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Regulatory and Accreditation Programs

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

30 Day All-cause Risk Standardized Mortality Odds Ratio following Transcatheter Aortic Valve Replacement (TAVR).

  • This measure estimates hospital risk standardized odds ratio for death from all causes within 30 days following transcatheter aortic valve replacement. The measure uses clinical data available in the STS/ACC TVT Registry for risk adjustment. For the purpose of development and testing, the measure used site-reported 30-day follow-up data contained in the STS/ACC TVT Registry.

    CBE ID
    3534

Adjuvant chemotherapy is recommended, or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer

  • Percentage of patients, age = 18 and < 80 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy) that is lymph node positive and at AJCC stage III, whose primary tumor is of the colon and chemotherapy was recommended or administered within 4 months (120 days) of diagnosis

    CBE ID
    0223

Adjuvant hormonal therapy is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0 or Stage IB – Stage III hormone receptor positive breast cancer

  • Percentage of female patients, age = 18 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC T1cN0M0 or stage IB to IIIC, whose primary tumor is of the breast, and is progesterone or estrogen receptor positive with adjuvant hormonal therapy (recommended or administered) within 1 year (365 days) of diagnosis

    CBE ID
    0220

Adult Inpatient Risk Adjusted Sepsis Mortality

  • Annual risk adjusted inpatient mortality rate for adult patients (aged 18 and over) admitted to acute care hospitals with diagnosis of severe sepsis or septic shock. The measure includes patients in acute care hospital settings over one year timeframe who had, either on admission, or during their hospital stay, a clinical diagnosis of severe sepsis (now referred to as ´sepsis´) or septic shock using criteria described in the International Sepsis Definitions (Sepsis-2)

    CBE ID
    3215

Annual monitoring for patients on persistent medications

  • The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the four rates separately and as a total rate.

    • Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
    • Annual monitoring for members on digoxin
    • Annual monitoring for members on diuretics

    CBE ID
    0021