Fall 2019

The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.

The STS CABG Composite Score comprises four domains consisting of 11 individually NQF-endorsed cardiac surgery measures:
Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure;

Percent of acute ischemic stroke patients receiving intravenous alteplase therapy during the hospital stay who have a time from hospital arrival to initiation of thrombolytic therapy (door-to-needle time) of 60 minutes or less

Percentage of female patients aged 18 and over with HER2/neu positive invasive breast cancer who are administered trastuzumab

Accidental punctures or lacerations (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older who have undergone an abdominopelvic procedure; in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. Excludes cases with accidental puncture or laceration as a principal diagnosis, cases with accidental puncture or laceration as a secondary diagnosis that is present on admission, and obstetric cases.

Proportion of inpatient hospitalizations for patients 65 years of age and older who receive an order for antipsychotic medication therapy.

Percentage of children and adolescents 1-17 years of age who had a new prescription for an antipsychotic medication, but no U.S. Food and Drug Administration primary indication for antipsychotics, and had documentation of psychosocial care as first-line treatment.

This measure assesses the percentage of patients 40 years of age and older with a new diagnosis of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis.

Percentage of end stage renal disease (ESRD) patients aged 18 years and older receiving hemodialysis during the 12-month reporting period and on dialysis >90 days who:

1. have a functional autogenous AVF (defined as two needles used or a single-needle device [NOT one needle used in a two-needle device]) (computed and reported separately);

2. have a functional AV graft (computed and reported separately); or

0-100 measure of workforce development related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit