Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period
Hospital specific risk-adjusted measure of mortality or one or more of the following major complications (cardiac arrest, myocardial infarction, CVA/stroke, on ventilator >48 hours, acute renal failure (requiring dialysis), bleeding/transfusions, graft/prosthesis/flap failure, septic shock, sepsis, and organ space surgical site infection), within 30 days of a lower extremity bypass (LEB) in patients age 16 and older.
Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical or medical discharges for patients ages 17 years and younger. Excludes normal newborns; neonates with a birth weight less than 500 grams; cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic surgery repair or cardiac surgery; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.
Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.
Percentage of patients age 50 and over with fragility fracture who have had appropriate laboratory investigation for secondary causes of fracture ordered or performed prior to discharge from inpatient status.
Percentage of all adult (>=18 years old) hemodialysis patients, peritoneal dialysis, and home hemodialysis patients with ESRD >=3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb <10.0 g/dL for a 3 month study period, irrespective of ESA use.
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
Percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to the physician(s) providing continuing care and to the patient within one month of completing treatment
In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]