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NQF Endorsed

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

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

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

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

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

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

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

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

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

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

The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS 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

Controlling High Blood Pressure for People with Serious Mental Illness

The percentage of patients 18-85 years of age with serious mental illness who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year.
Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0018: Controlling High Blood Pressure). It was originally endorsed in 2009 and is owned and stewarded by NCQA. The specifications for the existing measure (Controlling High Blood Pressure NQF #0018) have been updated based on 2013 JNC-8 guideline. NCQA will submit the revised specification for Controlling High Blood Pressure NQF #0018 in the 4th quarter 2014 during NQF’s scheduled measure update period. This measure uses the new specification to be consistent with the current guideline.

Date Reviewed: July 21, 2018

Dehydration Admission Rate (PQI 10)

Admissions with a principal diagnosis of dehydration per 100,000 population, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.
[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

Date Reviewed: July 21, 2018

Diabetes Monitoring for People with Diabetes and Schizophrenia

The percentage of patients 18 – 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.

Date Reviewed: July 21, 2018

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

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

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

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

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

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

National Healthcare Safety Network Antimicrobial Use Measure

This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN). The antimicrobial use data that are in scope for this measure are antibacterial agents administered to adult and pediatric patients in a specified set of ward and intensive care unit locations: medical, medical/surgical, and surgical wards and units. The measure compares antimicrobial use that the hospitals report with antimicrobial use that is predicted on the basis of nationally aggregated data. The measure is comprised of a discrete set of ratios, Standardized Antimicrobial Administration Ratios (SAARs), each of which summarizes observed-to-predicted antibacterial use for one of 16 antibacterial agent-patient care location combinations. The SAARs are designed to serve as high value targets or high level indicators for antimicrobial stewardship programs (ASPs). SAAR values that are outliers are intended to prompt analysis of possible overuse, underuse, or inappropriate use of antimicrobials, subsequent actions aimed at improving the quality of antimicrobial prescribing, and impact evaluations of ASP interventions.

Date Reviewed: July 21, 2018

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

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

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

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

Severe Sepsis and Septic Shock: Management Bundle

This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, the measure contains several elements, including measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, these elements should be performed in the early management of severe sepsis and septic shock.

Date Reviewed: July 21, 2018

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

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

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

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

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

Colorectal Cancer Screening

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

Date Reviewed: November 19, 2017

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

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

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: Foot Exam

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.

Date Reviewed: November 19, 2017

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

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/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

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

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

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

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

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

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

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

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

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

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

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

30-day, all-cause, risk-standardized mortality rate following Percutaneous Coronary Intervention for patients with ST segment elevation MI or cardiogenic shock

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

Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation (AF) ablation

Date Reviewed: November 7, 2015

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

Chronic Liver Disease: Hepatitis A Vaccination

The percentage of adult patients with chronic liver disease who have received a hepatitis A vaccine.

Date Reviewed: November 7, 2015

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

Gap in HIV Medical Visits

Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of 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

Heart Failure Admission Rate (PQI 8)

Admissions with a principal diagnosis of heart failure per 100,000 populations, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions. NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000.

Date Reviewed: November 7, 2015

HIV medical visit frequency

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. 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

Hospital 30-day, all cause, risk-standardized mortality rate following acute MI hospitalization for patients 18 and older

The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of acute MI. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities

Date Reviewed: November 7, 2015

Hospital 30-day, all cause, unplanned, risk-standardized readmission rate following CABG surgery

The measure estimates a hospital-level risk-standardized readmission rate, defined as unplanned readmission for any cause within 30 days from the date of discharge of the index CABG procedure, for patients 18 years and older discharged from the hospital after undergoing a qualifying isolated CABG procedure. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

Date Reviewed: November 7, 2015

Hospital 30-day, all-cause, risk standardized readmission rate following acute MI hospitalization

The measure estimates a hospital-level 30-day risk-standardized readmission rate for patients discharged from the hospital with a principal diagnosis of acute MI. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients aged 18 years and older. CMS annually reports the measure for individuals who are 65 years and older and are either Medicare FFS beneficiaries hospitalized in non-federal hospitals or patients hospitalized in Department of VA facilities

Date Reviewed: November 7, 2015

Hospital 30-Day, all-cause, risk standardized readmission rate following heart failure hospitalization

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal diagnosis of heart failure (HF). The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.

Date Reviewed: November 7, 2015

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft Surgery

The measure estimates a hospital-level risk-standardized mortality rate for patients 18 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 30 days of the procedure date of an index CABG admission. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

Date Reviewed: November 7, 2015

Hospital 30-day, all-cause, risk-standardized mortality rate following heart failure hospitalization for patients 18 and older

The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of HF. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities.

Date Reviewed: November 7, 2015

Hospital Risk-Standardized Complication Rate Following Implantation of ICD

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

Hospital Wide All Cause Readmission Measure

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

In-hospital Risk Adjusted Rate of Bleeding Events for Patients Undergoing PCI

Risk adjusted rate of intra and post procedure bleeding for all patients aged 18 and over undergoing PCI

Date Reviewed: November 7, 2015

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

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

Skilled Nursing Facility 30-Day All Cause Readmission

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

Therapy with ASA, P2Y12 inhibitor, and statin at discharge following PCI in eligible patients

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

Total Cost of Care Population-Based PMPM Index (Cost/Resource use Measure)

Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices.

Total Cost Index (TCI) is a measure of a primary care provider's risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.

A Total Cost of Care Index when viewed together with a Resource Use measure provides a more complete picture of population based drivers of health care costs.

Date Reviewed: November 7, 2015

Pharmacologic Therapy for Persistent Asthma

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

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)

The percentage of members 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: April 27, 2015

Depression Response at Twelve Months, Progress Towards Remission

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate a response to treatment at twelve months defined as a PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment.

Date Reviewed: April 27, 2015

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

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

Heart Failure: Left Ventricular Ejection Fraction Assessment (Outpatient Setting)

Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12 month period

Date Reviewed: November 26, 2014

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

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

Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent-Hemoglobin Level > 12.0 g/dL

Percentage of calendar months within a 12-month period during which a Hemoglobin is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT) or ESRD (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy and have a Hemoglobin Level > 12.0 g/dL

Date Reviewed: November 23, 2013

Adults with Diabetes Mellitus That Had a Serum Creatinine in the Last 12 Reported Months

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months

Date Reviewed: November 23, 2013