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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Proportion of Patients with a Chronic Condition that have a Potentially Avoidable Complication during a Calendar Year

Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months. Please reference attached document labeled NQF_Chronic_Care_PACs_01_24_17.xls, in the tabs labeled PACs I-9 & I-10 for a list of code definitions of PACs relevant to each of the above chronic conditions.

We define PACs as one of two types:
(1) Type 1 PACs - PACs related to the index condition: Patients are considered to have a PAC, if they receive services during the episode time window for any of the complications directly related to the chronic condition, such as for acute exacerbation of the index condition, respiratory insufficiency in patients with Asthma or COPD, hypotension or fluid and electrolyte disturbances in patients with CAD, HF or diabetes etc.
(2) Type 2 PACs - PACs related to Patient Safety or broader System Failures: Patients are also considered to have a PAC, if they receive services during the episode time window for any of the complications related to patient safety or health system failures such as for sepsis, infections, phlebitis, deep vein thrombosis, pressure sores etc.

Date Reviewed: July 21, 2018

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

Management of Neuropsychiatric Symptoms

Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period

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

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

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

Referral to Otologic Evaluation for Patients with Acute or Chronic Dizziness

Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.

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

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

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

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

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: 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

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

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

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

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

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

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Date Reviewed: November 19, 2017

More Than One CT Scan Within 90 Days for Chronic Sinusitis

Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis.

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

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

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

Adult Kidney Disease: Blood Pressure Management

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care.

Date Reviewed: November 19, 2017

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

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

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

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

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

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

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

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/AIDS: Screening for High Risk Sexual Behaviors

Percentage of patients, aged 13 years and older, who were screened for high risk sexual behaviors at least once within 12 months.

Date Reviewed: November 7, 2015

Post-Discharge Evaluation for Heart Failure Patients

Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program team member within 72 hours after inpatient discharge.

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 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, 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

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

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

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 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 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

Chlamydia Screening and Follow-up

The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up

Date Reviewed: November 7, 2015

Asthma Medication Ratio

The percentage of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Date Reviewed: July 26, 2015

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)

Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 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 26, 2015

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

Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: April 27, 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

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

Hepatitis C: Antiviral Treatment Prescribed

Date Reviewed: July 26, 2014

Hepatitis C Ribonucleic Acid (RNA) Testing Before Initiating Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment (paired with NQF 0396)

Date Reviewed: July 26, 2014

Hepatitis C: HCV RNA Testing at No Greater Than Week 12 of Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at no greater than 12 weeks from initiation of antiviral treatment

Date Reviewed: July 26, 2014

HCV Genotype Testing Prior to Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment (paired with NQF 0395)

Date Reviewed: July 26, 2014

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, who had at least two medical visits during the measurement year, with at least 90 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load < 200 copies/mL after at least 6 months of potent antiretroviral therapy

Date Reviewed: July 26, 2014

HIV/AIDS: Medical Visit

Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS, with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit

Date Reviewed: July 26, 2014

Hepatitis C: Hepatitis A Vaccination

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A (paired with PQRS 184)

Date Reviewed: July 26, 2014

HIV/AIDS: Adolescent and Adult Patients who are Prescribed Potent Antiretroviral Therapy

Percentage of patients with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit: aged 13 years and older who have a history of a CD4 count less than or equal to 500 cells/mm3; aged 13 years and older who have a history of an AIDS-defining illness, regardless of CD4 count; or who are pregnant, regardless of CD4 count or age, who were prescribed potent antiretroviral therapy

Date Reviewed: July 26, 2014

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period

Date Reviewed: July 26, 2014

Hepatitis C: Hepatitis B Vaccination

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B

Date Reviewed: July 26, 2014

Staging of Dementia

Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period

Date Reviewed: April 7, 2014

Dementia: Screening for Depressive Symptoms

Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge

Date Reviewed: April 7, 2014

Dementia: Counseling Regarding Risks of Driving

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Screening for Dysphagia

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered DVT prophylaxis by the end of hospital day two

Date Reviewed: April 7, 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

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

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

Adult Kidney Disease: Laboratory Testing (Lipid Profile)

Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy (RRT)) who had a fasting lipid profile performed at least once within a 12-month period

Date Reviewed: November 23, 2013

Non-Diabetic Nephropathy - Use of ACE Inhibitor or ARB Therapy

The percentage of patients aged 18 years and older with proteinuria who are taking an ACE inhibitor or ARB

Date Reviewed: November 23, 2013

GERD - Upper Gastrointestinal Study in Adults with Alarm Symptoms

The percentage of adult patients with gastroesophogeal reflux disease (GERD) with alarm symptoms who have had an upper gastrointestinal study

Date Reviewed: November 18, 2013

As part of an ongoing effort to improve user experience, we have made some updates to the Performance Measures section of ACP. Tell us what you think!