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Highest Opportunity for Improvement

Medical Assistance With Smoking and Tobacco Use Cessation

The three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:

Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who received advice to quit during the measurement year.

CBE ID
0027

Medicare Spending Per Beneficiary (MSPB) - Hospital

The MSPB Hospital measure evaluates hospitals’ risk-adjusted episode costs relative to the risk-adjusted episode costs of the national median hospital. Specifically, the MSPB Hospital measure assesses the cost to Medicare for Part A and Part B services performed by hospitals and other healthcare providers during an MSPB Hospital episode, which is comprised of the periods 3-days prior to, during, and 30-days following a patient’s hospital stay. The MSPB Hospital measure is not condition specific and uses standardized prices when measuring costs.

CBE ID
2158

National Healthcare Safety Network (NHSN) Antimicrobial Use Measure

This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN).

CBE ID
2720

Neonatal Blood Stream Infection Rate (NQI 03)

Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.

CBE ID
0478

Oncology: Cancer Stage Documented

Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have cancer staging documented using any standardized system or documentation that the cancer is metastatic in the medical record within one month of first office visit

CBE ID
0386

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

Optimal End Stage Renal Disease (ESRD) Starts

Information From 2015 Submission

Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis (peritoneal dialysis or home hemodialysis), or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.

CBE ID
2594