Quality Improvement (Internal to the specific organization)

This measure identifies patients with pulmonary embolism (PE) on anticoagulation for at least 3 months after the diagnosis.

Percentage of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major lung resection (pneumonectomy, lobectomy, or formal segmentectomy)

This measure is an all-or-none composite of the number of patients following an ICD/CRT-D implant procedure who received prescriptions for all medications (Angiotensin-converting enzyme inhibitors (ACE-I)/ Angiotensin receptor blockers (ARB)/ Angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers) for which they are eligible at discharge and those patients with procedures that fulfill class I, IIa, or IIb guideline indications.

Percentage of patients with quantitative breast tumor HER2 IHC evaluation using the ASCO/CAP recommended manual system or a computer-assisted system consistent with the optimal algorithm for HER2 testing as described in the current ASCO/CAP guidelines.

In-hospital deaths per 1,000 pediatric heart surgery admissions among patients with congenital heart disease ages 17 years and younger.

The number of hospital discharges with a pediatric heart surgery procedure for patients with congential heart disease ages 17 years and younger.

The measure requires hospitals and output facilities that conduct Computed Tomography (CT) studies to assess the radiation dose associated with the most frequently conducted examination types – CT’s of the head, chest, abdomen/pelvis obtained in children and adults. The measure provides a simple framework for how facilities can assess their dose, a framework that currently does not exist. By assessing their doses, facilities can monitor the doses they use over time and compare their doses to benchmarks. The creation of benchmarks is not part of this measure per se.

Percentage of female patients, age = 18 and < 70 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), whose primary tumor is of the breast, had breast conserving surgery and was administered radiation therapy within 1 year (365 days) of diagnosis

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.

Percentage of adult patients (aged 18 and over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed