Highest Opportunity for Improvement

Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

Risk adjusted rate of intra and post procedure bleeding for all patients age 18 and over undergoing PCI.

Admissions for any-listed diagnosis of perforations or abscesses of the appendix per 1,000 admissions with any-listed appendicitis, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

[NOTE: The software provides the rate per hospital admission. However, common practice reports the measure as per 1,000 admissions. The user must multiply the rate obtained from the software by 1,000 to report cases per 1,000 admissions.]

Percentage of patients undergoing hysterectomy for the indication of pelvic organ prolapse in which a concomitant vaginal apical suspension (i.e. uterosacral, iliococygeus, sacrospinous or sacral colpopexy, or enterocele repair) is performed.

This measure assesses the percentage of COPD exacerbations for patients 40 years of age and older who had an acute inpatient discharge or ED visit on or between January 1-November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported:
1. Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event.
2. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event.

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:

1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission

*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

PointRight OnPoint-30 is an all-cause, risk adjusted rehospitalization measure. It provides the rate at which all patients (regardless of payer status or diagnosis) who enter skilled nursing facilities (SNFs) from acute hospitals and are subsequently rehospitalized during their SNF stay, within 30 days from their admission to the SNF.

Percentage of persons > 13 years of age with diagnosed HIV infection who are virally suppressed in the measurement year.

The percentage of patients 65 years of age and older who have evidence of an underlying disease, condition or health concern and who are dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Three rates are reported for this measure:
-Rate 1: The percentage of those with a history of falls that received a potentially harmful medication
-Rate 2: The percentage of those with dementia that received a potentially harmful medication

Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year

A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.