Quality Id

Measure Name

High Priority

Measure Type

Measure Description

001

Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Yes

Intermediate Outcome

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

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

024

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

Yes

Process

Percentage of patients aged 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

039

Screening for Osteoporosis for Women Aged 65-85 Years of Age

No

Process

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

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

048

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

No

Process

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

050

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

Yes

Process

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

065

Appropriate Treatment for Children with Upper Respiratory Infection (URI)

No

Process

Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

066

Appropriate Testing for Children with Pharyngitis

No

Process

Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

091

Acute Otitis Externa (AOE): Topical Therapy

No

Process

Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

093

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

No

Process

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

109

Osteoarthritis (OA): Function and Pain Assessment

Yes

Process

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

110

Preventive Care and Screening: Influenza Immunization

No

Process

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

111

Pneumococcal Vaccination Status for Older Adults

No

Process

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

112

Breast Cancer Screening

No

Process

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

113

Colorectal Cancer Screening

No

Process

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

116

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

No

Process

The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription

117

Diabetes: Eye Exam

No

Process

Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period

119

Diabetes: Medical Attention for Nephropathy

No

Process

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

126

Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

No

Process

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

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 

Normal Parameters: 

Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

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