No risk adjustment or stratification

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.

The Practice Environment Scale – Five-Item Composite (PES-5) is a composite instrument that measures five domains of the nursing work environment associated with patient outcomes and nurse well-being. The PES-5 is derived from the 31-item Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing quality measure.

This electronic clinical quality measure (eCQM) assesses the proportion of inpatient hospitalizations for patients aged 18 years and older who were administered at least one medication known to cause hypoglycemia (hypoglycemic medication) during their hospitalization, and who suffered a severe hypoglycemic event (blood glucose less than 40 mg/dL) during the hospitalization.

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.

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge.

Primary Measure - Most and Moderately Effective Contraceptive Provision or Use: Percentage of patients ages 15-44 and assigned female at birth who received a most or moderately effective contraceptive, or were documented to use a most or moderately effective contraceptive method in the measurement period. The primary measure captures new provision as well as current use of most and moderately effective contraceptive methods to accurately capture contraceptive utilization even if provided in a different calendar year or a different health care site.

Primary Measure - Most and Moderately Effective Contraceptive Provision or Use: Percentage of patients ages 15-44 assigned female at birth with a live birth delivery who received a most or moderately effective contraceptive, or were documented to use a most or moderately effective contraceptive method, in the postpartum period. The primary measure captures new provision as well as current use of most and moderately effective contraceptive methods to accurately capture postpartum contraceptive utilization even if provided in a different calendar year or a different health care site.

The measure is a PRE-PM, which calculates the percentage of contraceptive care patients who give a “top box” score for their experience of contraceptive counseling. The measure is a four-question survey which asks patients about key components of patient-centered counseling, including respect and adequate information. A “top box” score is defined as a response which gives the highest score for each of the four questions. Respondents give answers evaluating the quality of contraceptive care they received in the past six months.

Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or  have had female sterilization from the denominator.