Percentage of patients aged 18 years and older at the start of the measurement period with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.
Percentage of patients aged 50 years to 75 years receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
This measure calculates the percentage of stress echocardiography, single photon emission computed tomography myocardial perfusion imaging (SPECT MPI), stress magnetic resonance imaging (MRI), or computed coronary tomography angiography (CCTA) performed at each facility in the 30 days prior to an ambulatory non-cardiac, low-risk surgery performed at any location. The measure is calculated based on a one-year window of Medicare claims data.
Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery
This measure assesses facility level compliance with administration of the CollaboRATE Shared Decision-Making tool to patients undergoing outpatient or ambulatory surgery. To be compliant, facilities must offer 95% of patients the option to complete the CollaboRATE survey within 1 week of the shared decision making conversation.
CollaboRATE has been administered as a paper handout, via mail, electronic mail, computer or web interface, voice recorded telephone interviews, SMS text messages, and through MyChart EHR integration.
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy
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.
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.
The facility-level, post-surgical risk-standardized hospital visit ratio (RSHVR) of the predicted to expected number of all-cause, unplanned hospital visits within 7 days of a same-day surgery at a hospital outpatient department among Medicare Fee-for-Service (FFS) patients aged 65 years and older.
The surgery measure outcome is all-cause unplanned hospital visits, defined as 1) an inpatient admission directly following surgery or 2) an emergency department (ED) visit, observation stay, or unplanned inpatient admission occurring after discharge from the HOPD and within 7 days of the outpatient surgery.
N/A
N/A
Eligible same-day surgeries or cystoscopy procedures with intervention performed at HOPDs for Medicare FFS patients aged 65 years and older, with the exception of eye surgeries and same-day surgeries performed concurrently with high-risk procedures.
The measure excludes:
N/A
Link to Endorsement Measure Record: Hospital Visits after Hospital Outpatient Surgery
Impact Summary: This measure supports the Hospital Outpatient Quality Reporting Program’s goal of improving outpatient care quality and patient experience in hospital settings by monitoring the post-surgical risk-standardized hospital visit ratio within 7 days of a same-day surgery at a hospital outpatient department.
Performance varied from 2020 to 2024, with the widest range of measure scores for hospital outpatient departments (HOPDs) occurring in 2023. As shown in Table 1, the highest-performing 10% of the entities (Decile 1) contains 21% of the total patients, indicating that larger entities tend to perform better.
For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:
Battelle analyzed all values for “Measure_ID”=”OP_36” not marked as “Not Available” from the corresponding Unplanned_Hospital_Visits-Hospital.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Because this measure is a ratio of an entity’s risk-adjusted rate to the national rate for the same year, Figure 1 is not very informative for assessing change over time. The median ratio is always 1.0. Slight variation in spread year-over-year suggests gap between best and worst performers shifted modestly over time, but no clear trend can be drawn from this alone. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the population represented within each group, for the most recent year with data available. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain larger or smaller populations than other groups. For example, if the lowest-scoring decile includes only 5% of the total population, then smaller group size may be associated with lower performance scores.
Table 1. Importance in the most recent year of data available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 1.010 (0.128) | 0.801 | 0.900 | 0.900 | 0.978 | 1.000 | 1.000 | 1.013 | 1.100 | 1.114 | 1.252 |
| Entities | 2,725 | 273 | 272 | 273 | 272 | 273 | 272 | 273 | 272 | 273 | 272 |
| Population | 1,228,348 | 259,203 | 137,172 | 138,342 | 96,259 | 89,338 | 93,799 | 103,467 | 108,595 | 94,959 | 107,214 |
Table 1 Interpretation: The highest-performing 10% of the entities (Decile 1) contains 259,203 patients, 21% of the 1,228,348 total patients, indicating that larger entities tend to perform better. Based on the information available in the datasets utilized, Battelle could not calculate an estimate of what plausible improvement on this measure might look like across entities. Additional analyses beyond the scope of this impact assessment may be warranted to directly evaluate the association between population size and measure score and to identify the institutional factors that contribute to stronger performance on this measure.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.