Outcome

This outcome measure tracks the rate of adult patients (aged 18 years and older) treated and released from the Emergency Department (ED) with either a non-specific, presumed benign symptom-only dizziness diagnosis or a specific inner ear/vestibular diagnosis (collectively referred to as “benign dizziness”) who were subsequently admitted to a hospital for a stroke within 30 days of their ED visit.

Percentage of patients with esophageal biopsy reports for Barrett’s esophagus that contain a statement about dysplasia and if present the grade of dysplasia.

Bilateral cardiac catheterization discharges per 1,000 heart catheterizations discharges for coronary artery disease for patients ages 18 years and older. Excludes valid indications for right- side catheterization discharges and obstetric discharges.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report specific procedure discharges per 1,000 hospital discharges.]

Percentage of newborn discharges with an ICD-9-CM diagnosis code of birth trauma in a one-year time period.

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation (AF) ablation.

The CARE survey is mortality follow back survey that is administered to the bereaved family members of adult persons (age 18 and older) who died of a chronic progressive illness receiving services for at least 48 hours from a home health agency, nursing homes, hospice, or acute care hospital. The survey measures perceptions of the quality of care either in terms of unmet needs, family reports of concerns with the quality of care, and overall rating of the quality of care.

The measure calculates a skilled nursing facility’s (SNFs) average change in mobility for patients admitted from a hospital who are receiving therapy. The measure calculates the average change in mobility score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the mobility subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment.

The measure calculates a skilled nursing facility’s (SNFs) average change in self care for patients admitted from a hospital who are receiving therapy. The measure calculates the average change in self care score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the self care subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment.