Endorsement Removed

A composite measure of in-hospital mortality indicators for selected conditions.

This measure evaluates the percentage of magnetic resonance imaging (MRI) of the lumbar spine studies for low back pain performed in the outpatient setting where conservative therapy was not attempted prior to the MRI. Antecedent conservative therapy may include claim(s) for physical therapy in the 60 days preceding the lumbar spine MRI, claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine MRI, or claim(s) for evaluation and management at least 28 days but no later than 60 days preceding the lumbar spine MRI.

De.2. Brief description of measure
Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (CAUTI) will be calculated among patients in the following patient care locations:
• Intensive Care Units (ICUs) (excluding patients in neonatal ICUs [NICUs: Level II/III and Level III nurseries])
• Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in the following patient care locations:
• Intensive Care Units (ICUs)
• Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

This supplemental set of items was developed jointly by NCQA and the AHRQ-sponsored CAHPS Consortium and is intended for use with the CAHPS 4.0 Health Plan survey. Some items are intended for Commercial health plan members only and are not included here. This measure provides information on the experiences of Medicaid health plan members with the organization. Results summarize member experiences through composites and question summary rates.

Percentage of patients presenting with AJCC Stage Group 0, I, II, or III disease, who undergo a needle biopsy to establish diagnosis of breast cancer.

Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.

Percent of neonates with a length of stay greater than 60 days receiving DPT, Hepatitis B, Polio, Hib, and PCV immunizations in adherence with current guidelines.

Percentage of patient refined diagnostic-related groups (APR-DRG) who received neonate immunization administration

This measure identifies patients with new-onset atrial fibrillation during the measurement year who have had a thyroid function test 6 weeks before or after the diagnosis of atrial fibrillation.