Endorsed

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Categories, a multi-institutional validated risk stratification tool

The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:
• HbA1c less than 8.0 mg/dL
• Blood Pressure less than 140/90 mmHg
• On a statin medication, unless allowed contraindications or exceptions are present
• Non-tobacco user
• Patient with ischemic vascular disease is on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present

Information From 2015 Submission

Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis (peritoneal dialysis or home hemodialysis), or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.

Measure Description: The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:
• Blood pressure less than 140/90 mmHg
• On a statin medication, unless allowed contraindications or exceptions are present
• Non-tobacco user
• On daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present

Exclusions

Percentage of enrolled children under age 21 years who received a comprehensive or periodic oral evaluation within the reporting year.

Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials

The proportion of acute MI patients >= 18 years of age that receive "perfect care" based upon their eligibility for each performance measures

Participation in at least one multi-center, standardized data collection and feedback program for pediatric and congenital heart surgery that provides benchmarking of the physician’s data relative to national and regional programs and uses process and outcome measures.

Participation in a multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.