Performance Measures:
Measures We Support
- Group/Practice
- Health Plan
- Individual Clinician
Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening or monitoring test or had evidence of nephropathy during the measurement year.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
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.
Date Reviewed: November 19, 2017
- Group/Practice
- Health Plan
- Individual Clinician
Cervical Cancer Screening
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
- Women age 21-64 who had cervical cytology performed within the last 3 years
- Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years
- Women age 30-64 who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years
Date Reviewed: January 27, 2022
- Group/Practice
- Individual Clinician
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit.
Date Reviewed: September 28, 2022
- Facility
- Population: Regional and State
Primary Percutaneous Coronary Intervention within 90 minutes of hospital arrival
INACTIVE REVIEW: This measure review is older than five years.
Percentage of acute MI patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary percutaneous coronary artery intervention during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less
Date Reviewed: November 7, 2015
- Facility
- Population: Regional and State
ACEI or ARB Therapy for Left Ventricular Systolic Dysfunction-HF Patients
INACTIVE REVIEW: This measure review is older than five years.
Percent of HF patients with LVSD who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a LVEF less than 40% or a narrative description of left ventricular systolic function consistent with moderate or severe systolic dysfunction.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
Percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting or at hospital discharge
Date Reviewed: November 19, 2017
- Group/Practice
- Health Plan
- Individual Clinician
Diabetes: Eye Exam
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.
Date Reviewed: November 4, 2018
- Individual Clinician
- Population: Regional and State
Use of Pharmacotherapy for Opioid Use Disorder
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Screening for Osteoporosis for Women 65-85 Years of Age
Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis
Date Reviewed: May 4, 2022
- Health Plan
- Integrated Delivery System
Chlamydia Screening in Women
The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
Date Reviewed: November 7, 2015
- Individual Clinician
- Group/Practice
- Health Plan
Colorectal Cancer Screening
Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
Date Reviewed: January 27, 2022
- Group/Practice
- Individual Clinician
One-Time Screening for Hepatitis C Virus for Patients at Risk
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.
Date Reviewed: November 19, 2017
- Facility
- Population: Regional and State
National Healthcare Safety Network Facility-Wide Inpatient Hospital Onset MRSA Bacteremia Outcome
Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset unique blood source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility.
Date Reviewed: July 21, 2018
- Facility
Influenza Immunization
Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Overuse of Neuroimaging for patients with Primary Headache and a Normal Neurological Evaluation
Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Use of Imaging Studies for Low Back Pain
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.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks or older with a diagnosis of HIV/AIDS, who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
Date Reviewed: July 26, 2014
- Group/Practice
- Health Plan
- Individual Clinician
- Integrated Delivery System
- Population: Community, County, or City, Regional and State
Annual Cervical Screening in High Risk Women
This measure identifies women age 12 to 65 diagnosed with cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS prior to the measurement year, and who still have a cervix, who had a cervical CA screen during the measurement year.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Tobacco Use: Screening & Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Date Reviewed: November 19, 2017
- Facility
Sub-1 Alcohol Use Screening
Hospitalized patients 18 years of age and older who are screened within the first day of admission using a validated screening questionnaire for unhealthy alcohol use.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
- Health Plan
Osteoporosis Management in Women who had a Fracture
The percentage of women 50–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.
Date Reviewed: May 4, 2022
- Health Plan
Chronic Liver Disease: Hepatitis A Vaccination
INACTIVE REVIEW: This measure review is older than five years.
The percentage of adult patients with chronic liver disease who have received a hepatitis A vaccine.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Annual Hepatitis C Virus Screening for Patients who are Active Injection Drug Users
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period.
Date Reviewed: November 19, 2017
- Facility
- Population: Regional and State
National Healthcare Safety Network Central Line-Associated Blood Stream Infection (CLABSI) Outcome Measure
Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations. This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.
Date Reviewed: July 21, 2018
- Individual Clinician
- Integrated Delivery System
INR for Individuals Taking Warfarin and Interacting Anti-Infective Medications
Date Reviewed: April 8, 2019
- Facility
- Group/Practice
Risk-Adjusted Operative Mortality for CABG
Percent of patients aged 18 years and older undergoing isolated CABG who die, including both: 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure.
Date Reviewed: November 7, 2015
- Health Plan
- Integrated Delivery System
Medication Management for People with Asthma
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.
Date Reviewed: November 19, 2017
- Facility
- Group/Practice
- Individual Clinician
HIV: Viral Load Suppression
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. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed antithrombotic therapy at discharge.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Angiotensin Converting Enzyme-Inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARB) Therapy--Diabetes of LVSD (LVEF <40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.
Date Reviewed: November 4, 2018
- Facility
Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for Left Ventricular Systolic Dysfunction (LVSD) Prescribed at Discharge
INACTIVE REVIEW: This measure review is older than five years.
Proportion of heart failure patients age18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
- Integrated Delivery System
- Population: Community, County, or City, Regional and State
Annual cervical cancer screening or follow-up in high-risk women
INACTIVE REVIEW: This measure review is older than five years.
This measure identifies women age 12 to 65 diagnosed with cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS prior to the measurement year, and who still have a cervix, who had a cervical CA screen during the measurement year.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
- Health Plan
Follow-Up After Hospitalization for Mental Illness (FUH)
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 a follow-up visit with a mental health practitioner. Two rates are submitted:
• The percentage of discharges for which the patient received follow-up within 30 days after discharge.
• The percentage of discharges for which the patient received follow-up within 7 days after discharge.
Date Reviewed: April 1, 2021
- ACO
- Health Plan
Plan All-Cause Readmissions (PCR)
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:
1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission
*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).
Date Reviewed: April 1, 2021
- Group/Practice
- Individual Clinician
Influenza Immunization
Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.
Date Reviewed: November 19, 2017
- Facility
Prescription of HIV Antiretroviral Therapy
Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.
Date Reviewed: November 7, 2015
- Facility
- Individual Clinician
Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
INACTIVE REVIEW: This measure review is older than five years.
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation (AF) ablation
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
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.
Date Reviewed: November 19, 2017
- Individual Clinician
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Ischemic Vascular Disease: Use of Aspirin or Another Platelet
The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and were on daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.
Date Reviewed: November 19, 2017
- Group/Practice
- Health Plan
- Individual Clinician
- Integrated Delivery System
Persistence of Beta-Blocker Treatment After a Heart Attack
The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Chronic Stable Coronary Artery Disease: Antiplatelet Therapy
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel.
Date Reviewed: November 19, 2017
- Facility
Post-Discharge Appointment for Heart Failure Patients
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of heart failure for whom a follow up appointment was scheduled and documented prior to discharge (as specified).
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
HIV/AIDS: CD4 Cell Count or Percentage Performed
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged six months and older with a diagnosis of HIV/AIDS, with at least two CD4 cell counts or percentages performed during the measurement year at least 3 months apart
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
Date Reviewed: November 19, 2017
- Health Plan
- Integrated Delivery System
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.
Date Reviewed: November 19, 2017
- Facility
30-day, all-cause, risk-standardized mortality rate following Percutaneous Coronary Intervention for patients with ST segment elevation MI or cardiogenic shock
INACTIVE REVIEW: This measure review is older than five years.
This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention among patients who are 18 years of age or older with STEMI or cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry CathPCI registry for risk adjustment. For the purpose of development, the measure cohort was derived in a Medicare FFS population of patients 65 years of age or older with a PCI. For the purpose of development and testing, the measure used a Medicare FFS population of patients 65 years of age or older with a PCI. However, the measure is designed to be used in the broader population of PCI patients
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Rheumatoid Arthritis: Functional Status Assessment
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.
Date Reviewed: April 27, 2015
- Group/Practice
- Individual Clinician
Evaluation or Interview for Risk of Opioid Misuse
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.
Date Reviewed: November 19, 2017
- Health Plan
- Individual Clinician
- Integrated Delivery System
Breast Cancer Screening
Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.
Date Reviewed: January 27, 2022
- Group/Practice
- Individual Clinician
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Percentage of the following patients-all considered at high risk of cardiovascular events-who were prescribed or were on statin therapy during the measurement period:
Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
Adults aged >=21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Assessment of Hepatitis B Virus (HBV) Status before Initiating Anti-Tumor Necrosis Factor (TNF) Therapy
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.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
Coronary Artery Disease: Beta Blocker Therapy - Prior Myocardial Infarction or Left Ventricular Systolic Dysfunction (LVEF <40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior myocardial infarction or a current or prior LVEF <40% who were prescribed beta-blocker therapy.
Date Reviewed: November 19, 2017
- Health Plan
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received an HbA1c test during the measurement year.
Date Reviewed: November 7, 2015
- Facility
Risk-Adjusted CABG Readmission Rate
INACTIVE REVIEW: This measure review is older than five years.
Risk adjusted percentage of Medicare FFS beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.
Date Reviewed: November 7, 2015
- Facility
Hospital Risk-Standardized Complication Rate Following Implantation of ICD
INACTIVE REVIEW: This measure review is older than five years.
This measure provides hospital specific risk-standardized rates of procedural complications following the implantation of an ICD in patients at least 65 year of age. At present, the measure uses clinical data available in the National Cardiovascular Data Registry ICD registry for risk adjustment that has been linked with administrative claims data using direct and indirect patient identifiers to identify procedural complications
Date Reviewed: November 7, 2015
- Facility
- Integrated Delivery System
Hospital Wide All Cause Readmission Measure
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital-level risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge. The measure reports a single summary risk-standardized readmission rate (RSRR), derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology, each of which will be described in greater detail below. The measure also indicates the hospital-level standardized risk ratios (SRR) for each of these five specialty cohorts. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Admissions for planned procedures that are not accompanied by an acute diagnosis do not count as readmissions in the measure outcome. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals.
Date Reviewed: November 7, 2015
- Facility
Skilled Nursing Facility 30-Day All Cause Readmission
INACTIVE REVIEW: This measure review is older than five years.
This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions.
A risk-adjusted readmission rate for each facility is calculated as follows:
- Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility's effects on readmission rates.
- Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate.
For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures.
The measure specifications are designed to harmonize with CMS' hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM.
Date Reviewed: November 7, 2015
- Individual Clinician
Sleep Apnea: Positive Airway Pressure Therapy Prescribed
INACTIVE REVIEW: This measure review is older than five years.
Patients who were prescribed positive airway pressure therapy as a proportion of all patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea
Date Reviewed: April 8, 2013
- Health Plan
- Integrated Delivery System
Flu Vaccinations for Adults Ages 18 and Older
The percentage of adults 18 years of age and older who self-report receiving an influenza vaccine within the measurement period. This measure is collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, and commercial populations. It is reported as two separate rates stratified by age: 18-64 and 65 years of age and older.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
- Integrated Delivery System
Cardiac Rehabilitation: Patient Referral from an Outpatient Setting
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.
Date Reviewed: November 19, 2017
- Individual Clinician
AFib and Aflutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation 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 .
Date Reviewed: March 19, 2017
- Group/Practice
- Individual Clinician
Hepatitis C: Testing for Chronic Hepatitis C - Confirmation of Hepatitis C Viremia
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.
Date Reviewed: November 19, 2017
- Facility
Therapy with ASA, P2Y12 inhibitor, and statin at discharge following PCI in eligible patients
INACTIVE REVIEW: This measure review is older than five years.
Patients undergoing PCI who receive prescriptions for all medications (ASA, P2Y12 and statins) for which they are eligible for at discharge
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge
Date Reviewed: April 7, 2014
- Group/Practice
- Individual Clinician
Rheumatoid Arthritis: Tuberculosis Screening
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who have documentation of a tuberculosis (TB) screening performed within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).
Date Reviewed: April 27, 2015
- Group/Practice
- Individual Clinician
Rheumatoid Arthritis: Assessment of Disease Activity
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.
Date Reviewed: April 27, 2015
- Facility
In-hospital Risk Adjusted Rate of Bleeding Events for Patients Undergoing PCI
INACTIVE REVIEW: This measure review is older than five years.
Risk adjusted rate of intra and post procedure bleeding for all patients aged 18 and over undergoing PCI
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Adult Sinusitis: CT for Acute Sinusitis (Overuse)
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.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
COPD: Spirometry Evaluation
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Comprehensive Diabetes Care: Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening or monitoring test or had evidence of nephropathy during the measurement year.
Date Reviewed: March 29, 2019