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Highest Opportunity for Improvement

30-day all-cause risk-standardized mortality rate following Percutaneous Coronary Intervention (PCI) for patients with ST segment elevation myocardial infarction (STEMI) or cardiogenic shock

  • This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention (PCI) among patients who are 18 years of age or older with STEMI or cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) CathPCI Registry for risk adjustment. For the purpose of development and testing, the measure cohort was derived in a Medicare fee-for-service (FFS) population of patients 65 years of age or older with a PCI.

    CBE ID
    0536

30-day all-cause risk-standardized mortality rate following percutaneous coronary intervention (PCI) for patients without ST segment elevation myocardial infarction (STEMI) and without cardiogenic shock

  • This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention (PCI) among patients who are 18 years of age or older without STEMI and without cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry (NCDR) CathPCI Registry for risk adjustment. For the purpose of development and testing, the measure used a Medicare fee-for-service (FFS) population of patients 65 years of age or older with a PCI.

    CBE ID
    0535

30-day Risk Standardized Morbidity and Mortality Composite following Transcatheter Aortic Valve Replacement (TAVR)

  • The TAVR 30-day morbidity/mortality composite is a hierarchical, multiple outcome risk model that estimates risk standardized results (reported as a “site difference”) for the purpose of benchmarking site performance. This measure estimates hospital risk standardized site difference for 5 endpoints (death from all causes, stroke, major or life-threatening bleeding, acute kidney injury, moderate or severe paravalvular aortic regurgitation) within 30 days following transcatheter aortic valve replacement.

    CBE ID
    3610

Acute Myocardial Infarction (AMI) Mortality Rate

  • In-hospital deaths per 1,000 hospital discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes cases in hospice care at admission, obstetric discharges, and transfers to another hospital.

    CBE ID
    0730

Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder

  • Percentage of individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and had a Proportion of Days Covered (PDC) of at least 0.8 for mood stabilizer medications during the measurement period (12 consecutive months).

    CBE ID
    1880

Adjuvant hormonal therapy is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0 or Stage IB – Stage III hormone receptor positive breast cancer

  • 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

    CBE ID
    0220