new diagnosis of corneal injury prior to anesthesia end time.**",Patient Safety,"Patients who undergo anesthesia care and who do not have a new diagnosis of corneal injury prior to anesthesia end time**. + +Definition: A corneal injury is either a corneal abrasion (a scratch or scrape on the cornea, the clear front window of the eye that transmits and focuses light into the eye) or exposure keratitis (inflammation of the cornea from drying of the corneal tear film). Includes both exposure keratitis and corneal abrasion. For the purposes of this measure, the distinction does not need to be made with fluorescein examination of the cornea under ultraviolet light; however, it can be diagnosed in this manner. Corneal injury also includes any new symptom of eye pain treated with topical antibiotic (e.g., erythromycin) while in the post-anesthesia care unit/recovery area. Other causes of eye pain (e.g. acute angle-closure glaucoma) can be excluded by instilling one drop of local anesthetic (e.g., proparacaine) into the eye. If the pain is immediately and completely relieved, corneal injury is confirmed and acute angle-closure glaucoma is excluded.i + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care.i + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +10A26 Patient was NOT newly diagnosed with exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room. +OR +Performance Not Met: +10A27 Patient was diagnosed with new exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room.","All patients, aged 18 and older, who undergo anesthesia care*, except those with pre-existing eye trauma or those patients undergoing ophthalmologic surgery. + +Definition: * Anesthesia care includes general, regional and monitored anesthesia care. + +Denominator Criteria (Eligible Cases): +Patients, aged 18 years or older, on date of encounter +AND +Patient encounter during the reporting period (CPT): +00100, 00102, 00104, 00120, 00124, 00126, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908,00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953, 01958, 01960, 01961, 01962, 01963, 01965, 01966,01967, 01968, 01969, 01991, 01992, 20526, 20550, 20551, 20552, 20553, 20600, 20604, 20605, 20606, 20610, 20611, 27096, 36555, 36556, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 62263, 62264, 62270, 62272, 62273, 62280, 62281, 62282, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62355, 62360, 62361, 62362, 62365, 62370, 63650, 63661, 63662, 63663, 63664, 63685, 63688, 64400, 64402, 64405, 64408, 64410, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 64461, 64462, 64463, 64479, 64480, 64483, 64484, 64486, 64487, 64488, 64489, 64490, 64491, 64492, 64493, 64494, 64495, 64505, 64508, 64510, 64517, 64520, 64530, 64600, 64605, 64610, 64620, 64630, 64633, 64634, 64635, 64636, 64640, 64680, 64681, 72275, 93503, 95990, 95991",Organ Donors as designated by ASA Physical Status 6," +· Patient undergoes ophthalmologic surgery or has a diagnosis of either eye trauma or corneal injury before anesthesia care: 10A22 +· Patients is sedated pharmacologically at time of PACU discharge: 10A23 +· Patient has a co-occurring condition that limits ability to communicate at the time of PACU discharge (e.g. severe dementia, developmental delay or mechanical ventilation): 10A24 +· Patient bypassed the PACU: 10A25 +Denominator Note: Measure not applicable to anesthesia care described by code 00300 when the underlying surgical procedure is described by CPT Codes: 67800, 67801, 67805, 67808, 67810, 67840, 67850, 67875, 67900, or 67938.",None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED3,Dental Injury,"Percentage of patients experiencing dental trauma due to intubation during an anesthetic +procedure.",Patient Safety,"All patients who undergo an anesthetic procedure resulting in chipped or otherwise damaged +teeth due to intubation. +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM03A NO unanticipated dental injury +OR +Performance Not Met: +MM03B EXPERIENCED unanticipated dental injury","All patients who undergo an anesthetic procedure requiring intubation. +Denominator Criteria (Eligible Cases): +All patients, regardless of age +AND +Patient received general anesthesia for a procedure via endotracheal tube: MM3A1 +AND +Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, +00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, +00170, 00172, 00174, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, +00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, +00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, +00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, +00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, +00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, +00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, +00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, +00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, +00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, +00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, +01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, +01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, +01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, +01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, +01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, +01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, +01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, +01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860","• Organ Donors as designated by ASA Physical Status 6 +",• Patients not intubated for anesthetic procedure G22,None,N/A,simple average of the performance rates submitted,Intermediate Outcome,High Priority,Intermediate Outcome,N,Y,N,N,N,Yes,MiraMed +9181695,MiraMed,ABG12,Patient Experience Survey,"Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care. ",Person and Caregiver-Centered Experience and Outcomes,This measure is to be reported each time a patient underwent a procedure* with anesthesia during the reporting period.,"Patients, aged 18 and older, who undergo a procedure* under anesthesia. ","• Organ Donors as designated with ASA Physical Status 6 +• Patient died ",None,None,N/A,simple average of the performance rates submitted,Process,High Priority,,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,AQI31,Perioperative Cardiac Arrest,"Percentage of patients, regardless of age, who undergo a procedure under anesthesia and who experience a cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time.**",Patient Safety,"Patients who experienced an unanticipated cardiac arrest under the care of a qualified anesthesia provider prior to anesthesia end time**. + +Definition: Cardiac arrest is the unplanned cessation of the mechanical activity of the heart as confirmed by the absence of signs of effective circulation. Cardiac compression and/or defibrillation may be required for treatment. + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care.","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic ",• Organ Donors as designated by ASA Physical Status 6,"• Cases with a documented planned cardiac arrest (i.e., use of CPT Code 99116 for deep hypothermia)",None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +9181695,MiraMed,MIRAMED4,Perioperative Mortality Rate,"Percentage of patients, regardless of age, who undergo a procedure* under anesthesia and who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** ",Patient Safety," +Patients who experience mortality under the care of an anesthesia provider prior to anesthesia end time.** + +Definition: Death or mortality is defined as the irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration and brain activity; the end of life. + +** Anesthesia End (Finish) Time is the time at which the anesthesiologist turns over care of the patient to a post anesthesia care team (either PACU or ICU). This time ends when the anesthesia team is no longer furnishing anesthesia services to the patient, that is when the patient may be placed safely under postoperative care and when the anesthesia team has completed transfer of patient care. ","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic ",Organ Donors as designated by ASA Physical Status 6,None,None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED16,Perioperative Pain Plan,"Percentage of patients with signed documentation that a perioperative pain plan using a multimodal, narcotic sparing technique was discussed ",Communication and Care Coordination,"All visits with patients aged 18 years or older at the time of the visit where documentation has been signed attesting to the review of a perioperative pain plan using a multimodal, narcotic sparing technique was discussed. ","All patients, regardless of age, who undergo a procedure* under anesthesia. + +Definition: *Any procedure including surgical, therapeutic or diagnostic ",None,None,None,N/A,simple average of the performance rates submitted,Outcome,High Priority,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,ABG16,Planned use of difficult airway equipment,"For all patients on whom difficult airway equipment is used in the operating room/procedure room, the rate with which it's use is planned ahead of time for either therapeutic or educational purposes.",Effective Clinical Care,"All patients on whom difficult airway equipment is used in the operating room/procedure room for whom use is planned prior to the induction of anesthesia for any reason. The word ""planned"" in this measure means that the equipment was physically present in the operating room/procedure room prior to the induction of anesthesia. + +Performance Met: ABG Observation 036 (use of difficult airway equipment, planned) Reported intraoperatively +Performance Not Met: ABG Observation 037, 38 or 4 (unplanned use of difficult airway equipment, unable to intubate or failed airway) Reported intraoperatively","Patient with an encounter +Criteria (Eligible Cases) +Excluding the following ABG observations: 002, 063, 064, 065 (case cancellations) AND +Excluding Labor Epidural (CPT codes 01960, 01967)",Difficult airway equipment not used,None,None,N/A,simple average of the performance rates submitted,Process,,,N,Y,N,N,N,Yes,Anesthesia Business Group +9181695,MiraMed,AQI31,Postanesthesia Care Unit (PACU) Re-intubation Rate,"Percentage of patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or the postanesthesia care unit (PACU), and required re-intubation prior to PACU discharge. ",Patient Safety,"Patients who required re-intubation in the postanesthesia care unit + +Definition: Reintubation is defined as the need to insert an endotracheal tube resulting from the inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway ","All patients, regardless of age, who received general anesthesia for a procedure via endotracheal tube who were extubated in the operating room or postanesthesia care unit. ","Denominator Exclusions +• Organ Donors as designated by ASA Physical Status 6 +• Patients who bypassed PACU care +• Patient received a planned trial of extubation documented in the medical record prior to removal of the original airway device ",None,None,N/A,N/A,Intermediate Outcome,High Priority,Intermediate Outcome,Y,Y,N,N,N,Yes,Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) +9181695,MiraMed,MIRAMED13,Screening and patient education for high risk patients meeting guidelines for Abdominal Aortic Ultrasound Screening,"Percentage of patients receiving an abdominal aortic aneurysm screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider",Community/Population Health,"All visits with patients aged 18 years or over at the time of the visit where the patient receives an +abdominal aortic aneurysm screening risk assessment using a patient portal or PHR. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM13A1 Patient received an aortic aneurysm screening risk assessment; +follow-up required and provided +MM13A2 Patient received an aortic aneurysm screening risk assessment; +follow-up NOT required +OR +Performance Not Met: +MM13B1 Patient did NOT receive an aortic aneurysm screening risk +assessment +MM13B2 Patient received an aortic aneurysm screening risk assessment; +follow-up required and NOT provided","All patients aged 18 years or older with a visit during the measurement period and meeting the +criteria for abdominal aortic aneurysm screening established by AHRQ, ACP, SVS*. +*AHRQ - Agency for Healthcare Research and Quality +ACS - American Cancer Society +SVS - Society for Vascular Surgery + +Denominator Criteria (Eligible Cases): +Patients aged ≥ 18 years on date of encounter +AND +Patient meets the current screening requirements for abdominal aortic aneurysm +screening established by AHRQ, ACP, SVS",None,None,None,N/A,simple average of the performance rates submitted,Outcome,,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED14,Screening and patient education for high risk patients meeting guidelines for Breast Cancer screening with MRI,"Percentage of patients received a breast cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider. ",Community/Population Health,"All visits with female patients aged 18 years or over at the time of the visit where the patient +received a breast cancer risk assessment using a patient portal or PHR. +Numerator Quality-Data Coding Options for Reporting Satisfactorily + +Performance Met: +MM14A1 Patient received a breast cancer screening risk assessment; followup +required and provided + +MM14A2 Patient received a breast cancer screening risk assessment; followup +NOT required +OR +Performance Not Met: +MM14B1 Patient did NOT receive a breast cancer screening risk assessment +MM14B2 Patient did receive a breast cancer screening risk assessment; +follow-up required and NOT provided ","All female patients aged 18 years or older with a visit during the measurement period and +meeting the criteria for breast cancer screening established by AHRQ, ACS, and NCCN*. + +*AHRQ - Agency for Healthcare Research and Quality +ACS - American Cancer Society +NCCN - National Comprehensive Cancer Network + +Denominator Criteria (Eligible Cases): +Female patients aged ≥ 18 years on date of encounter +AND +Patient meets the current screening requirements for breast cancer screening established +by AHRQ, ACS, and NCCN",None,None,None,N/A,simple average of the performance rates submitted,Outcome,,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED12,Screening and patient education for high risk patients meeting guidelines for Lung Cancer Screening with CT,"Percentage of patients receiving a lung cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow-up from the provider",Community/Population Health,"All visits with patients aged 18 years or over at the time of the visit where the patient receives a +lung cancer screening risk assessment using a patient portal or PHR. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM12A1 Patient received lung cancer screening risk assessment; follow-up +required and provided +MM12A2 Patient received lung cancer screening risk assessment; follow-up NOT required +OR +Performance Not Met: +MM12B1 Patient did NOT receive a lung cancer screening risk assessment +MM12B2 Patient received lung cancer screening risk assessment; follow-up +required and NOT provided","All patients aged 18 years or older with a visit during the measurement period and meeting the +criteria for lung cancer screening established by AHRQ, ACS, and NCCN*. + +*AHRQ - Agency for Healthcare Research and Quality +ACS - American Cancer Society +NCCN - National Comprehensive Cancer Network + +Denominator Criteria (Eligible Cases): +Patients aged ≥ 18 years on date of encounter +AND +Patient meets the current screening requirements for lung cancer screening established by +the AHRQ, ACS, and NCCN",None,None,None,N/A,simple average of the performance rates submitted,Outcome,,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED15,Screening and patient education for high risk patients meeting guidelines for osteoporosis screening,"Percentage of patients received an osteoporosis risk assessment via a patient portal, and if +meeting established criteria, notified of need for follow-up from the provider.",Community/Population Health,"All visits with patients aged 18 years or over at the time of the visit where the patient received an +osteoporosis risk assessment via a patient portal or PHR. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM15A Patient received osteoporosis risk assessment; follow-up required +and provided +OR +Performance Not Met: +MM15B1 Patient did not receive an osteoporosis risk assessment +MM15B2 Patient received an osteoporosis risk assessment; follow-up +required and NOT provided","All patients aged 18 years or older with a visit during the measurement period and meeting the +criteria for osteoporosis screening established by AHRQ, AACE, and NOF*. + +*AHRQ - Agency for Healthcare Research and Quality +AACE - American Association of Clinical Endocrinologists +NOF - National Osteoporosis Foundation + +Denominator Criteria (Eligible Cases): +Patients aged ≥ 18 years on date of encounter +AND +Patient meets the current screening requirements for osteoporosis screening established +by AHRQ, AACE, and NOF",None,None,None,N/A,simple average of the performance rates submitted,Outcome,,Outcome,N,Y,N,N,N,No,MiraMed +9181695,MiraMed,MIRAMED11,Screening and patient education for patients meeting guidelines for Colorectal Cancer screening,"Percentage of patients receiving a colon cancer screening risk assessment via a patient portal, and if meeting established criteria, notified of need for follow up from the provider.",Community/Population Health,"All visits with patients aged 18 years of age or over at the time of visit where the patient receives +an electronic patient portal or PHR that included colon cancer risk assessment, including ability +to input or edit relevant family history and problem list risk factors. + +Numerator Quality-Data Coding Options for Reporting Satisfactorily +Performance Met: +MM11A1 Patient received a colon cancer screening risk assessment; followup +required and provided +MM11A2 Patient received a colon cancer screening risk assessment; follow up NOT required +OR +Performance Not Met: +MM11B1 Patient did NOT receive a colon cancer screening risk assessment +MM11B2 Patient received a colon cancer screening","All patients aged 18 years or older with a visit during the measurement period and meeting the criteria for colorectal cancer screening established by AHRQ, ACS, and NCCN*. + +*AHRQ - Agency for Healthcare Research and Quality +ACS - American Cancer Society +NCCN - National Comprehensive Cancer Network  + +Denominator Criteria (Eligible Cases): +Patients aged ≥ 18 years on date of encounter +AND +Patient meets the current screening requirements for colorectal cancer screening +established by the AHRQ, ACS, and NCCN",None,None,None,N/A,simple average of the performance rates submitted,Outcome,,Outcome,N,Y,N,N,N,No,MiraMed +7881104,MN Community Measurement,"MNCM1 +",Optimal Diabetes Care,"The percentage of patients 18‐75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following: +>HbA1c less than 8.0 mg/dL > Blood Pressure less than 140/90 mmHg >On a statin medication, unless allowed contraindications or exceptions are present +>Non‐tobacco user >Patient with ischemic vascular disease is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present ",Effective Clinical Care,"The number of patients in the denominator whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following: *The most recent HbA1c in the measurement period has a value less than 8.0 mg/dL * The most recent Blood Pressure in the measurement period has a systolic value of less than 140 mmHg AND a diastolic value of less than 90 mmHg *On a statin medication, unless allowed contraindications or exceptions are present * Patient is not a tobacco user *Patient with ischemic vascular disease (Ischemic Vascular Disease Value Set) is on daily aspirin or anti‐platelets, unless allowed contraindications or exceptions are present ","Eligible Population: Eligible Specialties: Family Medicine, Internal Medicine, Geriatric Medicine, Endocrinology Eligible Providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) Ages: 18 years or older at the start of the measurement period AND less than 76 years at the end of the measurement period +Diagnosis: Patient had a diagnosis of diabetes (Diabetes Value Set) with any contact during the current or prior measurement period OR had diabetes (Diabetes Value Set) present on an active problem list at any time during the measurement period. Event: At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period ","Allowable Exclusions: The following exclusions are allowed to be applied to the eligible population: +* Patient was a permanent nursing home resident at any time during the measurement period +* Patient was in hospice or receiving palliative care at any time during the measurement period +* Patient died prior to the end of the measurement period +* Patient was pregnant (Diabetes with Pregnancy Value Set) at any time during measurement period +* Documentation that diagnosis was coded in error +* Patient had only urgent care visits during the measurement period ",None,None,1,,Composite,High Priority,Outcome,N,Y,N,N,N,No,MN Community Measurement +7881104,MN Community Measurement,MNCM2,Optimal Vascular Care,"The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following: +* Blood Pressure less than 140/90 mmHg +* On a statin medication, unless allowed contraindications or exceptions are present +* Non-tobacco user +*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present +",Effective Clinical Care,"The number of patients in the denominator whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following: +*The most recent Blood Pressure in the measurement period has a systolic value of less than 140 mmHg AND a diastolic value of less than 90 mmHg +*On a statin medication, unless allowed contraindications or exceptions are present +* Patient is not a tobacco user +* On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present +","Eligible Population: +Eligible Specialties: Family Medicine, Internal Medicine, Geriatric Medicine, Cardiology +Eligible Providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) Ages: 18 years or older at the start of the measurement period AND less than 76 years at the end of the measurement period +Diagnosis: Patient had a diagnosis of ischemic vascular disease (Ischemic Vascular Disease Value Set) with any contact during the current or prior measurement period OR had ischemic vascular disease (Ischemic Vascular Disease Value Set) present on an active problem list at any time during the measurement period. Event: At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period +","Allowable Exclusions: +The following exclusions are allowed to be applied to the eligible population: +* Patient was a permanent nursing home resident at any time during the measurement period +* Patient was in hospice or receiving palliative care at any time during the measurement period +* Patient died prior to the end of the measurement period +* Documentation that diagnosis was coded in error +* Patient had only urgent care visits during the measurement period",None,None,1,,Composite,High Priority,Outcome,N,Y,N,N,N,No,MN Community Measurement +7881104,MN Community Measurement,MNCM3,Optimal Asthma Control,"Rate 1: The percentage of pediatric (5-17 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period +•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months + +Rate 2: The percentage of adult (18-50 years of age) patients who had a diagnosis of asthma and whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +•Asthma well-controlled as defined by the most recent asthma control tool result available during the measurement period +•Patient not at elevated risk of exacerbation as defined by less than two emergency department visits and/or hospitalizations due to asthma in the last 12 months +",Effective Clinical Care,"The number of patients in the denominator whose asthma was optimally controlled during the measurement period as defined by achieving BOTH of the following: +1. Asthma well -controlled as defined by the most recent asthma control tool result during the Measurement period: +• Asthma Control Test (ACT) greater than or equal to 20 (patients 12 years of age and older) +• Childhood Asthma Control Test (C-ACT) greater than or equal to 20 (patients 11 years of age and younger) +• Asthma Control Questionnaire (ACQ) less than or equal to 0.75 (patients 17 years of age and older) +• Asthma Therapy Assessment Questionnaire (ATAQ) equal to 0 – Pediatric (5 to 17 years of age) or Adult (18 years of age and older). +2. Patient not at elevated risk of exacerbation as defined by less than two patient reported emergency department visits and/or hospitalizations due to asthma in the last 12 months +","Eligible Population: +Eligible Specialties: Family Medicine, Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology +Eligible Providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) +Ages: 5 years or older at the start of the measurement period AND less than 51 years at the end of the measurement period +Event: At least one established patient office visit (Established Pt Asthma Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period + +","The following exclusions must be applied to the eligible population: +• Patient had a diagnosis of cystic fibrosis, COPD, emphysema or acute respiratory failure (Obstructive Lung and Respiratory Failure Value Set) +The following exclusions are allowed to be applied to the eligible population: +• Patient was a permanent nursing home resident at any time during the measurement period +• Patient was in hospice or receiving palliative care at any time during the measurement period +• Patient died prior to the end of the measurement period +• Documentation that diagnosis was coded in error +• Patient had only urgent care visits during the measurement period",None,None,2,weighted average,Outcome,High Priority,Outcome,N,Y,N,N,N,No,MN Community Measurement +7881104,MN Community Measurement,MNCM4,Diabetes Hemoglobin A1c Poor Control (>9.0%),"The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose A1c (HbA1c) was in poor control (> 9.0%) +*HbA1c greater than 9.0 mg/dL",Effective Clinical Care,"The number of patients in the denominator whose A1c (HbA1c) was in poor control (> 9.0%) + +*The most recent HbA1c in the measurement period has a value greater than 9.0 mg/dL","Eligible Population: +Eligible Specialties: Family Medicine, Internal Medicine, Geriatrice Medicine, Endocrinology +Eligible Providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) +Ages:18 years or older at the start of the measurement period AND less than 76 years at the end of the measurement period +Diagnosis: Patient had a diagnosis of diabetes (Diabetes Value Set) with any contact during the current or prior measurement period OR had diabetes (Diabetes Value Set) present on an active problem list at any time during the measurement period. +Event: At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period +","The following exclusions are allowed to be applied to the eligible population: +* Patient was a permanent nursing home resident at any time during the measurement period +* Patient was in hospice or receiving palliative care at any time during the measurement period +* Patient died prior to the end of the measurement period +* Patient was pregnant (Diabetes with Pregnancy Value Set) at any time during measurement period +* Documentation that diagnosis was coded in error +* Patient had only urgent care visits during the measurement period",None,None,1,,Outcome,High Priority,Outcome,Y,Y,N,N,N,No,MN Community Measurement +7881104,MN Community Measurement,MNCM5,Ischemic (IVD): Use of Aspirin or Another Antiplatelet,"The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and are on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present. + +On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present",Effective Clinical Care,"The number of patients in the denominator who are on daily aspirin or anti-platelets unless exceptions or contraindications present +*On daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present","Eligible Population: +Eligible Specialties: Family Medicine, Internal Medicine, Geriatric Medicine, Cardiology +Eligible Providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) +Ages:18 years or older at the start of the measurement period AND less than 76 years at the end of the measurement period +Diagnosis: Patient had a diagnosis of ischemic vascular disease (Ischemic Vascular Disease Value Set) with any contact during the current or prior measurement period OR had ischemic vascular disease (Ischemic Vascular Disease Value Set) present on an active problem list at any time during the measurement period. +Event: At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) performed or supervised by an eligible provider in an eligible specialty for any reason during the measurement period","Allowable Exclusions: +The following exclusions are allowed to be applied to the eligible population: +* Patient was a permanent nursing home resident at any time during the measurement period +* Patient was in hospice or receiving palliative care at any time during the measurement period +* Patient died prior to the end of the measurement period +* Documentation that diagnosis was coded in error +* Patient had only urgent care visits during the measurement period","Allowable Numerator Exceptions: +* Prescribed anti-coagulant medication during the measurement period +* History of gastrointestinal bleeding +* History of intracranial bleeding +* Bleeding disorder +* Other provider documented reason: allergy to aspirin or anti-platelets +* Other provider documented reason: use of non-steroidal anti-inflammatory agents +* Other provider documented reason: documented risk for drug interaction with a medication taken during the measurement period. +* Other provider documented reason: uncontrolled hypertension (systolic blood pressure greater than 180 mmHg and/or diastolic blood pressure greater than 110 mmHg) +* Other provider documented reason: gastroesophageal reflux disease (GERD) + +Note: patients who have these conditions documented reamin in the denominator and receive numerator credit (numerator pass)",None,1,,Process,,,N,Y,N,N,N,No,MN Community Measurement +4454298,"MSN Healthcare Solutions, LLC",MSN6,Report Turnaround Time: Facility CT,Mean CT report turnaround time (RTAT).,Communication and Care Coordination,"The percentage of tests transmitted within a