Percentage of the following patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the performance period:
• All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
• Patients aged 20 to 75 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
• Patients aged 40 to 75 years with a diagnosis of diabetes; OR
• Patients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent.
Category: Quality Measures
Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician
Percentage of biopsies with a diagnosis of cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization’s total IVD denominator. All-or-None Outcome Measure (Optimal Control) – Using the IVD denominator optimal results include:
• Most recent blood pressure (BP) measurement is less than or equal to 130/80 mm Hg — AND
• Most recent tobacco status is Tobacco Free — AND
• Daily Aspirin or Other Antiplatelet Unless Contraindicated – AND
• High Intensity Statin Use Unless Contraindicated
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.
Appropriate Workup Prior to Endometrial Ablation
Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.
Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer
Percentage of patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.
RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor (EGFR) monoclonal antibody (MoAb) therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed before initiation of anti-EGFR MoAb.
Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)
Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.
Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)
Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.