Functional Status Change in Balance Confidence

This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted functional status (FS) change in balance confidence for patients aged 14+ with balance impairments. The change in FS is assessed using the FOTO Balance Confidence, an item-response theory-based PROM derived from the 16-items of the Activities-specific Balance Confidence (ABC) Scale©, (1-3) scored using the T-score metric (mean=50, SD=10), with higher scores representing higher balance confidence.(4)

Patient responses to ABC Scale© items may be used to directly score Balance Confidence PROM, thus allowing clinicians flexibility of choice of PROM used in routine clinical care without adding to patient response burden. In order to fairly measure performance between providers, this quality measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure the patient and provider levels to assess quality.

Functional Status Change for Patients Post Stroke

This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older who have experienced a stroke with sequelae impacting physical functional abilities. For patients with such conditions affecting use of the hand, arm, and upper trunk, the change in FS is assessed using the FOTO Stroke Upper Extremity (SUE) FS PROM.1 For patients with such conditions affecting the foot, leg, and lower trunk, the change in FS is assessed using the FOTO Stroke Lower Extremity (SLE) FS PROM.1 PROM cores were scaled to the 0-100 metric, with higher scores representing higher perceived functional status. In order to fairly measure performance between providers, the measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure (PM) at the patient and provider levels to assess quality.

Jaw Functional Status Scale (JFSS) Change

This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted functional status (FS) change in jaw functional status for patients aged 14+ with impairments related to jaw function. The change in FS is assessed using the FOTO Jaw Functional Status Scale (JFSS), an item-response theory (IRT)-based PROM derived from 13 of the 20 items of the Jaw Functional Limitation Scale (JFLS).1, 2 The JFLS is a condition-specific PROM for functional limitations in the masticatory system.3 The 13-item FOTO JFSS is scored using the T-score metric (mean=50, SD=10), with higher scores representing higher functional status. The JFSS PROM can be administered using either computerized adaptive test (CAT)4 or a 6-item short form.

In order to fairly measure performance between providers, this quality measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure at the patient and provider levels to assess quality.

Complete Reporting of Gastrointestinal Metaplasia

Percentage of pathology reports for gastric specimens with intestinal metaplasia that comment on the presence or absence of H. pylori and of dysplasia. If dysplasia is present, comment on the grade of dysplasia. If dysplasia is not present, comment on completeness of intestinal metaplasia.

Molecular Assessment for Endometrial Carcinoma

Percentage of pathology reports for endometrial carcinoma that comment on POLE and p53 testing status, and status of IHC for PMS2 and MSH6.

Avoidance of Opiates for Low Back Pain or Migraines

Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate

Discharge Prescription of Naloxone after Opioid Poisoning or Overdose

Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge

Squamous Cell Skin Cancer: Complete Reporting

Percentage of final pathology reports for excisions for squamous cell carcinoma of the skin that include a comment on margin status, degree of differentiation/histologic grade, depth or level of invasion, presence of perineural invasion* and presence of lymphovascular invasion

*Perineural invasion defined as tumor cells within the nerve sheath of a nerve deep to the dermis or with a caliber of 0.1 mm or higher.

Barrett’s Esophagus: Complete Analysis with Appropriate Consultation

Percentage of esophageal biopsy reports with a diagnosis of Barrett’s esophagus that include documentation of a consultation* with a second pathologist for confirmation of dysplasia grading.

*Consultation at the time of diagnosis or addendum to preliminary pathology report

CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information