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Clinician: Group/Practice

Valid for Measure Submission

STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score

  • The STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score measures surgical performance for MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF). To assess overall quality, the STS MVRR +CABG Composite Score comprises two domains consisting of six measures:

    Domain 1 – Absence of Operative Mortality

    CBE ID
    3032

STS Mitral Valve Repair/Replacement (MVRR) Composite Score

  • The STS Mitral Valve Repair/Replacement (MVRR) Composite Score measures surgical performance for isolated MVRR with or without concomitant tricuspid valve repair (TVr), surgical ablation for atrial fibrillation (AF), or repair of atrial septal defect (ASD). To assess overall quality, the STS MVRR Composite Score comprises two domains consisting of six measures:

    Domain 1 – Absence of Operative Mortality

    CBE ID
    3031

Substance Use Screening and Intervention Composite

  • 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

    CBE ID
    2597

Surgical Volume for Pediatric and Congenital Heart Surgery: Total Programmatic Volume and Programmatic Volume Stratified by the 5 STAT Mortality Categories

  • Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool

    CBE ID
    0732

The percentage of patients assigned female at birth ages 15-44 who were asked the Self-Identified Need for Contraception (SINC) question with a recorded response, among patients with a qualifying encounter. (Contraceptive Care Screening eCQM)

  • Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or  have had female sterilization from the denominator.

    CBE ID
    4655e

Timing of Antibiotic Prophylaxis for Cardiac Surgery Patients

  • Percent of patients aged 18 years and older undergoing cardiac surgery who received prophylactic antibiotics within one hour of surgical incision or start of procedure if no incision was required (two hours if receiving vancomycin or fluoroquinolone)

    CBE ID
    0125

Timing of Prophylactic Antibiotics - Administering Physician

  • Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of a prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required)

    CBE ID
    0269

Tobacco Use and Help with Quitting Among Adolescents

  • The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.

    CBE ID
    2803

Total Cost of Care Population-based PMPM Index

  • Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices. Total Cost Index (TCI) is a measure of a primary care provider’s risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.

    CBE ID
    1604