No risk adjustment or risk stratification

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.

This measure assesses the number of patients with confirmed venous thromboembolism (VTE) during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

0-100 measure of individual engagement related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit