Inpatient/Hospital

This patient-reported outcome-based performance measure uses the same measure specifications as the NQF-endorsed (NQF # 3559) hospital-level risk-standardized improvement rate (RSIR) following elective primary THA/TKA with the following exception: this measure attributes the outcome to a clinician or clinician group. Specifically, this measure will estimate a clinician-level and/or a clinician group-level RSIR following elective primary THA/TKA for Medicare fee-for-service (FFS) patients 65 years of age and older.

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy

Percentage of female patients, age >= 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC stage T1cN0M0 or Stage IB - IIIC, whose primary tumor is of the breast, and progesterone and estrogen receptor negative is recommended or administered multi-agent chemotherapy within 4 months (120 days) of diagnosis

Percentage of adults 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication.

Discharges with a principal diagnosis of community acquired bacterial pneumonia per 100,000 population, age 18 or older. Excludes sickle cell or hemoglobin-S admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed

Measure title continued: Composite weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)

Any time an endotracheal tube is placed into a patients airway in the Emergency Department (ED)or a patient arrives to the ED with an endotracheal tube already in place ( via EMS or hospital transfer) there should be appropriate confirmation of ETT placement and documentation of its performance in the medical record.

Admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

Percentage of Medicaid discharges, ages 18 to 64, being treated for a substance use disorder (SUD) from an inpatient or residential provider that received SUD follow-up treatment within 7 or 30 days after discharge. SUD follow-up treatment includes outpatient, intensive outpatient, or partial hospitalization visits; telehealth encounters; SUD medication fills or administrations; or residential treatment (after an inpatient discharge). Two rates are reported: continuity within 7 and 30 days after discharge.