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Empirical validity testing at the accountable entity-level (e.g., criterion validity, construct validity, known groups analysis)

Valid for Measure Submission

Improvement in Management of Oral Medications

  • Percentage of home health episodes of care during which the patient improved in ability to take their medicines correctly, by mouth. This is a rate/proportion measure targeted at elderly individuals with multiple chronic conditions during home health quality of care episodes. 

    CBE ID
    0176

Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

  • The Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia. Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms.

    CBE ID
    4545e

Oncology: Medical and Radiation – Pain Intensity Quantified

  • This measure looks at the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

     

    This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients with a diagnosis of cancer who are also currently receiving chemotherapy or radiation therapy during the measurement period. 

     

    CBE ID
    0384e

Oncology: Medical and Radiation – Pain Intensity Quantified

  • This measure looks at the percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified. This measure is to be submitted at each denominator eligible visit occurring during the performance period for patients with a diagnosis of cancer who are seen during the performance period / measurement period. The time period for data collection is intended to be 12 consecutive months.

     

    CBE ID
    0384

Oncology: Medical and Radiation – Plan of Care for Pain

  • This measure looks at the percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain. This measure is to be submitted at each denominator eligible visit occurring during the performance period for patients with a diagnosis of cancer and in which pain is present who are seen during the performance period / measurement period. The time period for data collection is intended to be 12 consecutive months.

     

    CBE ID
    0383

Optimal Vascular Care (Composite)

  • Measure Description: The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and whose IVD was optimally managed during the measurement period as defined by achieving ALL of the following:
    • Blood pressure less than 140/90 mmHg
    • On a statin medication, unless allowed contraindications or exceptions are present
    • Non-tobacco user
    • On daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present

    Exclusions

    CBE ID
    0076

Patient Safety Indicator (PSI) 90: Patient Safety and Adverse Events Composite

  • PSI 90 is a composite of ten adverse event indicators that summarizes hospitals’ performance on patient safety for the CMS Medicare fee-for-service population. The timeframe used in the CMS Hospital Acquired Conditions Reduction Program (HACRP) and CareCompare public reporting are set within the Inpatient Prospective Payment Systems (IPPS) Final Rule annually. Typically, the performance periods use multiple months of claims data.

    CBE ID
    0531

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

  • This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

    CBE ID
    4210

Pediatric All-Condition Readmission Measure

  • This measure calculates case-mix-adjusted readmission rates, defined as the percentage of admissions followed by 1 or more readmissions within 30 days, for patients less than 18 years old. The measure covers patients discharged from general acute care hospitals, including children’s hospitals.

    CBE ID
    2393