Prevention and Population Health

This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

Percentage of adult patients (aged 18 and over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug (DMARD) therapy within 12 months.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who have documentation of a tuberculosis (TB) screening performed within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).

Percentage of women 65-85 years of age who ever had a central dual-energy x-ray absorptiometry (DXA) test to check for osteoporosis.

The percentage of children who received visual acuity screening at least once by their 6th birthday; and if necessary, were referred appropriately.

Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

This measure calculates the percentage of thorax computed tomography (CT) studies that are performed without and with contrast, out of all thorax CT studies performed (those without contrast, those with contrast, and those with both) at each facility. The measure is calculated based on a one-year window of Medicare fee-for-service claims data. The measure has been publicly reported annually by the measure steward, the Centers for Medicare & Medicaid Services (CMS), since 2010, as a component of its Hospital Outpatient Quality Reporting (HOQR) Program.