No risk adjustment or risk stratification

Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

The percentage of home and community-based services (HCBS) recipients aged 18 years or older who have identified at least as many total personal priorities (up to three) as needs in the areas of self-care, mobility, or instrumental activities of daily living (IADL) combined as determined by the most recent FASI assessment.

The percentage of adolescents who turned 18 years during the measurement year who had proper immunizations by the time they turn 18 years of age.

Percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.

Percentage of patients undergoing elective endovascular repair of asymptomatic infrarenal abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers. The measure is currently reported in the Vascular Quality Initiative (VQI) Registry.

Proportion of adult patients with a new CIED with an in-person evaluation within 2 to 12 weeks following implantation.

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).

Percent of patients undergoing CT pulmonary angiogram for the evaluation of possible PE who are at low-risk for PE consistent with guidelines(1,2) prior to CT imaging.

(1) Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008 Sep;29(18):2276-315

Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed.