Accountable Entity-Level (e.g., signal-to-noise analysis)

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.

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

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.

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.

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.

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

Percentage of pediatric (< 18 years old) peritoneal dialysis patient-months whose delivered peritoneal dialysis dose was a weekly Kt/Vurea >= 1.8 (dialytic + residual)

The chest imaging-confirmed measure of pneumonia diagnosis is a process measure of inpatient hospitalizations that identifies the proportion of adult patients hospitalized patients with a discharge diagnosis of pneumonia and who received systemic or oral antimicrobials at any time during admission who received chest imaging that supported the diagnosis of pneumonia, as recommended by clinical practice guidelines.  The measure applies to a target population of adult hospitalized patients.

This electronic Clinical Quality Measure (eCQM) reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening (BI-RADS 0) or screening-to-diagnostic (BI-RADS 4, 5) mammogram during the measurement period (i.e., calendar year) who received timely diagnostic resolution defined as either follow-up imaging with negative/benign/probably benign results or a breast biopsy within 60 days after their index (i.e., first) abnormal screening mammogram.

This electronic Clinical Quality Measure (eCQM) reports the percentage of patients aged 45 to 75 years with at least one positive stool-based colorectal cancer screening test (i.e., high-sensitivity guaiac fecal occult blood test, fecal immunochemical test, or Cologuard) during the measurement period (i.e., calendar year) who completed a colonoscopy within 180 days after their index (i.e., first) positive stool-based test result date.