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Patient-and Caregiver-Focused

Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS) Eligible Clinicians and Eligible Clinician Groups

  • This measure is a re-specified version of the measure, “Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)” (NQF 1550), which was developed for patients 65 years and older using Medicare claims data.

    CBE ID
    3493

Severe Sepsis and Septic Shock: Management Bundle

  • This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.

    CBE ID
    0500

Shared Decision Making Process

  • This measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option. This proposal is to focus on patients who have undergone any one of 7 common, important surgical procedures: total replacement of the knee or hip, lower back surgery for spinal stenosis of herniated disc, radical prostatectomy for prostate cancer, mastectomy for early stage breast cancer or percutaneous coronary intervention (PCI) for stable angina.

    CBE ID
    2962

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

  • The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

    CBE ID
    2510

Standardized Mortality Ratio for Dialysis Facilities

  • Standardized mortality ratio is defined to be the ratio of the number of deaths that occur for Medicare ESRD dialysis patients treated at a particular facility to the number of deaths that would be expected given the characteristics of the dialysis facility’s patients and the national norm for dialysis facilities. This measure is calculated as a ratio but can also be expressed as a rate.

    CBE ID
    0369

Standardized Readmission Ratio (SRR) for dialysis facilities

  • The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

    CBE ID
    2496

Statin Use in Persons with Diabetes

  • The percentage of patients ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication.

    CBE ID
    2712