Percentage of patients at least 18 years of age and younger than 80 with back pain lasting more than 12 weeks, with documentation of physician advice for supervised exercise.
Percentage of patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more who received inappropriate repeat imaging studies in the absence of red flags or progressive symptoms (overuse measure, lower performance is better).
Percentage of patients at least 18 years of age and younger than 80 with back pain with whom a physician or other clinician reviewed the range of treatment options, including alternatives to surgery prior to surgery. To demonstrate shared decision making, there must be documentation in the patient record of a discussion between the physician and the patient that includes all of the following.
1) Treatment choices, including alternatives to surgery;
2) Risks and benefits;
3) Evidence of effectiveness
Percentage of patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more without documentation of red flags who had surgery within the first six weeks of back pain onset (overuse measure, lower performance is better).
Note: This measure is applicable only for physicians who perform surgery.
Percentage of patients with esophageal biopsy reports for Barrett’s esophagus that contain a statement about dysplasia and if present the grade of dysplasia.
Proportion of ICD implant patients with a diagnosis of previous MI who are prescribed a Beta Blocker at discharge.
Percentage of acute myocardial infarction (AMI) patients who are prescribed a beta-blocker at hospital discharge
Percentage of pneumonia patients 18 years of age and older who have had blood cultures performed in the emergency department prior to initial antibiotic received in hospital
Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer