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Statistical risk model

Optimal Diabetes Care

  • The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose diabetes was optimally managed during the measurement period as defined by achieving ALL of the following:
    • HbA1c less than 8.0 mg/dL
    • Blood Pressure less than 140/90 mmHg
    • On a statin medication, unless allowed contraindications or exceptions are present
    • Non-tobacco user
    • Patient with ischemic vascular disease is on daily aspirin or anti-platelets, unless allowed contraindications or exceptions are present

    CBE ID
    0729

Pancreatic Resection Mortality Rate (IQI 9)

  • In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.
    [NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

    CBE ID
    0365

PC-04 Health Care-Associated Bloodstream Infections in Newborns

  • This measure assesses the number of staphylococcal and gram negative septicemias or bacteremias in high-risk newborns. This measure is a part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-03: Antenatal Steroids, PC-05: Exclusive Breast Milk Feeding; Beginning 1/1/2019 PC-06 Unexpected Complications in Term Newborns will be added).

    CBE ID
    1731

Pediatric Asthma Emergency Department Use

  • This measure estimates the rate of emergency department visits for children ages 3 – 21 who are being managed for identifiable asthma, using specified definitions. The measure is reported in visits per 100 child-years.

    CBE ID
    3599

Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

  • This measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter.

    CBE ID
    0686

Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

  • This measure reports the percentage of long-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.

    CBE ID
    0677

Percentage of Prevalent Patients Waitlisted (PPPW)

  • This measure tracks the percentage of patients in each dialysis practitioner group practice who were on the kidney or kidney-pancreas transplant waitlist. Results are averaged across patients prevalent on the last day of each month during the reporting year.

    Please note, this measure is at the dialysis practitioner level (the clinician who receives the Monthly Capitation Payment for overseeing dialysis care).

    The proposed measure is a directly standardized percentage, which is adjusted for covariates (e.g. age and risk factors).

    CBE ID
    3695