Endorsed

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:
a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

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

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

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

The percentage of individuals 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80 percent during the measurement year.

Report a rate for each of the following:
• Diabetes All Class (PDC-DR)
• Renin Angiotensin System Antagonists (PDC-RASA)
• Statins (PDC-STA)

A higher rate indicates better performance.

Percentage of children from 3.00 to 17.99 years of age seen for a pediatric well child visit who have a Pediatric Symptom Checklist (PSC) Tool administered as a component of that visit.

This measure is an all-or-none composite of the number of patients following an ICD/CRT-D implant procedure who received prescriptions for all medications (Angiotensin-converting enzyme inhibitors (ACE-I)/ Angiotensin receptor blockers (ARB)/ Angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers) for which they are eligible at discharge and those patients with procedures that fulfill class I, IIa, or IIb guideline indications.

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

Percentage of female patients, age = 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the breast, had breast conserving surgery and was administered radiation therapy within 1 year (365 days) of diagnosis