Safety: Overuse

A self-report outcome measure of functional status for patients 14 years+ with elbow, wrist, hand impairments. The change in functional status assessed using FOTO (elbow, wrist and hand) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.

The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.

The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

The proportion of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications.

The proportion of patients, age greater than and equal to 1 year, discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification.

Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies

The measure estimates a hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) for patients age 65 and older discharged from the hospital with a principal diagnosis of acute myocardial infarction (AMI). Readmission is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Readmissions are classified as planned and unplanned by applying the planned readmission algorithm.

Number of hospital discharges from an acute care hospital (PPS or CAH) per 1000 FFS Medicare beneficiaries at the state and community level by quarter and year.

The inappropriate diagnosis of CAP in hospitalized medical patients (or “Inappropriate Diagnosis of CAP”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for CAP who do not meet diagnostic criteria for pneumonia (thus are inappropriately diagnosed and treated).

The inappropriate diagnosis of UTI in hospitalized medical patients (or “Inappropriate Diagnosis of UTI”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for UTI who do not meet diagnostic criteria for UTI (thus are inappropriately diagnosed and overtreated).