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Valid for Measure Submission

Excess days in acute care (EDAC) after hospitalization for pneumonia

  • This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for pneumonia, including aspiration pneumonia or for sepsis (not severe sepsis) with a secondary discharge diagnosis of pneumonia coded in the claim as present on admission (POA) and no secondary diagnosis of severe sepsis coded as POA.

    CBE ID
    2882

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility Level)

  • This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

    CBE ID
    3663e

External Beam Radiotherapy for Bone Metastases

  • This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline.

    CBE ID
    1822

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

  • This measure was developed to improve the quality of care delivered to patients undergoing outpatient colonoscopy procedures. The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure, estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a colonoscopy procedure performed at a hospital outpatient department (HOPD) or ambulatory surgical center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and older.

    CBE ID
    2539

Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers

  • This measure was developed to improve the quality of care delivered to patients undergoing general surgery procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of return to a hospital for an acute, unplanned hospital visit within seven days of qualified general surgery procedures performed at an ambulatory surgical center (ASC) among Medicare Fee-For-Service (FFS) patients aged 65 years and older.

    CBE ID
    3357

Falls with injury

  • All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

    (Total number of injury falls / Patient days) X 1000

    Measure focus is safety.
    Target population is adult acute care inpatient and adult rehabilitation patients.

    CBE ID
    0202

Family Evaluation of Hospice Care

  • Derived from responses to 17 items on the Family Evaluation of Hospice Care(FEHC)survey presented as a single score ranging from 0 to 100 and is an indication of the hospice´s overall performance on key aspects of care delivery.

    CBE ID
    0208

Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

  • This measure calculates the percentage of Emergency Department (ED) acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. The measure is calculated using chart-abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

    CBE ID
    0288