|
Quality Id |
Measure Name |
High Priority |
Measure Type |
Measure Description |
|
005 |
Heart
Failure (HF): Angiotensin-Converting Enzyme (ACE)
Inhibitor or Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
No |
Process |
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 ACE inhibitor or ARB therapy either within a 12 month
period when seen in the outpatient setting OR at each hospital discharge |
|
006 |
Coronary
Artery Disease (CAD): Antiplatelet Therapy |
No |
Process |
Percentage
of patients aged 18 years and older with a diagnosis of coronary artery
disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel |
|
007 |
Coronary
Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI)
or Left Ventricular Systolic Dysfunction (LVEF < 40%) |
No |
Process |
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 MI OR a current
or prior LVEF <40% who were prescribed beta-blocker therapy |
|
008 |
Heart
Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD) |
No |
Process |
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 |
|
047 |
Care
Plan |
Yes |
Process |
Percentage
of patients aged 65 years and older who have an advance care plan or
surrogate decision maker documented 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 |
|
118 |
Coronary
Artery Disease (CAD): Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF <
40%) |
No |
Process |
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 |
|
128 |
Preventive
Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
No |
Process |
Percentage
of patients aged 18 years and older with a BMI documented during the current
encounter or during the previous twelve months AND with a BMI outside of
normal parameters, a follow-up plan is documented during the encounter or
during the previous twelve months of the current encounter |
|
130 |
Documentation
of Current Medications in the Medical Record |
Yes |
Process |
Percentage
of visits for patients aged 18 years and older for which the eligible
professional or eligible clinician 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 |
|
204 |
Ischemic
Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic |
No |
Process |
Percentage
of patients 18 years of age and older who were diagnosed with acute
myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12
months prior to the measurement period, or who had an active diagnosis of
ischemic vascular disease (IVD) during the measurement period, and who had
documentation of use of aspirin or another antiplatelet
during the measurement period |
|
226 |
Preventive
Care and Screening: Tobacco Use: Screening and Cessation Intervention |
No |
Process |
Percentage
of patients aged 18 years and older who were screened for tobacco use one or
more times within 24 months AND who received tobacco cessation intervention
if identified as a tobacco user |
|
236 |
Controlling
High Blood Pressure |
Yes |
Intermediate
Outcome |
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 |
|
238 |
Use
of High-Risk Medications in the Elderly |
Yes |
Process |
Percentage
of patients 65 years of age and older who were ordered high-risk medications.
Two rates are submitted. |
|
243 |
Cardiac
Rehabilitation Patient Referral from an Outpatient Setting |
Yes |
Process |
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 |
|
317 |
Preventive
Care and Screening: Screening for High Blood Pressure and Follow-Up
Documented |
No |
Process |
Percentage
of patients aged 18 years and older seen during the submitting 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 |
|
322 |
Cardiac
Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation
in Low Risk Surgery Patients |
No |
Efficiency |
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 submission period |
|
323 |
Cardiac
Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) |
No |
Efficiency |
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 patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference
to timing of test after PCI and symptom status |
|
324 |
Cardiac
Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic,
Low-Risk Patients |
No |
Efficiency |
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 |
|
326 |
Atrial Fibrillation and Atrial
Flutter: Chronic Anticoagulation Therapy |
No |
Process |
Percentage
of patients aged 18 years and older with nonvalvular
atrial fibrillation (AF) or atrial
flutter who were prescribed warfarin OR another
FDA- approved anticoagulant drug for the prevention of thromboembolism
during the measurement period |
|
344 |
Rate
of Carotid Artery Stenting (CAS) for Asymptomatic
Patients, Without Major Complications (Discharged to Home by Post-Operative
Day #2) |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CAS who are discharged to home no later
than post-operative day #2 |
|
345 |
Rate
of Asymptomatic Patients Undergoing Carotid Artery Stenting
(CAS) Who Are Stroke Free or Discharged Alive |
Yes |
Outcome |
Percent
of asymptomatic patients undergoing CAS who are stroke free while in the
hospital or discharged alive following surgery |
|
374 |
Closing
the Referral Loop: Receipt of Specialist Report |
Yes |
Process |
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 |
|
402 |
Tobacco
Use and Help with Quitting Among Adolescents |
No |
Process |
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 |
|
431 |
Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling |
No |
Process |
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 |
|
438 |
Statin Therapy for the Prevention and Treatment of
Cardiovascular Disease |
No |
Process |
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: |
|
441 |
Ischemic
Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) |
Yes |
Intermediate
Outcome |
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: |