Facility

Proportion of ICD implant patients with a diagnosis of previous MI who are prescribed a Beta Blocker at discharge.

Percentage of acute myocardial infarction (AMI) patients who are prescribed a beta-blocker at hospital discharge

Proportion of heart failure patients age 18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Bilateral cardiac catheterization discharges per 1,000 heart catheterizations discharges for coronary artery disease for patients ages 18 years and older. Excludes valid indications for right- side catheterization discharges and obstetric discharges.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report specific procedure discharges per 1,000 hospital discharges.]

Percentage of infants born to hepatitis B surface antigen (HBsAg)-positive mothers who receive a birth dose of hepatitis B virus (HBV) vaccine and hepatitis B immune globulin (HBIG)

Percentage of newborn discharges with an ICD-9-CM diagnosis code of birth trauma in a one-year time period.

Percentage of pneumonia patients 18 years of age and older who have had blood cultures performed in the emergency department prior to initial antibiotic received in hospital

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

Percentage of adults 18 years old or older with valid BMI documentation in the past 24 month.

The Breast Cancer Screening Recall Rates measure calculates the percentage of beneficiaries with mammography or digital breast tomosynthesis (DBT) screening studies that are followed by a diagnostic mammography, DBT, ultrasound, or magnetic resonance imaging (MRI) of the breast in an outpatient or office setting within 45 days.