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
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%)
Percentage of non-small cell lung cancer (NSCLC) pathology reports that include anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), AND tyrosine protein kinase ROS1 mutation status.
Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period.
The measure consists of four performance rates:
a. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery whose blood glucose level is tested prior to the start of anesthesia
b. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than or equal to 180 mg/dL (10.0 mmol/L) who received insulin prior to anesthesia end time
c. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who received insulin perioperatively and who received a follow-up blood glucose level check following the administration of insulin and prior to discharge
d. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than or equal to 180 mg/dL (10.0 mmol/L) who received education on managing their glucose in the postoperative period prior to discharge
The percentage of patients, aged 1 and above, who undergo a surgical, therapeutic, or diagnostic procedure that involves using a non-depolarizing neuromuscular blockade medication who have a documented quantitative train-of-four ratio of greater than or equal to 0.9 before tracheal extubation in the operating room, post-anesthesia care unit, non-operating room anesthetizing location, or earliest extubation.
Percentage of patients, age 13 and older, undergoing an inpatient surgical procedure who have an outpatient prescription for buprenorphine/naloxone or suboxone in their admissions documentation, who are continued on buprenorphine for the duration of their inpatient stay or undergoing an inpatient or ambulatory surgical procedure who are taking methadone as outpatients or who have a prescription for methadone in their admittance documentation, and where methadone is either continued or changed to an equivalent IV dose to maintain the therapeutic level regimen during the perioperative period. For patients receiving care in an ambulatory surgical setting, methadone medication was provided as scheduled before surgery.
This measure will consist of two performance rates:
Measure A: Percentage of patients, age 13 and older, undergoing an inpatient surgical procedure who have an outpatient prescription for buprenorphine/naloxone or suboxone in their admissions documentation are continued on buprenorphine for the duration of their inpatient stay.
Measure B: Percentage of patients, 13 years and older, undergoing an inpatient or ambulatory surgical procedure who are taking methadone as outpatients or who have a prescription for methadone in their admittance documentation and where methadone is either continued or changed to an equivalent IV dose to maintain the therapeutic level regimen during the perioperative period. For patients receiving care in an ambulatory surgical setting, methadone medication was provided as scheduled before surgery.
NOTE: The overall measure score will be calculated as an average of the performance rates of A and B. In order to be scored on this measure, clinicians must have at least one eligible case reported for each sub-metric: Measure A and Measure B.
All patients, aged 65 and older, who are diagnosed with a hip fracture and receive peripheral nerve blocks for pain management in the emergency room or inpatient setting.
Percentage of patients who undergo an open cardiac procedure over 240 minutes duration and who receive initial cephalosporin within 60 minutes before surgical incision and receive either a bolus infusion or an intravenous cephalosporin antibiotic re-dose at four-hour intervals.
Percentage of patients with a documented urinalysis or urine culture within 14 days prior to surgical stone procedures
Percentage of patients with T1 disease who had a second transurethral resection of bladder tumor (TURBT) within 6 weeks of the initial TURBT
