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Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma

  • Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both

    CBE ID
    3661

Monthly Hemoglobin Measurement for Pediatric Patients

  • Percentage of patient months of pediatric (< 18 years old) in-center hemodialysis, home hemodialysis, and peritoneal dialysis patients who have monthly measures for hemoglobin during the reporting period.

    CBE ID
    1424

National Healthcare Safety Network (NHSN) Antimicrobial Use Measure

  • This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN).

    CBE ID
    2720

National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU).
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

    CBE ID
    0138

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
    This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.

    CBE ID
    0139

Non-Emergent Coronary Artery Bypass Graft (CABG) Measure

  • The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a CABG procedure during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

    CBE ID
    3625

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.

    CBE ID
    0205

Oncology: Medical and Radiation – Plan of Care for Pain

  • This measure looks at the percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain. This measure is to be submitted at each denominator eligible visit occurring during the performance period for patients with a diagnosis of cancer and in which pain is present who are seen during the performance period / measurement period. The time period for data collection is intended to be 12 consecutive months.

     

    CBE ID
    0383