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MIPs Measures

Adherence to Antipsychotic Medications for Individuals with Schizophrenia

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).

Date Reviewed: November 4, 2018

Adult major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: November 19, 2017

Adult Major Depressive Disorder: Coordination of Care of Patients with Specific Comorbid Conditions

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.

Date Reviewed: November 19, 2017

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

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

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

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

Age Appropriate Screening Colonoscopy

The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.

Date Reviewed: November 4, 2018

Angiotensisn Converting Enzyme-Inhibitor (ACE-I) or Angiotensisn 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

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

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: November 19, 2017

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

Percentage of patients aged 50 years to 75 years 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: November 4, 2018

Assessment and Classification of Disease Prognosis

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.

Date Reviewed: April 27, 2015

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

Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.

Date Reviewed: November 19, 2017

Avoidance of Antibioitc 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

Breast Cancer Screening

The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

Date Reviewed: November 4, 2018

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

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

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients

Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period.

Date Reviewed: November 19, 2017

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Surgery Patients

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 asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.

Date Reviewed: November 19, 2017

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 every 3 years.
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.

Date Reviewed: November 17, 2017

Closing the Referral Loop: Receipt of the Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Date Reviewed: July 21, 2018

Colorectal Cancer Screening

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

Date Reviewed: November 19, 2017

Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

Percentage of adults 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication.

Date Reviewed: November 4, 2018

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

Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

Percentage of adults 18-64 years of age with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.

Date Reviewed: November 4, 2018

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

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

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

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

Dementia: Caregiver Education Support

Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

Date Reviewed: November 19, 2017

Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.

Date Reviewed: November 19, 2017

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

Dementia: Functional Status Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

Date Reviewed: November 19, 2017

Dementia: Neuropsychiatric Symptom Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

Date Reviewed: November 19, 2017

Depression Remission at Six Months

Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator.

Date Reviewed: November 19, 2017

Depression Remission at Twelve Months

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the denominator

Date Reviewed: November 19, 2017

Depression Utilization of the PHQ-9 Tool

Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit.

Date Reviewed: November 19, 2017

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

Diabetic Foot & Ankle Care, Peripheral Neuropathy-Neurological Evaluation

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.

Date Reviewed: November 19, 2017

Diabetic Foot & Ankle Care, Ulcer Prevention-Evaluation of Footwear

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.

Date Reviewed: November 19, 2017

Discussion and Shared Decision Making Surrounding Treatment Options

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.

Date Reviewed: November 19, 2017

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

Elder Maltreatment Screen and Follow-up Plan

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.

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

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

Falls: Screening, Risk-Assessment, and Plan of care to Prevent Future Falls

This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:
A) Screening for Future Fall Risk: Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months
B) Falls Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
C) Plan of Care for Falls: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months

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

Glucocorticoid Management

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.

Date Reviewed: November 19, 2017

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

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

HIV Infection Screening

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

Date Reviewed: November 4, 2018

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

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

IBD: Preventive Care: Corticosteroid Related Iatrogenic Injury-Bone Loss Assessment

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 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.

Date Reviewed: November 19, 2017

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

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following.
- Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
- Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.

Date Reviewed: July 21, 2018

Ischemic Vascular Disease: All or None Outcome Measure

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

Date Reviewed: November 19, 2017

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

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

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

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

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

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

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

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

Osteoarthritis: Function and Pain Assessment

Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain.

Date Reviewed: November 19, 2017

Osteoporosis Management in Women who had a Fracture

The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture.

Date Reviewed: November 19, 2017

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

Pain Assessment and Follow-up

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.

Date Reviewed: November 19, 2017

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

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

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

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

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

Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented.

Date Reviewed: November 19, 2017

Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

Date Reviewed: November 19, 2017

Quality of Life Assessment for Patients with Primary Headache Disorders

Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.

Date Reviewed: November 19, 2017

Rheumatoid Arthritis: Assessment of Disease Activity

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

Rheumatoid Arthritis: Functional Status Assessment

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

Rheumatoid Arthritis: Tuberculosis Screening

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

Screening for Hepatocellular Carcinoma in Patients with Cirrhosis

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.

Date Reviewed: November 19, 2017

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: November 19, 2017

Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.

Date Reviewed: November 4, 2018

Sleep Apnea: Assessment of Sleep Symptoms

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness.

Date Reviewed: November 19, 2017

Sleep Apnea: Severity Assessment at Initial Diagnosis

Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.

Date Reviewed: November 4, 2018

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

Stroke and Stroke Rehabilitation: Thrombolytic Therapy

This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well

Date Reviewed: April 7, 2014

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

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

Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier

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.

Date Reviewed: November 4, 2018

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

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

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

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

Zoster (Shingles) Vaccination

The percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination.

Date Reviewed: November 4, 2018