Regulatory and Accreditation Programs

Goal:

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.

Annual risk-adjusted standardized infection ratio (SIR) of observed over predicted deep incisional primary and organ/space surgical site infections (SSIs), over a 30-day post-operative surveillance period, among hospitalized adults who are >=18 year of age with a date of admission and date of discharge that are different calendar days, and the patient underwent a colon surgery (COLO) or abdominal hysterectomy (HYST) at an acute care hospital or oncology hospital.  The 30-day postoperative surveillance period includes SSIs detected upon admission to the facility or a readmission to t

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

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

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)

This measure identifies patients with diabetes mellitus taking insulin that had evidence of self-monitoring blood glucose testing in last 12 reported months.

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months.

This measure identifies adults with migraines who are frequently taking acute (abortive) medications and are also taking a prophylactic medication for migraine control.

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