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Hospital Harm-Acute Kidney Injury

This electronic clinical quality measure (eCQM) assesses the proportion of inpatient hospitalizations for patients 18 years of age or older who have an acute kidney injury (stage 2 or greater) that occurred during the encounter. Acute kidney injury (AKI) stage 2 or greater is defined as a substantial increase in serum creatinine value, or by the initiation of kidney dialysis (continuous renal replacement therapy (CRRT), hemodialysis or peritoneal dialysis).
CBE ID
3713e

Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Service (HCBS) Participants

The Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Participants measure is a risk-adjusted, state-level measure that assesses rates of hospital admissions for ambulatory care sensitive conditions per 1,000 Medicaid HCBS participants aged 18 years and older. This measure has three rates reported for potentially avoidable inpatient hospital admissions:

  1. Chronic Conditions
  2. Acute Conditions
  3. Chronic and Acute Conditions Composite
CBE ID
4490

Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

The Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia. Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms.

CBE ID
4545e

Kidney Health Evaluation

Percentage of patients aged 18-85 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the 12-month measurement period

CBE ID
4315e

Patient Reported Fatigue Following Chemotherapy among Adults with Breast Cancer

The PRO-PM assesses fatigue among adult women with breast cancer entering survivorship after completion of chemotherapy administered with curative intent. Fatigue is assessed using the PROMIS Fatigue 4a scale administered at baseline (prior to chemotherapy) and at follow-up (about three months following completion of chemotherapy). The measure is risk-adjusted.
CBE ID
3720

Patient Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer

The PRO-PM assesses pain interference among adult women with breast cancer entering survivorship after completion of chemotherapy administered with curative intent. Pain interference is assessed using the PROMIS Pain Interference 4a scale administered at baseline (prior to chemotherapy) and at follow-up (about three months following completion of chemotherapy). The measure is risk-adjusted.
CBE ID
3718

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

CBE ID
4210

Percent of hospitalized pneumonia patients with chest imaging confirmation

The chest imaging-confirmed measure of pneumonia diagnosis is a process measure of inpatient hospitalizations that identifies the proportion of adult patients hospitalized patients with a discharge diagnosis of pneumonia and who received systemic or oral antimicrobials at any time during admission who received chest imaging that supported the diagnosis of pneumonia, as recommended by clinical practice guidelines.  The measure applies to a target population of adult hospitalized patients.

CBE ID
4440e

Prevent Standardized Waitlist Ratio (PSWR)

The PSWR measure tracks the number of prevalent dialysis patients in a practitioner (inclusive of physicians and advanced practice providers) group who are under the age of 75 and were listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant. For each practitioner group, the Prevalent Standardized Waitlist Ratio (PSWR) is calculated to compare the observed number of waitlist events in a practitioner group to its expected number of waitlist events.
CBE ID
3719

Quality of Care Composite for Implantable Cardioverter-Defibrillator (ICD)/Cardiac Resynchronization Therapy Defibrillator (CRT-D)

This measure is an all-or-none composite of the number of patients following an ICD/CRT-D implant procedure who received prescriptions for all medications (Angiotensin-converting enzyme inhibitors (ACE-I)/ Angiotensin receptor blockers (ARB)/ Angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers) for which they are eligible at discharge and those patients with procedures that fulfill class I, IIa, or IIb guideline indications.

CBE ID
3748