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Other Data Source

Valid for Measure Submission

Comprehensive Diabetes Care

  • The percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:
    - Hemoglobin A1c (HbA1c) testing (NQF#0057)
    - HbA1c poor control (>9.0%) (NQF#0059)
    - HbA1c control (<8.0%) (NQF#0575)
    - HbA1c control (<7.0%) for a selected population*
    - Eye exam (retinal) performed (NQF#0055)
    - LDL-C screening (NQF#0063)
    - LDL-C control (<100 mg/dL) (NQF#0064)
    - Medical attention for nephropathy (NQF#0062)
    - BP control (<140/90 mm Hg) (NQF#0061)
    - Smoking status and cessation advice or treatment

    CBE ID
    0731

Confirmation of Endotracheal Tube Placement

  • Any time an endotracheal tube is placed into a patients airway in the Emergency Department (ED)or a patient arrives to the ED with an endotracheal tube already in place ( via EMS or hospital transfer) there should be appropriate confirmation of ETT placement and documentation of its performance in the medical record.

    CBE ID
    0501

Consumer Assessment of Health Providers and Systems (CAHPS®) Nursing Home Survey: Family Member Instrument

  • The CAHPS Nursing Home Survey: Family Member Instrument is a mail survey instrument to gather information on the experiences of family members of long stay (greater than 100 days) residents currently in nursing homes. The Centers for Medicare & Medicaid Services requested development of this questionnaire, which is intended to complement the CAHPS Nursing Home Survey: Long-Stay Resident Instrument and the Discharged resident Instrument.

    CBE ID
    0693

Counseling for Women of Childbearing Potential with Epilepsy

  • All female patients of childbearing potential (12–44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    CBE ID
    1814

Depression Assessment with PHQ-9/ PHQ-9M

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during a four month measurement period.

    CBE ID
    0712

Depression Remission at Six Months

  • The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.

    CBE ID
    0711

Depression Remission at Twelve Months

  • Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. 
    This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the denominator.

    CBE ID
    0710e