Percentage of Adult Patients Who Completed a Survey Regarding Their Care Visit Who Reported They Would Trust the Doctor/Provider to Care for their Friends/Family
Submission Method: Registry
Avoidance of Advanced Imaging for Pediatric Patients with Unprovoked, Generalized Seizure
Percentage of patients aged younger than 18 years with diagnosis of seizure that did not have a CT or MRI of the head ordered.
Inhaled Corticosteroid for Patients with Acute Asthma Exacerbation
Percentage of patients aged 6+ diagnosed with an acute asthma exacerbation and prescribed inhaled corticosteroid
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
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
Urinary Bladder Cancer: Complete Analysis and Timely Reporting
Percentage of urinary bladder carcinoma pathology reports that include the procedure, histologic tumor grade, histologic type, presence/absence of muscularis propria, presence/absence of lymphovascular invasion, and tumor extent.
AND
meet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date is less than or equal to 2 business days).
INSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:
Stratum 1. Percent of cases for which all required data elements of the urinary bladder carcinoma pathology report are included.
Stratum 2. Percent of cases that meet the maximum 2 business day turnaround time.
The overall performance score submitted is a weighted average of:
(Performance rate 1 x 70%)+(Performance rate 2 x 30%)