Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.
Measure Type: High Priority
Multimodal Pain Management
Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.
Functional Status Change for Patients with Neck Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
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.
Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
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.