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["Table Legend for the List of Measures under Consideration"]
["CMS has included a list of terms used in the List of Measures under Consideration for clarity and consistency. They are presented below in the order in which they appear as headings in this List."]
[]
["Term","Defintion"]
["MUC ID: ","Gives users an identifier to refer to a measure.\n\n•\tAn “E” prefix indicates a measure that is currently endorsed by the NQF.\n\n•\tA “D” prefix indicates a measure that was once endorsed by the NQF but has subsequently been de‐endorsed.\n\n•\tAn “F” prefix indicates a measure that was submitted to the NQF for endorsement but was not endorsed.\n\n•\tAn “S” prefix indicates a measure that is currently submitted to the NQF for endorsement.\n\n•\tAn “X” prefix indicates a measure that has yet to be submitted to the NQF for endorsement."]
["Measure Title: ","Refers to the title of the measure."]
["Description:","Gives users more detailed information about the measure, such as medical conditions to be measured, particular outcomes or results that could or should/should not result from the care and patient populations."]
["Measure Type: ","Refers to the domain of quality that a measure assesses: •\tProcess: Refers to a measure that focuses on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.\n•\tOutcome: Refers to a measure that assesses the results that are experienced by patients who have received health care.\n\n•\tIntermediate Outcome: Refers to a measure that aims to meet specific thresholds of health outcomes.\n\n•\tStructure: Refers to a measure that assesses aspects of the health care infrastructure that generally are broad in scope and system wide (for example, staffing level).\n•\tEfficiency: Refers to a measure concerning the cost of care associated with a specified level of health outcome.\n\n•\tPatient Reported Outcome: Refers to a measure that focuses on a patient’s report concerning observations of and participation in health care.\n•\tCost/Resource Use: Refers to broadly applicable and comparable measures of health services counts (in terms of units or dollars) applied to a population or event (broadly defined to include diagnoses, procedures, or encounters). A resource use measure counts the frequency of defined health system resources; some may further apply a dollar amount (for example, allowable charges, paid amounts, or standardized prices) to each unit of resource use—that is, monetizes the health service or resource use units.\n•\tComposite: Refers to a measure that contains two or more individual measures, resulting in a single measure and a single score. Composite measures may be composed of one or more process measures and/or one or more outcome measures. •\tPatient Engagement/Experience: Refers to a measure that uses feedback from patients and their families/caregivers about their experience and/or engagement in decision making around care."]
["Measure Steward: ","Refers to the primary (and secondary, if applicable) party responsible for updating and maintaining a measure."]
["CMS Program(s): ","Refers to the applicable Medicare program(s) that may adopt the measure through rulemaking in the future."]
["Numerator:","The numerator reflects the subset of patients in the denominator for whom a particular service has been provided or for whom a particular outcome has been achieved."]
["Denominator:","The lower part of a fraction used to calculate a rate, proportion, or ratio. The denominator is associated with a given patient population that may be counted as eligible to meet a measure’s inclusion requirements."]
["Exclusions:","Exclusions are patients included in an initial population for which there are valid reasons a process or outcome of care has not occurred. These cases are removed from the denominator. When clinical judgment is allowed, these are referred to as “exceptions”. Denominator exceptions fall into three general categories: medical reasons, patients’ reasons, and system reasons. Exceptions must be captured in a way that they could be reported separate."]
["Rationale: ","Refers to the rationale and/or impact the measure is anticipated to achieve."]

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["CMS Program2","Number of Measures Under Consideration"]
["Ambulatory Surgical Center Quality Reporting",9]
["End‐Stage Renal Disease Quality Incentive Program",7]
["Home Health Quality Reporting",1]
["Hospice Quality Reporting",0]
["Hospital‐Acquired Condition Reduction Program",2]
["Hospital Inpatient Quality Reporting",29]
["Hospital Outpatient Quality Reporting",16]
["Hospital Readmission Reduction Program",1]
["Hospital Value‐Based Purchasing",12]
["Inpatient Psychiatric Facility Quality Reporting",4]
["Inpatient Rehabilitation Facility Quality Reporting",6]
["Long‐Term Care Hospital Quality Reporting",4]
["Medicare and Medicaid EHR Incentive Programs for Eligible Professionals",31]
["Medicare and Medicaid EHR Incentive Programs for Eligible Hospitals or Critical Access Hospitals",4]
["Medicare Physician Quality Reporting System3",96]
["Medicare Shared Savings",116]
["Physician Compare4",96]
["Physician Feedback/Quality and Resource Utilization Reports4 (QRUR)",102]
["Physician Value‐Based Payment Modifier4",102]
["Prospective Payment System‐Exempt Cancer Hospital Quality Reporting",9]
["Skilled Nursing Facility Value‐Based Purchasing Program",1]
[]
[]
["Publishing in the Federal Register the rationale for the use of any quality and efficiency measures that are not endorsed by the entity with a contract under Section 1890 of the Act, which is currently the National Quality Forum (NQF)1"]
[]
["1 The rationale for adopting measures not endorsed by the consensus‐based entity will be published in notice‐and‐comment rulemaking where such measures are proposed and finalized."]
["2 A single measure may be under consideration for more than one program."]
["3 Medicare Physician Quality Reporting System:"]
["PQRS is the primary means of collecting physician quality data in the Medicare program. As Physician Compare, Physician Feedback, and Value‐Based Modifier programs all take physician quality performance into account, all quality measures under consideration for PQRS would also be under consideration for the Physician Feedback/QRUR, Physician Value‐Based Payment Modifier, and Physician Compare programs."]
["4 Physician Feedback/QRUR, Physician Value‐Based Payment Modifier, and Physician Compare:"]
["Measures that are already finalized and remain current for the Medicare Physician Quality Reporting System, Hospital Inpatient Quality Reporting, and Hospital Outpatient Quality Reporting programs that are not specifically included on this list may also be considered for the Physician Feedback/QRUR, Physician‐Value Based Payment Modifier, and Physician Compare programs. Therefore, for future regulatory action for the Physician Feedback/QRUR, Physician Value‐Based Payment Modifier, and Physician Compare programs, CMS may consider measures that were included in the 2011, 2012, and 2013 Lists of Measures under Consideration; and measures that have been finalized and remain current in the 2007–2015 Physician Fee Schedule Final Rules, 2002–2015 Inpatient Prospective Payment System Final Rules, and 2008–2015 Hospital Outpatient Prospective Payment System Final Rules. The unique measures developed for these specific programs, such as cost measures, that are not found in the Medicare PQRS program are also included on this list."]

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["MUC\nID","Measure Title","Description","Measure\nType","Measure Steward","CMS Program(s)","Numerator","Denominator","Exclusions","Rationale"]
["X3719","Normothermia Outcome","This measure evaluates whether patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU","Intermediate\nOutcome","ASC Quality Collaboration","Ambulatory Surgical Center Quality Reporting","Surgery patients with a bodytemperature equal to or greaterthan 96.8 Fahrenheit/36 Celsiusrecorded within fifteen minutesof Arrival in PACU","All patients, regardless of age,undergoing surgical proceduresunder general or neuraxialanesthesia of greater than orequal to 60 minutes duration","None","Anesthetic‐induced thermoregulatory impairment may cause perioperative hypothermia, which is associated withadverse outcomes."]
["X3720","Unplanned Anterior Vitrectomy","This measure evaluates the number of cataract surgery patients who have an unplanned anterior vitrectomy","Outcome","ASC Quality Collaboration","Ambulatory Surgical Center Quality Reporting","All cataract surgery patients whohad an unplanned anteriorvitrectomy","All cataract surgery patients","None","Cataract surgery is a commonly performed operation and should be associated with low intra‐operative morbidity."]
["E0515","Ambulatory surgery patients with appropriate method of hair","Percentage of ASC admissions with appropriate surgical site hair removal.","Process","ASC Quality Collaboration","Ambulatory Surgical Center Quality Reporting","ASC admissions with surgical sitehair removal with a razor orclippers from the scrotal area, orwith clippers or depilatory creamfrom all other surgical sites","All ASC admissions with surgicalsite hair removal","ASC admissions who perform their ownhair removal","The literature regarding preoperative hair removal has been systematically reviewed twice, once by Kjonniksen et alin 2002 and again by Tanner et al in 2007. Three randomized controlled trials (Alexander et al 1983, Balthazar et al1983, Ko et al 1992) compared the rates of infection at the surgical site when hair removal at the site wasperformed with clippers or with razors. A statistically significant difference in infection rates in the pooled results(Tanner et al 2007) was seen, with 2.8% of the patients who were shaved developing a surgical site infectioncompared with 1.4% rate of surgical site infection in the patients who were clipped. Additional randomizedcontrolled trials (Court‐Brown 1981, Powis et al 1976, Seropian 1971, Thur de Koos 1983) have demonstrated thatpatients were more likely to develop a surgical site infection when shaved as compared to having hair removal witha depilatory. Observational studies have suggested that no hair removal is less likely to result in surgical siteinfection, but this has not been confirmed in randomized controlled trials.The HICPAC/CDC Guideline for Prevention of Surgical Site Infection (Mangram at al 1999), the Association ofOperating Room Nurses Recommended Practices for Preoperative Patient Skin Antisepsis (AORN 2002) and theSHEA/IDSA Strategies to Prevent Surgical Site Infections in Acute Care Hospitals (Anderson et al 2008) are consistentwith the intent of this measure.Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair‐removal methods on woundinfections. Arch Surg. 1983 Mar;118(3):347‐52.Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V,Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S,Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent surgical site infections in acute care hospitals.Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51‐61.Association of Operating Room Nurses. Recommended practices for skin preparation of patients. AORN J. 2002Jan;75(1):184‐7.Balthazar ER, Colt JD, Nichols RL. Preoperative hair removal: a random prospective study of shaving versus clipping. South Med J. 1982 Jul;75(7):799‐801.Court‐Brown CM. Preoperative skin depilation and its effect on postoperative wound infections. J R Coll Surg Edinb. 1981 Jul;26(4):238‐41.Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal‐‐a systematic literature review. AORN J. 2002 May;75(5):928‐38, 940.Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg. 1992 Feb;53(2):301‐5.Powis SJ, Waterworth TA, Arkell DG. Preoperative skin preparation: clinical evaluation of depilatory cream. Br Med J. 1976 Nov 13;2(6045):1166‐8.Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971 Mar;121(3):251‐4.Tanner J, Moncaster K, Woodings D. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004122.Thur de Koos P, McComas B. Shaving versus skin depilatory cream for preoperative skin preparation. A prospectivestudy of wound infection rates. Am J Surg. 1983 Mar;145(3):377‐8"]
["X3697","O/ASPECS Discharge and Recovery","Multi‐item measure: P1: “Discharge instructionsinclude things like symptoms you should watchout for after your procedure, instructions aboutyour medicines, and home care. Before you left the facility, did you receive written discharge instructions?” P2: “Did your doctor or anyone from the facility prepare you for what to expect during your recovery?” P3: “Ways to control pain can include prescription medicine, over‐the‐counter pain relievers or ice packs, for example. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure” (of those that had pain as a result of the procedure). P4: “Before you left, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting” (of those that had either nausea or vomiting as a result of either your procedure or anesthesia).  P5:   “Before you left, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure”  (of those that had bleeding as a result of the procedure). P6:  “Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection (of those having signs of infection as a result of the procedure).","Patient\nEngagement\n/Experience","Centers for Medicare & Medicaid Services","Ambulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting","Proportions of top box responses(YES, YES DEFINITELY) arecalculated for each question.These proportions are thenaveraged over all questions in themulti‐item measure. (P1 + P2 +P3 + P4 + P5+ P6)/6","See numerator statement.","Persons younger than 18 years having asurgery or procedure in a hospitaloutpatient surgery department orambulatory surgery center, CPT codedoes not fall between 100021‐69990without Modifier 53 (procedure did nottake place); discharged to hospice.","Patient experience of care measures are a CMS priority"]
["X3699","O/ASPECS Communication","Multi‐item measure: P1: “Did your doctor or anyone from the facility give you all the information you needed about your procedure?”P2: “Did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?” P3: “Did the doctors, nurses and other staff explain things about your procedure in a way that was easy for you to understand?” P4 “Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand? P5: “Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?","Patient\nEngagement\n/Experience","Centers for Medicare & Medicaid Services","Ambulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting","Proportions of top box responses(YES, YES DEFINITELY) arecalculated for each question. P4and P5 count only those who hadanesthesia. These proportionsare then averaged over allquestions in the multi‐itemmeasure. (P1 + P2 + P3 + P4 + P5)/5","See numerator statement.","Persons younger than 18 years having asurgery or procedure in a hospitaloutpatient surgery department orambulatory surgery center, CPT codedoes not fall between 100021‐69990without Modifier 53 (procedure did nottake place); discharged to hospice.","Patient experience of care measures are a CMS priority"]
["X3698","O/ASPECS About Facility and Staff","Multi‐item measure: P1: \"When you arrived at this facility on the day of your procedure, did the check‐in process run smoothly?\" P2: \"Was the facility clean?\" P3: \"Were the clerks and receptionists at the facility as helpful as you thought they should be?\" P4: \"Did the clerks and receptionists at the facility treat you with courtesy and respect?\" P5: \"Did the doctors, nurses and other staff treat you with courtesy and respect?\" P6: \"Did the doctors, nurses and other staff make sure you were as comfortable as possible?\"","Patient\nEngagement","Centers for Medicare & Medicaid Services","Ambulatory Surgical Center Quality Reporting","Proportions of top box responses(YES) are calculated for eachquestion. The proportions arethen averaged over all questionsin the multi‐item measure.(P1+P2+P3+P4+P5+P6)/6","See numerator statement.","Persons younger than 18 years having asurgery or procedure in a hospitaloutpatient surgery department orambulatory surgery center, CPT codedoes not fall between 100021‐69990without Modifier 53 (procedure did nottake place); discharged to hospice.","Patient experience of care measures are a CMS priority"]
["X3703","O/ASPECS Recommend","Survey question: Would you recommend this facility to your friends and family? Response options: Definately no, Probably no, Probably yes, Definately yes.","Patient\nEngagement\n/Experience","Centers for Medicare & Medicaid Services","Ambulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting","Number of respondentsanswering “Definately yes”.","Number of respondents answeringthe survey question","Persons younger than 18 years having asurgery or procedure in a hospitaloutpatient surgery department orambulatory surgery center, CPT codedoes not fall between 100021‐69990without Modifier 53 (procedure did nottake place); discharged to hospice.","Patient experience of care measures are a CMS priority"]
["X3702","O/ASPECS Overall Facility Rating","Survey Question: Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?","Patient\nEngagement\n/Experience","Centers for Medicare & Medicaid Services","Ambulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting","Number of respondentsanswering 9 or 10","Number of respondents answeringthe survey question","Persons younger than 18 years having asurgery or procedure in a hospitaloutpatient surgery department orambulatory surgery center, CPT codedoes not fall between 100021‐69990without Modifier 53 (procedure did nottake place); discharged to hospice.","Patient experience of care measures are a CMS priority"]
["E0326","Care Plan","Percentage of patients aged 65 years and older who have a care plan or surrogate decision maker documented in the medical record or documentation in the medical record that a care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide a care plan","Process","National Committee for Quality Assurance","Ambulatory Surgical Center Quality Reporting, Hospital Outpatient Quality Reporting","Patients who have a care plan orsurrogate decision makerdocumented in the medicalrecord or documentation in themedical record that a care planwas discussed but patient did notwish or was not able to name asurrogate decision maker","All patients aged 65 years andolder","None","This measure would be consistent with a legislative mandate affecting Medicare beneficiaries, the Patient Self Determination Act (PSDA), approved in 1990. The act requires that beneficiaries be informed about their rights to self‐determination and the use of advance directives, and identifies particular facilities accountable for providing the information. Despite this, a recent cancer research study had found that most patients had not spoken extensively to health professionals or close persons about the future. Furthermore, a recent meta‐analysis found that awareness of patients´ and surrogates´ decision‐making characteristics and communication styles can help clinicians identify potential barriers and variations in patterns of communication. To that end, the authors contend that initial and ongoing assessments of patients´ and surrogates´ communication style and characteristics must be incorporated into the plan of care (Melhado 2011). A cross‐sectional study out of Oklahoma found that among community dwelling older persons, a living will is a positive first step towards healthcare planning and designating a power of attorney. They also found that the state’s effort to increase the use of advance directives among older residents was successful, indicating that organizations have the power to influence people with respect ACP (Mcauley 2008). An observational study from La Crosse County, Wisconsin found that a system for ACP can be managed in a geographic region so that, at the time of death, almost all adults have a care plan that is specific and available and treatment is consistent with their plan. The data from this study suggest that quality efforts have improved the prevalence, clarity, and specificity of ACPs (Hammes 2010).Barnes KA, Barlow CA, Harrington J, Ornadel K, Tookman A, King M, & Jones L. (2011). Advance Care Planning Discussions in Advanced Cancer: Analysis of Dialogues Between Patients and Care Planning Mediators. Palliative & Supportive Care;9(1):73‐9.Basanta WE. (2002). Advance Directives and Life‐Sustaining Treatment: A Legal Primer. Hematology/Oncology Clinics of North America;16(6):1381‐96.Garand L, Drew MA, Lingler JH, & DeKosky ST. (2011). Incidence and Predictors of Advance Care Planning Among Persons With Cognitive Impairment. American Journal of Geriatric Psychiatry;18(8):712‐20.Hammes BJ, Rooney BL, & Gundrum JD. (2010). A Comparative, Retrospective, Observational Study of the Prevalence, Availability, and Specificity of Advance Care Plans in a County that Implemented an Advance Care Planning Microsystem. Journal of the American Geriatrics Society;58(7):1249‐55.Mcauley WJ, McCutheon ME, & Travis SS. (2008). Advance Directives for Health Care Among Older Community Residents. Journal of Health & Human Services Administration, 30(4), 402‐419.Melhado LW & Byers JF. (2011). Patients’ and Surrogates’ Decision‐Making Characteristics Withdrawing, Withholding, and Continuing Life‐Sustaining Treatments. Journal of Hospice & Palliative Nursing;13(1):16‐28. Sampson EL, Jones L, Thune‐Boyle IC, Kukkastenvehmas R, King M, Leurent B, Tookman A, & Blanchard MR. Palliative assessment and advance care planning in severe dementia: An exploratory randomized controlled trial of acomplex intervention. Palliative Care;25(3):197‐209. Sanders A, Schepp M, & Baird M. (2011). Partial do‐not‐resuscitate orders: A Hazard to Patient Safety and Clinical Outcomes? Critical Care Medicine;39(1):14‐8.Tung EE, Vickers KS, Lackore K, Cabanela R, Hathaway J, & Chaudhry R. (2011). Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting. American Journal of Hospice and PalliativeMedicine;28(4):230‐5."]
["X3717","Delivered Dose of Hemodialysis Above Minimum","Percentage of all patient months whose average delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V ≥ 1.2.","Intermediate\nOutcome","Centers for Medicare & Medicaid Services","End‐Stage Renal Disease Quality Incentive Program","Number of patient months indenominator whose delivereddose of hemodialysis (calculatedfrom the last measurements ofthe month using the UKM orDaugirdas II formula) was aspKt/V ≥ 1.2.","To be included in the denominatorfor a particular month, thepatients must have been ondialysis for at least 90 days andmust be dialyzing thrice weeklyduring the month.","Pediatric home hemodialysis patients andfrequent hemodialysis patients (≥4 timesper week).","This is a revision of the existing NQF measure 0249. The measure has been revised to include both adult andpediatric patients"]
["X3718","Delivered Dose in Peritoneal Dialysis Above Minimum","Percentage of all patient months whose delivered peritoneal dialysis dose was a weeklyKt/V urea of at least 1.7 within past four months (Adult ≥ 18) or 1.8 within past 6 months (pediatric <18).","Intermediate\nOutcome","Centers for Medicare & Medicaid Services","End‐Stage Renal Disease Quality Incentive Program","Number of patient months in thedenominator whose deliveredperitoneal dialysis was a weeklyKt/Vurea of at least 1.7 withinpast four months (Adult ≥ 18) or1.8 within past 6 months(pediatric <18).","To be included in the denominatorfor a particular month, the patientmust have been on dialysis for atleast 90 days.","None","This is a revision of the existing NQF measure 0318. The measure has been revised to include both adult andpediatric patients"]
["X2051","Delivered Dose of Dialysis Above Minimum ‐Composite Score","Percentage of all patient months whose delivered dose of dialysis (either hemo orperitoneal) met the specified threshold. This measure is a composite of NQF #0318 and NQF#0249.","Intermediate\nOutcome","Centers for Medicare & Medicaid Services","End‐Stage Renal Disease Quality Incentive Program","Number of patients months inthe denominator whosedelivered dose of dialysis met thespecified thresholds. Thethresholds are as follows:• Hemodialysis (all ages): Kt/V≥1.2• Peritoneal dialysis (pediatric):Kt/V ≥1.8 (within past 6 months)• Peritoneal dialysis (adult): Kt/V≥1.7 (within past 4 months)","To be included in the denominatorfor a particular month, patientsneed to meet the followingrequirements that month:Peritoneal dialysis patients: Allperitoneal dialysis patients whohave been on dialysis for at least90 days.Hemodialysis patients: Pediatric(<18 years old) in‐center HDpatients who have been ondialysis for 90 days or more anddialyzing thrice weekly, adult (≥ 18years old) patients who have beenon dialysis for 90 days or moreand dialyzing thrice weekly.","Frequent hemodialysis patients (≥4 timesper week).","This measure is a composite of two existing Kt/V dialysis adequacy measures. It permits assessment for all dialysispatients included in those two measures with a single composite score, avoiding the systematic exclusion ofpediatric and peritoneal dialysis patients from assessment in the QIP."]
["E1919","Cultural Competency Implementation Measure","The Cultural Competence Implementation Measure is an organizational survey designed to assist healthcare organizations in identifying the degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as their adherence to 12 of the 45 NQF‐endorsed®cultural competency practices prioritized for the survey. The target audience for this survey includes healthcare organizations across a range of health care settings,including hospitals, health plans, community clinics, and dialysis organizations. Information from the survey can be used for quality improvement, provide information that can help health care organizations establish benchmarks and assess how they compare in relation to peer organizations, and for public reporting.","Process","RAND Corporation","End‐Stage Renal Disease Quality Incentive Program","The target audience for this survey includes health care organizations across a range of health care settings, including hospitals, health plans, community clinics, and dialysis organizations. The focus of the measure is the degree to which health care organizations have adopted or implemented 12 of the 45 NQF-endorsed cultural competency preferred practices.","As mentioned above, the survey can be used to measure adherence to 12 of the 45-NQF endorsed cultural competence preferred practices. The survey could be used to focus on a particular type of health care organization, or more broadly to collect information across various organization types.","None","Numerous studies have documented the existence of significant disparities in access to health care, outcomes, andhealth status among racial and ethnic minorities. Studies conducted across a variety of healthcare settings havefound that racial/ethnic minority patients as well as those with low socioeconomic status or LEP report worseexperiences of care, compared with whites, those with higher socioeconomic status, and English speakers. Growingevidence points to the fact that minority populations tend to receive lower quality of care even when factors such asaccess, health insurance, and income are taken into account. In short, racial and ethnic minorities facedisproportionately higher rates of disease, disability, and mortality. For example, compared to whites, AfricanAmericans have higher death rates from heart disease, diabetes, AIDS, and cancer, and American Indians andAlaskan Natives have lower life expectancies and higher rates of infant mortality. Despite the fact that health caresystems in the U.S. have improved over time, that racial and ethnic disparities have been widely documented, andthat numerous attempts have been made to reduce or eliminate these disparities, they continue to be widespreadand pervasive. No doubt the causes of these health disparities are the result of multiple factors including bias(conscious or unconscious) on the part of the providers, differences in patients’ expectations, miscommunication caused by cultural differences, and organizational factors that impact the quality of patient–provider interactions. However, there is also growing evidence that a major contributor to healthcare disparities is a lack of culturally competent care. Cultural competence can be defined as the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse populations high quality care that is safe, patient and family centered, evidence‐based, and equitable. To be culturally competent, health care providers have to employ various interpersonal and organizational strategies to overcome or at the very least reduce the barriers to access, communication, and understanding that stem from racial, ethnic, cultural, and linguistic differences. Providing culturally appropriate care has the potential to reduce disparities and improve outcomes while at the same time improving patient satisfaction. In recent years, more and more organizations have begun exploring ways to improve cultural competency—that is, to ensure that diverse patient populations receive high‐quality care that is safe, patient and family centered, evidence‐based, and equitable. The National Quality Forum (NQF), an organization dedicated to improving healthcare quality, aims to promote culturally competent care, to reduce disparities, and to make care more patient‐centered by endorsing a comprehensive framework for measuring and reporting cultural competency. It also endorsed a set of 45 preferred practices to provide culturally competent care. The framework and practices were published in an NQF report titled, \"A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency\", and cover issues such as communication, community engagement and workforce training, and providing healthcare systems with practices they can implement to help reducepersistent disparities in healthcare and create higher‐quality, more patient‐centered care."]
["X3716","Cultural Competency Reporting Measure","This reporting measure is designed to collect data needed to score NQF #1919 in the ESRD QIP.","Process","RAND Corporation","End‐Stage Renal Disease Quality Incentive Program","Facility reports CulturalCompetency survey data to CMS.","N/A","None","Numerous studies have documented the existence of significant disparities in access to health care, outcomes, andhealth status among racial and ethnic minorities. Studies conducted across a variety of healthcare settings havefound that racial/ethnic minority patients as well as those with low socioeconomic status or LEP report worseexperiences of care, compared with whites, those with higher socioeconomic status, and English speakers. Growingevidence points to the fact that minority populations tend to receive lower quality of care even when factors such asaccess, health insurance, and income are taken into account. In short, racial and ethnic minorities facedisproportionately higher rates of disease, disability, and mortality. For example, compared to whites, AfricanAmericans have higher death rates from heart disease, diabetes, AIDS, and cancer, and American Indians andAlaskan Natives have lower life expectancies and higher rates of infant mortality. Despite the fact that health caresystems in the U.S. have improved over time, that racial and ethnic disparities have been widely documented, andthat numerous attempts have been made to reduce or eliminate these disparities, they continue to be widespreadand pervasive. No doubt the causes of these health disparities are the result of multiple factors including bias(conscious or unconscious) on the part of the providers, differences in patients’ expectations, miscommunication caused by cultural differences, and organizational factors that impact the quality of patient–provider interactions. However, there is also growing evidence that a major contributor to healthcare disparities is a lack of culturally competent care. Cultural competence can be defined as the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse populations high quality care that is safe, patient and family centered, evidence‐based, and equitable. To be culturally competent, health care providers have to employ various interpersonal and organizational strategies to overcome or at the very least reduce the barriers to access, communication, and understanding that stem from racial, ethnic, cultural, and linguistic differences. Providing culturally appropriate care has the potential to reduce disparities and improve outcomes while at the same time improving patient satisfaction. In recent years, more and more organizations have begun exploring ways to improve cultural competency—that is, to ensure that diverse patient populations receive high‐quality care that is safe, patient and family centered, evidence‐based, and equitable. The National Quality Forum (NQF), an organization dedicated to improving healthcare quality, aims to promote culturally competent care, to reduce disparities, and to make care more patient‐centered by endorsing a comprehensive framework for measuring and reporting cultural competency. It also endorsed a set of 45 preferred practices to provide culturally competent care. The framework and practices were published in an NQF report titled, \"A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency\", and cover issues such as communication, community engagement and workforce training, and providing healthcare systems with practices they can implement to help reducepersistent disparities in healthcare and create higher‐quality, more patient‐centered care."]
["X3721","Medications Documentation Reporting","This reporting measure is designed to collect data needed to score NQF #0419 in the ESRDQIP.","Structure","Centers for Medicare & Medicaid Services","End‐Stage Renal Disease Quality Incentive Program","For each eligible patient‐visit,facility reports whether or notthe patient's list of currentmedications is documented.","All eligible patient visits.","Patient is in an urgent or emergentmedical situation where time is of theessence and to delay treatment wouldjeopardize the patient’s health status.","In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per1,000 patient days. Emerging research suggests the scope of medication‐related errors in ambulatory settings is asor more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% ofthe time. One study estimated the rate of adverse drug events (ADE) in the ambulatory setting to be 27 per 100patients. It is estimated that between 2004 and 2005, in the United States 701,547 patients were treated for ADEs inemergency departments and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65years and older are more likely than any other population group to require treatment in the emergency departmentfor ADEs (American Medical Association (AMA), 2010). In the United States, it is estimated that in any given week,most adults aged 18 years and older take at least one prescription medication, OTC drug, vitamin, mineral, herbalproduct or supplement, while 10 percent take five or more. Overall, 26 percent of the population takes herbalproducts and supplements, and 30 percent of prescription drug users take an herbal product or supplement. In allsettings of care, drug‐drug interactions are significant, but undetected causes of ADEs. Drug‐drug interactions—including interactions between drugs a patient is known to be taking—are frequently not recognized. Controversy, confusion and uncertainty about the significance of many drug‐drug interactions further increase risk andopportunity for ADEs (AMA, 2010)."]
["E0419","Documentation of Current Medications in theMedical Record","Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/herknowledge and ability. This list must include ALL prescriptions, over‐the‐counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’name, dosage, frequency and route ofadministration","Process","Centers for Medicare & Medicaid Services","End‐Stage RenalDisease QualityIncentive Program, Medicare Shared Savings","Percentage of specified visits forpatients aged 18 years and olderfor which the eligible professionalattests to documenting a list ofcurrent medications to the bestof his/her knowledge and ability.This list must include ALLprescriptions, over‐the‐counters,herbals, andvitamin/mineral/dietary(nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration","All visits occurring during the 12month reporting period forpatients aged 18 years and olderon the date of the encounterwhere one or more CPT or HCPCScodes are reported on the claimssubmission for that encounter. Alldiscussed coding is listed in\"2a1.7. Denominator Details\"section below.","A patient is not eligible or excluded (B)from the performance denominator (PD)if one or more of the following reasonexists:• Patient is in an urgent or emergentmedical situation where time is of theessence and to delay treatment wouldjeopardize the patient’s health status.","Meets gap in medication reconciliation measures and aligns with PQRS and MU. In 2005, the rate of medicationerrors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emergingresearch suggests the scope of medication‐related errors in ambulatory settings is as or more extensive than duringhospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimatedthe rate of adverse drug events (ADE) in the ambulatory setting to be 27 per 100 patients. It is estimated thatbetween 2004 and 2005, in the United States 701,547 patients were treated for ADEs in emergency departmentsand 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are morelikely than any other population group to require treatment in the emergency department for ADEs (AmericanMedical Association (AMA), 2010). In the United States, it is estimated that in any given week, most adults aged 18years and older take at least one prescription medication, OTC drug, vitamin, mineral, herbal product orsupplement, while 10 percent take five or more. Overall, 26 percent of the population takes herbal products andsupplements, and 30 percent of prescription drug users take an herbal product or supplement. In all settings of care,drug‐drug interactions are significant, but undetected causes of ADEs. Drug‐drug interactions—includinginteractions between drugs a patient is known to be taking—are frequently not recognized. Controversy, confusionand uncertainty about the significance of many drug‐drug interactions further increase risk and opportunity forADEs (AMA, 2010)."]
["X3704","Percent of Patients with Pressure Ulcers That Are New or Worsened","Percentage of home health episodes of care in which the patient is discharged from home health with one or more pressure ulcer(s) that are Stage 2 ‐ 4 or unstageable due to slough or eschar and are new or worsened since the start or resumption of care. The measure is based on data obtained from the Outcome Assessment and Information Set (OASIS‐C1) Data Item Set.","Intermediate\nOutcome","Centers for Medicare & Medicaid Services","Home Health QualityReporting","Number of home health episodes of care in which the patient is discharged from home health with one or more pressure ulcer(s) that are Stage 2 ‐4 or unstageable due to slough or eschar and are new or have worsened since the start or resumption of care.","Number of home health episodes of care ending with a discharge during the reporting period, other than those covered by generic or measure‐specific exclusions.","Episodes of care ending with a transfer to an inpatient setting or death are excluded from the denominator. HHA's with denominator counts of less than 20 in the sample will be excluded from public reporting owing to small sample size.","Studies have demonstrated that while pressure ulcers may be relatively rare in the home health setting, they have asubstantial adverse impact on patient quality of life, and incidence is associated with an increased morbidity andmortality. They are a national focus because they are widely seen as preventable with sufficient risk assessment andquality care provision. This measure is envisioned to encourage agencies to implement actions that can reduce thedevelopment of new pressure ulcers and facilitate healing to prevent the worsening of existing pressure ulcers.Additionally, the measure will provide home health agencies and consumers with information that will enable themto monitor the quality of care received by all patients at risk of developing pressure ulcers."]
["S0138","National Healthcare Safety Network (NHSN) Catheter‐associated Urinary Tract Infection (CAUTI) Outcome","CAUTI can be minimized by a collection ofprevention efforts. These include reducing the number of unnecessary indwelling catheters inserted, removing in dwelling catheters at the earliest possible time, securing catheters to thepatient´s leg to avoid bladder and urethral trauma, keeping the urine collection bag below the level of the bladder, and utilizing a septic technique for urinary catheter insertion. These efforts will result in decreased morbidity and mortality and reduce healthcare costs. Use of this measure to track CAUTIs through a nationalized standard for HAI monitoring, leads to improved patient outcomes and provides a mechanism for identifying improvements and quality efforts.","Outcome","Centers for Disease Control and Prevention","Hospital Acquired Condition Reduction Program, Hospital Inpatient Quality Reporting, Hospital Value‐Based Purchasing, Medicare Shared Savings","Total number of observed healthcare‐associated CAUTI among patients in bedded inpatient care locations (excluding patients in Level II or III neonatal ICUs).","S.7. Denominator Statement: Total number of indwelling urinary catheter days for each location under surveillance for CAUTI during the data period. S.10. Denominator Exclusions: The following are not considered indwelling catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.","The following are not considered indwelling catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3. “In and out” catheterizations 4. Nephrostomy tubes Note, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.","Measure has been revised and now in NQF re‐endorsement process.CAUTI can be minimized by a collection of prevention efforts. These include reducing the number of unnecessaryindwelling catheters inserted, removing indwelling catheters at the earliest possible time, securing catheters to thepatient´s leg to avoid bladder and urethral trauma, keeping the urine collection bag below the level of the bladder,and utilizing aseptic technique for urinary catheter insertion. These efforts will result in decreased morbidity and mortality and reduce healthcare costs. Use of this measure to track CAUTIs through a nationalized standard for HAImonitoring, leads to improved patient outcomes and provides a mechanism for identifying improvements andquality efforts.Additionally, CDC has added another risk adjustment methodology besides the Standardized Infection Ratio. Thetwo risk adjustment methodologies are:1.\tStandardized Infection Ratio (annual and quarter aggregation)The SIR is constructed by using an indirect standardization method for summarizing HAI experience across any number of stratified groups of data. CAUTI incidence rates stratified by patient care location type and in some instances, location bed size and type of medical school affiliation which form the basis of the population standardization. Example: predicted numbers of CAUTI (and CAUTI rates) in a medical ICU are not the same as in an SICU. See also Scientific Validity section for further information on risk adjustment and variables.2.\tAdjusted Ranking Metric (annual aggregation)The adjusted ranking metric (ARM) combines the method of indirect standardization with a Bayesian random effects hierarchical model to account for the potentially low precision and/or reliability inherent in the unadjusted SIR mentioned above. A Bayesian posterior distribution constructed through Monte Carlo Markov Chain sampling isused to produce the adjusted numerator."]
["S0139","National Healthcare SafetyNetwork (NHSN) Central line‐associated Bloodstream Infection (CLABSI) Outcome","CLABSI can be minimized through propermanagement of the central line. Efforts toimprove central lineinsertion and maintenance practices, with earlydiscontinuance of lines are recommended. Theseefforts result in decreasedmorbidity and mortality and reduced healthcarecosts.","Outcome","Centers for Disease Control and Prevention","Hospital Acquired Condition Reduction Program, Hospital Inpatient Quality Reporting, Hospital Value‐Based Purchasing, Medicare Shared Savings","Total number of observed healthcare‐associated CLABSI among patients in bedded inpatient care locations.","S.7. Denominator Statement: Total number of central line days for each location under surveillance for CLABSI during the data period. S.10. Denominator Exclusions: 1. Pacemaker wires and other nonlumened devices inserted into central blood vessels or the heart are excluded as CLs. 2. Extracorporeal membrane oxygenation lines, femoral arterial catheters, intraaortic balloon pump devices, and hemodialysis reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines are excluded as CLs.","1. Pacemaker wires and other nonlumened devices inserted into central blood vessels or the heart are excluded as CLs. 2. Extracorporeal membrane oxygenation lines, femoral arterial catheters, intraaortic balloon pump devices, and hemodialysis reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines are excluded as CLs.","Updated version of a current measure in IQR, HVBP, and HACRPCLABSI can be minimized through proper management of the central line. Efforts to improve central line insertionand maintenance practices, with early discontinuance of lines are recommended. These efforts result in decreasedmorbidity and mortality and reduced healthcare costs. Use of this measure to track CLABSIs through a nationalizedstandard for HAI monitoring, leads to improved patient outcomes and provides a mechanism for identifyingimprovements and evaluating prevention efforts. Additionally, CDC has added another risk adjustment methodologybesides the Standardized Infection Ratio. The two risk adjustment methodologies are:1. Standardized Infection Ratio (annual and quarter aggregation)The SIR is constructed by using an indirect standardization method for summarizing HAI experience across anynumber of stratified groups of data. CLABSI incidence rates stratified by patient care location type and in someinstances, location bed size and type of medical school affiliation which form the basis of the populationstandardization. Example: predicted numbers of CLABSI (and CLABSI rates) in a medical ICU are not the same as inan NICU. See also Scientific Validity section for further information on risk adjustment and variables.2. Adjusted Ranking Metric (annual aggregation)The adjusted ranking metric (ARM) combines the method of indirect standardization with a Bayesian random effects hierarchical model to account for the potentially low precision and/or reliability inherent in the unadjusted SIR mentioned above. A Bayesian posterior distribution constructed through Monte Carlo Markov Chain sampling isused to produce the adjusted numerator."]
["E0705","Proportion of Patients Hospitalized with Stroke that have a Potentially Avoidable Complication (during the Index Stay or in the 30 day Post‐Discharge Period)","Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke,were followed for one‐month after discharge,and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30‐day post discharge period. Define PACs during each time period as one of three types: (A) PACs during the Index Stay (Hospitalization): (1) PACs related to the anchor condition: The index stay is regarded as having a PAC if during the index hospitalization for stroke the patient develops one or more complications such as hypertensive encephalopathy, malignant hypertension, coma, anoxic brain damage, or respiratory failure etc. that may result directly from stroke or its management. (2) PACs due to Comorbidities: The index stay is also regarded as having a PAC if one or more of the patient’s controlled comorbid conditions is exacerbated during the hospitalization (i.e. it was not present on admission). Examples of these PACs are diabetic emergency with hypo‐or hyperglycemia, pneumonia, lung complications, acute myocardial infarction, gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting Patient Safety Failures: The index stay is regarded as having a PAC if there are one or more complications related to patient safety issues. Examples of these PACs are septicemia, meningitis, other infections, phlebitis, deep vein thrombosis, pulmonary embolism or any of the CMS‐defined hospital acquired conditions (HACs).","Outcome","Bridges to Excellence","Hospital Inpatient Quality Reporting","Outcome: Potentially avoidable complications (PACs) in patients hospitalized for stroke occurring during the index stay or in the 30day post‐discharge period.","Adult patients aged 18 – 65 years who had a relevant hospitalization for stroke (with no exclusions) and were followed for one‐month after discharge.","Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those with that have any form of cancer, ESRD (end‐stage renal disease), transplants such as lung or heart‐lung transplant or complications related to transplants, intracranial trauma, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the stroke measure if they are considered not relevant to stroke care or are for major surgical services that suggests that stroke may be a comorbidity or complication associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.","Hospital acquired conditions (HACs) have been defined by the Centers for Medicare and Medicaid (CMS) under theproposed rules for 2008 and 2009 and are avoidable conditions in hospitalized patients. Our potentially avoidablecomplications (PACs) go beyond the CMS defined HACs and identify conditions related to the index condition, tocomorbidities that got exacerbated, as well as those related to patient safety failures. While there is a generalunderstanding of the nature of care failures during hospitalizations or post‐discharge such as readmissions andemergency room visits, there has been no attempt to measure the magnitude or the type of potentially avoidablecomplications, and the cost reductions that would ensue if a payment model encouraged care to be optimized atbenchmarks achieved in studies.Well‐managed patients with stroke should rarely incur a potentially avoidable complication such as an emergencyroom visit post‐discharge, and readmissions related to stroke should occur only in the rarest of circumstances. Theenclosed workbook entitled NQF_Stroke_PACs_Risk_Adjustment 2.16.10.xls lists the types of PACs, their frequencyand costs as calculated in our national database, for both the inpatient stays and readmissions (see tabsCIP_Index_PAC_Stays and CIP_PAC_Readmissions). The PAC Overview tab shows that 57.8% of all hospitalizationsfor stroke had a PAC, with 53% of index stays having a PAC during the initial hospitalization. Of these PACs, over18.5% were incurred for direct complications of stroke, another 47% for acute exacerbation of a comorbidity, andanother 34.4% due to patient safety failures such as sepsis and other widespread infections, complications ofsurgical procedures, phlebitis and deep vein thrombosis or CMS‐defined hospital acquired conditions. The primarycause for readmissions and emergency room visits during the 30‐day post‐discharge period was due to ahypertensive encephalopathy, diabetic emergency with hypo‐ or hyperglycemia, pneumonia or lung complications,or patient safety failures such as skin or wound infections or sepsis. The ability to clearly identify the type andfrequency of each PAC creates a highly actionable measure for all providers that are managing or co‐managing thepatient, as well as for the health plan with whom the patient is a member."]
["E0708","Proportion of Patients Hospitalized with Pneumonia that have a Potentially Avoidable Complication (during the Index Stay or in the 30 day Post‐Discharge Period)","Percent of adult population aged 18 – 65 years who were admitted to a hospital with Pneumonia, were followed for one‐month after discharge, and had one or more potentially avoidable complications (PACs).","Outcome","Bridges to Excellence","Hospital Inpatient Quality Reporting","Outcome: Potentially avoidable complications (PACs) in patients hospitalized for pneumonia occurring during the index stay or in the 30‐day post‐discharge period.","Adult patients aged 18 – 65 years who had a relevant hospitalization for Pneumonia (with no exclusions) and were followed for one‐month after discharge.","Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those that have any form of cancer (especially cancer of lung and bronchus), thalassemia, sickle‐cell disease, ESRD (end‐stage renal disease), transplants such as lung or heart‐lung transplant or complications related to transplants, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the Pneumonia measure if they are considered not relevant to pneumonia care or are for major surgical services that suggests that pneumonia may be a comorbidity associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.","A study from the Boston Medical Center, Boston MA, demonstrated that although one in five hospitalizations arecomplicated by post‐discharge adverse events, development of a strong discharge services program for patientsadmitted for medical conditions reduced hospital utilization within 30 days of discharge.Umscheid et al used 2002 estimates of hospital‐acquired infections (HAI) and determined the range of HAI riskreductions from US studies. They report that 18%‐82% of blood‐stream infections, 46%‐55% of ventilator associatedpneumonia, 17% ‐ 69% of urinary tract infections and 26%‐54% of surgical site infections are preventable. Healy et al analyzed complications in hospitalized surgical patients and reported that between 39% and 61% of major complications (wound infections, pneumonia, urinary tract infections, arrhythmias, respiratory failure, gastrointestinal complications, deep vein thrombosis) and about an equal percent of minor complications could have been avoided. The National Pressure Ulcer Advisory Panel (NPUAP) reported in 2001 that pressure ulcer prevention programs had reported 50% or greater reductions in facility‐acquired pressure ulcers. Similarly, appropriate prophylaxis could reduce the risk of venous thromboembolism by 45% in acutely ill medical patients, and a recent study found a 50% reduction in thromboembolic events with extended pharmacologic prophylaxis. Adequate evidence‐based treatment protocols in preventing contrast nephropathy and adequate drug dosing have demonstrated a risk reduction between 52% and 90% in the incidence of acute renal failure in patients in the intensive care unit. Additionally, use of electronic medical systems has demonstrated that in a sample hospital that used prompts for protocols for nursing care, infection rates dropped 88%, bedsores were reduced and complianceto guidelines for care of patients on ventilator increased by 77%."]
["E0704","Proportion of Patients Hospitalized with AMI that have a Potentially Avoidable Complication (during the Index Stay or in the 30‐day Post‐Discharge Period)","Percent of adult population aged 18 – 65 years who were admitted to a hospital with acute myocardial infarction (AMI), were followed for one‐month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30‐day post discharge period. Define PACs during each time period as one of three types:(A) PACs during the Index Stay (Hospitalization):(1) PACs related to the anchor condition: The index stay is regarded as having a PAC if during the index hospitalization the patient develops one or more complications such as cardiac arrest, ventricular fibrillation, cardiogenic shock,stroke, coma, acute post‐hemorrhagic anemiaetc. That may result directly due to AMI or its management.(2) PACs due to Comorbidities: The index stay is also regarded as having a PAC if one or more of the patient’s controlled comorbid conditions is exacerbated during the hospitalization (i.e. it was not present on admission). Examples of these PACs are diabetic emergency with hypo‐or hyperglycemia, tracheostomy, mechanical ventilation, pneumonia, lung complications gastritis, ulcer, GI hemorrhage etc. (3) PACs suggesting Patient Safety Failures: The index stay is regarded as having a PAC if there are one or more complications related to patient safety issues. Examples of these PACs are septicemia, meningitis, other infections, phlebitis, deep vein thrombosis, pulmonary embolism or any of the CMS‐defined hospital acquired conditions (HACs). (B) PACs during the 30‐day post discharge period: (1) PACs related to the anchor condition: Readmissions and emergency room visits during the 30‐day post discharge period after an AMI are considered as PACs if they are for angina, chest pain, another AMI, stroke, coma, heart failure etc. (2) PACs due to Comorbidities: Readmissions and emergency room visits during the 30‐day post discharge period are also considered PACs if they are due to an exacerbation of one or more of the patient’s comorbid conditions, such as a diabetic emergency with hypo‐or hyperglycemia, pneumonia, lung complications, tracheostomy, mechanical ventilation etc. (3) PACs suggesting Patient Safety Failures: Readmissions or emergency room visits during the 30‐day post discharge period are considered PACs if they are due to sepsis, infections, phlebitis, deep vein thrombosis, or for any of the CMS‐defined hospital acquired conditions (HACs).","Outcome","Bridges to Excellence","Hospital Inpatient Quality Reporting","Outcome: Potentially avoidable complications (PACs) in patients hospitalized for AMI occurring during the index stay or in the 30Adult day post-discharge period.","patients aged 18 – 65 years who had a relevant hospitalization for AMI (with no exclusions) and were followed for one‐month after discharge","Denominator exclusions include exclusions of either “patients” or “claims” based on the following criteria: (1)“Patients” excluded are those that have any form of cancer, ESRD (end‐stage renal disease), transplants such as lung or heart‐lung transplant or complications related to transplants, pregnancy and delivery, HIV, or suicide. (2)“Claims” are excluded from the AMI measure if they are considered not relevant to AMI care or are for major surgical services that suggests that AMI may be a comorbidity associated with the procedure e.g. CABG procedure. Patients where the index hospitalization claim is excluded are automatically excluded from both the numerator and the denominator.","\"High priority aspect of healthcare: Acute Myocardial Infarction (AMI) is a common cause of hospitalization and theinitial cost of treatment of AMI has been estimatedto begin at approximately $10,000. However, due to considerable variability in costs of care of typical AMI patients,the average costs per patient is close to $15,000. Extrapolated to the more than 200,000 Medicare beneficiarieswho are annually hospitalized with AMI, the costs related to initial hospitalizations from AMI could be upwards of $3billion. Moreover, when AMI admissions incur potentially avoidable complications, these costs can go up severalfold and are truly a waste within the healthcare system.\""]
["E2104","Paired Measures 0702 and 0703; Intensive Care Unit (ICU) Length‐of‐ Stay (LOS) and Intensive Care: In‐ hospital mortality rate","Paired Measure: Intensive Care Unit (ICU) Length‐of‐Stay (LOS) paired with Intensive Care: In‐hospital mortality rate. E0702 Measure Description: For all patients admitted to the ICU, total duration of time spent in the ICU until time of discharge; both observed and risk‐adjusted LOS reported with the predicted LOS measured using the Intensive Care Outcomes Model ‐ Length‐of‐ Stay (ICOMLOS). E0703 Measure Description: For all adult patients admitted to the intensive care unit (ICU), the percentage of patients whose hospital outcome is death; both observed and risk‐adjusted mortality rates are reported with predicted rates based on the Intensive Care Outcomes Model ‐ Mortality (ICOMmort).","Outcome","Philip R. Lee Institute for Health Policy Studies","Hospital Inpatient Quality Reporting","E0702 Numerator Statement: For all eligible patients admitted to the ICU, the time at discharge from ICU (either death or physical departure from the unit) minus the time of admission (first recorded vital sign on ICU flow sheet) E0703 Numerator Statement: Total number of eligible patients whose hospital outcome is death","E0702 Denominator Statement: Total number of eligible patients who are discharged (including deaths and transfers) E0703 Denominator Statement: Total number of eligible patients who are discharged (including deaths and transfers)","E0702 Exclusions: <18 years of age at time of ICU admission, ICU readmission, <4 hours in ICU, primary admission due to trauma, burns, or immediately post‐CABG, admitted to exclude myocardial infarction (MI) and subsequently found without MI or any other acute process requiring ICU care, transfers from another acute care hospital E0703 Exclusions: <18 years of age at time of ICU admission, ICU readmission, <4 hours in ICU, primary admission due to trauma, burns, or immediately post‐CABG, admitted to exclude myocardial infarction (MI) and subsequently found without MI or any other acute process requiring ICU care, transfers from another acute care hospital","Angus DC, Linde‐Zwirble WT, Sirio CA, et al. 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Variation in ICU risk‐adjusted mortality: impact of methods of assessment and potential confounders. Chest. Jun 2008;133(6):1319‐1327.Rothen HU, Stricker K, Einfalt J, et al. Variability in outcome and resource use in intensive care units. Intensive Care Med. Aug 2007;33(8):1329‐1336.Knaus WA, Wagner DP, Zimmerman JE, Draper EA. Variations in mortality and length of stay in intensive care units. Ann Intern Med. May 15 1993;118(10):753‐761.Render ML, Kim HM, Deddens J, et al. Variation in outcomes in Veterans Affairs intensive care units with a computerized severity measure. Crit Care Med. May 2005;33(5):930‐939.Vasilevskis EE, Kuzniewicz MW, Cason BA, et al. Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV. Chest. Jul 2009;136(1):89‐101.Rosenthal GE, Harper DL, Quinn LM, Cooper GS. Severity‐adjusted mortality and length of stay in teaching and nonteaching hospitals. Results of a regional study. JAMA. Aug 13 1997;278(6):485‐490.Woods AW, MacKirdy FN, Livingston BM, Norrie J, Howie JC. Evaluation of predicted and actual length of stay in 22 Scottish intensive care units using the APACHE III system. Acute Physiology and Chronic Health Evaluation.Anesthesia. Nov 2000;55(11):1058‐1065. Glance LG, Osler TM, Dick AW. Identifying quality outliers in a large, multiple‐institution database by using customized versions of the Simplified Acute Physiology Score II and the Mortality Probability Model II0. Crit Care Med. Sep 2002;30(9):1995‐2002.Markgraf R, Deutschinoff G, Pientka L, Scholten T, Lorenz C. Performance of the score systems Acute Physiology and Chronic Health Evaluation II and III at an interdisciplinary intensive care unit, after customization. Crit Care.2001;5(1):31‐36.Murphy‐Filkins R, Teres D, Lemeshow S, Hosmer DW. Effect of changing patient mix on the performance of an intensive care unit severity‐of‐illness model: how to distinguish a general from a specialty intensive care unit. Crit Care Med. Dec 1996;24(12):1968‐1973.Rivera‐Fernandez R, Vazquez‐Mata G, Bravo M, et al. The Apache III prognostic system: customized mortality predictions for Spanish ICU patients. Intensive Care Med. Jun 1998;24(6):574‐581.Zhu BP, Lemeshow S, Hosmer DW, Klar J, Avrunin J, Teres D. Factors affecting the performance of the models in the Mortality Probability Model II system and strategies of customization: a simulation study. Crit Care Med. Jan 1996;24(1):57‐63.Higgins TL, Teres D, Copes WS, Nathanson BH, Stark M, Kramer AA. Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0‐III). Crit Care Med. Mar 2007;35(3):827‐835. Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA. Nov 24 1993;270(20):2478‐2486.Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. Dec 1991;100(6):1619‐1636.Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. May 2006;34(5):1297‐1310.Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. Dec 22‐29 1993;270(24):2957‐2963.Moreno RP, Metnitz PG, Almeida E, et al. SAPS 3‐‐From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med. Oct 2005;31(10):1345‐1355.Galeiras R, Lorente JA, Pertega S, et al. A model for predicting mortality among critically ill burn victims. Burns. Mar 2009;35(2):201‐209.Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma. Apr 1987;27(4):370‐378.Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. Jul 1999;16(1):9‐13.Tunnell RD, Millar BW, Smith GB. The effect of lead time bias on severity of illness scoring, mortality prediction and standardized mortality ratio in intensive care‐‐a pilot study. Anesthesia. Nov 1998;53(11):1045‐1053.Combes A, Luyt CE, Trouillet JL, Chastre J, Gibert C. Adverse effect on a referral intensive care unit's performance of accepting patients transferred from another intensive care unit. Crit Care Med. Apr 2005;33(4):705‐710.Rosenberg AL, Hofer TP, Strachan C, Watts CM, Hayward RA. Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures. Ann Intern Med. Jun 3 2003;138(11):882‐890.Mourouga P, Goldfrad C, Rowan KM. Does it fit? Is it good? Assessment of scoring systems. Current Opinion in Critical Care June 2000;6(3):176‐180.Kramer AA, Zimmerman JE. Assessing the calibration of mortality benchmarks in critical care: The Hosmer‐ Lemeshow test revisited. Crit Care Med. Sep 2007;35(9):2052‐2056‐ See more at: http://healthpolicy.ucsf.edu/content/icu‐outcomes#sthash.mvzpFUY3.dpuf"]
["E0349","Transfusion Reaction (PSI 16)","The count of medical and surgical discharges for patients age greater than or equal to 18 or in MDC 14 with ICD‐9‐CM code for transfusion reaction in any secondary diagnosis field.","Outcome","Agency for Healthcare Research & Quality","Hospital Inpatient Quality Reporting","Discharges 18 years and older or in MDC 14 with ICD‐9‐CM codes for transfusion reaction in any secondary diagnosis field of all medical and surgical discharges defined by specific DRGs or MS‐DRGs","N/A","None","Transfusion reaction is a health outcome measure. This measure captures illness or injury resulting fromadministration of mismatched blood or blood products, based on ABO or Rh antigens. These events are consideredto be almost entirely preventable. For example, the 2011 Update of the NQF Serious Reportable Events inHealthcare includes this specification of “Patient death or serious injury associated with unsafe administration ofblood products”: “Unsafe administration includes, but is not limited to hemolytic reactions and administering a)blood or blood products to the wrong patient; b) the wrong type; or c) blood or blood products that have beenimproperly stored or handled.” Similarly, “Hemolytic transfusion reaction involving administration of blood or bloodproducts having major blood group incompatibilities” is classified as a sentinel event by The Joint Commission.Preoperative evaluation of a patient for blood transfusion includes (1) reviewing previous medical records, (2)conducting a patient or family interview, and (3) reviewing laboratory test results.American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies.Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the AmericanSociety of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology.2006 Jul;105(1):198‐208.According to one recent review (Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical outcomes of ABO‐incompatible RBC transfusions. Am J Clin Pathol 2008; 129(2):276‐81), “the most frequent error leading totransfusion of ABO‐incompatible blood is failure of the final patient identification check at the bedside, leading totransfusion of properly labeled blood to a recipient other than the one intended. In a recent report from Ireland´shemovigilance system, more than half of all adverse reactions to blood transfusion were caused by the patient being given the wrong blood component. The relative distribution of errors in our cases and survey results are similar to those in other reports, with failures in pretransfusion verification of patient identification comprising a majority of all errors, followed by laboratory errors, and errors in sample collection and labeling… With an increased awareness of the root causes of transfusion errors, hospitals have taken steps to address them, such as requiring 2 pre‐ transfusion samples to confirm a patient´s initial ABO blood type result (independent of the American Association of Blood Banks standard requiring 2 determinations of the recipient´s ABO type if using computer crossmatching). In theory, requiring a second sample to confirm the ABO blood type could significantly reduce ABO‐incompatible transfusion because the vast majority of errors are due to sample collection and labeling and bedside errors. A reduction in the use of stationary refrigerators in the operating room is reported to have reduced some transfusion errors… Various devices have also been introduced to minimize errors in sample collection and transfusion to the intended recipient and have prevented some errors. These are summarized in a recent review. However, it is difficult to know whether actual use of these devices is widespread and their effectiveness in preventing ABO‐ incompatible transfusions…. Quality improvement dictates that analysis of adverse sentinel events such as ABO‐ incompatible transfusions be performed. When such an event has been identified, corrective measures should beinstituted to prevent recurrences."]
["X3727","Hospital 30‐day, all‐cause, unplanned risk‐ standardized days in acute care following pneumonia hospitalization","This measure assesses days spent in acute care after discharge from an acute care setting for a pneumonia hospitalization to provide a patient‐ centered assessment of the post‐discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital‐acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow‐up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post‐ discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with pneumonia by collectively measuring a set of adverse outcomes that can occur post‐discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post‐discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day‐count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk‐ standardized by subtracting the expected number of acute care days from the predicted number. The risk‐standardized days of acute care are multiplied by 100 to represent risk‐ standardized days of events per 100 admissions.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217‐99220 or 99234‐99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30‐day post‐discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30‐day readmission measure for pneumonia.","The target population for this measure is patients aged 65 years and older hospitalized for pneumonia and who are either Medicare Fee‐for‐Service (FFS) beneficiaries admitted to non‐federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: ‐Having a principal discharge diagnosis of pneumonia; ‐Enrolled in Medicare FFS or are VA beneficiaries; ‐Aged 65 or over; ‐Discharged from non‐federal acute care hospitals or VA hospitals alive; ‐Not transferred to another acute care facility; ‐and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0, and 488.11; ICD10‐CM codes J120, J121, J122, J1281, J1289, J129, J13, J181, J150, J151, J14, J154, J154, J153, J154, J1520, J1521, J1521, Z16, J1529, J158, J155, J156, A481, J158, J159, J157, J160, J168, J180, J189, J1100, J129, J09119).","This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post‐discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non‐VA hospitals).","The goal of this measure is to improve patient outcomes by providing patients, physicians, and hospitals withinformation about hospital‐level, risk‐standardized outcomes following hospitalization for pneumonia.Measurement of patient outcomes allows for a broad view of quality of care that cannot be captured entirely byindividual process‐of‐care measures. Safely transitioning patients from hospital to home requires a complex seriesof tasks which would be cumbersome to capture individually as process measures: timely and effectivecommunication between providers, prevention of and response to complications, patient education about post‐discharge care and self‐management, and timely follow‐up, and more. Inadequate transitional care contributes to avariety of adverse outcomes post‐discharge, including readmission, need for observation, and emergencydepartment evaluation. There already exist measures for readmission, but there are no current measures for EDutilization and observation stay. It is thus difficult for providers and consumers to gain a complete picture of post‐discharge outcomes. Moreover, separately reporting each outcome encourages “gaming,” such as recategorizingreadmission stays as observation stays to avoid a readmission outcome. By constructing a composite of outcomesthat are important to patients, we can produce a more complete picture of post‐discharge outcomes that betterinforms consumers about care quality and incentivizes global improvement in outcomes.Pneumonia results in approximately 1.2 million hospital admissions each year and accounts for more than $10billion annually in hospital expenditures. Among patients over 65 years of age, it is the second leading cause of hospitalization, and is the leading infectious cause of death (Lindenauer et al., 2011). Approximately 20% of pneumonia patients were rehospitalized within thirty days, representing the second‐highest proportion of all rehospitalizations at 6.3% (Jencks et al., 2009).Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital‐acquired infections and complications. Although some readmissions are unavoidable, they may also result from poor quality of care or inadequate transitional care. Transitional care includes effective discharge planning, transfer of information at the time of discharge, patient assessment and education, and coordination of care and monitoring in the post‐discharge period. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30‐day) readmission rates for a wide range of conditions including pneumonia (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Dean et al., 2006).Several studies also have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. ED visits represent a significant proportion of post‐discharge acute care utilization. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013).Additionally, over the past decade, the use of observation stays has rapidly increased. Specifically, between 2001 and 2008, the use of observation services increased nearly three‐fold (Venkatesh et al., 2011) and significant variation has been demonstrated in the use of observation services for conditions such as chest pain (Schuur et al., 2011). These rising rates of observation stays among Medicare beneficiaries have gained the attention of patients, providers, and policymakers (Feng et al., 2012; Rising et al., 2013; Vashi et al., 2013). A report from the Office of the Inspector General (OIG) notes that in 2012, Medicare beneficiaries had 1.5 million observation stays. Many of these observation stays lasted longer than the intended one day. The OIG report also notes the potential relationship between hospital use of observation stays as an alternative to short‐stay inpatient hospitalizations as a response to changing hospital payment incentives (Wright, 2013).Thus, in the context of the publicly reported CMS 30‐day readmission measures, the increasing use of ED visits and observation stays has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post‐discharge period. In particular, there exists concern that high use of observation stays could in some cases replace readmissions, and hospitals with high rates of observation stays in the post‐discharge period may therefore have low readmission rates that do not accurately reflect the quality of care (Carlson, 2013).References Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta‐analysis of the evidence. Med Care. Oct 1997;35(10):1044‐1059.Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Archives of Internal Medicine. Apr 24 2000;160(8):1074‐1081.Carlson J. Faulty Gauge? Readmissions are down, but observational‐status patients are up and that could skew Medicare numbers. Modern Healthcare. June 8, 2013 2013.Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. Apr 1992;27(1):81‐101.Courtney EDJ, Ankrett S, McCollum PT. 28‐Day emergency surgical re‐admission rates as a clinical indicator of performance. Ann R Coll Surg Engl. Mar 2003;85(2):75‐78.Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community‐acquired pneumonia guideline. Chest. 2006;130(3):794‐799Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health affairs (Project Hope). Jun 2012;31(6):1251‐1259.Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. Jun 1991;90(6):667‐ 674.Halfon P, Eggli Y, Pr, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Medical Care. Nov 2006;44(11):972‐981.Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. N Engl J Med. 2009;360(14):1418‐28.Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results of a measure of 30‐day readmission following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142‐150Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. Journal of General Internal Medicine. 1996;11(10):597‐607.Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine.Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post‐emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Jun 2011;18(6):e52‐63.Vashi AA, Fox JP, Carr BG, et al. Use of hospital‐based acute care among patients recently discharged from thehospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364‐371. Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.Wright S. Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. Washington, DC: OIG;2013."]
["X3722","Hospital 30‐day, all‐cause, unplanned risk‐ standardized days in acute care following heart failure hospitalization","This measure assesses days spent in acute care after discharge from an acute care setting for a heart failure hospitalization to provide a patient‐ centered assessment of the post‐discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital‐acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow‐up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post‐ discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with heart failure by collectively measuring a set of adverse outcomes that can occur post‐discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post‐discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day‐count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk‐ standardized by subtracting the expected number of acute care days from the predicted number. The risk‐standardized days of acute care are multiplied by 100 to represent risk‐ standardized days of events per 100 admissions.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zeor to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 or 0451 or 0452 or 0459 or 0981 and an observation stay is defined as revenue center code 0726 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217-99220 or 99234-99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30-day post-discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30-day readmission measure for heart failure.","The target population for this measure is patients aged 65 years and older hospitalized for heart failure and who are either Medicare Fee‐for‐Service (FFS) beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcfome is attributed. These measures include index admissons for patients: - Having a principal discharge diagnosis of heart failure; -Enrolled in Medicare FFS or are VA beneficiaries; -Aged 65 or over; -Discharged from non-federal acute care hospitals or VA hospitals alive; -Not transferred to another acute care facility; - and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of heart failure International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9.","This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post‐discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non-VA hospitals).","The goal of this measure is to improve patient outcomes by providing patients, physicians, and hospitals withinformation about hospital‐level, risk‐standardized outcomes following hospitalization for heart failure.Measurement of patient outcomes allows for a broad view of quality of care that cannot be captured entirely byindividual process‐of‐care measures. Safely transitioning patients from hospital to home requires a complex seriesof tasks which would be cumbersome to capture individually as process measures: timely and effectivecommunication between providers, prevention of and response to complications, patient education about post‐discharge care and self‐management, and timely follow‐up, and more. Inadequate transitional care contributes to avariety of adverse outcomes post‐discharge, including readmission, need for observation, and emergencydepartment evaluation. There already exist measures for readmission, but there are no current measures for EDutilization and observation stay. It is thus difficult for providers and consumers to gain a complete picture of post‐discharge outcomes. Moreover, separately reporting each outcome encourages “gaming,” such as recategorizingreadmission stays as observation stays to avoid a readmission outcome. By constructing a composite of outcomesthat are important to patients, we can produce a more complete picture of post‐discharge outcomes that betterinforms consumers about care quality and incentivizes global improvement in outcomes.Heart failure is the most common principal discharge diagnosis among older adults and the third highest for hospitalreimbursements in 2005 (CMS, 2006) and the leading cause of death and readmission among Medicarebeneficiaries, with nearly half of heart failure patients expected to return to the hospital within six months ofdischarge (Jencks et al., 2009; Krumholz et al., 1997; Lloyd‐Jones et al., 2010). Readmission rates following dischargefor heart failure are high and variable across hospitals in the United States (Krumholz et al., 2009; Bernheim et al.,2010). For example, for the time period of July 2011‐June 2012, publicly reported 30‐day risk‐standardizedreadmission rates ranged from 17.5% to 30.3% for patients admitted with heart failure (CMS, 2013)Acute care utilization after discharge (return to the emergency department, observation stay and readmission), forany reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additionalrisk of hospital‐acquired infections and complications. Although some readmissions are unavoidable, they may alsoresult from poor quality of care or inadequate transitional care. Transitional care includes effective dischargeplanning, transfer of information at the time of discharge, patient assessment and education, and coordination ofcare and monitoring in the post‐discharge period. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30‐day) readmission rates for a wide range of conditions including heart failure (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Hernandez et al., 2010).Several studies also have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. ED visits represent a significant proportion of post‐discharge acute care utilization. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013).Additionally, over the past decade, the use of observation stays has rapidly increased. Specifically, between 2001 and 2008, the use of observation services increased nearly three‐fold (Venkatesh et al., 2011) and significant variation has been demonstrated in the use of observation services for conditions such as chest pain (Schuur et al., 2011). These rising rates of observation stays among Medicare beneficiaries have gained the attention of patients, providers, and policymakers (Feng et al., 2012; Rising et al., 2013; Vashi et al., 2013). A report from the Office of the Inspector General (OIG) notes that in 2012, Medicare beneficiaries had 1.5 million observation stays. Many of these observation stays lasted longer than the intended one day. The OIG report also notes the potential relationship between hospital use of observation stays as an alternative to short‐stay inpatient hospitalizations as a response to changing hospital payment incentives (Wright, 2013).Thus, in the context of the publicly reported CMS 30‐day readmission measures, the increasing use of ED visits and observation stays has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post‐discharge period. In particular, there exists concern that high use of observation stays could in some cases replace readmissions, and that hospitals with high rates of observation stays in the post‐discharge period may therefore have low readmission rates that do not accurately reflect the quality of care (Carlson et al., 2013).Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta‐analysis of the evidence. Med Care. Oct 1997;35(10):1044‐1059.Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Archives of Internal Medicine. Apr 24 2000;160(8):1074‐1081.Bernheim SM, Grady JN, Lin Z, Wang Y, Savage SV, Bhat KR, et al. National patterns of risk‐standardized mortality and readmission for acute myocardial infarction and heart failure. Update on publicly reported outcomes measures based on the 2010 release. Circ Cardiovasc Qual Outcomes 2010;3:459‐67.Carlson J. Faulty Gauge? Readmissions are down, but observational‐status patients are up and that could skewMedicare numbers. Modern Healthcare. June 8, 2013 2013. Centers for Medicare and Medicaid Services. Medicare Hospital Quality Chartbook 2013: Performance Report on Outcome Measures. Centers for Medicare and Medicaid Services, September 2013.Centers for Medicare & Medicaid Services, Office of Information Services (OIS). Available at: http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SSDischarges0405.pdf, accessed October 21, 2006.Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. Apr 1992;27(1):81‐101.Courtney EDJ, Ankrett S, McCollum PT. 28‐Day emergency surgical re‐admission rates as a clinical indicator of performance. Ann R Coll Surg Engl. Mar 2003;85(2):75‐78.Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health affairs (Project Hope). Jun 2012;31(6):1251‐1259.Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. Jun 1991;90(6):667‐ 674.Halfon P, Eggli Y, Pr, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Medical Care. Nov 2006;44(11):972‐981.Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow‐up and 30‐day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA : the journal of the American Medical Association. May 5 2010;303(17):1716‐1722.Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. N Engl J Med. 2009;360(14):1418‐28.Krumholz HM, Parent EM, Tu N, Vaccarino V, Wang Y, Radford MJ, Hennen J. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med. 1997;157:99‐104.Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, Wang Y, Wang Y, Lin Z, Straube BM, Rapp MT, Normand SL, Drye EE. 2009. Patterns of hospital performance in acute myocardial infarction and heart failure 30‐day mortality and readmission. Circ Cardiovasc Qual Outcomes (2):407‐413.Lloyd‐Jones D et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics‐‐2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46‐e215. Epub 2009 Dec 17.Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. Journal of General Internal Medicine. 1996;11(10):597‐607.Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine.Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post‐emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. Jun 2011;18(6):e52‐63.Vashi AA, Fox JP, Carr BG, et al. Use of hospital‐based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364‐371.Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.Wright S. Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. Washington, DC:OIG;2013."]
["X3728","Hospital 30‐day, all‐cause, unplanned risk‐ standardized days in acute care following acute myocardial infarction (AMI) hospitalization","This measure assesses days spent in acute care after discharge from an acute care setting for an acute myocardial infarction (AMI) hospitalization to provide a patient‐centered assessment of the post‐discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital‐ acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow‐up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post‐discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with AMI by collectively measuring a set of adverse outcomes that can occur post‐discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post‐discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day‐count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk‐ standardized by subtracting the expected number of acute care days from the predicted number. The risk‐standardized days of acute care are multiplied by 100 to represent risk‐ standardized days of events per 100 admissions.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","The outcome of the measure is the number of days the patient spends in acute care (ED observation stay, and readmission) during the first 30 days after discharge from the hospital. The outcome can thus range from zero to 30 days, or zero to 300 per 100 discharges. An ED visit is defined as presence of revenue center codes 0450 OR 0451 OR 0452 OR 0459 OR 0981 and an observation stay is defined as revenue center code 0762 (in the outpatient file) OR HCPCS G0378 (in the outpatient file) OR CPT codes 99217‐99220 or 99234‐99236 (in the carrier file). Days in which an ED visit occurs are counted as 0.5 days of events since ED visits last on average less than a day. ED visits that result in an observation stay or readmission are not counted. Days of observation stay are calculated on the basis of hours. Total hours are divided by 24 and rounded up to the nearest integer. Any qualifying event in the 30‐day post‐discharge window is included, except planned readmissions, as defined by the planned readmission algorithm used in the publicly reported CMS 30‐day readmission measure for AMI.","The target population for this measure is patients aged 65 years and older hospitalized for AMI and who are either Medicare Fee‐for‐Service (FFS) beneficiaries admitted to non‐federal hospitals or patients admitted to VA hospitals. An index admission is the hospitalization to which the outcome is attributed. These measures include index admissions for patients: ‐Having a principal discharge diagnosis of AMI; ‐Enrolled in FFS or are VA beneficiaries; ‐Aged 65 or over; ‐Discharged from non‐federal acute care hospitals or VA hospitals alive; ‐Not transferred to another acute care facility; ‐and, Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the index admission. This requirement is dropped for patients with an index admission within a VA hospital. The denominator includes admissions for patients discharged from the hospital with a principal diagnosis of AMI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91.","This measure excludes index admissions for patients who leave the hospital against medical advice. This measure also excludes index admissions for patients without at least 30 days post‐discharge enrollment in FFS Medicare (note that this exclusion applies only to patients who have index admissions in non‐VA hospitals). An additional exclusion criterion for the AMI cohort is that patients admitted and discharged on the same day are not included as an index admission.","The goal of this measure is to improve patient outcomes by providing patients, physicians, and hospitals withinformation about hospital‐level, risk‐standardized outcomes following hospitalization for AMI. Measurement ofpatient outcomes allows for a broad view of quality of care that cannot be captured entirely by individual process‐of‐care measures. Safely transitioning patients from hospital to home requires a complex series of tasks whichwould be cumbersome to capture individually as process measures: timely and effective communication betweenproviders, prevention of and response to complications, patient education about post‐discharge care and self‐management, and timely follow‐up, and more. Inadequate transitional care contributes to a variety of adverseoutcomes post‐discharge, including readmission, need for observation, and emergency department evaluation.There already exist measures for readmission, but there are no current measures for ED utilization and observationstay. It is thus difficult for providers and consumers to gain a complete picture of post‐discharge outcomes.Moreover, separately reporting each outcome encourages “gaming,” such as recategorizing readmission stays asobservation stays to avoid a readmission outcome. By constructing a composite of outcomes that are important topatients, we can produce a more complete picture of post‐discharge outcomes that better informs consumers aboutcare quality and incentivizes global improvement in outcomes.Acute myocardial infarction (AMI) is among the most common principal hospital discharge diagnoses amongMedicare beneficiaries, and, in 2008, it was the sixth most expensive condition billed to Medicare, accounting for4.8% of Medicare’s hospital bill (Wier and Andrews, 2011). Readmission rates following discharge for AMI are high.For example, between July 2005 and June 2008, the median 30‐day readmission rate for AMI was 19.9%, with arange of 15.3% to 29.4% (Krumholz et al., 2009).Acute care utilization after discharge (return to the emergency department, observation stay and readmission), forany reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital‐acquired infections and complications. Although some readmissions are unavoidable, they may also result from poor quality of care or inadequate transitional care. Transitional care includes effective discharge planning, transfer of information at the time of discharge, patient assessment and education, and coordination of care and monitoring in the post‐discharge period. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30‐day) readmission rates for a wide range of conditions including AMI (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Bondestam et al., 1995; Carlhed et al., 2009).Several studies have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. ED visits represent a significant proportion of post‐discharge acute care utilization. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013).Additionally, over the past decade, the use of observation stays has rapidly increased. Specifically, between 2001 and 2008, the use of observation services increased nearly three‐fold (Venkatesh et al., 2011) and significant variation has been demonstrated in the use of observation services for conditions such as chest pain (Schuur et al., 2011). These rising rates of observation stays among Medicare beneficiaries have gained the attention of patients, providers, and policymakers (Feng et al., 2012; Rising et al., 2013; Vashi et al., 2013). A report from the Office of the Inspector General (OIG) notes that in 2012, Medicare beneficiaries had 1.5 million observation stays. Many of these observation stays lasted longer than the intended one day. The OIG report also notes the potential relationship between hospital use of observation stays as an alternative to short‐stay inpatient hospitalizations as a response to changing hospital payment incentives (Wright, 2013).Thus, in the context of the publicly reported CMS 30‐day readmission measures, the increasing use of ED visits and observation stays has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post‐discharge period. In particular, there exists concern that high use of observation stays could in some cases replace readmissions, and that hospitals with high rates of observation stays in the post‐discharge period may therefore have low readmission rates that do not accurately reflect the quality of care (Carlson et al., 2013).Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta‐analysis of the evidence. Med Care. Oct 1997;35(10):1044‐1059.Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Archives of Internal Medicine. Apr 24 2000;160(8):1074‐1081.Bondestam E, Breikss A, Hartford M. Effects of early rehabilitation on consumption of medical care during the first year after acute myocardial infarction in patients > or = 65 years of age. American Journal of Cardiology. 1995;75(12):767‐771.Carlhed R, Bojestig M, Peterson A, et al. Improved clinical outcome after acute myocardial infarction in hospitals participating in a Swedish quality improvement initiative. Circulation. Cardiovascular Quality & Outcomes.2009;2(5):458‐464.Carlson J. Faulty Gauge? Readmissions are down, but observational‐status patients are up and that could skew Medicare numbers. Modern Healthcare. June 8, 2013 2013.Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. Apr 1992;27(1):81‐101.Courtney EDJ, Ankrett S, McCollum PT. 28‐Day emergency surgical re‐admission rates as a clinical indicator of performance. Ann R Coll Surg Engl. Mar 2003;85(2):75‐78.Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health affairs (Project Hope). Jun 2012;31(6):1251‐1259.Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. Jun 1991;90(6):667‐ 674.Halfon P, Eggli Y, Pr, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Medical Care. Nov 2006;44(11):972‐981.Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. Journal of General Internal Medicine. 1996;11(10):597‐607.Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine.Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post‐emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Jun 2011;18(6):e52‐63.Vashi AA, Fox JP, Carr BG, et al. Use of hospital‐based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364‐371.Venkatesh AK, Geisler BP, Gibson Chambers JJ, Baugh CW, Bohan JS, Schuur JD. Use of observation care in US emergency departments, 2001 to 2008. PloS one. 2011;6(9):e24326.Wier, L.M. (Thomson Reuters), and Andrews, R.M. (AHRQ).The National Hospital Bill: The Most Expensive Conditions by Payer, 2008. HCUP Statistical Brief #107. March 2011. Agency for Healthcare Research and Quality, Rockville, MD.http://www.hcupus.ahrq.gov/reports/statbriefs/sb107.pdf. Wright S. Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. Washington, DC:OIG; 2013."]
["X3620","Hospital‐level, risk‐standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA)","This measure estimates hospital‐level, risk‐ standardized payments for a primary elective total THA/TKA episode of care starting with inpatient admission to a short term acute‐care facility for Medicare fee‐for‐service (FFS) patients who are 65 years of age or older.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","Outcome: hospital‐level, risk‐standardized payment for Medicare patients for a primary elective total hip and/or knee arthroplasty episode of care. Payment timeframe: admission date through 90 days post‐admission.","Admissions for Medicare FFS patients: with qualifying THA/TKA procedure; Aged 65 or over; Admitted to non‐federal acute care hospitals; Enrolled in Medicare Parts A and B for index and 12 months prior; Not transferred from acute care facility.","1) Patients without complete administrative data in the 90 days following the index admission, if alive 2) Patients with no payment information during the index admission 3) Patients discharged against medical advice (AMA) 4) Patients transferred to federal hospitals 5) Patients with more than two THA/TKA procedure codes during the admission","Due to their frequency and cost, THA and TKA are priority areas for outcome measure development. More than onethird of the US population 65 years and older suffers from osteoarthritis [1]. Between 2009 and 2012, there were337,419 THA procedures and 750,569 TKA procedures for Medicare fee‐for‐service patients 65 years and older [2].Estimates place the annual insurer cost of osteoarthritis in the US at $149 billion, with Medicare direct payments tohospitals for THA/TKA exceeding $15 billion annually [3]. Further, there are conflicting data regarding costs aftertotal joint arthroplasty, with evidence to support both increased [4] and decreased costs [5] following arthroplasty,suggesting there is great variation in the costs of a full episode of care for THA and TKA.Clinical outcomes for THA and TKA depend not only on the surgeon performing the procedure, but on carecoordination across provider groups and specialties, and the patient’s engagement in his or her recovery. Even thevery best surgeon will not get outstanding results if there are gaps in the quality of care for the patient before,during, and after surgery. The goal of hospital‐level resource use measurement is to capture the full spectrum ofcare in order to incentivize collaboration and shared responsibility for improving patients’ health and reducing theburden of their disease.Variation in the cost of a THA or TKA episode of care is often related to the quality of care, where complications andreadmissions increase the total payment for post‐surgical care. Given the well‐documented variation in readmissionand complication rates following THA and TKA, there is expected variation in total episode of care costs for theprocedures [6]. Birkmeyer et al. found that the average 30‐day cost increased by $2,436 among hospitals with thehighest quintile of complication rates, compared to the lowest quintile following THA [7]. The same study also foundthat rehabilitation costs accounted for 50% of “excess” payments among those undergoing THA. Miller et al. foundthat a major driver of differences in episode payments for THA was that hospitals within Accountable CareOrganizations (ACO) had smaller payments for post‐discharge care compared to non‐ACO hospitals [8]. Takentogether, these studies suggest that much of the variation in total episode costs arises in the post‐acute setting.Health systems have taken notice of opportunities to improve value by encouraging collaboration of care betweenhospitals and post‐acute providers. The Centers for Medicare & Medicaid Services’ (CMS’s) Bundled Payment forCare Improvement initiative aims to assess the feasibility and effectiveness of various models of bundled payments[9]. One analysis of hospitals found that the overall episode of care, particularly post‐discharge care, was lessexpensive in hospitals affiliated with Integrated Delivery Systems [10]. Transparency regarding the variation ofepisode of care payments triggered by THA and TKA helps to guide health systems and providers towardsimprovement in the value of care. 1.\tCenters for Disease Control and Prevention (CDC). Osteoarthritis. 2011; http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed August 13, 2013.2.\tSuter LG, Grady JN, Lin Z, et al. 2013 Measure Updates and Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or Total Knee Arthroplasty (TKA) All‐Cause Unplanned 30‐Day Risk‐Standardized Readmission Measure (Version 2.0). March 2013.3.\tMiller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health affairs (Project Hope). Nov 2011;30(11):2107‐2115.4.\tBozic KJ, Stacey B, Berger A, Sadosky A, Oster G. Resource utilization and costs before and after total joint arthroplasty. BMC health services research. 2012;12:73.5.\tHawker GA, Badley EM, Croxford R, et al. A population‐based nested case‐control study of the costs of hip and knee replacement surgery. Med Care. 2009;47(7):732‐741.6.\tSuter LG, et al., Medicare Hospital Quality Chartbook 2013: Performance Report on Outcome Measures, 2013.7.\tBirkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS. Hospital quality and the cost of inpatient surgery in the United States. Annals of surgery. 2012;255(1):1‐5.8.\tMiller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatient surgery. JAMA surgery. Jun 2013;148(6):549‐554.9.\tCMS. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. http:/ / innovation.cms.gov/initiatives/bundled‐payments/ [accessed Jan 7, 2014]10.\tMiller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatientsurgery. JAMA surgery. Jun 2013;148(6):549‐554."]
["X3689","Participation in a Patient Safety Culture Survey","Participation in a patient safety culture survey involves a) What is the name of the survey? b) How frequently is the survey administered? c) Which staff positions complete the survey? d) Are survey results reported to a centralized location? e) What is the survey response rate?","Structure","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","The facility/hospital conducts a patient safety culture survey among physicians, nurses, technicians, and support staff","None","None","A Patient Safety Culture Survey is TJC element of performance.Making care safer is a priority for CMS and as such is one of the CMS quality goals. One way to implement this goalwould be to create a patient safety culture assessment measure.This structural measure will allow us to gain an understanding of the patient safety culture assessment landscapewithout adding undue reporting burden to hospitals.Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events andpatient harm in healthcare organizations.They can be used to:■raise staff awareness about patient safety■diagnose and assess the current status of patient safety culture ■\tidentify strengths and areas for improvement■\texamine trends in patient safety culture and trends overtime"]
["E0202","Falls with injury","All documented patient falls with an injury levelof minor or greater on eligible unit types in acalendar quarter. Reported as Injury falls per1000 Patient Days.(Total number of injury falls / Patient days) X1000Measure focus is safety.Target population is adult acute care inpatientand adult rehabilitation patients. All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days. (Total number of injury falls / Patient days) X 1000 Measure focus is safety. Target population is adult acute care inpatient and adult rehabilitation patients.","Outcome","American Nurses Association","Hospital Inpatient Quality Reporting","Total number of patient falls of injury level minor or greater (whether or not assisted by a staff member) by eligible hospital unit during the calendar month X 1000.","Patient days by Type of Unit during the calendar month.","Other unit types (e.g., pediatric, psychiatric, obstetrical, etc.)","The measure focus addresses several national health goals and priorities, for example:1. Recently enacted Centers for Medicare and Medicaid Services regulations limit hospital reimbursement for carerelated to fall related injuries.2. The falls measures fits within the priorities set forth by the National Priorities Parternship. Specifically, it fitswithin the national priority of Making Care Safer (National Priorities Partnership, 2011).3. As part of their National Patient Safety Goals, The Joint Commission requires hospitals to reduce the risk ofpatient harm resulting falls and to implement a falls reduction program.Other evidence: Falls are one of the most common inpatient adverse events, with estimates of between 2 and 5 fallsper 1,000 patient days (Agostini, Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et al., 2002, 2008).In quarter 3 of 2009, fall rates for nursing units in participating NDNQI hospitals averaged 3.2 per 1000 patient days(median = 2.8 per 1000 patient days). About 30% of falls result in injury, disability, or death (Shorr, 2008) –particularly in older adults. Injury falls lead to as much as a 61% increase in patient‐care costs and lengthen apatient’s hospital stay (Fitzpatrick, 2011). Jorgensen (2011) estimated that by 2020 the direct and indirect costs ofinjuries related to falls will reach $54.9 billion. In addition injury falls are a significant source of liability for hospitals.Agnostini, J.V., Baker, D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized and institutionalized olderpeople. In Making health care safer: A critical analysis of patient safety practices (pp. 281‐299). EvidenceReport/Technology Assessment Number 43, AHRQ publication No. 01‐E058. Rockville, MD: Agency for HealthcareResearch and Quality.Fitzpatrick, M.A. (2011, March). Meeting the challenge of fall reduction [Supplement]. American Nurse Today, p. 1.Jorgensen, J. (2011, March). Reducing patient falls: A call to action [Supplement]. American Nurse Today, p. 2‐3.National Priorities Partnership. (2011, September). Input to the Secretary of Health and Human Services on Prioritiesfor the National Quality Strategy. Retrieved from: http://www.qualityforum.org/Home.aspxOliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to prevent falls and fractures in hospitals and carehomes and effect of cognitive impairment. 384, 82.Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use, restrain orders, and the risk of falls in hospitalizedpatients. Journal of the American Geriatric Society, 50, 526‐529.Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving the capture of fall events in hospitals: Combining aservice for evaluating inpatient falls with an incident report system. Journal of the American Geriatric Society, 56,701‐704. Unruh, L. (2002). Tends in adverse events in hospitalized patients. Journal of Healthcare Quality, 24, 4‐10."]
["E0642","Cardiac Rehabilitation Patient Referral From an Inpatient Setting","Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.","Process","American College of Cardiology","Hospital Inpatient Quality Reporting","Number of eligible patients with a qualifying event/diagnosis who have been referred to an outpatient Cardiac Rehabilitation/Secondary Prevention (CR/SP) program prior to hospital discharge or have a documented medical or patient‐centered reason why such a referral was not made.","Number of hospitalized patients in the reporting period hospitalized with a qualifying cardiovascular disease event/diagnosis who do not meet any of the criteria listed in the denominator exclusion section below.","Exceptions criteria require documentation of one or more of the following factors that may prohibit cardiac rehabilitation participation: Patient factors (e.g., patient resides in a long‐term nursing care facility). Medical factors (e.g., patient deemed by provider to have a medically unstable, life‐threatening condition). Health care system factors (e.g., no cardiac rehabilitation/secondary prevention (CR/SP) program available within 60 min of travel time from the patient’s home). The only exclusion criterion for this measure is noted below: Patients who expired before discharge.","1. Cardiac rehabilitation/secondary prevention programs (CR/SP) improve patient outcomes, including quality of life,function, recurrent myocardial infarction, and mortality.2. CR/SP is underutilized with geographic variability and decreased participation by patients with economicdisadvantages, women and older patients.3. The CR/SP performance measures were developed for use in systematic quality improvement projects to closethis treatment gap.4. Use of systematic referral processes and tools have been shown to increase CR/SP referral.5. Enrollment and participation in CR/SP, not referral, have been shown to improve patient outcomes. However,referral is necessary for patients to enroll and participate in CR/SP. The strength of provider referral to CR has beenshown to correlate with participation in CR."]
["E0204","Skill mix (Registered Nurse [RN], Licensed Vocational/Practica l Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract)","NSC‐12.1 ‐ Percentage of total productive nursing hours worked by RN (employee and contract) with direct patient care responsibilities by hospital unit. NSC‐12.2 ‐ Percentage of total productive nursing hours worked by LPN/LVN (employee and contract) with direct patient care responsibilities by hospital unit. NSC‐12.3 ‐ Percentage of total productive nursing hours worked by UAP (employee and contract) with direct patient care responsibilities by hospital unit. NSC‐12.4 ‐ Percentage of total productive nursing hours worked by contract or agency staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities by hospital unit. Note that the skill mix of the nursing staff (NSC‐ 12.1, NSC‐12.2, and NSC‐12.3) represent the proportions of total productive nursing hours by each type of nursing staff (RN, LPN/LVN, and UAP); NSC‐12.4 is a separate rate. Measure focus is structure of care quality in acute care hospital units.","Structure","American Nurses Association","Hospital Inpatient Quality Reporting","Four separate numerators are as follows: RN hours – Productive nursing care hours worked by RNs with direct patient care responsibilities for each hospital in‐patient unit during the calendar month. LPN/LVN hours – Productive nursing care hours worked by LPNs/LVNs with direct patient care responsibilities for each hospital in‐patient unit during the calendar month. UAP hours – Productive nursing care hours worked by UAP with direct patient care responsibilities for each hospital in‐patient unit during the calendar month. Contract or agency hours – Productive nursing care hours worked by nursing staff (contract or agency staff) with direct patient care responsibilities for each hospital in‐patient unit during the calendar month.","Denominator is the total number of productive hours worked by employee or contract nursing staff with direct patient care responsibilities (RN, LPN/LVN, and UAP) for each hospital in‐patient unit during the calendar month.","Same as numerator; nursing staff with no direct patient care responsibilities are excluded. Excluded nursing staff: Persons whose primary responsibility is administrative in nature. Specialty teams, patient educators, or case managers who are not assigned to a specific unit. Unit secretaries or clerks, monitor technicians, and other with no direct patient care responsibilities.","With the increasing concerns about cost and quality of patient care over the past 2 decades, hospital nurse staffinghas become a major focus in examining health care workforce relationships with patient outcomes. Nurses are thelargest group of clinical providers of care in healthcare systems. The Institute of Medicine recently concluded, in itsreport, The Future of Nursing: Leading Changing, Advancing Health (2010), that nurses are vital in providing qualitycare to patients.A large body of research has demonstrated that higher nurse staffing levels are significantly associated with betterpatient outcomes, including shorter length of stay and lower rates of mortality, failure to rescue, hospital acquiredinfections, falls, medication errors, and pressure ulcers (Blegen, Goode,Spetz, Vaughn, & Park, 2011; Kane,Shamliyan, Mueller, Duval, & Wilt, 2007; Lake & Cheung, 2006; Lang, Hodge, Olson, Romano, & Kravitz, 2004;Lankshear, Sheldon, & Maynard, 2005; Needleman et al., 2011; Stone et al., 2007; Unruh, 2008).The Agency for Healthcare Research and Quality (AHRQ) conducted a comprehensive and systematic review of the97 observational studies on the relationship between nurse staffing and patient outcomes published between 1990and 2006. This AHRQ’s meta‐analysis found a strong and consistent relationship between nurse staffing and specificpatient outcomes (mortality and length of stay), particularly for patients in intensive care units and surgical units(Kane et al., 2007). For example, length of stay was shorter by 24% in intensive care units and by 31% in surgicalunits as 1 RN per patient day was increased. In addition, nurse staffing affects care costs. There was evidence thatan additional RN hour per patient day or a 10% increase in the proportion of RNs decreased the odds of patients’pneumonia by 8.9% or 9.5%, respectively (Cho, 2003).American Nurses Association (ANA). (2012). ANA’s Principles for Nurse Staffing, 2nd Edition, Nursebooks.org, SilverSpring, MD. Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient outcomes: safety‐net and non‐safety‐net hospitals. Medical Care, 49(4), 406‐414.Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research, 52(2), 71‐79.Elliott, M.N., Kanouse, D.E., Edwards, C.A., & Hilborne, L.H. (2009). Components of care vary in importance for overall patient‐reported experience by type of hospitalization. Medicare Care, (47), 842–849.Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Wahington, D.C.: National Academies Press.Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. (2007). The association of registered nurse staffing levels and patient outcomes: systematic review and meta‐analysis. Medical Care, 45(12), 1195‐1204.Kutney‐Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Neff, D.F., Aiken, L.H. (2009). Nursing: a key to patient satisfaction. Health Affairs, 28(4). Epub 2009 Jun 12.Lake, E. T., & Cheung, R. B. (2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing? Western Journal of Nursing Research, 28(6), 654‐677.Lang, T. A., Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L. (2004). Nurse‐patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34(7‐8), 326‐337.Lankshear, A. J., Sheldon, T. A., & Maynard, A. (2005). Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. Advances in Nursing Science, 28(2), 163‐174.Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037‐1045.Nursing Alliance for Quality Care (NAQC). (2013). Fostering successful patient and family engagement: Nursing's critical role. Washington, DC: NAQC.Press Ganey. (2013). The rising tide measure: Communication with nurses. South Bend, IN: Press Ganey. Stone, P. W., Mooney‐Kane, C., Larson, E. L., Horan, T., Glance, L. G., Zwanziger, J., & Dick, A. W. (2007). Nurse working conditions and patient safety outcomes. Medical Care, 45(6), 571‐578.Unruh, L. (2008). Nurse staffing and patient, nurse, and financial outcomes. The American Journal of Nursing, 108(1),62‐71."]
["E0205","Nursing Hours per Patient Day","NSC‐13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in‐patient unit in a calendar month. NSC‐13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN,LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in‐patient unit in a calendar month. Measure focus is structure of care quality in acute care hospital units.","Structure","American Nurses Association","Hospital Inpatient Quality Reporting","Total number of productive hours worked by nursing staff with direct patient care responsibilities for each hospital inpatient unit during the calendar month.","Denominator is the total number of patient days for each in‐patient unit during the calendar month. Patient days must be from the same unit in which nursing care hours are reported.","Patient days from some non‐reporting unit types, such as Emergency Department, peri‐operative unit, and obstetrics, are excluded.","With the increasing concerns about cost and quality of patient care over the past 2 decades, hospital nurse staffinghas become a major focus in examining health care workforce relationships with patient outcomes. Nurses are thelargest group of clinical providers of care in healthcare systems. The Institute of Medicine recently concluded, in its report, The Future of Nursing: Leading Changing, Advancing Health (2010), that nurses are vital in providing quality care to patients.A large body of research has demonstrated that higher nurse staffing levels are significantly associated with better patient outcomes, including shorter length of stay and lower rates of mortality, failure to rescue, hospital acquired infections, falls, medication errors, and pressure ulcers (Blegen, Goode,Spetz, Vaughn, & Park, 2011; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Lake & Cheung, 2006; Lang, Hodge, Olson, Romano, & Kravitz, 2004; Lankshear, Sheldon, & Maynard, 2005; Needleman et al., 2011; Stone et al., 2007; Unruh, 2008).The Agency for Healthcare Research and Quality (AHRQ) conducted a comprehensive and systematic review of the 97 observational studies on the relationship between nurse staffing and patient outcomes published between 1990 and 2006. This AHRQ’s meta‐analysis found a strong and consistent relationship between nurse staffing and specific patient outcomes (mortality and length of stay), particularly for patients in intensive care units and surgical units (Kane et al., 2007). For example, length of stay was shorter by 24% in intensive care units and by 31% in surgical units as 1 RN per patient day was increased. In addition, nurse staffing affects care costs. There was evidence that an additional RN hour per patient day or a 10% increase in the proportion of RNs decreased the odds of patients’ pneumonia by 8.9% or 9.5%, respectively (Cho, 2003).American Nurses Association (ANA). (2012). ANA’s Principles for Nurse Staffing, 2nd Edition, Nursebooks.org, Silver Spring, MD.Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient outcomes: safety‐net and non‐safety‐net hospitals. Medical Care, 49(4), 406‐414.Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research, 52(2), 71‐79.Elliott, M.N., Kanouse, D.E., Edwards, C.A., & Hilborne, L.H. (2009). Components of care vary in importance for overall patient‐reported experience by type of hospitalization. Medicare Care, (47), 842–849.Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Wahington, D.C.: National Academies Press.Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. (2007). The association of registered nurse staffing levels and patient outcomes: systematic review and meta‐analysis. Medical Care, 45(12), 1195‐1204.Kutney‐Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Neff, D.F., Aiken, L.H. (2009). Nursing: a key to patient satisfaction. Health Affairs, 28(4). Epub 2009 Jun 12.Lake, E. T., & Cheung, R. B. (2006). Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing? Western Journal of Nursing Research, 28(6), 654‐677.Lang, T. A., Hodge, M., Olson, V., Romano, P. S., & Kravitz, R. L. (2004). Nurse‐patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34(7‐8), 326‐337.Lankshear, A. J., Sheldon, T. A., & Maynard, A. (2005). Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. Advances in Nursing Science, 28(2), 163‐174.Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037‐1045.Nursing Alliance for Quality Care (NAQC). (2013). Fostering successful patient and family engagement: Nursing's critical role. Washington, DC: NAQC.Press Ganey. (2013). The rising tide measure: Communication with nurses. South Bend, IN: Press Ganey. Stone, P. W., Mooney‐Kane, C., Larson, E. L., Horan, T., Glance, L. G., Zwanziger, J., & Dick, A. W. (2007). Nurse working conditions and patient safety outcomes. Medical Care, 45(6), 571‐578.Unruh, L. (2008). Nurse staffing and patient, nurse, and financial outcomes. The American Journal of Nursing, 108(1),62‐71."]
["E0506","Hospital 30‐day, all‐cause, risk‐ standardized readmission rate (RSRR) following pneumonia hospitalization","The measure estimates a hospital‐level risk‐ standardized readmission rate (RSRR) for patients discharged from the hospital with a principal diagnosis of pneumonia. The outcome  is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee‐for‐service (FFS) Medicare and hospitalized in non‐federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting,Hospital Readmission Reduction Program","The outcome for this measure is 30‐day readmission. We define readmission as an inpatient admission for any cause, with the exception of certain planned readmissions, within 30 days from the date of discharge from the index pneumonia admission. If a patient has more than one unplanned admission within 30 days of discharge from the index admission, only the first one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.","The denominator includes patients 18 and over hospitalized for pneumonia. The measure is currently publicly reported by CMS for those 65 years and older who are either Medicare FFS beneficiaries admitted to non-federal hospitals or patients admitted to VA hospitals. In 2014, we propose updating our current definition of pneumonia to include patients with a principal discharge diagnosis of aspiration pneumonia (defined by ICD‐9‐CM Code 507.0) and patients with a principal discharge diagnosis of sepsis (defined by ICD‐9‐CM codes 995.91, 995.92, 038, 038.0, 038.1, 038.10, 038.11, 038.12, 038.19, 038.2,038.3, 038.4, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49, 038.8, 038.9, and 785.52) or respiratory failure (defined by ICD‐9‐CM codes 518.81, 518.82. 518.84, and 799.1) and a secondary diagnosis of pneumonia coded as present on admission (POA). To be included in the measure cohort used in public reporting, patients must meet the following additional inclusion criteria: enrolled in Part A and Part B Medicare for the 12 months prior to the date of admission, and enrolled in Part A during the index admission (this criterion does not apply to patients discharged from VA hospitals); not transferred to another acute care facility; and alive at discharge.","For all cohorts, the measure excludes admissions for patients: ‐Discharged against medical advice (AMA); ‐Admitted with pneumonia within 30 days of discharge from a qualifying index admission (Admissions within 30 days of discharge of an index admission will be considered readmissions. No admission is counted as a readmission and an index admission. The next eligible admission after the 30‐day time period following an index admission will be considered another index admission.) For Medicare FFS patients, the measure additionally excludes admissions for patients: ‐Without at least 30 days post‐discharge enrollment in FFS Medicare","The Medicare Payment Advisory Commission (MedPAC) has called for hospital‐specific public reporting ofreadmission rates, identifying pneumonia as a priority condition (MedPAC, 2007). MedPAC finds that readmissionsare common, costly, and often preventable. Based on 2005 Medicare data, MedPAC estimates that about 8.9% ofMedicare pneumonia admissions were followed by a readmission within 15 days, accounting for more than 74,000admissions at a cost of $533 million. Pneumonia results in approximately 1.2 million hospital admissions each yearand accounts for more than $10 billion annually in hospital expenditures. Among patients over 65 years of age, it isthe second leading cause of hospitalization, and is the leading infectious cause of death (Lindenauer et. al., 2011).Approximately 20% of pneumonia patients were rehospitalized within thirty days, representing the second‐highestproportion of all rehospitalizations at 6.3% (Jencks 2009). Pneumonia readmission is a costly event and representsan undesirable outcome of care from the patient’s perspective, and highly disparate pneumonia readmission ratesamong hospitals suggest there is room for improvement. (MedPAC 2007, Bernheim 2010).References:Bernheim SM, et al. 2010 Measures Maintenance Technical Report: Acute Myocardial Infarction, Heart Failure andPneumonia 30‐day Risk Standardized Mortality Rate. 2010 Available at:http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier3&cid=1163010421830Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. NEngl J Med. 2009 Apr 2;360(14):1418‐28. Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results of a measure of 30‐day readmission following hospitalization for pneumonia. J Hosp Med. 2011;6(3):142‐150Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission,2007."]
["E0468","Hospital 30‐day, all‐cause, risk‐ standardized mortality rate (RSMR) following pneumonia hospitalization","The measure estimates a hospital 30‐day risk‐ standardized mortality rate (RSMR), defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of pneumonia. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee‐for‐ service (FFS) Medicare and hospitalized in non‐ federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting,Hospital Value‐Based Purchasing","The outcome for this measure is30‐day all‐cause mortality. Wedefine mortality as death fromany cause within 30 days of theindex admission date for patients18 and older discharged from thehospital with a principal diagnosisof pneumonia.","The denominator includespatients aged 18 and overadmitted to an acute care hospitalfor pneumonia and with acomplete claims history for the 12months prior to admission. Themeasure is currently publiclyreported by CMS for those 65years and older who are eitherMedicare FFS beneficiariesadmitted to non‐federal hospitalsor patients admitted to VAhospitals. In 2014, we proposeupdating our current definition ofpneumonia to include patientswith a principal dischargediagnosis of aspiration pneumonia(defined by ICD‐9‐CM Code 507.0)and patients with a principaldischarge diagnosis of sepsis(defined by ICD‐9‐CM codes995.91, 995.92, 038, 038.0, 038.1,038.10, 038.11, 038.12, 038.19,038.2,038.3, 038.4, 038.40,038.41, 038.42, 038.43, 038.44,038.49, 038.8, 038.9, and 785.52)or respiratory failure (defined byICD‐9‐CM codes 518.81, 518.82.518.84, and 799.1) and asecondary diagnosis of pneumoniacoded as present on admission (POA). Patients who are transferred from one acute care facility to another must have a principal discharge diagnosis of pneumonia at both hospitals. The initial hospital for a transferred patient is designated as the responsible institution for the episode.","The measure excludes index admissionsfor patients:1. Discharged alive on the day ofadmission or the following day who werenot transferred;2. With inconsistent or unknown vitalstatus or other unreliable demographicdata;3. Enrolled in the Medicare hospiceprogram or VA hospice services any timein the 12 months prior to the indexadmission, including the first day of theindex admission; and4. Who were discharged against medicaladvice (AMA).After the above exclusions (#1‐4) areapplied, the measure randomly selectsone index admission per patient per yearfor inclusion in the cohort. Each episodeof care must be mutually independentwith the same probability of theoutcome. The probability of deathincreases with each subsequentadmission and therefore the episodes ofcare are not mutually independent. Forthe three year combined data, whenindex admissions occur during thetransition between measure reportingperiods (June and July of each year) andboth are randomly selected for inclusion in the measure, the measure only includes the June admission. The July admissions are excluded from the measure to avoid assigning a single death to two admissions.","Among patients over 65 years of age, pneumonia is the second leading cause of hospitalization, and is the leadinginfectious cause of death (Lindenauer et al., 2011). Many current hospital interventions are known to decrease therisk of death within 30 days of hospital admission (Jha et. al., 2007). Current process‐based performance measures,however, cannot capture all the ways that care within the hospital might influence outcomes. As a result, manystakeholders, including patient organizations, are interested in outcomes measures that allow patients andproviders to assess relative outcomes performance for hospitals (Bratzler et al., 2007).References:Bratzler, DW, Nsa W, Houck PM. Performance measures for pneumonia: are they valuable, and are processmeasures adequate. Current Opinion in Infectious Diseases. 20(2):182‐189, April 2007.Jha AK, Orav EJ, Li Z, Epstein AM. The inverse relationship between mortality rates and performance in the HospitalQuality Alliance measures. Health Aff (Millwood) 2007 Jul‐Aug;26(4):1104‐10.Lindenauer PK, Normand SL, Drye EE, et al. Development, validation, and results of a measure of 30‐day readmissionfollowing hospitalization for pneumonia. J Hosp Med. 2011;6(3):142‐150"]
["X0351","Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure","The Kidney/Urinary Tract Infection Clinical Episode‐Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐based incentive payments. Kidney/Urinary Tract Infection episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient with a kidney/urinary tract infection hospital admission. The Kidney/Urinary Tract Infection Clinical Episode‐ Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Kidney/Urinary Tract Infection Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the kidney/urinary tract infection treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk‐adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting","The numerator of theKidney/Urinary Tract InfectionClinical Episode‐Based PaymentMeasure is the sum of aprovider’s risk‐adjusted spendingand the preadmission and post‐discharge medical services thatare clinically related tokidney/urinary tract infectionacross a provider’s eligiblekidney/urinary tract infectionepisodes during the period ofperformance. A kidney/urinarytract infection episode begins 3days prior to the initial (i.e.,index) admission and extends 30days following the discharge fromthe index hospital stay.","A count of the provider’skidney/urinary tract infectionepisodes during the period ofperformance.","The exclusion methodology applied tothe measure is similar to the one used tocalculate the NQF‐endorsed MedicareSpending per Beneficiary (MSPB)measure. A beneficiary’s episode isexcluded if the beneficiary meets any ofthe following criteria:• received Medicare‐covered services forwhich Medicare was not the primarypayer during the episode window;• not continuously enrolled in both PartsA and B in the 90 days prior to and duringthe episode window; or• missing date of birth in the Medicareenrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based onresource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Availableat http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of carein response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of theDepartment of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality(Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["X0352","Knee Replacement/ Revision Clinical Episode‐Based Payment Measure","The Knee Replacement/Revision Clinical Episode‐ Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐based incentive payments. Knee Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient who receives a knee replacement/revision. The Knee Replacement/Revision Clinical Episode‐Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Knee Replacement/Revision Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the knee replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk-adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital InpatientQuality Reporting, Hospital Value‐Based Purchasing, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The numerator of the KneeReplacement/Revision ClinicalEpisode‐Based Payment Measureis the sum of a provider’s risk‐adjusted spending and the preadmission and post‐discharge medical services that are clinically related to the knee replacement/revision across a provider’s eligible Knee Replacement/Revision episodes during the period of performance. A knee replacement/revision episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.","A count of the provider’s kneereplacement/revision episodesduring the period of performance.","The exclusion methodology applied tothe measure is similar to the one used tocalculate the NQF‐endorsed MedicareSpending per Beneficiary (MSPB)measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare‐covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Available at http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of care in response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of the Department of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality(Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["X0353","Spine Fusion/ Refusion Clinical Episode‐Based Payment Measure","The Spine Fusion/Refusion Clinical Episode‐Based Payment Measure constructs a clinically  coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐based incentive payments. Spine Fusion/Refusion episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient who receives a spine fusion/refusion. The Spine Fusion/Refusion Clinical Episode‐Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Spine Fusion/Refusion Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the spine fusion/refusion performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk‐adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital InpatientQuality Reporting, Hospital Value‐Based Purchasing, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The numerator of the SpineFusion/Refusion Clinical Episode‐Based Payment Measure is thesum of a provider’s risk‐adjustedspending and the preadmissionand post‐discharge medicalservices that are clinically relatedto the spine fusion/refusionacross a provider’s eligible spinefusion/refusion episodes duringthe period of performance. Aspine fusion/refusion episodebegins 3 days prior to the initial(i.e., index) admission andextends 30 days following thedischarge from the index hospitalstay.","A count of the provider’s spinefusion/refusion episodes duringthe period of performance.","The exclusion methodology applied tothe measure is similar to the one used tocalculate the NQF‐endorsed MedicareSpending per Beneficiary (MSPB)measure. A beneficiary’s episode isexcluded if the beneficiary meets any ofthe following criteria:• received Medicare‐covered services forwhich Medicare was not the primarypayer during the episode window;• not continuously enrolled in both PartsA and B in the 90 days prior to and duringthe episode window; or• missing date of birth in the Medicareenrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based onresource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Availableat http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of carein response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of theDepartment of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality(Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["X0354","Cellulitis Clinical Episode‐Based Payment Measure","The Cellulitis Clinical Episode‐Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐ based incentive payments. Cellulitis episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient with a cellulitis hospital admission. The Cellulitis Clinical Episode‐ Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Cellulitis Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the cellulitis treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk‐adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital InpatientQuality Reporting, Hospital Value‐Based Purchasing, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The numerator of the Cellulitis Clinical Episode-Based Payment Measure is the sum of a provider's risk adjusted spending and the preadmission and post discharge medical services that are clinically related to cellulitis across a provider's eligible cellulitis episodes during the period of performance. A cellulitis episode begins 3 days prior to the initial (i.e., index) admission and extends 30 days following the discharge from the index hospital stay.","A count of the provider’s cellulitis episodes during the period of performance.","The exclusion methodology applied to the measure is similar to the one used to calculate the NQF-endorsed Medicare Spending per Beneficiary (MSPB) measure. A beneficiary’s episode is excluded if the beneficiary meets any of the following criteria: • received Medicare‐covered services for which Medicare was not the primary payer during the episode window; • not continuously enrolled in both Parts A and B in the 90 days prior to and during the episode window; or • missing date of birth in the Medicare enrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based onresource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Availableat http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of carein response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of theDepartment of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality (Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["X0355","Gastrointestinal Hemorrhage Clinical Episode‐ Based Payment Measure","The Gastrointestinal Hemorrhage Clinical Episode‐Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐based incentive payments. Gastrointestinal Hemorrhage episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient with a gastrointestinal hemorrhage hospital admission. The Gastrointestinal Hemorrhage Clinical Episode‐ Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Gastrointestinal Hemorrhage Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the gastrointestinal hemorrhage treated during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk‐adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital InpatientQuality Reporting, Hospital Value‐Based Purchasing, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The numerator of theGastrointestinal HemorrhageClinical Episode‐Based PaymentMeasure is the sum of aprovider’s risk‐adjusted spendingand the preadmission and post‐discharge medical services thatare clinically related togastrointestinal hemorrhageacross a provider’s eligiblegastrointestinal hemorrhageepisodes during the period ofperformance. A gastrointestinalhemorrhage episode begins 3days prior to the initial (i.e.,index) admission and extends 30days following the discharge fromthe index hospital stay.","A count of the provider’sgastrointestinal hemorrhageepisodes during the period ofperformance.","The exclusion methodology applied tothe measure is similar to the one used tocalculate the NQF‐endorsed MedicareSpending per Beneficiary (MSPB)measure. A beneficiary’s episode isexcluded if the beneficiary meets any ofthe following criteria:• received Medicare‐covered services forwhich Medicare was not the primarypayer during the episode window;• not continuously enrolled in both PartsA and B in the 90 days prior to and duringthe episode window; or• missing date of birth in the Medicareenrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based onresource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Availableat http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of carein response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of theDepartment of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality(Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["X0356","Hip Replacement/ Revision Clinical Episode‐Based Payment Measure","The Hip Replacement/Revision Clinical Episode‐ Based Payment Measure constructs a clinically coherent group of medical services that can be used to inform providers about their resource use and effectiveness and establish a standard for value‐based incentive payments. Hip Replacement/Revision episodes are defined as the set of services provided to treat, manage, diagnose, and follow up on (including post‐acute care) a patient who receives a hip replacement/revision. The Hip Replacement/Revision Clinical Episode‐Based Payment Measure, like the NQF‐endorsed Medicare Spending Per Beneficiary (MSPB) measure, assesses the cost of services initiated during an episode that spans the period immediately prior to, during, and following a patient’s hospital stay. In contrast to the MSPB measure, the Hip Replacement/Revision Clinical Episode‐Based Payment Measure includes Medicare payments only for services that are clinically related to the hip replacement/revision performed during the index hospital stay. The measure sums the Medicare payment amounts for clinically related Part A and Part B services provided during this timeframe and attributes them to the hospital at which the index hospital stay occurred or to the physician group primarily responsible for the beneficiary’s care during the index hospital stay. Medicare payments included in this episode‐based measure are standardized and risk‐adjusted.","Efficiency","Centers for Medicare & Medicaid Services","Hospital InpatientQuality Reporting, Hospital Value‐Based Purchasing, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The numerator of the HipReplacement/Revision ClinicalEpisode‐Based Payment Measureis the sum of a provider’s risk‐adjusted spending and thepreadmission and post‐dischargemedical services that areclinically related to the hipreplacement/revision across aprovider’s eligible hipreplacement/revision episodesduring the period ofperformance. A hipreplacement/revision episodebegins 3 days prior to the initial(i.e., index) admission andextends 30 days following thedischarge from the index hospitalstay.","A count of the provider’s hipreplacement/revision episodesduring the period of performance.","The exclusion methodology applied tothe measure is similar to the one used tocalculate the NQF‐endorsed MedicareSpending per Beneficiary (MSPB)measure. A beneficiary’s episode isexcluded if the beneficiary meets any ofthe following criteria:• received Medicare‐covered services forwhich Medicare was not the primarypayer during the episode window;• not continuously enrolled in both PartsA and B in the 90 days prior to and duringthe episode window; or• missing date of birth in the Medicareenrollment database.","CMS is constructing episodes of care because they allow meaningful comparisons between providers based onresource use for certain clinical conditions or procedures, as noted in the recent National Quality Forum draft reportfor the “Episode Grouper Evaluation Criteria” project (see National Quality Forum (NQF) “Comment on the ProposedRecommendations for Evaluating Episode Groupers.” (2014) Available athttp://www.qualityforum.org/ProjectMaterials.aspx?projectID=73777) and in various peer‐reviewed articles (seePeter S. Hussey, Melony E. Sorbero, Ateev Mehrotra, Hangsheng Liu and Cheryl L. Damberg. “Episode‐BasedPerformance Measurement And Payment: Making It A Reality.” Health Affairs, 28, no.5 (2009):1406‐1417. Availableat http://content.healthaffairs.org/content/28/5/1406.full.pdf). Furthermore, CMS is constructing episodes of carein response to the mandate in Section 3003 of the Affordable Care Act (ACA) of 2010 that the Secretary of theDepartment of Health and Human Services (HHS) develop an episode grouper to improve care efficiency and quality(Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, § 3003, 124 Stat. 366 (2010))."]
["E0647","Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)","Percentage of patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Inpatient Psychiatric Facility Quality Reporting","Patients or their caregiver(s) whoreceived a transition record (andwith whom a review of allincluded information wasdocumented) at the time ofdischarge including, at aminimum, all of the followingelements:Inpatient Care• Reason for inpatient admission,AND• Major procedures and testsperformed during inpatient stay and summary of results, AND • Principal diagnosis at discharge Post‐Discharge/ Patient Self‐Management • Current medication list, AND • Studies pending at discharge (e.g., laboratory, radiological), AND • Patient instructions Care Plan • Advance directives or surrogate decision maker documented OR • Documented reason for not providing care plan Contact Information/Plan for Follow‐up Care • 24‐hour/7‐day contact information including physician for emergencies related to inpatient stay, AND • Contact information for obtaining results of studies pending at discharge, AND • Plan for follow‐up care, AND • Primary physician, other health care professional, or site designated for follow‐up care","All patients, regardless of age,discharged from an inpatientfacility (e.g., hospital inpatient orobservation, skilled nursingfacility, or rehabilitation facility) tohome/self‐care or any other siteof care.","Patients who died.Patients who left against medical advice(AMA) or discontinued care.","This measure is important to decrease cost, address gaps in care, and enhance coordination of communication.Cost• In 2006, there were over 39 million hospital discharges; of those, 13 percent of these patients are repeatedlyhospitalized and use 60 percent of the healthcare resources.• A 2007 report by the Medicare Payment Advisory Commission estimated approximately 18 percent of admissionsresult in readmissions within 30 days, costing CMS $15 billion.Gaps in Care: •\tSabogal and colleagues found that uncoordinated transitions between sites of care, even within the sameinstitution, and between caregivers increase hospital readmissions, medical errors, duplication of services, andwaste of resources.•\tMoore and colleagues examined three types of discontinuity of care among older patients transferred from thehospital: medication, test result follow‐up, and initiation of a recommended work‐up. They found that nearly 50percent of hospitalized patients experienced at least one discontinuity and that patients who did not have arecommended work‐up initiated were six times more likely to be re‐hospitalized.•\tA prospective, cross‐sectional study by Roy and colleagues found that approximately 40 percent of patients havepending test results at the time of discharge and that 10 percent of these require some ac Emergency DepartmentVisits•\tThe 2008 National Health Statistics Report determined that 2.3 million (2 percent) emergency department visitsare from patients who were discharged from the hospital within the previous 7 days.The report also cited the following:•\tTen percent of the 2.3 million emergency department visits were for complications related to their recenthospitalization, and•\tThe uninsured are 3 times more likely to visit the emergency department.Medication errors:•\tAn estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, ordischarge of a patient.•\tDuring care transitions, patients receive medications from different prescribers who rarely have access to patients’comprehensive medication list.•\tForster and colleagues found that 19 percent of discharged patients experienced an associated adverse eventwithin three weeks of leaving the hospital; 66 percent of these were adverse drug events.Coleman EA, Min S, Chomiak A, Kramer AM. 2004. Post‐hospital care transitions: patterns, complications, and riskidentification. Health Services Research 39:1449–1465.Agency for Healthcare Research and Quality (ARHQ). 1999. Outcomes by Patient and Hospital Characteristics for AllDischarges. Available at: http://www.ahrq.gov/HCUPnet.asp.Kramer A, Eilertsen T, Lin M, Hutt E. 2000. Effects of nurse staffing on hospital transfer quality measures for newadmissions. Pp. 9.1–9.22. Inappropriateness of Minimum Nurse Staffing Ratios for Nursing Homes. Health CareFinancing Administration.Hutt E, Ecord M, Eilertsen TB, et al. Precipitants of emergency room visits and acute hospitalization in short‐stayMedicare nursing home residents. J Am Geriatr Soc 2001; 50: 223‐229. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med 2009; 150:178‐187.Agency for Healthcare Research and Quality (ARHQ). 2006. Outcomes by Patient and Hospital Characteristics for All Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp.Medicare Payment Advisory Commission. A data book: Healthcare spending and the Medicare program. June 2007. Available at: http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf.Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=508    8&partner=rssnyt&emc=rss.Sabogal F, Coots‐Miyazaki M, Lett JE. Effective care transitions interventions: Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2).Moore C, Wisnevesky J, Williams S, McGinn T. 2003. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18:646–651.Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143(2):121‐128.Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from US hospitals. National Health Statistics Reports, July 24, 2008; Number 6.Rozich JD & Resar, RK. 2001. Medication safety: One organization’s approach to the challenge. J. Clin. Outcomes Manag. 8:27‐34.Partnership for Solutions. 2002. Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University.Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3):161‐167."]
["E0141","Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)","Percentage of patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow‐up care within 24 hours of discharge Target population is adult acute care inpatient and adult rehabilitation patients.","Outcome","American Nurses Association","Hospital Inpatient Quality Reporting,Inpatient Rehabilitation Facility Quality Reporting,Long‐Term Care Hospital Quality Reporting","Total number of patient falls(with or without injury to thepatient and whether or notassisted by a staff member) byhospital unit during the calendarmonth X 1000.Target population is adult acutecare inpatient and adultrehabilitation patients. Eligibleunit types include adult criticalcare, adult step‐down, adultmedical, adult surgical, adultmedical‐surgical combined,critical access, adultrehabilitation in‐patient.","Patient days by hospital unitduring the calendar month.Included Populations:•Inpatients, short stay patients,observation patients, and sameday surgery patients who receivecare on eligible inpatient units forall or part of a day on thefollowing unit types:•Adult critical care, step‐down,medical, surgical, medical‐surgicalcombined, critical access, andadult rehabilitation units.•Patients of any age on an eligiblereporting unit are included in thepatient day count","Other unit types (e.g., pediatric,psychiatric, obstetrical, etc.)","The measure focus addresses several national health goals and priorities, for example:1. Recently enacted Centers for Medicare and Medicaid Services regulations limit hospital reimbursement for carerelated to fall related injuries.2. The falls measures fits within the priorities set forth by the National Priorities Parternship. Specifically, it fitswithin the national priority of Making Care Safer (National Priorities Partnership, 2011).3. As part of their National Patient Safety Goals, The Joint Commission requires hospitals to reduce the risk ofpatient harm resulting falls and to implement a falls reduction program.Other evidence: Falls are one of the most common inpatient adverse events, with estimates of between 2 and 5 fallsper 1,000 patient days (Agostini, Baker, & Gogardus, 2001; Oliver et al., 2007; Unruh, 2002; Shorr et al., 2002, 2008). In quarter 3 of 2009, fall rates for nursing units in participating NDNQI hospitals averaged 3.2 per 1000 patient days (median = 2.8 per 1000 patient days). About 30% of falls result in injury disability or death (Shorr, 2008) – particularly in older adults. Injury falls lead to as much as a 61% increase in patient‐care costs and lengthen a patient’s hospital stay (Fitzpatrick, 2011). Jorgensen (2011) estimated that by 2020 the direct and indirect costs of injuries related to falls will reach $54.9 billion. In addition injury falls are a significant source of liability for hospitals.Agnostini, J.V., Baker, D.I., & Bogardus, S.T. (2001). Prevention of falls in hospitalized and institutionalized older people. In Making health care safer: A critical analysis of patient safety practices (pp.281‐299). Evidence Report/Technology Assessment Number 43, AHRQ publication No. 01‐E058. Rockville, MD: Agency for Healthcare Research and Quality.Fitzpatrick, M.A. (2011, March).Meeting the challenge of fall reduction [Supplement]. American Nurse Today, p. 1. Jorgensen, J. (2011, March). Reducing patient falls: A call to action [Supplement]. American Nurse Today, p. 2‐3.National Priorities Partnership. (2011, September). Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy. Retrieved from: http://www.qualityforum.org/Home.aspxOliver, D., Connelly, J.B., Victor, C.R. et al. (2007). Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment. 384, 82.Shorr, R.I., Guillen, M.k. Rosenblatt, L.C. (2002). Restraint use, restrain orders, and the risk of falls in hospitalized patients. Journal of the American Geriatric Society, 50, 526‐529.Shorr, R.I., Mion, L.C., Chandler, M., et al. (2008). Improving the capture of fall events in hospitals: Combining a service for evaluating inpatient falls with an incident report system. Journal of the American Geriatric Society, 56, 701‐704.Unruh, L. (2002). Tends in adverse events in hospitalized patients. Journal of Healthcare Quality, 24, 4‐10."]
["E0648","Patient fall rate","All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days and Unassisted Falls per 1000 Patient Days. (Total number of falls / Patient days) X 1000 Measure focus is safety.","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Inpatient Psychiatric Facility Quality Reporting","Patients for whom a transitionrecord was transmitted to thefacility or primary physician orother health care professionaldesignated for follow‐up care within 24 hours of discharge","All patients, regardless of age,discharged from an inpatientfacility (e.g., hospital inpatient orobservation, skilled nursingfacility, or rehabilitation facility) to home/self‐care or any other site of care","Patients who diedPatients who left against medical advice(AMA) or discontinued care","This measure is important to decrease cost, address gaps in care, and enhance coordination of communication.Cost• In 2006, there were over 39 million hospital discharges; of those, 13 percent of these patients are repeatedlyhospitalized and use 60 percent of the healthcare resources.• A 2007 report by the Medicare Payment Advisory Commission estimated approximately 18 percent of admissionsresult in readmissions within 30 days, costing CMS $15 billion.Gaps in Care:• Sabogal and colleagues found that uncoordinated transitions between sites of care, even within the same institution, and between caregivers increase hospital readmissions, medical errors, duplication of services, andwaste of resources.•\tMoore and colleagues examined three types of discontinuity of care among older patients transferred from thehospital: medication, test result follow‐up, and initiation of a recommended work‐up. They found that nearly 50 percent of hospitalized patients experienced at least one discontinuity and that patients who did not have a recommended work‐up initiated were six times more likely to be re‐hospitalized.•\tA prospective, cross‐sectional study by Roy and colleagues found that approximately 40 percent of patients have pending test results at the time of discharge and that 10 percent of these require some ac Emergency Department Visits•\tThe 2008 National Health Statistics Report determined that 2.3 million (2 percent) emergency department visits are from patients who were discharged from the hospital within the previous 7 days.The report also cited the following:•\tTen percent of the 2.3 million emergency department visits were for complications related to their recent hospitalization, and•\tThe uninsured are 3 times more likely to visit the emergency department. Medication errors:•\tAn estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, or discharge of a patient.•\tDuring care transitions, patients receive medications from different prescribers who rarely have access to patients’ comprehensive medication list.•\tForster and colleagues found that 19 percent of discharged patients experienced an associated adverse event within three weeks of leaving the hospital; 66 percent of these were adverse drug events.Coleman EA, Min S, Chomiak A, Kramer AM. 2004. Post‐hospital care transitions: patterns, complications, and risk identification. Health Services Research 39:1449–1465.Agency for Healthcare Research and Quality (ARHQ). 1999. Outcomes by Patient and Hospital Characteristics for All Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp.Kramer A, Eilertsen T, Lin M, Hutt E. 2000. Effects of nurse staffing on hospital transfer quality measures for new admissions. Pp. 9.1–9.22. Inappropriateness of Minimum Nurse Staffing Ratios for Nursing Homes. Health Care Financing Administration.Hutt E, Ecord M, Eilertsen TB, et al. Precipitants of emergency room visits and acute hospitalization in short‐stay Medicare nursing home residents. J Am Geriatr Soc 2001; 50: 223‐229.Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med 2009; 150:178‐187.Agency for Healthcare Research and Quality (ARHQ). 2006. Outcomes by Patient and Hospital Characteristics for All Discharges. Available at: http://www.ahrq.gov/HCUPnet.asp.Medicare Payment Advisory Commission. A data book: Healthcare spending and the Medicare program. June 2007. Available at: http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf.Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=508    8&partner=rssnyt&emc=rss.Sabogal F, Coots‐Miyazaki M, Lett JE. Effective care transitions interventions: Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2).Moore C, Wisnevesky J, Williams S, McGinn T. 2003. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18:646–651.Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143(2):121‐128.Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from US hospitals. National Health Statistics Reports, July 24, 2008; Number 6.Rozich JD & Resar, RK. 2001. Medication safety: One organization’s approach to the challenge. J. Clin. Outcomes Manag. 8:27‐34.Partnership for Solutions. 2002. Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University.Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients afterdischarge from the hospital. Ann Intern Med 2003;138(3):161‐167."]
["X3701","Hospital‐Wide All‐ Cause Unplanned Readmission Hybrid eMeasure","This eMeasure estimates the hospital‐level, risk‐ standardized rate of unplanned, all‐cause readmission after admission for any eligible condition within 30 days of hospital discharge (RSRR). The eMeasure reports a single summary RSRR, derived from the volume‐weighted results of five different models, one for each of the following specialty cohorts (grouped by discharge condition categories or procedure categories): surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology. The eMeasure also indicates the hospital standardized risk ratios (SRR) for each of these five specialty cohorts. This eMeasure is a re‐engineering of measure 1789, the Hospital‐Wide All‐Cause Risk‐ Standardized Readmission Measure developed for patients 65 years and older using Medicare claims. This reengineered measure uses clinical data elements from patients’ electronic health records for risk adjustment in addition to claims data.","Outcome","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting,Medicare and Medicaid HER Incentive Programs for Eligible Hospitals or Critical Access Hospitals","The outcome for this measure isunplanned all‐cause 30‐dayreadmission. We defined areadmission as an inpatientadmission to any acute carefacility which occurs within 30days of the discharge date of anearlier, eligible index admission.","Admissions for patients: Who arematched in the EHR/claims data;Enrolled in Medicare FFS; Aged 65or over; Discharged from non‐federal acute care hospitals;Discharged alive; Not transferredto an acute care facility; Enrolledin Part A for 12 mo prior","The measure excludes admissions forpatients:•Admitted to Prospective PaymentSystem (PPS)‐exempt cancer hospitalsRationale: These hospitals care for aunique population of patients thatcannot reasonably be compared topatients admitted to other hospitals•Without at least 30 days of post‐discharge enrollment in FFS Medicare Rationale: The 30‐day readmission outcome cannot be assessed in this group since claims data are used to determine whether a patient was readmitted. •Discharged against medical advice (AMA) Rationale: Providers did not have the opportunity to deliver full care and prepare the patient for discharge. •Admitted for primary psychiatric diagnoses Rationale: Patients admitted for psychiatric treatment are typically cared for in separate psychiatric or rehabilitation centers that are not comparable to acute care hospitals. •Admitted for rehabilitation Rationale: These admissions are not typically to an acute care hospital and are not for acute care. •Admitted for medical treatment of cancer Rationale: These admissions have a different mortality and readmission profile than the rest of the Medicare population, and outcomes for these admissions do not correlate well with outcomes for other admissions. Patients with cancer admitted for other diagnoses or for surgical treatment of their cancer remain in the measure.","Currently, the Centers for Medicare & Medicaid Services (CMS) publicly reports risk‐standardized readmission rates(RSRRs) for several conditions, including acute myocardial infarction (AMI), heart failure (HF), pneumonia, and hipand knee arthroplasty. CMS has also developed hospital readmission measures for stroke and chronic obstructivepulmonary disease (COPD). While it is helpful to assess readmission rates for specific groups of patients, theseconditions account for only a small proportion of total readmissions. In 2013, CMS began publicly reporting ahospital‐wide, all‐condition readmission measure which provides a broader assessment of the quality of care athospitals. This measure, which uses the same cohort and outcome definitions as the proposed eMeasure, includes93% of admissions to acute care non‐federal hospitals of Medicare Fee‐for‐Service patients over age 65 who aredischarged alive to the non‐acute care setting. The measure captures 92% of readmissions following eligible admissions.The proposed measure will build on the hospital‐wide readmission measure by using clinical data elements derived from electronic health records (EHR), such as laboratory test values and vital signs, to risk adjust for patient‐level factors that influence readmission. The proliferation of EHR systems and standardization of extraction and reporting of clinical data for quality measurement provide an opportunity to integrate these data into measures of hospital performance. This effort is also responsive to the preference expressed by the clinical community for the use ofclinical data to adjust for patients’ severity of illness in hospital outcome measures."]
["X1234","Timely Evaluation of High‐Risk Individuals in the Emergency Department","Median time from emergency department (ED) arrival to provider evaluation for individuals triaged at the two highest levels based on a five‐ level triage system (e.g., triaged as “immediate” or “emergent”).","Process","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting,Medicare and Medicaid HER Incentive Programs for Eligible Hospitals or Critical Access Hospitals","Measure Observation 1:Median time (in minutes)from ED arrival to QualifiedProvider Contact forEmergency Departmentpatients triaged with an acuitylevel of \"1‐immediate\".Measure Observation 2:Median time (in minutes)from ED arrival to QualifiedProvider Contact forEmergency Departmentpatients triaged with an acuitylevel of \"2‐emergent\".","Measure Population: Anyemergency departmentencounter for which individualswith a triage score of “1‐Immediate” or \"2‐Emergent\"based on a 5‐level triagesystem.","ED visit for trauma","This is a new eCQM that assesses a different aspect of ED provider care, and specifically assesses provider timelinessto evaluation.The anticipated effect of implementing this measure would be to reduce the time for high risk patients to be seenby a physician in the emergency department and thereby reduce adverse events (i.e., morbidity and mortality).High‐risk individuals are identified by assignment of the highest or most urgent score from a valid triage system."]
["X3323","Adverse Drug Events: ‐ Inappropriate Renal Dosing of Anticoagulants","Percentage of patient‐drug days with administration of anticoagulants requiring renal dosing with at least one error in renal dosing","Process","Centers for Medicare & Medicaid Services","Hospital Inpatient Quality Reporting,Medicare and Medicaid HER Incentive Programs for Eligible Hospitals or Critical Access Hospitals","The total number of patient‐drugdays with at least one renaldosing error.","The total number of patient‐drugdays with administration ofanticoagulants requiring renaldosing.","1. Admissions for individuals less than 18years old.2. Admissions that are for observationonly.3. Admissions with length of stay greaterthan or equal to 120 days.4. Admissions with length of stay lessthan 24 hours.5. Drugs administered in the OR.6. Admissions on dialysis of any kind.7. Antibiotics given less than 2 hoursprior to surgery and up to 24 hours post‐surgery are ignored. Ignore the first doseof antibiotic more than 2 hours beforesurgery and the first dose more than 24 hours after surgery. 8. First 96 hours of drugs for patients with labor & delivery codes.","Additional process measure to assess medication adverse drug event associated with widely used anticoagulants.The anticipated effect of implementing this measure would be to reduce or eliminate inpatient anticoagulant dosingerrors that could lead to adverse drug events (ADEs) for patients with renal impairment. Anticoagulants are one ofthree high risk drug classes targeted in the National Action Plan for Adverse Drug Event Prevention."]
["X1970","Perinatal Care Cesarean section (PC O2) Nulliparous women with a term, singleton baby in vertex position delivered by cesarean section","This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position who are delivered by a cesarean section. PC O2 is also part of a set of five nationally implemented measures that address perinatal care (PC‐01: Elective Delivery, PC‐03: Antenatal Steroids, PC‐04: Health Care‐Associated Bloodstream Infections in Newborns, PC‐05: Exclusive Breast Milk Feeding).","Outcome","The Joint Commission","Hospital Inpatient Quality Reporting,Medicare and Medicaid HER Incentive Programs for Eligible Hospitals or Critical Access Hospitals","Patients with cesarean sections","Nulliparous patients delivered of alive term singleton newborn invertex presentation","Excluded Populations:ICD‐10‐CM Principal Diagnosis Code orICD‐10‐CM Other Diagnosis Codes formultiple gestations and otherpresentations as defined in Appendix A,Table 11.09Less than 8 years of ageGreater than or equal to 65 years of ageLength of Stay >120 daysEnrolled in clinical trialsGestational Age < 37 weeks or UTD","PC O2 is newly specified for electronic health records.Rationale: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, stateand national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15‐20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are nodata that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focusattention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This populationsegment accounts for the large majority of the variable portion of the CS rate, and is the area most affected bysubjectivity.As compared to other CS measures, what is different about NTSV CS rate (Low‐risk Primary CS in first births) is thatthere are clear cut quality improvement activities that can be done to address the differences. Main et al. (2006)found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and firstbirth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have rates with a 3‐5 fold variation.Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐ Instruments/MMS/CallforPublicComment.html."]
["E0294","Patient Information","Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that patient information was communicated to the receiving FACILITY within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to anotherHEALTHCARE FACILITY whosemedical record documentationindicated that patientinformation was communicatedto the receiving FACILITY within60 minutes of departure• Patient name• Address• Date of birth• Gender• Significant other contactinformation• Health insurance information","All emergency departmentpatients who are transferred toanother healthcare facility","All emergency department patients notdischarged to another healthcare facility","Patients who are transferred from an Emergency Department to another acute facility are excluded from thecalculation of most national quality measures, such as the Hospital Compare measures. In addition, limited attentionhas been paid to the development and implementation of quality measures specifically focused on patient transfersbetween Emergency Departments and other facilities. This type of measure is important for all healthcare facilities,but is especially important for small rural hospitals, which transfer a higher proportion of Emergency Departmentpatients to other hospitals than do larger urban facilities (Newgard CD 2006, Wakefield DS 2004, Ellerbeck EF 2004,Baldwin LM 2004, Westfall JM 2006).Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% ofsentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist inthe transfer of patient information between hospitals and primary care physicians in the community (Kripalani S2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted NationalPatient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for thisgoal requires all accredited hospitals to implement a standardized approach to hand‐off communications, includingnursing and physician hand‐offs from the emergency department to inpatient units, other hospitals, and other typesof health care facilities. The process must include a method of communicating up‐to‐date information regarding thepatient’s care, treatment and services, condition and any recent or anticipated changes (JCAHO‐2 2007).1. Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the HarvardMedical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2. Thomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah andColorado. Medical Care 38:261‐271, 2000.3. Schenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. AcademicEmergency Medicine 7:1204‐1222, 2000.4. Welch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5.\tNewgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospital emergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6.\tWakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7.\tEllerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004.8.\tBaldwin LM, MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in rural and urban US hospitals. Journal of Rural Health, 20:99‐108, 2004.9.\tWestfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in rural hospitals: Implementation of the ACI‐TIPI in the High Plains Research Network. Annals of Family Medicine. 4:153‐158, 2006.10.\tJoint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Available at: http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July 18, 2007.11.\tKripalani, S., LeFevre, F., Phillips, C. et al. Deficits in Communication and Information Transfer between Hospital‐ Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA 297(8):831‐841, 2007.12.\tCortes T., Wexler S. and Fitzpatrick J. The transition of elderly patients between hospitals and nursing homes. Improving nurse‐to‐nurse communication. Journal of Gerontological Nursing. 30(6):10‐5, 2004.13.\tJoint Commission on Accreditation of Healthcare Organizations. 2008 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18,2007."]
["X607","Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache","This measure calculates the percentage of Emergency Department (ED) visits for atraumatic headache with a coincident brain computed tomography (CT) study for Medicare beneficiaries.","Efficiency","Centers for Medicare & Medicaid Services","Hospital Outpatient Quality Reporting","Of ED visits identified in thedenominator, visits with a coincident brain CT study (i.e., brain CT studies on the same day for the same patient).","ED patients with a primarydiagnosis of atraumatic headache.","\"This measure uses exceptions from thenumerator, rather than exclusions from the denominator. The following secondary diagnosis codes are exceptions from the numerator: -Anticoagulant use, ‐Lumbar puncture ‐Dizziness or paresthesia ‐Lack of coordination ‐Subarachnoid hemorrhage ‐Complicated or thunderclap headache ‐Focal neurologic deficit ‐Pregnancy ‐Trauma ‐HIV ‐Tumor(s)/mass(es) ‐Imaging studies for ED patients admitted to the hospital\"","Development of efficiency measures is one of the primary objectives highlighted by both the 2012 report on theNational Quality Strategy and the Centers for Medicare & Medicaid Services (CMS). This measure's concept is similarto one which was identified within the 2011 release of the Choosing Wisely campaign recommendations as an areaof concern. Moreover, there is evidence that diagnostic imaging for headaches is overused, with only 2% of patientscans yielding pathology. Unnecessary imaging is costly and needlessly exposes patients to radiation."]
["E0295","Physician Information","Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that physician information was communicated to the receiving FACILITY within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to anotherHEALTHCARE FACILITY whosemedical record documentationindicated that physicianinformation was communicatedto the receiving FACILITY within60 minutes of departure• Physician or practitioner historyand physical• Physician or practitioner ordersand plan","All emergency departmentpatients who are transferred toanother healthcare facility","All emergency department patients nottransferred to another healthcare facility","Patients who are transferred from an Emergency Department to another acute facility are excluded from thecalculation of most national quality measures, such as the Hospital Compare measures. In addition, limited attention has been paid to the development and implementation of quality measures specifically focused on patient transfers between Emergency Departments and other facilities. This type of measure is important for all healthcare facilities, but is especially important for small rural hospitals, which transfer a higher proportion of Emergency Department patients to other hospitals than do larger urban facilities (Newgard CD 2006, Wakefield DS 2004, Ellerbeck EF 2004, Baldwin LM 2004, Westfall JM 2006).Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% of sentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist in the transfer of patient information between hospitals and primary care physicians in the community (Kripalani S 2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted National Patient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for this goal requires all accredited hospitals to implement a standardized approach to hand‐off communications, including nursing and physician hand‐offs from the emergency department to inpatient units, other hospitals, and other types of health care facilities. The process must include a method of communicating up‐to‐date information regarding the patient’s care, treatment and services, condition and any recent or anticipated changes (JCAHO‐2 2007).1.\tLeape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2.\tThomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Medical Care 38:261‐271, 2000.3.\tSchenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. Academic Emergency Medicine 7:1204‐1222, 2000.4.\tWelch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5.\tNewgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospital emergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6.\tWakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7.\tEllerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004.8.\tBaldwin LM, MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in rural and urban US hospitals. Journal of Rural Health, 20:99‐108, 2004.9.\tWestfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in rural hospitals:Implementation of the ACI‐TIPI in the High Plains Research Network. Annals of Family Medicine. 4:153‐158, 2006. 10.\tJoint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Available at: http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July 18, 2007.11.\tKripalani, S., LeFevre, F., Phillips, C. et al. Deficits in Communication and Information Transfer between Hospital‐ Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA 297(8):831‐841, 2007.12.\tCortes T., Wexler S. and Fitzpatrick J. The transition of elderly patients between hospitals and nursing homes. Improving nurse‐to‐nurse communication. Journal of Gerontological Nursing. 30(6):10‐5, 2004.13.\tJoint Commission on Accreditation of Healthcare Organizations. 2008 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18,2007."]
["E0297","Procedures and Tests","Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that procedure and test information was communicated to the receiving FACILITY within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to anotherHealthcare Facility whose medical record documentation indicated that procedure and test information was communicated to the receiving FACILITY within 60 minutes of departure • Tests & procedures done • Tests & procedure results sent","All emergency departmentpatients who are transferred toanother healthcare facility","ED admissions not transferred to anotherHealthcare facility.","Patients who are transferred from an Emergency Department to another acute facility are excluded from thecalculation of most national quality measures, such as the Hospital Compare measures. In addition, limited attentionhas been paid to the development and implementation of quality measures specifically focused on patient transfersbetween Emergency Departments and other facilities. This type of measure is important for all healthcare facilities,but is especially important for small rural hospitals, which transfer a higher proportion of Emergency Departmentpatients to other hospitals than do larger urban facilities (Newgard CD 2006, Wakefield DS 2004, Ellerbeck EF 2004,Baldwin LM 2004, Westfall JM 2006).Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% ofsentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist inthe transfer of patient information between hospitals and primary care physicians in the community (Kripalani S2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted NationalPatient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for thisgoal requires all accredited hospitals to implement a standardized approach to hand‐off communications, includingnursing and physician hand‐offs from the emergency department to inpatient units, other hospitals, and other typesof health care facilities. The process must include a method of communicating up‐to‐date information regarding thepatient’s care, treatment and services, condition and any recent or anticipated changes (JCAHO‐2 2007).1. Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the HarvardMedical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2. Thomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah andColorado. Medical Care 38:261‐271, 2000. 3.\tSchenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. Academic Emergency Medicine 7:1204‐1222, 2000.4.\tWelch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5.\tNewgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospital emergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6.\tWakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7.\tEllerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urbanhospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004."]
["E0296","Nursing Information","Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that nursing information was communicated to the receiving FACILITY within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to another healthcarefacility whose medical recorddocumentation indicated thatnursing information wascommunicated to the receivingfacility within 60 minutes ofdeparture• Assessments/intervention/response• Impairments• Catheters• Immobilizations• Respiratory support• Oral limitations","All emergency departmentpatients who are transferred toanother healthcare facility","All emergency department patients notdischarged to another healthcare facility","Patients who are transferred from an Emergency Department to another acute facility are excluded from thecalculation of most national quality measures, such as the Hospital Compare measures. In addition, limited attentionhas been paid to the development and implementation of quality measures specifically focused on patient transfersbetween Emergency Departments and other facilities. This type of measure is important for all healthcare facilities,but is especially important for small rural hospitals, which transfer a higher proportion of Emergency Departmentpatients to other hospitals than do larger urban facilities (Newgard CD 2006, Wakefield DS 2004, Ellerbeck EF 2004,Baldwin LM 2004, Westfall JM 2006).Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% ofsentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist inthe transfer of patient information between hospitals and primary care physicians in the community (Kripalani S2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted NationalPatient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for thisgoal requires all accredited hospitals to implement a standardized approach to hand‐off communications, includingnursing and physician hand‐offs from the emergency department to inpatient units, other hospitals, and other typesof health care facilities. The process must include a method of communicating up‐to‐date information regarding thepatient’s care, treatment and services, condition and any recent or anticipated changes (JCAHO‐2 2007).1. Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the HarvardMedical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2. Thomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah andColorado. Medical Care 38:261‐271, 2000.3. Schenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. Academic Emergency Medicine 7:1204‐1222, 2000.4.\tWelch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5.\tNewgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospital emergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6.\tWakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7.\tEllerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004."]
["E0292","Vital Signs","Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that the entire vital signs record was communicated to the receiving FACILITY within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to another healthcarefacility whose medical recorddocumentation indicated that theentire vital signs record wascommunicated to the receivingfacility within 60 minutes ofdeparture• Pulse• Respiratory rate • Blood pressure • Oxygen saturation • Temperature • Glasgow score (where appropriate)","All emergency departmentpatients who are transferred toanother healthcare facility.","All emergency department patients notdischarged to another healthcare facility.","Patients who are transferred from an Emergency Department to another acute facility are excluded from thecalculation of most national quality measures, such as the Hospital Compare measures. In addition, limited attentionhas been paid to the development and implementation of quality measures specifically focused on patient transfersbetween Emergency Departments and other facilities. This type of measure is important for all healthcare facilities,but is especially important for small rural hospitals, which transfer a higher proportion of Emergency Departmentpatients to other hospitals than do larger urban facilities (Newgard CD 2006, Wakefield DS 2004, Ellerbeck EF 2004,Baldwin LM 2004, Westfall JM 2006).Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% ofsentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist inthe transfer of patient information between hospitals and primary care physicians in the community (Kripalani S2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted NationalPatient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for thisgoal requires all accredited hospitals to implement a standardized approach to hand‐off communications, includingnursing and physician hand‐offs from the emergency department to inpatient units, other hospitals, and other typesof health care facilities. The process must include a method of communicating up‐to‐date information regarding thepatient’s care, treatment and services, condition and any recent or anticipated changes (JCAHO‐2 2007).1. Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the HarvardMedical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2. Thomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah andColorado. Medical Care 38:261‐271, 2000.3. Schenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. AcademicEmergency Medicine 7:1204‐1222, 2000. 4.\tWelch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5.\tNewgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospital emergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6.\tWakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7.\tEllerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004.8.\tBaldwin LM, MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in rural and urban US hospitals. Journal of Rural Health, 20:99‐108, 2004.9.\tWestfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in rural hospitals: Implementation of the ACI‐TIPI in the High Plains Research Network. Annals of Family Medicine. 4:153‐158, 2006.10.\tJoint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Available at: http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July 18, 2007.11.\tKripalani, S., LeFevre, F., Phillips, C. et al. Deficits in Communication and Information Transfer between Hospital‐ Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA 297(8):831‐841, 2007.12.\tCortes T., Wexler S. and Fitzpatrick J. The transition of elderly patients between hospitals and nursing homes. Improving nurse‐to‐nurse communication. Journal of Gerontological Nursing. 30(6):10‐5, 2004.13.\tJoint Commission on Accreditation of Healthcare Organizations. 2008 National Patient Safety Goals. Available at:http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18, 2007."]
["E1822","External Beam Radiotherapy for Bone Metastases","This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.","Process","American Society for Radiation Oncology","Hospital Outpatient Quality Reporting","All patients, regardless of age,with painful bone metastases,and no previous radiation to thesame anatomic site who receiveEBRT with any of the followingrecommended fractionationschemes: 30Gy/10fxns,24Gy/6fxns, 20Gy/5fxns,8Gy/1fxn.","All patients with painful bonemetastases and no previousradiation to the same anatomicsite who receive EBRT","The medical reasons for denominatorexclusions are:1) Previous radiation treatment to thesame anatomic site;2) Patients with femoral axis corticalinvolvement greater than 3 cm in length;3) Patients who have undergone asurgical stabilization procedure; and4) Patients with spinal cord compression,cauda equina compression or radicularpain","The measure is developed from the recommendations by the clinical‐practice guideline. This measure is intended toclose the gap in the demonstrated treatment variation and ensure the use of an appropriate fractionation schedule.The measure also takes into account the effective schedule for relieving pain from bone metastases, patientpreferences and the time and cost effectiveness.Population: The measure is applicable to all patients, regardless of age with a diagnosis of painful bone metastaseswho are prescribed EBRT unless there is a documented exclusion as specified.1. Jeremic B, Shibamoto Y, Acimovic L, et al. A randomized trial of three single‐dose radiation therapy regimens inthe treatment of metastatic bone pain. Int J Radiat Oncol Biol Phys 1998;42:161–167.2. Bone Pain Trial Working Party. 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: Randomized comparison with a multifraction schedule over 12 months of patient follow‐up. Radiother Oncol 1999;52:111–121.3.\tRoos D, Turner S, O’Brien P, et al. Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans‐Tasman Radiation Oncology Group, TROG 96.05). Radiother Oncol 2005;75:54–63.4.\tHartsell W, Konski A, Scott C, et al. Randomized trial of short versus long‐course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 2005;97:798–804."]
["E0293","Medication Information","Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that medication information was communicated to the receiving Facility within 60 minutes of departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to anotherHEALTHCARE FACILITY whosemedical record documentationindicated that medicationinformation was communicatedto the receiving FACILITY within60 minutes of departure• Documentation regardingmedication history• Allergies• Medications given (MAR)","All emergency departmentpatients who are transferred toanother healthcare facility","All emergency department patients notdischarged to another healthcare facility.","Patient safety studies have identified the Emergency Department as the location within a hospital that has thehighest percentage of preventable and negligent adverse events.1‐2 Increasing attention is being paid to preventionof medical errors in Emergency Department settings, but considerable work still needs to be done to developperformance measures for Emergency Department care.3‐4Patients who are transferred from an Emergency Department to another facility are excluded from the calculationof most national quality measures, such as the Hospital Compare measures. In addition, limited attention has beenpaid to the development and implementation of quality measures specifically focused on patient transfers betweenEmergency Departments and other facilities. This type of measure is important for all healthcare facilities, but isespecially important for small rural hospitals, which transfer a higher proportion of Emergency Department patientsto other facilities than do larger urban facilities.5‐91. Leape, L., Brennan, T., Laird, N. et al. The Nature of Adverse Events in Hospitalized Patients. Results of the HarvardMedical Practice Study II. New England Journal of Medicine 324:377‐384, 1991.2. Thomas, E., Studdert, D., Burstin, H. et al. Incidence and Types of Adverse Events and Negligent Care in Utah andColorado. Medical Care 38:261‐271, 2000.3. Schenkel, S. Promoting Patient Safety and Preventing Medical Error in Emergency Departments. AcademicEmergency Medicine 7:1204‐1222, 2000.4. Welch, S., Augustine, J., Camago, C. and Reese, C. Emergency Department Performance Measures andBenchmarking Summit. Academic Emergency Medicine, 13(10):1074‐1080, 2006.5. Newgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non‐tertiary care hospitalemergency departments. . Academic Emergency Medicine 13:746‐754, 2006.6. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potentialindicators of rural hospital quality. Journal of Rural Health. 20:394‐400, 2004.7. Ellerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. Journal of Rural Health. 20:363‐367, 2004.8.\tBaldwin LM, MacLehose RF, Hart LG et al. Quality of care for acute myocardial infarction in rural and urban US hospitals. Journal of Rural Health, 20:99‐108, 2004.9.\tWestfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in rural hospitals: Implementation of the ACI‐TIPI in the High Plains Research Network. Annals of Family Medicine. 4:153‐158, 2006.10.\tJoint Commission on Accreditation of Healthcare Organizations. Sentinel Events Statistics. Available at: http://www.jointcommission.org/SentinelEvents /Statistics/. Accessed July 18, 2007.11.\tKripalani, S., LeFevre, F., Phillips, C. et al. Deficits in Communication and Information Transfer between Hospital‐ Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA 297(8):831‐841, 2007.12.\tCortes T., Wexler S. and Fitzpatrick J. The transition of elderly patients between hospitals and nursing homes. Improving nurse‐to‐nurse communication. Journal of Gerontological Nursing. 30(6):10‐5, 2004.13.\tJoint Commission on Accreditation of Healthcare Organizations. 2008 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed July 18,2007."]
["E0291","AdministrativeCommunication","Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that administrative information was communicated to the receiving facility within prior to departure","Process","University of Minnesota Rural Health Research Center","Hospital Outpatient Quality Reporting","Percentage of patientstransferred to another healthcarefacility whose medical record documentation indicated that administrative information was communicated to the receiving facility prior to departure • Nurse communication with receiving hospitals • Practitioner communication with receiving practitioner or transfer coordinator","All emergency departmentpatients who are transferred toanother healthcare facility","All emergency department patients notdischarged to another healthcare facility.","Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% ofsentinel events tracked by the Joint Commission (JCAHO 2007). In addition, research indicates that deficits exist inthe transfer of patient information between hospitals and primary care physicians in the community (Kripalani S2007), and between hospitals and long term facilities (Cortes T 2004). The Joint Commission has adopted NationalPatient Safety Goal #2, “Improve the Effectiveness of Communication Among Caregivers.” Requirement 2E for thisgoal requires"]
["E1898","Health literacy measure derived from the health literacy domain of the C‐CAT","0‐100 measure of health literacy related to patient‐centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit","Outcome","American Medical Association","Hospital Outpatient Quality Reporting","Health literacy component ofpatient‐centered communication:an organization should considerthe health literacy level of itscurrent and potential populationsand use this information todevelop a strategy for the clearcommunication of medicalinformation verbally, in writingand using other media. Measureis scored based on 15 items fromthe patient survey of the C‐CATand 13 items from the staffsurvey of the C‐CAT. Minimum of100 patient responses and 50staff responses.","There are two components to thetarget population: staff (clinicaland nonclinical) and patients. Sitesusing this measure must obtain atleast 50 staff responses and atleast 100 patient responses.","Staff respondents who do not have directcontact with patients are excluded fromquestions that specifically addresspatient contact.","Evidence generated through national validation study of C‐CAT instrument, including surveys of patients and staff.Results of study demonstrated that better scores on the measure of health literacy is correlated to importantindicators of health care quality. Multivariate analysis showed that a 5‐point increase in the measure results in morethan a 1/3 greater odds that patients would report receiving high‐quality medical care (OR 1.40, 95% CI 1.22‐1.61)and a more than 25% greater odds that patients would report a belief that their medical records are kept private(OR 1.28, 95% CI 1.10‐1.47). Likewise, a 5‐point increase in the measure score is correlated with a more than 25%decrease in the odds a patient would believe that a mistake made in their care would be hidden from them (OR0.73, 95% CI 0.62‐0.86).Additional evidence of the importance of health literacy to patient‐centered communication from ImprovingCommunication ‐‐ Improving Care: How Health Care Organizations Can Ensure Effective, Patient‐Centered Communication with People from Diverse Populations.http://www.ama‐assn.org/resources/doc/ethics/pcc‐consensus‐report.pdf"]
["X2698","AMI episode of care (inpatient hospitalization + 30 days post‐discharge)","Hospital‐specific, risk‐standardized, 30‐day episode of care payment for AMI. The measure includes all payments across care settings for the 30‐days following an inpatient admission for AMI. The payments are either \"stripped” or \"“standardized\"\" to remove the effect of policy adjustments. The measure uses hierarchical\" modelling to estimate hospital‐level risk‐ standardized total payments for the 30‐day window from admission.","Cost/\nResource\nUse","Centers for Medicare & Medicaid Services","Hospital Value‐Based Purchasing","The outcome for this measure isMedicare payments for an AMIepisode of care. The paymenttimeframe is defined asadmission for an indexhospitalization through 30 dayspost‐admission. We include payments for inpatient settings and up to 6 other post‐discharge settings (Skilled Nursing Facility, Outpatient, Home Health Agency, Hospice, Carrier, and Durable Medical Equipment).","The target population for thismeasure includes episodes of care(as defined above) for patientswho are 65 years of age or olderwith a principal dischargediagnosis of AMI (as defined byICD‐9 codes 410.xx, excluding 410.x2) during a qualifying index hospitalization.","1) Lack of continuous enrollment inMedicare FFS Parts A and B in the 12months prior to index hospital stay.2) Lack of continuous enrollment inMedicare FFS Parts A and B in the monthfollowing the index hospital stay (if alive). 3) Patients discharged alive on the day of admission who did not get transferred. 4) Transfers into the hospital (excluded from eligibility as an index admission), or transfers to federal hospitals. 5) Patients who are discharged against medical advice (AMA). 6) Occurred in Maryland hospitals and U.S. territories. 7)Episodes for Patients with 0 Payment","This is a high priority (per episode) resource use measure. AMI is a condition with a substantial range in costs of careand for which there are well‐established publicly reported quality measures; therefore, it is an ideal condition forassessing relative value for an episode of care that begins with an acute hospitalization. Moreover, AMI is one of theleading cause of hospitalization for Americans over 65 years old and costs the US roughly $18 billion annually.Medicare payments are difficult to interpret in isolation. Some high payment hospitals may have better clinicaloutcomes when compared with low payment hospitals; other high payment hospitals may not. For this reason, thevalue of hospital care is more clearly assessed when pairing hospital payments with hospital quality. A measure ofpayments for Medicare patients during an episode of care for AMI aligned with current quality of care measures willfacilitate profiling hospital value (payments and quality). This measure, which uses standardized payments, reflectsdifferences in the management of care for patients with AMI both during hospitalization and immediately post‐discharge. By focusing on one specific condition, value assessments may provide actionable feedback to hospitalsand incentivize targeted improvements in care. This measure is harmonized with NQF E0230."]
["E0351","Death among surgical inpatients with serious, treatable complications (PSI 4)","Percentage of cases having developed specified complications of care with an in‐hospital death.","Outcome","Agency for Healthcare Research & Quality","Hospital Value‐Based Purchasing","All discharges with a dispositionof “deceased” (DISP=20) amongcases meeting the inclusion andexclusion rules for thedenominator.","All surgical discharges age 18years and older or MDC 14(pregnancy, childbirth, andpuerperium) defined by specificDRGs or MS‐DRGs and an ICD‐9‐CM code for an operating roomprocedure, principal procedurewithin 2 days of admission ORadmission type of elective(ATYPE=3) with potentialcomplications of care listed inDeath among Surgical definition(e.g., pneumonia, DVT/PE, sepsis,shock/cardiac arrest, or GIhemorrhage/acute ulcer).","Exclude cases:• age 90 years and older• transferred to an acute care facility(DISP = 2)• missing discharge disposition(DISP=missing), gender (SEX=missing),age (AGE=missing), quarter(DQTR=missing), year (YEAR=missing) orprincipal diagnosis (DX1 =missing)","Silber and colleagues have published a series of studies establishing the construct validity of failure to rescue ratesthrough their associations with hospital characteristics and other measures of hospital performance. Amongpatients admitted for cholecystectomy and transurethral prostatectomy, failure to rescue was independent ofseverity of illness at admission, but was significantly associated with the presence of surgical housestaff and a lowerpercentage of board‐certified anesthesiologists.31 The adverse occurrence rate was independent of this hospitalcharacteristic. In a larger sample of 74,647 patients who underwent general surgical procedures in 1991‐92, lowerfailure to rescue rates were found at hospitals with high ratios of registered nurses to beds.68 Failure rates werestrongly associated with risk adjusted mortality rates, as expected, but not with complication rates.143 Finally,among 16,673 patients admitted for coronary artery bypass surgery, failure rates were lower (whereas complicationrates were higher) at hospitals with magnetic resonance imaging facilities, bone marrow transplantation units, orapproved residency training programs.More recently, Needleman and Buerhaus, confirmed that higher registered nurse staffing (RN hours/adjustedpatient day) and better nursing skill mix (RN hours/licensed nurse hours) were consistently associated with lowerfailure to rescue rates among major surgery patients from 799 hospitals in 11 states in 1997, even usingadministrative data to define complications. An increase from the 25th to the 75th percentile on these twomeasures of staffing was associated with 5.9% (95% CI, 1.5% to 10.2%) and 3.9% (95% CI, ‐1.1% to 8.8%) decreases,respectively, in the rate of failure‐to‐rescue among major surgery patients.138 These associations were inconsistent among medical patients, in that nursing skill mix was associated with the failure‐to‐rescue rate (rate ratio 0.81, 95% CI 0.66‐1.00) but aggregate registered nurse staffing was not (rate ratio 1.00, 95% CI 0.99‐1.01). An increase from the 25th to the 75th percentile on nursing skill mix was associated with a 2.5% (95% CI, 0.0% to 5.0%) decrease inthe failure‐to‐rescue rate among medical patients."]
["E1893","Hospital 30‐Day, All‐Cause, Risk‐Standardized Mortality Rate (RSMR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization","The measure estimates a hospital‐level risk‐ standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients 40 and older discharged from the hospital with either a principal diagnosis of COPD or a principal diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD. CMS will annually report the measure for patients who are 65 years or older, enrolled in fee‐for‐ service (FFS) Medicare, and hospitalized in non‐ federal hospitals.","Outcome","Centers for Medicare & Medicaid Services","Hospital Value‐Based Purchasing","The outcome for this measure is30‐day all‐cause mortality. We define mortality as death from any cause within 30 days from the date of admission for patients 40 and older discharged from the hospital with either a principal diagnosis of COPD or a principal diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD.","This claims‐based measure can beused in either of two patient cohorts: (1) patients aged 65 years or older or (2) patients aged 40 years or older. The cohort includes admissions for patients discharged from the hospital with either a principal diagnosis of COPD OR a principal diagnosis of respiratory failure WITH a secondary diagnosis of acute exacerbation of COPD and with a complete claims history for the 12 months prior to admission.","The measure excludes index admissionsfor patients: 1. Discharged alive on the day of admission or the following day who were not transferred; 2. With inconsistent or unknown vital status or other unreliable demographic data; 3. Enrolled in the Medicare hospice program any time in the 12 months prior to the index admission, including the first day of the index admission; and 4. Who were discharged against medical advice (AMA).","The prevalence of heart failure (HF) in the United States (U.S.) is high, with 5.2 million Americans currentlydiagnosed with this condition (Rosamond et al., 2007). HF incidence increases with age and approaches 10 per 1000population after age 65 (Rosamond et al., 2007). HF is one of the most common causes for hospital admissionsamong Medicare beneficiaries (Merrill and Elixhauser, 2005) and hospital discharges for HF increased 175% from1979 to 2004 (Rosamond et al., 2007). A recent study reported that more than 2.5 million Medicare Fee‐for‐Service(FFS) beneficiaries were hospitalized for HF during 2001‐2005, and more than 1 in 10 Medicare beneficiaries diedwithin 30 days of hospitalization (Curtis et al., 2008). Thirty‐day HF mortality rates vary considerably across hospitals(Rosenthal et al., 2000) and hospitals that perform well on the Hospital Quality Alliance (HQA) performancemeasures have lower risk‐adjusted mortality rates (Jha et al., 2007).The high prevalence and considerable morbidity and mortality associated with HF create an economic burden onthe healthcare system. In 2005, HF was the fifth most expensive condition treated in U.S. hospitals, accounting for3.5% of the national hospital bill. It was also the second most expensive condition billed to Medicare that year,accounting for 5.5% of Medicare's hospital bill (Andrews and Elixhauser, 2007).Many current hospital interventions are known to decrease the risk of death within 30 days of hospital admission.Current process‐based performance measures, however, cannot capture all the ways that care within the hospitalmight influence outcomes. As a result, many stakeholders, including patient organizations, are interested inoutcomes measures that would permit groups of providers to assess their relative outcomes performance for thepurpose of internal quality improvement or public reporting.Mortality of patients with HF represents a significant outcome potentially related to quality of care. This rate‐basedindicator identifies an undesirable outcome of care. High rates warrant investigation into the quality of careprovided."]
["E1663","SUB‐2 Alcohol Use Brief Intervention Provided or Offered. SUB‐2a Alcohol Use Brief Intervention Received.","The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB‐2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB‐2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included.","Process","The Joint Commission","Inpatient Psychiatric Facility Quality Reporting","SUB‐2 The number of patientswho received or refused a briefintervention.SUB‐2a The number of patientswho received a briefintervention.","The number of hospitalizedinpatients 18 years of age andolder who screen positive forunhealthy alcohol use or analcohol use disorder (alcoholabuse or alcohol dependence).","• Patients less than 18 years of age• Patient who are cognitively impaired• Patients who refused or were notscreened for alcohol use during thehospital stay• Patients who have a duration of stayless than or equal to three days orgreater than 120 days• Patients receiving Comfort MeasuresOnly documented","Excessive use of alcohol and drugs has a substantial harmful impact on health and society in the United States. It is adrain on the economy, and a source of enormous personal tragedy (The National Quality Forum, A consensusReport, 2007). In 1998 the economic costs to society were 185 billion dollars for alcohol misuse and 143 billiondollars for drug misuse (Harwood 2000). Health care spending was 19 billion dollars for alcohol problems and 14billion dollars was spent treating drug problems. Nearly a quarter of a trillion dollars per year in lost productivity isattributable to substance use. More than 537,000 die each year as a consequence of alcohol, drug, and tobacco use, making use of these substances the cause of one out of four deaths in the United States (Mokdad 2004). Anestimated 22.6 million adolescents and adults meet criteria for a substance use disorder. In a multi‐state study thatscreened 459,599 patients in general hospital and medical settings, 23% of patients screened positive (Madras2009). Clinical trials have demonstrated that brief interventions, especially prior to the onset of addiction, significantly improve health and reduce costs, and that similar benefits occur in those with addictive disorders who are referred to treatment (Fleming 2002). In a study on the provision of evidence‐based care and preventive services provided in hospitals for 30 different medical conditions, quality varied substantially according to diagnosis. Adherence to recommended practices for treatment of substance use ranked last, with only 10% of patients receiving proper care (Gentilello 2005). Currently, less than one in twenty patients with an addiction are referred for treatment (Gentilello 1999). Hospitalization provides a prime opportunity to address the entire spectrum ofsubstance use problems within the health care system (Bernstein 2005)."]
["E1656","TOB‐3 Tobacco Use Treatment Provided or Offered at Discharge AND TOB‐3a Tobacco Use Treatment at Discharge","The measure is reported as an overall rate which includes all hospitalized patients 18 years of age an older to whom tobacco use treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment at discharge. \"Treatment at discharge includes a referral to outpatient counseling and a prescription for one of the FDA‐approved tobacco cessation medications. TOB‐3 Patients identified as tobacco product users within the past 30 days who were referred to or refused evidence‐based outpatient counseling AND received or refused a prescription for FDA‐ approved cessation medication upon discharge. TOB‐3a Patients who were referred to evidence‐ based outpatient counseling AND received a prescription for FDA‐approved cessation medication upon discharge as well as those who were referred to outpatient counseling and had reason for not receiving a prescription for medication.\"","Process","The Joint Commission","Inpatient Psychiatric Facility Quality Reporting","TOB‐3: The number of patientswho received or refusedevidence‐based outpatientcounseling AND received orrefused a prescription for FDA‐approved cessation medication atdischargeTOB‐3a: The number of patientswho were referred to evidence‐ based outpatient counseling AND received a prescription for FDA‐approved cessation medication at discharge.","The number of hospitalizedinpatients 18 years of age andolder identified as current tobaccousers","The exclusions to this measure are asfollows:1. Patients less than 18 years of age2. Patients who are cognitively impaired3. Patients who are not current tobaccousers4. Patients who refused or were notscreened for tobacco use status duringthe hospital stay (as tobacco status cannot be known) 5. Patients who have a length of stay less than or equal to one day or greater than 120 days 6. Patients who expired during the hospital stay 7. Patients who left against medical advice 8. Patients discharged/transferred to another hospital for inpatient care 9. Patients discharged/transferred to a federal health care facility 10. Patients discharged/transferred to hospice 11. Patients who do not reside in the United States","Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 435,000deaths each year (CDC MMWR 2008; McGinnis 1993). Smoking is a known cause of multiple cancers, heart disease,and stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorerwound healing, and many other diseases (DHHS 2004). Tobacco use creates a heavy cost to society as well as toindividuals. Smoking‐attributable health care expenditures are estimated at 96 billion dollars per year in directmedical expenses and 97 billion dollars in lost productivity (CDC 2007). There is strong and consistent evidence thattobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the smoker’srisk of suffering from tobacco‐related disease and improved outcomes for those already suffering from a tobacco‐related disease (DHHS 2000; Baumeister 2007; Lightwood 2003 and 1997; Rasmussen 2005; Hurley 2005; Critchley2004; Ford 2007; Rigotti 2008). Effective, evidence‐based tobacco dependence interventions have been clearlyidentified and include clinician advice, individual, group, or telephone counseling, and use of FDA‐approvedmedications. These treatments are clinically effective and extremely cost‐effective relative to other commonly useddisease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco‐freeenvironment and because patients may be more motivated to quit as a result of their illness) offers an idealopportunity to provide cessation assistance that may promote the patient’s medical recovery. Patients who receiveeven brief advice and intervention from their care providers are more likely to quit than those who receive nointervention. Studies indicate that the combination of counseling and medications is more effective for tobaccocessation than either medication or counseling alone, except in specific populations for which there is insufficientevidence of the effectiveness of the FDA‐approved cessation medications. These populations include pregnantwomen, smokeless tobacco users, light smokers, and adolescents. Tobacco dependence should be viewed as a chronic disease. The treatment of this chronic disease is most effective when the initial interventions provided in thehospital setting are continued upon discharge to other care settings."]
["S2634","IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients","This quality measure estimates the average risk‐ adjusted mean change in mobility function between admission and discharge for patients discharged from an IRF.","Outcome","Centers for Medicare & Medicaid Services","Inpatient Rehabilitation Facility Quality Reporting","The mean change in mobilityfunction.","Patients discharged from the IRF.","Three exclusion criteria apply to thechange in mobility function score qualitymeasure:1) Patients with incomplete stays: It canbe challenging to gather accuratedischarge functional status data forpatients who experience incompletestays. Patients with incomplete staysinclude patients who are unexpectedlydischarged to an acute care setting (IPPS,CAH, IPF, or LTCH) due to a medicalemergency; patients who die or leave anIRF against medical advice; and patientswith a length of stay less than 3 days.2) Patients who are independent withCARE mobility activities at the time of admission: Patients who are independent with the CARE mobility items at the time of admission are assigned the highest score on all the mobility items, and thus, would not be able to show functional improvement on this same set of items at discharge. 3) Patients younger than age 21.","Given that the primary goal of rehabilitation is improvement in function, IRF clinicians have traditionally assessedand documented patients’ functional status at admission and discharge to evaluate the effectiveness of therehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospitaloverall.Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, andrace/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, whichsupports the need to monitor IRF patients’ functional outcomes."]
["S2636","IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients","This measure calculates the percent of patients who meet or exceed an expected discharge mobility score.","Outcome","Centers for Medicare & Medicaid Services","Inpatient Rehabilitation Facility Quality Reporting","The number of patients whomeet or exceed an expecteddischarge mobility score.","Patients discharged during theselected time period.","Two exclusion criteria apply to thedischarge mobility function scoremeasure:1) Patients with incomplete stays: It canbe challenging to gather accuratedischarge functional status data forpatients who experience incompletestays. Patients with incomplete staysinclude patients who are unexpectedlydischarged to an acute‐care setting (IPPS,CAH, or LTCH) due to a medicalemergency; patients who die or leave anIRF against medical advice; and patientswith a length of stay less than 3 days.2) Patients younger than age 21.","Given that the primary goal of rehabilitation is improvement in function, IRF clinicians have traditionally assessedand documented patients’ functional status at admission and at discharge to evaluate the effectiveness of therehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospitaloverall.Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, andrace/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, whichsupports the need to monitor IRF patients’ functional outcomes."]
["S2635","IRF Functional Outcome Measure: Discharge Self‐Care Score for Medical Rehabilitation Patients","This quality measure calculates the percent of patients who meet or exceed an expected discharge self‐care score in IRFs.","Outcome","Centers for Medicare & Medicaid Services","Inpatient Rehabilitation Facility Quality Reporting","The number of patients whomeet or exceed an expecteddischarge self‐care score.","Patients discharged during theselected time period.","Two exclusion criteria apply to thedischarge in self‐care function qualitymeasure:1) Patients with incomplete stays: It canbe challenging to gather accuratedischarge functional status data forpatients who experience incompletestays. Patients with incomplete staysinclude patients who are unexpectedly discharged to an acute‐care setting (IPPS, CAH, IPF, or LTCH) due to a medical emergency; patients who die or leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients younger than age 21.","Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionallyassessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness ofthe rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit orhospital overall.Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, andrace/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, whichsupports the need to monitor IRF patients’ functional outcomes."]
["S2633","IRF Functional Outcome Measure: Change in Self‐Care Score for Medical Rehabilitation Patients","This measure estimates the average risk‐adjusted mean change in self‐care function between admission and discharge for patients discharged from IRFs.","Outcome","Centers for Medicare & Medicaid Services","Inpatient Rehabilitation Facility Quality Reporting","The mean change in self‐carefunction.","Patients discharged from the IRF.","Four exclusion criteria apply to thechange in self‐care function scoremeasure:1) Patients with incomplete stays: It canbe challenging to gather accuratedischarge functional status data forpatients who experience incompletestays. Patients with incomplete staysinclude patients who are unexpectedlydischarged to an acute‐care setting(Inpatient Prospective Payment System,Critical Access Hospital, InpatientPsychiatric Hospital, or LTCH) due to amedical emergency; patients who die;patients who leave an IRF against medicaladvice; and patients with a length of stayless than 3 days.2) Patients who are independent withCARE self‐care activities at the time ofadmission: Patients who are independentwith the CARE self‐care items at the timeof admission are assigned the highestscore on all the self‐care items, and thus,would not be able to show functionalimprovement on this same set of items atdischarge. 3) Patients in coma, persistent vegetative state, complete teraplegia, and locked‐in syndrome are excluded, because they may have limited or less predictable self‐care improvement. 4) Patients younger than age 21.","Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionallyassessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness ofthe rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit orhospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, andrace/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, whichsupports the need to monitor IRF patients’ functional outcomes."]
["E0371","VenousThromboembolism Prophylaxis","This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. This measure is part of a set of six nationally implemented prevention and treatment measures that address VTE (VTE‐2: ICU VTE Prophylaxis, VTE‐3: VTE Patients with \"Anticoagulation Overlap Therapy, VTE‐4: VTE Patients Receiving UFH with Dosages/Platelet\" Count Monitoring, VTE‐5: VTE Warfarin Therapy Discharge Instructions and VTE‐6: Hospital Acquired Potentially‐Preventable VTE) that are used in The Joint Commission’s accreditation process.","Process","The Joint Commission","Inpatient Rehabilitation Facility Quality Reporting,Long‐Term Care Hospital Quality Reporting","Patients who received VTEprophylaxis or havedocumentation why no VTEprophylaxis was given:• the day of or the day afterhospital admission• the day of or the day aftersurgery end date for surgeriesthat start the day of or the dayafter hospital admission","All discharged hospital inpatients","• Patients less than 18 years of age• Patients who have a length of stay(LOS) less than two days and greater than120 days• Patients with Comfort Measures Onlydocumented on day of or day afterhospital arrival• Patients enrolled in clinical trials relatedto VTE• Patients who are direct admits tointensive care unit (ICU), or transferredto ICU the day of or the day after hospitaladmission with ICU LOS greater than orequal to one day• Patients with ICD‐9‐CM PrincipalDiagnosis Code of Mental Disorders orStroke as defined in Appendix A, Table7.01, 8.1 or 8.2• Patients with ICD‐9‐CM Principal orOther Diagnosis Codes of Obstetrics orVTE as defined in Appendix A, Table 7.02,7.03 or 7.04• Patients with ICD‐9‐CM PrincipalProcedure Code of Surgical CareImprovement Project (SCIP) VTE selectedsurgeries as defined in Appendix A, Tables 5.17, 5.19, 5.20, 5.21, 5.22, 5.23, 5.24","The estimated annual incidence of deep‐vein thrombosis (DVT) and pulmonary embolism (PE), known collectively asvenous thromboembolism (VTE), is approximately 900,000 cases. Of these, approximately one third of the cases(300,000) are fatal PE, and the remaining two‐thirds are non‐fatal episodes of DVT or PE. The majority of fatal eventsoccur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step forreducing death from PE. Of the estimated 600,000 cases of non‐fatal venous thromboembolism each year, about60% are cases of DVT, and 40% are episodes PE. Among patients who present with symptomatic DVT as the chiefpresenting complaint, 50% or more have evidence of pulmonary embolism (mostly asymptomatic) by diagnosticimaging procedures such as radionuclide lung scanning or CT imaging .The incidence of venous thromboembolismincreases markedly in patients of age 60 years or more. Approximately two‐thirds of cases of DVT or PE areassociated with recent hospitalization. This is consistent with the 2001 report by The Agency for HealthcareResearch and Quality (AHRQ). AHRQ indicates that “the appropriate application of effective preventive measures inhospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism.”Although the majority of cases of DVT and PE are associated with recent hospitalization, many of the patientspresent clinically after hospital discharge, because the length of stay for most surgeries and medical conditions hasbeen markedly reduced in recent years. The aging of the United States population, the more extensive use ofsurgical procedures in older patients, and multiple hospital admissions of patients for the care of chronic conditionssuch as heart failure or diabetes, are strong factors fostering the potential for an increase in the incidence of DVTand PE in future years. Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40%have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital‐acquired DVT is approximately 10% to 40% among medical or general surgical patients and 40% to 60% followingmajor orthopedic surgery."]
["X3705","Compliance with Ventilator Process Elements during LTCH stay","This measure \"Compliance with Ventilator Process Elements during LTCH stay\" is a paired quality measure (QM#1 and QM#2); it assesses facility‐level compliance with Ventilator Process Elements for eligible patients in the LTCH setting. Quality Measure #1: Compliance with Tracheostomy Collar Trial (TCT) or Spontaneous Breathing Trial (SBT) by the end of the first calendar day following admission to the LTCH. Quality Measure #2: Compliance with TCT or SBT during LTCH stay ‐ day 2 through discharge date/ date when patient is fully weaned. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Tracheostomy Collar Trial: Trial of unassisted breathing via a tracheostomy collar (mask) with aerosol (mist), administered to patients with tracheostomy tubes.","Process","Centers for Medicare & Medicaid Services","Long‐Term Care Hospital Quality Reporting","QM#1: The percentage of discharge, planned discharge, death) during the reporting period who were admitted to the LTCH requiring invasive mechanical ventilation. (a) Percentage of ventilator days that TCT or SBT was assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (b) Percentage of ventilator days that TCT or SBT was not assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (c) Percentage of ventilator days that TCT or SBT was deemed medically inappropriate during each day of invasive mechanical ventilation LTCH stay.","All patients admitted to the LTCH","Patients identified as unweanable at the","1. There is evidence for interventions developed to decrease incidence of ventilator‐associated pneumonia andimprove ventilator care2. VAP and VAE is associated with substantial morbidity, mortality, and excess healthcare costs.3. Patients who develop VAP incur an extra $10K (2005) in hospital costs (Sadfar 2005).4. Based on an analysis of CY 2004 MedPAR data for Medicare beneficiaries, 25% of ventilated patients in LTCHsacquired VAP (Buczko 2009)."]
["X3706","Ventilator Weaning (Liberation) Rate","This measure assesses facility‐level patient weaning (liberation) rate for patients in the LTCH setting. This measure reports the percentage of patients who are discharged from a Long‐Term Care Hospital (LTCH) and reported as successfully (fully) weaned at discharge.  The measure will analyze and report the fully weaned and not weaned separately for patients discharged alive. The measure will also analyze and report on weaning status of patients who die. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Weaning covers the entire process of liberating the patient from invasive mechanical ventilation support. iii. Fully weaned: Patients who are discharged alive from a LTCH and require no invasive mechanical ventilation support for 72 consecutive hours or more during 3 consecutive days immediately prior to discharge. iv. Not weaned (invasive mechanical ventilation dependent): Patients who require continuous invasive mechanical ventilation support for more than 12 consecutive hours per day during each of the 3 consecutive calendar days immediately prior to discharge.","Outcome","Centers for Medicare & Medicaid Services","Long‐Term Care Hospital Quality Reporting","The ventilator weaning rate willbe calculated and reported forthe following four numeratorcomponents separately. Each ofthe numerator components willbe calculated and reported as apercentage of all patientsrequiring invasive mechanicalventilation immediately prior toadmission to an LTCH:(a) Fully weaned: Patients who are discharged alive and fully weaned prior to discharge from an LTCH. (b) Not weaned (invasive mechanical ventilization dependent): Patients who are discharged alive and require invasive mechanical ventilation support for more than 12 consecutive hours per day during each fo the three consecutive calendar days immediately prior to discharge. (c) Patients who died.","All patients requiring continuousinvasive mechanical ventilationsupport of any durationimmediately prior to admission toan LTCH.Patients discharged (unplanneddischarge, planned discharge,death) from the LTCH during thereporting period.If patient has had more than one LTCH stay during the reporting period, then, each LTCH stay will be included in the measure calculation and reporting. If patient is admitted to LTCH, weaned, has to return to the short-stay acute care hospital for a procedure, surgery, or some other reason, returns to the LTCH within 3 calendar days, and then, is the discharged from the LTCH, this is considered one \"patient stay\". However, if patient returns to the LTCH after 3 calendar days, a new admission assessment is conducted and this will be the start of a \"second patient stay\" for this same patient. Each of these two stays will be included in the measure calculation and reporting.","Patients identified as unweanable at thetime of admission to an LTCH areexcluded. These include (a) patients whoare chronically ventilated (i.e., who havebeen on invasive mechanical ventilatorsupport for more than 180 days prior toadmission to the short‐stay acute carehospital (if it this stay preceded thecurrent LTCH stay) or prior to admissionto the LTCH, whichever is earlier) [thiswould include patients on a ventilator due to cerebral palsy since childhood); or (b) patients with an acute or chronic condition (for e.g., irreversible neurological injury or disease or dysfunction such as ALS, or high (C2) spinal cord injury that has rendered the patient unweanable. This measure also excludes patients admitted to LTCH and requiring on noninvasive mechanical ventilation. LTCHs with denominator counts of less than 20 in the sample during the reporting period will be excluded from public reporting, owing to small sample size.","1. MedPAC analysis of the Medicare Provider Analysis and Review data found that 16 percent of LTCH patients usedat least one ventilator‐related service in 2012.2. In 2012, Respiratory diagnosis with ventilator support for 96 or more hours (MS‐LTC‐DRG‐207) represented themost frequently occurring diagnosis among LTCH patients (11.3% of all discharges).3. Tracheostomy with ventilator support for 96 or more hours or primary diagnosis except face, mouth, and neckwithout major OR procedure (MS‐LTC‐DRG‐4) represented an additional 1.3% of all LTCH discharges.4. These two diagnosis‐related groups account for a total of nearly 18,000 LTCH discharges.http://www.medpac.gov/chapters/Mar14_Ch11.pdf5. Weaning comprises 40 percent of the duration of mechanical ventilation. (Cite)6. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality.(McIntyre 2012)7. Complications of mechanical ventilation include respiratory muscle weakness, ventilator‐associated pneumonia,upper airway pathology (Burns 2014)8. Prolonged mechanical ventilation is associated with even higher rates of mortality and LOS (Zilberberg 2009)."]
["X4208","Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period","This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial and pharmacologic treatment options for opioid addiction within the 12 month reporting period.","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals","Patients who were counseledregarding psychosocial ANDpharmacologic treatment optionsfor opioid addiction within the 12month reporting period","All patients aged 18 years andolder with a diagnosis of currentopioid addiction (see the related\"DenominatorInclusions/Exclusions\")","Denominator Inclusions/ExclusionsInclusionsAll patients aged 18 years and older witha diagnosis of current opioid addictionThe term \"opioid addiction\" in thiscontext corresponds to the Diagnosticand Statistical Manual of MentalDisorders, Fourth Edition (DSM‐IV)classification of opioid dependence thatis characterized by a maladaptive patternof substance use causing clinically significant impairment or distress, and manifesting by 3 (or more) of the 7 designated criteria. This classification is distinct from and not to be confused with physical dependence (i.e., tolerance and withdrawal) that is commonly experienced by patients with chronic pain who are treated with opioid analgesics. Refer to the \"Rationale\" field for additional information regarding this distinction. Exclusions Patients may be excluded from the denominator for medical, patient or system reasons.","Methadone and buprenorphine, in combination with psychosocial treatment, are effective in reducing drug use andsupporting treatment retention. Until recently, their use had been limited due to regulatory requirements withcapacity at approved facilities only able to meet the treatment needs of 15% of opioid dependent individuals. Whilethe increased access to opioid agonist treatments has resulted in an increase in their use, a large number ofclinicians have yet to gain eligibility to prescribe the appropriate medications. Moreover, among physicians withwaivers to prescribe buprenorphine, 33% were not actively prescribing. Pharmacotherapy and psychosocialtreatment should be routinely considered for all patients with opioid addiction, and patients should be informed ofthis option.The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines andrepresent the evidence base for the measure:Empirically validated psychosocial treatment interventions should be initiated for all patients with substance useillnesses. (National Quality Forum [NQF])Pharmacotherapy should be recommended and available to all adult patients diagnosed with opioid dependenceand without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to anddirectly linked with psychosocial treatment/support. (NQF)• Maintenance treatment with methadone or buprenorphine is appropriate for patients with a prolonged history(greater than 1 year) of opioid dependence. (American Psychiatric Association [APA]) •\tMaintenance treatment with naltrexone is an alternative strategy, although the utility of this strategy is often limited by lack of patient adherence and low treatment retention. (APA)Psychosocial treatments are effective components of a comprehensive treatment plan for patients with an opioid use disorder. Behavioral therapies (e.g., contingency management), cognitive behavioral therapies (CBTs), psychodynamic psychotherapy, and group and family therapies have been found to be effective for some patients with an opioid use disorder. (APA)Note: Federal and state regulations govern the use of methadone, levo‐alpha‐acetylmethadol (LAAM), and buprenorphine, the three opioids approved by the FDA for the treatment of opioid dependence. (APA) [Note: since the publication of the APA practice guideline, LAAM is no longer available in the United States for agonist maintenance treatment.]The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine issued a consensus statement to recognize and recommend definitions related to the use of opioids for the treatment of pain. They are as follows:•\tAddiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.•\tPhysical Dependence: Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.•\tTolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of opioid misuse that may involve any or all of the following:•\tUse of prescription opioids in an unapproved or inappropriate manner (such as cutting time‐release preparations, injecting oral formulations, and applying fentanyl topical patches to oral or rectal mucosa)•\tObtaining opioids outside of medical settings•\tConcurrent abuse of alcohol or illicit drugs•\tRepeated requests for dose increases or early refills, despite the presence of adequate analgesia•\tMultiple episodes of prescription \"loss\"•\tRepeatedly seeking prescriptions from other clinicians or from emergency rooms without informing prescriber, or after warnings to desist•\tEvidence of deterioration in the ability to function at work, in the family, or socially, which appears to be related to drug use•\tRepeated resistance to changes in therapy despite clear evidence of adverse physical or psychological effects from the drug•\tPositive urine drug screen—other substance use (cocaine, opioids, amphetamines or alcohol)•\tMeets DSM IV criteria for dependence on opioids (VA/DoD) EVIDENCE FOR RATIONALE:American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine; 2006.American Psychiatric Association (APA), Physician Consortium for Performance Improvement® (PCPI), National Committee for Quality Assurance (NCQA). Substance use disorders physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Jul. 22 p. [11 references]American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders. 2nd ed. Washington (DC): American Psychiatric Association (APA); 2006 Aug. 275 p. [1789 references]Merrill JO. Policy progress for physician treatment of opiate addiction. J Gen Intern Med. 2002 May;17(5):361‐8. PubMedNational Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence‐based treatment practices; a consensus report. Washington (DC): National Quality Forum; 2007.Substance Abuse and Mental Health Services Administration. The determinations report: a report on the Physician Waiver Program established by the Drug Addiction Treatment Act of 2000 (DATA). Rockville (MD): Substance Abuse and Mental Health Services Administration; 2006 Mar 30. 8 p. [4 references]U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Rockville (MD): U.S. Preventive Services Task Force (USPSTF); 2002. 13 p. [13 references]Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of opioid therapy for chronic pain. Washington (DC): Veterans Health Administration, Department of Defense; 2003 Mar."]
["X4007","Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting","This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals","Patients who were counseledregarding psychosocial ANDpharmacologic treatment optionsfor alcohol dependence withinthe 12 month reporting period","All patients aged 18 years andolder with a diagnosis of currentalcohol dependence","None","Research has shown that among patients diagnosed with alcohol dependence, only 4.64% were referred forpsychosocial treatment in the form of substance abuse counseling, inpatient rehabilitation programs, outpatientrehabilitation programs, or mutual help groups. While pharmacologic therapy has established efficacy, often incombination with psychosocial therapy, in promoting abstinence and preventing relapse in alcohol‐dependentpatients, physician rates of prescribing pharmacologic therapy for alcohol dependence are also considerably low. Arecent study found that these low rates prevail even among addiction medicine physicians who prescribednaltrexone to only 13% of their alcohol dependent patients. Pharmacotherapy and psychosocial treatment shouldbe routinely considered for all patients with alcohol dependence, and patients should be informed of this option.The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines(from the American Psychiatric Association [APA]) and represent the evidence base for the measure:Psychosocial treatments found effective for some patients with an alcohol use disorder include motivationalenhancement therapy (MET), cognitive‐behavioral therapy (CBT), behavioral therapies, 12‐step facilitation (TSF),marital and family therapies, group therapies, and psychodynamic therapy/interpersonal therapy (IPT). (APA, 2006)Specific pharmacotherapies for alcohol‐dependent patients have well‐established efficacy and moderateeffectiveness:• Naltrexone may attenuate some of the reinforcing effects of alcohol, although data on its long‐term efficacy arelimited. The use of long‐acting, injectable naltrexone may promote adherence, but published research is limited andFDA approval is pending. [Note: Extended‐release naltrexone for injection has since received FDA approval]• Acamprosate, a gamma‐aminobutyric acid (GABA) analog that may decrease alcohol craving in abstinentindividuals, may also be an effective adjunctive medication in motivated patients who are concomitantly receivingpsychosocial treatment.• Disulfiram is an effective adjunct to a comprehensive treatment program for reliable, motivated patients whosedrinking may be triggered by events that suddenly increase alcohol craving. (APA, 2006)Empirically validated psychosocial treatment interventions should be initiated for all patients with substance useillnesses. Pharmacotherapy should be offered and available to all adult patients diagnosed with alcohol dependenceand without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to anddirectly linked with psychosocial treatment/support. (National Quality Forum [NQF], 2007)EVIDENCE FOR RATIONALE: American Psychiatric Association (APA), Physician Consortium for Performance Improvement® (PCPI), National Committee for Quality Assurance (NCQA). Substance use disorders physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Jul. 22 p. [11 references]American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders. 2nd ed. Washington (DC): American Psychiatric Association (APA); 2006 Aug. 275 p. [1789 references]Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor‐ quality health care. N Engl J Med. 2006 Mar 16;354(11):1147‐56. [32 references] PubMedMark TL, Kranzler HR, Song X. Understanding US addiction physicians' low rate of naltrexone prescription. Drug Alcohol Depend. 2003 Sep 10;71(3):219‐28. PubMedNational Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence‐based treatment practices; a consensus report. Washington (DC): National Quality Forum; 2007."]
["E1507","Risky Behavior Assessment or Counseling by Age 18 Years","The percentage of children with documentation of a risk assessment or counseling for risky behaviors by 18 years of age. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity.","Process","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals","Adolescents who haddocumentation of a RiskyBehavior Assessment orCounseling By Age 18 Years.","Adolescents with a visit whoturned 18 years of age in themeasurement year.","None","NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment orcounseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessmentor Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity.Early alcohol and drug use (pre‐adolescent/early adolescent) is a predictor of later dependence. In the 2003National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s.Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral HealthCoordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reportsseparate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 theBHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is morelikely to see their doctor without their parent, which promotes more honest conversations.References: 2010‐2011 National Survey on Drug Use and Health.http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm"]
["E1406","Risky Behavior Assessment or Counseling by Age 13 Years","The percentage of adolescents with documentation of assessment or counseling for risky behavior by the age of 13 years. Four rates are reported: Risk Assessment or Counseling for Alcohol Use, Risk Assessment or Counseling for Tobacco Use, Risk Assessment or Counseling for Other Substance Use, Risk Assessment or Counseling for Sexual Activity.","Process","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals","Adolescents who haddocumentation of a RiskyBehavior Assessment orCounseling By Age 13 Years.","Adolescents with a visit whoturned 13 years of age in themeasurement year.","None","NQF measures 1406 and 1507 assess the percentage of children with documentation of a risk assessment orcounseling for risky behaviors by the age of 13 or 18 years (respectively). Four rates are reported: Risk Assessmentor Counseling for Alcohol Use, for Tobacco Use, for Other Substance Use, and for Sexual Activity.Early alcohol and drug use (pre‐adolescent/early adolescent) is a predictor of later dependence. In the 2003National Survey on Drug Use and Health (NSDUH), individuals who stated that they began drinking prior to age 15were over 5 times more likely to report alcohol dependence or abuse at some point in their lives. Approximately58% of Americans begin drinking alcohol before age 18 and heavy alcohol use spikes in the late teens and early 20’s.Because there is strong evidence for the utility of preventive counseling at both ages, the Behavioral HealthCoordinating Committee (BHCC) at HHS recommends combining these measures into one measure that reportsseparate rates for counseling provided at age13 and 18. If this is not possible in the time frame for MU Stage 3 theBHCC prioritizes NQF 1507 (age 18). Age 18 is an important transitional year and by this age the patient is morelikely to see their doctor without their parent, which promotes more honest conversations.References:2010‐2011 National Survey on Drug Use and Health.http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm"]
["X3446","Intimate Partner (Domestic) Violence Screening","Percentage of female patients aged 15‐40 years old who were screened for intimate partner (domestic) violence at any time during the reporting period.","Process","Indian Health Service","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals,Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","1. GPRA: Patients screened for ordiagnosed with IPV/DV duringthe report period.Note: This numerator does notinclude refusals.A. Patients with documentedIPV/DV exam.B. Patients with IPV/DV relateddiagnosis.C. Patients provided with IPV/DVpatient education or counseling.2. Patients with documentedrefusal in past year of an IPV/DVexam or IPV/DV relatededucation","Female Active Clinical patientsages 13 and older.Female Active Clinical patientsages 15 through 40. (GPRADenominator)Female User Population patientsages 13 and older.","None","This screening helps to determine, evaluate, and lower the occurrence of family violence, abuse, and neglect inAmerican Indian and Alaska Native communities. In the United States, 30% of women experience domestic violenceat some time in their lives. AI/AN women experience domestic violence at the same rate or higher than the nationalaverage. A survey of Navajo women getting routine care at an IHS facility reported that 14% had experiencedphysical abuse in the past year. In this same group of Navajo women, 42% reported having experienced physicalabuse from a male partner at least once in their lives. The consequences of intimate partner violence to the healthof a woman are numerous. In January 2013, the US Preventive Services Task Force updated its recommendations onintimate partner violence (IPV) to recommend that clinicians screen women of childbearing age and provide or referwomen who screen positive to intervention services. IPV is common in the United States but often remainsundetected. Nearly 31% of women report experiencing some form of IPV and approximately 25% experiencing themost severe types of in their lifetime (1‐3). These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death (4, 5), IPV is also associated with increased sexually transmitted, unintended pregnancies, chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age (12‐14). Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior (15‐19). For adolescent and young adults, the effects of physical and sexual assault are associated with poor self‐esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions (20, 21). The USPSTF concluded that there is sufficient evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age.Basile KC, Saltzman LE. (2002), Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Chamberlain L. (2005). The USPSTF recommendation on intimate partner violence: What we can learn from it and what can we do about it. Family Violence Prevention and Health Practice, 1, 1‐24. Ghiselli EE, Campbell JP, Zedeck S. (1981). Measurement theory for the behavioral sciences. New York: W.H. Freeman and Company.National Center for Injury Prevention and Control (2002). CDC Injury Research Agenda. Atlanta (GA): Centers for Disease Control and Prevention. Rathus JH, Feindler EL. (2004). Assessment of partner violence: A handbook for researchers and practitioners. Washington DC: American Psychological Association. Robinson JP, Shaver PR, Wrightsman LS. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control. Teutsch SM, Churchill RE. (Eds.). (2000). Principles and practice of public health surveillance (2nd ed.). New York, NY: Oxford University Press, Inc. US Preventive Services Task Force. (2004). See website:http://www.ahrq.gov/clinic/uspstf/  uspsfamv.htm"]
["X3445","Alcohol Screening and Brief Intervention (ASBI) in the ER","Percentage of patients aged 15 to 34 seen in the ER for injury who were screened for hazardous alcohol use AND provided a brief intervention within 7 days of the ER visit if screened positive.","Process","Indian Health Service","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals,Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Numerators1. Number of visits wherepatients were screened in the ERfor hazardous alcohol use. A. Number of visits where patients were screened positive (also used as denominator #2) 2. Number of visits where patients were provided a brief negotiated interview (BNI) at or within seven days of the ER visit (used only with denominator #2). A. Number of visits where patients were provided a BNI at the ER visit. B. Number of visits where patients were provided a BNI not at the ER visit but within seven days of the ER visit.","1. Number of visits for ActiveClinical Plus BH patients age 15through 34 seen in the ER forinjury during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 2. Number of visits for Active Clinical Plus BH patients age 15 through 34 seen in the ER for injury and screened positive for hazardous alcohol use during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 3. Number of visits for User Population patients age 15 through 34 seen in the ER for injury during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34. 4. Number of visits for User Population patients age 15 through 34 seen in the ER for injury and screened positive for hazardous alcohol use during the report period. Broken down by gender and age groups of 15 through 24 and 25 through 34.","None","The IHS Office of Clinical and Preventive Services has developed an active injury and alcohol control program calledASBI. It targets young, non‐dependent alcohol/drugs users who present to IHS –Tribal Hospitals and Clinics with aninjury related to alcohol and drug misuse. Via ASBI, reductions in repeat injury (recidivism) and lower alcoholconsumption may reach up to 50%. Up to half of the people treated in hospital emergency departments and traumacenters are under the influence of alcohol. Between 24 and 31% of these patients have an alcohol use disorder .Excessive alcohol consumption contributes to more than 80,000 deaths each year in the United States . Nearly halfof alcohol‐related deaths result from motor‐vehicle crashes, falls, fires, drowning, homicides, and suicides. Providing brief intervention to patients screened in the ED leads to improved outcomes including alcohol intake, risky drinking practices, alcohol‐related negative consequences, and injury frequency.1.\thttp://www.ihs.gov/NonMedicalPrograms/DirInitiatives/index.cfm2.\tGrim, Charles. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference, PIMC, Phoenix, AZ. 20 April, 2007.3.\tNational Highway Traffic Safety Administration. Race and Ethnicity in Fatal Motor Vehicle Traffic Crashes 1999‐ 2004. National Center for Statistics and Analysis. Washington, D.C. May 2006.4.\tNational Highway Traffic Safety Administration. [internet] Traffic Safety Facts: 2005 Data, Alcohol. National Center for Statistics and Analysis. Washington, D.C. [Internet] Accessed 12/5/2007. http://www‐ nrd.nhtsa.dot.gov/Pubs/810616.PDF5.\tMaier RV. “Controlling Alcohol Problems Among Hospitalized Trauma Patients.” The Journal of Trauma. 2005; 59S(3): S1‐S2.6.\tRivara FB, Koepsell TD, Jurkovitch GH, et al. “The Effects of Alcohol Abuse on Readmission for Trauma.” JAMA. 1993; 270: 1962‐1964.7.\tDischinger PC, Mitchell KA, Kufera JA, Soderstrom CA and Lowenfels AB. “A Longitudinal Study of Former Trauma Center Patients: The Association Between Toxicology Status and Subsequent Injury Mortality.” Journal of Trauma. 2001. 51(5):877‐886.8.\tSanddal TL, Upchurch J, Sanddal ND, Esposito TJ. “Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians.” Injury Prevention. Winter 2005. Pp 65‐69.9.\tSoderstrom, Carl. Professor of Surgery, University of Maryland, Shock Trauma Center. Personal Communication, 31 January 200710.\tBoyd, David. National Trauma Systems Coordinator. Indian Health Service Emergency Health Services; Office of Clinical and Preventive Services. Personal Communication. 12 December 2007.11.\tMonti PM, Colby SM, Barnett NP, Spirito A, Myers M, et al. “Brief Intervention for Harm Reduction With Alcohol‐ Positive Older Adolescents in a Hospital Emergency Department.” Journal of Consulting and Clinical Psychology. 1999. 67(6): 989‐994.12.\tGentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence.” Annals of Surgery.1999; 230(4): 473‐483.13.\tSchermer CR, Moyers TB, Miller WR, and Bloomfield LA. “Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests.” Journal of Trauma Injury Infection and Critical Care. 2006; 60(1): 29‐34.14.\tWilk AI, Jensen NM, and Havighurst TC. “Meta‐analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Drinkers.” Journal of General Internal Medicine. May 1997. 12:274‐283.15.\tWorld Health Organization. “A Cross‐National Trial of Brief Interventions with Heavy Drinkers.” American Journal of Public Health. July 1996. 86(7): 948‐95516.\tFleming MF, Mundt MP, French MT, Mandwell LB, et al. “Brief Physician Advice for Problem Drinkers: Long‐Term Efficacy and Brief‐Cost Analysis.” Alcoholism: Clinical and Experimental Research. Jan 2002. 26(1): 36‐43.17.\tSpirito A, Monti PM, Barnett NP, Colby SM, et al. “A Randomized Clinical Trial of a Brief Motivational Intervention for Alcohol Positive Adolescents Treated in an Emergency Department.” Pediatrics. 2004. 145:396‐404.18.\tBien TH, Miller WR, and Tonigan JS. “Brief Interventions for Alcohol Problems: A Review.” Addiction. 1993; 88:315‐336.19.\tAcademic ED SBIRT Research Collaborative. “The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients’ Alcohol Use.” Annals of Emergency Medicine. 2007; 50: 699‐710.20.\tMoyer A, Finney JW, Swearingen EC and Vergun P. “Brief Interventions for Alcohol Problems: A Meta‐Analytic Review of Controlled Investigations in Treatment‐Seeking and Non‐Treatment‐Seeking Populations.” Addiction. 2002; 97: 279‐292.21.\tGrossberg PM, Brown DD, Fleming MF. “Brief Physician Advice for High‐Risk Drinking Among Young Adults.” Annals of Family Medicine. Sept/Oct 2004. 2(5): 474480.22.\tDinh‐Zarr T, Goss C, Roberts I, DiGuiseppi C. “Interventions for Preventing Injuries in Problem Drinkers.” Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No: CD001857. DOI: 10.1002/14651858.CD001857.pub.2.www.thecochranelibrary.com23.\tWorld Health Organization. Alcohol and Injury in Emergency Departments. Summary of the Report from the WHO Collaborative Study on Alcohol and Injuries.France, 2007. France. .24.\tD’Onofrio G, Degutis LC. “Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review.” Academic Emergency Medicine. June 2002; 9(6): 627‐638.25.\tIrvin CB, Wyer PC, Gerson LW, et al. for the SAEM Public Health and Education Task Force Preventive Services Work Group. “Preventive Care in the Emergency Department Part II: Clinical Preventive Services—An Emergency Medicine Evidence‐based Review.” Academic Emergency Medicine. Sept 2000; 7(9): 1042‐1054.26.\tWhitlock EP, Polen MR, Green CA, Orleans CT, and Klein J. “Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services TaskForce.” Annals of Internal Medicine. 2004; 140(7): 557‐568. 27.\tUnited States Preventive Services Task. National Guideline Clearinghouse. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. [Internet] Accessed 12 December 2007.http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=4618&nbr=003399$   string=alcohol28.\tSubstance Abuse and Mental Health Administration; Center for Substance Abuse Treatment. Screening, Brief Intervention, Referral, and Treatment. [Internet] Accessed 7 December 2007. http://sbirt.samhsa.gov/about/htm29.\tNational Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005 Edition. National Institutes of Health Publication No 07‐3769. Rockville, Maryland.30.\tD’Onofrio G, Pantalon MV, Degutis LC, Fiellin D, and O’Connor PG. Alcohol Screening and Brief Intervention Project: BNI Training Manual. New Haven, Connecticut: Yale University School of Medicine, 2002.31.\tInstitute of Medicine. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington D.C. 1990.32.\tSubstance Abuse and Mental Health Administration: Office of Applied. 2006 National Survey on Drug Use and Health: National Results. 2006 Accessed 12/4/2007, http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#Ch333.\tHungerford, Daniel. Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, Georgia. Personal Communication. 28 November 2007.34.\tRose G. “Sick Individuals and Sick Population.” International Journal of Epidemiology. 1985. 14(1):32‐38.35.\tSpurling MC and Vinson DC. “Alcohol‐Related Injuries: Evidence for the Prevention Paradox.” Annals of Family Medicine. Jan/Feb 2005. 3(1): 47‐52.36.\tHungerford DW. “Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady.” Journal of Trauma. Sept 2005. 59(3s): s10‐s16.37.\tMcBride CM, Emmons KM, and Lipkus IM. Understanding the Potential of the Teachable Moment: The Case of Smoking Cessation.” Health Education Research. 2003; 18(2): 156‐170.38.\tProchasaka JO, DiClemente CC, and Norcross JC. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist. Sept 1992; 47(9): 1102‐1114.39.\tLongabaugh R, Minugh PA, Nirenberg TD, et al. “Injury as a Motivator to Reduce Drinking.” Academic Emergency Medicine. 1995; 2: 817‐825.40.\tBarnett NP, Lebearu‐Craven R, O’Learly TA, Colby SM, Woolard R, Rohsenow DJ, Spirito A, and Monti PM. “Predictors of Motivation to Change After Medical Treatment for Drinking‐Related Events in Adolescents.” Psychology of Addictive Behaviors. 2002; 16(2): 106‐112.50. Schermer CR, Bloomfield LA, Lu SW and Demarest GB. “Trauma Patient Willingness to Participate in Alcohol Screening and Intervention.” Journal of Trauma. 2003; 54(4): 701‐706.51.\tMonti PM, Barnett NP, Colby SM, Gwaltney CH, Spirito A, et al. “Motivational Interviewing vs. Feedback Only in Emergency Care for Young Adult Problem Drinking.” Addiction. 2007; 102: 1234‐1243.52.\tMello MJ, Nirenberg T, Longabaugh R, Woolard R, et al. “Emergency Department Brief Motivational Interventions for Alcohol with Motor Vehicle Crash Patients.” Annals of Emergency Medicine. June 2005; 45(6): 620‐ 625.53.\tLongabaugh R, Woolard RF, Nirenberg TD, Minugh AP, et al. “Evaluating the Effects of a Brief Motivational Intervention for Injured Drinkers in the Emergency Department.” Journal of Studies on Alcohol. 2001; 62: 806‐816.54.\tHungerford D, Williams JM, Furbee PM, Manley WG, et al. “Feasibility of Screening and Intervention for Alcohol Problems Among Young Adults in the E.D.” American Journal of Emergency Medicine. Jan 2003. 21(1): 14‐22.55.\tBlose JO and Holder HD. “Injury Related Medical Care Utilization in a Problem‐Drinking Population.” American Journal of Public Health. Dec 1991. 81(12): 1571‐1575.56.\tDennis, Terry. “Alcohol Screening and Brief Intervention.” Lecture. Train the Trainer Telemedicine Conference. Billings, MT. 5 June, 2007.57.\tGentilello LM, Ebel BE, Wickizer TM, et al. “Alcohol Interventions for Trauma Patients Treated in EmergencyDepartments and Hospitals: A Cost Benefit Analysis.” Annals of Surgery. April 2005; 241(4): 541‐550."]
["X3792","Controlling High Blood Pressure","Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period based on the following criteria: • Patients 18–59 years of age whose BP was <140/90 mm Hg. • Patients 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Patients 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.","Intermediate\nOutcome","National Committee for Quality Assurance","Medicare Physician Quality Reporting System, Medicare Shared Savings,Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients whose most recentblood pressure is adequatelycontrolled during themeasurement period.","Patients 18 through 85 years ofage who had a diagnosis ofessential hypertension within thefirst six months of themeasurement period or any timeprior to the measurement period","None","Hypertension is a very significant health issue in the United States. Nearly 78 million adults have high bloodpressure. Yet, only fifty three percent of adults with hypertension have their blood pressure under control. TheUnited States spends over $46 billion annually in direct and indirect costs due to high blood pressure. (Go AS,Mozaffarian D, Roger VL et al. 2014) Uncontrolled hypertension can lead to serious complications such as coronaryheart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease and retinopathy. Amongadults with diagnosed diabetes, 71 percent also have hypertension (CDC 2014). Uncontrolled hypertension placesadults with diabetes at a higher risk of developing serious complications. Controlling blood pressure has been shownto reduce the probability of undesirable and costly outcomes. The relationship between the measure (control ofhypertension) and the long‐term clinical outcomes is well established. In clinical trials, antihypertensive therapy hasbeen associated with reductions in stroke, heart failure, coronary heart disease, diabetes complications and overallmortality (Eighth Joint National Committee)."]
["X3797","Breast Cancer Screening","Percentage of women 50‐74 years of age who had a mammogram to screen for breast cancer in the past 27 months.","Process","National Committee for Quality Assurance","Medicare Physician Quality Reporting System, Medicare Shared Savings,Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Women with one or moremammograms any time on orbetween October 1, 27 monthsprior to the measurement period,and December 31 of themeasurement period, not toprecede the patient's 50^{th}birthday.","Women 52‐74 years of age with avisit during the measurementperiod","Women who had a bilateral mastectomyor for whom there is evidence of twounilateral mastectomies","Breast cancer is the second most commonly diagnosed cancer among women (after skin cancer). After lung cancer,it causes more deaths in women than any other kind of cancer—there were nearly 40,000 estimated deaths frombreast cancer in 2010. Deaths from breast cancer have decreased over the years, in part due to early detection usingmammography. On average, mammography will detect about 80‐90 percent of breast cancers in women without symptoms (American Cancer Society 2011). Based on evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality with higher benefit in older women (National Cancer Institute 2010). There is a demonstrated reduction in breast cancer mortality due to mammogram screening (National Business Group onHealth 2011)."]
["E0032","Cervical Cancer Screening","Percentage of women 21‐64 years of age who were screened for cervical cancer using either of the following criteria: 1. Women age 21‐64 who had cervical cytology performed every 3 years. 2. Women age 30‐64 who had cervical cytology/human papillomavirus (HPV) co‐testing performed every 5 years.","Process","National Committee for Quality Assurance","Medicare Physician Quality Reporting System, Medicare Shared Savings,Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Either: 1. Women age 21‐64 whohad cervical cytology performedduring the measurement periodor in the 2 years prior to themeasurement period. 2. Womenage 30‐64 who had cervicalcytology/human papillomavirus(HPV) co‐testing performedduring the measurement periodor in the 4 years prior to themeasurement period","Women 24‐64 years of age with avisit during the measurementperiod","Women who had a hysterectomy with noresidual cervix","Cervical cancer has a high survival rate when detected early, yet it is the second most common cancer amongwomen worldwide (Myers et al. 2008). In the United States, about 12,000 women are diagnosed with cervicalcancer each year. In 2010, more than 4,000 women died from cervical cancer (American Cancer Society 2010). Forwomen in whom pre‐cancerous lesions have been detected through Pap tests, the likelihood of survival is nearly100 percent with appropriate evaluation, treatment and follow‐up (American Cancer Society 2011). For womenunder 50 years old, cervical cancer is diagnosed in the early stage 61 percent of the time (American Cancer Society2010). In 2008, the prevalence of recent Pap test use was lowest among older women, women with no healthinsurance and recent immigrants (American Cancer Society 2011)."]
["E2152","Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling","Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients who were screened atleast once within the last 24months for unhealthy alcohol useusing a systematic screeningmethod AND who received briefcounseling if identified as anunhealthy alcohol userDefinitions:Systematic screening method ‐For purposes of this measure,one of the following systematic methods to assess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for defining unhealthy alcohol use include: AUDIT Screening Instrument (score ≥ 8) AUDIT‐C Screening Instrument (score ≥4 for men; score ≥ for women) Single Question Screening ‐How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 y) or more drinks in a day? (response ≥2) Brief counseling ‐Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5‐15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking.","All patients aged 18 years andolder who were seen twice for anyvisits or who had at least onepreventive care visit during the 12month measurement period","Documentation of medical reason(s) fornot screening for unhealthy alcohol use(e.g., limited life expectancy, othermedical reasons)","This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shownto be effective in reducing alcohol consumption. About 30% of the U.S. population misuse alcohol, with mostengaging in what is considered risky drinking. (SAMHSA, 2012) A recent analysis of data from the National AlcoholSurvey shows that approximately one‐third of at‐risk drinkers (32.4%) and persons with a current alcohol usedisorder (31.5%) in the United States had at least 1 primary care visit during the prior year, demonstrating thepotential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting. (Mulia et al.,2011) A number of studies, including patient and provider surveys, have documented low rates of alcohol misusescreening and counseling in primary care settings. In the national Healthcare for Communities Survey, only 8.7% ofproblem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amicoet al., 2005) A nationally representative sample of 648 primary care physicians were surveyed to determine howsuch physicians identify‐‐or fail to identify‐‐substance abuse in their patients, what efforts they make to help thesepatients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual healthhistories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent saythey ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000)The USPSTF recommends that providers screen for alcohol misuse and provide persons engaged in risky orhazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. About 3 in 10 U.S.adults drink at levels that elevate their risk for physical, mental health, and social problems. About 1 in 4 of theseheavy drinkers has alcohol abuse or dependence. Excessive alcohol use is the third‐leading cause of preventabledeaths in the United States, and is responsible for 80,000 deaths and $224 billion or $1.90 per drink in economic costs per year. Binge drinking is responsible for over half of these deaths and three‐quarters of the economic costs due to excessive drinking, and yet it often goes undetected. Furthermore, only about 10% of patients with alcohol dependence receive the recommended quality of care, including assessment and referral to treatment.This measure is intended to promote unhealthy alcohol use screening and brief counseling which has been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Research data suggests that unhealthy alcohol use contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide,injury, and violence."]
["X3475","Substance Use Screening and \"Intervention Composite\"","Percentage of patients aged 18 years and older who were screened at least once within the last \"24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit\" drug use AND who received an intervention for all positive screening results","Process","American Society of Addiction Medicine","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients who received thefollowing substance usescreenings at least once withinthe last 24 months AND who received an intervention for all positive screening results: 1) Tobacco use component ‐Patients who were screened for tobacco use at least once within the last 24 months AND who received tobacco cessation intervention if identified as a tobacco user 2) Unhealthy Alcohol Use Component ‐Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user 3) Drug use component (nonmedical prescription drug use and illicit drug use) ‐Patients who were screened for nonmedical prescription drug use and illicit drug use at least once within the last 24 months using a systematic screening method AND who received brief counseling if identified as a nonmedical prescription drug user or illicit drug user","All patients aged 18 years andolder who were seen twice for anyvisits or who had at least onepreventive care visit during the 12 month measurement period","EXCEPTION (not exclusion):1) Tobacco Component ‐ Documentationof medical reason(s) for not screening fortobacco use (e.g., limited life expectancy, other medical reasons) 2) Alcohol Component ‐Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) 3) Drug Component ‐Documentation of medical reason(s) for not screening for nonmedical prescription drug use and illicit drug use (e.g., limited life expectancy, other medical reasons)","Substance use problems and illnesses have substantial impact on health and societal costs, and often are linked tocatastrophic personal consequences. In 2010, an estimated 19.3% (45.3 million) of U.S. adults were current cigarettesmokers; of these, 78.2% smoked every day, and 21.8% smoked some days. 30% of the U.S. population misusealcohol, with most engaging in what is considered risky drinking. In 2010, an estimated 22.6 million Americans aged12 or older (~8.9 percent of the population) were current illicit drug users, which means they had used an illicit drugduring the month prior to the survey. About 1 in 5 Americans aged 18−25 used illicit drugs in the past. Becausemany patients will not self‐identify or have not yet developed detectable problems associated with substance use,screening can identify patients for whom intervention may be indicated. Brief motivational counseling for thesevarious substances has been shown to be an effective treatment for reducing problem use, particularly in primarycare settings. The 2011 National Survey on Drug Use and Health found that 1 in 20 persons in the U.S. aged 12 orolder reported nonmedical use of prescription pain killers in the past year. Prescription drug overdose is now theleading cause of accidental death in the United States ‐ surpassing motor vehicle accidents. Many scientific studieshave also shown there are dire health consequences from untreated substance use disorders on medicalcomplications of diabetes mellitus and other co‐occurring chronic conditions. Substance use disorders (SUD) is oneof the 10 categories of essential health benefits which the ACA requires most private insurers to cover. Insurers alsomust ensure these benefits comply with the Mental Health Parity and Addiction Equity Act of 2008. Consequently, itis necessary that health care providers in general medical settings be equipped with an appropriate training andresources as well as CMS 'meaningful use' reimbursement incentives, to support and guide science‐based screeningand counseling for substance use disorders in primary care, utilizing relevant electronic‐health‐record‐basedperformance measures and accompanying evidence‐based clinical decision support tools."]
["X3512","Hepatitis C: One‐ Time Screening for Hepatitis C Virus (HCV) for Patients at Risk","Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945– 1965 who received a one‐time screening for HCV infection","Process","American Medical Association","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients who received one‐timescreening for HCV infectionScreening for HCV infectionincludes current or prior receiptof: HCV antibody test, HCV RNAtest or recombinant immunoblotassay (RIBA) test","All patients aged 18 years andolder who were seen twice for anyvisit or who had at least onepreventive care visit within the 12month reporting period with oneor more of the following: a historyof injection drug use, receipt of ablood transfusion prior to 1992,receiving maintenancehemodialysis, OR birthdate in theyears 1945–1965","Exclusions: Patients with a diagnosis ofchronic hepatitis CExceptions: Documentation of medicalreason(s) for not receiving one‐time HCVantibody test (e.g., advanced disease,limited life expectancy, other medicalreasons)Documentation of patient reason(s) fornot receiving one‐time HCV antibody test(e.g., patient declined, other patientreasons)","In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that: • Adults born during 1945–1965 should receive one‐time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation,Moderate Quality of Evidence), and • All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services forHCV infection and related conditions (Strong Recommendation, Moderate Quality of Evidence). Providers andpatients can discuss HCV testing as part of an individual’s preventive health care. For persons identified with HCVinfection, CDC recommends that they receive appropriate care, including HCV‐directed clinical preventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy‐related adverse events, and benefits of treatment. (CDC, 2012). The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis C virus (HCV) infection in adults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992. Grade B recommendation.Assessment of Risk:Established high‐risk factors for HCV infection include blood transfusion prior to 1992 and past or current intravenous drug use. Because of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who report injecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV‐infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited.The USPSTF recommends that clinicians consider offering screening for HCV infection in adults born between 1945 and 1965. Grade B recommendation. The USPSTF concludes with moderate certainty that screening for HCV infection in the 1945–1965 birth cohort has at least a moderate net benefit. The USPSTF concluded that screening is of moderate benefit for populations at high risk. The USPSTF concluded that the benefit of screening all adults in the birth cohort born between 1945 and 1965 is moderate. The benefit is smaller given the lower. Birth‐cohort screening is probably less efficient than risk‐based screening, meaning more persons will need to be screened to identify 1 patient with HCV infection. Nevertheless, the overall number of Americans who will probably benefit from birth‐cohort screening is greater than the number who will benefit from risk‐based screening. A risk‐based approach may miss detection of a substantial proportion of HCV‐infected individuals in the birth cohort, due to either lack of patient disclosure or knowledge about prior risk status. As a result, clinicians should consider a birth cohort–based screening approach for patients born between 1945 and 1965 who have no other known HCV risk factors. Screening in the birth cohort for HCV infection will identify infected patients at earlier stages of disease, before they develop complications from liver damage.In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States. Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected, do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%–85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection.29 HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection‐drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Current risk‐based testing strategies have had limited success, as evidenced by the substantial number of HCV‐infected persons who remain unaware of their infection. Of the estimated 2.7–3.9 million persons living with HCV infection in the United States, 45%–85% are unaware of their infection; this proportion varies by setting, risk level in the population, and site‐specific testing practices. Studies indicate that even among high‐risk populations for whom routine HCV testing is recommended, prevalence of testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history of injection‐drug use who are infected with HCV remain unaware of their infection status. Barriers to testing include inadequate health insurance coverage and limited access to regular health care47; however, risk‐based testing practices have not been successful in identifying most HCV‐infected persons, even those covered by healthinsurance."]
["X3816","Hepatitis C: Appropriate Screening Follow‐ Up for Patients Identified with Hepatitis C Virus (HCV) Infection","Percentage of patients aged 18 years and older with a positive HCV antibody test and either a positive HCV RNA test result or an absent HCV RNA test result who are prescribed treatment or are referred to treatment services for HCV infection","Process","American Medical Association","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients who are prescribedtreatment or are referred totreatment services for HCVinfection","All patients aged 18 years andolder with a positive HCV antibodytest and either a positive HCV RNAtest result or an absent HCV RNAtest result","Exceptions:Documentation of medical reason(s) fornot being referred to treatment servicesfor HCV infection (e.g., advanced disease,limited life expectancy, other medicalreasons)Documentation of patient reason(s) fornot being referred to treatment servicesfor HCV infection (e.g., patient declined,other patient reasons)","In addition to testing adults of all ages at risk for HCV infection, CDC7 recommends that:• Adults born during 1945–1965 should receive one‐time testing for HCV without prior ascertainment of HCV risk(Strong Recommendation, Moderate Quality of Evidence), and• All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinicallyindicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions(Strong Recommendation, Moderate Quality of Evidence).Providers and patients can discuss HCV testing as part of an individual’s preventive health care. For personsidentified with HCV infection, CDC recommends that they receive appropriate care, including HCV‐directed clinicalpreventive services (e.g., screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, andmedical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy‐related adverse events, and benefits of treatment. (CDC, 2012)Clinical preventive services, regular medical monitoring, and behavioral changes can improve health outcomes for persons with HCV infection. HCV care and treatment recommendations have been issued by AASLD and endorsed by the Infectious Disease Society of America and the American Gastroenterological Association. Routine testing of persons born during 1945–1965 is expected to lead to more HCV‐infected persons being identified earlier in the course of disease. To improve health outcomes, persons testing positive for HCV must be provided with appropriate treatment. Linking patients to care and treatment is a critical component of the strategy to reduce the burden of disease.Attaining treatment‐related SVR among persons with HCV is associated with a reduction in the relative risk for hepatocellular carcinoma (HCC). A systematic review published in 2013 summarized the evidence from 30 observational studies examining the risk for HCC among HCV‐infected persons who have been treated and either achieved an SVR or did not respond to therapy. Findings showed a protective effect of treatment‐related SVR on the development of HCC among HCV‐infected persons at all stages of fibrosis and among those with advanced liver disease. With the availability of newer and more effective therapies, SVR rates can be increased and HCC incidence rates can be reduced in HCV‐infected persons.38 The association between SVR and HCC should be considered when weighing the benefits and harms of identifying and treating HCV‐infected persons. Many persons identified as HCV‐ infected do not receive recommended medical evaluation and care after the diagnosis of HCV infection; this gap in linkage to care can be attributed to several factors, including being uninsured or underinsured, failure of providers to provide a referral, failure of patients to follow up on a referral, drug or alcohol use, and other barriers.7 The lack of such care, or substantial delays before care is received, negatively impacts the health outcomes of infectedpersons."]
["X3482","Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements","Average change in functional status assessment score for 19 years and older with primary total knee arthorplasty (TKA) in the 180-270 days after surgery compared to their initial score within 90 days prior to surgery.","Patient Reported Outcome","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Continuous Variable:Measure Observations:Average change in functionalstatus assessment score (beforeand after surgery)","Continuous Variable:Eligible Population:Adults, aged 19 and older duringthe measurement period, with aprimary total knee arthroplasty(TKA) in the first 90 days of themeasurement period or the last 270 days in the year prior to the measurement period and an encounter during the measurement period Measure Population: Patients must meet the following criteria to be counted in the numerator: 1. A patient reported functional status assessment (i.e., VR‐12, PROMIS‐10‐Global Health, KOOS) completed in the 3 months prior to or including the day of surgery 2. A patient reported functional status assessment (i.e., VR‐12, PROMIS‐10‐Global Health, KOOS) completed during the 6‐9 months after surgery 3. DO NOT have an acute fracture of hip or lower limb at the time of TKA 4. DO NOT have severe cognitive impairment For a functional status assessment to be completed, the score must be documented in the EHR","None","Measuring functional status for patient undergoing total knee replacement permits longitudinal assessment ‐ fromthe patient’s perspective ‐ of the impact of surgical intervention on pain, physical function, as well as health‐relatedquality of life."]
["X3483","Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements","Average change in functional status assessment score for 19 years and older with primary total hip arthroplasty (THA) in the 180‐270 days after surgery compared to their initial score within 90 days prior to surgery.","Patient\nReported\nOutcome","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Continuous Variable:Measure Observations:Average change in functionalstatus assessment score (before and after surgery)","Continuous Variable:Eligible Population:Adults, aged 19 and older duringthe measurement period, with a primary or total hip arthroplasty (THA) in the first 90 days of the measurement period or the last 270 days in the year prior to the measurement period and an encounter during the measurement period. Measure Population: Patients must meet the following criteria to be counted in the numerator: 1. A patient reported functional status assessment (i.e., VR‐12, PROMIS‐10‐Global Health, HOOS) completed in the 3 months prior to or including the day of surgery 2. A patient reported functional status assessment (i.e., VR‐12, PROMIS‐10‐Global Health, HOOS) completed during the 6‐9 months after surgery 3. DO NOT have an acute fracture of hip or lower limb at the time of THA 4. DO NOT have severe cognitive impairment For a functional status assessment to be completed, the score must be documented in the EHR","None","Measuring functional status for patient undergoing total hip replacement permits longitudinal assessment ‐ from the patient’s perspective ‐ of the impact of surgical intervention on pain, physical function, as well as health‐related quality of life."]
["X3476","Diabetes: Hemoglobin A1c Overtreatment in the Elderly","Percentage of patients 65 years of age and older with diabetes who had hemoglobin A1c < 7.0% during the measurement period.","Process","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients whose most recent A1c level is < 7.0%","Patients 65 years of age and older with diabetes who are on antihyperglycemic medications with a visit during the measurement period","None","There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes isbeneficial. Among non‐older adults, except for long‐term reductions in myocardial infarction and mortality withmetformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms,including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemiain older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemictargets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 –7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a lifeexpectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy"]
["X3283","Closing the Referral Loop ‐ Critical Information Communicated with Request for Referral","Percentage of referrals sent by a referring provider to another provider for which the referring provider sent a CDA‐based Referral Note that included the type of activity requested, reason for referral, preferred timing, problem list, medication list, allergy list, and medical history","Process","National Committee for Quality Assurance","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Referrals for which the referringprovider sent a CDA‐basedReferral Note that included thetype of activity requested, reasonfor referral, preferred timing,problem list, medication list,allergy list, and medical history.","Referrals sent by a referringprovider to another providerduring the measurement period.","None","There is evidence that the communication between primary care physicians and specialists is inadequate. Thismeasure intends to improve the communication between primary and specialty care and enhance care continuity."]
["X3485","Adverse Drug Events ‐ Minimum INR Monitoring for Patients with Atrial Fibrillation on Warfarin","Percentage of patients aged 18 and older with atrial fibrillation/flutter who are on chronic warfarin therapy and received minimum appropriate International Normalized Ratio (INR) monitoring","Process","Office of the National Coordinator for Health Information Technology","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients who had at least 1 INR ineach 90‐day interval of themeasurement period duringwhich they are on warfarintherapy","Patients aged 18 and older withatrial fibrillation or atrial flutterwho had been on chronic warfarintherapy for at least 180 daysbefore the start of themeasurement period. Patientsshould have at least oneoutpatient visit during themeasurement period.","Patients on any of the followingmedications at any point during themeasurement year: dabigatran,rivaroxaban, apixaban","Millions of patients in the United States use warfarin to prevent strokes or to prevent or treat venousthromboembolism. Warfarin is highly effective, and has been in clinical use for over 50 years (Rose 2009a).However, warfarin is difficult to manage because it has many possible interactions with diet, variability inmetabolism, other drugs, and comorbid conditions that may destabilize anticoagulation control (Rose 2009b). Thepossible consequences of insufficient or excessive anticoagulation are extremely serious and often fatal, making itimperative to pursue good control (White 2007). The international normalized ratio (INR) test is the laboratory testused to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin Kantagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3, which roughly corresponds to the blood taking 2 to 3 times as long to clot as would a normal person's blood. This level of anticoagulation has been shown to maximize benefit (i.e., protect patients from blood clots) while minimizing risk (i.e., risk of hemorrhage attributable to excessive anticoagulation) (Holbrook 2012). Time in therapeutic INR range (TTR) is a way of summarizing INR control over time (Phillips 2008). The 2012 ACCP anticoagulation clinical practice guidelines recommend a routine INR testing frequency of up to 12 weeks for patients on stable warfarin dosing (Holbrook 2012). Therefore, all patients who are on chronic warfarin should have at least 4 INR tests during a 12‐month period or at least 1 INR test during each 12‐week period of a measurement year. Any patient that does not have at least one INR test result in each 12‐week period while on chronic warfarin therapy is not undergoing minimum appropriate monitoring. Antithrombotic therapy for atrial fibrillation (AF) is evolving rapidly because of the development of new oral anticoagulants that do not require INR monitoring. Included in this new group of drugs are direct thrombin inhibitors (e.g., dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban).” (You 2012) The 2012 ACCP anticoagulation clinical practice guidelines state that patients on the newer oral anticoagulant dabigatran do not require routine INR monitoring. Dabigatran and medications such as rivaroxaban and apixabanmay be used in place of warfarin for some patients requiring chronic anticoagulation."]
["X3300","HIV Screening of STI patients","Percentage of patients diagnosed with an acute STI who were tested for HIV","Process","Centers for Disease Control and Prevention","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients with an HIV test duringperiod extending from 30 daysbefore STI diagnosis to 120 daysafter STI diagnosis","Patients diagnosed with an acuteSTI during the one year periodending 120 days prior to the endof the measurement year. STIsinclude: primary and secondarysyphilis, gonorrhea, chlamydia, &trichomonas.","Patients diagnosed with HIV/AIDS on orbefore the date of STI diagnosis","Persons with STIs are a subgroup of the population at increased risk for HIV. CDC recommends HIV testing ofpersons seeking evaluation for STI during each visit for a new STI complaint. The USPSTF includes persons with STIsamong those high risk persons who require more frequent testing than the one time testing recommended for thegeneral population (rated “A”). The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S.Preventive Services Task Force Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement.Annals Internal Medicine 2013. Published at www.annals.org (accessed July 1, 2013) This recommendation extendsthe earlier recommendation for testing of persons at increased risk for HIV, including persons being treated for STDs(U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. American Family Physician2005; 72:2287‐2292.), and reiterates the need for more frequent testing of persons at increased risk, includingpersons who have acquired STIs or request testing for STI."]
["X3299","HIV: Ever screened for HIV","Percentage of persons 15‐65 ever screened for HIV","Process","Centers for Disease Control and Prevention","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value-Based Payment Modifier","Patients with documentation ofan HIV test, including all personswith evidence of HIV/AIDS","Patients age 15‐65 with at leastone outpatient visit during theone year measurement period.","None","Increasing the number of HIV‐infected persons who are aware of their serostatus is an important component of theNational HIV/AIDS Strategy. Once diagnosed, persons with HIV can receive treatment that reduces risk forprogression to AIDS or death, and that substantially decreases risk for transmission to uninfected partners. TheUSPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years (Rated A).The evidence is summarized in: Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task ForceScreening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals Internal Medicine 2013.Published at www.annals.org (accessed July 1, 2013)"]
["X3773","Optimal Asthma Care 2014","Composite (“optimal” care) measure of the percentage of pediatric and adult patients who have asthma and meet specified targets to control their asthma.","Outcome","MN Community Measurement","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, PhysicianValue‐Based Payment Modifier","The number of asthma patientswho meet ALL of the followingtargets:A) Asthma well‐controlled (takethe most recent asthma controltool available during themeasurement period(07/01/2013 to 06/30/2014)):∙ Patient has an Asthma ControlTest (ACT) score of 20 or above(taken from most recent AsthmaControl Test on file) – for patients12 and olderOR∙ Patient has a Childhood AsthmaControl Test (C‐ACT) score of 20or above (taken from most recentC‐ACT on file) – for patients 11and youngerOR∙ Patient has an Asthma ControlQuestionnaire (ACQ) score of0.75 or lower (taken from mostrecent ACQ on file) – for patients17 and olderOR∙ Patient has an Asthma TherapyAssessment Questionnaire(ATAQ) score of 0 (taken frommost recent ATAQ) – for children,adolescents, and adults.B) Patient not at elevated risk of exacerbation: ∙ Patient reports values for both of the following questions (asked/documented within the measurement period): o Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months AND o Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months. ∙ The total number of emergency department visits and hospitalizations due to asthma must be less than 2. C) Patient has been educated about his or her asthma and self‐management of the condition and also has a written asthma management plan present (created or reviewed and revised within the measurement period (07/01/2013 to 06/30/2014)): Patient has a written asthma management plan in the chart with the following documented: o Plan contains information on medication doses and purposes of these medications. o Plan contains information on how to recognize and what to do during an exacerbation. o Plan contains information on the patient’s triggers.","Established patient who meetseach of the following criteria isincluded in the population:∙ Patient was age 5 to 50 at thestart of the measurement period(date of birth was on or between07/01/1963 to 07/01/2008).o Age 5‐17 at the start of themeasurement period (date ofbirth was on or between07/01/1996 to 07/01/2008).o Age 18‐50 at the start of themeasurement period (date ofbirth was one or between07/01/1963 to 06/30/1996).∙ Patient was seen by an eligibleprovider in an eligible specialtyface‐to‐face at least two timesduring the last two measurementperiods (07/01/2012 to06/30/2014) with visits codedwith an asthma ICD‐9 code (in anyposition, not only primary). Usethis date of service range whenquerying the practicemanagement or EMR system toallow a count of the visits withinthe measurement period.∙ Patient was seen by an eligibleprovider in an eligible specialtyface‐to‐face at least one timeduring the measurement period (07/01/2013 to 06/30/2014) for any reason. This may or may not include one of the face‐to‐face asthma visits. ∙ Diagnosis of Asthma; ICD‐9 diagnosis codes include: 493.00493.12, 493.81, 493.82‐493.92.","Patient was a permanent nursing homeresident during the measurement period.∙ Patient was in hospice at any timeduring the measurement period.∙ Patient died prior to the end of themeasurement period.∙ Documentation that diagnosis wascoded in error.∙ Patients with any of the followingdiagnoses (see Table 2):o Cystic fibrosis (ICD‐9 diagnosis codes277.00‐277.09).o COPD (ICD‐9 diagnosis codes 491.20‐491.22, 493.20‐493.22, 496, 506.4). oEmphysema (ICD‐9 diagnosis codes492.0, 492.8, 518.1, 518.2).o Acute respiratory failure (ICD‐9diagnosis codes 518.81).","Evidence: In 2009, current asthma prevalence was 8.2% of the U.S. population (24.6 million people); withinpopulation subgroups it was higher among females, children, persons of non‐Hispanic black and Puerto Rican raceor ethnicity, persons with family income below the poverty level, and those residing in the Northeast and Midwestregions. In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to theirasthma. In 2007, there were 1.75 million asthma‐related emergency department visits and 456,000 asthmahospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, amongchildren than adults, and among black than white persons. Despite the high burden from adverse impacts, use ofsome asthma management strategies based on clinical guidelines for the treatment of asthma remained below thetargets set by the Healthy People 2010 initiative. It is up to providers to assess patients, prescribe medications,educate about self‐management, help patients identify and mitigate triggers so patients can prevent theirexacerbations."]
["X3768","Primary C‐Section Rate 2014","A measure of the percentage of cesarean deliveries for nulliparous births.","Outcome","MN Community Measurement","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, PhysicianValue‐Based Payment Modifier","The number of live, singleton,vertex position, term (greater orequal to 37 weeks gestation)newborns who were delivered viacesarean section.When no prenatal care isprovided by the medicalgroup/clinic, the C‐sectiondelivery is not included in thenumerator calculation for the C‐section rate. (","Patients who meet each of thefollowing criteria is included in themeasure denominator:∙ Female patient was nulliparousand of any age.∙ Patient had a single liveborndelivery.∙ Patient had vertex positiondelivery of a term (greater orequal to 37 weeks gestation) babyvia a vaginal or cesarean birth.∙ Patient had at least one prenatalcare visit with an eligible providerin an eligible specialty in themedical group prior to the onsetof labor.Patient was delivered by aneligible provider in an eligiblespecialty who had a delivery dateduring the measurement period(07/01/2013 to 06/30/2014).","Patient had pregnancy with multiplegestations; Patient had pregnancy with astillborn; patient had delivery with a non‐vertex fetal position","The growing support for the claim that provider‐dependent indications are contributing to the overall increaseamong cesareans can be seen from the results of two recent studies examining the drivers for the increase incesarean deliveries. Barber et al. (2011) at Yale analyzed primary and repeat cesareans from 2003 to 2009. Amongprimary cesarean deliveries, more subjective indications (non‐reassuring fetal status and arrest of dilation)contributed larger proportions than more objective indications (malpresentation, maternal‐fetal, and obstetricconditions). Similarly, Getahun et al. (2009) examined the causes for the rise in cesarean deliveries among differentracial and ethnic groups in Kaiser Permanente Southern California over the last 17 years. Their findings were similarto those from Yale. In a retrospective cohort study conducted by Ehrenthal et al. (2010), labor induction wasassociated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. This wasmore pronounced among a low‐risk group of women without major complications. Beyond the medical burden tomothers and babies, the financial burden on payers is large: facility charges for cesarean are nearly twice that forvaginal delivery ($24,700 vs. $14,500). In California alone, the additional heath care costs to the system areconservatively estimated to be over $300 million annually (Main et al., 2011) The most frequent causes of severematernal morbidity are obstetric hemorrhage (bleeding) and uterine infection. These are significantly more commonwith cesarean surgery and also represent the two leading causes of hospital readmission in the first 30 days post‐delivery. A recent CDC analysis showed that the rate of severe obstetric hemorrhage has significantly increased (by50%) over the last 15 years in the U.S. There has also been a 270% increase in blood transfusions, with bothhemorrhage and transfusions correlated to the rise in cesarean deliveries. Infection is the most common seriouscomplication of cesarean delivery with typical rates of 3 to 9% (Kuklina et al., 2009). The American College ofObstetrics and Gynecology (ACOG) report, “Evaluation of Cesarean Delivery,” recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. Furthermore, the report identified a target of 15.5% for NTSV births, one recommended by the National Center for Health Statistics. Although the ACOG target rate was directed at the NTSV cesarean delivery rate, the recommendation has been widely misread as recommending a 15.5% total cesarean delivery rate (ACOG,2000)."]
["E0076","Optimal Vascular Care","Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all‐or‐none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco‐free status, and daily aspirin use","Outcome","MN Community Measurement","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare,Physician Feedback/Quality and Resource Utilization Reports, PhysicianValue‐Based Payment Modifier","Patients ages 18 to 75 withischemic vascular disease (IVD)who meet all of the followingtargets from the most recent visitduring the measurement period:Blood Pressure less than 140/90,Tobacco‐Free Status, Daily Aspirin Use (unless contraindicated). Values are collected as the most recent during the measurement period (January 1 through December 31).","Patients ages 18 to 75 withischemic vascular disease whohave at least two visits for thiscondition over the last twomeasurement periods and at leastone visit in the last measurementperiod.","Valid exclusions include patients who haddied during the measurement period,patients in hospice during themeasurement period, patients who werepermanent nursing home residentsduring the measurement period, orpatients who were coded with IVD in error.","According to the MN Department of Health, vascular disease is a high impact clinical condition in Minnesota. Morethan 20% of all deaths in Minnesota are due to heart disease and more than 6% are due to stroke, making them thesecond and third leading causes of death, respectively, in the state behind cancer. Inpatient hospitalization chargesalone in Minnesota were more than $1.85 billion for heart disease patients and $362 million for stroke patients in2008. Risk factors reported by Minnesotans include 34% high blood cholesterol, 22% high blood pressure, 16.7%cigarette smoke, 6.7% diabetes, 62% overweight, and 16% physical inactivity.1a.4 Citations for Evidence of High Impact: Minnesota Department of Health 2010 Fact Sheets on Heart Disease andStroke in Minnesota; http://www.health.state.mn.us/divs/hpcd/chp/cvh/Data.htm"]
["X3469","Cognitive Impairment Assessment Among At‐Risk Older Adults","Percentage of patients age 80 years or older at the start of the measurement period with documentation in the electronic health record at least once during the measurement period of (1) results from a standardized cognitive impairment assessment tool or (2) a patient or informant interview.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with results from astandardized cognitiveimpairment assessment tool, or apatient or informant interviewdocumented in the electronichealth record (EHR) at least onceduring the measurement period.","Patients age 80 or older with avisit during the measurementperiod.","Patients diagnosed with cognitiveimpairment or dementia before the startof the measurement period and whosediagnosis remained active throughout themeasurement period.","Alzheimer’s disease is a leading cause of death for those over age 65. Age is the strongest and best documentedcorrelate of cognitive impairment. The financial burden of cognitive impairment is sizable, conservatively costing anestimated $157 to $215 billion annually in institutional and home‐based long‐term care, health care expenses, andunfunded caregiver time. Clinical guidelines emphasize that adequate patient assessment is the critical first step forappropriate identification of cognitive impairment. Adequate patient assessment and diagnosis of cognitiveimpairment enables effective management of the condition, including interventions to maximize patient safety andplan for future care."]
["X3053","Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis","Percentage of patients 18 years of age and older with a diagnosis of hip or knee osteoarthritis for whom a score from one of a select list of validated pain interference assessment tools was recorded at least twice during the measurement period and for whom a care goal was documented and linked to the initial assessment.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients for whom a score fromone of a select list of paininterference assessment toolswas recorded at least twiceduring the measurement periodand for whom a care goal wasdocumented and linked to theinitial assessment","Patients 18 years of age and olderwith a diagnosis of hip or kneeosteoarthritis and an encounterduring the measurement periodwho have their first encounterwithin the first 335 days of themeasurement period","None","Chronic pain affects approximately 116 million adults and costs between $560‐$635 billion in healthcare expenses,lost productivity, and other costs. Functional status assessments and goal setting could improve patient engagementand aid providers in managing pain. Goal‐setting addresses patient engagement, one of the primary objectives ofCMS and the National Quality Strategy. Only 4 of the 64 (6.25%) measures in the 2014 EHR Incentive Programs forEligible Professionals (encompassing both Meaningful Use 1 and Meaningful Use 2 measures) address patientengagement."]
["X3466","Coordinating Care ‐ Emergency Department Referrals","Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission), whose emergency department provider attempted to communicate with the patient's primary care provider or their specialist about the patient's visit to the emergency department.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients whose ED visit providercommunicated informationabout the visit to their primarycare provider or a specialistprovider by making a telephonecall or scheduling a follow upappointment with an ambulatorycare provider during the visit, ortransmission of electronicnotification or transmission of the visit record within 24 hours of the visit.","Patients (1) of any age withasthma, or (2) age 18 and overwith chest pain, who had a visit tothe emergency department (notresulting in an inpatientadmission)","None","There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use isinadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow‐up(Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who sought emergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al.2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events."]
["X3465","Coordinating Care ‐ Follow‐Up with Eligible Provider","Percentage of patients (1) of any age with asthma or (2) ages 18 and over with chest pain who had a visit to the emergency department (not resulting in an inpatient admission) and had a follow‐up visit or contact with their primary care provider or relevant specialist or the provider’s designee within 72 hours of the visit to the emergency department.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who were contacted bytelephone by their primary careprovider, relevant specialist, ortheir designee, or had a follow upoffice visit with their primary careprovider, relevant specialist, ortheir designee within 72 hours ofthe visit to the emergencydepartment.","Patients (1) of any age withasthma, or (2) age 18 and overwith chest pain, who had a visit tothe emergency department (notresulting in an inpatientadmission), and whose emergencydepartment providercommunicated information aboutthe visit to the primary careprovider or relevant specialistthrough: a telephone call,transmission of electronicnotification, or transmission of thevisit record.","None","There is evidence that the communication between EDs and primary care physicians surrounding patients' ED use isinadequate. Studies suggest that among adults who have had an ED visit, 46 to 71% miss recommended follow‐up(Barlas et al. 1999; Ritchie et al. 2000, Baren et al. 2001) while another study found 43% of patients who soughtemergency care had no record or acknowledgement of the ED visit in their primary care medical record (Vinker et al.2004). Poor care coordination is associated with patient readmissions, medication errors, and adverse drug events."]
["X3468","Documentation of a Health Care Proxy for Patients with Cognitive Impairment","The percentage of patients with a diagnosis of dementia or a positive result on a standardized tool for assessment of cognitive impairment, with documentation of a designated health care proxy during the measurement period.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients for whomdocumentation of a designatedhealth care proxy in the medicalrecord has been confirmedduring the measurement period.","All patients with (1) a positiveresult on a standardizedassessment for cognitiveimpairment or (2) a diagnosis ofdementia or cognitive impairment,regardless of age, prior to thestart of the measurement period.","None","Establishment of a health care proxy helps to ensure that the patient’s health care preferences are communicated,protects the patient from making decisions that they may not understand and provides the practitioner aresponsible party with whom to discuss the risks and benefits of care management or planning options.Given that cognitive impairment has significant downstream implications for patient safety and quality of life,measures that encourage patients to take steps that facilitate management and planning of care—includingdesignation of a health care proxy—could accrue significant benefits to patients. This measure specifically evaluateswhether persons with cognitive impairment, including mild cognitive impairment, have documentation of a healthcare proxy to ensure the provision of future care that is consistent with the wishes of the patient. Studies havefound a decline in the ability to consent to medical treatment or decision making as cognitive impairmentprogresses, suggesting potential constraints to patient preferences if they are unable to communicate decisionsrelevant to their care. Therefore, naming a health care proxy can maximize agreement between patient wishes andactual care, and lead to improved autonomy over health care decisions made in the advanced stages of cognitiveimpairment (including—but not limited to—decisions regarding specific care and navigation of the health systemoverall) and facilitate decision making that reduces aggressive treatments the patient may not want."]
["X3729","Statin Therapy for the Prevention and Treatment of Cardiovascular Disease","Percentage of high‐risk adult patients aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged ≥21 years with any fasting or direct Low‐Density Lipoprotein Cholesterol (LDL‐C) level ≥ 190 mg/dL; OR patients aged 40‐ 75 years with a diagnosis of diabetes with a fasting or direct LDL‐C level of 70‐189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who are current statinmedication therapy users or whoreceive an order (prescription) toreceive statin medication therapy","\"Denominator 1: Patients aged ≥21 years at the beginning of themeasurement period with clinicalASCVD diagnosisDenominator 2: Patients aged ≥ 21years at the beginning of themeasurement period with anyfasting or direct laboratory result of LDL‐C ≥ 190 mg/dL Denominator 3: Patients aged 40 through 75 years at the beginning of the measurement period with Type 1 or Type 2 Diabetes with the highest fasting or direct laboratory test result of LDL‐C 70 – 189 mg/dL in the measurement year or two years prior to the beginning of the measurement period\"","Exclusions: NoneExceptions:• Patients with adverse effect, allergy orintolerance to statin medication therapy• Patient who have an active diagnosis ofpregnancy or breastfeeding• Patients who are receiving palliativecare • Patients with active liver disease or hepatic disease or insufficiency • Patients with End Stage Renal Disease (ESRD) • Fasting or Direct LDL‐C laboratory test result of < 70 mg/dL for Diabetes diagnosis who are not currently receiving statin medication therapy\"","Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk for all adults aged>=21 years is essential to not only prevent ASCVD but also to reduce ASCVD events for those individuals with acurrent diagnosis. The new guidelines: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to ReduceAtherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines” published in Circulation in November, 2013, focuses on those mostlikely to benefit from evidence‐based statin medication therapy to reduce ASCVD risk. LDL‐C treatment goals ortargets are not the focus of treatment as in the past."]
["S2521","Gout: Serum Urate Monitoring","Percentage of patients aged 18 and older with a diagnosis of gout who were either started on urate lowering therapy (ULT) or whose dose of ULT was changed in the year prior to the measurement period, and who had their serum urate level measured within 6 months","Process","American College of Rheumatology","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients whose serum urate levelwas measured within six monthsafter initiating ULT or afterchanging the dose of ULT","Adult patients aged 18 and olderwith a diagnosis of gout who wereeither started on urate loweringtherapy (ULT) or whose dose ofULT was changed in the year priorto the measurement period","None","The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: SystematicNonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patients with indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C of gout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceous deposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut‐off was used to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds to changes in urate lowering therapy within 14‐days. The Guidelines recommends dose titration every 2‐5 weeks.Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C."]
["S2550","Gout: Urate Lowering Therapy","Percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level > 6.0 mg/dL, who are prescribed urate lowering therapy (ULT)","Process","American College of Rheumatology","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients who areprescribed urate loweringtherapy.","Adult patients aged 18 and olderwith a diagnosis of gout and aserum urate level > 6.0 mg/dL whohave at least one of the following:presence of tophus/tophi or twoor more gout flares (attacks) in thepast year","None","The 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: SystematicNonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia recommend that all gout patientswith indications for ULT should have their serum urate lowered to 6 mg/dl. Serum urate is the hemoglobin A1C ofgout. Lower levels of serum urate are associated with less frequent gout attacks and reduction of tophaceousdeposits. Based on feedback from public comment and expert panel, the less stringent level of 6.8 mg/dl cut‐off wasused to evaluate quality of care. 6.8 mg/dl is the solubility concentration of urate crystals. Serum urate responds tochanges in urate lowering therapy within 14‐days. The Guidelines recommends dose titration every 2‐5 weeks.Twelve months was selected as sufficient time to achieve serum urate target, evidence Level C."]
["E0555","INR Monitoring for Individuals on Warfarin (e‐ specified version of NQF #0555)","Percentage of individuals at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56‐day interval with warfarin.","Process","Centers for Medicare & Medicaid Services","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Individuals in the denominatorwho have at least one INRmonitoring test during each 56‐day interval with warfarin.","Individuals at least 18 years of ageas of the beginning of themeasurement period withwarfarin therapy for at least 56days and have at least oneoutpatient visit during themeasurement period.","Individuals who are monitoring INR athome","The measure focuses on International Normalized Ratio (INR) monitoring for individuals on warfarin. Warfarin is avitamin K antagonist and inhibits the production of clotting factors. It is prescribed to prevent “furtherthromboembolism in patients with atrial fibrillation, after mechanical heart valve replacement, and following deepvein thrombosis or pulmonary embolism” (Dharmarajan, Gupta, Baig, & Norkus, 2011). Warfarin has a narrowtherapeutic range and therefore, requires regular monitoring with the INR test and dose adjustment for the patientto stay within the therapeutic range and avoid thromboembolism or bleeding complications. Since its approval bythe Food and Drug Administration in 1954, warfarin has been used as an oral anticoagulant in clinical practice (Foodand Drug Administration, 2011). It continues to be widely prescribed, with about 33 million prescriptions issued inthe United States during 2011 (Pierson, 2012). Several important benefits related to quality improvement areenvisioned with the implementation of this measure. Specifically, the measure will help providers identifyindividuals on warfarin who do not have regular INR tests and will encourage providers to conduct appropriate INRtesting for those patients. More regular INR monitoring should increase time in the therapeutic range (TTR) andtherefore, would be expected to result in fewer thromboembolic and bleeding events and lower mortality.Recently published evidence from a large (n=56,490) well‐designed study suggests that patients with two or moregaps of at least 56 days are associated with an average Time in Therapeutic Range (TTR) that is 10% lower (p<0.001)than patients without gaps (Rose et al., 2013). Clinical practice guidelines suggest a range of 4 weeks (Anderson etal., 2013) up to a maximum of 12 weeks (Guyatt et al, 2012) for INR monitoring depending on the indication, stability of patient dosing, and the guideline used. Eight weeks (i.e., 56 days) is the mid‐point between these guidelines. The measure is supported by recommendations in the following clinical practice guidelines:•\tHolbrook et al. (2012). Evidence‐based management of anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines (page e153S):3.1 Monitoring Frequency for Vitamin K Antagonists (VKAs)3.1.\tFor patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B).•\tAnderson et al. (2013). Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (page 1918):1.\tManagement1.1.\tPharmacological and Nonpharmacological Therapeutic Options1.1.2. Preventing Thromboembolism5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable.(Class I; Level of Evidence: A)"]
["X3472","Use of Multiple Concurrent Antipsychotics in Children and Adolescents","The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.","Process","National Committee for Quality Assurance","Medicare and Medicaid HER Incentive Programs for Eligible Professionals,Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Children and adolescents on twoor more concurrent antipsychoticmedications for greater than orequal to 90 days during themeasurement year.","Children and adolescents 1‐17years of age with a visit during themeasurement year, with greaterthan or equal to 90 days ofcontinuous antipsychoticmedication treatment during themeasurement year.","None","Although there is little empirical evidence to support its use, the use of multiple concurrent antipsychotics isbecoming an increasingly frequent practice in the mental health treatment of youth. One study of a large stateMedicaid fee‐for‐service program found that 7 percent of children age 6‐17 on any antipsychotic were prescribedtwo or more antipsychotics for longer than 60 days (Constantine et al., 2010). As of September 1, 2011, 4.1 percentof youth under age 18 in the New York State Medicaid behavioral health population on any antipsychotic were ontwo or more antipsychotics for longer than 90 days. Risks of multiple concurrent antipsychotics in comparison tomonotherapy have not been systematically investigated; existing evidence appears largely in case reports, andincludes increased risk of serious drug interactions, delirium, serious behavioral changes, cardiac arrhythmias, anddeath (Safer, Zito, & DosReis, 2003). None of the 10 AACAP practice parameters recommended concurrent use ofmultiple antipsychotic medications. The AACAP Practice Parameters for the Use of Atypical AntipsychoticMedications in Children and Adolescents states, “the use of multiple AAAs [atypical antipsychotics] has not beenstudied rigorously and generally should be avoided.” The Texas Psychotropic Medication Utilization Parameters forFoster Children includes “two or more concomitant antipsychotic medications” as a situation that “suggests theneed for additional review of a patient’s clinical status.”Constantine RJ, Boaz T, Tandon R. (2010). Antipsychotic polypharmacy in the treatment of children and adolescents in the fee‐for‐service component of a large state Medicaid program. Clinical therapeutics, 32, 949‐959.Safer, D.J., J.M. Zito, and S. DosReis, Concomitant psychotropic medication for youths. Am J Psychiatry, 2003. 160(3):p. 438‐49.AACAP Practice Parameters for the Use of Atypical Antipsychotic Medications in Children and Adolescents2010 Texas Psychotropic Medication Utilization Parameters for Foster Children."]
["E1553","Blood Pressure Screening by age 18","The percentage of adolescents who turn 18 years of age in the measurement year who had a blood pressure screening with results.","Process","National Committee for Quality Assurance","Medicare and Medicaid HER Incentive Programs for Eligible Professionals,Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Adolescents who haddocumentation in the medicalrecord of blood pressurescreening and whether resultsare abnormal at least once in themeasurement period or the yearprior.","Adolescents with a visit whoturned 18 years old in themeasurement period.","None","High blood pressure (hypertension) is a growing concern for children and adolescents in the U.S. due mostly in partto a rapid increase in childhood obesity (Luma, 2006). A recent study of National Health and Nutrition ExaminationSurvey data showed that, during 2003‐2006, 2.6 percent of boys and 3.4 percent of girls age eight to 17 years hadhigh blood pressure. Moreover, 13.6 percent of boys and 5.7 percent of girls in this age group had pre‐high bloodpressure. Overweight boys and obese boys and girls were significantly more likely to have these classifications(Ostchega Y, 2009). Autopsy reports of children and adolescents who have died unexpectedly have shown a positiveand significant association with systolic and diastolic blood pressure and body mass index (BMI) (Hayman, 2003).Autopsy reports of adults with high levels of cholesterol and coronary heart disease showed that precursors to thesediseases began in childhood (National Cholesterol Education Program). High blood pressure represents a significantfinancial burden, in 2006, the direct and indirect costs of high blood pressure were estimated at $63.5 billion overall(CDC, 2007). In addition to costs, resource utilization is also significantly higher among hypertensive people.Prescription medicines, inpatient visits, and outpatient visits constitute more than 90 percent of the overallincremental cost of treating hypertension (Balu, 2005). These costs can be expected to rise with increasingprevalence among children."]
["X3817","Amblyopia Screening in Children","The percentage of children who were screened for the presence of amblyopia at least once by their 6th birthday; and if necessary, were referred appropriately.","Process","Office of the NationalCoordinator for Health Information Technology/Centers for Medicare &Medicaid Services","Medicare and Medicaid HER Incentive Programs for Eligible Professionals,Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Children who were screened todetect the presence of amblyopiabetween their 3rd and 6thbirthdays, and if necessary, werereferred to an eye care specialist.","Children who turn 6 years of ageduring the measurement periodand who had at least one visitduring the measurement period.","None","Vision problems are commonplace among children and adolescents, affecting 25 percent of children five to 17 yearsof age. Problems specific to children include strabismus, color vision defects, refractive error, reduced visual acuityand amblyopia. Amblyopia, also known as lazy eye, affects nearly 500,000 preschoolers and is the primary cause ofpermanent vision loss among children of any age. Early detection, treatment and follow‐up are critical in preventingand managing vision disorders. Undetected vision problems affect up to 10 percent of preschool‐aged children.Fewer than 15 percent of all preschool children receive an eye examination and less than 22 percent of preschoolchildren receive some type of vision screening. Early screening can lead to the detection of amblyopia (2‐5%),strabismus (3‐4%), and significant refractive error (15‐20%), the most prevalent and significant vision disorders ofpreschool children. The USPSTF recommends vision screening for all children at least once between the ages of 3and 5 years, to detect the presence of amblyopia or its risk factors. The AAP recommends that all children who arefound to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologistor an eye care specialist appropriately trained to treat pediatric patients."]
["X3280","ADHD: Symptom Reduction in Follow‐up Period","Percentage of children aged 4 through 18 years, with a diagnosis of Attention Deficit  Hyperactivity Disorder (ADHD), who demonstrated a 25% reduction in symptoms 6‐12 months from baseline as measured using the Vanderbilt ADHD Diagnostic Rating Scale, regardless of treatment prescribed.","Patient\nReported\nOutcome","Office of the NationalCoordinator for Health Information Technology/Centers for Medicare &Medicaid Services","Medicare and Medicaid EHR Incentive Programsfor Eligible Professionals, Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Children who demonstrated a25% reduction in the meanresponse for either or both ADHDsymptom screen subsegments 6‐12 months from baselineassessment as measured usingthe Vanderbilt ADHD DiagnosticRating Scale.","Children aged 4 through 18 years,with a visit during themeasurement period, and with anactive diagnosis of ADHD, and whomeet the diagnostic threshold ofthe Vanderbilt ADHD DiagnosticRating Scale at the time ofbaseline assessment, and withbaseline mean responsesdocumented for the ADHDsymptom screen subsegments forthe Vanderbilt ADHD Diagnostic Rating Scale during the 6 months prior to the measurement period.","None","According to the CDC, approximately 9% of children age 4‐17 have ADHD and the rate of ADHD diagnosis hasincreased an average of 5% per year from 2003 to 2007. Evidence exists that shows there is a lack of a standardapproach to ADHD diagnosis and adherence to treatment guidelines. One likely cause of the poor provision of ADHDcare is the logistical issue surrounding collection of ADHD rating scales from parents and teachers. Collection ofrating scales requires knowledge of appropriate ratings scales to use, time to explain the purpose of collecting ratingscales to parents, distribution of rating scales to and from home, coordination of distributing and collecting ratingscales from school, scoring of completed ratings, and, finally, interpretation of results. This comprises a complexdata management process that typically goes un‐ or under‐reimbursed in pediatric settings. Without the collectionof these results, the quality of ADHD care suffers. ADHD Clinical Practice Guideline for the Diagnosis, Evaluation, andTreatment of Attention‐Deficit/Hyperactivity Disorder in Children and Adolescents. AAP 2011. Primary CareClinicians should evaluate children 4 ‐18 years of age for ADHD who present with academic or behavioral problemsand symptoms of inattention, hyperactivity or impulsivity. Evidence continues to be fairly clear with regard to thelegitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish adiagnosis, identify co‐occurring conditions, and treat effectively with both behavioral and pharmacologicinterventions. For pharmacologic treatment, the primary care clinician should titrate doses of medication for ADHDto achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation)ADHD Process‐of‐Care Algorithm, Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition. AAP2011. Continued systematic monitoring (to include reconsideration of the diagnosis if improvements in symptomsare not apparent) is an on‐going process, to be addressed throughout the child’s/adolescent’s care within thepractice. Clinicians should regularly monitor all aspects of ADHD treatment, to include:‐ Systematic reassessment of core symptoms and function;‐ Regular reassessment of target goals;‐ Assurance that the family is satisfied with the care they are receiving from other clinicians and therapists, ifapplicable;‐ Provision of anticipatory guidance, further child/adolescent and family education, and transition planning asneeded and appropriate;‐ Assurance that care coordination is occurring and meeting the needs of the child/adolescent and family;‐ Confirmation of adherence to any prescribed medication regimen, with adjustments made as needed;‐ Heart rate, blood pressure, height, and weight monitoring; and‐ Continuing to form a therapeutic relationship with the child/adolescent andempower families and children/adolescents to be strong, informed advocates."]
["X3513","Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users","Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period","Process","American Medical Association","Medicare and Medicaid EHR Incentive Programs for Eligible Professionals, Medicare Shared Savings","Patients who received screeningfor HCV infection within the 12month reporting periodScreening for HCV infectionincludes: HCV antibody test orHCV RNA test","All patients, regardless of age,who were seen twice for any visitor who had at least onepreventive care visit within the 12month reporting period who areactive injection drug usersActive injection drug users arethose who have injected anydrug(s) within the past 12 months","Exclusions: Patients with a diagnosis ofchronic hepatitis CExceptions: Documentation of medicalreason(s) for not receiving annualscreening for HCV (e.g., advanceddisease, limited life expectancy, othermedical reasons)Documentation of patient reason(s) fornot receiving annual screening for HCV(e.g., patient declined, other patientreasons)","The U.S. Preventive Services Task Force (USPSTF)40 recommends screening for hepatitis C virus (HCV) infection inadults at high risk, including those with any history of intravenous drug use or blood transfusions prior to 1992.Grade B recommendation. Assessment of Risk: Established high‐risk factors for HCV infection include bloodtransfusion prior to 1992 and past or current intravenous drug use. The most important risk factor for HCV infectionis past or current injection drug use. Because of screening programs for donated blood, blood transfusions are nolonger an important source of HCV infection. In contrast, 60% of new HCV infections occur in individuals who reportinjecting drugs within the last 6 months. Other risk factors include chronic hemodialysis, being born to an HCV‐infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneousexposures (e.g., in health care workers, having surgery prior to the implementation of universal precautions).Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. In the UnitedStates, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection, and anestimated 17,000 persons were newly infected in 2010, the most recent year that data are available. With an HCVantibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of allchronic HCV infections among adults in the United States. Although effective treatments are available to clear HCVinfection from the body, most persons with HCV do not know they are infected do not receive needed care (e.g.,education, counseling, and medical monitoring), and are not evaluated for treatment. Since 1998, routine HCVtesting has been recommended by CDC for persons most likely to be infected with HCV. These recommendationswere made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection.HCV testing is the first step toward improving health outcomes for persons infected with HCV. In a recent analysis ofdata from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection‐drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC,unpublished data, 2012). Current risk‐based testing strategies have had limited success, as evidenced by thesubstantial number of HCV‐infected persons who remain unaware of their infection. Of the estimated 2.7–3.9million persons living with HCV infection in the United States, 45%–85% are unaware of their infectionstatus44,45,46,47; this proportion varies by setting, risk level in the population, and site‐specific testing practices.Studies indicate that even among high‐risk populations for whom routine HCV testing is recommended, prevalenceof testing for HCV seromarkers varies from 17%–87%; according to one study, 72% of persons with a history ofinjection‐drug use who are infected with HCV remain unaware of their infection status."]
["E0711","Depression Remission at Six Months","Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ‐9 score greater than nine who achieve remission at six months as demonstrated by a six month (± 30 days) PHQ‐9 score of less than five. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ‐9 score indicates a need for treatment.","Patient\nReported\nOutcome","MN Community Measurement","Medicare Shared Savings","Adults age 18 and older with adiagnosis of major depression ordysthymia and an initial PHQ‐9score greater than nine whoachieve remission at six monthsas demonstrated by a six month(± 30 days) PHQ‐9 score of lessthan five.","Adults age 18 and older; no upperage limitHave the diagnosis of majordepression or dysthymia definedby any of the following ICD‐9codes:296.2x Major depressive disorder,single episode296.3x Major depressive disorder,recurrent episode300.4 Dysthymic disorderANDPHQ‐9 Score is greater than nine.For primary care providers thediagnosis codes can be in anyposition (primary or secondary).For behavioral health providers the diagnosis codes need to be in the primary position. This is to more accurately define major depression and exclude patients who may have other more serious mental health diagnoses (e.g. schizophrenia, psychosis) with a secondary diagnosis of depression.Patients who do not have a six month ± 30 day PHQ‐9 score obtained are included in the denominator for this measure.","Denominator exclusions include death,permanent nursing home resident orreceiving hospice or palliative care anytime during the measurement period.Bipolar Disorder or Personality Disorder(in any position), ICD‐9 Codes include:296.00, 296.01, 296.02, 296.03, 296.04,296.05, 296.06, 296.10, 296.11, 296.12,296.13, 296.14, 296.15, 296.16, 296.40,296.41, 296.42, 296.43, 296.44, 296.45,296.46, 296.50, 296.51, 296.52, 296.53,296.54 , 296.55, 296.56, 296.60, 296.61,296.62, 296.63, 296.64, 296.65, 296.66,296.7, 296.80, 296.81, 296.82, 296.89,301.0, 301.1, 301.10, 301.11, 301.12,301.1 , 301.2, 301.20, 301.21, 301.22,301.3, 301.4, 301.5, 301.50, 301.51, 301.59, 301.6, 301.7, 301.8, 301.81,301.82, 301.83, 301.84, 301.89, 301.9","The Centers for Disease Control and Prevention states that nationally 15.7% of people report being told by a healthcare professional that they had depression at some point in their lifetime. Persons with a current diagnosis ofdepression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily. According to National Institute of Mental Health (NIMH), 6.7 percent of theU.S. population ages 18 and older (14.8 million people) in any given year have a diagnosis of a major depressive disorder. Major depression is the leading cause of disability in the U.S. for ages 15 ‐ 44. Additionally, dysthymiaaccounts for an additional 3.3 million Americans."]
["X3810","Post‐Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)","Percentage of patients who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post‐anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.","Process","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","All age patients who have beencared for by an anesthesiapractitioner and are transferreddirectly from the procedure roomto post‐anesthesia care unit(PACU) for post‐procedure carefor whom a checklist or protocolwhich includes the key transfer ofcare elements is utilized.• All age patients under the careof an anesthesia practitioner AND• Are transferred to anotherpractitioner in a PACU followingcompletion of the anesthetic careAND a transfer of care protocolor handoff tool/checklist thatincludes the required key handoffelements is used. The key handoff elements that must be included in the transition of care include: 1. Identification of patient 2. Identification of responsible practitioner (PACU nurse or advanced practitioner) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issues/concerns. 6. Expectations/Plans for the early post‐procedure period. 7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team","All age patients who are cared forby an anesthesia practitioner andare transferred directly from theprocedure room to the PACU uponcompletion of the anesthetic.• All age patients under the careof an anesthesia practitioner AND• Who are transferred directly tothe PACU at the completion of theanesthetic.• This measure does not includetransfer of care during ananesthetic or to the ICU.","All age patients who have been cared forby an anesthesia practitioner who are notadmitted from the operating roomdirectly to a PACU.","Peri‐procedure transitions of care place patients at risk for incomplete sharing of important information betweenpractitioners. Effective communication between providers at the time of admission to PACU promotes safe care andenhances coordination of care."]
["X3808","Preoperative Use of Aspirin for Patients with Drug‐ Eluting Coronary Stents","Percentage of patients, aged 18 years and older with a pre‐existing drug‐eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to surgical start time","Process","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who receive aspirin 24hours prior to surgical start timeDefinition:Patient reports taking aspirin ORhospital staff administeredaspirinThe foregoing list ofmedications/drug names is basedon clinical guidelines and otherevidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up‐to‐date drug recall and alert information when prescribing medications.","All patients, aged 18 years andolder with a pre‐existing drug‐eluting coronarystent, who undergo a surgical ortherapeutic procedure underanesthesia","Exclusions: NoneExceptions: Documentation of medicalreasons for not receiving aspirin 24 hoursprior to anesthesia start time (e.g., risksof preoperative aspirin therapy aregreater than the risks of withholdingaspirin, other medical reasons)","Late stent thrombosis is a relatively rare but serious complication of stent placement, with an estimated case fatalityrate of up to 45%. Multiple studies have shown that premature discontinuation of dual antiplatelet therapy isassociated with increased risk of stent thrombosis in patients with drug‐eluting stents. Late stent thrombosis, orthrombosis >1 year after stent placement, is of particular concern for drug‐eluting stents. This concern indicates aneed for a longer course of dual antiplatelet therapy for patients with drug‐eluting stents compared to those withbare metal stents."]
["X3811","Anesthesiology Smoking Abstinence","The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.","Intermediate\nOutcome","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients as defined in theDenominator who are identifiedas current cigarette smokers andwho abstained from smokingprior to anesthesia on the day ofsurgery or procedure. Abstinencemay be defined by either patientself‐report or an exhaled carbonmonoxide level of < 10 ppm.Numerator Includes:Patients 18 and olderANDAre evaluated in preparation forelective surgical, diagnostic, orpain procedure in settings thatinclude routine screening forsmoking status with instructionto abstain from smoking on theday of surgery or procedureAND Are identified as current cigarette smokers AND Abstained from smoking prior to anesthesia on the day of surgery or procedure","All patients aged 18 years andolder who are evaluated inpreparation for elective surgical,diagnostic, or pain procedure insettings that include routinescreening for smoking status withinstruction to abstain fromsmoking on the day of surgery orprocedure.Denominator Includes:Patients 18 and olderANDAre evaluated in preparation forelective surgical, diagnostic, orpain procedure in settings thatinclude routine screening forsmoking status with instruction toabstain from smoking on the dayof surgery or procedureAND Are identified as current cigarette smokers","Non‐elective emergent surgery","Each year, millions of cigarette smokers require surgery and anesthesia in the US. Smoking is a significantindependent risk factor for perioperative heart, lung, and wound‐related complications. There now is good evidencethat perioperative abstinence from smoking reduces the risk of heart, lung, and wound‐related perioperativecomplications, and that the perioperative period represents a “teachable moment” for smoking cessation thatimproves long‐term abstinence rates; over 100,000 smokers quit in the US each year as a result of having a surgicalprocedure. Although evidence suggests that the longer the duration of abstinence the better, there is also evidencethat even brief abstinence (e.g., abstaining from smoking on the morning of surgery) can dramatically reduce bothnicotine and carbon monoxide levels and reduce risks for complications such as intraoperative myocardial ischemia.Evidence shows that tobacco interventions can 1) increase perioperative abstinence rates in surgical patients whosmoke and 2) decrease the rate of perioperative complications. Thus, this measure, which incents the provision oftobacco interventions by clinicians as a part of routine clinical practice, will significantly improve the health ofsmokers who require surgery. In its Clinical Practice Guideline for Treating Tobacco Use and Dependence, the US Public Health Services recognizes the important role that clinicians play in delivering tobacco use intervention services, strongly recommending that clinicians screen all adults for tobacco use and provide tobacco cessationinterventions for those who use tobacco products."]
["X3809","Perioperative Temperature Management","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 recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time","Outcome","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients for whom at least onebody temperature greater thanor equal to 35.5 degrees Celsius(or 95.9 degrees Fahrenheit) wasrecorded within the 30 minutesimmediately before or the 15minutes immediately afteranesthesia end time","All patients, regardless of age,who undergo surgical ortherapeutic procedures undergeneral or neuraxial anesthesia of60 minutes duration or longer","Exclusions: Patients undergoing:Cardiopulmonary bypass: 00561, 00562,00563, 00566, 00567, 00580Regional nerve block: 01958, 01960,01967, 01991, 01992Monitored anesthesia care: any CPTcode with ‐QS modifierExceptions: Documentation of one of thefollowing medical reason(s) for notachieving at least one body temperaturegreater than or equal to 35.5 degreesCelsius or 95.9 degrees Fahrenheit withinthe 30 minutes immediately before orthe 15 minutes immediately afteranesthesia end timeEmergency casesIntentional hypothermia","A drop in core temperature during surgery, known as perioperative hypothermia, can result in numerous adverseeffects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence ofsurgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical effectsdue to perioperative hypothermia, is affected by maintenance of normothermia during surgery."]
["X3806","Prevention of Post‐ Operative Nausea and Vomiting (PONV) – Combination","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 or intraoperatively","Process","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who receivecombination therapy consistingof at least two prophylacticpharmacologic anti‐emeticagents of different classespreoperatively orintraoperativelyDefinition: The recommended first‐ and second‐line classes of pharmacologic anti‐emetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to):• 5‐hydroxytryptamine (5‐HT3) receptor antagonists• dexamethasone• phenothiazine• phenylethylamines• butyrophenones• antihistamines• anticholinergics The foregoing list ofmedications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up‐to‐date drug recall and alert informationwhen prescribing medications.","All patients, aged 18 years andolder, who undergo a procedureunder aninhalational general anesthetic,AND who have three or more riskfactors forPONVDefinition: Risk factors for PONV are: 1. female gender, 2. history of PONV or a history of motion sickness, 3. non‐smoker, and 4. intended administration of opioids for post‐operative analgesia Any procedure including surgical, therapeutic or diagnostic This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post‐operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.","Exclusions: NoneExceptions: Documentation of medicalreason(s) for not administeringcombination therapy of at least twoprophylactic pharmacologic anti‐emeticagents of different classes (e.g.,intolerance or other medical reason)","Postoperative nausea and vomiting (PONV) is an important patient‐centered outcome of anesthesia care. PONV ishighly dis‐satisfying to patients, although rarely life‐threatening. A large body of scientific literature has defined riskfactors for PONV, demonstrated effective prophylactic regimes based on these risk factors, and demonstrated highvariability in this outcome across individual centers and providers. Further, a number of papers have shown thatperformance can be assessed at the level of individual providers ‐‐ the outcome is common enough that sufficientpower exists to assess variability and improvement at this level."]
["X3807","Post‐Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)","Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member","Process","American Society of Anesthesiologists","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who have a documenteduse of a checklist or protocol forthe transfer of care from theresponsible anesthesia practitioner to the responsibleICU team or team memberDefinition: The key handoffelements that must be includedin the transfer ofcare protocol or checklist include:1.\tIdentification of patient, key family member(s) or patient surrogate2.\tIdentification of responsible practitioner (primary service)3.\tDiscussion of pertinent medical history4.\tDiscussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)5.\tIntraoperative anesthetic management and issue/concerns to includethings such as airway, hemodynamic, narcotic, sedation level andparalytic management and intravenous fluids/blood products and urineoutput during the procedure6.\tExpectations/Plans for the early post‐procedure period to include thingssuch as the anticipated course (anticipatory guidance),complications, need for laboratory or ECG and medication administration7. Opportunity for questions and acknowledgement of understanding ofreport from the receiving ICUteam","All patients, regardless of age,who undergo a procedure underanesthesia and are admitted to anICU directly from the anesthetizing locationAny procedure including surgical,therapeutic or diagnostic","None","A uniform transfer of care protocol or handoff tool/checklist that is utilized for all patients directly admitted to theICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effectivecommunications between the medical practitioner who provided anesthesia during the procedure and the carepractitioner in the ICU who is responsible for post‐procedural care. This should minimize errors and oversights inmedical care of ICU patients after procedures. Hand‐offs of care are a vulnerable moment for patient safety, butrequired in any 24/7 healthcare system. Anesthesia providers routinely transfer critically ill patients from the OR tothe ICU, and are responsible for transmitting knowledge about patient history, a summary of intraoperative events,and future plans for hemodynamic and pain management to the ICU team. Evidence demonstrates that this processcan be facilitated by use of a checklist that motivates completion of all key components of the transfer. This is anemerging best practice in anesthesia care."]
["X3789","Patient Counseled About Health Care Decision‐Making","All patients with a diagnosis of a muscular dystrophy (MD), or their caregivers who were counseled about advanced health care decision making, palliative care, or end‐of‐life issues at least once annually.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients or caregivers who werecounseled about advanced healthcare decision‐making, palliativecare, or end‐of‐life issues at leastonce annually.","All patients with a diagnosis of amuscular dystrophy.","Exceptions: Medical exception for notcounseling about advanced health caredecision making, palliative care or end‐of‐life issues (i.e., patient is unable tocommunicate and caregiver is notavailable; not indicated because of earlystage of disease without any comorbidcomplications)","An important aspect of ongoing management includes proactively preparing patients with MD and their families forthe long‐term consequences of muscular dystrophies and engaging in discussions regarding end‐of‐life care. Thishelps patients come to terms with their condition and prepare for the expected complications of their form of MDand avoids the need for hasty decisions made in the throes of a medical crisis. Palliative care is useful to alleviate thesuffering of these patients."]
["X3800","Patient Queried about Pain and Pain Interference with Function","All visits for patients diagnosed with a muscular dystrophy (MD) where the patient was queried about pain and pain interference with function using a validated and reliable instrument.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patient visits where the patientwas queried about pain and paininterference with function usinga validated and reliableinstrument.","All visits for patients diagnosedwith a muscular dystrophy.","Exceptions: Patient reason for notquerying about pain and paininterference with function (i.e., patientdeclines to respond to questions)","Between 68‐82% of patients with muscular dystrophies live in pain. Pain is a common feature of some MDs, notablymyotonic dystrophy and FSHD, but also many of the limb girdle muscular dystrophies (LGMDs). Pain interferes withphysical and psychological functioning in these patients. Lower extremity pain intuitively affects ambulation. Painand fatigue are independent predictors of lower physical functioning and greater depression. Thus identification andtreatment of pain is important to improve the care of patients with MD."]
["X3801","Nutritional Status or Growth Trajectories Monitored","All visits for patients diagnosed with muscular dystrophy (MD) where the patient’s nutritional status or growth trajectories were monitored.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patient visits where the patient’snutritional status or growthtrajectories were monitored.","All visits for patients diagnosedwith muscular dystrophy.","Exceptions: Medical reason for notmonitoring for nutrition or growthtrajectory problems or referring for thesepurposes (i.e., patient is already beingfollowing by a nutritionist or otherqualified specialist for these issues); •Patient reason for not monitoring fornutrition or growth trajectory problemsor referring for these purposes (i.e.,patient or family caregiver declines); •System reason for not monitoring for nutrition or growth trajectory problems or referring for these purposes (i.e.,patient is unable to travel)","Delayed growth, short stature, muscle wasting and increased fat mass are characteristics of DMD and impact onnutritional status and energy requirements. The early introduction of steroids has altered the natural history of thedisease, but can exacerbate weight gain in a population already susceptible to obesity. Prior to commencingsteroids, anticipatory guidance for weight management should be provided. Malnutrition is a feature of end stagedisease requiring a multidisciplinary approach, such as texture modification and supplemental feeding. As a result ofcorticosteroid treatment, vitamin D and calcium should be supplemented. Patients with MD may have difficultyreceiving adequate oral intake due to dysphagia and/or inability to feed themselves due to excessive arm weakness.Maintaining adequate nutrition and body weight is important for optimizing strength, function, and quality of life.When oral intake is inadequate, other means of maintaining intake, such as gastrostomy or jejunostomy feedingtubes, may be needed to maintain optimal nutrition. There is evidence from related conditions (amyotrophic lateralsclerosis [ALS]) that maintenance of nutrition and body weight prolongs survival."]
["X3798","Scoliosis Evaluation Ordered","All visits for patients with a diagnosis of a muscular dystrophy (MD) where the patient had a scoliosis evaluation ordered.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who had a scoliosisevaluation ordered.","All visits for patients with adiagnosis of a muscular dystrophy.","Medical reason for not ordering ascoliosis evaluation (i.e., patient cannottolerate evaluation, MD phenotype notassociated with scoliosis); • Patientreason for not ordering a scoliosisevaluation (i.e., patient or familycaregiver declines evaluation); • Systemreason for not ordering a scoliosisevaluation (i.e., patient has no insurancecoverage for x‐rays or referral forconsultation evaluation)","There is a risk of evolving musculoskeletal spine deformities, such as scoliosis, kyphosis, or rigid spine syndrome, invarious dystrophies. These musculoskeletal deformities can result in discomfort and functional impairment,interfering with gait, activities of daily living, and pulmonary function. The proper management of musculoskeletalspine deformities is important in order to reduce discomfort, preserve mobility or ability to sit in a wheelchair, andreduce pulmonary complications."]
["X3791","MD Multidisciplinary Care Plan Developed or Updated","All patients diagnosed with a muscular dystrophy (MD) for whom a MD multi‐disciplinary care plan was developed, if not done previously, or the plan was updated at least once annually.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients for whom a MD multi‐disciplinary care plan wasdeveloped, if not donepreviously, or the plan wasupdated at least once annually. ","All patients diagnosed with amuscular dystrophy.","Exceptions: Medical reason for notdeveloping or updating amultidisciplinary care plan (i.e., plan wasupdated within 12 months of the date ofthe encounter); • Patient reason for notdeveloping or updating amultidisciplinary care plan (i.e., patient orfamily caregiver declines); • Systemreason for not developing or reviewing amultidisciplinary care plan (i.e., patienthas no insurance to cover the cost of aseeing specialists or other clinicians in amultidisciplinary care plan, cannot travelto see specialist, multidisciplinaryservices unavailable)","A systematic review of muscular dystrophies has highlighted the medical complexity of caring for patients with MD.Such patients may develop cardiac, pulmonary, nutritional, and musculoskeletal complications that require theassistance of cardiologists, pulmonologists, orthopedists, physiatrists, physical therapists, occupational therapists,nutritionists, orthotists, and speech pathologists, in addition to neurologists. Additionally, myopathies with a limb‐girdle, humeroperoneal, or distal pattern of weakness may be challenging to diagnose. A specific diagnosis providespatients with “closure,” assists genetic counseling, and directs monitoring for complications and optimalmanagement."]
["X3787","Patients with DMD Prescribed Appropriate Disease Modifying Pharmaceutical Therapy","All patients diagnosed with Duchenne muscular dystrophy (DMD) prescribed appropriate DMD disease modifying pharmaceutical therapy.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients prescribed appropriateDMD disease modifying pharmaceutical therapy.","All patients diagnosed withDuchenne muscular dystrophy DMD).","Exceptions: Medication exception for notprescribing disease modifying pharmaceutical therapy (i.e., medicalcontraindication; patient already oncorticosteroid; may not be medicallyappropriate depending upon functionalcapability, age, and existing risk factors);•\tPatient exception for not prescribing disease modifying pharmaceutical therapy (i.e., patient or family caregiver declines); • System exception for not prescribing disease modifying pharmaceutical therapy (i.e., patient has no insurance to cover prescription andcannot afford it)","DMD is a recessive X‐ linked genetic disorder characterized by progressive muscle weakness and reduced muscle tone. Affecting only boys, it limits life expectancy to approximately 20 years. Care for patients with DMD is poorlystandardized. This leads to inequality in access to treatment. Although there is no cure, a Cochrane Review and AANpractice parameter concluded that prednisone may provide short term effective treatment that prolongs the abilityto walk, reduces the complications such as scoliosis, respiratory insufficiency and cardiac impairment. Despite thewell documented beneficial effects of corticosteroids in DMD, a population based study of corticosteroid usebetween 1991 and 2005 reported that only 50.9% of individuals had ever been on corticosteroids. The annual meanpercent corticosteroid use varied widely from 8.4% to 80.2% across clinics. Another survey showed that nearly 10% of neuromuscular disease clinics do not offer such therapy. Glucocorticoids are currently the only medication available that slows the decline in muscle strength and function in DMD, which in turn reduces the risk of scoliosis and stabilizes pulmonary function. Approximately 16% of Muscular Dystrophy Association clinic directors report notusing corticosteroids."]
["X3794","Plan Of Care For Migraine Or Cervicogenic Headache Developed Or Reviewed","All patients diagnosed with migraine headache or cervicogenic headache who had a headache management plan of care developed or reviewed at least once during the 12 month measurement period.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who had a headachemanagement plan of care formigraine headache orcervicogenic headache developedor reviewed by the clinician atleast once during the 12 monthmeasurement period.","All patients diagnosed withmigraine headache or cervicogenicheadache.","Exceptions: Medical exceptions for notdeveloping or reviewing a plan of care formigraine or cervicogenic headache (i.e.,patient is cognitively impaired, cannotcommunicate and no caregiver isavailable)","Optimizing headache management requires a systematic assessment of symptoms, including the development of anindividualized plan of care. Clinicians are advised to base their treatment choice on degree of disability along withattack frequency and duration, non‐headache symptoms, patient preference, and prior history of treatmentresponse, using a stratified approach to care. This information should be included in the patient’s plan of care.HRQoL and disability are positively impacted by treatment interventions and a continuity of care."]
["X3796","Migraine Or Cervicogenic Headache Related Disability Functional Status","Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache‐related disability days during the past 3 months is documented in the medical record.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of days during the past 3months, as categorized bypatients or their caregivers, thatthey are unable to performcommon daily activities (e.g.,school, work, household chores,social activities, IndependentActivities of Daily Living (IADLS),etc.) due to migraine headacheor cervicogenic headache.","All patients age 6 years old andolder who have a diagnosis ofmigraine headache or cervicogenicheadache.","Exceptions: Medication exception for notadministering a disability tool (i.e.,patient has a cognitive orneuropsychiatric impairment that impairshis/her ability to complete the survey);Patient exception for not administering adisability tool (i.e., patient has theinability to read and/or write in order tocomplete the questionnaire); Systemexception for not administering adisability tool (i.e., patient does not haveinsurance to cover the cost of the quality of life assessment).","The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the systemlevel to indicate where improvements in the management and treatment of patients with headache should bemade."]
["X3786","Quality Of Life Assessment For Patients With Primary Headache Disorders","Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.","Patient‐\nReported\nOutcome","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patient whose health relatedquality of life was assessed with atool(s) during at least two visitsduring the 12 monthmeasurement period AND whosehealth related quality of life scorestayed the same or improved.","All patients with a diagnosis with aprimary headache disorder.","Exceptions: Medication exception for notassessing for QoL (i.e., patient has acognitive or neuropsychiatric impairmentthat impairs his/her ability to completethe HRQoL survey); Patient exception fornot assessing for QoL (i.e., patient has theinability to read and/or write in order tocomplete the HRQoL questionnaire","This measure establishes an initial or baseline QoL score from which the patient should use the same QoLtool/questionnaire at least one additional time during the measurement period. The two assessments must beseparated by at least 90 days for MIDAS and at least 4 weeks for any other tool. It is expected that the QoL score orranking will stay the same or improve in order for this measure to be successfully completed."]
["X3785","Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination","Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with a normalneurological examination forwhom advanced brain imaging(CTA, CT, MRA or MRI) was NOTordered.","All patients with a diagnosis ofprimary headache.","Exceptions: Medical exceptions forordering an advanced brain imagingstudy (i.e., patient has an abnormalneurological examination; patient has thecoexistence of seizures, or both; recentonset of severe headache; change in thetype of headache; signs of increasedintracranial pressure (e.g., papilledema,absent venous pulsations on funduscopicexamination, altered mental status, focalneurologic deficits, signs of meningealirritation); HIV‐positive patients with anew type of headache;immunocompromised patient withunexplained headache symptoms;patient on coagulopathy/anti‐coagulationor anti‐platelet therapy; very youngpatients with unexplained headachesymptoms); System exceptions forordering an advanced brain imagingstudy (i.e., needed as part of a clinicaltrial; other clinician ordered the study).","Imaging headache patients absent specific risk factors for structural disease is not likely to change management orimprove outcome. Those patients with a significant likelihood of structural disease requiring immediate attentionare detected by clinical screens that have been validated in many settings. Many studies and clinical practiceguidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improvepatient well‐being."]
["X3784","Plan Of Care Or Referral For Possible Medication Overuse Headache","Percentage of patients diagnosed with medication overuse headache (MOH) within the past 3 months or who screened positive for possible MOH (measure 6a) who had a medication overuse plan of care created or who were referred for this purpose.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who had a medicationoveruse headache plan of carecreated or who were referred forthis purpose.","All patients a diagnosis ofmedication overuse headachewithin the past three months orwho screened positive for possiblemedication overuse headache(measure 6a).","Exceptions: Medical exception for notcreating a medication overuse plan ofcare or referring the patient for thispurpose (i.e., patient already has anactive plan of care in place)","MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondaryheadaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent andoften at its worst on awakening. This is a paired, or a two‐part measure, that is scored separately for part A and partB. The measure 6A focuses on assessing for MOH using the July 2013 ICHD‐III medication overuse headache criteria.In measure 6B, if the patient is found have MOH from measure 6A and is diagnosed with MOH, then he/she sheshould have a plan of care created by the clinician or the clinician should refer the patient for this purpose."]
["X3783","Assessment Of Medication Overuse In The Treatment Of Primary Headache Disorders","Percentage of patients diagnosed with a primary headache disorder, who are actively taking an acute headache medication and experiencing headaches ≥15 days per month for 3 months, who were assessed for medication overuse headache (MOH).","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who were assessed formedication overuse headache(MOH).","All patients diagnosed with aprimary headache disorder, whoare actively taking an acuteheadache medication andexperiencing headaches ≥15 daysper month for 3 months, whowere assessed for medicationoveruse headache (MOH).","Exceptions: Medical Exception for notassessing the patient for MOH (i.e.,patient has already had MOH ruled outwithin the past three months; theabortive pain medication is medicallyappropriate for a non‐headachecondition)","MOH is caused by chronic and excessive use of medication to treat headache. MOH is the most common secondaryheadaches. It may affect up to 5% of some populations, women more than men. MOH is oppressive, persistent andoften at its worst on awakening. This is a paired (or two part measure) that is scored separately for part A and partB. The measure 6A focuses on assessing for MOH using the July 2013 ICHD‐III MOH criteria. In measure 6B, if thepatient is found have MOH from measure 6A and is diagnosed with MOH, then he/she she should have a plan ofcare created by the clinician or the clinician should refer the patient for this purpose during the measurementperiod."]
["X3770","Overuse Of Opioid Containing Medications For Primary Headache Disorders","Percentage of patients aged 12 years and older diagnosed with primary headache disorder and taking opioid containing medication who were assessed for opioid containing medication overuse within the 12‐month measurement period and treated or referred for treatment if identified as overusing opioid containing medication.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients assessed for opioidcontaining medication overusewithin the 12‐monthmeasurement period and treatedor referred for treatment ifidentified as overusing opioidcontaining medication","All patients aged 12 years andolder diagnosed with a primaryheadache disorder and takingopioid containing medication.","Exceptions: Medical exception for notassessing, treating, or referring patientfor treatment of opioid medicationoveruse (i.e., patient already assessedand treated for opioid use disorderwithin the last year; patient has adocumented failure of non‐opioidoptions and does not have an opioid usedisorder; patient has contraindications toall other medications for primaryheadache).","Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the USHeadache Consortium Guideline. The use of barbiturates or opioids increases the risk of chronic daily headache anddrug induced hyperalgesia. In one study, any use of barbiturates and opiates was associated with increased risk oftransformed migraine after adjusting for covariates, while triptans were not. In a sample of 5,796 people withheadache, 4,076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were currentopioid users."]
["X3769","Unnecessary Screening Colonoscopy in Older Adults","Percentage of patients age 86 or older who received an unnecessary screening colonoscopy.","Efficiency","American Gastroenterological Association","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","\"Colonoscopy examinationsperformed on patients aged 86and older for screening purposesonly.Denominator Criteria (Eligible Cases):Patients aged ≥ 8650 years on the date of the procedureANDPatient encounter during the reporting period (CPT or HCPCS): 45378, 45380, 45381, 45383,45384, 45385, and G0121","Colonoscopy examinationsperformed on patients aged 86and older for screening purposesonly reported with CPT / HCPCScodes 45378, 45380, 45381,45383, 45384, 45385, and G0121.","None","\"Colorectal cancer is the third most common malignancy and the second leading cause of cancer‐related deaths in the United States. The lifetime risk of being diagnosed with cancer in the colon or rectum is about 5 percent. Thepercentage of new cases is higher in people from 65‐84 years of age; the median age of diagnosis is 69 (NCI, 2013).The overall incidence by age for both men and women are as follows:•\t4 percent between 35 and 44 years•\t13.8 percent between 45 and 54 years•\t20.8 percent between 55 and 64 years•\t24 percent between 65 and 74 years•\t24.1 percent between 75 and 84 years•\t12 percent in 85 years and olderThe incidence of mortality rates for colorectal cancer are about 35 percent – 40 percent higher in men than in women,; however, both rates have decreased significantly since 1975 (ACS, 2013). The incidence rate declined from 60 cases to 45 cases per 100,000 people, and the mortality rate declined from 28 deaths to 17 deaths per 100,000 people (NCI, 2013). Declines in the incidence and mortality rates are due, in part, to the routine performance of preventive screening: improved screening is responsible for half of the observed reduction in both rates, while the remaining half derives from changes in the population prevalence of contributing risk factors (NCI, 2013).Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permits immediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographic imaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology for histologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow‐up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation.However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm).In a cohort study of Medicare enrollees from 2000‐2008, the authors concluded that one‐third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying anddecreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335‐1343. doi:10.1001/archinternmed.2011.212). This is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357‐2365).The charge for a colonoscopy can range from $1,000‐$3,000; Medicare reimbursement covers 75 percent – 80 percent of charges. Based on the 2011 U.S. Census, there are currently 8.1 million individuals 85 and older in theU.S. Given this count, regular performance of colonoscopies among this population could result in significant health care spending (not including downstream costs due to subsequent clinical complications)(Goodwin, 2011). The population of individuals 85 years and older is projected to double by 2050; hence, the financial burden related to potentially inappropriate performance of colorectal screening can be expected to increase (Goodwin, 2011). CLINICAL RECOMMENDATION STATEMENTS :The USPTF (2008) recommends three screening regimens for individuals 50‐75 years of age with average risk:•\tAnnual high‐sensitivity FOBT.•\tSigmoidoscopy every 5 years, combined with high‐sensitivity fecal occult blood testing every 3 years.•\tOptical colonoscopy every 10 years.For individuals from 76‐85 years of age, the Task Force recommends against routine performance of screening unless individuals have not been previously screened, in which case it should be considered in the context of health status and competing risks for each individual (USPTF, 2008).For individuals older than 85 years, the Task Force recommends against screening when comparing overall benefits to harms (D Recommendation)(USPTF, 2008). The Task Force based these recommendations on a systematic review of the literature, supplemented with modeling data (USPTF, 2008; NCI 2013; USCR, 2011).For this subgroup, the Task Force concluded that the utility of screening is limited, given the time it takes for a polyp to develop into a clinically observable malignancy (10‐26 years)(USPTF, 2008; NCI 2013; UCSR 2011). Moreover, individuals older than 85 are likely to have multiple comorbidities that influence any potential life‐year gain (USPTF, 2008; NCI 2013; UCSR, 2011). They are also at increased risk of suffering from adverse events related to performance of a colonoscopy, with the rate of adverse events being 2.8 per 1,000 procedures and increased byseven‐fold if a polypectomy is performed (USPTF, 2008; CDC 2012, NCI, 2013)."]
["X3765","Overuse of Barbiturate Containing Medications for Primary Headache Disorders","Percentage of patients age 18 years old and older with a diagnosis of primary headache who were NOT prescribed bariturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who were NOTprescribed barbiturate containingmedications related to theprimary headache disorderdiagnosis during the 12‐monthmeasurement period.","All patients age 18 years old andolder diagnosed with a primaryheadache disorder.","Exceptions: Medical exception forprescribing a barbiturate containingmedications for primary headachedisorder (i.e., use as a last resort for apatient who has failed all other guidelinerecommended medications for headacheor who have contraindications; may beconsidered for rescue therapy in asupervised setting for acute migrainewhen sedation side effects will not putthe patient at risk and when the riskabuse has been addressed).","Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the USHeadache Consortium Guideline. However, barbiturates or butalbital containing agents are prescribed frequently.The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. One study notedthat barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to atertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen,46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti‐inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of alltriptans, 17.8%)."]
["X3772","Preventive Migraine Medication Prescribed","Percentage of patients age 18 years old and older diagnosed with migraine headache whose migraine frequency is ≥4 migraine attacks per month or migraine frequency was ≥8 days per month who were prescribed a guideline recommended prophylactic migraine treatment within the 12 month reporting period.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients whose migrainefrequency is ≥4 migraine attacksper month or migraine frequencywas ≥8 days per month who wereprescribed a guidelinerecommended prophylacticmigraine treatment within the 12month reporting period.","All patients age 18 years old andolder diagnosed with migraineheadache.","Exceptions: Medical exception for notprescribing a prophylactic medication formigraine (i.e., patient migraine frequency<8 days per month or <4 attacks permonth; patient is already on aprophylactic medication for migraine;patient has failed all prophylacticmedications; patient has acontraindication to all migrainepreventive treatments; patientadequately responding to non‐pharmacologic preventive treatment); Patient exception for not prescribing a prophylactic medication for migraine (i.e., patient declines any prophylactic medication for migraine); System exception for not prescribing a prophylactic medication for migraine (i.e., patient has no insurance coverage for any prophylactic migrainemedication)","This measure is designed to address the strong gap in care in the use of prophylactic medication for migraineheadache. Migraine is suboptimally treated in the majority of patients. Note: this measure does not specificallyaddress chronic migraine or MRM."]
["X3766","Acute Medication Prescribed for Cluster Headache","Percentage of patients age 18 years old and older with a diagnosis of cluster headache (CH) who were prescribed a guideline recommended acute medication for cluster headache within the 12‐month measurement period.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who were prescribed aguideline recommended acutemedication for cluster headachewithin the 12 monthmeasurement period.","All patients age 18 years old andolder with a diagnosis of clusterheadache.","Exceptions: Medical exception for notprescribing a guideline recommendedacute CH medication (i.e., guidelinerecommended medication is medicallycontraindicated or ineffective for thepatient; patient reports no CH attackswithin the past 12 months; CH aresufficiently controlled with over thecounter [OTC] medications; patient isalready on an effective prescribed acuteCH medication); Patient exception for notprescribing a guideline recommendedacute CH medication (i.e., patientdeclines any prescription of an acute CHmedication); System exception for notprescribing a guideline recommendedacute CH medication (i.e., patient doesnot have insurance to cover the cost ofany prescribed an acute CH medications)","CH is under diagnosed and undertreated. Although CH has a much lower prevalence than many other types ofheadache, it is often considered the most severe headache pain. Suicidality ideations in one study were as high as55% of the study population."]
["X3771","Medication Prescribed for Acute Migraine Attack","Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12 month measurement period.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who were prescribed aguideline recommendedmedication for acute migraineattacks within the 12 month measurement period.","All patients age 12 years old andolder with a diagnosis of migraineheadache.","Exceptions: Medical exception for notprescribing a guideline recommendedacute migraine medication (i.e., guidelinerecommended medication is medically contraindicated or ineffective for the patient; migraines are effectively controlled with OTC medications or with NSAIDs; patient is already on an effective acute migraine medication prescribed by another clinician; patient has no pain with migraine); Patient exception for not prescribing a guideline recommended acute migraine medication (i.e., patient declines a prescription for any acute migraine medication); System exception for not prescribing a guideline recommended acute migraine medication (i.e., patient does not have insurance to cover the cost of prescribedabortive migraine medication)","Migraine is under diagnosed and suboptimally treated in the majority of patients. The Work Group noted althoughthere are no guidelines available, almotriptan is approved for ages 12‐17 and rizatriptan was recently approved bythe FDA for ages 6‐17. The Work Group also noted that although the triptans in individuals less than 12 years oldmay be prescribed off label, there is limited or no evidence to support this."]
["X3775","Chronic Opioid Therapy Follow‐up Evaluation","All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow‐ up evaluation conducted at least every three months during COT documented in the medical record.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who had a follow‐upevaluation conducted at leastevery three months during COT.","All patients 18 and olderprescribed opiates for longer thansix weeks duration.","None","Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoringshould include documentation of pain intensity and level of functioning, assessments of progress toward achievingtherapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation,low‐quality evidence). In patients on COT who are at high risk or who have engaged in aberrant drug‐relatedbehaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to theCOT plan of care (strong recommendation, low‐quality evidence). In patients on COT not at high risk and not knownto have engaged in aberrant drug‐related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low‐qualityevidence)"]
["X3776","Consideration of Non‐Pharmacologic Interventions","All patients 18 and older prescribed opiates for longer than six weeks duration with whom the clinician discussed non‐pharmacologic interventions (e.g. graded exercise, cognitive/behavioral therapy, activity coaching at least once during COT documented in the medical record.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with whom the cliniciandiscussed non‐pharmacologicinterventions (e.g. gradedexercise, cognitive/behavioraltherapy, activity coaching) forchronic pain at least once duringCOT.","All patients 18 and olderprescribed opiates for longer thansix weeks duration.","None","As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integratepsychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive non opioidtherapies (strong recommendation, moderate‐quality evidence)"]
["X3777","Documentation of Signed Opioid Treatment Agreement","All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during COT documented in the medical record.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who signed an opioidtreatment agreement at leastonce during COT.","All patients 18 and olderprescribed opiates for longer thansix weeks duration.","None","When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COTshould include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low‐qualityevidence). Clinicians may consider using a written COT management plan to document patient and clinicianresponsibilities and expectations and assist in patient education (weak recommendation, low‐quality evidence)"]
["X3774","Evaluation or Interview for Risk of Opioid Misuse","All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP‐R) or patient interview documented at least once during COT in the medical record.","Process","American Academy of Neurology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients evaluated for risk of misuse of opiates by using a briefvalidated instrument (e.g. OpioidRisk Tool, SOAAP‐R) or patientinterview at least once during COT.","All patients 18 and older prescribed opiates for longer thansix weeks duration.","None","Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including anassessment of risk of substance abuse, misuse, or addiction (strong recommendation, low‐quality evidence).Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain ishaving an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely tooutweigh potential harms (strong recommendation, low‐quality evidence). A benefit‐to‐harm evaluation including ahistory, physical examination, and appropriate diagnostic testing, should be performed and documented before andon an ongoing basis during COT (strong recommendation, low‐quality evidence)"]
["X3802","Appropriate follow‐up imaging for non‐traumatic knee pain","Percentage of imaging studies for patients aged 18 years and older with non‐traumatic knee pain who undergo knee magnetic resonance imaging (MRI) or magnetic resonance arthrography (MRA) who are known to have had knee radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient‐provided radiological history, or other health‐care source","Process","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Imaging studies for patientsknown to have had kneeradiographs performed withinthe preceding 3 months based oninformation from the RIS,patient‐provided radiologicalhistory, or other health‐caresourceNote: Images and/or results ofprior knee radiographs should beavailable to the radiologist at thetime of the knee MRI or MRA. Ifthe report, but not images, fromprior radiographs are available,this should be noted in the finalreport.","All imaging studies for patientsaged 18 years and older with non‐traumatic knee pain who undergoknee MRI or MRA","None","Knee pain is common, affecting approximately 13.3% of the U.S. population (1). Radiographs are indicated as part ofthe initial work‐up for knee pain. Advanced imaging studies should only be utilized when the diagnosis remainsunclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). One reportestimates that 20%‐50% of diagnostic imaging studies fail to provide information that improves the diagnosis ortreatment of the patient (3).1.Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J PublicHealth. 1984;74:574‐579.2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients shouldquestion. http://www.choosingwisely.org/doctor‐patient‐lists/american‐college‐of‐radiology/. Accessed March 24,2014.3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging.http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008.Accessed March 24, 2014. Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% Carrier Claims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathways database in 2010. About 28% of all knee MRIs and 35‐37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee‐for‐service Medicare population was between $20‐35 million. Between 20 and 23% of patients undergoing knee MRI and 27‐32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year.Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one‐quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1)1.\tArticle in press: Journal of American College of Radiology"]
["X3803","Appropriate use of imaging for non‐ traumatic shoulder pain","Percentage of imaging studies for patients aged 18 years and older with non‐traumatic shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient‐provided radiological history, or other health‐care source","Process","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Imaging studies for patientsknown to have had shoulderradiographs performed withinthe preceding 3 months based oninformation from the RIS,patient‐provided radiologicalhistory, or other health‐caresourceNote: Images and/or results of prior shoulder radiographs should be available to radiologist at the time of the shoulder MRI, MRA, or ultrasound. If the report, but not images, from prior radiographs are available, this should be noted in the finalreport.","All imaging studies for patientsaged 18 years and older with non‐traumatic shoulder pain whoundergo shoulder MRI, MRA, or ashoulder ultrasound","None","Shoulder pain is common, affecting approximately 6.7% of the U.S. population (1). Radiographs are indicated as partof the initial work‐up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosisremains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (2). Onereport estimates that 20%‐50% of diagnostic imaging studies fail to provide information that improves the diagnosisor treatment of the patient (3).1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J PublicHealth. 1984;74:574‐579.2. American College of Radiology for ABIM Choosing Wisely Campaign. Five things physicians and patients shouldquestion. http://www.choosingwisely.org/doctor‐patient‐lists/american‐college‐of‐radiology/. Accessed March 24,2014.3. America’s Health Insurance Plans. Ensuring quality through appropriate use of diagnostic imaging.http://www.medsolutions.com/clinical_quality/facts/AHIP%202008%20Imaging%20Stats.pdf. Published July 2008.Accessed March 24, 2014.Data analysis was conducted to determine the percentage of MRI examinations for knee and shoulder pain ortendonitis performed without prior radiography. This was estimated among patients in the Medicare 5% CarrierClaims Limited Data Set and among commercially insured patients in the Truven MarketScan® Treatment Pathwaysdatabase in 2010. About 28% of all knee MRIs and 35‐37% of all shoulder MRIs were performed without recent priorradiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee‐for‐service Medicarepopulation was between $20‐35 million. Between 20 and 23% of patients undergoing knee MRI and 27‐32% patient undergoing shoulder MRI did not have radiographic examination at any point before the MRI in the calendar year. Patients for whom MRI is performed without prior radiography represent an area of potential gap in care and should be considered for establishment of performance measures. Greater than one‐quarter of all knee and shoulder MRIs are performed without recent prior radiographs and hence represent an area of potential inappropriate imaging utilization and gap in care. (1)1. Article in press: Journal of American College of Radiology"]
["X3523","Extravasation of contrast following contrast‐enhanced computed tomography (CT)","Percentage of final reports for patients aged 18 years and older who received intravenous iodinated contrast for a computed tomography (CT) examination who had an extravasation of contrast Lower performance rate is the goal.","Outcome","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Final reports for patients whohad an extravasation of contrastDefinition:Extravasation‐ Although mostpatients complain of initialswelling or tightness, and/orstinging or burning pain at thesite of extravasation, someexperience little or nodiscomfort. On physicalexamination, the extravasationsite may be edematous,erythematous, and tender (ACRContrast Manual, 2013)","All final reports for patients aged18 years and older who receivedintravenous iodinated contrast fora CT examination","None","Extravasation of contrast leads to a local inflammatory response that can, in turn, cause acute tissue injury. Patientsexperiencing extravasation can have symptoms ranging from swelling and burning pain to skin ulceration, tissuenecrosis, and compartment syndrome in extreme cases.Extravasation is a relatively common occurrence that affects 1 out of 147 patients who are given intravenouscontrast. Elderly patients and small children, as well as patients with limited communication abilities, severe illnessor debilitation, or abnormal circulation, are at increased risk for extravasation.1. American College of Radiology Committee on Drugs and Contrast Media. ACR manual on contrast media‐ Version9.2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation ofnonionic iodinated contrast medium in 69657 intravenous injections. Radiology. 2007;243(1):80‐87.doi:10.1148/radiol.2431060554."]
["X3781","Use of premedication before contrast-enhanced imaging studies in patients with documented contrast allergy","Percentage of final reports for patients aged 18 years and older who had a previously documented contrast reaction who undergo any imaging examination using intravenous iodinated contrast that include documentation that the patients were pre-medicated with corticosteroids with or without H1 antihistamines","Process","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Final reports for patients whowere pre‐medicated withcorticosteroids with or withoutH1 antihistamines","All final reports for patients aged18 years and older with apreviously documented contrastreaction who undergo any imagingexamination using intravenousiodinated contrastDefinition:Contrast reaction: allergic‐like reaction following a prior imaging examination with intravenousiodinated contrast","None","Reactions to contrast media are common, occurring in as many as 13% of patients (1) . Most reactions are mild, withsevere reactions occurring in <1% of cases (1). Premedication with corticosteroids has been shown to reduce therate of contrast reactions by as much as 35% among “high risk” patients who have had a previous reaction tocontrast media (2) .1. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, andspecific treatment. Am J Roentgenol. 1991;157:1153‐1161.2. Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM. Pretreatment with corticosteroids toprevent adverse reactions to nonionic contrast media. Am J Roentgenol. 1994;162:523‐525.In a 2011 survey (1) of uroradiologists, 86% of respondents reported having a standardized premedication regimen.Additionally, the survey found significant variability in the use of premedication for specific clinical scenarios such asan urgent or emergent situation.1. O’Malley RB, Cohan RH, Ellis JH, et al. A survey on the use of premedication prior to iodinated and gadolinium‐based contrast material administration. J Am Coll Radiol. 2011;8:345‐354. doi:10.1016/j.jacr.2010.09.001."]
["X3764","Imaging in adult ED patients with minor head injury","Percent of adult patients who presented within 24 hours of a non‐penetrating head injury with a Glasgow coma score (GCS)≤15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines prior to imaging","Process","American College of Emergency Physicians (previous steward Partners‐Brigham & Women's)","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of denominator patientswho have a documentedindication consistent with theACEP clinical policy for mildtraumatic brain injury prior toimagingIndications for Head CT inpatients presenting to the ED formild traumatic brain injury:Patients with loss ofconsciousness or posttraumaticamnesia AND• Headache OR; Vomiting OR;Age>60 OR; Drug/alcoholintoxication OR; Short‐termmemory deficits OR; Evidence oftrauma above the clavicles OR;Posttraumatic seizure OR;GCS<15 OR; Focal neurologicaldeficit OR CoagulopathyPatients without loss ofconsciousness or posttraumaticamnesia AND• Severe headache OR; VomitingOR; Age>65 OR; GCS<15 OR;Physical signs of a basilar skull fracture OR; Focal neurological deficit OR; Coagulopathy OR Dangerous MechanismPatient taking anticoagulation (warfarin, fractionated or unfractionated heparin) or has a documented coagulation disorderDangerous mechanism of injury includes: ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than3 feet or 5 stairs.","Number of adult patientsundergoing head CT for traumawho presented within 24 hours ofa non‐penetrating head injurywith a Glasgow Coma Scale(GCS)≤15","Exclusions: Number of adult patientsundergoing head CT for trauma whopresented within 24 hours of a non‐penetrating head injury with a GlasgowComa Scale (GCS)≤15Exception: Also consider potentialexclusions from MTBI Pathway:","This measure is needed to close the gap in provider performance as patients with mild closed head injuries withoutguideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcareexpenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times."]
["X3813","Proportion of patients sustaining a ureter injury at the time of any pelvic organ prolapse repair","Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery","Outcome","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients receiving aureter injury at the time of apelvic organ prolapse procedure,with repair during the procedureor subsequently up to 1 monthpostoperatively","Denominator = All patientsundergoing anterior or apicalpelvic organ prolapse (POP)surgery: All patients with any ofthe following prolapse surgerycodes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)57200, 57260, 57265(colporrhaphy and combined)57268, 57270, 57556 (enterocelerepair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair)58400, uterine suspension57120 colpocleisis","Patients with a gynecologic or otherpelvic malignancy noted at the time ofhysterectomy","Ureteral injury is an uncommon but potentially serious complication of surgery for pelvic organ prolapse. It iscritically important for surgeons who are performing these procedures to recognize and repair any ureteral injuriesintraoperatively, in order to minimize postoperative morbidity, including the need for subsequent surgicalintervention to address these complications. Surgeons who have a higher than expected rate of ureteric injuryduring pelvic organ prolapse repair would potentially benefit from interventions to improve the quality of theirsurgical care."]
["X3788","PC‐02 Cesarean Section (Provider Level)","This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. This measure is part of a set of five nationally implemented measures that address perinatal care (PC‐01: Elective Delivery, PC‐03: Antenatal Steroids, PC‐04: Health Care‐Associated Bloodstream Infections in Newborns, PC‐05: Exclusive Breast Milk Feeding).","Outcome","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with cesarean sectionswith ICD‐9‐CM PrincipalProcedure Code or ICD‐9‐CMOther Procedure Codes forcesarean section","Nulliparous patients delivered of alive term singleton newborn invertex presentation ICD‐9‐CMPrincipal or Other Diagnosis Codesfor pregnancy","• ICD‐9‐CM Principal Diagnosis Code orICD‐9‐CM Other Diagnosis Codes forcontraindications to vaginal delivery• Less than 8 years of age• Greater than or equal to 65 years of age• Length of Stay >120 days• Enrolled in clinical trials• Gestational Age < 37 weeks","This AMA – PCPI measure is harmonized with the Joint Commission’s measure (PC‐02 Cesarean Section) in languageand intent. The Joint Commission measure is a facility‐level measures whereas this measure includes attribution atthe individual provider level measure Cesarean deliveries are performed for many reasons. Some, such as those forbreech presentation, are supported by strong clinical consensus. However, many cesareans, especially those done inthe course of labor, are the result of labor management practices that vary widely and suggest clinician discretion(CMQCC) There is growing evidence to support the claim that provider‐dependent indications (i.e., those that relyon provider judgment) combined with provider discretion contribute significantly to the overall increase in bothprimary and repeat cesareans. The fact that cesarean delivery rates and practices vary widely among states, regions,hospitals, and providers for both primary and repeat cesareans demonstrates that hospitals and clinicians can differin their responses to the same conditions. This fact suggests the need for more precise clinical practice guidelinesand/or greater accountability and incentives for following them. (California Maternal Quality Care Collaborative)California Maternal Quality Care Collaborative clinician interviews (funded by California HealthCare Foundation)reveal that many nurses talked about the timing of cesareans done during labor, citing the competing demands onphysicians for clinic appointments and their desire for balance between work and the rest of life. Institutionalpressures and the pace of high‐volume facilities was another factor mentioned, along with physicians’ impatiencewith labor progress—a response that can be exacerbated in clinicians and mothers alike by the use of inductions,which can set up an expectation for a quick birth experience"]
["X3274","Assessment for Psoriatic Arthritis","This measure evaluates the number of all psoriasis patients who are screened for psoriatic arthritis. Doing this helps to prevent structural damage, and maximizes quality of life (QOL).","Process","American Academyof Dermatology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who are “screened” forpsoriatic arthritis.”Screening” for psoriatic arthritismust, at a minimum, includeinquiry about the presence orabsence of joint symptomsincluding any of the following:morning stiffness, pain, redness,and/or swelling of joints. If adermatologist wishes to performadditional optional screeningmeasures, these may includephysical examination (e.g.visualization of joints,surrounding structures(entheses) and fingers/toes fordactylitis) and/or use of avalidated psoriatic arthritisscreening instrument (PsoriaticArthritis Screening andEvaluation) 2,3, ToPAS (TorontoPsoriatic Arthritis Screening) 4 orPEST (Psoriasis Epidemiology Screening Tool) 5.Numerator Instructions: To satisfy this measure, presence or absence of joint symptoms should be documented at leastonce during the reporting period.","All patients with a diagnosis ofpsoriasis.","None","The prevalence of psoriatic arthritis (PsA) in the general population of the United States has been estimated to bebetween 0.1% to 0.25%. Among those with psoriasis, the prevalence of PsA is approximately 10%. This measure encourages dermatologists to actively seek signs and symptoms of PsA at each visit. Quick diagnosis of PsA leads to early treatment which alleviates signs and symptoms of PsA, prevents structural damage, and maximizes quality of life (QOL). As a result regular assessment or PsA which is the goal of this measure has a lot ofpotential for preventing negative outcomes, for reducing healthcare expenditure and improving outcomes."]
["X3726","Clinical Response to Oral Systemic or Biologic Medications","This measure evaluates the proportion of psoriasis patients receiving systemic or biologic therapy 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.","Outcome","American Academyof Dermatology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who have a documentedphysician global assessment(PGA; 6‐point scale), body surfacearea (BSA), psoriasis area andseverity index (PASI) and/ordermatology life quality index(DLQI) that meet any one of thebelow specified benchmarks.Numerator Instructions: Tosatisfy this measure, a patientmust achieve any ONE of thefollowing:a. PGA (6‐point scale) ˂ 2 (clearto mild skin disease)b. BSA < 3% (mild disease)c. PASI < 3 (no or minimaldisease)d. DLQI < 5 (no effect or smalleffect on patient’s quality oflife).9,10","All patients with a diagnosis ofpsoriasis and treated with an oralsystemic or biologic medicationfor psoriasis for at least 6 months.","Any patient for whom it is documentedthat he/she declines therapy change inorder to achieve better disease control asmeasured by PGA, BSA, PASI or DLQI.‐ Any patient who has contraindicationsto or has experienced adverse effects orlack of efficacy with all other therapyoptions.","A significant proportion of psoriasis patients who are receiving treatment remain unsatisfied with their therapiesdue to various reasons including lack of or loss of efficacy, side effects, and inconvenience, among others. Treatmentdissatisfaction also contributes to patients discontinuing therapy. This measure evaluates the proportion of psoriasispatients receiving systemic or biologic therapy who meet minimal physician‐ or patient‐reported disease activitylevels. It is implied that establishment and maintenance of an established minimum level of disease control asmeasured by physician‐ and/or patient‐reported outcomes will increase patient satisfaction with and adherence totreatment."]
["X3763","Appropriate follow‐ up imaging for incidental thyroid nodules in patients","Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the 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 Lower performance rate is goal.","Process","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Final reports for CT or MRI of thechest or neck or ultrasound ofthe neck with follow‐up imagingrecommended","All final reports for CT or MRIstudies of the chest or neck orultrasound of the neck for patientsaged 18 and older with a thyroid nodule < 1.0 cm noted","Exclusions: NoneExceptions: Documentation of medicalreason(s) for not including documentation that follow up imaging is not needed (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medicalreason(s))","Thyroid nodules are common, with estimates of prevalence as high as 50% 2. Desser and Kamaya3 found that themajority of incidentally noted thyroid nodules were benign with approximately 5% being malignant. Due to thecommon nature of small thyroid nodules combined with the low malignancy rate, additional follow‐up is notrecommended (ATA, 2009) 1.1. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guidelines Taskforce on ThyroidNodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines forpatients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1‐48.doi:10.1089/thy.2009.0110.2. Mortensen JD, Woolner LB, Bennet WA. Gross and microscopic findings in clinically normal thyroid glands. J ClinEndocrinol Metab. 1955;15(10):1270‐1280. doi:10.1210/jcem‐15‐10‐1270.3. Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimaging Clin N Am. 2008;18(3):463‐478.doi:10.1016/j.nic.2008.03.005.4. Ahmed S, Horton KM, Jeffrey RB Jr., Sheth S, Fishman EK. Incidental thyroid nodules on chest CT: review of theliterature and management suggestions. Am J Roentgenol. 2010;195:1066‐1071. doi:10.2214/AJR.10.4506.In their 2010 review4 of the literature, Ahmed et al concluded that there is significant inconsistency in howincidental thyroid nodules are reported and followed up by radiologists. Given the common nature of thyroidnodules, unnecessary follow‐up of these nodules can result in excessive testing and costs for patients."]
["X3759","Appropriate follow‐ up imaging for incidental abdominal lesions","Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: ‐ liver lesion < 1.5 cm ‐ kidney lesion < 1.0 cm ‐ adrenal lesion < 4.0 cm Lower performance rate is goal","Process","American College of Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Final reports for abdominalimaging studies with follow‐upimaging recommended","All final reports for abdominalimaging studies for patients aged18 years and older with one ormore of the following noted:‐ liver lesion < 1.5 cm‐ kidney lesion < 1.0 cm‐ adrenal lesion < 4.0 cm","Exclusions: NoneExceptions: Documentation of medicalreason(s) that follow‐up imaging isindicated (e.g., patient has a knownmalignancy that can metastasize, othermedical reason(s)","Incidental kidney, liver, and adrenal lesions are commonly found during abdominal imaging studies, with most of thefindings being benign 1,2,3,4, 5. Given the low rate of malignancy, unnecessary follow‐up procedures are costly and present a significant burden to patients1,6. To avoid excessive testing and costs, follow‐up is not recommended forthese small lesions.1. Pickhardt PJ, Hanson ME, Vanness DJ, et al. Unexpected extracolonic findings at screening CT colonography:clinical and economic impact. Radiology. 2008;249(1):151‐159. doi:10.1148/radiol.2491072148.2.\tYee J, Kumar NN, Godara S, et al. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology. 2005;236:519‐526. doi:10.1148/radiol.2362040166.3.\tSong JH, Chaudhry FS, Mayo‐Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. Am J Roentgenol. 2009;190:1163‐1168. doi:10.2214/AJR.07.2799.4.\tSilverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology. 2008;249:16‐31. doi:10.1148/radiol.2491070783.5.\tBerland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754‐773. doi:10.1016/j.jacr.2010.06.013.6.\tCasarella WJ. A patient’s viewpoint on a current controversy. Radiology. 2002;224(3):927.7.\tJohnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762‐767. doi:10.1016/j.jacr.2011.05.012.There is considerable variability among radiologists in the management of incidental findings. A 2011 survey 7 conducted by Johnson et al found significant variability in how radiologists report and manage incidental findings. In a more recent survey2 of members of the American College of Radiology, 38% of respondents were aware of the guidance around incidental findings. Among respondents who were aware of the guidance, 89% replied that they were applying the recommendations in their practice.1.\tJohnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK. Common incidental findings on MDCT: survey of radiologist recommendations for patient management. J Am Coll Radiol. 2011;8:762‐767. doi:10.1016/j.jacr.2011.05.012.2.\tBerland LL, Silverman SG, Megibow AJ, Mayo‐Smith WW. ACR members’ response to JACR white paper onmanagement of incidental abdominal CT findings. J Am Coll Radiol. 2014;11:30‐35. doi:10.1016/j.jacr.2013.06.002."]
["X3758","Appropriate age for colorectal cancer screening","Percentage of average‐risk patients age 86 or older who underwent screening colonoscopy","Cost/\nResource\nUse","American Society for Gastrointestinal Endoscopy","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients aged 86 and older whoreceived a routine colonoscopyscreening for colorectal cancer","All patients aged 50 and older whoreceive a routine colonoscopyscreening for colorectal cancer","Patient under the age of 86 on the dateof the procedurePatient 86 and older received a routinecolonoscopy for a reason other than thefollowing: an assessment ofsigns/symptoms of GI tract illness, and/orthe patient is considered high risk, and/orto follow up previously diagnosedadvanced lesions","Colonoscopy is considered to be the most effective screening option for colorectal cancer. Colonoscopy permitsimmediate polypectomy and removal of macroscopically abnormal tissue in contrast to tests based on radiographicimaging or detection of occult blood or exfoliated DNA in stool. Following removal, the polyp is sent to pathology forhistologic confirmation of cancer. Colonoscopy directly visualizes the entire extent of the colon and rectum, including segments of the colon that are beyond the reach of flexible sigmoidoscopy. Colonoscopy therefore has become either the primary screening method or a follow‐up modality for all colorectal cancer screening methods and is one of the most widely performed procedures in the United States. Given that, appropriate use of colonoscopy is crucial. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy, beginning at 50 years of age and continuing until 75 years of age. The risks and benefits of these screening methods vary. A recommendation. The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C recommendation. However, the USPSTF recommends against screening for colorectal cancer in adults older than 85 years. D recommendation (http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm).In a cohort study of Medicare enrollees from 2000‐2008, the authors concluded that one‐third of patients 80 years or older at their initial negative screening examination result underwent a repeated screening examination within 7 years. In addition the authors also stated that use of colonoscopy outside the scope of the recommendations, can not only cause overuse that exposes patients to unnecessary procedures but also increases costs. Identifying and decreasing overuse of screening colonoscopy is important to free up resources to increase appropriate colonoscopy in inadequately screened populations.(Goodwin JS, Singh A, Reddy N, Riall TS, Kuo Y. Overuse of Screening Colonoscopy in the Medicare Population. Arch Intern Med. 2011;171(15):1335‐1343. doi:10.1001/archinternmed.2011.212). Overuse of screening colonoscopy in patients age 86 or older is of special concern, given the increased potential for complications, decreased completion rate and decreased benefit of this examination in the very elderly. In addition, even though the prevalence of colonic neoplasia increases with age, screening colonoscopy in very elderly patients results in smaller gains in life expectancy compared with younger patients, even when adjusted for life expectancy (Lin OS, Kozarek RA, Schembre DB, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357‐2365)."]
["X3760","Frequency of inadequate bowel preparation","The percentage of outpatient examinations with “inadequate” bowel preparation that require repeat colonoscopy in one year or less","Cost/\nResource\nUse","American Society for Gastrointestinal Endoscopy","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patientsrecommended for early repeatcolonoscopy in one year or lessdue to inadequate bowelpreparation","Patients aged 50‐75 for whom ascreening or surveillancecolonoscopy was performed","None","Poor bowel preparation is a major impediment to the effectiveness of colonoscopy, affecting the ability to detectpolyps and influencing the timing of repeat examinations. Given the increased premalignant potential of advancedadenomas, suboptimal bowel preparation may cause an unacceptably high failure rate at identifying theseimportant lesions, thereby compromising the effectiveness of the colonoscopy. Adenoma miss rates in the contextof suboptimal bowel preparation are as high as 42%. Poor bowel preparation influences the timing of repeatexamination with practitioners recommending follow‐up examinations earlier than standard intervals due toinadequate bowel preparation. The economic burden of repeating examinations because of inadequate bowel preparation is substantial. This leads our societies to recommend this measure so individual practitioners can monitor their percentages of examinations requiring repeat because of preparation and compare their percentages to others. We believe that adherence to this measure will result in a reduction of duplicative or unnecessary testsand, therefore, savings to the Medicare program."]
["X3761","Photodocumentati on of cecal intubation","The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination","Process","American Society for Gastrointestinal Endoscopy","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients undergoingscreening or surveillancecolonoscopy who havephotodocumentation of landmarks of cecal intubation toestablish a complete examination","Patients aged 50‐75 for whom ascreening or surveillancecolonoscopy was performed","Exclusions: post‐surgical anatomyExceptions: CPT Modifiers 52, 53,73, 74","Patients who undergo complete colon examination have a lower risk of colorectal cancer than patients withincomplete colonoscopy. Effective colonoscopists should be able to intubate the cecum in > 90% of cases, and in >95% of cases when the indication is screening in a healthy adult. Studies have shown that physicians do notroutinely document the depth of insertion in the colonoscopy report. Quality evaluation of the colon consists ofintubation of the entire colon – from the rectum to the cecum. Knowing the depth of insertion can inform physiciansof whether a radiographic procedure or repeat colonoscopy is necessary. However, the lack of comprehensivedocumentation can lead to unnecessary or repeat tests."]
["E1523","In‐hospital mortality following elective open repair of AAAs","Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers.","Outcome","The Society for Vascular Surgery","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Mortality following elective openrepair of asymptomatic AAAs inmen with < 6 cm dia and womenwith < 5.5 cm dia AAAs","All elective open repairs ofasymptomatic AAAs in men with <6 cm dia and women with < 5.5cm dia AAAs","= 6 cm minor diameter ‐ men= 5.5 cm minor diameter ‐ womenSymptomatic AAAs that requiredurgent/emergent (non‐elective) repair","Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of theprocedure must be contrasted with the risk of rupture over time. Surgeons should select patients for interventionwho have a reasonable life expectancy and who do not have a high surgical risk."]
["E0465","Perioperative Anti‐ platelet Therapy for Patients undergoing Carotid Endarterectomy","Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti‐ platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor etc) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery","Process","The Society for Vascular Surgery","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients over age 18 undergoingcarotid endarterectomy whoreceived anti‐platelet agents suchas aspirin or aspirin‐like agents,or P2y12 antagonists within 48hours prior to the initiation ofsurgery AND are prescribed thismedication at hospital dischargefollowing surgery.","Patients over age 18 undergoingcarotid endarterectomy.","Patients with known intolerance to anti‐platelet agents such as aspirin or aspirin‐like agents, or P2y12 antagonists, orthose on heparin or other intravenousanti‐coagulants; patients with activebleeding or undergoing urgent oremergent operations or endarterectomycombined with cardiac surgery. Patientswith known intolerance to anti‐plateletagents such as aspirin or aspirin‐likeagents, or P2y12 antagonists, or those onor other intravenous anti‐coagulants;patients with active bleeding orundergoing urgent or emergentoperations or endarterectomy combinedwith cardiac surgery.","The Vascular Study Group of Northern New England (VSGNNE) has published validated registry data from 48surgeons in 9 hospitals concerning more than 3000 patients undergoing CEA (Cronenwett, 2007). This demonstratedinitially that only 82% of patients were taking ASA or clopidogrel preoperatively before CEA in 2004. Through qualityimprovement efforts, this percentage has increased to 91% during the first 6 months of 2007. Further, a recentstudy from Austria found that 37% of 206 patients undergoing CEA were not on preoperative antiplatelet therapy,and concluded that this practice does not meet current guidelines and provides substantial opportunity forimprovement (Assadian, 2006)."]
["X3740","Performing an intraoperative rectal examination at the time of prolapse repair","Percentage of patients having a documented rectal examination at the time of surgery for repair of apical and posterior prolapse.","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients in whom anintraoperative rectal examinationwas performed and documented.These would be identified bychart review or entry into theRegistry.","Denominator = All patientsundergoing apical or posteriorpelvic organ prolapse (POP)surgery: All patients with any ofthe following prolapse surgerycodes:57280, 57282, 57283, 57425(colpopexies) 45560, 57250, 57210 (posterior repairs)57200, 57260, 57265(colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair) 58400, uterine suspension57120 colpocleisis :56800, 56810 (introital repair/perineoplasty) Uterus 250 G or Less58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s)58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo‐ Urethrocystopexy (Marshall‐ Marchetti‐Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repair of Enterocele58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy 58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele58290 Vaginal Hysterectomy, for Uterus Greater than 250 G 58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, withRemoval of Tube(s) and/or Ovary(s), with Repair of Enterocele58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo‐Urethrocystopexy (Marshall‐Marchetti‐Krantz Type, Pereyra Type)58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s)58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G 58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal ofTube(s) and/or Ovary(s) 58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s)58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G58573 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)57120 colpocleisis","Patients who have undergone prior totalproctectomyPatients who have exclusively anteriorcompartment repairs","Rectal injuries occur with surgery for pelvic organ prolapse involving the posterior and apical vaginal compartments.Correcting such injuries at the time they occur is preferable over delayed recognition due to an increase in morbidityand the need for additional surgery. Therefore, performing and documenting a rectal examination during thesurgery would help identify such rectal injury in a timely manner and would potentially increase the safety inperforming such surgeries."]
["X3741","Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair","Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse.","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients that wereasked about abnormal uterine orpostmenopausal bleeding, orthose that had an ultrasoundand/or endometrial sampling ofany kind. These would beidentified by chart review orentry into the Registry.","The number of patientsundergoing hysterectomy forpelvic organ prolapse.Hysterectomy (identified by CPTcodes) performed for theindication of pelvic organ prolapse(identified by supportingICD9/ICD10 codes) The prolapsecodes for ICD9 ‐> ICD‐10 aredetailed below, respectively:618.01 ‐> N81.10, Cystocele,midline618.02 ‐> N81.12, Cystocele,lateral618.03 ‐> N81.0, Urethrocele618.04 ‐> N81.6, Rectocele618.05 ‐> N81.81, Perineocele618.2 ‐> N81.2, Incompleteuterovaginal prolapse618.3 ‐> N81.3, Complete uterovaginal prolapse618.4 ‐> N81.4, Uterovaginal prolapse, unspecified618.6 ‐> N81.5, Vaginal enterocele618.7 ‐> N81.89, Old laceration of muscles of pelvic floor618.81\t‐> N81.82, incompetence or weakening of pubocervical tissue618.82\t‐> N81.83, incompetence or weakening of rectovaginal tissue618.83\t‐> N81.84, pelvic muscle wastingCPT codes for hysterectomy are: 57530 Trachelectomy58150 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo‐Urethrocystopexy (e.g. Marshall‐Marchetti‐Krantz, Burch) 58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s)58260 Vaginal Hysterectomy, for ","Patients who have undergone a priorhysterectomy","This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to hysterectomyand can be referred to a gynecologic oncologist for appropriate staging and treatment for the malignancy. Theincidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3‐ 3.2%. In a review of allsurgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women wereevaluated and 2 were diagnosed with endometrial cancer (0.3%). In a recent review of 63 robotic‐assistedsupracervical hysterectomies with sacrocervicopexies for pelvic organ prolapse, 2 patients (3.2%) were found onfinal pathology to have endometrial carcinoma.. Ensuring that providers ask about possible symptoms that may hintat the need for further evaluation would increase the quality of care provided to these patients."]
["X3742","Preoperative assessment of sexual function prior to any pelvic organ prolapse repair","Percentage of patients having a documented assessment of sexual function prior to surgery for pelvic organ prolapse","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of female patients whoundergo a preoperativeassessment of sexual function","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapsesurgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posterior repairs)57200, 57260, 57265(colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair) 58400, uterine suspension57120 colpocleisis","None","Since surgeries to correct urinary incontinence and pelvic organ prolapse in women aim to improve quality of life, itis also important to assess sexual function, which affects quality of life and often improves after these types ofsurgeries. By assessing preoperative sexual function, we will be able to assess if sexual function is regained,improves, or worsens after these types of surgeries. Because urinary incontinence and pelvic organ prolapse tend tooccur in middle age, these are modifiable conditions that can be successfully treated and contribute to healthy agingand improved quality of life."]
["X3746","Preoperative assessment of occult stress urinary incontinence prior to any pelvic organ prolapse repair","Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients undergoingpreoperative assessmentincluding: 1) history asking aboutincontinence and its character. 2)Urinalysis documented 3)physical exam testing for stressincontinence or occult stressincontinence if patient deniessymptoms of stress incontinence.","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapsesurgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posteriorrepairs)57200, 57260, 57265(colporrhaphy and combined)57268, 57270, 57556 (enterocelerepair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair)58400, uterine suspension57120 colpocleisis","• Patients with a gynecologic or otherpelvic malignancy noted at the time ofhysterectomy","When a woman with pelvic organ prolapse experiences urinary leakage only when the prolapse is reduced, hercondition is called an occult stress urinary incontinence. The underlying cause may be urethral compression orurethral kinking. The percentage of patients in whom evidence of occult stress urinary incontinence is discoveredprior to prolapse surgery varies from 23 to 69%. According to the guidelines of the German society of obstetrics andgynecology, a stress test with and without reduction of the prolapse should be conducted prior to prolapse surgery .Guidelines of the International Continence Society go even further, stating urodynamic investigations with andwithout stress test should be included in the diagnostic workup of patients prior to prolapse surgery.While several studies have shown improved urinary incontinence rates following prolapse surgery that included ananti‐incontinence component, the potential risks of adding another procedure must be considered as well. Asystematic review and meta‐analysis of randomized trials concluded that in the group of women with occult stressurinary incontinence there is a lower incidence of objective stress urinary incontinence after combined(prolapse+sling) surgery 22% versus 52% with no difference in bladder storage symptoms, urgency incontinence,and long‐term obstructive voiding symptoms. However, to benefit from this data and to support good decision‐making, the surgeon must determine whether there is or isn't occult stress incontinence preoperatively.In a recent study we found that 78.6% of patients had a pre‐operative stress test and that 93.5% of high volumesurgeons evaluated their patients for occult prior to surgery for pelvic organ prolapse while 63% of low volume surgeons and 72% of intermediate volume surgeons did."]
["X3744","Proportion of patients sustaining a major viscous injury at the time of any pelvic organ prolapse repair","Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscous at the time of index surgery that is recognized intraoperative or within 1 month after surgery","Outcome","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","The number of patients receivinga major viscous injury with repairat the time of initial surgery orsubsequently up to 1 month postoperatively","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapse surgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posterior repairs)57200, 57260, 57265(colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair) 58400, uterine suspension57120 colpocleisis","• Patients with a gynecologic or otherpelvic malignancy noted at the time ofhysterectomy","There are numerous approaches to surgical correction of pelvic organ prolapse‐ vaginal, open, laparoscopic androbotic. The incidence of visceral injury ranges from 0.1‐4% ( SGS Systemic Review Obstet Gynecol 2008: 112: 1131‐1142) depending on the approach with high potential for morbidity. Unrecognized injury to the intestine increasesthe risk of mortality from 2 to 23 % (Chapron et al. J Am Coll Surg. 1991;185:461‐465, Baggish, MS J Gynecol Surg.2003;19:63‐73). It is critically important for surgeons who are performing these procedures to recognize and repairany visceral injuries intraoperatively, in order to minimize postoperative morbidity, including the need forsubsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate ofvisceral injury during pelvic organ prolapse repair would potentially benefit from interventions to improve thequality of their surgical care."]
["X3743","Proportion of patients sustaining a bladder injury at the time of any pelvic organ prolapse repair","Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery","Outcome","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Total number of patient'sreceiving a bladder injury at thetime of surgery to repair a pelvicorgan prolapse with repair duringthe procedure or subsequentlyup to 1 month post‐surgery","Denominator = All patientsundergoing anterior or apicalpelvic organ prolapse (POP)surgery: All patients with any ofthe following prolapse surgerycodes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)57200, 57260, 57265(colporrhaphy and combined)57268, 57270, 57556 (enterocelerepair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair)58400, uterine suspension 57120 colpocleisis","Exclusions: • Patients with a gynecologicor other pelvic malignancy noted at thetime of hysterectomyExceptions: Patients having concurrentsurgery involving bladder neoplasia orotherwise to treat a bladder specificproblem","Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgeryfor pelvic organ prolapse. It is critically important for surgeons who are performing these procedures to recognizeand repair any bladder injury intraoperatively, in order to minimize postoperative morbidity, including the need forsubsequent surgical intervention to address these complications. Surgeons who have a higher than expected rate ofbladder injury during pelvic organ prolapse repair would potentially benefit from interventions to improve thequality of their surgical care."]
["X3745","Preoperative pessary for pelvic organ prolapse attempted","The percentage of patients who have attempted pessary placement for the treatment of pelvic organ prolapse prior to surgical intervention","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients that whohave attempted pessaryplacement for the treatment ofpelvic organ prolapse prior tosurgical intervention. Thesewould be identified by chartreview or entry into the Registry.","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapsesurgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posteriorrepairs)57200, 57260, 57265(colporrhaphy and combined)57268, 57270, 57556 (enterocelerepair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair)58400, uterine suspension57120 colpocleisis","Patients requiring surgery for agynecologic condition who also haveconcurrent prolapse surgery. For examplea patient with endometrial cancer whohas a concurrent prolapse surgery","Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected(Obstet and Gynecol 2004; 104: 489‐96). The mainstay of conservative care for pelvic organ prolapse is utilization ofa vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGSmembers, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931‐5. Experts notethat it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852‐60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated withthis low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147‐147). As a woman'slifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6):1201‐6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. Ina recent study we found that 38% (219/575) of patients actually tried a pessary with their surgeon before beingoperated on for pelvic organ prolapse."]
["X3750","Preoperative pessary for pelvic organ prolapse offered","The percentage of patients who have been offered a pessary for the treatment of pelvic organ prolapse prior to surgical intervention.","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients that whohave been offered a pessary forthe treatment of pelvic organprolapse prior to surgicalintervention. These would beidentified by chart review orentry into the Registry.","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapsesurgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posteriorrepairs)57200, 57260, 57265 (colporrhaphy and combined) 57268, 57270, 57556 (enterocele repair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair) 58400, uterine suspension57120 colpocleisis","Patients requiring surgery for agynecologic condition who also haveconcurrent prolapse surgery. For examplea patient with endometrial cancer whohas a concurrent prolapse surgery","Pelvic organ prolapse is a common condition with >50% of women presenting for routine gynecologic affected(Obstet and Gynecol 2004; 104: 489‐96). The mainstay of conservative care for pelvic organ prolapse is utilization of a vaginal pessary. Pessaries provide offer low risk improvement in patient symptomology. In a study of AUGSmembers, 77% reported offering a pessary prior to surgery (Obstet Gynecol. 2000; 95(6 Pt 1): 931‐5. Experts notethat it is appropriate to offer nonsurgical management to most people with POP (Obstet Gynecol 2012;119(4): 852‐60). Yet in a study of approx 35,000 Medicare beneficiaries with pelvic organ prolapse only 12% were treated with this low risk, minimally invasive option (Female Pelvic Med Reconstr Surg. 2013; 19(3): 147‐147). As a woman's lifetime risk of surgery for incontinence or POP has now doubled to 20% by age 80 (Obstet Gynecol 2014; 123(6): 1201‐6), it important that patients are offered pessaries for management prior to pursuing surgical interventions. In a recent study we found that 77% (443/575) of surgeons offered their patients a pessary prior to surgery for pelvicorgan prolapse."]
["X3751","Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair","Percentage of patients undergoing surgical repair of pelvic organ prolapse who have a documented, complete characterization of the degree of prolapse in each vaginal compartment, using one of the accepted, objective measurement systems (POP‐Q or Baden/Walker)","Process","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients that receiveda complete characterization ofeach vaginal compartment usingan objective measurement ofstage or grade of pelvic organprolapse (i.e. POPQ, orBaden/Walker) as part of theassessment and evaluation oftheir pelvic organ prolapse. Thesewould be identified by chartreview or entry into the Registry.","Denominator = All patientsundergoing pelvic organ prolapse(POP) surgery: All patients withany of the following prolapsesurgery codes:57280, 57282, 57283, 57425(colpopexies)57240, 57284, 57285, 57423(anterior repairs)45560, 57250, 57210 (posteriorrepairs)57200, 57260, 57265(colporrhaphy and combined)57268, 57270, 57556 (enterocelerepair)58263, 58270, 58280, 58292,58294 (hyst w/ enterocele repair)58400, uterine suspension57120 colpocleisis","None","Implementing this quality measure will lead to a more complete pre‐operative evaluation of pelvic organ prolapse(POP) which will result in: 1) more appropriate surgery performed with better surgical outcomes, lower recurrencerates, and fewer re‐operations for POP, 2) prevention of unnecessary surgery and 3) improved ability to assesssurgical outcomes over time.Reoperation rates for recurrent POP have been shown to be as high as 30%. It is self‐evident that if one does notidentify a defect in a specific compartment, one is unlikely to correct it. Failure to identify the full extent of POP atthe time of initial surgery has been implicated as a significant cause of repeat surgery for POP, as recurrencefollowing the initial surgery commonly occurs early in the post‐operative period and often involves a differentcompartment than that addressed during the initial surgery.ACOG guidelines recommend that when POP surgery is performed defects in all compartments should be addressedusing a standardized reproducible exam. Anger et al proposed a series of quality indicators (QI’s) for the purpose ofmeasuring and comparing the care provided to women with prolapse in different clinical settings. The QI’s werebased on the Assessing the Care of Vulnerable Elders (ACOVE) project and evaluated using the “RANDAppropriateness Method”. One of the QI’s identified and validated by the panel was: a standardized exam for POPusing the Pelvic Organ Prolapse Quantification scale (POP‐Q) should be conducted and the prolapse stage of eachcompartment documented prior to undertaking surgical intervention to correct pelvic organ prolapse. The authorsaffirmed that objective standardized assessment of vaginal prolapse pre‐operatively ensures that the selectedprocedure is the most appropriate. In addition the POP‐Q provides a means of assessing surgical outcomes. Finally,the panel concluded that woman with asymptomatic POP of stage 1 or less should not be offered surgicalintervention. The final QI was determined to prevent physicians from offering surgical therapy to women with noindication for surgery. The assignment of Stage 1 prolapse is predicated on conducting an objective standardizedexam for vaginal prolapse. (POPQ). In a recent study we found that 67.6% (431/638) of women had a Baden Walker or POP‐Q prior to the exam and that 91% of high volume surgeons vs 41% of low volume surgeons completed eithera POP‐Q or a Baden‐Walker formal evaluation of pelvic organ prolapse prior to surgery."]
["X3752","Performing cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury","Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.","Outcome","American Urogynecologic Society","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Numerator is the number ofpatients in whom anintraoperative cystoscopy wasperformed to evaluate for lowerurinary tract injury at the time ofhysterectomy for pelvic organ prolapse.","The number of patientsundergoing hysterectomy forpelvic organ prolapse.Hysterectomy (identified by CPTcodes) performed for theindication of pelvic organ prolapse (identified by supportingICD9/ICD10 codes) The prolapsecodes for ICD9 ‐> ICD‐10 aredetailed below, respectively:618.01\t‐> N81.10, Cystocele, midline618.02\t‐> N81.12, Cystocele, lateral618.03\t‐> N81.0, Urethrocele618.04\t‐> N81.6, Rectocele618.05\t‐> N81.81, Perineocele618.2\t‐> N81.2, Incomplete uterovaginal prolapse618.3\t‐> N81.3, Complete uterovaginal prolapse618.4\t‐> N81.4, Uterovaginal prolapse, unspecified618.6\t‐> N81.5, Vaginal enterocele618.7\t‐> N81.89, Old laceration of muscles of pelvic floor618.81\t‐> N81.82, incompetence or weakening of pubocervical tissue618.82\t‐> N81.83, incompetence or weakening of rectovaginal tissue618.83\t‐> N81.84, pelvic muscle wastingCPT codes for hysterectomy are: 57530 Trachelectomy58150 Total AbdominalHysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s) 58152 Total Abdominal Hysterectomy (Corpus and Cervix), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s), with Colpo‐Urethrocystopexy (e.g. Marshall‐Marchetti‐Krantz, Burch) 58180 Supracervical Abdominal Hysterectomy (Subtotal Hysterectomy), w/ or w/out Removal of Tube(s), w/ or w/out Removal of Ovary(s)58260 Vaginal Hysterectomy, for Uterus 250 G or Less58262 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s)58263 Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s), and/or Ovary(s), with Repair of Enterocele58267 Vaginal Hysterectomy, for Uterus 250 G or Less, with Colpo‐ Urethrocystopexy (Marshall‐ Marchetti‐Krantz Type, Pereyra Type), w/ or w/out Endoscopic Control58270 Vaginal Hysterectomy, for Uterus 250 G or Less, with Repairof Enterocele 58275 Vaginal Hysterectomy, with Total or Partial Vaginectomy 58280 Vaginal Hysterectomy, with Total or Partial Vaginectomy, with Repair of Enterocele58290 Vaginal Hysterectomy, for Uterus Greater than 250 G 58291 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58292 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s), with Repair of Enterocele58293 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Colpo‐Urethrocystopexy (Marshall‐Marchetti‐Krantz Type, Pereyra Type)58294 Vaginal Hysterectomy, for Uterus Greater than 250 G, with Repair of Enterocele58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s)58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G 58544 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58550 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less58552 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s)58553 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G58554 Laparoscopy, Surgical, with Vaginal Hysterectomy, for Uterus Greater than 250 G, with Removal of Tube(s) and/or Ovary(s)58570 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less58571 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus 250 G or Less, with Removal of Tube(s) and/or Ovary(s)58572 Laparoscopy, Surgical, with Total Hysterectomy, for Uterus Greater than 250 G58573 Laparoscopy, Surgical, withTotal Hysterectomy, for Uterus Greater than 250 G, with Removalof Tube(s) and/or Ovary(s)","None","Lower urinary tract (bladder and/or ureter(s)) injury is a common complication of prolapse repair surgery, occurringin up to 5% of patients. Delay in detection of lower urinary tract injury has an estimated cost of $54, 000 per injury(Visco et al), with significant morbidity for patients who experience them. Universal cystoscopy may detect up to97% of all injuries at the time of surgery (Ibeanu et al, 2009), resulting in the prevention of significant morbidity andproviding significant cost savings (over $108 million per year) In a recent study we found that 84.5% (539/638)performed cystoscopy 97% of high volume surgeons performed a cystoscopy at the time of hysterectomy for pelvicorgan prolapse while low volume surgeons performed this procedure only 75 % of the time (p<.001)."]
["X3747","Door to puncture time for endovascular stroke treatment","Door to puncture time less than 2 hours for patients undergoing endovascular stroke treatment","Intermediate\nOutcome","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with acute ischemicstroke undergoing endovascularstroke treatment who have adoor to puncture time of lessthan 2 hours","All patients with acute ischemicstroke undergoing endovascularstroke treatment","Patients who are transferred from oneinstitution to another with a knowndiagnosis of acute ischemic stroke forendovascular stroke treatment; In‐patients with newly diagnosed acuteischemic stroke considered forendovascular stroke treatment","Acknowledgment of the critical importance of time to reperfusion for obtaining favorable outcomes in myocardialreperfusion treatments has led to the formation of initiatives such as Door to Balloon. The impressive results inshortening the time to myocardial reperfusion for acute MI obtained by such initiatives provided an impetus forlaunching similar initiatives related to IV tPA for stroke.This measures is supported by the multispecialty guidelines published in 2013 (1).1. Sacks, D., C. M. Black, et al. (2013). \"\"Multisociety Consensus Quality Improvement Guidelines for IntraarterialCatheter‐directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, CanadianInterventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society forCardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventionalSurgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and InterventionalNeurology.\"Journal of vascular and interventional radiology : JVIR 24(2): 151‐163."]
["X3756","Clinical Outcome post Endovascular Stroke Treatment","Patients with 90 day mRs score of 0 to 2 post endovascular stroke intervention","Outcome","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients with acute ischemicstroke undergoing endovascularstroke treatment who have amRs of 0 to 2 at 90 days","All patients with acute ischemicstroke undergoing endovascularstroke treatment","None","The standard definition of a good clinical outcome from IA therapy is an mRS score of 0‐2 at 90 days as assessed by acertified examiner independent of the interventional physician.This measures is supported by the multispecialty guidelines published in 2013 (1).1. Sacks, D., C. M. Black, et al. (2013). \"\"Multisociety Consensus Quality Improvement Guidelines for IntraarterialCatheter‐directed Treatment of Acute Ischemic Stroke, from the American Society of Neuroradiology, CanadianInterventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society forCardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventionalSurgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology.\" Journal of vascular and interventional radiology : JVIR 24(2): 151‐163."]
["X3754","Rate of surgical conversion from lower extremity endovascular revascularization procedure","In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure","Outcome","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients undergoingmajor amputation or opensurgical bypass within 48 hours ofthe index endovascular lowerextremity revascularizationprocedure","Patients undergoing endovascularlower extremity revascularization","Patient in denominator with plannedhybrid or staged procedure","Conversions from a planned lower extremity endovascular revascularization procedure to a surgical procedureindicates either poor patient assessment/procedural assignment, or procedural failure. This represents a patientcare quality measure. Patients who undergo unplanned surgical conversion have a higher cost of care and highermorbidity and mortality. There is a higher expense for dual procedures, with use of endovascular tools and surgicalprocedural time and equipment, as well as longer length of stay and rehabilitation. Studies show higher rates of limbsalvage in patients with foot ulcers after surgical or catheter based restoration of arterial blood flow than withmedical therapy alone, but there is insufficient robust data to indicate better outcomes with endovascular or openbypass treatment of arterial insufficiency in this patient group. (1) Both amputation‐free survival and quality of lifeoutcomes have been shown to be comparable for patients with critical limb ischemia treated with either openbypass or endovascular repair, but the bypass‐first strategy has been shown to be more costly. (2) There are manystudies suggesting benefit of an endovascular‐first approach to limb salvage because of the proposed patientbenefits, including ability to avoid general anesthesia for these procedures, avoidance of a surgical incision andattendant healing time, shorter length of hospital stay with endovascular revascularization when compared tobypass, strong patient preference for endovascular approaches, and decreased cost of a successful endovascularapproach. Although long term limb salvage outcomes are equivalent regardless of the initial strategy adopted, somedata indicate a high rate of early technical failure of endovascular treatment of critical limb ischemia, but highsecondary patency rates and high limb conservation rates in spite of initial technical failures, indicating that repeatprocedures, both endovascular and open, tend to be successful in this patient group. A meta‐analysis of 30 studiesof below knee angioplasty showed a higher technical failure rate of endovascular treatment than that seen withopen (bypass) repair. (3) This same meta‐analysis reports that repeat procedures in patients with endovascular‐firstfailures were more likely to be bypass procedures than repeated endovascular procedures. Another study of 1023patients undergoing either endovascular or open surgical treatment for critical limb ischemia demonstrated a higherrate of secondary surgical procedures in the endovascular group compared with the surgical group, but againshowed comparable 5 year limb salvage rates in the two groups. (4) Notably, it has been demonstrated that thedifference in patency rates and differences in rates of conversion to bypass appear to be partly related to thespecialty of the operator, based on studies of procedural failure and open conversion rates in different physiciangroups. Two large studies of extracted data, one of Medicare claims data assessing mortality, transfusion rates,intensive care unit use, length of stay, and subsequent repeat revascularization procedures or amputation (5), andone of National Inpatient Sample (NIS) data reviewing in‐hospital mortality and iatrogenic arterial injuries (6),showed statistically significant differences in outcomes across physician groups. One of these studies (Zafar, et al) suggested that there may be a higher use of repeat intervention, including adjunctive, unplanned surgical bypass, and a higher rate of amputation following a primary endovascular procedure in some physician cohorts. The reasons for this discrepancy are unclear, and may represent patient selection, operator bias towards endovascular revascularization in all comers, technical ability, or other factors. The newly‐approved NHLBI trial, Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia, proposes to look at outcomes, including open conversions and amputations, in a cohort of patients randomized to open vs endovascular therapy. This trial will be multidisciplinary, evaluating all specialists involved in procedural care of this group of patients, and will ultimately provide guidance for physicians in terms of patient assignment to open vs endovascular care, and will establish solid data to support thresholds for conversion and amputation. However, data will not be available for years to come.This measure proposes, based on the data available in the existing literature, to track use of repeat or unplanned adjunctive surgical (bypass or amputation) procedures in patients undergoing revascularization procedures for lower extremity arterial insufficiency. It is expected that this rate should be equivalent across all physician groups performing endovascular procedures when adjusted for specific patient risk factors. With establishment of a baseline benchmark rate for conversion to surgical therapy based on existing data from the Medicare sample, rates of conversion may be tracked to encourage appropriate patient selection or referral to expert operators to improve patient outcomes and reduce excessive resource use by selection of the most appropriate procedure and procedural operator.1.\tHinchliffe RJ et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metabolism Research and Reviews 2012; 28(Suppl. 1):179‐ 217.2.\tAdam DJ et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet 2005;366:1925‐34.3.\tRomiti M, et al. Meta‐analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975‐81.4.\tSöderström MI et al. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First‐Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis. Annals of Surgery 2010;252:765‐773.5.\tZafar AM et al. Lower‐Extremity Endovascular Interventions for Medicare Beneficiaries: Comparative Effectiveness as a Function of Provider Specialty, J Vasc Interv Radiol 2012; 23:3–9.6.\tEslami MH et al. Peripheral arterial interventions: Trends in market share and outcomes by specialty, 1998‐2005; JVasc Surg 2009;50:1071‐8."]
["X3755","Percentage of patients with a retrievable inferior vena cava filter who are appropriately assessed for continued filtration or device removal","Proportion 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.","Outcome","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients in whom aretrievable IVC filter is placedwho, within 3 months post‐placement, either have a) thefilter removed; b) documentedre‐assessment for theappropriateness of filter removal;or c) documentation of at leasttwo attempts to reach thepatient to arrange a clinical re‐assessment for the appropriateness of filter removal","All patients who have a retrievableIVC filter placed with the intent forpotential removal at time ofplacement","None","Retrievable filter complications have been increasingly noted in the FDA MAUDE database and in the literature. Retrievable filters were designed differently than permanent filters and the incidence of device relatedcomplications with long term insertions are higher than in comparison to permanent filters. The FDA hasrecommended that physicians that place these filters, carefully monitor these patients and remove these filters atthe earliest possible time. The proposed quality measure will encourage physicians who place filters to follow‐upwith their patients at 3 months and document that a decision has been made to either a) remove the filter, b)document that re‐assessment has established the appropriateness of continued filter use or c) documentation of atleast two attempts to reach the patient, proxy or primary care provider to arrange a clinical re‐assessment for theappropriateness of filter removal. Dedicated follow‐up for IVC filters has led to an increase in retrieval rate (1).FDA recommends that all physicians placing IVC Filters and those responsible for ongoing care of these patients,remove the filter as soon as protection from PE is no longer needed. The FDA encourages follow‐up on patients toconsider risks and benefits of filter removal (2,3,4). Data on IVC Filters will be collected through the PRESERVE trialwhich is sponsored by teh IVC Filter Study Group Foundation. This trial will look at commercially available IVC Filters(retrievable) from participating manufacturers. The study objective is to evaluate the safety and effectiveness ofparticipating IVC Filters in subjects with clinical need for mechanical prophylaxis of PE.1. Improving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic JeetMinocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu,Robert J. LewandowskiJournal of Vascular and Interventional Radiology ‐ December 2010 (Vol. 21, Issue 12, Pages 1847‐1851, DOI:10.1016/j.jvir.2010.09.003)2. “Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Uses.” August, 9,2010.http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm221707.htm3. “Removing Retrievable Inferior Vena Cava Filters: Initial Communication.” August 9, 2010.http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm221676.htmImproving Inferior Vena Cava Filter Retrieval Rates: Impact of a Dedicated Inferior Vena Cava Filter Clinic JeetMinocha, Ibrahim Idakoji, Ahsun Riaz, Jennifer Karp, Ramona Gupta, Howard B. Chrisman, Riad Salem, Robert K. Ryu,Robert J. LewandowskiJournal of Vascular and Interventional Radiology ‐ December 2010 (Vol. 21, Issue 12, Pages 1847‐1851, DOI:10.1016/j.jvir.2010.09.003)4. “Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication.” Amy 6, 2014.http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm"]
["X3739","Percentage of patients treated for varicose veins who are treated with saphenous ablation and receive an outcomes survey before and after treatment","Percentage of patients treated for varicose veins (CEAP C2) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that receive a disease specific patient reported outcome survey before and after treatment.","Patient\nReported\nOutcome","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Number of patients who aretreated for varicose veins withsaphenous ablation and receivean outcomes survey before andafter treatment","All patients who are treated forvaricose veins with saphenousablation","None","Surrogate measures for success of saphenous ablation have numerous flaws. The ultimate measure of success ofsaphenous ablation in patients with varicose veins is improved quality of life. This quality measure motivatesphysicians to assess quality of life after an ablation as compared with before an ablation to understand theimprovement in quality of life that they offer their patients. Eventually, some threshold for improvement based ondisease state may serve as a benchmark for quality care. The Intersocietal Accreditation Commission‐Vein CenterDivision strongly recommends the use of the disease specific patient reported outcome (PRO) instrument beforeand after ablation and to use the data collected for an analysis of the quality of care being delivered by the center(1).These guidelines have been created by the IAC and are being implemented by several groups including SVS.1. “Vein Center Accreditation A Process to Demonstrate a Commitment to Quality Vein Care.” March 11, 2014.http://www.veindirectory.org/magazine/article/vein_center_accreditation_a_process_to_demonstrate_a_commitment_to_quality_vein_careThe American Venous Forum recommends the use of PRO before and after vein treatment for all patients (2).2. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines ofthe Society for Vascular Surgery and the American Venous Forum.” May 2011.http://www.bendvein.com/downloads/Journal‐Vascular‐Surgery.pdf"]
["X3735","Communication and shared decision‐making with patients and families for interventional oncology procedures","Percentage of patients who have undergone an interventional oncology ablation or catheter‐ directed therapy with documentation that the intent of the procedure (e.g., cure, downstaging to curative resection/transplantation, prolongation of survival, palliation) was  discussed with the patient and/or family member","Process","Society of Interventional Radiology","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who have undergone apercutaneous ablationprocedure, bland embolization ofa malignancy,chemoembolization orradioembolization withdocumentation that the intent ofthe procedure was discussedwith the patient, and/or familymember","Patients who have undergone apercutaneous ablation procedure,bland embolization of amalignancy, chemoembolizationor radioembolization","None","As with any cancer therapy, patients and family members may misunderstand or not know the intent of aninterventional oncologic procedure. This measure aims to enhance the patient experience with health care byincreasing patient and family understanding of their care and to promote an environment of shared decision‐making. The American Society of Clinical Oncology has a similar practice guideline for medical oncologists providingchemotherapy."]
["X3732","Adult Kidney Disease: Referral to Hospice","Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care","Process","Renal Physicians Association; joint copyright with American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients who are referred tohospice care","All patients aged 18 years andolder with a diagnosis of ESRDwho withdraw from hemodialysisor peritoneal dialysis","Documentation of patient reason(s) fornot referring to hospice care (e.g., patientdeclined, other patient reasons)","Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those whochoose not to start or to discontinue dialysis. With the patient’s consent, a multi‐professional team with expertise inrenal palliative care, including nephrology professionals, family or community‐based professionals, and specialisthospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritualaspects of treatment for these patients, including end‐of‐life care. Physical and psychological symptoms should beroutinely and regularly assessed and actively managed. The professionals providing treatment should be trained inassessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate supportto enable this option."]
["X3780","Coagulation studies in adult patients presenting with chest pain with no coagulopathy or bleeding","Percentage of emergency department patients aged 18 years and older without coagulopathy or bleeding who received coagulation studies","Process","American College of Emergency Physicians","Medicare Physician Quality Reporting System, Medicare Shared Savings, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Denominator patients whoreceived coagulation studies (PTor PTT tests)","All emergency departmentpatients aged 18 years and olderpresenting with chest pain,without coagulopathy or bleeding","Exclusions:• Diagnosis of stroke• Diagnosis of TIA• Diagnosis of DVT •\tDiagnosis of Acute Coronary Syndromes•\tChronic liver disease•\thereditary coagulopathy (286 and286.Xcoagulation defects), hematologic diseases (289 and 289.X other blood disease•\ttaking or being prescribed anticoagulant, anti‐platelet or coagulation cascade modifying therapy, or documented concern for coagulopathy or DIC.•\tPregnancy codes•\tPatients receiving TPA for strokeExceptions:•\ttraumatic injury with concern for DIC•\tmedical illness with concern for DIC","Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient.Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resourceutilization without any decrease in value of healthcare provided to the patient."]
["X3778","Imaging in pediatric ED patients aged 2 through 17 years with minor head injury","Percent of pediatric patients who presented within 24 hours of a non‐penetrating head injury with a Glasgow coma score (GCS) of 14 or 15 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines (PECARN) prior to imaging","Process","American College of Emergency Physicians","Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","\"Number of denominatorpatients classified as low riskaccording to the PECARN clinicalpolicy for mild traumatic braininjury prior to imagingIdentification as low‐risk:‐ No signs of altered mentalstatus‐ No signs of basilar skull fracture‐ No history of LOC‐ No history of vomiting‐ No severe mechanism of injury‐ No severe headache\"","Number of patients aged 2 to 17years undergoing head CT fortrauma who presented within 24hours of a non‐penetrating headinjury with a Glasgow Coma Scale(GCS) of 14 or 15","Exclusions:\"• Ventricular shunt• Multisystem trauma• Coagulopathy‐ History of bleeding disorder such ashemophilia‐ History of clotting disorder‐ Documented concern for coagulopathy‐ Current treatment with ananticoagulant medication below:§ Argatroban§ Arixtra (Fondaparinux)§ Fragmin (Dalteparin)§ Heparin IV§ Innohep (Tinzaparin) § Lovenox (Enoxaparin)§ Pradaxa (Dabigatran)§ Warfarin (Coumadin)•\tThrombocytopenia or patients on any of the following medications affecting platelet function:‐ Aggrenox (ASA/dipyridamole)‐ Plavix (Clopidogrel)‐ Ticlid (Ticlopidine)\"","This measure is needed to close the gap in provider performance as patients with mild closed head injuries withoutguideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcareexpenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. A new study inJAMA demonstrated to a growing trend in ED visits for TBI, with adults older than 60 years accounting for the largestincrease in rates."]
["X3733","Pediatric Kidney Disease: Discussion of Care Planning","Percentage of patients aged 17 years and younger with a diagnosis of ESRD on hemodialysis or peritoneal dialysis for whom there is documentation of a discussion regarding care planning","Process","Renal Physicians Association; joint copyright with American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Physician Quality Reporting System, Physician Compare, Physician Feedback/Quality and Resource Utilization Reports, Physician Value‐Based Payment Modifier","Patients for whom there isdocumentation of a discussionregarding care planning Note:Although the discussion can takeplace with other providers, thephysician overseeing the dialysisshould confirm that theconversation has beenundertaken either [i] directly bythe nephrologist or dialysiscenter staff, or [ii] by anotherphysician overseeing thepatient’s care.Discussion should result in a planto establish treatment goalsbased on patient's medicalcondition and prognosis.Discussion must endorse a familycentered approach andtreatment goals must bedetermined. The benefits andburdens of dialysis should bediscussed, and the quality of the life of the individual be taken into account. Kidney transplant should be discussed ifappropriate.","All patients aged 17 years andyounger with a diagnosis of ESRDon hemodialysis or peritonealdialysis","None","Institute family‐centered care planning for children and adolescents with CKD and ESRD. The plan should establishtreatment goals based on a child’s medical condition and prognosis. (RPA, 2010) Care planning should be an ongoingprocess in which treatment goals are determined and revised based on observed benefits and burdens of dialysisand the values of the pediatric patient and the family. The renal care team should designate a person to be primarilyresponsible for ensuring that care planning is offered to each patient. Patients with decision‐making capacity shouldbe strongly encouraged to talk to their parents to ensure that they know the patient’s wishes and agrees to makedecisions according to these wishes. Ongoing discussions that include reestablishing goals of care based on thechild’s response to medical treatment and optimal quality of life is the mechanism by which care planning occurs.Discussions should include pros and cons of dialysis as well as potential morbidity associated with dialysis. Kidneytransplantation should also be discussed if appropriate. (RPA, 2010)"]
["X2809","ALS Multidisciplinary Care Plan Developed or Updated","Percentage of patients diagnosed with ALS for whom a multi‐disciplinary care plan was developed, if not done previously, and the plan was updated at least once annually.","Process","American Academy of Neurology","Medicare Shared Savings","Patients for whom a multi‐disciplinary care plan wasdeveloped, if not donepreviously, and the plan wasupdated at least once annually.","All patients with a diagnosis ofamyotrophic lateral sclerosis.","A system reason exclusion has beenincluded for patients who have noinsurance to cover the cost of amultidisciplinary care plan.","In specialized multidisciplinary clinics, patients with ALS receive comprehensive care from a neurologist,pulmonologist, gastroenterologist, physiatrist, social worker, occupational therapist, speech language pathologist,respiratory therapist, specialized nurse case manager, physical therapist, dietitian, psychologist, dentist, and/orpalliative care expert.1,2 Moreover, the level of satisfaction with the rendering of the diagnosis and overall satisfaction with care is significantly higher for patients attending a multidisciplinary clinic.2 Specialized clinics coordinate care and interface with a primary care physician, local neurologist and community‐based services. Patients who attend specialized ALS clinics are younger and have longer symptom duration than neurology clinic patients, indicating possible referral bias.3 Patient care and survival were examined for 97 patients attending specialized ALS clinics in Italy compared with 124 patients in neurology clinics.4 There was increased utilization of riluzole, percutaneous endoscopic gastrostomy (PEG), and noninvasive ventilation (NIV) in the ALS clinics, and fewer hospital admissions. Mean survival was longer in specialized ALS clinics (1,080 days vs. 775 days, p=0.008). Using COX multivariate analysis, attending an ALS specialized clinic independently predicted longer survival for patients.Prolonged survival (7.5 months, p<0.0001) was found for patients in Ireland attending multidisciplinary ALS clinics.5 Patients at ALS clinics were younger and more likely to receive riluzole (99% vs. 61%). Multidisciplinary care was an independent predictor of survival (p=0.02) and reduced the risk of death by 47% in a 5‐year study.5 Dutch patients in multidisciplinary ALS clinics (n=133) were compared with 75 patients receiving general care6 (6). Patients were well‐matched and data were collected by a blinded nurse. Patients in multidisciplinary clinic received more aids and appliances (93% vs. 81%, p =0.008) and had higher quality of life (SF‐36® Health Survey, p <0.01). Beneficial effects derived from a single visit to a multidisciplinary clinic, suggesting better coordination of care. Importantly, patients attending multidisciplinary clinics had fewer hospital admissions and shorter inpatient stays than those cared for inthe community."]
["E2082","HIV Viral Load Suppression","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","Outcome","Health Resources and Services Administration (HRSA) ‐ HIV/AIDS Bureau","Medicare Shared Savings","Number of patients in thedenominator with a HIV viral loadless than 200 copies/mL at lastHIV viral load test during themeasurement year","Number of patients, regardless ofage, with a diagnosis of HIV withat least one medical visit in themeasurement year","None","Viral load suppression is a critical component of the HIV care continuum and the ultimate outcome of HIVcare/treatment.1. HIV Trialists´ Collaborative Group. Zidovudine, didanosine, andzalcitabine in the treatment of HIV infection: meta‐analyses of the randomized evidence. Lancet. Jun 12 1999;353(9169):2014‐2025.2. Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir inpersons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDSClinical Trials Group 320 Study Team. N Engl J Med. Sep 11 1997; 337(11):725‐733.3. Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death inindividuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009; 4(5):e5575.4. Mocroft A, Vella S, Benfield TL, et al. Changing patterns of mortality across Europe in patients infected with HIV‐1.EuroS IDA Study Group. Lancet. Nov 28 1998; 352(9142):1725‐1730.5. Hogg RS, Yip B, Chan KJ, et al. Rates of disease progression by baseline CD4 cell count and viral load after initiatingtriple‐drug therapy. JAMA. Nov 28 2001; 286(20):2568‐2577. 6.\tSterne JA, May M, Costagliola D, et al. Timing of initiation of antiretroviral therapy in AIDS‐free HIV‐1‐infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet. Apr 18 2009; 373(9672):1352‐1363.7.\tBaker JV, Peng G, Rapkin J, et al. CD4+ count and risk of non‐AIDS diseases following initial treatment for HIV infection. AIDS. Apr 23 2008; 22(7):841‐848.8.\tPalella FJ, Jr., Deloria‐Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV‐infected personsin different CD4+ cell strata. Ann Intern Med. Apr 15 2003; 138(8):620‐626.9.\tCain LE, Logan R, Robins JM, et al. When to initiate combined antiretroviral therapy to reduce mortality and AIDS‐ defining illness in HIV‐infected persons in developed countries: an observational study. Ann Intern Med. Apr 19 2011; 154(8):509‐515.10.\tSevere P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV‐infected adults in Haiti. N Engl J Med. Jul 15 2010; 363(3):257‐265.11.\tKitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009; 360(18):1815‐1826.12.\tWriting Committee of the CASCADE Collaboration. Timing of HAART initiation and clinical outcomes in human immunodeficiency virus type 1 seroconverters. Arch Intern Med. Sep 26 2011; 171(17):1560‐1569.13.\tAtta MG, Gallant JE, Rahman MH, et al. Antiretroviral therapy in the treatment of HIV‐associated nephropathy. Nephrol Dial Transplant. Oct 2006; 21(10):2809‐2813.14.\tSchwartz EJ, Szczech LA, Ross MJ, Klotman ME, Winston JA, Klotman PE. Highly active antiretroviral therapy and the epidemic of HIV+ end‐stage renal disease. J Am Soc Nephrol. Aug 2005; 16(8):2412‐2420.15.\tKalayjian RC, Franceschini N, Gupta SK, et al. Suppression of HIV‐1 replication by antiretroviral therapy improves renal function in persons with low CD4 cell counts and chronic kidney disease. AIDS. Feb 19 2008; 22(4):481‐487.16.\tCalmy A, Gayet‐Ageron A, Montecucco F, et al. HIV increases markers of cardiovascular risk: results from a randomized, treatment interruption trial. AIDS. May 15 2009; 23(8):929‐939.17.\tKuller LH, Tracy R, Belloso W, et al. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. PLoS Med. Oct 21 2008; 5(10):e203.18.\tTorriani FJ, Komarow L, Parker RA, et al. Endothelial function in human immunodeficiency virus‐infected antiretroviral naive subjects before and after starting potent antiretroviral therapy: The ACTG (AIDS Clinical Trials Group) Study 5152s. J Am Coll Cardiol. Aug 12 2008; 52(7):569‐576.19.\tMellors JW, Rinaldo CR, Jr., Gupta P, White RM, Todd JA, Kingsley LA. Prognosis in HIV‐1 infection predicted by the quantity of virus in plasma. Science. May 24 1996; 272(5265):1167‐1170.20.\tVlahov D, Graham N, Hoover D, et al. Prognostic indicators for AIDS and infectious disease death in HIV‐infected injection drug users: plasma viral load and CD4+ cell count. JAMA. Jan 7 1998; 279(1):35‐40.21.\tAnastos K, Kalish LA, Hessol N, et al. The relative value of CD4 cell count and quantitative HIV‐1 RNA in predicting survival in HIV‐1‐infected women: results of the women´s interagency HIV study. AIDS. Sep 10 1999; 13(13):1717‐ 1726.22.\tO´Brien TR, Blattner WA, Waters D, et al. Serum HIV‐1 RNA levels and time to development of AIDS in the Multicenter Hemophilia Cohort Study. JAMA. Jul 10 1996; 276(2):105‐110.23.\tEgger M, May M, Chene G, et al. Prognosis of HIV‐1‐infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. Jul 13 2002; 360(9327):119‐129.24.\tAnastos K, Barron Y, Cohen MH, et al. The prognostic importance of changes in CD4+ cell count and HIV‐1 RNA level in women after initiating highly active antiretroviral therapy. Ann Intern Med. Feb 17 2004; 140(4):256‐264.25.\tO´Brien WA, Hartigan PM, Martin D, et al. Changes in plasma HIV‐1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS. N Engl J Med. Feb 15 1996; 334(7):426‐431.26.\tHughes MD, Johnson VA, Hirsch MS, et al. Monitoring plasma HIV‐1 RNA levels in addition to CD4+ lymphocyte count improves assessment of antiretroviral therapeutic response. ACTG 241 Protocol Virology Substudy Team. Ann Intern Med. Jun 15 1997; 126(12):929‐938.27.\tChene G, Sterne JA, May M, et al. Prognostic importance of initial response in HIV‐1 infected patients starting potent antiretroviral therapy: analysis of prospective studies. Lancet. Aug 30 2003; 362(9385):679‐686.28.\tDeeks SG, Gange SJ, Kitahata MM, et al. Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy‐experienced patients with HIV infection in North America. Clin Infect Dis. Nov 15 2009; 49(10):1582‐1590.29.\tQuinn TC, Wawer MJ, Sewankanbo N, et al. for the Rakai Project Study Group. Viral Load and heterosexual transmission of human immunodeficiency virus type‐1. NEJM 2000;342:921‐929.30.\tChakraborty H., Sen, PK, Helms, RW, et.al. Viral burden in genital secretions determines male‐to‐female sexual transmission of HIV‐1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621‐7.31.\tBaeten JM, Kahle E, Lingappa JR, et al, Partners in Prevention HSV/HIV Transmission Study Team. Genital HIV‐1 RNA predicts risk of heterosexual HIV‐1 transmission. Sci Transl Med. 2011 Apr 6;3(77):77ra29.32.\tGulick RM, Mellors JW, Havlir D, et al. Treatment with indinavir, zidovudine, and lamivudine in adults with human immunodeficiency virus infection and prior antiretroviral therapy. N Engl J Med. 1997 Sep 11;337(11):734‐9.33.\tZhang H, Dornadula G, Beumont M, et al. Human immunodeficiency virus type 1 on the semen of men receiving highly active antiretroviral therapy. N Engl J Med 1998;339:1803‐1809.34.\tVernazza PL, Troiani L, Flepp MJ, et al, The Swiss HIV Cohort Study. Potent antiretroviral treatment of HIV‐ infection results in suppression of the seminal shedding of HIV. AIDS. 2000 Jan 28;14(2):117‐21.35.\tCu‐Uvin S, Caliendo AM, Reinert S, et al. Effect of highly active antiretroviral therapy on cervicovaginal HIV‐1 RNA. AIDS. 2000 Mar 10;14(4):415‐21.36.\tKotler DP, Shimada T, Snow G, et al. Effect of combination antiretroviral therapy upon rectal mucosal HIV RNA burden and mononuclear cell apoptosis. AIDS. 1998 Apr 16;12(6):597‐604.37.\tCohen MS, Chen YQ, McCauley M, et al. Prevention of HIV‐1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493‐505.38.\tHughes JP, Baeten JM, Lingappa JR, et al. Determinants of Per‐Coital‐Act HIV‐1 Infectivity Among African HIV‐1‐ Serodiscordant Couples. J Infect Dis. Feb 2012;205(3):358‐365.transmission of HIV‐1: a probabilistic empiric model. AIDS, 2001 Mar 30;15(5):621‐7."]
["E2079","HIV medical visit frequency","Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6‐month period of the 24‐month measurement period with a minimum of 60 days between medical visits","Process","Health Resources and Services Administration (HRSA) ‐ HIV/AIDS Bureau","Medicare Shared Savings","Number of patients in thedenominator who had at leastone medical visit in each 6‐monthperiod of the 24‐monthmeasurement period with aminimum of 60 days betweenfirst medical visit in the prior 6‐month period and the lastmedical visit in the subsequent 6‐month period. (Measurementperiod is a consecutive 24‐monthperiod of time","Number of patients, regardless ofage, with a diagnosis of HIV withat least one medical visit in thefirst 6 months of the 24‐monthmeasurement period","Patients who died at any time during the24‐month measurement period.","Retention is a critical component of the HIV care continuum. Although HIV viral suppression is the ultimate outcomeof HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap‐around supportive services within HIV care."]
["X3481","Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure","Percentage of patients aged 65 years and older with congestive heart failure who had a target improvement goal defined after completing an initial patient‐reported functional status assessment and met the goal after completing a follow‐up functional status assessment","Patient\nReported\nOutcome","National Committee for Quality Assurance","Medicare Shared Savings","Patients who completed initialand follow‐up functional statusassessments using a qualifyingtool, set a goal with theirprovider for a change in functional status score and who met the target goal by the follow‐up functional status assessment","Adults aged 65 years and olderwho had at least one outpatientencounter during themeasurement year and an activediagnosis of heart failure","Patients with severe cognitiveimpairment","Goal‐setting addresses patient engagement, a high priority of the National Quality Strategy and CMS. Only 4 of 64measures in the 2014 measure set address this domain. Evidence suggests that physicians rarely conduct functionalstatus assessments for patients with congestive heart failure."]
["X3302","Closing the Referral Loop ‐ Specialist Report Sent to Primary Care Physician","Percentage of referrals received for which the receiving provider sent a consultant report back to the referring provider.","Process","National Committee for Quality Assurance","Medicare Shared Savings","Referrals received for which aconsultant report is sent back tothe referring provider","Referrals received by a providerduring the measurement period.","None","There is evidence that the communication between primary care physicians and specialists is inadequate. Thismeasure intends to improve the communication between primary and specialty care and enhance care continuity."]
["E0712","Depression Utilization of the PHQ‐9 Tool","Adult patients age 18 and older with the diagnosis of major depression or dysthymia (ICD‐ 9 296.2x, 296.3x or 300.4) who have a PHQ‐9 tool administered at least once during the four month measurement period.","Process","MN Community Measurement","Medicare Shared Savings","Adult patients age 18 and olderwith the diagnosis of majordepression or dysthymia (ICD‐9296.2x, 296.3x or 300.4) whohave a PHQ‐9 tool administeredat least once during the fourmonth measurement period.","Adults age 18 and older; no upperage limitHave the diagnosis of majordepression or dysthymia definedby any of the following ICD‐9codes:296.2x Major depressive disorder,single episode296.3x Major depressive disorder,recurrent episode300.4 Dysthymic disorderFor primary care providers thediagnosis codes can be in anyposition (primary or secondary).For behavioral health providersthe diagnosis codes need to be inthe primary position. This is tomore accurately define majordepression and exclude patientswho may have other more seriousmental health diagnoses (e.g.schizophrenia, psychosis) with asecondary diagnosis of depression.","Denominator exclusions include death,permanent nursing home resident orreceiving hospice or palliative care anytime during the measurement period.Bipolar Disorder or Personality Disorder(in any position), ICD‐9 Codes include:296.00, 296.01, 296.02, 296.03, 296.04,296.05, 296.06, 296.10, 296.11, 296.12,296.13, 296.14, 296.15, 296.16, 296.40,296.41, 296.42, 296.43, 296.44, 296.45,296.46, 296.50, 296.51, 296.52, 296.53,296.54, 296.55, 296.56, 296.60, 296.61,296.62, 296.63, 296.64, 296.65, 296.66,296.7, 296.80, 296.81, 296.82, 296.89,301.0, 301.1, 301.10, 301.11, 301.12,301.1 , 301.2, 301.20, 301.21, 301.22,301.3, 301.4, 301.5, 301.50, 301.51,301.59, 301.6, 301.7, 301.8, 301.81,301.82, 301.83, 301.84, 301.89, 301.9","Process measure, administration of the PHQ‐9 tool, that is paired with and supports the outcome measures ofremission and response"]
["X2147","Total Per Capita Cost measure for Medicare fee‐for‐ service Beneficiaries","The ratio of all actual Medicare FFS Parts A and B payments to a medical group practice for beneficiaries attributed to it over a calendar year to all expected payments to the medical group practice, multiplied by the payment for the average beneficiary in the sample.","Cost/\nResource\nUse","Centers for Medicare & Medicaid Services","Medicare Shared Savings","The sum of the payment‐standardized actual MedicarePart A and Part B costs during thecalendar year for all Medicarebeneficiaries who wereattributed to the medical grouppractice, multiplied by the actualMedicare FFS Part A and Part Bpayments for the averagebeneficiary in the sample. Note:Actual costs above the 99^{th}percentile are set to the cost atthe 99^{th} percentile.","The sum of the payment‐standardized expected (based onbeneficiary medical histories)Medicare Part A and Part B costsduring the calendar year for allMedicare beneficiaries who wereattributed to the medical grouppractice.","Exclusions:• Beneficiaries without Medicare FFSParts A and B coverage for all 12 monthsof the calendar year• Beneficiaries who died in the calendaryear• Beneficiaries without a prior calendaryear Hierarchical Condition Category riskscore (which is used to computeexpected beneficiary costs)• Beneficiaries for whom non‐risk‐adjusted total Medicare costs were in thebottom one percent of the distribution ofcosts for all beneficiaries• Beneficiaries who resided outside theUnited States• Beneficiaries attributed to a RuralHealth Clinic, Federally Qualified HealthCenter, Method 2 Critical Access Hospital,or Elected Teaching AmendmentHospitals.","Addresses gap in cost/resource use and aligns with VM"]
["X3715","Prevention Quality Indicators #90 (PQI #90)","Prevention Quality Indicators (PQI) overall composite per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short‐term complications, diabetes with long‐term complications, uncontrolled diabetes without complications, diabetes with lower‐extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection.","Outcome","Agency for Healthcare Research & Quality","Medicare Shared Savings","Discharges, for patients ages 18years and older, that meet theinclusion and exclusion rules forthe numerator in any of thefollowing PQIs:• PQI #1 Diabetes Short‐TermComplications Admission Rate• PQI #3 Diabetes Long‐TermComplications Admission Rate• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate•\tPQI #7 Hypertension Admission Rate•\tPQI #8 Heart Failure Admission Rate•\tPQI #10 Dehydration Admission Rate•\tPQI #11 Bacterial Pneumonia Admission Rate•\tPQI #12 Urinary Tract Infection Admission Rate•\tPQI #13 Angina Without Procedure Admission Rate•\tPQI #14 Uncontrolled Diabetes Admission Rate•\tPQI #15 Asthma in Younger Adults Admission Rate•\tPQI #16 Lower‐Extremity Amputation among Patients with Diabetes RateDischarges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the compositenumerator.","Population ages 18 years andolder in metropolitan area† orcounty. Discharges in thenumerator are assigned to thedenominator based on themetropolitan area or county of thepatient residence, not themetropolitan area or county of thehospital where the dischargeoccurred.","None","Addresses prevention and is a composite with PQIs already in program."]
["E2111","Antipsychotic Use in Persons with Dementia","The percentage of individuals 65 years of age and older with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.","Process","Pharmacy Quality Alliance","Medicare Shared Savings","The number of patients in thedenominator who had at leastone prescription and > 30 dayssupply for any antipsychotic medication during the measurement period and do not have a diagnosis of schizophrenia, bipolar disorder, Huntington’s disease orTourette’s Syndrome.","All patients 65 years of age andolder continuously enrolled duringthe measurement period with adiagnosis of dementia and/or two or more prescription claims and>60 days supply for a cholinesterase inhibitor or an NMDA receptor antagonist.","None","Recommended by MAP for dual eligible beneficiaries."]
["E0055","Comprehensive Diabetes Care: Eye Exam","The percentage of members 18‐75 years of age with diabetes (type 1 and type 2) who received a retinal or dilated eye exam during the measurement year or a negative retinal or dilated eye exam in the year prior to the measurement year.","Process","National Committee for Quality Assurance","Medicare Shared Savings","Members who received an eyescreening for diabetic retinaldisease. This includes diabeticswho had the following:‐ A retinal or dilated eye exam byan eye care professional(optometrist or ophthalmologist)in the measurement yearOR‐ A negative retinal exam ordilated eye exam (negative forretinopathy) by an eye careprofessional in the year prior tothe measurement year.For exams performed in the yearprior to the measurement year, aresult must be available.","Members 18‐75 years of age bythe end of the measurement yearwho had a diagnosis of diabetes(type 1 or type 2) during themeasurement year or the yearprior to the measurement year.","Exclude members with a diagnosis ofpolycystic ovaries who did not have aface‐to‐face encounter, in any setting,with a diagnosis of diabetes during themeasurement year or the year prior tothe measurement year. Diagnosis mayoccur at any time in the member’shistory, but must have occurred by theend of the measurement year.Exclude members with gestational orsteroid‐induced diabetes who did nothave a face‐to‐face encounter, in anysetting, with a diagnosis of diabetesduring the measurement year or the yearprior to the measurement year. Diagnosismay occur during the measurement yearor the year prior to the measurementyear, but must have occurred by the endof the measurement year.","Clinically important area for at risk population and aligns with PQRS and MU"]
["E0056","Diabetes: Foot exam","The percentage of patients 18‐75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year.","Process","National Committee for Quality Assurance","Medicare Shared Savings","Patients who received a footexam (visual inspection witheither a sensory exam or a pulseexam) during the measurementyear.","Patients 18‐75 years of age by theend of the measurement year whohad a diagnosis of diabetes (type 1or type 2) during themeasurement year or the yearprior to the measurement year.","Exclude patients with a diagnosis ofpolycystic ovaries who did not have aface‐to‐face encounter, in any setting,with a diagnosis of diabetes during themeasurement year or the year prior tothe measurement year. Diagnosis may occur at any time in the patient’s history, but must have occurred by the end of the measurement year. Exclude patients with gestational or steroid‐induced diabetes who did not have a face‐to‐face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred by the end of the measurement year.","Clinically important area for at risk population and aligns with PQRS and MU"]
["E0070","Coronary Artery Disease (CAD): Beta‐Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)","\"Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta‐blocker therapy There are two reporting criteria for this measure: (1) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% OR (2) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have prior myocardial infarction\"","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Shared Savings","REPORTING CRITERIA 1: Patientswho were prescribed beta‐blocker therapyREPORTING CRITERIA 2: Patientswho were prescribed beta‐blocker therapy","REPORTING CRITERIA 1: Allpatients aged 18 years and olderwith a diagnosis of coronary arterydisease or history of cardiacsurgery seen within a 12 monthperiod who also have a current orprior LVEF < 40%REPORTING CRITERIA 2: Allpatients aged 18 years and olderwith a diagnosis of coronary arterydisease or history of cardiacsurgery seen within a 12 monthperiod who also have prior MI","Documentation of medical reason(s) fornot prescribing beta‐blocker therapy(e.g., allergy, intolerant, bradycardia, AVblock without permanent pacemaker,arrhythmia, hypotension, asthma, othermedical reasons)Documentation of patient reason(s) fornot prescribing beta‐blocker therapy(e.g., patient declined, other patientreasons)Documentation of system reason(s) fornot prescribing beta‐blocker therapy(e.g., other reasons attributable to thehealth care systemDocumentation of patient reason(s) fornot prescribing aspirin or clopidogrel(e.g., patient declined, other patientreasons) Documentation of system reason(s) for not prescribing aspirin or clopidogrel (e.g., lack of drug availability, other reasons attributable to the health care system)","Clinically important area for at risk populations."]
["E0067","Coronary Artery Disease (CAD): Antiplatelet Therapy","Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Shared Savings","Patients who were prescribedaspirin or clopidogrel","All patients aged 18 years andolder with a diagnosis of coronaryartery disease seen within a 12month period","Documentation of medical reason(s) fornot prescribing aspirin or clopidogrel(e.g., allergy, intolerant, receiving otherthienopyridine therapy, bleedingcoagulation disorders, receiving warfarintherapy, other medical reasons)Documentation of patient reason(s) fornot prescribing aspirin or clopidogrel(e.g., patient declined, other patientreasons)Documentation of system reason(s) fornot prescribing aspirin or clopidogrel(e.g., lack of drug availability, otherreasons attributable to the health caresystem)","Clinically important area and aligns with PQRS"]
["X1033","Coronary Artery Disease (CAD): Symptom Management:","Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period","Process","American Medical Association ‐Physician Consortium for Performance Improvement","Medicare Shared Savings","Patients with appropriatemanagement of anginalsymptoms within a 12 monthperiod","All patients aged 18 years andolder with a diagnosis of coronaryartery disease seen within a 12month period with an evaluationof level of activity and anassessment of whether anginalsymptoms are present or absent","None","Clinically important topic and aligns with PQRS"]
["E0171","Acute Care Hospitalization (Claims Based)","Percentage of home health stays in which patients were admitted to an acute care hospital during the 60 days following the start of the home health stay.","Outcome","Centers for Medicare & Medicaid Services","Medicare Shared Savings","Number of home health stays forpatients who have a Medicareclaim for an admission to anacute care hospital in the 60 days following the start of the home health stay.","Number of home health stays thatbegin during the 12‐monthobservation period. A homehealth stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.","Home health stays that begin with a LowUtilization Payment Adjustment (LUPA)claim. Home health stays in which thepatient receives service from multiple agencies during the first 60 days. Home health stays for patients who are not continuously enrolled in fee‐for‐service Medicare for the 6 months prior to and the 60 days following the start of thehome health stay or until death.","Addresses a gap of post‐acute outcome measures and supports alignment with Home Health quality reporting."]
["E0052","Use of Imaging Studies for Low Back Pain","The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x‐ray, MRI, CT scan) within 28 days of the diagnosis. The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur).","Process","National Committee for Quality Assurance","Medicare Shared Savings","Members who received animaging study (plain x‐ray, MRI,CT scan) conducted on the indexepisode start date or in the 28days following the index episodestart date.A diagnosis code from Table LBP‐A must be in conjunction with animaging study code in Table LBP‐D.","All members aged 18 years at thebeginning of the measurementyear to 50 years by the end of themeasurement year who had anoutpatient or ED encounter with aprincipal diagnosis of low backpain during period starting at thebeginning of the measurementyear through 28 days prior to theend of the measurement year","Exclude patients with a low back paindiagnosis during the 180 days prior to theindex episode start date.Exclude patients who have a diagnosis forwhich an imaging study in the presenceof low back pain is clinically indicated.‐ Cancer: Exclude members who with adiagnosis of cancer. Look as far back aspossible in the member’s history through28 days after the index episode startdate.‐ Recent trauma, intravenous drug abuse,neurological impairment: Excludemembers who have any of thesediagnoses in the 12 months prior to theindex episode start date through 28 daysafter the index episode start date.","Aligns with PQRS"]
["E0514","MRI Lumbar Spine for Low Back Pain","This measure calculates the percentage of MRI of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims‐based evidence of antecedent conservative therapy. Antecedent conservative therapy may include (see subsequent details for codes): 1. Claim(s) for physical therapy in the 60 days preceding the Lumbar Spine MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the Lumbar Spine MRI. 3. Claim(s) for evaluation and management in the period >28 days and <60 days preceding the Lumbar Spine MRI.\"","Efficiency","Centers for Medicare & Medicaid Services","Medicare Shared Savings","MRI of the lumbar spine studieswith a diagnosis of low back pain(from the denominator) withoutthe patient having claims‐basedevidence of prior antecedentconservative therapy.","MRI of the lumbar spine studieswith a diagnosis of low back painon the imaging claim.","Indications for measure exclusion includeany patients with the followingprocedures or diagnosis codes:• Patients with lumbar spine surgery inthe 90 days prior to MRI:• Cancer (Within 12 months prior to MRIprocedure. A cancer exclusion diagnosismust be in one of the diagnoses fields ofany inpatient, outpatient or Carrier claims) • Trauma: (Within 45 days prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims)•\tIV Drug Abuse: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.)•\tNeurologic Impairment: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.)•\tHuman Immunodeficiency Virus (HIV): (Within 12 months prior to MRI procedure An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.)•\tUnspecified Immune Deficiencies: (Within 12 months prior to MRI procedure. An exclusion diagnosis must be in one of the diagnoses fields of any inpatient, outpatient or Carrier claims.)•\tIntraspinal abscess: (An exclusion diagnosis must be in one of the diagnoses fields on the MRI lumbar spine claim.)","Addresses imaging efficiency/utilization gap and supports program alignment."]
["E0513","Thorax CT: Use of Contrast Material","This measure calculates the ratio of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both). The measure is calculated based on a one year window of claims data.","Efficiency","Centers for Medicare & Medicaid Services","Medicare Shared Savings","The number of thorax CT studieswith and without contrast(combined studies).","The number of thorax CT studiesperformed (with contrast, withoutcontrast or both with and withoutcontrast).","None","Addresses gaps in imaging efficiency, utilization, and patient safety while supporting alignment with other qualityreporting programs."]
["E2158","Payment‐ Standardized Medicare Spending Per Beneficiary (MSPB)","The MSPB Measure assesses the cost of services performed by hospitals and other healthcare providers during an MSPB hospitalization episode, which comprises the period immediately prior to, during, and following a patient’s hospital stay. Beneficiary populations eligible for the MSPB calculation include Medicare beneficiaries enrolled in Medicare Parts A and B who were discharged from short‐ term acute hospitals during the period of performance.","Cost/\nResource\nUse","Centers for Medicare & Medicaid Services","Medicare Shared Savings","The numerator for a hospital’sMSPB Measure is the hospital’saverage MSPB Amount, which isdefined as the sum ofstandardized, risk‐adjustedspending across all of a hospital’seligible episodes divided by thenumber of episodes for thathospital.","The denominator for a hospital’sMSPB Measure is the medianMSPB Amount across all episodesnationally.","None","Addresses gap of cost/resource use and aligns with other quality reporting programs."]
["E2083","Prescription of HIV Antiretroviral Therapy","Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year","Process","Health Resources and Services Administration (HRSA) ‐ HIV/AIDS Bureau","Medicare Shared Savings","Number of patients from thedenominator prescribed HIVantiretroviral therapy during themeasurement year","Number of patients, regardless ofage, with a diagnosis of HIV withat least one medical visit in themeasurement year","None","Prescription of HIV antiretroviral therapy is a critical component of the HIV care continuum. Although HIV viralsuppression is the ultimate outcome of HIV care/treatment, retention is a strongly associated with viral suppression and is the outcome for the wrap‐around supportive services within HIV care."]
["S2510","Skilled Nursing Facility All‐Cause 30 Day Post Discharge Readmission Measure","This measure estimates the risk‐standardized rate of all‐cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee‐for‐service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions. A risk‐adjusted readmission rate for each facility is calculated as follows: Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk‐ standardized ratio is the indicator of a facility’s effects on readmission rates. Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility‐ level standardized readmission rate. For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 ‐ 5 for a list of planned procedures. The measure specifications are designed to harmonize with CMS’s hospital‐wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital‐ level, risk‐standardize rate of unplanned, all‐ cause readmissions within 30 days of a hospital discharge and uses the same 30‐day risk window as the SNFRM.","Outcome","Centers for Medicare & Medicaid Services","Medicare Shared Savings, Skilled Nursing Facility Value‐Based Purchasing Program","The numerator is defined as therisk‐adjusted estimate of thenumber of unplannedreadmissions that occurredwithin 30 days from dischargefrom the prior proximal acutehospitalization.","The denominator includes allpatients who have been admittedto a SNF within one day ofdischarge from a prior proximalhospitalization, takingdenominator exclusions intoaccount.","Numerator exclusions: We exclude forplanned readmissions as per the HWRmeasure.Denominator exclusions: The followingare excluded from the denominator:1. SNF stays where the patient had one ormore intervening post‐acute care (PAC)admissions (inpatient rehabilitationfacility [IRF] or long‐term care hospital[LTCH]) which occurred either betweenthe prior proximal hospital discharge andSNF admission or after the SNF discharge,within the 30‐day risk window. Alsoexcluded are SNF admissions where thepatient had multiple SNF admissions afterthe prior proximal hospitalization, withinthe 30‐day risk window. 2.\tSNF stays with a gap of greater than 1 day between discharge from the prior proximal hospitalization and the SNF admission.3.\tSNF stays where the patient did not have at least 12 months of FFS Medicare enrollment prior to the proximal hospital discharge (measured as enrollment during the month of proximal hospital discharge and for the 11 months prior to that discharge).4.\tSNF stays in which the patient did not have FFS Medicare enrollment for the entire risk period (measured as enrollment during the month of proximal hospital discharge and the month following the month of discharge).5.\tSNF stays in which the principal diagnosis for the prior proximal hospitalization was for the medical treatment of cancer. Patients with cancer whose principal diagnosis from the prior proximal hospitalization was for other diagnoses or for surgical treatment of their cancer remain in the measure.6.\tSNF stays where the patient was discharged from the SNF against medical advice.7.\tSNF stays in which the principal primary diagnosis for the prior proximal hospitalization was for “rehabilitation care; fitting of prostheses and for theadjustment of devices”.","The Skilled Nursing Facility All‐Cause 30 Day Post Discharge Readmission Measure is a SNF VBP measure."]
["X3629","30 Day Unplanned Readmissions for Cancer Patients","Number of hospital‐specific 30‐day unscheduled and potentially avoidable readmissions following hospitalization among diagnosed malignant cancer patients","Outcome","Alliance of Dedicated Cancer Centers","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Total number of unscheduledreadmissions within 30 days ofindex admission","Total PPS‐Exempt Cancer Centeradmissions within the reportingyear for patients [aged 18+]discharged alive from the facilitywith an active malignant cancerdiagnosis","Numerator Exclusions: Medicalexclusions (1P) only are permitted for thismeasure, for example, patients whodevelop metastatic disease progressionand/or planned therapy (for examplechemotherapy)Denominator Exclusions:1. Patients readmitted to another acutecare centerRationale: Full data for admissionsoutside of index facility may beunavailable. This also includes admissionsfor primary diagnoses of psychiatricdisease (cared for in separate psychiatricor rehabilitation centers and do notcompare to acute care facilities).2. Patients that left Against MedicalAdvice in the index admissionRationale: Hospital had limitedopportunity to implement high qualitycare.3. Patients that were transferred toAnother Acute Care facility in the indexadmissionRationale: This does not capture thetarget population of patients who maybenefit from the specifications of themeasure.4. Admissions for patients without 30days of post‐discharge dataRationale: This is necessary in order toidentify readmissions in the dataset. 5. Admissions for patients without a complete enrollment history for the 12 months prior to admissionRationale: This is necessary to capture historical data for (pending) riskadjustment.","Readmission rates can be used as a source of both quality improvement and cost containment, contributing to thetriple aim of the Patient Protection and Affordable Care Act; better health, better care, and lower healthcare costsfor patients.The many facets and subsequent variation of readmissions across facilities demonstrate the need for a standardizedmethodology of data collection. Moreover, differentiation between organic disease and complications (potentiallyrequiring reoperation) is necessary to accurately determine quality of care (Brown et al.).The proposed measure addresses a cancer‐specific patient population, specified for PPS‐Exempt Cancer Centersoperating within the United States. The reduction in variability for patient diagnoses as well as care settingpromotes the development of an optimized measure to yield the greatest benefit to patients (i.e., one that has beenspecified for their unique conditions/diagnoses). For the purpose of this measure, “costs” should be understood tocomprehensively include1. The physiologic, psychologic, and monetary detriment to the patient2. Financial cost to the institution, and3. Potential cost to the practicing surgeon (when higher readmission rates are used as surrogates for substandardcare in quality improvement circles) (Brown et al).The outcome measured counts the number of all unplanned readmissions for patients who meet the specifieddenominator criteria. Unplanned readmissions are captured from acute clinical events requiring urgent re‐hospitalization within 30 days of discharge (from an index admission). This standardized time frame is necessary sothat patients may be uniformly compared, and the 30‐day time frame is chosen for its proven clinical significance inreadmission rates (see attached references). Note that a readmission is also eligible as an index admission if it meetsall other eligibility criteria. If the first admission after discharge is planned, then no readmission is considered in theoutcome, regardless of whether a subsequent unplanned readmission takes place because it would be unfair toattribute the unplanned readmission back to the care received during the index admission (consistent with NQF‐ endorsed measure #1789; 30‐Day Hospital‐Wide All‐Cause Unplanned Readmission, which excludes patientsadmitted to a PPS‐Exempt Cancer Center and patients receiving medical treatment for cancer)."]
["E1641","Hospice and Palliative Care-Treatment Preferences","Percentage of patients with chart documentation of preferences for life sustaining treatments.","Process","University of North Carolina - Chapel Hill","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Patients whose medical recordincludes documentation of lifesustaining preferences","Seriously ill patients enrolled inhospice OR receiving specialtypalliative care in an acute hospitalsetting.","Patients with length of stay < 1 day inpalliative care or < 7 days in hospice","The National Priorities Partnership has identified palliative and end‐of‐life care as one of its national priorities. Agoal of this priority is to ensure that all patients with life‐limiting illness have the right to express preferences thatguide use of invasive or life‐sustaining forms of treatment.(1) The affected populations are large; in 2009, 1.56million people with life‐limiting illness received hospice care.(2) In 2008, 58.5% of US hospitals with 50 or more bedshad some form of palliative care service, and national trends show steady expansion of these services.(3) Patientsand family caregivers rate control over treatment decisions as a high priority when living with serious and life‐limiting illnesses. (4) From a recent systematic review of clinical trials, moderate evidence supports \"care planningthrough engaging values, involving skilled facilitators, and focusing on key decision makers.” These studies foundimproved outcomes of patient‐physician communication, improved satisfaction with care, and increased hospiceenrollment.(5) The more recently published Coping with Cancer Study, a prospective observational study of over300 patients with advanced cancer, found that communication of patient treatment preferences was associatedwith use of treatments honoring those preferences and wish lesser use of aggressive, high‐cost treatments.(6,7) Thismeasure will enhance patient autonomy, facilitate patient‐centered decision‐making, and communicate patientpreferences via documentation to other treating providers.1.http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=6082. NHPCO Facts and figures: hospice care in America 2010 editionhttp://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct‐2010.pdf3. Center to Advance Palliative Care http://www.capc.org/news‐and‐events/releases/04‐05‐104.Singer PA, Martin DK, Kelner M. Quality end‐of‐life care: patients´ perspective. JAMA 1999; 281: 163‐168.5. Lorenz KA, Lynn J, Dy SM et al. Evidence for improving palliative care at the end of life: a systematic review. AnnIntern Med 2008: 148:147‐159.6. Wright AA, Mack JW, Kritek PA, Balboni TA, Massaro AF, Matulonis UA, Block SD, Prigerson HG. Influence ofpatients’preferences and treatment site on cancer patients’ end of life care. Cancer. 2010 Oct 1;;116(19):4656‐63.7. Wright AA, Zhang B, Ray A et al. Associations between end‐of‐life discussions, patient mental health, medical carenear death,and caregiver bereavement adjustment. JAMA 2008; 300:1665‐1673."]
["E0221","Needle biopsy to establish diagnosis of cancer precedes surgical excision/resection","Percentage of patients presenting with AJCC Stage Group 0, I, II, or III disease, who undergo surgical excision/resection of a primary breast tumor who undergo a needle biopsy to establish diagnosis of cancer preceding surgical excision/resection.","Process","American College of Surgeons","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Patient whose date of needlebiopsy precedes the date ofsurgery.","Women with AJCC Stage 0, I, II, orII breast cancer undergoingsurgery:• Women• Age ≥18 at time of diagnosis• Known or assumed first or onlycancer diagnosis• Primary tumors of the breast• Epithelial invasive malignancyonly• Surgically treated• Diagnosis and all or part of firstcourse of treatment performed atthe reporting facility","Exclusions:Men; not a first or only cancer diagnosis;non‐epithelial tumors; metastatic disease(AJCC Stage IV); not treated surgically;died before surgery","Improve the utilization of needle biopsy prior to surgery for breast cancer with resultant decreased morbidity andincreased cost effectiveness, and patient satisfaction Williams RT, Yao KT, Stewart AK et al. Needle versus excisional biopsy for noninvasive and invasive breast cancer, report from the National Cancer Data Base 2003‐2008. Ann Surg Oncol 2011;18(13):3802‐10. 2. Friese CR, Neville BA, Edge SB et al. Breast biopsy patterns and outcomes in Surveillance, Epidemiology, and End Results‐Medicare data. Cancer 2009;115(4):716‐24. 3. Holloway CM,Saskin R, Paszat L. Geographic variation and physician specialization in the use of percutaneous biopsy for breast cancer diagnosis. Can J Surg 2008;51(6):453‐63. 4. Clarke‐Pearson EM, Jacobson AF, Boolbol SK et al. Quality assurance initiative at one institution for minimally invasive breast biopsy as the initial diagnostic technique. J AmColl Surg 2009;208(1):75‐8."]
["E0219","Post breast conservation surgery irradiation","Percentage of female patients, age 18‐69, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC stage I, II, or III, receiving breast conserving surgery who receive radiation therapy within 1 year (365 days) of diagnosis.","Process","American College of Surgeons","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Radiation therapy to the breast isinitiated within 1 year (365 days)of the date of diagnosis","Include, if all of the followingcharacteristics are identified:WomenAge 18‐69 at time of diagnosisKnown or assumed to be first oronly cancer diagnosisPrimary tumors of the breast Epithelial malignancy only AJCC Stage I, II, or III Surgical treatment by breastconservation surgery (surgical excision less than mastectomy) All or part of 1st course of treatment performed at thereporting","Exclude, if any of the followingcharacteristics are identified:MenUnder age 18 at time of diagnosisOver age 69 at time of diagnosisSecond or subsequent cancer diagnosisTumor not originating in the breast Non‐epithelial malignancies Stage 0, in‐situ tumorStage IV, metastatic tumorNone of 1st course therapy performed at reporting facilityDied within 12 months (365 days) of diagnosis","CoC‐accredited (Commission on Cancer) facilities have the ability to submit this data. Measure is already NQF‐endorsed. There is an extensive literature demonstrating variations in the use of radiation with breast conservationsurgery based on factors including age, race/ethnicity, socioeconomic status, location of treatment, provider, tumorcharacteristics, and other factors. Daroui P, Gabel M, Khan AJ, Haffty BG, Goyal S. Utilization of breast conservingtherapy in Stage 0, I, and II breast cancer patients in New Jersey: An American College of Surgeons National CancerData Base (NCDB) Analysis. Am J Clin Oncol 2011; Feb 15(epub ahead of print). 2. Smith Gl, Shih YC, Xu Y, et al. Racialdisparities in the use of radiotherpay after breast conserving surgery: a national Medicare study. Cancer2010;11:734‐741. 3. Bickell NA, Wang JJ, Oluwole S, et al. Missed opportunities: racial disparities in adjuvant breastcancer treatment. J Clin Oncol 2006;24:1357‐1362."]
["E0225","At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer","Percentage of patients >18yrs of age, who have primary colon tumors (epithelial malignancies only), experiencing their first diagnosis, at AJCC stage I, II or III who have at least 12 regional lymph nodes removed and pathologically examined for resected colon cancer. 1b.1. Developer Rationale: Improved survival for patients","Process","American College of Surgeons","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","≥12 regional lymph nodespathologically examined.","Regional Lymph Nodes Positive","Exclude, if any of the followingcharacteristics are identified:Age <18; not a first or only cancerdiagnosis; non‐epithelial and non‐invasive tumors; metastatic disease (AJCCStage IV); not treatedsurgically at the reporting facility","CoC‐accredited (Commission on Cancer) facilities are eligible to submit data for this measure. This is a QualityImprovement measure and has already been endorsed by the CoC. Improved survival for patients with a greaternumber of lymph nodes resected ;greater accuracy of staging for patients, and consequently appropriate post‐surgical care Chang GJ, Rodriguez‐Bigas MA Skibber JM et al. Lymph node evaluation and survival after curativeresection of colon cancer: systematic review. JNCI 2007; 99(6)L433‐441. 2. Le Voyer TE, Sigurdson ER, Hamlin AL etal. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey ofintergroup trial INT‐0089. J Clin Oncol 2003; 21:2912‐2919. 3. Sarli L, Bader G, Lusco D, et al. Number of lymphnodes examined and prognosis of TNM stage II colorectal cancer. European Journal of Cancer 2005; 41:272‐279. 4.Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of T3N0 clon cancer is dependent on the number oflymph nodes examined. Ann Surg Oncol 2003; 10(1):65‐71"]
["E0431","Influenza vaccination coverage among healthcare personnel (HCP)","Percentage of healthcare personnel (HCP) who receive the influenza vaccination.","Process","Centers for Disease Control and Prevention","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","HCP in the denominatorpopulation who during the timefrom October 1 (or when thevaccine became available)through March 31 of thefollowing year:(a) received an influenzavaccination administered at thehealthcare facility, or reported inwriting (paper or electronic) orprovided documentation thatinfluenza vaccination wasreceived elsewhere; or(b) were determined to have amedicalcontraindication/condition of severe allergic reaction to eggs or to other component(s) of the vaccine, or history of Guillain‐ Barré Syndrome within 6 weeks after a previous influenza vaccination; or(c) declined influenza vaccination; or(d) persons with unknown vaccination status or who do not otherwise meet any of the definitions of the above‐ mentioned numerator categories. Numerators are to be calculated separately for each of the abovegroups.","Number of HCP who are workingin the healthcare facility for atleast 1 working day betweenOctober 1 and March 31 of thefollowing year, regardless ofclinical responsibility or patientcontact.Denominators are to be calculatedseparately for:(a) Employees: all persons whoreceive a direct paycheck from thereporting facility (i.e., on thefacility’s payroll).(b) Licensed independentpractitioners: include physicians(MD, DO), advanced practice nurses, and physician assistants only who are affiliated with the reporting facility who do not receive a direct paycheck from the reporting facility.(c) Adult students/trainees and volunteers: include all adult students/trainees and volunteers who do not receive a direct paycheck from the reporting facility.","None","Fill gap in program and for measure alignment across programs Use of this measure to monitor influenzavaccination among HCP is envisioned to result in increased influenza vaccination uptake among HCP, becauseimprovements in tracking and reporting HCP influenza vaccination status will allow healthcare institutions to betteridentify and target unvaccinated HCP. Increased influenza vaccination coverage among HCP is expected to result in reduced morbidity and mortality related to influenza virus infection among patients.1.\tHayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomized controlled trial. BMJ 2006; 333: 1241‐1246.2.\tPotter J, Stott DJ, Roberts MA, et al. Influenza vaccination of healthcare workers in long‐term‐care hospitals reduces the mortality of elderly patients. J Infect Dis. 1997; 175:1‐6.3.\tLemaitre M, Meret T, Rothan‐Tondeur M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster‐randomized trial. J Am Geriatr Soc. 2009; 57:1580‐1586.4.\tCarman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health‐care workers on mortality of elderly people in long‐term care: a randomized controlled trial. Lancet 2000; 355:93–97.5.\tTalbot TR, Babcock H, Caplan AL, et al. Revised SHEA position paper: influenza vaccination of healthcarepersonnel. Infection Control and Hospital Epidemiology 2010; 31:987‐995."]
["E1716","National Healthcare Safety Network (NHSN) Facility‐wide Inpatient Hospital‐ onset Methicillin‐\" resistant \"Staphylococcus aureus (MRSA) Bacteremia Outcome Measure","Standardized infection ratio (SIR) of hospital‐ onset unique blood source MRSA Laboratory‐ identified events (LabID events) among all inpatients in the facility","Outcome","Centers for Disease Control and Prevention","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Total number of observedhospital‐onset unique bloodsource MRSA LabID eventsamong all inpatients in the facility","Total number of expectedhospital‐onset unique bloodsource MRSA LabID events,calculated using the facility´snumber of inpatient days, bedsize,affiliation with medical school,and community‐onset MRSAbloodstream infection admissionprevalence rate.","Data from patients who are not assignedto an inpatient bed are excluded from thedenominator counts. These includeoutpatient clinic and emergencydepartment visits.","Cover gap in program and for measure alignment The SIR compares a healthcare facility´s performance compared toa national baseline. Facilities are able to see whether the number of LabID events that they have reported comparesto the number that would be expected, given national data. The measure can then be used to drive preventionpractices that will lead to improved outcomes, including the reduction of patient morbidity and mortality.Siegel, JD, et al., Guideline for Management of Multidrug‐Resistant Organisms In Healthcare Settings, 2006.Available at http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf."]
["E1717","National Healthcare Safety Network (NHSN) Facility‐wide Inpatient Hospital‐ onset Clostridium difficile Infection (CDI) Outcome Measure","Standardized infection ratio (SIR) of hospital‐ onset CDI Laboratory‐identified events (LabID events) among all inpatients in the facility, excluding well‐baby nurseries and neonatal intensive care units (NICUs)","Outcome","Centers for Disease Control and Prevention","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Total number of observedhospital‐onset CDI Lab ID eventsamong all inpatients in the facility, excluding well baby‐ nurseries and NICUs","Total number of expectedhospital‐onset CDI LabID events,calculated using the facility´s number of inpatient days, bedsize, affiliation with medical school, microbiological test used to identify C. difficile, and community‐onset CDI admission prevalence","Data from patients who are not assignedto an inpatient bed are excluded from thedenominator counts, including outpatient clinic and emergency department visits. Additionally, data from well‐baby nurseries and NICUs are excluded from the denominator count.","Addresses a gap in the programClinical guidelines for the management of C. difficile have been published. Adherence to the recommendations inthe guidelines can result in decreased rates of C. difficile transmission and infection. Decreasing rates of infectionwill result in a lower SIR, which indicates improving performance.Cohen SH, Gerding DN, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update bythe Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol, 2010. 31(5):431‐455.Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfectionand Sterilization in Healthcare Facilities, 2008. Available athttp://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee.2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.Boyce JM, Pittet D, et al. Guideline for Hand Hygiene in Health‐Care Settings: Recommendations of the Healthcare Infection Control Practices AdvisoryCommittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 2002. 51(RR‐16)."]
["E1659","InfluenzaImmunization","Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.","Process","Centers for Medicare & Medicaid Services","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Inpatient discharges who werescreened for influenza vaccinestatus and were vaccinated priorto discharge if indicated.","Acute care hospitalized inpatientsage 6 months and olderdischarged during October,November, December, January,February or March.","Excluded patients consist of thefollowing; Patients who expire prior tohospital discharge and patients with anorgan transplant during the currenthospitalization. See the 2a1.9 for ICD‐9and ICD‐10 tables for transplants.Patients who have a Length of Staygreater than 120 days. Patients who aretransferred or discharged to anotheracute care hospital. Patients who leaveAgainst Medical Advice (AMA).","Fill a measure gap in program and alignment of measures.Up to 1 in 5 people in the United States get influenza every season (CDC, Key Facts). Each year an average ofapproximately 226,000 people in the US are hospitalized with complications from influenza and between 3,000 and49,000 die from the disease and its complications (Thompson WW, JAMA). Combined with pneumonia, influenza isthe nation’s 8th leading cause of death (Minino, 2004 National Center for Health Statistics). Up to two‐thirds of alldeaths attributable to pneumonia and influenza occur in the population of patients that have been hospitalizedduring flu season regardless of age (Fedson). The Advisory Committee on Immunization Practices (ACIP)recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance ofpreventing influenza. Vaccination is associated with reductions in influenza among all age groups (CDC Press ReleaseFebruary 24, 2010). The influenza vaccination is the most effective method for preventing influenza virus infectionand its potentially severe complications. Screening and vaccination of inpatients is recommended, buthospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older."]

{"sheet":"MUC_List_2014_by_Program","index":3,"n_rows":646,"n_cols":4,"rows_kept":646,"cut":false,"hidden":false,"merged":[]}
["MUC ID","CMS Program","Measure Title","NQS Priority"]
["X3720","Ambulatory\nSurgical Center\nQuality Reporting","Unplanned Anterior Vitrectomy","Making Care Safer"]
["X3719","Ambulatory\nSurgical Center\nQuality Reporting","Normothermia Outcome","Effective Prevention and Treatment"]
["E0515","Ambulatory\nSurgical Center\nQuality Reporting","Ambulatory surgery patients withappropriate method of hair removal","Effective Prevention and Treatment"]
["E0326","Ambulatory\nSurgical Center\nQuality Reporting","Care Plan","Patient and Family Engagement"]
["X3702","Ambulatory\nSurgical Center\nQuality Reporting","O/ASPECS Overall Facility Rating","Patient and Family Engagement"]
["X3703","Ambulatory\nSurgical Center\nQuality Reporting","O/ASPECS Recommend","Patient and Family Engagement"]
["X3698","Ambulatory\nSurgical Center\nQuality Reporting","O/ASPECS About Facility and Staff","Patient and Family Engagement"]
["X3699","Ambulatory\nSurgical Center\nQuality Reporting","O/ASPECS Communication","Patient and Family Engagement"]
["X3697","Ambulatory\nSurgical Center\nQuality Reporting","O/ASPECS Discharge and Recovery","Patient and Family Engagement"]
["E0291","Hospital Outpatient\nQuality Reporting","Administrative Communication","Communication and Care Coordination"]
["E0293","Hospital Outpatient\nQuality Reporting","Medication Information","Communication and Care Coordination"]
["E1822","Hospital Outpatient\nQuality Reporting","External Beam Radiotherapy for BoneMetastases","Effective Prevention and Treatment"]
["E1898","Hospital Outpatient\nQuality Reporting","Health Literacy Measure derivedfrom the health literacy domain ofthe C‐CAT","Patient and Family Engagement"]
["E0292","Hospital Outpatient\nQuality Reporting","Vital Signs","Communication and Care Coordination"]
["E0296","Hospital Outpatient\nQuality Reporting","Nursing Information","Communication and Care Coordination"]
["E0297","Hospital Outpatient\nQuality Reporting","Procedures and Tests","Communication and Care Coordination"]
["E0295","Hospital Outpatient\nQuality Reporting","Physician Information","Communication and Care Coordination"]
["X607","Hospital Outpatient\nQuality Reporting","Use of Brain Computed Tomography(CT) in the Emergency Departmentfor Atraumatic Headache","Making Care Affordable"]
["E0294","Hospital Outpatient\nQuality Reporting","Patient Information","Communication and Care Coordination"]
["E0326","Hospital Outpatient\nQuality Reporting","Care Plan","Patient and Family Engagement"]
["X3702","Hospital Outpatient\nQuality Reporting","O/ASPECS Overall Facility Rating","Patient and Family Engagement"]
["X3703","Hospital Outpatient\nQuality Reporting","O/ASPECS Recommend","Patient and Family Engagement"]
["X3698","Hospital Outpatient\nQuality Reporting","O/ASPECS About Facility and Staff","Patient and Family Engagement"]
["X3699","Hospital Outpatient\nQuality Reporting","O/ASPECS Communication","Patient and Family Engagement"]
["X3697","Hospital Outpatient\nQuality Reporting","O/ASPECS Discharge and Recovery","Patient and Family Engagement"]
["X1970","Medicare and Medicaid EHR\nIncentive Programs for\nEligible Hospitals or Critical\nAccess Hospitals","Perinatal Care Cesarean section(PC O2) Nulliparous women with aterm, singleton baby in vertexposition delivered by cesareansection","Effective Prevention andTreatment"]
["X3323","Medicare and Medicaid EHR\nIncentive Programs for\nEligible Hospitals or Critical\nAccess Hospitals","Adverse Drug Events: ‐Inappropriate Renal Dosing ofAnticoagulants","Making Care Safer"]
["X1234","Medicare and Medicaid EHR\nIncentive Programs for\nEligible Hospitals or Critical\nAccess Hospitals","Timely Evaluation of High‐RiskIndividuals in the EmergencyDepartment","Making Care Safer"]
["X3701","Medicare and Medicaid EHR\nIncentive Programs for\nEligible Hospitals or Critical\nAccess Hospitals","Hospital‐Wide All‐CauseUnplanned Readmission HybrideMeasure","Communication and CareCoordination"]
["E0204","Hospital Inpatient\nQuality Reporting","Skill mix (Registered Nurse [RN], LicensedVocational/Practical Nurse [LVN/LPN], unlicensedassistive personnel [UAP], and contract)","Effective Preventionand Treatment"]
["X3728","Hospital Inpatient\nQuality Reporting","Hospital 30‐day, all‐cause, unplanned risk‐standardized days in acute care following acutemyocardial infarction (AMI) hospitalization","Communication andCare Coordination"]
["X3722","Hospital Inpatient\nQuality Reporting","Hospital 30‐day, all‐cause, unplanned risk‐standardized days in acute care following heart failurehospitalization","Communication andCare Coordination"]
["X3727","Hospital Inpatient\nQuality Reporting","Hospital 30‐day, all‐cause, unplanned risk‐standardized days in acute care following pneumoniahospitalization","Communication andCare Coordination"]
["E0349","Hospital Inpatient\nQuality Reporting","Transfusion Reaction (PSI 16)","Making Care Safer"]
["E2104","Hospital Inpatient\nQuality Reporting","Paired Measures 0702 and 0703; Intensive Care Unit(ICU) Length‐of‐Stay (LOS) and Intensive Care: In‐hospital mortality rate","Making Care Safer"]
["E0202","Hospital Inpatient\nQuality Reporting","Falls with injury","Making Care Safer"]
["E0141","Hospital Inpatient\nQuality Reporting","Patient fall rate","Making Care Safer"]
["E0642","Hospital Inpatient\nQuality Reporting","Cardiac Rehabilitation Patient Referral From anInpatient Setting","Effective Preventionand Treatment"]
["E0704","Hospital Inpatient\nQuality Reporting","Proportion of Patients Hospitalized with AMI that havea Potentially Avoidable Complication (during the IndexStay or in the 30‐day Post‐Discharge Period)","Making Care Safer"]
["E0708","Hospital Inpatient\nQuality Reporting","Proportion of Patients Hospitalized with Pneumoniathat have a Potentially Avoidable Complication (duringthe Index Stay or in the 30‐day Post‐Discharge Period)","Making Care Safer"]
["E0705","Hospital Inpatient\nQuality Reporting","Proportion of Patients Hospitalized with Stroke thathave a Potentially Avoidable Complication (during theIndex Stay or in the 30‐day Post‐Discharge Period)","Making Care Safer"]
["S0139","Hospital Inpatient\nQuality Reporting","National Healthcare Safety Network (NHSN) Centralline‐associated Bloodstream Infection (CLABSI)Outcome","Making Care Safer"]
["X3689","Hospital Inpatient\nQuality Reporting","Participation in a Patient Safety Culture Survey","Making Care Safer"]
["X1970","Hospital Inpatient\nQuality Reporting","Perinatal Care Cesarean section (PC O2) Nulliparouswomen with a term, singleton baby in vertex positiondelivered by cesarean section","Effective Preventionand Treatment"]
["X3323","Hospital Inpatient\nQuality Reporting","Adverse Drug Events: ‐ Inappropriate Renal Dosing ofAnticoagulants","Making Care Safer"]
["X1234","Hospital Inpatient\nQuality Reporting","Timely Evaluation of High‐Risk Individuals in theEmergency Department","Making Care Safer"]
["X3620","Hospital Inpatient\nQuality Reporting","Hospital‐level, risk‐standardized payment associatedwith an episode of care for primary elective total hipand/or total knee arthroplasty (THA/TKA)","Making CareAffordable"]
["X3701","Hospital Inpatient\nQuality Reporting","Hospital‐Wide All‐Cause Unplanned ReadmissionHybrid eMeasure","Communication andCare Coordination"]
["E0205","Hospital Inpatient\nQuality Reporting","Nursing Hours per Patient Day","Effective Preventionand Treatment"]
["S0138","Hospital Inpatient\nQuality Reporting","National Healthcare Safety Network (NHSN) Catheter‐associated Urinary Tract Infection (CAUTI) Outcome","Making Care Safer"]
["E0506","Hospital Inpatient\nQuality Reporting","Hospital 30‐day, all‐cause, risk‐standardizedreadmission rate (RSRR) following pneumoniahospitalization","Communication andCare Coordination"]
["E0468","Hospital Inpatient\nQuality Reporting","Hospital 30‐day, all‐cause, risk‐standardized mortalityrate (RSMR) following pneumonia hospitalization","Communication andCare Coordination"]
["X0351","Hospital Inpatient\nQuality Reporting","Kidney/Urinary Tract Infection Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["X0352","Hospital Inpatient\nQuality Reporting","Knee Replacement/ Revision Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["X0353","Hospital Inpatient\nQuality Reporting","Spine Fusion/ Refusion Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["X0354","Hospital Inpatient\nQuality Reporting","Cellulitis Clinical Episode‐Based Payment Measure","Making CareAffordable"]
["X0355","Hospital Inpatient\nQuality Reporting","Gastrointestinal Hemorrhage Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["X0356","Hospital Inpatient\nQuality Reporting","Hip Replacement/ Revision Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["S0139","Hospital Acquired Condition\nReduction Program","National Healthcare Safety Network (NHSN)Central line‐associated Bloodstream Infection(CLABSI) Outcome","Making Care Safer"]
["S0138","Hospital Acquired Condition\nReduction Program","National Healthcare Safety Network (NHSN)Catheter‐associated Urinary Tract Infection(CAUTI) Outcome","Making Care Safer"]
["E0506","Hospital Readmission Reduction Program","Hospital 30‐day, all‐cause, risk‐standardizedreadmission rate (RSRR) following pneumoniahospitalization","Communication andCare Coordination"]
["E1893","Hospital Value‐Based\nPurchasing","Hospital 30‐Day, All‐Cause, Risk‐StandardizedMortality Rate (RSMR) following ChronicObstructive Pulmonary Disease (COPD)Hospitalization","Effective Preventionand Treatment"]
["E0351","Hospital Value‐Based\nPurchasing","Death among surgical inpatients with serious,treatable complications (PSI 4)","Making Care Safer"]
["X2698","Hospital Value‐Based\nPurchasing","AMI episode of care (hospitalization + 30 dayspost‐discharge)","Making CareAffordable"]
["S0139","Hospital Value‐Based\nPurchasing","National Healthcare Safety Network (NHSN)Central line‐associated Bloodstream Infection(CLABSI) Outcome","Making Care Safer"]
["S0138","Hospital Value‐Based\nPurchasing","National Healthcare Safety Network (NHSN)Catheter‐associated Urinary Tract Infection(CAUTI) Outcome","Making Care Safer"]
["E0468","Hospital Value‐Based\nPurchasing","Hospital 30‐day, all‐cause, risk‐standardizedmortality rate (RSMR) following pneumoniahospitalization","Communication andCare Coordination"]
["X0351","Hospital Value‐Based\nPurchasing","Kidney/Urinary Tract Infection ClinicalEpisode‐Based Payment Measure","Making CareAffordable"]
["X0352","Hospital Value‐Based\nPurchasing","Knee Replacement/ Revision Clinical Episode‐Based Payment Measure","Making CareAffordable"]
["X0353","Hospital Value‐Based\nPurchasing","Spine Fusion/ Refusion Clinical Episode‐BasedPayment Measure","Making CareAffordable"]
["X0354","Hospital Value‐Based\nPurchasing","Cellulitis Clinical Episode‐Based PaymentMeasure","Making CareAffordable"]
["X0355","Hospital Value‐Based\nPurchasing","Gastrointestinal Hemorrhage Clinical Episode‐Based Payment Measure","Making CareAffordable"]
["X0356","Hospital Value‐Based\nPurchasing","Hip Replacement/ Revision Clinical Episode‐Based Payment Measure","Making CareAffordable"]
["E0225","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer","Effective Prevention and Treatment"]
["E0219","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Post breast conservation surgery irradiation","Effective Prevention andTreatment"]
["E0221","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Needle biopsy to establish diagnosis ofcancer precedes surgical excision/resection","Effective Prevention andTreatment"]
["E1717","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","National Healthcare Safety Network (NHSN)Facility‐wide Inpatient Hospital‐onsetClostridium difficile Infection (CDI)Outcome Measure","Making Care Safer"]
["E1716","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","National Healthcare Safety Network (NHSN)Facility‐wide Inpatient Hospital‐onsetMethicillin‐resistant Staphylococcus aureus(MRSA) Bacteremia Outcome Measure","Making Care Safer"]
["E0431","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Influenza vaccination coverage amonghealthcare personnel (HCP)","Making Care Safer"]
["E1659","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Influenza Immunization","Best Practice of HealthyLiving"]
["E1641","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","Hospice and Palliative Care – TreatmentPreferences","Patient and FamilyEngagement"]
["X3629","Prospective Payment System‐Exempt Cancer Hospital Quality Reporting","30 Day Unplanned Readmissions for CancerPatients","Communication and CareCoordination"]
["X3729","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Statin Therapy for thePrevention and Treatment ofCardiovascular Disease","Effective Prevention andTreatment"]
["X3468","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Documentation of a Health CareProxy for Patients with CognitiveImpairment","Effective Prevention andTreatment"]
["X3465","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Coordinating Care ‐ Follow‐Upwith Eligible Provider","Communication and CareCoordination"]
["X3466","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Coordinating Care ‐ EmergencyDepartment Referrals","Communication and CareCoordination"]
["X3053","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Functional Status Assessmentsand Goal Setting for ChronicPain Due to Osteoarthritis","Effective Prevention andTreatment"]
["X3469","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Cognitive ImpairmentAssessment Among At‐RiskOlder Adults","Best Practice of HealthyLiving"]
["X3485","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Adverse Drug Events ‐ MinimumINR Monitoring for Patients withAtrial Fibrillation on Warfarin","Making Care Safer"]
["X3283","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Closing the Referral Loop ‐Critical InformationCommunicated with Request forReferral","Communication and CareCoordination"]
["X3476","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Diabetes: Hemoglobin A1cOvertreatment in the Elderly","Effective Prevention andTreatment"]
["X3483","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Functional Status Outcomes forPatients Receiving Primary TotalHip Replacements","Patient and FamilyEngagement"]
["X3482","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Functional Status Outcomes forPatients Receiving Primary TotalKnee Replacements","Patient and FamilyEngagement"]
["X3816","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Hepatitis C: AppropriateScreening Follow‐Up for PatientsIdentified with Hepatitis C Virus(HCV) Infection","Communication and CareCoordination"]
["X3512","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Hepatitis C: One‐Time Screeningfor Hepatitis C Virus (HCV) forPatients at Risk","Best Practice of HealthyLiving"]
["X3475","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Substance Use Screening andIntervention Composite","Best Practice of HealthyLiving"]
["E2152","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Preventive Care and Screening:Unhealthy Alcohol Use:Screening & Brief Counseling","Best Practice of HealthyLiving"]
["X3445","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Alcohol Screening and BriefIntervention (ASBI) in the ER","Best Practice of HealthyLiving"]
["X3446","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Intimate Partner (Domestic)Violence Screening","Best Practice of HealthyLiving"]
["X3299","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","HIV: Ever screened for HIV","Effective Prevention andTreatment"]
["X3300","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","HIV Screening of STI patients","Effective Prevention andTreatment"]
["E0555","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","INR Monitoring for Individualson Warfarin (e‐specified versionof NQF #0555)","Making Care Safer"]
["S2550","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Gout: Urate Lowering Therapy","Effective Prevention andTreatment"]
["S2521","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Gout: Serum Urate Monitoring","Effective Prevention andTreatment"]
["X3280","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","ADHD: Symptom Reduction inFollow‐up Period","Patient and FamilyEngagement"]
["X3817","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Amblyopia Screening in Children","Communication and CareCoordination"]
["E1553","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Blood Pressure Screening by age18","Effective Prevention andTreatment"]
["X3472","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Use of Multiple ConcurrentAntipsychotics in Children andAdolescents","Making Care Safer"]
["X3513","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Annual Hepatitis C Virus (HCV)Screening for Patients who areActive Injection Drug Users","Patient and FamilyEngagement"]
["X4208","Medicare and Medicaid EHR Incentive\nPrograms for Eligible Professionals","Substance use disorders:percentage of patients aged 18years and older with a diagnosisof current opioid addiction whowere counseled regardingpsychosocial ANDpharmacologic treatmentoptions for opioid addictionwithin the 12 month reportingperiod","Effective Prevention andTreatment"]
["X3280","Medicare Physician Quality Reporting System","ADHD: Symptom Reduction in Follow‐up Period","Patient and FamilyEngagement"]
["X3817","Medicare Physician Quality Reporting System","Amblyopia Screening in Children","Communication andCare Coordination"]
["E1553","Medicare Physician Quality Reporting System","Blood Pressure Screening by age 18","Effective Preventionand Treatment"]
["X3472","Medicare Physician Quality Reporting System","Use of Multiple Concurrent Antipsychotics inChildren and Adolescents","Making Care Safer"]
["X3729","Medicare Physician Quality Reporting System","Statin Therapy for the Prevention and Treatmentof Cardiovascular Disease","Effective Preventionand Treatment"]
["X3468","Medicare Physician Quality Reporting System","Documentation of a Health Care Proxy forPatients with Cognitive Impairment","Effective Preventionand Treatment"]
["X3465","Medicare Physician Quality Reporting System","Coordinating Care ‐ Follow‐Up with EligibleProvider","Communication andCare Coordination"]
["X3466","Medicare Physician Quality Reporting System","Coordinating Care ‐ Emergency DepartmentReferrals","Communication andCare Coordination"]
["X3053","Medicare Physician Quality Reporting System","Functional Status Assessments and Goal Settingfor Chronic Pain Due to Osteoarthritis","Effective Preventionand Treatment"]
["X3469","Medicare Physician Quality Reporting System","Cognitive Impairment Assessment Among At‐Risk Older Adults","Best Practice ofHealthy Living"]
["E0076","Medicare Physician Quality Reporting System","Optimal Vascular Care","Effective Preventionand Treatment"]
["X3768","Medicare Physician Quality Reporting System","Primary C‐Section Rate 2014","Making CareAffordable"]
["X3773","Medicare Physician Quality Reporting System","Optimal Asthma Care 2014","Effective Preventionand Treatment"]
["E0032","Medicare Physician Quality Reporting System","Cervical Cancer Screening","Effective Preventionand Treatment"]
["X3797","Medicare Physician Quality Reporting System","Breast Cancer Screening","Effective Preventionand Treatment"]
["X3792","Medicare Physician Quality Reporting System","Controlling High Blood Pressure","Effective Preventionand Treatment"]
["X3485","Medicare Physician Quality Reporting System","Adverse Drug Events ‐ Minimum INR Monitoringfor Patients with Atrial Fibrillation on Warfarin","Making Care Safer"]
["X3283","Medicare Physician Quality Reporting System","Closing the Referral Loop ‐ Critical InformationCommunicated with Request for Referral","Communication andCare Coordination"]
["X3476","Medicare Physician Quality Reporting System","Diabetes: Hemoglobin A1c Overtreatment in theElderly","Effective Preventionand Treatment"]
["X3483","Medicare Physician Quality Reporting System","Functional Status Outcomes for PatientsReceiving Primary Total Hip Replacements","Patient and FamilyEngagement"]
["X3482","Medicare Physician Quality Reporting System","Functional Status Outcomes for PatientsReceiving Primary Total Knee Replacements","Patient and FamilyEngagement"]
["X3816","Medicare Physician Quality Reporting System","Hepatitis C: Appropriate Screening Follow‐Up forPatients Identified with Hepatitis C Virus (HCV) Infection","Communication andCare Coordination"]
["X3512","Medicare Physician Quality Reporting System","Hepatitis C: One‐Time Screening for Hepatitis CVirus (HCV) for Patients at Risk","Best Practice ofHealthy Living"]
["X3475","Medicare Physician Quality Reporting System","Substance Use Screening and InterventionComposite","Best Practice ofHealthy Living"]
["E2152","Medicare Physician Quality Reporting System","Preventive Care and Screening: UnhealthyAlcohol Use: Screening & Brief Counseling","Best Practice ofHealthy Living"]
["X3445","Medicare Physician Quality Reporting System","Alcohol Screening and Brief Intervention (ASBI)in the ER","Best Practice ofHealthy Living"]
["X3446","Medicare Physician Quality Reporting System","Intimate Partner (Domestic) Violence Screening","Best Practice ofHealthy Living"]
["X3299","Medicare Physician Quality Reporting System","HIV: Ever screened for HIV","Effective Preventionand Treatment"]
["X3300","Medicare Physician Quality Reporting System","HIV Screening of STI patients","Effective Preventionand Treatment"]
["E0555","Medicare Physician Quality Reporting System","INR Monitoring for Individuals on Warfarin (e‐specified version of NQF #0555)","Making Care Safer"]
["S2550","Medicare Physician Quality Reporting System","Gout: Urate Lowering Therapy","Effective Preventionand Treatment"]
["S2521","Medicare Physician Quality Reporting System","Gout: Serum Urate Monitoring","Effective Preventionand Treatment"]
["X3726","Medicare Physician Quality Reporting System","Clinical Response to Oral Systemic or BiologicMedications","Patient and FamilyEngagement"]
["X3274","Medicare Physician Quality Reporting System","Assessment for Psoriatic Arthritis","Patient and FamilyEngagement"]
["X3788","Medicare Physician Quality Reporting System","PC‐02 Cesarean Section (Provider Level)","Making CareAffordable"]
["X3732","Medicare Physician Quality Reporting System","Adult Kidney Disease: Referral to Hospice","Patient and FamilyEngagement"]
["X3735","Medicare Physician Quality Reporting System","Communication and shared decision‐makingwith patients and families for interventionaloncology procedures","Patient and FamilyEngagement"]
["X3739","Medicare Physician Quality Reporting System","Percentage of patients treated for varicose veinswho are treated with saphenous ablation andreceive an outcomes survey before and aftertreatment","Effective Preventionand Treatment"]
["X3755","Medicare Physician Quality Reporting System","Percentage of patients with a retrievable inferiorvena cava filter who are appropriately assessedfor continued filtration or device removal","Effective Preventionand Treatment"]
["X3754","Medicare Physician Quality Reporting System","Rate of surgical conversion from lower extremityendovascular revascularization procedure","Effective Preventionand Treatment"]
["X3756","Medicare Physician Quality Reporting System","Clinical Outcome post Endovascular StrokeTreatment","Effective Preventionand Treatment"]
["X3747","Medicare Physician Quality Reporting System","Door to puncture time for endovascular stroketreatment","Effective Preventionand Treatment"]
["X3752","Medicare Physician Quality Reporting System","Performing cystoscopy at the time ofhysterectomy for pelvic organ prolapse to detectlower urinary tract injury","Making Care Safer"]
["X3751","Medicare Physician Quality Reporting System","Complete assessment and evaluation ofpatient’s pelvic organ prolapse prior to surgicalrepair","Communication andCare Coordination"]
["X3750","Medicare Physician Quality Reporting System","Preoperative pessary for pelvic organ prolapseoffered","Communication andCare Coordination"]
["X3745","Medicare Physician Quality Reporting System","Preoperative pessary for pelvic organ prolapseattempted","Communication andCare Coordination"]
["X3743","Medicare Physician Quality Reporting System","Proportion of patients sustaining a bladderinjury at the time of any pelvic organ prolapserepair","Making Care Safer"]
["X3744","Medicare Physician Quality Reporting System","Proportion of patients sustaining a major viscusinjury at the time of any pelvic organ prolapserepair","Making Care Safer"]
["X3746","Medicare Physician Quality Reporting System","Preoperative assessment of occult stress urinaryincontinence prior to any pelvic organ prolapserepair","Effective Preventionand Treatment"]
["X3742","Medicare Physician Quality Reporting System","Preoperative assessment of sexual function priorto any pelvic organ prolapse repair","Effective Preventionand Treatment"]
["X3741","Medicare Physician Quality Reporting System","Preoperative exclusion of uterine malignancyprior to any pelvic organ prolapse repair","Making Care Safer"]
["X3740","Medicare Physician Quality Reporting System","Performing an intraoperative rectal examinationat the time of prolapse repair","Making Care Safer"]
["E0465","Medicare Physician Quality Reporting System","Perioperative Anti‐platelet Therapy for Patientsundergoing Carotid Endarterectomy","Effective Preventionand Treatment"]
["E1523","Medicare Physician Quality Reporting System","In‐hospital mortality following elective openrepair of AAAs","Making Care Safer"]
["X3761","Medicare Physician Quality Reporting System","Photodocumentation of cecal intubation","Effective Preventionand Treatment"]
["X3760","Medicare Physician Quality Reporting System","Frequency of inadequate bowel preparation","Making CareAffordable"]
["X3758","Medicare Physician Quality Reporting System","Appropriate age for colorectal cancer screening","Making CareAffordable"]
["X3759","Medicare Physician Quality Reporting System","Appropriate follow‐up imaging for incidentalabdominal lesions","Effective Preventionand Treatment"]
["X3763","Medicare Physician Quality Reporting System","Appropriate follow‐up imaging for incidentalthyroid nodules in patients","Effective Preventionand Treatment"]
["X3764","Medicare Physician Quality Reporting System","Imaging in adult ED patients with minor headinjury","Making CareAffordable"]
["X3781","Medicare Physician Quality Reporting System","Use of premedication before contrast‐enhancedimaging studies in patients with documentedcontrast allergy","Making Care Safer"]
["X3780","Medicare Physician Quality Reporting System","Coagulation studies in adult patients presentingwith chest pain with no coagulopathy orbleeding","Making CareAffordable"]
["X3803","Medicare Physician Quality Reporting System","Appropriate use of imaging for non‐traumaticshoulder pain","Making CareAffordable"]
["X3802","Medicare Physician Quality Reporting System","Appropriate follow‐up imaging for non‐traumatic knee pain","Making CareAffordable"]
["X3774","Medicare Physician Quality Reporting System","Evaluation or Interview for Risk of Opioid Misuse","Effective Preventionand Treatment"]
["X3777","Medicare Physician Quality Reporting System","Documentation of Signed Opioid TreatmentAgreement","Effective Preventionand Treatment"]
["X3776","Medicare Physician Quality Reporting System","Consideration of Non‐PharmacologicInterventions","Effective Preventionand Treatment"]
["X3775","Medicare Physician Quality Reporting System","Chronic Opioid Therapy Follow‐up Evaluation","Effective Preventionand Treatment"]
["X3771","Medicare Physician Quality Reporting System","Medication Prescribed For Acute MigraineAttack","Effective Preventionand Treatment"]
["X3766","Medicare Physician Quality Reporting System","Acute Medication Prescribed For ClusterHeadache","Effective Preventionand Treatment"]
["X3772","Medicare Physician Quality Reporting System","Preventive Migraine Medication Prescribed","Effective Preventionand Treatment"]
["X3765","Medicare Physician Quality Reporting System","Overuse of Barbiturate Containing Medicationsfor Primary Headache Disorders","Effective Preventionand Treatment"]
["X3769","Medicare Physician Quality Reporting System","Unnecessary Screening Colonoscopy in OlderAdults","Making CareAffordable"]
["X3770","Medicare Physician Quality Reporting System","Overuse Of Opioid Containing Medications ForPrimary Headache Disorders","Effective Preventionand Treatment"]
["X3783","Medicare Physician Quality Reporting System","Assessment Of Medication Overuse In TheTreatment Of Primary Headache Disorders","Effective Preventionand Treatment"]
["X3784","Medicare Physician Quality Reporting System","Plan Of Care Or Referral For Possible MedicationOveruse Headache","Making CareAffordable"]
["X3785","Medicare Physician Quality Reporting System","Overuse Of Neuroimaging For Patients WithPrimary Headache And A Normal NeurologicalExamination","Making CareAffordable"]
["X3786","Medicare Physician Quality Reporting System","Quality Of Life Assessment For Patients WithPrimary Headache Disorders","Effective Preventionand Treatment"]
["X3796","Medicare Physician Quality Reporting System","Migraine Or Cervicogenic Headache RelatedDisability Functional Status","Effective Preventionand Treatment"]
["X3794","Medicare Physician Quality Reporting System","Plan Of Care For Migraine Or CervicogenicHeadache Developed Or Reviewed","Effective Preventionand Treatment"]
["X3787","Medicare Physician Quality Reporting System","Patients with DMD Prescribed AppropriateDisease Modifying Pharmaceutical Therapy","Effective Preventionand Treatment"]
["X3791","Medicare Physician Quality Reporting System","MD Multidisciplinary Care Plan Developed orUpdated","Effective Preventionand Treatment"]
["X3798","Medicare Physician Quality Reporting System","Scoliosis Evaluation Ordered","Effective Preventionand Treatment"]
["X3801","Medicare Physician Quality Reporting System","Nutritional Status or Growth TrajectoriesMonitored","Effective Preventionand Treatment"]
["X3800","Medicare Physician Quality Reporting System","Patient Queried about Pain and PainInterference with Function","Effective Preventionand Treatment"]
["X3789","Medicare Physician Quality Reporting System","Patient Counseled About Health Care Decision‐Making","Effective Preventionand Treatment"]
["X3807","Medicare Physician Quality Reporting System","Post‐Anesthetic Transfer of Care: Use ofChecklist or Protocol for Direct Transfer of Carefrom Procedure Room to Intensive Care Unit(ICU)","Communication andCare Coordination"]
["X3806","Medicare Physician Quality Reporting System","Prevention of Post‐Operative Nausea andVomiting (PONV) – Combination","Patient and FamilyEngagement"]
["X3809","Medicare Physician Quality Reporting System","Perioperative Temperature Management","Making Care Safer"]
["X3811","Medicare Physician Quality Reporting System","Anesthesiology Smoking Abstinence","Effective Preventionand Treatment"]
["X3808","Medicare Physician Quality Reporting System","Preoperative Use of Aspirin for Patients withDrug‐Eluting Coronary Stents","Effective Preventionand Treatment"]
["X3810","Medicare Physician Quality Reporting System","Post‐Anesthetic Transfer of Care Measure:Procedure Room to a Post Anesthesia Care Unit(PACU)","Communication andCare Coordination"]
["X3813","Medicare Physician Quality Reporting System","Proportion of patients sustaining a ureter injuryat the time of any pelvic organ prolapse repair","Making Care Safer"]
["X3733","Medicare Physician Quality Reporting System","Pediatric Kidney Disease: Discussion of CarePlanning","Patient and FamilyEngagement"]
["X3778","Medicare Physician Quality Reporting System","Imaging in pediatric ED patients aged 2 through17 years with minor head injury","Making CareAffordable"]
["X3523","Medicare Physician Quality Reporting System","Extravasation of contrast following contrast‐enhanced computed tomography (CT)","Making Care Safer"]
["X3280","Physician Feedback/Quality and\nResource Utilization Reports","ADHD: Symptom Reduction in Follow‐up Period","Patient and FamilyEngagement"]
["X3817","Physician Feedback/Quality and\nResource Utilization Reports","Amblyopia Screening in Children","Communication andCare Coordination"]
["E1553","Physician Feedback/Quality and\nResource Utilization Reports","Blood Pressure Screening by age 18","Effective Prevention andTreatment"]
["X3472","Physician Feedback/Quality and\nResource Utilization Reports","Use of Multiple ConcurrentAntipsychotics in Children andAdolescents","Making Care Safer"]
["X3726","Physician Feedback/Quality and\nResource Utilization Reports","Clinical Response to Oral Systemic orBiologic Medications","Patient and FamilyEngagement"]
["X3274","Physician Feedback/Quality and\nResource Utilization Reports","Assessment for Psoriatic Arthritis","Patient and FamilyEngagement"]
["X3788","Physician Feedback/Quality and\nResource Utilization Reports","PC‐02 Cesarean Section (Provider Level)","Making Care Affordable"]
["X3732","Physician Feedback/Quality and\nResource Utilization Reports","Adult Kidney Disease: Referral toHospice","Patient and FamilyEngagement"]
["X3735","Physician Feedback/Quality and\nResource Utilization Reports","Communication and shared decision‐making with patients and families forinterventional oncology procedures","Patient and FamilyEngagement"]
["X3739","Physician Feedback/Quality and\nResource Utilization Reports","Percentage of patients treated forvaricose veins who are treated withsaphenous ablation and receive anoutcomes survey before and aftertreatment","Effective Prevention andTreatment"]
["X3755","Physician Feedback/Quality and\nResource Utilization Reports","Percentage of patients with aretrievable inferior vena cava filter whoare appropriately assessed forcontinued filtration or device removal","Effective Prevention andTreatment"]
["X3754","Physician Feedback/Quality and\nResource Utilization Reports","Rate of surgical conversion from lowerextremity endovascularrevascularization procedure","Effective Prevention andTreatment"]
["X3756","Physician Feedback/Quality and\nResource Utilization Reports","Clinical Outcome post EndovascularStroke Treatment","Effective Prevention andTreatment"]
["X3747","Physician Feedback/Quality and\nResource Utilization Reports","Door to puncture time for endovascularstroke treatment","Effective Prevention andTreatment"]
["X3752","Physician Feedback/Quality and\nResource Utilization Reports","Performing cystoscopy at the time ofhysterectomy for pelvic organ prolapseto detect lower urinary tract injury","Making Care Safer"]
["X3751","Physician Feedback/Quality and\nResource Utilization Reports","Complete assessment and evaluation ofpatient’s pelvic organ prolapse prior tosurgical repair","Communication andCare Coordination"]
["X3750","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative pessary for pelvic organprolapse offered","Communication andCare Coordination"]
["X3745","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative pessary for pelvic organprolapse attempted","Communication andCare Coordination"]
["X3743","Physician Feedback/Quality and\nResource Utilization Reports","Proportion of patients sustaining abladder injury at the time of any pelvicorgan prolapse repair","Making Care Safer"]
["X3744","Physician Feedback/Quality and\nResource Utilization Reports","Proportion of patients sustaining amajor viscus injury at the time of anypelvic organ prolapse repair","Making Care Safer"]
["X3746","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative assessment of occultstress urinary incontinence prior to anypelvic organ prolapse repair","Effective Prevention andTreatment"]
["X3742","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative assessment of sexualfunction prior to any pelvic organprolapse repair","Effective Prevention andTreatment"]
["X3741","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative exclusion of uterinemalignancy prior to any pelvic organprolapse repair","Making Care Safer"]
["X3740","Physician Feedback/Quality and\nResource Utilization Reports","Performing an intraoperative rectalexamination at the time of prolapserepair","Making Care Safer"]
["E0465","Physician Feedback/Quality and\nResource Utilization Reports","Perioperative Anti‐platelet Therapy forPatients undergoing CarotidEndarterectomy","Effective Prevention andTreatment"]
["E1523","Physician Feedback/Quality and\nResource Utilization Reports","In‐hospital mortality following electiveopen repair of AAAs","Making Care Safer"]
["X3761","Physician Feedback/Quality and\nResource Utilization Reports","Photodocumentation of cecalintubation","Effective Prevention andTreatment"]
["X3760","Physician Feedback/Quality and\nResource Utilization Reports","Frequency of inadequate bowelpreparation","Making Care Affordable"]
["X3758","Physician Feedback/Quality and\nResource Utilization Reports","Appropriate age for colorectal cancerscreening","Making Care Affordable"]
["X3759","Physician Feedback/Quality and\nResource Utilization Reports","Appropriate follow‐up imaging forincidental abdominal lesions","Effective Prevention andTreatment"]
["X3763","Physician Feedback/Quality and\nResource Utilization Reports","Appropriate follow‐up imaging forincidental thyroid nodules in patients","Effective Prevention andTreatment"]
["X3764","Physician Feedback/Quality and\nResource Utilization Reports","Imaging in adult ED patients with minorhead injury","Making Care Affordable"]
["X3781","Physician Feedback/Quality and\nResource Utilization Reports","Use of premedication before contrast‐enhanced imaging studies in patientswith documented contrast allergy","Making Care Safer"]
["X3523","Physician Feedback/Quality and\nResource Utilization Reports","Extravasation of contrast followingcontrast‐enhanced computedtomography (CT)","Making Care Safer"]
["X3780","Physician Feedback/Quality and\nResource Utilization Reports","Coagulation studies in adult patientspresenting with chest pain with no coagulopathy or bleeding","Making Care Affordable"]
["X3803","Physician Feedback/Quality and\nResource Utilization Reports","Appropriate use of imaging for non‐traumatic shoulder pain","Making Care Affordable"]
["X3802","Physician Feedback/Quality and\nResource Utilization Reports","Appropriate follow‐up imaging for non‐traumatic knee pain","Making Care Affordable"]
["X3774","Physician Feedback/Quality and\nResource Utilization Reports","Evaluation or Interview for Risk ofOpioid Misuse","Effective Prevention andTreatment"]
["X3777","Physician Feedback/Quality and\nResource Utilization Reports","Documentation of Signed OpioidTreatment Agreement","Effective Prevention andTreatment"]
["X3776","Physician Feedback/Quality and\nResource Utilization Reports","Consideration of Non‐PharmacologicInterventions","Effective Prevention andTreatment"]
["X3775","Physician Feedback/Quality and\nResource Utilization Reports","Chronic Opioid Therapy Follow‐upEvaluation","Effective Prevention andTreatment"]
["X3771","Physician Feedback/Quality and\nResource Utilization Reports","Medication Prescribed For AcuteMigraine Attack","Effective Prevention andTreatment"]
["X3766","Physician Feedback/Quality and\nResource Utilization Reports","Acute Medication Prescribed ForCluster Headache","Effective Prevention andTreatment"]
["X3772","Physician Feedback/Quality and\nResource Utilization Reports","Preventive Migraine MedicationPrescribed","Effective Prevention andTreatment"]
["X3765","Physician Feedback/Quality and\nResource Utilization Reports","Overuse of Barbiturate ContainingMedications for Primary HeadacheDisorders","Effective Prevention andTreatment"]
["X3769","Physician Feedback/Quality and\nResource Utilization Reports","Unnecessary Screening Colonoscopy inOlder Adults","Making Care Affordable"]
["X3770","Physician Feedback/Quality and\nResource Utilization Reports","Overuse Of Opioid ContainingMedications For Primary HeadacheDisorders","Effective Prevention andTreatment"]
["X3783","Physician Feedback/Quality and\nResource Utilization Reports","Assessment Of Medication Overuse InThe Treatment Of Primary HeadacheDisorders","Effective Prevention andTreatment"]
["X3784","Physician Feedback/Quality and\nResource Utilization Reports","Plan Of Care Or Referral For PossibleMedication Overuse Headache","Making Care Affordable"]
["X3785","Physician Feedback/Quality and\nResource Utilization Reports","Overuse Of Neuroimaging For PatientsWith Primary Headache And A NormalNeurological Examination","Making Care Affordable"]
["X3786","Physician Feedback/Quality and\nResource Utilization Reports","Quality Of Life Assessment For PatientsWith Primary Headache Disorders","Effective Prevention andTreatment"]
["X3796","Physician Feedback/Quality and\nResource Utilization Reports","Migraine Or Cervicogenic HeadacheRelated Disability Functional Status","Effective Prevention andTreatment"]
["X3794","Physician Feedback/Quality and\nResource Utilization Reports","Plan Of Care For Migraine OrCervicogenic Headache Developed OrReviewed","Effective Prevention andTreatment"]
["X3787","Physician Feedback/Quality and\nResource Utilization Reports","Patients with DMD PrescribedAppropriate Disease Modifying Pharmaceutical Therapy","Effective Prevention andTreatment"]
["X3791","Physician Feedback/Quality and\nResource Utilization Reports","MD Multidisciplinary Care PlanDeveloped or Updated","Effective Prevention andTreatment"]
["X3798","Physician Feedback/Quality and\nResource Utilization Reports","Scoliosis Evaluation Ordered","Effective Prevention andTreatment"]
["X3801","Physician Feedback/Quality and\nResource Utilization Reports","Nutritional Status or GrowthTrajectories Monitored","Effective Prevention andTreatment"]
["X3800","Physician Feedback/Quality and\nResource Utilization Reports","Patient Queried about Pain and PainInterference with Function","Effective Prevention andTreatment"]
["X3789","Physician Feedback/Quality and\nResource Utilization Reports","Patient Counseled About Health CareDecision‐Making","Effective Prevention andTreatment"]
["X3807","Physician Feedback/Quality and\nResource Utilization Reports","Post‐Anesthetic Transfer of Care: Useof Checklist or Protocol for DirectTransfer of Care from Procedure Roomto Intensive Care Unit (ICU)","Communication andCare Coordination"]
["X3806","Physician Feedback/Quality and\nResource Utilization Reports","Prevention of Post‐Operative Nauseaand Vomiting (PONV) – Combination","Patient and FamilyEngagement"]
["X3809","Physician Feedback/Quality and\nResource Utilization Reports","Perioperative TemperatureManagement","Making Care Safer"]
["X3811","Physician Feedback/Quality and\nResource Utilization Reports","Anesthesiology Smoking Abstinence","Effective Prevention andTreatment"]
["X3808","Physician Feedback/Quality and\nResource Utilization Reports","Preoperative Use of Aspirin for Patientswith Drug‐Eluting Coronary Stents","Effective Prevention andTreatment"]
["X3810","Physician Feedback/Quality and\nResource Utilization Reports","Post‐Anesthetic Transfer of CareMeasure: Procedure Room to a PostAnesthesia Care Unit (PACU)","Communication andCare Coordination"]
["X3813","Physician Feedback/Quality and\nResource Utilization Reports","Proportion of patients sustaining aureter injury at the time of any pelvicorgan prolapse repair","Making Care Safer"]
["X3733","Physician Feedback/Quality and\nResource Utilization Reports","Pediatric Kidney Disease: Discussion ofCare Planning","Patient and FamilyEngagement"]
["X3778","Physician Feedback/Quality and\nResource Utilization Reports","Imaging in pediatric ED patients aged 2through 17 years with minor headinjury","Making Care Affordable"]
["X3729","Physician Feedback/Quality and\nResource Utilization Reports","Statin Therapy for the Prevention andTreatment of Cardiovascular Disease","Effective Prevention andTreatment"]
["X3468","Physician Feedback/Quality and\nResource Utilization Reports","Documentation of a Health Care Proxyfor Patients with Cognitive Impairment","Effective Prevention andTreatment"]
["X3465","Physician Feedback/Quality and\nResource Utilization Reports","Coordinating Care ‐ Follow‐Up withEligible Provider","Communication andCare Coordination"]
["X3466","Physician Feedback/Quality and\nResource Utilization Reports","Coordinating Care ‐ EmergencyDepartment Referrals","Communication andCare Coordination"]
["X3053","Physician Feedback/Quality and\nResource Utilization Reports","Functional Status Assessments andGoal Setting for Chronic Pain Due to Osteoarthritis","Effective Prevention andTreatment"]
["X3469","Physician Feedback/Quality and\nResource Utilization Reports","Cognitive Impairment AssessmentAmong At‐Risk Older Adults","Best Practice of HealthyLiving"]
["E0076","Physician Feedback/Quality and\nResource Utilization Reports","Optimal Vascular Care","Effective Prevention andTreatment"]
["X3768","Physician Feedback/Quality and\nResource Utilization Reports","Primary C‐Section Rate 2014","Making Care Affordable"]
["X3773","Physician Feedback/Quality and\nResource Utilization Reports","Optimal Asthma Care 2014","Effective Prevention andTreatment"]
["E0032","Physician Feedback/Quality and\nResource Utilization Reports","Cervical Cancer Screening","Effective Prevention andTreatment"]
["X3797","Physician Feedback/Quality and\nResource Utilization Reports","Breast Cancer Screening","Effective Prevention andTreatment"]
["X3792","Physician Feedback/Quality and\nResource Utilization Reports","Controlling High Blood Pressure","Effective Prevention andTreatment"]
["X3485","Physician Feedback/Quality and\nResource Utilization Reports","Adverse Drug Events ‐ Minimum INRMonitoring for Patients with AtrialFibrillation on Warfarin","Making Care Safer"]
["X3283","Physician Feedback/Quality and\nResource Utilization Reports","Closing the Referral Loop ‐ CriticalInformation Communicated withRequest for Referral","Communication andCare Coordination"]
["X3476","Physician Feedback/Quality and\nResource Utilization Reports","Diabetes: Hemoglobin A1cOvertreatment in the Elderly","Effective Prevention andTreatment"]
["X3483","Physician Feedback/Quality and\nResource Utilization Reports","Functional Status Outcomes forPatients Receiving Primary Total HipReplacements","Patient and FamilyEngagement"]
["X3482","Physician Feedback/Quality and\nResource Utilization Reports","Functional Status Outcomes forPatients Receiving Primary Total KneeReplacements","Patient and FamilyEngagement"]
["X3816","Physician Feedback/Quality and\nResource Utilization Reports","Hepatitis C: Appropriate ScreeningFollow‐Up for Patients Identified withHepatitis C Virus (HCV) Infection","Communication andCare Coordination"]
["X3512","Physician Feedback/Quality and\nResource Utilization Reports","Hepatitis C: One‐Time Screening forHepatitis C Virus (HCV) for Patients atRisk","Best Practice of HealthyLiving"]
["X3475","Physician Feedback/Quality and\nResource Utilization Reports","Substance Use Screening andIntervention Composite","Best Practice of HealthyLiving"]
["E2152","Physician Feedback/Quality and\nResource Utilization Reports","Preventive Care and Screening:Unhealthy Alcohol Use: Screening &Brief Counseling","Best Practice of HealthyLiving"]
["X3445","Physician Feedback/Quality and\nResource Utilization Reports","Alcohol Screening and BriefIntervention (ASBI) in the ER","Best Practice of HealthyLiving"]
["X3446","Physician Feedback/Quality and\nResource Utilization Reports","Intimate Partner (Domestic) ViolenceScreening","Best Practice of HealthyLiving"]
["X3299","Physician Feedback/Quality and\nResource Utilization Reports","HIV: Ever screened for HIV","Effective Prevention andTreatment"]
["X3300","Physician Feedback/Quality and\nResource Utilization Reports","HIV Screening of STI patients","Effective Prevention andTreatment"]
["E0555","Physician Feedback/Quality and\nResource Utilization Reports","INR Monitoring for Individuals onWarfarin (e‐specified version of NQF#0555)","Making Care Safer"]
["S2550","Physician Feedback/Quality and\nResource Utilization Reports","Gout: Urate Lowering Therapy","Effective Prevention andTreatment"]
["S2521","Physician Feedback/Quality and\nResource Utilization Reports","Gout: Serum Urate Monitoring","Effective Prevention andTreatment"]
["X0351","Physician Feedback/Quality and\nResource Utilization Reports","Kidney/Urinary Tract Infection ClinicalEpisode‐Based Payment Measure","Making Care Affordable"]
["X0352","Physician Feedback/Quality and\nResource Utilization Reports","Knee Replacement/ Revision ClinicalEpisode‐Based Payment Measure","Making Care Affordable"]
["X0353","Physician Feedback/Quality and\nResource Utilization Reports","Spine Fusion/ Refusion Clinical Episode‐Based Payment Measure","Making Care Affordable"]
["X0354","Physician Feedback/Quality and\nResource Utilization Reports","Cellulitis Clinical Episode‐BasedPayment Measure","Making Care Affordable"]
["X0355","Physician Feedback/Quality and\nResource Utilization Reports","Gastrointestinal Hemorrhage ClinicalEpisode‐Based Payment Measure","Making Care Affordable"]
["X0356","Physician Feedback/Quality and\nResource Utilization Reports","Hip Replacement/ Revision ClinicalEpisode‐Based Payment Measure","Making Care Affordable"]
["X3280","Physician Value‐Based\nPayment Modifier","ADHD: Symptom Reduction in Follow‐up Period","Patient and FamilyEngagement"]
["X3817","Physician Value‐Based\nPayment Modifier","Amblyopia Screening in Children","Communication and CareCoordination"]
["E1553","Physician Value‐Based\nPayment Modifier","Blood Pressure Screening by age 18","Effective Prevention andTreatment"]
["X3472","Physician Value‐Based\nPayment Modifier","Use of Multiple Concurrent Antipsychotics inChildren and Adolescents","Making Care Safer"]
["X3726","Physician Value‐Based\nPayment Modifier","Clinical Response to Oral Systemic or BiologicMedications","Patient and FamilyEngagement"]
["X3274","Physician Value‐Based\nPayment Modifier","Assessment for Psoriatic Arthritis","Patient and FamilyEngagement"]
["X3788","Physician Value‐Based\nPayment Modifier","PC‐02 Cesarean Section (Provider Level)","Making Care Affordable"]
["X3732","Physician Value‐Based\nPayment Modifier","Adult Kidney Disease: Referral to Hospice","Patient and FamilyEngagement"]
["X3735","Physician Value‐Based\nPayment Modifier","Communication and shared decision‐makingwith patients and families for interventionaloncology procedures","Patient and FamilyEngagement"]
["X3739","Physician Value‐Based\nPayment Modifier","Percentage of patients treated for varicose veinswho are treated with saphenous ablation andreceive an outcomes survey before and aftertreatment","Effective Prevention andTreatment"]
["X3755","Physician Value‐Based\nPayment Modifier","Percentage of patients with a retrievable inferiorvena cava filter who are appropriately assessedfor continued filtration or device removal","Effective Prevention andTreatment"]
["X3754","Physician Value‐Based\nPayment Modifier","Rate of surgical conversion from lower extremityendovascular revascularization procedure","Effective Prevention andTreatment"]
["X3756","Physician Value‐Based\nPayment Modifier","Clinical Outcome post Endovascular StrokeTreatment","Effective Prevention andTreatment"]
["X3747","Physician Value‐Based\nPayment Modifier","Door to puncture time for endovascular stroketreatment","Effective Prevention andTreatment"]
["X3752","Physician Value‐Based\nPayment Modifier","Performing cystoscopy at the time ofhysterectomy for pelvic organ prolapse to detectlower urinary tract injury","Making Care Safer"]
["X3751","Physician Value‐Based\nPayment Modifier","Complete assessment and evaluation ofpatient’s pelvic organ prolapse prior to surgicalrepair","Communication and CareCoordination"]
["X3750","Physician Value‐Based\nPayment Modifier","Preoperative pessary for pelvic organ prolapseoffered","Communication and CareCoordination"]
["X3745","Physician Value‐Based\nPayment Modifier","Preoperative pessary for pelvic organ prolapseattempted","Communication and CareCoordination"]
["X3743","Physician Value‐Based\nPayment Modifier","Proportion of patients sustaining a bladderinjury at the time of any pelvic organ prolapserepair","Making Care Safer"]
["X3744","Physician Value‐Based\nPayment Modifier","Proportion of patients sustaining a major viscusinjury at the time of any pelvic organ prolapserepair","Making Care Safer"]
["X3746","Physician Value‐Based\nPayment Modifier","Preoperative assessment of occult stress urinaryincontinence prior to any pelvic organ prolapserepair","Effective Prevention andTreatment"]
["X3742","Physician Value‐Based\nPayment Modifier","Preoperative assessment of sexual function priorto any pelvic organ prolapse repair","Effective Prevention andTreatment"]
["X3741","Physician Value‐Based\nPayment Modifier","Preoperative exclusion of uterine malignancyprior to any pelvic organ prolapse repair","Making Care Safer"]
["X3740","Physician Value‐Based\nPayment Modifier","Performing an intraoperative rectal examinationat the time of prolapse repair","Making Care Safer"]
["E0465","Physician Value‐Based\nPayment Modifier","Perioperative Anti‐platelet Therapy for Patientsundergoing Carotid Endarterectomy","Effective Prevention andTreatment"]
["E1523","Physician Value‐Based\nPayment Modifier","In‐hospital mortality following elective openrepair of AAAs","Making Care Safer"]
["X3761","Physician Value‐Based\nPayment Modifier","Photodocumentation of cecal intubation","Effective Prevention andTreatment"]
["X3760","Physician Value‐Based\nPayment Modifier","Frequency of inadequate bowel preparation","Making Care Affordable"]
["X3758","Physician Value‐Based\nPayment Modifier","Appropriate age for colorectal cancer screening","Making Care Affordable"]
["X3759","Physician Value‐Based\nPayment Modifier","Appropriate follow‐up imaging for incidentalabdominal lesions","Effective Prevention andTreatment"]
["X3763","Physician Value‐Based\nPayment Modifier","Appropriate follow‐up imaging for incidentalthyroid nodules in patients","Effective Prevention andTreatment"]
["X3764","Physician Value‐Based\nPayment Modifier","Imaging in adult ED patients with minor headinjury","Making Care Affordable"]
["X3781","Physician Value‐Based\nPayment Modifier","Use of premedication before contrast‐enhancedimaging studies in patients with documentedcontrast allergy","Making Care Safer"]
["X3523","Physician Value‐Based\nPayment Modifier","Extravasation of contrast following contrast‐enhanced computed tomography (CT)","Making Care Safer"]
["X3780","Physician Value‐Based\nPayment Modifier","Coagulation studies in adult patients presentingwith chest pain with no coagulopathy orbleeding","Making Care Affordable"]
["X3803","Physician Value‐Based\nPayment Modifier","Appropriate use of imaging for non‐traumaticshoulder pain","Making Care Affordable"]
["X3802","Physician Value‐Based\nPayment Modifier","Appropriate follow‐up imaging for non‐traumatic knee pain","Making Care Affordable"]
["X3774","Physician Value‐Based\nPayment Modifier","Evaluation or Interview for Risk of Opioid Misuse","Effective Prevention andTreatment"]
["X3777","Physician Value‐Based\nPayment Modifier","Documentation of Signed Opioid TreatmentAgreement","Effective Prevention andTreatment"]
["X3776","Physician Value‐Based\nPayment Modifier","Consideration of Non‐PharmacologicInterventions","Effective Prevention andTreatment"]
["X3775","Physician Value‐Based\nPayment Modifier","Chronic Opioid Therapy Follow‐up Evaluation","Effective Prevention andTreatment"]
["X3771","Physician Value‐Based\nPayment Modifier","Medication Prescribed For Acute MigraineAttack","Effective Prevention andTreatment"]
["X3766","Physician Value‐Based\nPayment Modifier","Acute Medication Prescribed For ClusterHeadache","Effective Prevention andTreatment"]
["X3772","Physician Value‐Based\nPayment Modifier","Preventive Migraine Medication Prescribed","Effective Prevention andTreatment"]
["X3765","Physician Value‐Based\nPayment Modifier","Overuse of Barbiturate Containing Medicationsfor Primary Headache Disorders","Effective Prevention andTreatment"]
["X3769","Physician Value‐Based\nPayment Modifier","Unnecessary Screening Colonoscopy in OlderAdults","Making Care Affordable"]
["X3770","Physician Value‐Based\nPayment Modifier","Overuse Of Opioid Containing Medications ForPrimary Headache Disorders","Effective Prevention andTreatment"]
["X3783","Physician Value‐Based\nPayment Modifier","Assessment Of Medication Overuse In TheTreatment Of Primary Headache Disorders","Effective Prevention andTreatment"]
["X3784","Physician Value‐Based\nPayment Modifier","Plan Of Care Or Referral For Possible MedicationOveruse Headache","Making Care Affordable"]
["X3785","Physician Value‐Based\nPayment Modifier","Overuse Of Neuroimaging For Patients WithPrimary Headache And A Normal NeurologicalExamination","Making Care Affordable"]
["X3786","Physician Value‐Based\nPayment Modifier","Quality Of Life Assessment For Patients WithPrimary Headache Disorders","Effective Prevention andTreatment"]
["X3796","Physician Value‐Based\nPayment Modifier","Migraine Or Cervicogenic Headache RelatedDisability Functional Status","Effective Prevention andTreatment"]
["X3794","Physician Value‐Based\nPayment Modifier","Plan Of Care For Migraine Or CervicogenicHeadache Developed Or Reviewed","Effective Prevention andTreatment"]
["X3787","Physician Value‐Based\nPayment Modifier","Patients with DMD Prescribed AppropriateDisease Modifying Pharmaceutical Therapy","Effective Prevention andTreatment"]
["X3791","Physician Value‐Based\nPayment Modifier","MD Multidisciplinary Care Plan Developed orUpdated","Effective Prevention andTreatment"]
["X3798","Physician Value‐Based\nPayment Modifier","Scoliosis Evaluation Ordered","Effective Prevention andTreatment"]
["X3801","Physician Value‐Based\nPayment Modifier","Nutritional Status or Growth TrajectoriesMonitored","Effective Prevention andTreatment"]
["X3800","Physician Value‐Based\nPayment Modifier","Patient Queried about Pain and PainInterference with Function","Effective Prevention andTreatment"]
["X3789","Physician Value‐Based\nPayment Modifier","Patient Counseled About Health Care Decision‐Making","Effective Prevention andTreatment"]
["X3807","Physician Value‐Based\nPayment Modifier","Post‐Anesthetic Transfer of Care: Use ofChecklist or Protocol for Direct Transfer of Carefrom Procedure Room to Intensive Care Unit(ICU)","Communication and CareCoordination"]
["X3806","Physician Value‐Based\nPayment Modifier","Prevention of Post‐Operative Nausea andVomiting (PONV) – Combination","Patient and FamilyEngagement"]
["X3809","Physician Value‐Based\nPayment Modifier","Perioperative Temperature Management","Making Care Safer"]
["X3811","Physician Value‐Based\nPayment Modifier","Anesthesiology Smoking Abstinence","Effective Prevention andTreatment"]
["X3808","Physician Value‐Based\nPayment Modifier","Preoperative Use of Aspirin for Patients withDrug‐Eluting Coronary Stents","Effective Prevention andTreatment"]
["X3810","Physician Value‐Based\nPayment Modifier","Post‐Anesthetic Transfer of Care Measure:Procedure Room to a Post Anesthesia Care Unit(PACU)","Communication and CareCoordination"]
["X3813","Physician Value‐Based\nPayment Modifier","Proportion of patients sustaining a ureter injuryat the time of any pelvic organ prolapse repair","Making Care Safer"]
["X3733","Physician Value‐Based\nPayment Modifier","Pediatric Kidney Disease: Discussion of CarePlanning","Patient and FamilyEngagement"]
["X3778","Physician Value‐Based\nPayment Modifier","Imaging in pediatric ED patients aged 2 through17 years with minor head injury","Making Care Affordable"]
["X3729","Physician Value‐Based\nPayment Modifier","Statin Therapy for the Prevention and Treatmentof Cardiovascular Disease","Effective Prevention andTreatment"]
["X3468","Physician Value‐Based\nPayment Modifier","Documentation of a Health Care Proxy forPatients with Cognitive Impairment","Effective Prevention andTreatment"]
["X3465","Physician Value‐Based\nPayment Modifier","Coordinating Care ‐ Follow‐Up with EligibleProvider","Communication and CareCoordination"]
["X3466","Physician Value‐Based\nPayment Modifier","Coordinating Care ‐ Emergency DepartmentReferrals","Communication and CareCoordination"]
["X3053","Physician Value‐Based\nPayment Modifier","Functional Status Assessments and Goal Settingfor Chronic Pain Due to Osteoarthritis","Effective Prevention andTreatment"]
["X3469","Physician Value‐Based\nPayment Modifier","Cognitive Impairment Assessment Among At‐Risk Older Adults","Best Practice of HealthyLiving"]
["E0076","Physician Value‐Based\nPayment Modifier","Optimal Vascular Care","Effective Prevention andTreatment"]
["X3768","Physician Value‐Based\nPayment Modifier","Primary C‐Section Rate 2014","Making Care Affordable"]
["X3773","Physician Value‐Based\nPayment Modifier","Optimal Asthma Care 2014","Effective Prevention andTreatment"]
["E0032","Physician Value‐Based\nPayment Modifier","Cervical Cancer Screening","Effective Prevention andTreatment"]
["X3797","Physician Value‐Based\nPayment Modifier","Breast Cancer Screening","Effective Prevention andTreatment"]
["X3792","Physician Value‐Based\nPayment Modifier","Controlling High Blood Pressure","Effective Prevention andTreatment"]
["X3485","Physician Value‐Based\nPayment Modifier","Adverse Drug Events ‐ Minimum INR Monitoringfor Patients with Atrial Fibrillation on Warfarin","Making Care Safer"]
["X3283","Physician Value‐Based\nPayment Modifier","Closing the Referral Loop ‐ Critical InformationCommunicated with Request for Referral","Communication and CareCoordination"]
["X3476","Physician Value‐Based\nPayment Modifier","Diabetes: Hemoglobin A1c Overtreatment in theElderly","Effective Prevention andTreatment"]
["X3483","Physician Value‐Based\nPayment Modifier","Functional Status Outcomes for PatientsReceiving Primary Total Hip Replacements","Patient and FamilyEngagement"]
["X3482","Physician Value‐Based\nPayment Modifier","Functional Status Outcomes for PatientsReceiving Primary Total Knee Replacements","Patient and FamilyEngagement"]
["X3816","Physician Value‐Based\nPayment Modifier","Hepatitis C: Appropriate Screening Follow‐Up forPatients Identified with Hepatitis C Virus (HCV)Infection","Communication and CareCoordination"]
["X3512","Physician Value‐Based\nPayment Modifier","Hepatitis C: One‐Time Screening for Hepatitis CVirus (HCV) for Patients at Risk","Best Practice of HealthyLiving"]
["X3475","Physician Value‐Based\nPayment Modifier","Substance Use Screening and InterventionComposite","Best Practice of HealthyLiving"]
["E2152","Physician Value‐Based\nPayment Modifier","Preventive Care and Screening: UnhealthyAlcohol Use: Screening & Brief Counseling","Best Practice of HealthyLiving"]
["X3445","Physician Value‐Based\nPayment Modifier","Alcohol Screening and Brief Intervention (ASBI)in the ER","Best Practice of HealthyLiving"]
["X3446","Physician Value‐Based\nPayment Modifier","Intimate Partner (Domestic) Violence Screening","Best Practice of HealthyLiving"]
["X3299","Physician Value‐Based\nPayment Modifier","HIV: Ever screened for HIV","Effective Prevention andTreatment"]
["X3300","Physician Value‐Based\nPayment Modifier","HIV Screening of STI patients","Effective Prevention andTreatment"]
["E0555","Physician Value‐Based\nPayment Modifier","INR Monitoring for Individuals on Warfarin (e‐specified version of NQF #0555)","Making Care Safer"]
["S2550","Physician Value‐Based\nPayment Modifier","Gout: Urate Lowering Therapy","Effective Prevention andTreatment"]
["S2521","Physician Value‐Based\nPayment Modifier","Gout: Serum Urate Monitoring","Effective Prevention andTreatment"]
["X0351","Physician Value‐Based\nPayment Modifier","Kidney/Urinary Tract Infection Clinical Episode‐Based Payment Measure","Making Care Affordable"]
["X0352","Physician Value‐Based\nPayment Modifier","Knee Replacement/ Revision Clinical Episode‐Based Payment Measure","Making Care Affordable"]
["X0353","Physician Value‐Based\nPayment Modifier","Spine Fusion/ Refusion Clinical Episode‐BasedPayment Measure","Making Care Affordable"]
["X0354","Physician Value‐Based\nPayment Modifier","Cellulitis Clinical Episode‐Based PaymentMeasure","Making Care Affordable"]
["X0355","Physician Value‐Based\nPayment Modifier","Gastrointestinal Hemorrhage Clinical Episode‐Based Payment Measure","Making Care Affordable"]
["X0356","Physician Value‐Based\nPayment Modifier","Hip Replacement/ Revision Clinical Episode‐Based Payment Measure","Making Care Affordable"]
["X3280","Physician\nCompare","ADHD: Symptom Reduction in Follow‐up Period","Patient and FamilyEngagement"]
["X3817","Physician\nCompare","Amblyopia Screening in Children","Communication and CareCoordination"]
["E1553","Physician\nCompare","Blood Pressure Screening by age 18","Effective Prevention andTreatment"]
["X3472","Physician\nCompare","Use of Multiple Concurrent Antipsychotics in Childrenand Adolescents","Making Care Safer"]
["X3726","Physician\nCompare","Clinical Response to Oral Systemic or BiologicMedications","Patient and FamilyEngagement"]
["X3274","Physician\nCompare","Assessment for Psoriatic Arthritis","Patient and FamilyEngagement"]
["X3788","Physician\nCompare","PC‐02 Cesarean Section (Provider Level)","Making Care Affordable"]
["X3732","Physician\nCompare","Adult Kidney Disease: Referral to Hospice","Patient and FamilyEngagement"]
["X3735","Physician\nCompare","Communication and shared decision‐making withpatients and families for interventional oncologyprocedures","Patient and FamilyEngagement"]
["X3739","Physician\nCompare","Percentage of patients treated for varicose veins whoare treated with saphenous ablation and receive anoutcomes survey before and after treatment","Effective Prevention andTreatment"]
["X3755","Physician\nCompare","Percentage of patients with a retrievable inferior venacava filter who are appropriately assessed for continuedfiltration or device removal","Effective Prevention andTreatment"]
["X3754","Physician\nCompare","Rate of surgical conversion from lower extremityendovascular revascularization procedure","Effective Prevention andTreatment"]
["X3756","Physician\nCompare","Clinical Outcome post Endovascular Stroke Treatment","Effective Prevention andTreatment"]
["X3747","Physician\nCompare","Door to puncture time for endovascular stroketreatment","Effective Prevention andTreatment"]
["X3752","Physician\nCompare","Performing cystoscopy at the time of hysterectomy forpelvic organ prolapse to detect lower urinary tract injury","Making Care Safer"]
["X3751","Physician\nCompare","Complete assessment and evaluation of patient’s pelvicorgan prolapse prior to surgical repair","Communication and CareCoordination"]
["X3750","Physician\nCompare","Preoperative pessary for pelvic organ prolapse offered","Communication and CareCoordination"]
["X3745","Physician\nCompare","Preoperative pessary for pelvic organ prolapseattempted","Communication and CareCoordination"]
["X3743","Physician\nCompare","Proportion of patients sustaining a bladder injury at thetime of any pelvic organ prolapse repair","Making Care Safer"]
["X3744","Physician\nCompare","Proportion of patients sustaining a major viscus injury atthe time of any pelvic organ prolapse repair","Making Care Safer"]
["X3746","Physician\nCompare","Preoperative assessment of occult stress urinaryincontinence prior to any pelvic organ prolapse repair","Effective Prevention andTreatment"]
["X3742","Physician\nCompare","Preoperative assessment of sexual function prior to anypelvic organ prolapse repair","Effective Prevention andTreatment"]
["X3741","Physician\nCompare","Preoperative exclusion of uterine malignancy prior toany pelvic organ prolapse repair","Making Care Safer"]
["X3740","Physician\nCompare","Performing an intraoperative rectal examination at thetime of prolapse repair","Making Care Safer"]
["E0465","Physician\nCompare","Perioperative Anti‐platelet Therapy for Patientsundergoing Carotid Endarterectomy","Effective Prevention andTreatment"]
["E1523","Physician\nCompare","In‐hospital mortality following elective open repair ofAAAs","Making Care Safer"]
["X3761","Physician\nCompare","Photodocumentation of cecal intubation","Effective Prevention andTreatment"]
["X3760","Physician\nCompare","Frequency of inadequate bowel preparation","Making Care Affordable"]
["X3758","Physician\nCompare","Appropriate age for colorectal cancer screening","Making Care Affordable"]
["X3759","Physician\nCompare","Appropriate follow‐up imaging for incidental abdominallesions","Effective Prevention andTreatment"]
["X3763","Physician\nCompare","Appropriate follow‐up imaging for incidental thyroidnodules in patients","Effective Prevention andTreatment"]
["X3764","Physician\nCompare","Imaging in adult ED patients with minor head injury","Making Care Affordable"]
["X3781","Physician\nCompare","Use of premedication before contrast‐enhanced imagingstudies in patients with documented contrast allergy","Making Care Safer"]
["X3523","Physician\nCompare","Extravasation of contrast following contrast‐enhancedcomputed tomography (CT)","Making Care Safer"]
["X3780","Physician\nCompare","Coagulation studies in adult patients presenting withchest pain with no coagulopathy or bleeding","Making Care Affordable"]
["X3803","Physician\nCompare","Appropriate use of imaging for non‐traumatic shoulderpain","Making Care Affordable"]
["X3802","Physician\nCompare","Appropriate follow‐up imaging for non‐traumatic kneepain","Making Care Affordable"]
["X3774","Physician\nCompare","Evaluation or Interview for Risk of Opioid Misuse","Effective Prevention andTreatment"]
["X3777","Physician\nCompare","Documentation of Signed Opioid Treatment Agreement","Effective Prevention andTreatment"]
["X3776","Physician\nCompare","Consideration of Non‐Pharmacologic Interventions","Effective Prevention andTreatment"]
["X3775","Physician\nCompare","Chronic Opioid Therapy Follow‐up Evaluation","Effective Prevention andTreatment"]
["X3771","Physician\nCompare","MEDICATION PRESCRIBED FOR ACUTE MIGRAINEATTACK","Effective Prevention andTreatment"]
["X3766","Physician\nCompare","ACUTE MEDICATION PRESCRIBED FOR CLUSTERHEADACHE","Effective Prevention andTreatment"]
["X3772","Physician\nCompare","Preventive Migraine Medication Prescribed","Effective Prevention andTreatment"]
["X3765","Physician\nCompare","Overuse of Barbiturate Containing Medications forPrimary Headache Disorders","Effective Prevention andTreatment"]
["X3769","Physician\nCompare","Unnecessary Screening Colonoscopy in Older Adults","Making Care Affordable"]
["X3770","Physician\nCompare","Overuse Of Opioid Containing Medications For PrimaryHeadache Disorders","Effective Prevention andTreatment"]
["X3783","Physician\nCompare","Assessment Of Medication Overuse In The Treatment OfPrimary Headache Disorders","Effective Prevention andTreatment"]
["X3784","Physician\nCompare","Plan Of Care Or Referral For Possible MedicationOveruse Headache","Making Care Affordable"]
["X3785","Physician\nCompare","Overuse Of Neuroimaging For Patients With PrimaryHeadache And A Normal Neurological Examination","Making Care Affordable"]
["X3786","Physician\nCompare","Quality Of Life Assessment For Patients With PrimaryHeadache Disorders","Effective Prevention andTreatment"]
["X3796","Physician\nCompare","Migraine Or Cervicogenic Headache Related DisabilityFunctional Status","Effective Prevention andTreatment"]
["X3794","Physician\nCompare","Plan Of Care For Migraine Or Cervicogenic HeadacheDeveloped Or Reviewed","Effective Prevention andTreatment"]
["X3787","Physician\nCompare","Patients with DMD Prescribed Appropriate DiseaseModifying Pharmaceutical Therapy","Effective Prevention andTreatment"]
["X3791","Physician\nCompare","MD Multidisciplinary Care Plan Developed or Updated","Effective Prevention andTreatment"]
["X3798","Physician\nCompare","Scoliosis Evaluation Ordered","Effective Prevention andTreatment"]
["X3801","Physician\nCompare","Nutritional Status or Growth Trajectories Monitored","Effective Prevention andTreatment"]
["X3800","Physician\nCompare","Patient Queried about Pain and Pain Interference withFunction","Effective Prevention andTreatment"]
["X3789","Physician\nCompare","Patient Counseled About Health Care Decision‐Making","Effective Prevention andTreatment"]
["X3807","Physician\nCompare","Post‐Anesthetic Transfer of Care: Use of Checklist orProtocol for Direct Transfer of Care from ProcedureRoom to Intensive Care Unit (ICU)","Communication and CareCoordination"]
["X3806","Physician\nCompare","Prevention of Post‐Operative Nausea and Vomiting(PONV) – Combination","Patient and FamilyEngagement"]
["X3809","Physician\nCompare","Perioperative Temperature Management","Making Care Safer"]
["X3811","Physician\nCompare","Anesthesiology Smoking Abstinence","Effective Prevention andTreatment"]
["X3808","Physician\nCompare","Preoperative Use of Aspirin for Patients with Drug‐Eluting Coronary Stents","Effective Prevention andTreatment"]
["X3810","Physician\nCompare","Post‐Anesthetic Transfer of Care Measure: ProcedureRoom to a Post Anesthesia Care Unit (PACU)","Communication and CareCoordination"]
["X3813","Physician\nCompare","Proportion of patients sustaining a ureter injury at thetime of any pelvic organ prolapse repair","Making Care Safer"]
["X3733","Physician\nCompare","Pediatric Kidney Disease: Discussion of Care Planning","Patient and FamilyEngagement"]
["X3778","Physician\nCompare","Imaging in pediatric ED patients aged 2 through 17 yearswith minor head injury","Making Care Affordable"]
["X3729","Physician\nCompare","Statin Therapy for the Prevention and Treatment ofCardiovascular Disease","Effective Prevention andTreatment"]
["X3468","Physician\nCompare","Documentation of a Health Care Proxy for Patients withCognitive Impairment","Effective Prevention andTreatment"]
["X3465","Physician\nCompare","Coordinating Care ‐ Follow‐Up with Eligible Provider","Communication and CareCoordination"]
["X3466","Physician\nCompare","Coordinating Care ‐ Emergency Department Referrals","Communication and CareCoordination"]
["X3053","Physician\nCompare","Functional Status Assessments and Goal Setting forChronic Pain Due to Osteoarthritis","Effective Prevention andTreatment"]
["X3469","Physician\nCompare","Cognitive Impairment Assessment Among At‐Risk OlderAdults","Best Practice of HealthyLiving"]
["E0076","Physician\nCompare","Optimal Vascular Care","Effective Prevention andTreatment"]
["X3768","Physician\nCompare","Primary C‐Section Rate 2014","Making Care Affordable"]
["X3773","Physician\nCompare","Optimal Asthma Care 2014","Effective Prevention andTreatment"]
["E0032","Physician\nCompare","Cervical Cancer Screening","Effective Prevention andTreatment"]
["X3797","Physician\nCompare","Breast Cancer Screening","Effective Prevention andTreatment"]
["X3792","Physician\nCompare","Controlling High Blood Pressure","Effective Prevention andTreatment"]
["X3485","Physician\nCompare","Adverse Drug Events ‐ Minimum INR Monitoring forPatients with Atrial Fibrillation on Warfarin","Making Care Safer"]
["X3283","Physician\nCompare","Closing the Referral Loop ‐ Critical InformationCommunicated with Request for Referral","Communication and CareCoordination"]
["X3476","Physician\nCompare","Diabetes: Hemoglobin A1c Overtreatment in the Elderly","Effective Prevention andTreatment"]
["X3483","Physician\nCompare","Functional Status Outcomes for Patients ReceivingPrimary Total Hip Replacements","Patient and FamilyEngagement"]
["X3482","Physician\nCompare","Functional Status Outcomes for Patients ReceivingPrimary Total Knee Replacements","Patient and FamilyEngagement"]
["X3816","Physician\nCompare","Hepatitis C: Appropriate Screening Follow‐Up forPatients Identified with Hepatitis C Virus (HCV) Infection","Communication and CareCoordination"]
["X3512","Physician\nCompare","Hepatitis C: One‐Time Screening for Hepatitis C Virus(HCV) for Patients at Risk","Best Practice of HealthyLiving"]
["X3475","Physician\nCompare","Substance Use Screening and Intervention Composite","Best Practice of HealthyLiving"]
["E2152","Physician\nCompare","Preventive Care and Screening: Unhealthy Alcohol Use:Screening & Brief Counseling","Best Practice of HealthyLiving"]
["X3445","Physician\nCompare","Alcohol Screening and Brief Intervention (ASBI) in the ER","Best Practice of HealthyLiving"]
["X3446","Physician\nCompare","Intimate Partner (Domestic) Violence Screening","Best Practice of HealthyLiving"]
["X3299","Physician\nCompare","HIV: Ever screened for HIV","Effective Prevention andTreatment"]
["X3300","Physician\nCompare","HIV Screening of STI patients","Effective Prevention andTreatment"]
["E0555","Physician\nCompare","INR Monitoring for Individuals on Warfarin (e‐specifiedversion of NQF #0555)","Making Care Safer"]
["S2550","Physician\nCompare","Gout: Urate Lowering Therapy","Effective Prevention andTreatment"]
["S2521","Physician\nCompare","Gout: Serum Urate Monitoring","Effective Prevention andTreatment"]
["E0711","Medicare Shared Savings","Depression Remission at Six Months","Patient and FamilyEngagement"]
["X3513","Medicare Shared Savings","Annual Hepatitis C Virus (HCV) Screeningfor Patients who are Active Injection DrugUsers","Patient and FamilyEngagement"]
["X3726","Medicare Shared Savings","Clinical Response to Oral Systemic orBiologic Medications","Patient and FamilyEngagement"]
["X3274","Medicare Shared Savings","Assessment for Psoriatic Arthritis","Patient and FamilyEngagement"]
["X3788","Medicare Shared Savings","PC‐02 Cesarean Section (Provider Level)","Making Care Affordable"]
["X3732","Medicare Shared Savings","Adult Kidney Disease: Referral to Hospice","Patient and FamilyEngagement"]
["X3735","Medicare Shared Savings","Communication and shared decision‐making with patients and families forinterventional oncology procedures","Patient and FamilyEngagement"]
["X3739","Medicare Shared Savings","Percentage of patients treated for varicoseveins who are treated with saphenousablation and receive an outcomes surveybefore and after treatment","Effective Prevention andTreatment"]
["X3755","Medicare Shared Savings","Percentage of patients with a retrievableinferior vena cava filter who areappropriately assessed for continuedfiltration or device removal","Effective Prevention andTreatment"]
["X3754","Medicare Shared Savings","Rate of surgical conversion from lowerextremity endovascular revasculatizationprocedure","Effective Prevention andTreatment"]
["X3756","Medicare Shared Savings","Clinical Outcome post Endovascular StrokeTreatment","Effective Prevention andTreatment"]
["X3747","Medicare Shared Savings","Door to puncture time for endovascularstroke treatment","Effective Prevention andTreatment"]
["X3752","Medicare Shared Savings","Performing cystoscopy at the time ofhysterectomy for pelvic organ prolapse todetect lower urinary tract injury","Making Care Safer"]
["X3751","Medicare Shared Savings","Complete assessment and evaluation ofpatient’s pelvic organ prolapse prior tosurgical repair","Communication and CareCoordination"]
["X3750","Medicare Shared Savings","Preoperative pessary for pelvic organprolapse offered","Communication and CareCoordination"]
["X3745","Medicare Shared Savings","Preoperative pessary for pelvic organprolapse attempted","Communication and CareCoordination"]
["X3743","Medicare Shared Savings","Proportion of patients sustaining a bladderinjury at the time of any pelvic organprolapse repair","Making Care Safer"]
["X3744","Medicare Shared Savings","Proportion of patients sustaining a majorviscus injury at the time of any pelvic organprolapse repair","Making Care Safer"]
["X3746","Medicare Shared Savings","Preoperative assessment of occult stressurinary incontinence prior to any pelvicorgan prolapse repair","Effective Prevention andTreatment"]
["X3742","Medicare Shared Savings","Preoperative assessment of sexual functionprior to any pelvic organ prolapse repair","Effective Prevention andTreatment"]
["X3741","Medicare Shared Savings","Preoperative exclusion of uterinemalignancy prior to any pelvic organprolapse repair","Making Care Safer"]
["X3740","Medicare Shared Savings","Performing an intraoperative rectalexamination at the time of prolapse repair","Making Care Safer"]
["E0465","Medicare Shared Savings","Perioperative Anti‐platelet Therapy forPatients undergoing CarotidEndarterectomy","Effective Prevention andTreatment"]
["E1523","Medicare Shared Savings","In‐hospital mortality following electiveopen repair of AAAs","Making Care Safer"]
["X3761","Medicare Shared Savings","Photodocumentation of cecal intubation","Effective Prevention andTreatment"]
["X3760","Medicare Shared Savings","Frequency of inadequate bowelpreparation","Making Care Affordable"]
["X3758","Medicare Shared Savings","Appropriate age for colorectal cancerscreening","Making Care Affordable"]
["X3759","Medicare Shared Savings","Appropriate follow‐up imaging forincidental abdominal lesions","Effective Prevention andTreatment"]
["X3763","Medicare Shared Savings","Appropriate follow‐up imaging forincidental thyroid nodules in patients","Effective Prevention andTreatment"]
["X3764","Medicare Shared Savings","Imaging in adult ED patients with minorhead injury","Making Care Affordable"]
["X3781","Medicare Shared Savings","Use of premedication before contrast‐enhanced imaging studies in patients withdocumented contrast allergy","Making Care Safer"]
["X3523","Medicare Shared Savings","Extravasation of contrast followingcontrast‐enhanced computed tomography(CT)","Making Care Safer"]
["X3780","Medicare Shared Savings","Coagulation studies in adult patientspresenting with chest pain with nocoagulopathy or bleeding","Making Care Affordable"]
["X3803","Medicare Shared Savings","Appropriate use of imaging for non‐traumatic shoulder pain","Making Care Affordable"]
["X3802","Medicare Shared Savings","Appropriate follow‐up imaging for non‐traumatic knee pain","Making Care Affordable"]
["X3774","Medicare Shared Savings","Evaluation or Interview for Risk of OpioidMisuse","Effective Prevention andTreatment"]
["X3777","Medicare Shared Savings","Documentation of Signed Opioid TreatmentAgreement","Effective Prevention andTreatment"]
["X3776","Medicare Shared Savings","Consideration of Non‐PharmacologicInterventions","Effective Prevention andTreatment"]
["X3775","Medicare Shared Savings","Chronic Opioid Therapy Follow‐upEvaluation","Effective Prevention andTreatment"]
["X3771","Medicare Shared Savings","Medication Prescribed For Acute MigraineAttack","Effective Prevention andTreatment"]
["X3766","Medicare Shared Savings","Acute Medication Prescribed For ClusterHeadache","Effective Prevention andTreatment"]
["X3772","Medicare Shared Savings","Preventive Migraine Medication Prescribed","Effective Prevention andTreatment"]
["X3765","Medicare Shared Savings","Overuse of Barbiturate ContainingMedications for Primary HeadacheDisorders","Effective Prevention andTreatment"]
["X3769","Medicare Shared Savings","Unnecessary Screening Colonoscopy inOlder Adults","Making Care Affordable"]
["X3770","Medicare Shared Savings","Overuse Of Opioid Containing MedicationsFor Primary Headache Disorders","Effective Prevention andTreatment"]
["X3783","Medicare Shared Savings","Assessment Of Medication Overuse In TheTreatment Of Primary Headache Disorders","Effective Prevention andTreatment"]
["X3784","Medicare Shared Savings","Plan Of Care Or Referral For PossibleMedication Overuse Headache","Making Care Affordable"]
["X3785","Medicare Shared Savings","Overuse Of Neuroimaging For PatientsWith Primary Headache And A NormalNeurological Examination","Making Care Affordable"]
["X3786","Medicare Shared Savings","Quality Of Life Assessment For PatientsWith Primary Headache Disorders","Effective Prevention andTreatment"]
["X3796","Medicare Shared Savings","Migraine Or Cervicogenic HeadacheRelated Disability Functional Status","Effective Prevention andTreatment"]
["X3794","Medicare Shared Savings","Plan Of Care For Migraine Or CervicogenicHeadache Developed Or Reviewed","Effective Prevention andTreatment"]
["X3787","Medicare Shared Savings","Patients with DMD Prescribed AppropriateDisease Modifying Pharmaceutical Therapy","Effective Prevention andTreatment"]
["X3791","Medicare Shared Savings","MD Multidisciplinary Care Plan Developedor Updated","Effective Prevention andTreatment"]
["X3798","Medicare Shared Savings","Scoliosis Evaluation Ordered","Effective Prevention andTreatment"]
["X3801","Medicare Shared Savings","Nutritional Status or Growth TrajectoriesMonitored","Effective Prevention andTreatment"]
["X3800","Medicare Shared Savings","Patient Queried about Pain and PainInterference with Function","Effective Prevention andTreatment"]
["X3789","Medicare Shared Savings","Patient Counseled About Health CareDecision‐Making","Effective Prevention andTreatment"]
["X3807","Medicare Shared Savings","Post‐Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer ofCare from Procedure Room to IntensiveCare Unit (ICU)","Communication and Care"]
["X3806","Medicare Shared Savings","Prevention of Post‐Operative Nausea andVomiting (PONV) – Combination","Patient and FamilyEngagement"]
["X3809","Medicare Shared Savings","Perioperative Temperature Management","Making Care Safer"]
["X3811","Medicare Shared Savings","Anesthesiology Smoking Abstinence","Effective Prevention andTreatment"]
["X3808","Medicare Shared Savings","Preoperative Use of Aspirin for Patientswith Drug‐Eluting Coronary Stents","Effective Prevention andTreatment"]
["X3810","Medicare Shared Savings","Post‐Anesthetic Transfer of Care Measure:Procedure Room to a Post Anesthesia CareUnit (PACU)","Communication and CareCoordination"]
["X3813","Medicare Shared Savings","Proportion of patients sustaining a ureterinjury at the time of any pelvic organprolapse repair","Making Care Safer"]
["E0171","Medicare Shared Savings","Acute Care Hospitalization (Claims‐Based)","Communication and CareCoordination"]
["E0419","Medicare Shared Savings","Documentation of Current Medications inthe Medical Record","Communication and CareCoordination"]
["X1033","Medicare Shared Savings","Coronary Artery Disease (CAD): SymptomManagement:","Effective Prevention andTreatment"]
["E0067","Medicare Shared Savings","Coronary Artery Disease (CAD): AntiplateletTherapy","Effective Prevention andTreatment"]
["E0070","Medicare Shared Savings","Coronary Artery Disease (CAD): Beta‐Blocker Therapy – Prior MyocardialInfarction (MI) or Left Ventricular SystolicDysfunction (LVEF < 40%)","Effective Prevention andTreatment"]
["E0056","Medicare Shared Savings","Diabetes: Foot exam","Effective Prevention andTreatment"]
["E0055","Medicare Shared Savings","Comprehensive Diabetes Care: Eye Exam","Effective Prevention andTreatment"]
["E2111","Medicare Shared Savings","Antipsychotic Use in Persons withDementia","Making Care Safer"]
["X3715","Medicare Shared Savings","Prevention Quality Indicators #90 (PQI #90)","Effective Prevention andTreatment"]
["X2147","Medicare Shared Savings","Total Per Capita Cost Measure ForMedicate Fee‐For‐Service ServiceBeneficiaries","Making Care Affordable"]
["E0712","Medicare Shared Savings","Depression Utilization of the PHQ‐9 Tool","Patient and FamilyEngagement"]
["X3729","Medicare Shared Savings","Statin Therapy for the Prevention andTreatment of Cardiovascular Disease","Effective Prevention andTreatment"]
["X3468","Medicare Shared Savings","Documentation of a Health Care Proxy forPatients with Cognitive Impairment","Effective Prevention andTreatment"]
["X3465","Medicare Shared Savings","Coordinating Care ‐ Follow‐Up with EligibleProvider","Communication and CareCoordination"]
["X3466","Medicare Shared Savings","Coordinating Care ‐ Emergency DepartmentReferrals","Communication and CareCoordination"]
["X3053","Medicare Shared Savings","Functional Status Assessments and GoalSetting for Chronic Pain Due toOsteoarthritis","Effective Prevention andTreatment"]
["X3469","Medicare Shared Savings","Cognitive Impairment Assessment AmongAt‐Risk Older Adults","Best Practice of HealthyLiving"]
["E0076","Medicare Shared Savings","Optimal Vascular Care","Effective Prevention andTreatment"]
["X3768","Medicare Shared Savings","Primary C‐Section Rate 2014","Making Care Affordable"]
["X2809","Medicare Shared Savings","ALS Multidisciplinary Care Plan Developedor Updated","Effective Prevention andTreatment"]
["X3773","Medicare Shared Savings","Optimal Asthma Care 2014","Effective Prevention andTreatment"]
["E0032","Medicare Shared Savings","Cervical Cancer Screening","Effective Prevention andTreatment"]
["X3797","Medicare Shared Savings","Breast Cancer Screening","Effective Prevention andTreatment"]
["X3792","Medicare Shared Savings","Controlling High Blood Pressure","Effective Prevention andTreatment"]
["X3485","Medicare Shared Savings","Adverse Drug Events ‐ Minimum INRMonitoring for Patients with AtrialFibrillation on Warfarin","Making Care Safer"]
["X3302","Medicare Shared Savings","Closing the Referral Loop ‐ Specialist ReportSent to Primary Care Physician","Communication and CareCoordination"]
["X3283","Medicare Shared Savings","Closing the Referral Loop ‐ CriticalInformation Communicated with Requestfor Referral","Communication and CareCoordination"]
["X3481","Medicare Shared Savings","Functional Status Assessment and GoalAchievement for Patients with CongestiveHeart Failure","Effective Prevention andTreatment"]
["X3476","Medicare Shared Savings","Diabetes: Hemoglobin A1c Overtreatmentin the Elderly","Effective Prevention andTreatment"]
["X3483","Medicare Shared Savings","Functional Status Outcomes for PatientsReceiving Primary Total Hip Replacements","Patient and FamilyEngagement"]
["X3482","Medicare Shared Savings","Functional Status Outcomes for PatientsReceiving Primary Total Knee Replacements","Patient and FamilyEngagement"]
["X3816","Medicare Shared Savings","Hepatitis C: Appropriate Screening Follow‐Up for Patients Identified with Hepatitis CVirus (HCV) Infection","Communication and CareCoordination"]
["X3512","Medicare Shared Savings","Hepatitis C: One‐Time Screening forHepatitis C Virus (HCV) for Patients at Risk","Best Practice of HealthyLiving"]
["E2079","Medicare Shared Savings","HIV medical visit frequency","Effective Prevention andTreatment"]
["E2082","Medicare Shared Savings","HIV Viral Load Suppression","Effective Prevention andTreatment"]
["E2083","Medicare Shared Savings","Prescription of HIV Antiretroviral Therapy","Effective Prevention andTreatment"]
["X3475","Medicare Shared Savings","Substance Use Screening and InterventionComposite","Best Practice of HealthyLiving"]
["E2152","Medicare Shared Savings","Preventive Care and Screening: UnhealthyAlcohol Use: Screening & Brief Counseling","Best Practice of HealthyLiving"]
["X3445","Medicare Shared Savings","Alcohol Screening and Brief Intervention(ASBI) in the ER","Best Practice of HealthyLiving"]
["X3446","Medicare Shared Savings","Intimate Partner (Domestic) ViolenceScreening","Best Practice of HealthyLiving"]
["X3299","Medicare Shared Savings","HIV: Ever screened for HIV","Effective Prevention andTreatment"]
["X3300","Medicare Shared Savings","HIV Screening of STI patients","Effective Prevention andTreatment"]
["S0139","Medicare Shared Savings","National Healthcare Safety Network (NHSN)Central line‐associated BloodstreamInfection (CLABSI) Outcome","Making Care Safer"]
["E0555","Medicare Shared Savings","INR Monitoring for Individuals on Warfarin(e‐specified version of NQF #0555)","Making Care Safer"]
["S2550","Medicare Shared Savings","Gout: Urate Lowering Therapy","Effective Prevention andTreatment"]
["E2158","Medicare Shared Savings","Payment‐Standardized Medicare SpendingPer Beneficiary (MSPB)","Making Care Affordable"]
["E0513","Medicare Shared Savings","Thorax CT: Use of Contrast Material","Making Care Affordable"]
["E0514","Medicare Shared Savings","MRI Lumbar Spine for Low Back Pain","Making Care Affordable"]
["E0052","Medicare Shared Savings","Use of Imaging Studies for Low Back Pain","Making Care Affordable"]
["S0138","Medicare Shared Savings","National Healthcare Safety Network (NHSN)Catheter‐associated Urinary Tract Infection(CAUTI) Outcome","Making Care Safer"]
["S2521","Medicare Shared Savings","Gout: Serum Urate Monitoring","Effective Prevention andTreatment"]
["S2510","Medicare Shared Savings","Skilled Nursing Facility All‐Cause 30 DayPost Discharge Readmission Measure","Communication and CareCoordination"]
["X3704","Home Health\nQuality\nReporting","Percent of Patients with Pressure UlcersThat Are New or Worsened","Effective Prevention and Treatment"]
["E0648","Inpatient Psychiatric\nFacility Quality Reporting","Timely Transmission of TransitionRecord (Discharges from an InpatientFacility to Home/Self Care or AnyOther Site of Care)","Communication and CareCoordination"]
["E0647","Inpatient Psychiatric\nFacility Quality Reporting","Transition Record with SpecifiedElements Received by DischargedPatients (Discharges from an InpatientFacility to Home/Self Care or AnyOther Site of Care)","Communication and CareCoordination"]
["E1656","Inpatient Psychiatric\nFacility Quality Reporting","TOB‐3 Tobacco Use TreatmentProvided or Offered at Discharge ANDTOB‐3a Tobacco Use Treatment atDischarge","Effective Prevention andTreatment"]
["E1663","Inpatient Psychiatric\nFacility Quality Reporting","SUB‐2 Alcohol Use Brief InterventionProvided or Offered. SUB‐2a AlcoholUse Brief Intervention Received.","Effective Prevention andTreatment"]
["E0141","Inpatient\nRehabilitation\nFacility Quality\nReporting","Patient fall rate","Making Care Safer"]
["E0371","Inpatient\nRehabilitation\nFacility Quality\nReporting","Venous Thromboembolism Prophylaxis","Making Care Safer"]
["S2634","Inpatient\nRehabilitation\nFacility Quality\nReporting","IRF Functional Outcome Measure: Changein Mobility Score for Medical RehabilitationPatients","Patient and Family Engagement,Communication and CareCoordination"]
["S2636","Inpatient\nRehabilitation\nFacility Quality\nReporting","IRF Functional Outcome Measure: DischargeMobility Score for Medical RehabilitationPatients","Patient and Family Engagement"]
["S2635","Inpatient\nRehabilitation\nFacility Quality\nReporting","IRF Functional Outcome Measure: DischargeSelf‐Care Score for Medical RehabilitationPatients","Patient and Family Engagement,Communication and CareCoordination"]
["S2633","Inpatient\nRehabilitation\nFacility Quality\nReporting","IRF Functional Outcome Measure: Changein Self‐Care Score for Medical RehabilitationPatients","Patient and Family Engagement"]
["E1919","End‐Stage Renal\nDisease Quality\nIncentive Program","Cultural CompetencyImplementation Measure","Patient and Family Engagement"]
["X3716","End‐Stage Renal\nDisease Quality\nIncentive Program","Cultural Competency ReportingMeasure","Patient and Family Engagement"]
["X3721","End‐Stage Renal\nDisease Quality\nIncentive Program","Medications DocumentationReporting","Communication and Care Coordination"]
["X2051","End‐Stage Renal\nDisease Quality\nIncentive Program","Delivered Dose of Dialysis AboveMinimum ‐ Composite Score","Effective Prevention and Treatment"]
["X3718","End‐Stage Renal\nDisease Quality\nIncentive Program","Delivered Dose in PeritonealDialysis Above Minimum","Effective Prevention and Treatment"]
["X3717","End‐Stage Renal\nDisease Quality\nIncentive Program","Delivered Dose of HemodialysisAbove Minimum","Effective Prevention and Treatment"]
["E0419","End‐Stage Renal\nDisease Quality\nIncentive Program","Documentation of CurrentMedications in the Medical Record","Communication and Care Coordination"]
["E0141","Long‐Term Care Hospital\nQuality Reporting","Patient fall rate","Making Care Safer"]
["E0371","Long‐Term Care Hospital\nQuality Reporting","Venous Thromboembolism Prophylaxis","Making Care Safer"]
["X3706","Long‐Term Care Hospital\nQuality Reporting","Ventilator Weaning (Liberation) Rate","Making Care Safer"]
["X3705","Long‐Term Care Hospital\nQuality Reporting","Compliance with Ventilator Process Elementsduring LTCH stay","Making Care Safer"]
["S2510","Skilled Nursing Facility Value‐\nBased Purchasing Program","Skilled Nursing Facility All‐Cause 30 DayPost Discharge Readmission Measure","Communication andCare Coordination"]