Process

This measure evaluates the percentage of magnetic resonance imaging (MRI) of the lumbar spine studies for low back pain performed in the outpatient setting where conservative therapy was not attempted prior to the MRI. Antecedent conservative therapy may include claim(s) for physical therapy in the 60 days preceding the lumbar spine MRI, claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine MRI, or claim(s) for evaluation and management at least 28 days but no later than 60 days preceding the lumbar spine MRI.

Percentage of home health episodes of care in which patients who can ambulate had a multi-factor fall risk assessment at start/resumption of care.

This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN).

Percentage of patients presenting with AJCC Stage Group 0, I, II, or III disease, who undergo a needle biopsy to establish diagnosis of breast cancer.

Percent of neonates with a length of stay greater than 60 days receiving DPT, Hepatitis B, Polio, Hib, and PCV immunizations in adherence with current guidelines.

Percentage of patient refined diagnostic-related groups (APR-DRG) who received neonate immunization administration

This measure identifies patients with new-onset atrial fibrillation during the measurement year who have had a thyroid function test 6 weeks before or after the diagnosis of atrial fibrillation.

This measure identifies adult patients newly diagnosed with rheumatoid arthritis during the first 8 months of the measurement year who received erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) lab tests either 4 months (3 months + 1-month grace period) before or after the initial diagnosis.

The percentage of children 6 months of age who had documentation of a review of their newborn hearing screening results by their 3-month birthday.

The percentage of patients aged 18 years and older with proteinuria who are taking an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB)