Quality Measures – Page 22

Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and Percentage of Prevalent Patients Waitlisted for Kidney Transplant in Active Status (aPPPW)

The measure tracks dialysis patients who are under the age of 75 in a practitioner group and on the kidney or kidney-pancreas transplant waitlist (all patients or patients in active status). This measure is a risk-adjusted percentage of waitlist events among dialysis patients.

Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR)

The number of prevalent dialysis patients in a practitioner group who are under the age of 75 and were listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.

Patient Reported Falls and Plan of Care

Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit.

Diagnostic Delay of Venous Thromboembolism in Primary Care

Percentage of episodes for patients 18 years of age and older with documented Venous Thromboembolism (VTE) symptoms in the primary care setting and who had a diagnosis of VTE that occurs > 24 hours and within 30 days following the index primary care visit where symptoms for the VTE were first present.

Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes

Percentage of adult patients with risk factors for type 2 diabetes who are due for glycemic screening for whom the screening process was completed during the measurement period.

Hepatitis C Virus (HCV): Sustained Virological Response (SVR)

Percentage of patients aged greater than or equal to 18 years with active hepatitis C (HCV) with negative/undetectable HCV ribonucleic acid (RNA) at least 20 weeks to 12 months after positive/detectable HCV RNA test result.

Skin Cancer: Biopsy Reporting Time – Clinician to Patient

Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 8 days from the time the biopsy was performed.

Gains in Patient Activation Measure (PAM®) Scores at 12 Months

The Patient Activation Measure® (PAM®) is a 10- or 13- item questionnaire that assesses an individual’s knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®-PM) is the change in score on the PAM® from baseline to follow-up measurement.

Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk

Percentage of patients aged 12 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician’s evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.