Performance Measures:

Age Appropriate Screening Colonoscopy

The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.

Date Reviewed: January 27, 2022

Use of Opioids from Multiple Providers and at High Dosage in Persons without Cancer

The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies.

Date Reviewed: May 11, 2023

Dementia: Counseling Regarding Safety Concerns

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within in a 12 month period

Date Reviewed: November 19, 2017

Controlling High Blood Pressure

The percentage of adults 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.

Date Reviewed: July 1, 2021

Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence

The percentage of patients 18 years and older with a serious mental illness or alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user. Two rates are reported.
Rate 1: The percentage of patients 18 years and older with a diagnosis of serious mental illness who received a screening for tobacco use and follow-up for those identified as a current tobacco user.
Rate 2: The percentage of adults 18 years and older with a diagnosis of alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user.
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention NQF #0028). This measure is currently stewarded by the AMA-PCPI and used in the Physician Quality Reporting System.

Date Reviewed: July 21, 2018

Comprehensive Diabetes Care: Hemoglobin A1c Control (<8%)

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Date Reviewed: July 21, 2018

Care for Older Adults-Medication Review

Date Reviewed: April 8, 2019

Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis

The percentage of patients 18 years and older by the end of the measurement period, diagnosed with rheumatoid arthritis and who had at least one ambulatory prescription for a disease-modifying anti-rheumatic drug.

Date Reviewed: April 27, 2015

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System Groups

The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN) and assesses each group’s readmission rate. This clinician group-level, risk-standardized, all-cause unplanned readmission measure is a re-specified version of the hospital-level measure, “Hospital-wide Allcause Unplanned Readmission Measure” (NQF 1789), which is currently reported within the Inpatient Quality Reporting (IQR) program. This measure will replace the existing All-Cause Readmission (ACR) measure currently in use in QPP.

Date Reviewed: April 1, 2021

National Healthcare Safety Network Facility-Wide Inpatient Hospital-Onset Clostridium Difficile (CDI) Outcome Measure

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

Date Reviewed: July 21, 2018

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter.

Date Reviewed: September 28, 2022

Controlling High Blood Pressure

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

Date Reviewed: November 19, 2017

Medication Reconciliation Post-Discharge

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. This measure is reported as three rates stratified by age group:
Reporting Criteria 1: 18-64 years of age
Reporting Criteria 2: 65 years of age
Total Rate: All patients 18 years of age and older

Date Reviewed: November 19, 2017

Colorectal Cancer Screening

Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.

Date Reviewed: January 27, 2022

HIV Infection Screening

Percentage of patients 15-65 years of age who were tested at least once for HIV.

Date Reviewed: November 4, 2018

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin with or without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis

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.

Date Reviewed: November 19, 2017

Depression Remission at Six Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 60 days) after an index event date.

Date Reviewed: September 28, 2022

Depression Response at Six Months- Progress Towards Remission

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who are progressing towards remission by achieving a response (PHQ-9 or PHQ-9M score reduced by 50% or greater) six months (+/- 60 days) after an index visit.

Date Reviewed: September 28, 2022

SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB 2a Alcohol Use Brief Intervention

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included.

Date Reviewed: July 21, 2018

Medical Assistance with Smoking and Tobacco Cessation

he three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:
Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who received advice to quit during the measurement year.
Discussing Cessation Medications: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year.
Discussing Cessation Strategies: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year.

Date Reviewed: July 21, 2018

Adult Sinusitis: Appropriate Choice of Antibiotic Prescribed for Acute Sinusitis (Overuse)

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.

Date Reviewed: November 19, 2017

CAHPS for MIPS Clinician/Group Survey

Getting timely care, appointments, and information; How well providers communicate; Patient’s rating of provider; Access to specialists; Health promotion & education; Shared decision making; Health status/functional status; Courteous and helpful office staff; Care coordination; Between visit communication; Helping to take medications as directed; and Stewardship of patient resources.

Date Reviewed: November 19, 2017

Safe Use of Opioids-Concurrent Prescribing

Date Reviewed: April 8, 2019

COPD: Inhaled Bronchodilator Therapy

Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.

Date Reviewed: November 19, 2017

Depression Response at Twelve Months, Progress Towards Remission

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who are progressing towards remission by achieving a response (PHQ-9 or PHQ-9M score reduced by 50% or greater) twelve months (+/- 60 days) after an index visit.

Date Reviewed: September 28, 2022

Functional Outcome Assessment

Date Reviewed: April 8, 2019

Risk-Standardized Acute Admission Rates for Patients with Heart Failure

Date Reviewed: April 8, 2019

Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions

Date Reviewed: April 8, 2019

Pain Brought Under Control Within 48 Hours

Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours.

Date Reviewed: November 19, 2017

Depression Utilization of the PHQ-9 Tool

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 tool during a four month measurement period.

Date Reviewed: September 28, 2022

Potentially Harmful Drug-Disease Interactions in the Elderly

Date Reviewed: April 8, 2019

Post-Discharge Appointment for Heart Failure Patients

Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Date Reviewed: July 21, 2018

Shared Decision Making

Date Reviewed: April 8, 2019

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Date Reviewed: November 19, 2017

Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (AMI)

Date Reviewed: April 8, 2019

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

Venous Thromboembolism Prophylaxis

This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. This measure is part of a set of six nationally implemented prevention and treatment measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Hospital Acquired Potentially-Preventable VTE) that are used in The Joint Commission’s accreditation process.

Date Reviewed: July 21, 2018

Hypertension Improvement in Blood Pressure

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Date Reviewed: November 19, 2017

Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.

Date Reviewed: January 27, 2022

CollaboRATE Shared Decision Making Score

CollaboRATE is a patient-reported measure of shared decision making which contains three brief questions that patients, their parents, or their representatives complete following a clinical encounter. The CollaboRATE measure provides a performance score representing the percentage of adults 18 and older who experience a high level of shared decision making.

Date Reviewed: April 1, 2021

Patients Treated with an Opioid who are Given a Bowel Regimen

Date Reviewed: April 8, 2019

Risk-Standardized Acute Admission Rates for Patients with Diabetes

Date Reviewed: April 8, 2019

Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotic Medications (SSD)

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 measurement year.

Date Reviewed: July 21, 2018

Functional Status Assessment for Patients with Congestive Heart Failure

Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.

Date Reviewed: November 19, 2017

National Healthcare Safety Network Catheter Associated Urinary Tract Infection (CAUTI)

Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU). This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

Date Reviewed: July 21, 2018

Pharmacologic Therapy for Persistent Asthma

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patient aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication Three rates are reported for this measure:

1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication
2. Patients prescribed other alternative long term control medications (non-ICS)
3. Total patients prescribed long-term control medication

Date Reviewed: July 26, 2015

Concurrent Use of Opioids and Benzodiazepines (COB)*

The percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines during the measurement year.

Date Reviewed: May 11, 2023

Discharge to Community

Date Reviewed: April 8, 2019

TOB-2 Tobacco use Treatment provided or Offered and the subset measure TOB-2a: Tobacco Use Treatment

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom tobacco use treatment was provided during the hospital stay, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment during the hospital stay.

Date Reviewed: July 21, 2018

Advance Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Date Reviewed: November 19, 2017

Health-Related Quality of Life in Chronic Obstructive Pulmonary Disease (COPD) Patients Before and After Pulmonary Rehabilitation

Date Reviewed: April 8, 2019

HIV/AIDS: Sexually Transmitted Diseases - Screening for Chlamydia, Gonorrhea, and Syphilis

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.

Date Reviewed: November 19, 2017

Use of Appropriate Medications for People with Asthma

INACTIVE REVIEW: This measure review is older than five years.

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year

Date Reviewed: July 26, 2015

Rheumatoid Arthritis (RA): Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug therapy within 12 months.

Date Reviewed: April 27, 2015

Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient

Date Reviewed: April 8, 2019

Depression Remission at Twelve Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.

Date Reviewed: September 28, 2022

SUB-3a Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.

These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).

Date Reviewed: July 21, 2018

Alcohol Screening and Follow-up for People with Serious Mental Illness

The percentage of patients 18 years and older with a serious mental illness, who were screened for unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy alcohol user.
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (NQF #2152: Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling). It was originally endorsed in 2014 and is currently stewarded by the American Medical Association (AMA-PCPI).

Date Reviewed: July 21, 2018

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

Date Reviewed: November 19, 2017

Excess Days in Acute Care after Hospitalization for Heart Failure

Date Reviewed: April 8, 2019

Pneumococcal Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Date Reviewed: November 19, 2017

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year.

Date Reviewed: November 19, 2017

Use of High-Risk Medications in the Elderly

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported:

a. Percentage of patients who were ordered at least one high-risk medication

b. Percentage of patients who were ordered at least two different high-risk medications.

Date Reviewed: November 19, 2017

Optimal Asthma Control

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.

Date Reviewed: November 19, 2017

Anti-Depressant Medication Management

"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.
a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).
b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

Date Reviewed: September 28, 2022

Appropriate Use of DXA Scans in Women Under 65 Years Who do not Meet the Risk Factor Profile for Osteoporosis

Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.

Date Reviewed: May 4, 2022

Opioid Therapy: Follow-up Evaluation

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.

Date Reviewed: November 19, 2017

Ambulatory Palliative Care Patients’ Experience of Receiving Desired Help for Pain

The percentage of patients aged 18 years and older who had an ambulatory palliative care visit and report getting the help they wanted for their pain from their palliative care provider and team within 6 months of the ambulatory palliative care visit.

Date Reviewed: May 11, 2023

Comprehensive Diabetes Care: Hemoglobin A1c (HgbA1c)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  

Date Reviewed: November 19, 2017

Excess Days in Acute Care after Hospitalization for Pneumonia

Date Reviewed: April 8, 2019