Paper Patient Medical Records

Percentage of patients with esophageal biopsy reports for Barrett’s esophagus that contain a statement about dysplasia and if present the grade of dysplasia.

Percentage of acute myocardial infarction (AMI) patients who are prescribed a beta-blocker at hospital discharge

Proportion of heart failure patients age 18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

The percentage of adolescents 13 years of age who had a blood pressure screening with results during the measurement year or the year prior to the measurement year.

The percentage of adolescents 18 years of age who had a blood pressure screening with results during the measurement or the year prior to the measurement year.

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).

Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS and used in the Physician Quality Reporting System.

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Percentage of female patients aged 18 years and older with Stage I (T1b) through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period

Use of relievers in pediatric patients, age 2 years through 17 years, admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-2: Systemic Corticosteroids for Inpatient Asthma, and CAC-03: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver) that are used in The Joint Commission’s accreditation process.