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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.

The Risk Adjusted Post-Ambulance Provider Triage Emergency Department (ED) Visit Rate Measure (shorthand: Post-Triage ED Visit Rate Measure) assesses the quality of the triage and decision making by ambulance providers who transport low acuity patients to an alternative destination (non-ED location), or facilitate Treatment In Place (TIP), by identifying whether patients have a subsequent ED visit or death within three days.

The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

The Standardized Emergency Department Encounter Ratio is defined to be the ratio of the observed number of emergency department (ED) encounters that occur for adult Medicare ESRD dialysis patients treated at a particular facility to the number of encounters that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. Note that in this document an “emergency department encounter” always refers to an outpatient encounter that does not end in a hospital admission.

The standardized hospitalization ratio is defined to be the ratio of the number of hospital admissions that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of hospitalizations that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

Standardized mortality ratio is defined to be the ratio of the number of deaths that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of deaths that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

The Standardized Ratio of Emergency Department Encounters Occurring Within 30 Days of Hospital Discharge for Dialysis Facilities (ED30) is defined to be the ratio of observed over expected events. The numerator is the observed number of index discharges from acute care hospitals that are followed by an outpatient emergency department encounter within 4-30 days after discharge for eligible adult Medicare dialysis patients treated at a particular dialysis facility.

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

The risk adjusted facility level transfusion ratio “STrR” is specified for all adult dialysis patients. It is a ratio of the number of eligible red blood cell transfusion events observed in patients dialyzing at a facility, to the number of eligible transfusion events that would be expected under a national norm, after accounting for the patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.