Questions? Feedback? powered by Olark live chat software

IA Measures

Individual Quality Measures

Collection Type
Measure Type
High Priority

#QOPI23 Concurrent Chemo radiation for Patients with a Diagnosis of Stage IIIB NSCLC

Description:

Percentage of patients, regardless of age, with a diagnosis of Stage IIIB non-small cell lung cancer (NSCLC) receiving concurrent chemoradiation
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#POLAR1 Antiemetic Therapy for Low- and Minimal-Emetic-Risk Antineoplastic Agents - Avoidance of Overuse (Lower Score - Better).

Description:

Percentage of cancer patients aged 18 years and older treated with low- or minimal-emetic-risk antineoplastic agents who are administered inappropriate pre-treatment antiemetic therapy.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#QOPI27 Appropriate Antiemetic Therapy for High- and Moderate Emetic Risk Antineoplastic Agents

Description:

Percentage of cancer patients aged 18 years and older treated with high- or moderate-emetic risk antineoplastic agents who are administered appropriate pre-treatment antiemetic therapy
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

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

Description:

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

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#005 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Description:

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 or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#006 Coronary Artery Disease (CAD): Antiplatelet Therapy

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#009 Anti-Depressant Medication Management

Description:

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).
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Description:

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#014 Age-Related Macular Degeneration (AMD): Dilated Macular Examination

Description:

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

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

Description:

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 submitted by the physician who treats the fracture and who therefore is held accountable for the communication.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

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

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#047 Advance Care Plan

Description:

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation 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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

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

Description:

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

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

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

Description:

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.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#052 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#065 Appropriate Treatment for Upper Respiratory Infection (URI)

Description:

Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#066 Appropriate Testing for Pharyngitis

Description:

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#076 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections

Description:

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

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

Description:

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

Description:

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, who did not have a bone scan performed at any time since diagnosis of prostate cancer.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

Description:

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Description:

All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#110 Preventive Care and Screening: Influenza Immunization

Description:

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.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#111 Pneumococcal Vaccination Status for Older Adults

Description:

Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#112 Breast Cancer Screening

Description:

Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#113 Colorectal Cancer Screening

Description:

Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis

Description:

The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#117 Diabetes: Eye Exam

Description:

Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#119 Diabetes: Medical Attention for Nephropathy

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

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

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear

Description:

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Description:

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#130 Documentation of Current Medications in the Medical Record

Description:

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.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Description:

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to 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 eligible encounter.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#137 Melanoma: Continuity of Care – Recall System

Description:

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Structure
  • High Priority Measure:

    Yes
Details

#138 Melanoma: Coordination of Care

Description:

Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#143 Oncology: Medical and Radiation – Pain Intensity Quantified

Description:

Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#144 Oncology: Medical and Radiation – Plan of Care for Pain

Description:

Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy

Description:

Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available).
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Description:

Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#155 Falls: Plan of Care

Description:

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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation

Description:

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

Description:

Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

Description:

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#176 Tuberculosis Screening Prior to First Course Biologic Therapy

Description:

If a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

Description:

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at =50% of encounters for RA for each patient during the measurement year.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#178 Rheumatoid Arthritis (RA): Functional Status Assessment

Description:

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#180 Rheumatoid Arthritis (RA): Glucocorticoid Management

Description:

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 > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#181 Elder Maltreatment Screen and Follow-Up Plan

Description:

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.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#182 Functional Outcome Assessment

Description:

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

Description:

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Description:

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV alteplase was initiated within three hours of time last known well.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Description:

Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#217 Functional Status Change for Patients with Knee Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with knee impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#218 Functional Status Change for Patients with Hip Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#219 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle or lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient- reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#220 Functional Status Change for Patients with Low Back Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#221 Functional Status Change for Patients with Shoulder Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in functional status (FS) is assessed using the FOTO Elbow/Wrist/Hand FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#236 Controlling High Blood Pressure

Description:

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#238 Use of High-Risk Medications in Older Adults

Description:

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Description:

Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation • Percentage of patients with counseling for nutrition • Percentage of patients with counseling for physical activity.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#240 Childhood Immunization Status

Description:

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting

Description:

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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#249 Barrett’s Esophagus

Description:

Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#250 Radical Prostatectomy Pathology Reporting

Description:

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

Description:

Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#258 Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)

Description:

Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms (AAA) who do not experience a major complication (discharge to home no later than post-operative day #7).
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)

Description:

Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)

Description:

Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

Description:

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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer

Description:

The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#265 Biopsy Follow-Up

Description:

Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

Description:

Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

Description:

Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#277 Sleep Apnea: Severity Assessment at Initial Diagnosis

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#281 Dementia: Cognitive Assessment

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#282 Dementia: Functional Status Assessment

Description:

Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

Description:

Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

Description:

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#288 Dementia: Education and Support of Caregivers for Patients with Dementia

Description:

Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease

Description:

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#291 Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease

Description:

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#293 Rehabilitative Therapy Referral for Patients with Parkinson’s Disease

Description:

Percentage of all patients with a diagnosis of Parkinson’s Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

Description:

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

Description:

Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Engagement/Experience
  • High Priority Measure:

    Yes
Details

#305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Description:

Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis. b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#309 Cervical Cancer Screening

Description:

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 within the last 3 years * Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#310 Chlamydia Screening for Women

Description:

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 period.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Description:

Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#318 Falls: Screening for Future Fall Risk

Description:

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Description:

Percentage of patients aged 50 to 75 years of age 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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#321 CAHPS for MIPs Clinician/Group Survey

Description:

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: • Getting timely care, appointments, and information (Not endorsed by NQF); • How well providers Communicate (Not endorsed by NQF); • Patient’s Rating of Provider (NQF endorsed #0005); • Access to Specialists (Not endorsed by NQF); • Health Promotion & Education (Not endorsed by NQF); • Shared Decision Making (Not endorsed by NQF); • Health Status/Functional Status (Not endorsed by NQF); • Courteous and Helpful Office Staff (NQF endorsed #0005); • Care Coordination (Not endorsed by NQF); and • Stewardship of Patient Resources (Not endorsed by NQF).
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Engagement/Experience
  • High Priority Measure:

    Yes
Details

#322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Description:

Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)

Description:

Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#336 Maternity Care: Postpartum Follow-Up and Care Coordination

Description:

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breastfeeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#338 HIV Viral Load Suppression

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#340 HIV Medical Visit Frequency

Description:

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.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

Description:

Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

Description:

Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

Description:

Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#354 Anastomotic Leak Intervention

Description:

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#355 Unplanned Reoperation within the 30 Day Postoperative Period

Description:

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#356 Unplanned Hospital Readmission within 30 Days of Principal Procedure

Description:

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#357 Surgical Site Infection (SSI)

Description:

Percentage of patients aged 18 years and older who had a surgical site infection (SSI).
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#358 Patient-Centered Surgical Risk Assessment and Communication

Description:

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

Description:

Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

Description:

Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#366 Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Description:

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#370 Depression Remission at Twelve Months

Description:

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#374 Closing the Referral Loop: Receipt of Specialist Report

Description:

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.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#375 Functional Status Assessment for Total Knee Replacement

Description:

Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#376 Functional Status Assessment for Total Hip Replacement

Description:

Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#377 Functional Status Assessments for Heart Failure

Description:

Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#378 Children Who Have Dental Decay or Cavities

Description:

Percentage of children, 6 months - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement period.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#379 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists

Description:

Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Description:

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#383 Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Description:

Percentage of individuals at least 18 years of age as of the beginning of the performance 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 performance period.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

Description:

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

Description:

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

Description:

Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

Description:

Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#389 Cataract Surgery: Difference Between Planned and Final Refraction

Description:

Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#391 Follow-Up After Hospitalization for Mental Illness (FUH)

Description:

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are submitted: • The percentage of discharges for which the patient received follow-up within 30 days after discharge • The percentage of discharges for which the patient received follow-up within 7 days after discharge
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

Description:

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender: • Submission Age Criteria 1: Females 18-64 years of age • Submission Age Criteria 2: Males 18-64 years of age • Submission Age Criteria 3: Females 65 years of age and older • Submission Age Criteria 4: Males 65 years of age and older
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

Description:

Infection rate following CIED device implantation, replacement, or revision.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#394 Immunizations for Adolescents

Description:

The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#395 Lung Cancer Reporting (Biopsy/Cytology Specimens)

Description:

Pathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#396 Lung Cancer Reporting (Resection Specimens)

Description:

Pathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#397 Melanoma Reporting

Description:

Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#398 Optimal Asthma Control

Description:

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.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#400 One-Time Screening for Hepatitis C Virus (HCV) for all Patients

Description:

Percentage of patients age >= 18 years who received one-time screening for hepatitis C virus (HCV) infection.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

Description:

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 submission period.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#402 Tobacco Use and Help with Quitting Among Adolescents

Description:

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.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#404 Anesthesiology Smoking Abstinence

Description:

The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions

Description:

Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow-up imaging recommended based on radiological findings: • Cystic renal lesion that is simple appearing* (Bosniak I or II) • Adrenal lesion less than or equal to 1.0 cm • Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT, or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

Description:

Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#409 Clinical Outcome Post Endovascular Stroke Treatment

Description:

Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#410 Psoriasis: Clinical Response to Systemic Medications

Description:

Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#413 Door to Puncture Time for Endovascular Stroke Treatment

Description:

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

Description:

Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

Description:

Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#418 Osteoporosis Management in Women Who Had a Fracture

Description:

The percentage of women 50–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#419 Overuse of Imaging for the Evaluation of Primary Headache

Description:

Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

Description:

Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

Description:

Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

Description:

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#424 Perioperative Temperature Management

Description:

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#425 Photodocumentation of Cecal Intubation

Description:

The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

Description:

Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Description:

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 12 months AND who received brief counseling if identified as an unhealthy alcohol user.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

Description:

Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

Description:

Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

Description:

Percentage of final reports for patients aged 18 years and older undergoing computed tomography (CT) with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control. • Adjustment of the mA and/or kV according to patient size. • Use of iterative reconstruction technique.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Description:

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: *All patients who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR *Patients aged >=20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >=190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR *Patients aged 40-75 years with a diagnosis of diabetes
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#439 Age Appropriate Screening Colonoscopy

Description:

The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Efficiency
  • High Priority Measure:

    Yes
Details

#440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

Description:

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

Description:

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 or equal to 140/90 mm Hg -- AND• Most recent tobacco status is Tobacco Free -- AND• Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND• Statin Use Unless Contraindicated
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#443 Non-Recommended Cervical Cancer Screening in Adolescent Females

Description:

The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

Description:

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#448 Appropriate Workup Prior to Endometrial Ablation

Description:

Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#450 Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer

Description:

Percentage of female patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#451 RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy

Description:

Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#452 Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

Description:

Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#453 Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)

Description:

Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#455 Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)

Description:

Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)

Description:

Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#459 Back Pain After Lumbar Discectomy/Laminectomy

Description:

For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#460 Back Pain After Lumbar Fusion

Description:

For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at one year (9 to 15 months) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#461 Leg Pain After Lumbar Discectomy/Laminectomy

Description:

For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#462 Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

Description:

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)

Description:

Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#464 Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use

Description:

Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

Description:

The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

Description:

Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#469 Functional Status After Lumbar Fusion

Description:

For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#470 Functional Status After Primary Total Knee Replacement

Description:

For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#471 Functional Status After Lumbar Discectomy/Laminectomy

Description:

For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#472 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

Description:

Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.
  • NQS Domain:

    Efficiency and Cost Reduction
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#473 Leg Pain After Lumbar Fusion

Description:

For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at one year (9 to 15 months) postoperatively.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#475 HIV Screening

Description:

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.
  • NQS Domain:

    Community/Population Health
  • Measure Type:

    Process
  • High Priority Measure:

    No
Details

#476 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

Description:

Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.
  • NQS Domain:

    Person and Caregiver-centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#477 Multimodal Pain Management

Description:

Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#478 Functional Status Change for Patients with Neck Impairments

Description:

A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paperpencil).
  • NQS Domain:

    Person and Caregiver-centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups

Description:

This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.
  • NQS Domain:

    Communication and Care Coordination
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#480 Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)

Description:

This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.
  • NQS Domain:

    Patient Safety
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details

#481 Intravesical Bacillus-Calmette-Guerin for Non-muscle Invasive Bladder Cancer

Description:

Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Process
  • High Priority Measure:

    Yes
Details

#482 Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate

Description:

Percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Intermediate Outcome
  • High Priority Measure:

    Yes
Details

#483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)

Description:

The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.
  • NQS Domain:

    Person and Caregiver-Centered Experience and Outcomes
  • Measure Type:

    Patient Reported Outcome
  • High Priority Measure:

    Yes
Details

#484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Description:

Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).
  • NQS Domain:

    Effective Clinical Care
  • Measure Type:

    Outcome
  • High Priority Measure:

    Yes
Details