Instrument-Based Data

This patient-reported outcome-based performance measure will estimate a hospital-level, risk-standardized improvement rate (RSIR) following elective primary THA/TKA for Medicare fee-for-service (FFS) patients 65 years of age and older. Improvement will be calculated with patient-reported outcome data collected prior to and following the elective procedure. The preoperative data collection timeframe will be 90 to 0 days before surgery and the postoperative data collection timeframe will be 270 to 365 days following surgery.

Percentage of patients aged 20 years and older with risk factors for coronary artery disease who have an elevated LDL-C and who are taking a lipid lowering agent or have initiated therapeutic lifestyle changes

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

Percentage of healthcare personnel (HCP) who receive the influenza vaccination.

0-100 measure of language services related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit (C-CAT)

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

The following components of this measure assess the management of urinary incontinence in older adults.

- Discussing Urinary Incontinence. The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who discussed their urinary leakage problem with a health care provider.

- Treatment of Urinary Incontinence. The percentage of Medicare members 65 years of age and older who reported having urine leakage in the past six months and who treatment options for their current urine leakage problem.

This composite measure assesses whether or not children and adolescents (age 0-17 years) receive health care within a medical home according to the survey respondent (almost always the child’s parent). The medical home measure is based on six of the seven components of care first proposed by the American Academy of Pediatrics (AAP)—health care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. (Note: "accessible" is the one component of medical home that is not directly addressed in this composite measure.

The three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:

Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who received advice to quit during the measurement year.

The percentage of patients aged 18 years and older diagnosed with myocardial infarction (MI) who are taking a beta blocker