No risk adjustment or stratification

The CVD Risk Assessment Measure represents the proportion of pregnant and postpartum individuals assessed for CVD risk using a standardized tool at the clinic and facility levels of health care service delivery. The CVD risk assessment identifies pregnant and postpartum individuals without an existing CVD diagnosis who may have cardiovascular disease (CVD) or are at an increased risk of developing CVD, thus necessitating further evaluation. 

Percentage of all patient months for adult patients (>= 18 years old) whose delivered peritoneal dialysis dose was a weekly Kt/V urea >= 1.7 (dialytic + residual). 

The Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia who receive an excess antibiotic duration. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level for both quality improvement and pay-for-performance.

Percentage of adult dialysis patients with a 6-month rolling average phosphorus value greater than or equal to 6.5 mg/dL.  

The measure is the percentage of patients who achieve a 3-point increase in their Patient Activation Measure® (PAM®) survey score within 12 months. The outcome measure demonstrates how a clinician group performed in providing best care to its patients by quantifying the proportion of patients who had at least a 3-point score change. 

This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the emergency department (ED) within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. The measure is calculated using chart abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

The proportion of hospice patients who received hospice visits from a Registered Nurse or Medical Social Worker (non-telephonically) associated with the measured hospice entity during at least two of the final three days of life.

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.

The percentage of individuals ≥18 years of age with ≥1 initial opioid prescriptions for >7 cumulative days’ supply during the measurement year.