Process

Percentage of patients at least 18 years of age and younger than 80 with back pain with whom a physician or other clinician reviewed the range of treatment options, including alternatives to surgery prior to surgery. To demonstrate shared decision making, there must be documentation in the patient record of a discussion between the physician and the patient that includes all of the following.
1) Treatment choices, including alternatives to surgery;
2) Risks and benefits;
3) Evidence of effectiveness

Percentage of patients at least 18 years of age and younger than 80 with a back pain episode of 28 days or more without documentation of red flags who had surgery within the first six weeks of back pain onset (overuse measure, lower performance is better).

Note: This measure is applicable only for physicians who perform surgery.

This measure reflects the percentage of hospice patients with documentation of a discussion of spiritual/religious concerns or documentation that the patient/caregiver/family did not want to discuss.

Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on beta blockers

Proportion of ICD implant patients with a diagnosis of Left Ventricular Systolic Dysfunction who are prescribed beta-blocker therapy on discharge.

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

Number of procedures for which the patient was discharged from the facility on beta blockers/ Number of Isolated CABG procedures excluding those that resulted in in-hospital mortalities based on the variables Mortality Discharge Status, Mortality Date, and Discharge Date

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.

Percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care/referring physician and the patient.