|
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 |
|
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 |
|
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 |
|
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 |
|
134 |
Preventive
Care and Screening: Screening for Depression and Follow-Up Plan |
No |
Process |
Percentage
of patients aged 12 years and older screened for depression on the date of
the encounter using an age appropriate standardized depression screening tool
AND if positive, a follow-up plan is documented on the date of the positive
screen |
|
154 |
Falls:
Risk Assessment |
Yes |
Process |
Percentage
of patients aged 65 years and older with a history of falls that had a risk
assessment for falls completed within 12 months |
|
155 |
Falls:
Plan of Care |
Yes |
Process |
Percentage
of patients aged 65 years and older with a history of falls that had a plan
of care for falls documented within 12 months |
|
181 |
Elder
Maltreatment Screen and Follow-Up Plan |
Yes |
Process |
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 |
|
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 |
|
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 |
|
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 |
|
331 |
Adult
Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) |
No |
Process |
Percentage
of patients, aged 18 years and older, with a diagnosis of acute viral
sinusitis who were prescribed an antibiotic within 10 days after onset of
symptoms |
|
332 |
Adult
Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial
Sinusitis (Appropriate Use) |
No |
Process |
Percentage
of patients aged 18 years and older with a diagnosis of acute bacterial
sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of
diagnosis |
|
333 |
Adult
Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) |
No |
Efficiency |
Percentage
of patients aged 18 years and older with a diagnosis of acute sinusitis who
had a computerized tomography (CT) scan of the paranasal
sinuses ordered at the time of diagnosis or received within 28 days after
date of diagnosis |
|
334 |
Adult
Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for
Chronic Sinusitis (Overuse) |
No |
Efficiency |
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 date of diagnosis |
|
337 |
Psoriasis:
Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis
and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier |
No |
Process |
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 |
|
338 |
HIV
Viral Load Suppression |
Yes |
Outcome |
The
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 |
|
342 |
Pain
Brought Under Control Within 48 Hours |
Yes |
Outcome |
Patients
aged 18 and older who report being uncomfortable because of pain at the
initial assessment (after admission to palliative care services) who report
pain was brought to a comfortable level within 48 hours |
|
370 |
Depression
Remission at Twelve Months |
Yes |
Outcome |
The
percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days)
after an index visit |
|
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 |
|
383 |
Adherence
to Antipsychotic Medications For Individuals with Schizophrenia |
Yes |
Intermediate
Outcome |
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 prescriptions filled for any antipsychotic medication and who had a
Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic
medications during the measurement period (12 consecutive months) |
|
387 |
Annual
Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug
Users |
No |
Process |
Percentage
of patients, regardless of age, who are active injection drug users who
received screening for HCV infection within the 12 month reporting period |
|
398 |
Optimal
Asthma Control |
Yes |
Outcome |
Composite
measure of the percentage of pediatric and adult patients whose asthma is
well-controlled as demonstrated by one of three age appropriate patient
reported outcome tools and not at risk for exacerbation |
|
400 |
One-Time
Screening for Hepatitis C Virus (HCV) for Patients at Risk |
No |
Process |
Percentage
of patients aged 18 years and older with one or more of the following: a
history of injection drug use, receipt of a blood transfusion prior to 1992,
receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time
screening for hepatitis C virus (HCV) infection |
|
401 |
Hepatitis
C: Screening for Hepatocellular Carcinoma (HCC) in
Patients with Cirrhosis |
No |
Process |
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 |
|
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 |
|
408 |
Opioid Therapy Follow-up Evaluation |
No |
Process |
All
patients 18 and older prescribed opiates for longer than six weeks duration
who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |
|
412 |
Documentation
of Signed Opioid Treatment Agreement |
No |
Process |
All
patients 18 and older prescribed opiates for longer than six weeks duration
who signed an opioid treatment agreement at least
once during Opioid Therapy documented in the
medical record |
|
414 |
Evaluation
or Interview for Risk of Opioid Misuse |
No |
Process |
All
patients 18 and older prescribed opiates for longer than six weeks duration
evaluated for risk of opioid misuse using a brief
validated instrument (e.g. Opioid Risk Tool,
SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record |
|
418 |
Osteoporosis
Management in Women Who Had a Fracture |
No |
Process |
The
percentage of women age 50-85 who suffered a fracture and who either had a
bone mineral density test or received a prescription for a drug to treat
osteoporosis in the six months after the fracture |
|
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: |
|
442 |
Persistence
of Beta-Blocker Treatment After a Heart Attack |
No |
Process |
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 |
|
443 |
Non-Recommended
Cervical Cancer Screening in Adolescent Females |
No |
Process |
The
percentage of adolescent females 16–20 years of age screened unnecessarily
for cervical cancer |
|
444 |
Medication
Management for People with Asthma |
Yes |
Process |
The
percentage of patients 5-64 years of age during the measurement year who were
identified as having persistent asthma and were dispensed appropriate
medications that they remained on for at least 75% of their treatment period |
|
447 |
Chlamydia
Screening and Follow Up |
No |
Process |
The
percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the
measurement period |