Spring 2021

The TAVR 30-day morbidity/mortality composite is a hierarchical, multiple outcome risk model that estimates risk standardized results (reported as a “site difference”) for the purpose of benchmarking site performance. This measure estimates hospital risk standardized site difference for 5 endpoints (death from all causes, stroke, major or life-threatening bleeding, acute kidney injury, moderate or severe paravalvular aortic regurgitation) within 30 days following transcatheter aortic valve replacement.

The percentage of adults 19 years of age and older who are up-to-date on Advisory Committee on Immunization Practice (ACIP) recommended routine vaccines for influenza, tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap), zoster and pneumococcal.

The percentage of ED patients with a diagnosis of STEMI who received appropriate and timely treatment. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level in a CMS accountability program, through which it may be publicly reported.

The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.

Measure title continued: Composite weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)

The percentage of individuals >=18 years of age with concurrent use of prescription opioids and benzodiazepines during the measurement year.

A lower rate indicates better performance.

Percentage of adults of at least 18 years of age with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment

Percentage of women aged 15-44 years at risk of unintended pregnancy that is provided a long-acting reversible method of contraception (i.e., implants, intrauterine devices or systems (IUD/IUS)).

It is an access measure because it is intended to identify very low rates (less than 1-2%) of long-acting reversible methods of contraception (LARC), which may signal barriers to LARC provision.

Among women ages 15 through 44 who had a live birth, the percentage that is provided:
1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately (i.e., injectables, oral pills, patch, or ring) effective method of contraception within 3 and 60 days of delivery.

2) A long-acting reversible method of contraception (LARC) within 3 and 60 days of delivery.

The percentage of women aged 15-44 years at risk of unintended pregnancy that is provided a most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately effective (i.e., injectables, oral pills, patch, or ring) method of contraception.

The measure is an intermediate outcome measure because it represents a decision that is made at the end of a clinical encounter about the type of contraceptive method a woman will use, and because of the strong association between type of contraceptive method used and risk of unintended pregnancy.