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Combination chemotherapy or chemo-immunotherapy (if HER2 positive), is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0 or stage IB - III hormone receptor negative breast cancer

  • Percentage of female patients, age >= 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC stage T1cN0M0 or Stage IB - IIIC, whose primary tumor is of the breast, and progesterone and estrogen receptor negative is recommended or administered multi-agent chemotherapy within 4 months (120 days) of diagnosis

    CBE ID
    0559

Death Rate among Surgical Inpatients with Serious Treatable Complications (PSI 04)

  • In-hospital deaths per 1,000 surgical discharges, among patients ages 18 through 89 years or obstetric patients, with serious treatable complications (shock/cardiac arrest, sepsis, pneumonia, deep vein thrombosis/ pulmonary embolism or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility. A risk-adjusted rate is available. The risk-adjusted rate of PSI 04 relies on stratum-specific risk models.

    CBE ID
    0351

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.

    CBE ID
    1822

Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

  • This measure calculates the percentage of Emergency Department (ED) acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. The measure is calculated using chart-abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

    CBE ID
    0288

Follow-Up After Hospitalization for Mental Illness (FUH)

  • The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are reported:
    1. The percentage of discharges for which the member received follow-up within 30 days after discharge.
    2. The percentage of discharges for which the member received follow-up within 7 days after discharge.

    CBE ID
    0576

HBIPS-2 Hours of physical restraint use

  • The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.

    CBE ID
    0640

HBIPS-3 Hours of seclusion use

  • The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

    CBE ID
    0641

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey

  • HCAHPS (NQF #0166) is a 29-item survey instrument that produces 10 publicly reported measures:

    6 multi-item measures (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, discharge information and care transition); and

    4 single-item measures (cleanliness of the hospital environment, quietness of the hospital environment, overall rating of the hospital, and recommendation of hospital).

    CBE ID
    0166

Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following acute myocardial infarction (AMI) hospitalization

  • The measure estimates a hospital-level 30-day risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal diagnosis of AMI. Mortality is defined as death for any cause within 30 days after the date of admission for the index admission. CMS annually reports the measure for patients who are 65 years or older and are either Medicare fee-for-service (FFS) beneficiaries and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.

    CBE ID
    0230