Process

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge.

Rate 1 (SAC): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler during the same 90-day period.

Rate 2 (ACT): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of short-acting beta2 agonist inhalers over a 90-day period and who did not receive controller therapy during the same 90-day period.

The percentage of children 6 months of age who had Suddent Infant Death Syndrome (SIDS) counseling.

Percentage of patients on beta blocker therapy prior to arrival who received a beta blocker during the perioperative period. To be in the denominator, the patient must be on a beta-blocker prior to arrival. The case is excluded if the patient is not on a beta-blocker prior to arrival.

Percentage of surgery patients who received appropriate Venous Thromboembolism (VTE) Prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time.

Percentage of surgery patients with surgical hair site removal with clippers or depilatory or no surgical site hair removal.

Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° F/36° C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time.

Percentage of surgery patients with recommended Venous Thromboembolism (VTE) Prophylaxis ordered during admission

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.

This measure calculates the percentage of thorax computed tomography (CT) studies that are performed without and with contrast, out of all thorax CT studies performed (those without contrast, those with contrast, and those with both) at each facility. The measure is calculated based on a one-year window of Medicare fee-for-service claims data. The measure has been publicly reported annually by the measure steward, the Centers for Medicare & Medicaid Services (CMS), since 2010, as a component of its Hospital Outpatient Quality Reporting (HOQR) Program.